66 100 6561 http://exhibits.library.stonybrook.edu/mfp/files/original/4829a346731c642d4b009d69ede20ef4.pdf f52f80e5b4fabf3b53f885310a3d6354 PDF Text Text Clinical and electroencephalographic effects of Megimide in patients Without cerebral disease Martin A. Green, M.D., and Max Fink, M.D. the introduction of Megimide (beta, beta methylethylglutarimide) as an antagonist for barbiturate intoxication in 1955, considerable interest has been stimulated in its clinical applicability. Initial reports noted its efficacy in barbiturate poisoning,1—4 but subsequent studies failed to substantiate this applicationf)"8 In this laboratory, barbiturates are frequently administered under the standardized conditions of the “amobarbital test.”9 It was thus possible to assess the efficacy of Megimide in altering the behavioral response of human subjects to physiologic equivalent amounts of barbiturate. In addition to its suggested antagonism to barbiturate, Megimide induces both paroxys— mal discharges in the electroencephalogram and clinical grand mal seizures.10—14 The present report concerns our experience with both the behavioral and electroencephalographic effects of Megimide. FOLLOWIXG AIATERIAL AND METHODS Thirty-four hospitalized voluntary psychiatric patients with psychoneurosis, depression, or schizophrenia, ranging in age from 27 to 64 years, were studied. Megimide in a concentration of 5 mg. per cc. was administered intravenously at the rate of 0.5 mg. per kg. per minute, until definite changes were observed in the electroencephalogram and often beyond this point. The amount of Megimide varied from 45 mg. to 250 mg. In 15 subjects Megimide was administered without prior amobarbital. In 19 patients it was given following the administration of in— travenous amobarbital which was injected at 0.5 mg. per kg. every 40 seconds, in amounts necessary to induce nystagmus, slurred speech, and marked drowsiness or sleep. All experiments were undertaken in the elec- troencephalographic laboratory. An electroencephalogram was made prior to the injections and was run continuously during the administration of both drugs. The electrode placement consisted of frontal, motor—parietal, occipital, anterior temporal, posterior temporal, vertex, and earlobe'. Both scalp—to-earlobe and scalp-to-scalp combinations were used. RESULTS The electroencephalogram in all subjects prior to the administration of the drugs was “normal,” that is, symmetric and non-dysrhythmic. Electroencephalographic Response In the amount and rate of injection of Megimide employed, electroencephalographic changes occurred in every patient. The type of response and the amount of drug necessary to induce such a response were highly variable. The electroencephalographic changes included irregular low- and moderate-voltage slow ac— tivity, bursts of slow activity (usually of high voltage), single spike discharges, and spikewave forms (figure 1 A, B, and C). These ef— fects were diffuse and symmetric, with greatest prominence in the temporal leads. The sequence of these responses was inconstant. Irregular, low-voltage slow activity was the most frequent initial change in the record. In other instances, bursts of highvoltage slow activity or spike activity appeared initially. As the injection continued, the amplitude and per cent time delta activity inFrom the department of experimental psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. Read at the meeting of the Eastern Association of Electroencephalographers, New York, December 1956. Aided by Grant M 927, National Institute of Mental Health, National Institutes of Health, US. Public Health Service. Reprinted from NEUROLOGY, Minneapolis, September 1958, Vol. 8, N0. 9 Copyright 1958, by Lancet Publications, Inc. �EFFECTS OF MEGIMIDE "NV‘VV Mvw LP-RP *V‘JlWMAA/‘fr'rwm“MWHWIMS‘WWVWWMmeLMMA. L0‘ R 0 (memwwmewwWWW» WM WflM‘j(Ml/\rlY/‘Vr'j‘fluj'wwMWWWWWWJWMW VWLWMW WWW/wWWJMWW *WWWWWWW AT R P T I‘ 5A , ”v w. a WW1 '«M “-34x4“ MW‘WMMWW I ‘A ‘M’m‘rv‘v‘rfi‘w Jam.M’w’M—‘fi' draw; R “ij MW ® .I 50 35cc MEGIMIDE (5 cc/ MIN) mv lSEC, LP-RP @ 30 cc MEGIMIDE (Soc/MIN.) ' SEC' creased. Bursts of high—voltage slow activity were seen eventually in almost all patients. Spike discharges, however, were less frequent, even with relatively large doses of Megimide. For example, the tracings in one subject after receiving 220 mg. of Megimide and in another after receiving 250 mg. showed irregular diffuse slow activity without spike activity. Seizures Because of the nature of the population and the goals of our study, we specifically avoided administering Megimide in rates and amounts that would produce clinical grand mal seizures. Despite these precautions, a grand mal seizure was inadvertently induced in one patient. A 33 year old woman was given 200 mg. of Megimide at the rate of 50 mg. per minute. Up to 150 mg. there was only a decrease in the voltage of the alpha activity. After 200 mg. there was a sudden long run of diffuse, rhythmic 4 to 5% cycles per second high voltage activity, with intermixed spike activity which was immediately followed by the seizure. The electroencephalogram during injection and prior to the seizure showed minimal changes, and the seizure was not anticipated 35M: MEGIMIDE (Sac/MIN.) SE“ F IG. 1. Different types of electroencephalographic response to Megimide. A, delta activity, irregularly and in bursts, B, single spike activity, C, spike-wave activity Subjective Response The subjective reaction to Megimide was minimal, even when the induced changes in the electroencephalogram were severe. A few subjects complained of nausea, “dizziness,” “shakiness,” or a peculiar sensation in the abdomen. It was possible, however, to continue the injection without further increase in the symptoms. Two subjects became apprehensive, and in one of these the injection had to be discontinued. Myoclonic jerks occurred frequently. They were usually mild and confined to one extremity. Less frequently they were bilateral and more severe. The relationship between these movements and spike activity was inconstant. The myoclonic jerks usually preceded the appearance of spike activity, althOugh the reverse occurred occasionally. The simultaneous appearance of spike activity with myoclonic jerks was infrequent. The effect of Megimide was short-lived. There were no instances of seizures or other abnormal responses later in the day following its administration. However, since intravenous amobarbital followed in all patients, this may have prevented such occurrences. The clinical and electroencephalographic responses to intravenous amobarbital following Megimide appeared similar to those seen in subjects in whom amobarbital is administered without prior medication. The slow-wave or spike activity induced by Megimide disappeared and the usual patterns associated with barbiturates developed (figure 2). However, �NE UROLOGY 684 the well-modulated high per cent time beta activity usually noted after barbiturate administered was less prominent. M egz’mide Following Amobarbital One group of subjects received intravenous amobarbital prior to Megimide until drowsiness, slurred speech, and nystagmus were induced. The electroencephalogram showed the patterns commonly associated with barbiturates, that is, an increase in voltage and per cent time fast activity and a decrease in amount and voltage of alpha activity. The most prominent clinical change was the awakening of the subject. Within the few minutes necessary for the injection, the patient became more responsive, slurred speech disappeared, and drowsiness, both on subjective and objective evaluation, was minimal or absent. Nystagmus became inconstant, unsustained, or disappeared completely. Gait, including heel-totoe walking, was steady. However, the awakening effect was not uniform for all aspects of behavior altered by barbiturate. For ex— ample, if the subject became euphoric and more talkative with barbiturate, such behavior may have persisted in a milder form, even after the drowsiness of amobarbital was abolished by Megimide. These clinical changes were accompanied by alterations in the electroencephalogram (figure 3). Patterns of drowsy activity disappeared. Alpha activity increased both in amount and voltage. Fast activity induced by amobarbital usually persisted unchanged or was reduced only sightly. In some instances it increased in amount and voltage. The prior administration of amobarbital did not prevent the appearance of paroxysmal discharges. WW W LP-RP W WJMWW LO'RO LF-RF -om A mmwwwwwwvwvv WWW/”WWW AT-PT @RESTING RECORD W wa~VMMMWh~WMphfiwnw~ L AT-F R MMKWWWMMVWVJ @ UL ‘vr—WW‘W wabwuvmh1-vun~pa~h4qu WWW» 50!”?— 1 azsrmc RECORD 252 (28 mg. AIOBARBIYAL rug/40 SEC.) 40 c: IEGEIIDE (5 cc / III.) FIG. 2. Effect of amobarbital following administration of Megimide fiWWA/VWW 38cm MEGIMIDEHScc/MIN.) r. W WWW WWWWHW WWW WWW WVNMWMWWM o LO . R0 F: MNVWVWVWVW—M’NW’ Megimide is similar to pentalenetetrazol (Metrazol) in that it induces delta activity, spike and spike-wave activity in the electro— encephalogram, and clinical grand mal seizures. Such changes occur in nonepileptic subjects without brain disease, and considerable individual variability in the threshold for these changes exists. These discharges are nonspecific and cannot be used as evidence of the presence of a seizure disorder. The possibility of using Megimide in activating the electroencephalogram has received study.10—1‘-’ Several investigators have noted a more gradual onset of the electroencephalographic and clinical changes with Megimide than with Metrazol. For this reason, the opinion is expressed that Megimide may be more facile in reproducing both clinical and electro— encephalographic seizures in patients with seizure disorders. It should be emphasized, however, that in the one patient in the present study in whom a grand mal seizure occurred, the seizure began suddenly and was not anticipated either from the electroencephalogram or previous clinical responses. Megimide is effective in counteracting the clinical effects of small doses of intravenous amobarbital. This property has been previously demonstrated in animals3 and is being utilized LF-RF k WN-WINW‘MWMNWVM DISCUSSION 0%va6Wwaw'wwrwwqp'v LM-RM {-0 Bursts of high-voltage slow activity, spike activity, or spike-wave activity often appeared, usually during or after awakening. Such activity was not a necessary accompaniment of the awakening response, however, since other subjects in whom clinical drowsiness disappeared did not show such discharges. 500 mg.AMOBARBlTAL (50 mq./40 SEC.) Effect of Megimide following administration of amobarbital FIG. 3. SEC. �EFFECTS OF MEGIMIDE in anesthesiology to shorten the recovery period from barbiturate anesthesia postoperatively.15 It is questionable whether this action is specific for barbiturates or whether it also applies to states of altered consciousness due to other agents as well.16 CONCLUSIONS Thirty-four psychiatric patients without cerebral disease were given Megimide (beta, beta-methylethylglutarimide) before and after the administration of intravenous amobarbital. 2. Megimide produces irregular delta activ~ ity, bursts of delta activity, and spike and spike-wave activity in the electroencephalo1. 685 gram. Such effects are similar to those produced by pentalenetetrazol (Metrazol). 3. Considerable individual variability exists in the amount of drug necessary to produce these changes. 4. A grand mal seizure was inadvertently induced in one patient. The electroencephalogram during the injection and prior to the seizure showed minimal changes and the seizure was not anticipated. 5. Megimide counteracts the clinical and some of the electroencephalographic effects of small doses of intravenous amobarbital. Megimide supplied through the courtesy of A. las Ltd., Slough, Bucks, England. & I. Nicho- REFERENCES A., SHAW, F. H., CASS, N. M., and \Van, H. M.:M. A new treatment of barbiturate intoxication. Brit. J. 1:1238, 1955. 1. SCHULMAN, to . 3. 4. 5. 6. 1. 8. 9. F. H.: Further experiences with Megimide—a barbiturate antagonist. M. J. Australia 2:889, 1955. SHAW, F. H., SIMON, S. E., CAss, N., and SCHULMAN, .-\.: Barbiturate antagonism. Nature 174:402, 1954. HARRIS, T. A. 13.: A barbiturate antagonist. Lancet 1:268, 1955. L()U\V, A., and SONNE, L. M.: Megimide in the treatment of barbituric acid poisoning. Lancet 2:961, 1956. PEDERSEN, ].: Amusing effect of Megimide and Ami— phenazole in allypropymal poisoning. Lancet 2:965, 1956. PLUM, F., and SWANSON, A. G.: Barbiturate poisoning treated by physiological methods. J.A.M.A. 163:827, 1957. CERSHON, S., and SHAW, F. H.: Effects of Bemegridc on barbiturate overdosage in humans. Brit. M. J. 2: 1509, 1957. \VEINSTEIN, 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, 1953. SHAW, 10. COURJON, 1., and BONNET, H.: Comparative effects of Metrazol and Megimide in activation of epileptic pa- tients. EEG 11. 12. 13. 14. 15. Clin. Neurophysiol. 8:710, 1956. DROSSOPOULO, G., GASTAUT, H., VERDEAUX, G. and J., and SCHULLER, E.: Comparison of EEG “activation” by pentamethylenetetrazol (Metrazol) and Bemegride (Megimide). EEG & Clin. Neurophysiol. 8:710, 1956. Room, E. A., RUTLEDGE, L. T., and CALHOUN, H. D.: Megimide and Metrazol (A comparison of their convulsant action in man and in the cat). EEG & Clin. Neurophysiol. 10:208, 1958. SOD‘TRBERG, U.: Eflect of Bemegride (Megimide) on cerebral blood flow and electrical activity of brain. Arch. Neurol. & Psychiat. 792239, 1958. PEACOCK, J. M.: An electroencephalographic examina— tion of the effects of Megimide and Daptazole in bar— biturate narcosis. EEG 8: Clin. Neurophysiol. 8:289, 1956. VVYKE, B. D., and FRAYVVORTH, E.: Use of Bemegride in terminating barbiturate anesthesia. Lancet 2:1025, & 1.957. 16. BOTTINGER, L. E., ENGSTEDT, L., and STRANDBERG, 0.: Is Bemegride a specific barbiturate antagonist? Lancet 1:932, 1957. �6mm and m We“: at Was in Patients WW?» 66”me Mum W m A. 11.3. ‘W-AMWI < I . the m Gala, Wt30!.of mm mm. mm swam. Glen 1mm... matting at the Max “manhunt: or m at thoMubor Elsemmm. 1956. Nam Yam-k, " Aiéadhy Grant Wham 3/58 65f I! 92?, Katina}. M‘W‘lfii at mm Kalil), 0.3. fibula Knuth 3031“. mm. Ram ��4-:— hospnmua Wm Mulmon ma, yam, um studied. a:- whammy mum“! ranging in We inat an Watered inbmmaly per mama“ gamma with psycho0.39 tram 27 to a maxim-influx: o: 5 mg; put am, the mm at 9.5 mg. par mm. until «finite 611mg” m ubsowad in tin Ma mm. the amt» beyond am: may he wounds, in spam, We varied Mm viii and aim m. ta 290 mg. lumen» Home» was magnum without mic: m» In mum 1.4: as given immg New summation at unhrbital which as inject“! at 0.5 as. per rm mum. m 6k. M“ from 1:5 mm amt: Wavy ta induce mums, and marked «112%:thme~ or slurred film. m momma mm mama in the ma Mathew.An memeephamm m 13m Mar to tho mmctiw and was Wavim cantmmly during tho phmt mm mind 91‘ frontal, run Mama-cl, memo: at“ both fixings. The mam WWam, manta}... mtariw W31, vim ma earlobe inads. mm: mm scalp ’w snip «mum awn aplayad. Bail: map ta ��.V of gang. Warmth voliaga at iha alpha lang mm . 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Magma: as net 6.1119195.qu of men. dawn of tutu-amp“ maba'rhim. etfeete, �� 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 Clinical and electroencephalographic effects of megimide in patients without cerebral disease. Neurology. 1958 Sep; 8(9):682-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-22b-027 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.; <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, September 1958, Vol.8, N0.9 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/538bdc6ba0530077be0ac863533401f5.pdf 74bce06bc6e20def0793fd89b0e7d725 PDF Text Text 3mm mam mum mm nwrxrmuox arm: ML. WW4; or A 0A3: MA Mb. (firm) g; (\Mmc ~39:qu QNUULJ».6§~UJ\MA1 4% (0.2.1:? #:g Afod. I751: Viz/b. wk. 316% 3.17/‘3. �1. sustained by patients during hospitalisations' in mental institutions may cause disease of the nervous systemunrelated to the original illness. The trauma may be disregarded and the resulting complications may be interpreted as further progression of the original mental illness, thereby thwarting possible definitive therapy. This is most apt to occur in patients with organic psychoses. For this reason it is felt that a report of a case of subdural heaatcna developing during hospitalization in a patient with organic psychosis will be of Head trauma interest. ‘ fiftyoeight year old white feaale a nurse was admitted to Bellevue Psychiatric Hospital because of aental and personality changes. Four to five years previously the patient began to aislay objects and complained of occasional headaches. During the next two years it was noted that she would repeat herself in conversation, did not play bridge as often as before and complained of a constant feeling of fatigue. One and a half adaission to a marked change in her behavior occurred. years prior She had difficulty in asking decisions, became caliess in her dress, nislaid objects more frequently and exhibited stereotyped HISTGRY: A aoveaents (rubbing hands together, crossing legs) when excited. During the subsequent months she became ”confused" and incontinent. Prior to her illness the patient was a nurse doing private duty and was described as an excellent worker. She was. a happy individual with a pleasant and sociable disposition and had had zany friends. She had been an excellent bridge player, winning aany prises. �2. pressure was 95/60, pulse 88, temperature 98, respirations 18. General physical examination was negative. The patient was well nourished and alert. neurological examination disclosed her to be aphasic and apraetio. There were disturbances in body scheme, a left hononyuous visual field defect was present bu t the remaining cranial nerve functions were intact. There was no ataxia or inooordination. hotor power was noraal. The deep tendon reflexes were active and equal bilaterally and the plantar responses were normal. There was a left henisensory defect to pinpriek and touch. gegggégggz; hunter puncture disclosed clear, colorless fluid under an initial pressure of lho an. containing 5 lymphocytes and a total protein of 62 ng.%. The Hassernann and colloidal gold reactions were negative. X~rays of the skull and chest were negative. in electroencephalogram was diffusely abnormal containing a prevalence of slow activity maximal in the temporal and posterior parietal regions bilaterally. GOURSIa' The differential diagnosis was that of presenile and cerebral neoplasm. A degenerative disease of the brain pneuaoeneephalograa revealed generalised dilatation of the ventricular system without displacement or distortion. The cortical aarkings were increased bilaterally. The patient was kept in the hospital for further study of her mental and sensory defects. On at least one occasion during this period bruises were noted overthe patient's head and fees. these were thought to be sustained tron falls or from busping into objects on the ward. The patient remained alert and no new neurological signs developed. Approximately three EIAIIIAEIOK: Blood ‘ ' �months after admission the patient gradually became lethargic and exhibited rhythmic myoclonio movements, frequent in the corner of the mouth and the left upper extremity and occasional in the right upper extremity. A left hemiperosia developed end the patient became etuporoue. Lumbar puncture diacloeed clear, oolorleee fluid under an initial preeeure or 200 mm. and containing 3 white blood cells. Loft temporal and right A hugh oubdurel henntoma were performed. trephinationo perietal was found on the right eide. It contained dark red, liquid blood. There we: no definite aotive bleeding. The outer membrane one very thin and the inner nenbrene wee inoonepiououe. The right hemisphere wee nerkedly compreeeed and failed to re-expend after evacuation of the hlnmtona. 0n the left side there were two eubdurel membranes about 3~5 mm. apart and oontaining a small amount or yellowish fluid between then. There wee no blood. A cerebral biopsy wee teken.fron the left parietal lobe by introducing a glaee euotion tube for a distance of one inch at a right angle to the eurteoe of the cortexand eepirating a specimen. Following operation the patient became more alert but the apheeie and the disturbance in body scheme were more marked left and epeeoh was unintelligible. The myoolonie movements diaeppeered and the left henipareeie improved. Seventeen days efter operation a pneunoencephelogran showed dilated lateral ventricle: more marked on the left side. The enterior and poeterior horns were aeynaetrioal and slightly diapleoed to the left. The patient died eight days later. An autopsy was not obtained. hieroaeopio examination of the cerebral biopsy at the �shoved numerous senile plaques and time or trephinstion Alzheimer cells, oomputible with the diagnosis of Alzheimer's diseaoe. signs of progreooive diocese of the cerebral hemisphere: which this patient developed during the latter part of hospitalization were initially interpreted as the end stage of an organic psychoaia. In view of the head traumn sustained exclude done subdurel henntonn ward was the on trephination to although this diagnosis was considered improbable. That the subdurel'hanntonntn were of recent origin.end yore not present before hospitalization is demonstrated by the following observations: 1) s pneuloenoophnlogrsn prior to the progression or neurological ventriculnr showed system without a symmetrically dilated signs 'diaplaoinent or distortion and increased cortical markings nontranen the of the hematonats were very thin. 2) bilsterdlly; Patients with organic ptyohosie in nentsl hospitals are psrtioulerly prone to head trauma which may initiate subdursl hemntamn; Progressive usurologioal signs in such patients should be evaluated with this oonsiderstion in mind. The � 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 Subdural hematoma developing during hospitalization. Arch. Neurol Psychiatry. 1951 Aug; 66(2): 230-1 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-1-001 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 Green, Martin; <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]. 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/1e8c795fb4f587faa06c7827a2d53d1f.pdf 8dbcc77f9a018fd443642f4f0191daf3 PDF Text Text \Lz. MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS BY ALTERED BRAIN FUNCTION J. JAFFE, M.D., H. ESECOVER, M.D., R. L. KAHN, and M., FINK, M.D. Glen Oaks, N. Y. PHD. This report is derived from a supervisory seminar in which the effects of convulsive treatment upon psychotherapeutic transactions were studied. The therapist’s observations have been described in a previous publication (1) . The present paper describes the process from the frame of reference of the supervisor and supervisory group. It is intended as a complementary set of observations of this combined therapy. In addition, concurrent neurophysiologic data are included, of which both therapist and supervisor were unaware. This additional frame of reference may broaden the understanding of certain phenomena in the patient-therapist, and therapist-supervisor interactions. Our purpose is to demonstrate that the introduction of a measurable physiologic variable is a useful method for the investigation of the psychotherapeutic process. The histories of the patients under study were given in the above-mentioned publication (1). In the following report, a detailed analysis of one of the cases" discussed in that paper is presented as most illustrative of the modification of interpersonal transactions by altered brain function. The patient, a 44—year-old widow and mother of a 12-year-old son, had been admitted to the hospital with symptoms of depression, anxiety, anorexia, varied physical complaints, and feelings of unreality and isolation. In her psychotherapeutic sessions she would reiterate her difficulties in a complaining pattern, repetitiously illustrating her inadequacy. During a three-month-period no improvement occurred and a course of electroshock therapy was recommended. At this juncture the patient was included in the present study. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by the Foundations’ Fund for Research in Psychiatry (56151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. The assistance of Miss Esther Sanders and Mrs. Anita Bellow, who participated actively in the seminars, is gratefully acknowledged. : * Case #3, G. C. 46 Reprinted from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. pages 46—55. January, 1961. XV, No. 1, �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 47 The setting was a weekly multi-disciplinary supervisory conference. Included in the group were: (a) the therapist (H.E.), (at the time a senior resident in psychiatry), who presented the case material; (b) a social worker who reported the response of the patient’s family; (c) a psychoanalyst (J .J .), Who dealt mainly with the didactic aspects of psychotherapeutic technique; (d) a psychologist (R.K.), who studied the cases independently; and (e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of the concomitant changes in physiologic measures, and although this information influenced their questions, the data were not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. The procedure was informal, with the therapist taking the lead in presenting his verbatim notes of the psychotherapeutic sessions. The order of the case reports and the amount of time devoted to each was not prescribed. Following the spontaneous case presentation, more directive questioning was introduced, aimed at clarifying and relating the information presented by therapist and social worker. Observations made during the period of somatic therapy are depicted in the accompanying chart. During the 94 days of supervision, two different forms of somatic treatment were utilized. This procedure was part of a hospital-wide convulsive-subconvulsive control study then in progress, in which therapists were unaware of the introduction of subconvulsive phases of treatment. . For the first treatment period (27 days) the patient received subconvulsive electro-stimulation with pentothal premedication. Twelve such treatments were given at the rate of three per week. No changes in the quantitative measures of EEG slow wave activity (2) were manifest during this time. This period served to establish a baseline for the behavioral observations and the expectancies of the staff. In the second treatment period (29th to 59th day), grand mal convulsions were induced three times weekly for a total of 14 treatments. In that period, minimal degrees of EEG change were recorded on the 37th day, and moderate degrees were shown on three subsequent recordings. Twelve days after the termination of convulsive therapy, EEG slow wave activity was considerably diminished. This information was not available tothe therapist or the supervisor until after the conclusion of the study. �‘ arr-fir». 48 AMERICAN JOURNAL OF PSYCHOTHERAPY EFFECT OF CHANGING BRAIN FUNCTION ON PSYCHOTHERAPY SUPERVISORS REPORT OF DISCOURAGEMEHT. AVOIDINCE FRUSTRATION. EXHORTATION APlST'S ATTITUDE TNEFMPIST'S REPORT 'SLIGNT CHANGE' (MINIMIZEDI DEPRESSED. couPanmG. SELF—REPROACHFUL, OF FATIENT'S A" ITUDE HELPLESS, HEW COMPLAINTS PARTICIPATION IN ACTIVITIES I I mnznlon } DEPRESSION I I "ORE COMFORTABLE, EASIER TO RELATE. POSITIVE FEELINGS CAUTIOUS, SOLICITOUS CHEERFUL, PRIMPING, SELF- CONVERSATIONALJRUSTING. AFFECTIONATE. ADULATING I I I I “APPRAISAL. SUPPORTIVE, DETACHED ASSERTIVE. OBJECTIVE. INDEPENDENT; ANXIOUS I I ANXIOUS .. .— I __ __ 20~ PAGES nous Unaware 5553101: m 10' 0 WW ......... 26EE 6 ". nu: nun) scum TREATMENT °"""°°""‘ I-COWULSIVE n'0- :— - _-.. B_|—|_I____J__J_l—J_L_'.l—L—L——L—J—-l——I—-—J___ 85 70 75 80 55 0 5 DAYS l0 [5 20 FROM 60 40 45 50 ONSET OF SOMATIC THERAPY 25 30 35 The patient was seen in psychotherapeutic sessions three times weekly throughout her hospitalization. While the therapist was he somatic was unaware that of treatment, the concurrent aware subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. Changes in the patient-therapist relationship as reported in the supervisory meetings are summarized in the chart and are detailed below. Supervisors’ Notes Ist to 19th day: During the first three weeks the therapist did not discuss this patient in the supervisory group. Other patients occupied the allotted time, in spite of a resolution to consider each patient weekly. In retrospect, the failure to report this patient’s progress canstituted a pattern of avoidance. Somatic therapy had not modified the patient ’3 ward behavior or the doctor-patient relationship. Both were the same as in the initial months of hospitalization. The neurophysiologic indices were unchanged. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. The therapist reported no alteration in �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 4:9 the patient ’3 clinging, whining, helpless attitude throughout the preceding three months. Efforts to explore her problems in living were blocked by physical complaints and by recitals of guilt, selfreproach, and feelings of failure. He was left little opening for comment. In the three supervisory meetings during this period the group atmosphere was one of discouragement whenever this case was presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the feeling that “she wasn’t trying.” The family reported that the patient considered her doctor “too young,” reflecting her attitude of reproach toward those who were unable to help her. He, in turn, felt that she was “throwing up her hands and giving up.” The therapeutic impasse was empathically communicated to the group by the case report. The transactions during this period were typically those leading to referral of depressed patients for somatic (i.e., nan-verbal) treatment. They may be characterized as follows. Verbal methods of therapy are incompatible with the affective mode of communication adopted by such patients (3'). The doctor’s efforts to help are not met by a collaborative response, and he feels frustrated. The insatiable quality of the patient’s demands also calls forth defensive reactions in the therapist. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship, however, continued unaltered. Perhaps the lack of the expected response of somatic treatment contributed to the therapist’s discouragement. He assumed that convulsions had been induced from the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (2). 34th to 42nd day: In the meeting that took place on the 38th day, a “slight change” was reported. Although the patient was still “crying, ranting, raving” in therapy sessions, it was also noted that “she participates in activities a little bit more, but not much.” The therapist and the group discounted this change in social relationships. The first spontaneous complaint of memory difficulty was also reported. The first evidence of neurophysiologic change appeared at this time. The EEG taken the day prior to this meeting showed a significant increase in slow wave activity. �50 AMERICAN JOURNAL OF PSYCHOTHERAPY 43rd to 63rd day: In the meeting on the 45th day the therapist reported a full psychotherapeutic session for the first time. He described the patient as “brighter,” “with a little more rouge and lipstick” and “smiling.” Two days later her mood was noted as “euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist described this as a “cessation of complaining.” Concomitantly, the affective mode of expression was replace-d by a more intellectualized pattern. Instead of stating “I have to cling to my mother,” the patient said “I’m dependent on my mother for many things.” This was described as “talking about her dependency in a different way.” Another change in communication pattern evoked ‘ ‘uncanny’ ’ feelings in the therapist. He stated that the patient “mentions things we had talked about as if it were new information.” With these changes, there was a concomitant increase in the patient ’s sociability and participation in hospital activities, and a diminution of her clinging to the family and therapist. The supervisory group atmosphere also changed— from one of hopelessness to well-being, with increased joking, smiling, and animated participation. On the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her sessions. She expressed feelings of trust and enjoyment of the meetings. The doctor experienced similar emotions, and was eager to report the progress of this patient. She was now “upset” because she couldn’t recall her problems, and the therapist noted that he was inclined to a directive “remembering” role. She complained of memory loss and attempted to relate in a friendly, realistically gratifying way to prevent further psychologic exploration. A greater detachment from her family was expressed. Social improvement continued. The family stated that she no longer considered the doctor “too young,” but rather a “guiding angel.” The abrupt, gross change in the clinical picture paralleled the development of maximum physiologic change. The three EEG- records during this period showed a moderate degree of slow- wave activity. The advent of positive feelings elicited reciprocal emotions in the therapist which were cammunicated in the supervisory sessions. The aflect was empathically reflected in members of the conference group. (The clinical picture resembled that of a “transference cure.” ) It is of interest that a change from “ physical” to “memory” �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 51 complaints was described as a “cessation of complaining.” Perhaps the memory deficit, an expected concomitant of convulsive therapy, is more acceptable to the staff because it is understandable. They feel a responsibility for this symptom and can authoritatively reassure the patient that it will be transient. An afiectionate dependency may also be more tolerable than a hostile one, especially when accompanied by gratifying social improvement. The language changes are indicative of a more detached, intellectualized cammunication of familiar content (4). The patient now “talked about” rather than emoting or “acting out.” This new language pattern was more in keeping with her background of college education, and the therapist’s implicit expectations (5‘). In contrast to her prior mode of communication it seemed to be more compatible with a psychoanalytioally-oriented approach. The concomitant development of memory difiiculty, however, perpetuated the essentially non-insightful therapeutic situation. 64th to 72nd day: This period followed the termination of somatic treatment. The patient reported a “sudden feeling of selfawareness.” Euphoria and memory difficulty were no longer Observed, and an anxious state supervened. Psychotherapeutic sessions were characterized by more critical appraisal of her life situation. For the first time the doctor gave the patient extra time in the sessions. The group voiced some concern that she was “slipping back.” When the patient occasionally talked positively about career, emancipation from mother, and so forth, the therapist felt called upon to respond optimistically, rather than to explore. There was a revival of Old complaints. At this point, the supervisor and therapist reviewed a tape-res corded therapy session. A recurrence of the earlier verbal patterns could indeed be identified. However, these occurred in circumscribed fashion rather than throughout the interview. The events antecedent tO such periods were examined and the adaptive nature of the recurrent affective patterns became apparent. The EEG record during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the period of altered brain function. The conference group responded with anxiety, reflected in the solicitousness of the therapist in prolonging the sessions. The phenomenon observed in the supervisory group, for lack of �52 AMERICAN JOURNAL OF PSYCHOTHERAPY Statedependency.” “electroshock be called better term, may a ments were made in the meeting such as “she’s slipping back,” “needs more treatments” and “improvement not holding up.’ These statements imply that the hostile- dependent pattern was being rather depression,” “a nosologic entity, as a thought of primarily than a mode of human relatedness. Perhaps because behavioral it now alone, means psychologic been by effected had not change seemed totally dependent upon the alteration in cerebral function. The change in interaction was conceptualized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group’s uneasiness on the sporadic reappearance of preconvulsive patterns. The detailed examination of a taperecorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of “electroshock dependency” was not observed in subsequent group meetings. 73rd to 94th day: During this period a more stable psychotheraindebecame The more patient apparent. was relationship peutic assertiveselfand of compliance discussed problems and pendent ness. Although her attitude remained positive and collaborative, her adulation of the therapist diminished. In one session she said She was at you.” I unless won’t better get I angry get “Maybe less elated. She moved from the closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were treated by the therapist without solicitude. His attitude was one of interest, support and detachment. They discussed plans for discharge and outpatient treatment. Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared, which differed both from the original negative and the artificially induced positive relationships. Therapist’s Notes as an Index of Relatedness Following the conclusion of the study, another index of the psydescribed Rioch has investigated. was relationship chotherapeutic stafiof index notes staff of as an volume of the the use progress in his notes a had The kept therapist interaction (6). patient standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session was made, and �MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS 53 is represented graphically on the chart. No written notes were taken during occasional tape-recorded sessions, and these are omitted from the chart. The change in the relationship is apparent from the abrupt and persistent increase in note-taking from the 44th day. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern (not illustrated), although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. DISCUSSION This report describes an investigation of psychotherapy when somatic therapy is introduced as an adjunctive procedure. One difficulty in the objective study of psychotherapeutic transactions is the absence of a quantifiable and controllable variable. Adjunctive therapies, somatic and pharmacologic, provide such a variable. They produce alteration in behavior as well as measurable neurophysiologic changes (2, 7). This opportunity has been utilized in the present project. For example, one mode of adaptation to altered brain function is a euphoric type of relatedness (8). The occurrence of the phenomenon in this case permitted us to observe how induced alternation of positive and negative attitudes call forth similar attitudes in therapist and supervisor. Another illustration was the discounting of the earliest clinical change during the 34th to 42nd day of treatment. The electroencephalogram indicated the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of stalf expectancies. Finally, the alteration of brain function was accompanied by a change in complaint pattern, that is, from physical symptoms to memory difficulty. This resulted in a new form of the dependency relationship (43rd to 63rd day) which was experienced differently by the supervisory staff, with resultant change in their feelings about the patient. This effect was also observed in the patient ’s family group. The observations also illustrate a phenomenon peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (9) suggests that the supervisee may communicate the affective aspects of his experience with the patient non-verbally in the supervisory meet- �54 AMERICAN JOURNAL or PSYCHOTHERAPY ing. His formulation is that “The supervisee unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally.” He also describes the diflusion of this affect in the other participants of a supervisory seminar. Thus he reports that “This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor’s emotional perceptions by matching them with the emotional reactions of the other participants present.” Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the relationship (45th day). The patient mentioned familiar topics “as if it were new information.” The “uncanny” quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic, and other forms of “acting-out” which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (2). Also in each case there were concomitant changes in behavior in the supervisory group. Our experience also highlights some of the difliculties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction of the eflicacy of verbal communication for improvement of the patient ’s adaptation. In the case reported, a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal, a “social recovery” occurred, apparently unrelated to interpretation of psychodynamic factors. When the induced neurophysiologic changes subsided, a recurrence �[MODIFICATION OF PSYCHOTHERAPEUTIC TRANSACTIONS ' 55 of earlier communication patterns led the therapist to doubt that the improvement could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of differing conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (10) between practitioners using somatic and analytically-oriented therapies. SUMMARY A study of concurrent somatic therapy and psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship and social adaptations were made. The observations in a group supervisory seminar reflected the pattern of neurophysiologic alteration. It is concluded that the introduction of a measurable physiologic variable is a useful method for investigation of interpersonal relationships. 1. 2. 3. BIBLIOGRAPHY Eseeover, H., Jaffe, J. and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients. J. Hillside Hosp, 7: 17, 1958. Fink, M. and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Resp0nse in Electroshock. Quantitative Serial Studies. A.M.A. Arch. Neurol. & Psychiat., 78: 516, 1957. Cohen, M. 8., Baker, G., Cohen, R. A., Fromm-Reichmann, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic-Depressive Psychosis. Psychiatry, 17: 103, 1954. Kahn, R. L. and Fink, M.: Changes in Language During Electroshock Therapy. In Psychopathology of Communication, P. Hoch and J. Zubin, Eds., Grune & Stratton, 1958. Kahn, R. L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. A.M.A. Arch. Gen. Psychiat, 1: 565, 1959. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies. T. W. Salmon Lecture, New York ' 4. 5. 6. Academy of Medicine, 1957. 7. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hosp, 6: 197, 1957. 8. Fink, M., Kahn, R. L. and Green, M.: Experimental Studies of the Electroshock Process. Dis Nero. Sys., 19: 113, 1958. 9. Hora, T.: Phenomenology of the Supervisory Process. Am. J. Psychother., 11: 769, 1957. 10. Hollingshead, A. B. and Redlich, F. 0.: Social Class and Mental Illness. J. Wiley & Son, New York, 1958. ��Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function J. Jaffe, M.D., B. Esecover, M.D. R.L. Kahn, Ph.D. a M. Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. From Aided, in part, by the Foundations' Fund for Research in Psychiatry (56-151) and grant M-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. assistance of Miss Esther Sanders and Mrs. Anita Bellow, caseworkers in the Department of Social Services, who participated actively in the seminars, is gratefully acknowledged. The VII: 11-15-58 �Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function seminar from a supervisory derived is psychotreatment upon convulsive of which the effects in The studied. therapist's were communication therapeutic observations have been described in a previous publication (2), and are based mainly upon his personal experiences with the patients. The present paper describes the process intended as is of frame reference. It from the supervisor;s combined complex of this observations of a complementary set data is neurophysiologic concurrent In addition, therapy. unaware. were and supervisor both which of therapist included, This additional level of observation seems to account for and the in patient-therapist, certain clinical phenomena This report therapist-supervisor interactions. Our purpose is to demonstrate that the introduction method a useful is variables of measurable physiological for the investigation of the psychotherapy process. �METHOD: setting was a weekly multi-disciplinary conference composed of five people, and thus departed from the conventional supervisory situation. The group included: a) the therapist (H.E.), at the time a senior resident in psychiatry, who presented the case material; b) a social worker assigned to The the cases selected for study, who reported the on-going response of the patient's family; c) a psychoanalyst (J.J.), who dealt mainly with the didactic aspects of psychotherapeutic technique; d) a psychologist (R.L.K.), who had studied the cases independently; and e) a neuropsychiatrist (M.F.), who coordinated the discussion. The last two members were aware of concomitant changes in the physiologic measures, and although this information influenced their questions, the data was not introduced at these conferences. The actual somatic treatment was performed by a physician who was not a participant at the meetings. procedure was informal. The therapist took the lead in presenting verbatim notes of his psychotherapy sessions with five patients receiving combined therapy. The order of The the case presentations and the amount of time devoted to each was not prescribed. Following the spontaneous case reports, directive questioning was introduced, aimed at clarifying and relating the information presented by the therapist and the social worker. Although roles were defined, the atmosphere was one of inquiry in which no participant claimed a definitive answer to the problem under investigation. more . �m SUBJECT: case histories of the subjects of this study were In a this (2). report in a publication previous reported most #3 as Case clearly of is presented detailed analysis illustrative of the modification of interpersonal transactions The widow old year by patient, and mother of a 12 year old son, had been admitted to the hospital because of depression, anxiety, anorexia, multiple somatic complaints, and feelings of being "unreal" and isolated. In therapeutic sessions she would reiterate her difficulties 'in a persistent complaining pattern, as illustrations of her altered brain function. This a hh After a three month period of psychotherapy without alteration in the clinical condition it was decided co utilize a course of electroshock therapy. At this time the patient was included in the present project. More detailed description of the psychotherapy sessions is included under "Observations" below. failures and inadequacies. SOMATIC THERAPY: during the intercurrent somatic therapy are depicted in the accompanying chart. During the 9b days of supervision two different forms of somatic treatment 'Serial observations made This procedure was part of a convulsivesubconvulsive control study then in progress, in which the therqmd.was unaware of the introduction of the subconvulsive were utilized. phase of treatment. �-hFor the first period the patient received subconvulsive electrostimulation with pentothal premedicaticn. Twelve such treatments were given at the rate of three per week. No manifest changes in quantitative analyses of the degree of the EEG (3) were observed during this time: in delta activity This period established a baseline for the behavioral observations and the staff eXpectancies. Grand mal convulsions were induced from the 29th to the 59th days of somatic treatment, also at a rate of three per week for a total of 1h treatments. In this convulsive period, minimal degrees of electroencephalographic delta activity appeared on the 37th day, and moderate degrees were shown on three subsequent recordings. On a follow-up record 12 days after the termination of convulsive therapy the delta activity had decreased considerably. This information was not available to the therapist or the supervisor until after the conclusion of the study. The patient was seen in psychotherapy sessions three times a week throughout her hospitalization. While the therapist was aware of the concurrent somatic treatment, he was unaware of the fact that subconvulsive stimulation was given initially, and of the change to convulsive therapy on the 29th day. The changes in patient-therapist relationship as reported in the supervisory meetings is summarized in the chart and is detailed in the following observations. -~‘ -------Figure I 27 day �OBSERVATIONS: let to 19th day: During the first three weeks of somatic treatment the therapist did not discuss this patient in the supervisory in the time, allotted occupied Other all patients group. the in about hear to patient every of resolution our spite study each week. The case histories presented during this time were those of patients undergoing gross day-to-day changes in clinical behavior. Comment: retrospect, we consider the omitted presentation A communication. pattenlof avoidance to be a significant characterized this period. The neurophysiologic indices during this time were unchanged. Similarly, the patient's clinical status and the doctor-patient months the three in same the as were relationship In preceding somatic treatment. 20th to 33rd day: The case history was first presented in the meeting on the 20th day. Over a three month period the psychotherapeutic unable to the being been had unchanged, therapist relationship discern any alteration in the patient's clinging, whining, in her living problems to explore Efforts attitude. helpless of and by long recitals complaints blocked by were physical In three the of and failure. feelings self—reproach, guilt, supervisory meetings during this period the group atmosphere �-6was one of discouragement when this case presented. The therapist reported impulses to exhort the patient to participate in ward activities, and reacted to her professions of helplessness with the subjective feeling that "she was'nt trying." The reproach against those who were unable to help her was reflected in the family's report that the patient considered her therapist "too young." was Comment: therapeutic impasse was empathically communicated to the group by the therapist's report. The interaction during this period may be characterized as follows: After prolonged, unsuccessful efforts at verbal communication the psychotherapist is realistically frustrated (I). The affective mode The patient rendered essentially verbal techniques useless. The doctor's efforts to help were not met by a collaborative response, while the insatiable quality of the patient's demands may also have called forth defensive reactions in the therapist. Such interactions are typically those that lead to the referral of psychotically depressed patients for somatic, 3,3. nonof communication adopted by the verbal forms of therapy. During this period the mode of somatic treatment was changed from subconvulsive to convulsive. The clinical status and therapeutic relationship however, �-7continued unaltered. Perhaps lack of the expected response to somatic treatment contributed to the therapist's discouragement. He assumed that convulsive therapy had begun at the outset, and his past experience had led him to anticipate a clinical response by the fourth week of treatment (3). Bhth to h2nd day: In the meeting that took place on the 38th day, a "slight change" reported. Although the patient was described as still "crying, ranting, and raving“ in therapy sessions, it was reported that "she participates in activities a little bit was more, but not much." The therapist and the tended to minimize the social improvement. The first group spontaneous complaint of memory difficulty was also reported in this meeting. Comment: retrospect, the first evidence of neurophysiologic change had appeared at this time. The electroencephalogram on the day prior to this meeting showed a significant increase in delta activity. The In group discounted the concomitant observation of clinical change in view of a persistent hostile- dependent transference, and negative counter- transference feelings. �23rd to 63rd day: In the meeting on the hSth day the therapist spontaneously reported a full verbatim psychotherapy session for the first time. The patient was described as "brighter," "with a little more rouge and lipstick," and "smiling." Within the next two days he described her mood as ”euphoric.” Physical complaints ceased and were replaced by complaints of forgetting. The therapist, however, described this change as a cessation of "complaining." There was a change in the form of verbal expression although the content remained the same. Her affective mode of expression was replaced by an intellectualized pattern. For example, instead of complaining mother" the patient said, "I'm "I have to cling to my dependent on my mother for many things." The therapist described this change as "talking about her dependency in a different way." Another of his observations, however, was reported with "uncanny" feelings which were shared by the supervisor. He stated that the patient "mentions things we had talked about as if it were new information." With these changes, there was a concomitant increase in her sociability participation in hospital activities, and a diminution of her overt dependency upon family and therapist. The supervisory group atmosphere at this time changed from one of discouragement to a feeling of well-being, with increased Joking, smiling and animated participation. and �-9the 52nd day the therapist reported that the patient dressed seductively and applied fresh make-up for her therapy meetings. She expressed feelings of trust and enjoyment of the sessions. The doctor experienced similar emotions, and was eager to report the progress of this case. The patient was now "upset" because she could'nt remember her problems, and the therapist noted that he was being continually led into a directive "remembering" role. He felt the patient used her memory loss as a defense against further psychologic exploration, and that she preferred to maintain the relationship on a 0n friendly, realistically gratifying level. A greater detachment from her family was also expressed. Indicafima of social improvement were prominent. The family' stated that she no longer considered the doctor "too young," but rather a "guiding angel." Comment: abrupt and gross change in the clinical picture paralleled the development of maximum physiological change in this case. The three electroencephalograms during this period showed a moderate degree of delta activity. The advent of markedly positive feelings elicited reciprocal emotions in the therapist. These were communicated in the supervisory sessions, and were empathically reflected in members of the conference group. The clinical pattern resembled that of a "transference cure." The �-10- It is of interest that change from "physical" to "memory" complaints was described as an overall "decrease in complaining." Perhaps a memory deficit, expected concomitant of convulsive therapy, was ;MOre acceptable to the staff because it was understandable. They felt some responsibility for this Syphon and could authoritatively reassure the patient that it would be transient. It is also probable that an affectionate dependency is more tolerable than a hostile dependency, especially when accompanied by obvious and gratifying social an improvement. The language changes were indicative of a more detached, intellectualized'communication of familiar content (8). The patient at this time "talked about“ rather than emoting or "acting out." These new language patterns were consistent with her college education and, in contrast to her prior mode of communication, appeared to be more compatible with a psychoanalytically-oriented approach. However, there was the concomitant development of memory difficulty, exemplified by her introduction of previously discussed topics as new information. The ne.t effect thus a non-communicative situation with regard to interpretive insight therapy. was �-116hth to 72nd day: This period followed the termination of somatic treatment. The patient reported a "sudden feeling of selfmemory The awareness." euphoria and difficulty were no longer observed, and an anxious state supervened. The content of the psychotherapy sessions changed to a more critical appraisal of her life situation. For the first time the therapist gave the patient extra time in the sessions. The group voiced some concern that she'was "slipping back." When the patient occasionally talked positively about such problems as her emancipation from mother, the therapist was inclined to respond optimistically, rather than to explore. She reacted to this with a revival of old complaints. At this point, supervisor and therapist reviewed a tape recorded therapy session. A recurrence of the earlier pattern could indeed be identified, although in circumscribed fashion rather than throughout the interview. It was possible to examine the antecedent events in the session and to clarify the pattern as an adaptive response to stressful content. Comment: electroencephalogram during this period showed a considerable decrease in slow wave activity. There was a concomitant reestablishment of some of the communication patterns which preceded the The period of altered cerebral function. group responded with uneasiness which The supervisory was reflected �.12in the solicitousness of the therapist in prolonging the sessions. At this point a phenomenon was observed in the supervisory group which, for lack of a better term, may be called "electroshock dependency." Statements were made in the meeting such as, "she's slipping back," "needs more treatments," and "improvement not holding up." These statements imply that the hostile-dependent pattern constituted a nosologic entity - ”a depression" - rather than relatedness. Perhaps because therapeutic change could not be a effected by interpersonal means alone, its persistence seemed dependent upon the alteration in cerebral function. The change in interaction was thus being conceptuala mode of human ized as the result of the brain syndrome, and not as a function of the doctor-patient relationship. Hence the group's uneasiness on the sporadic reappearance of the pre-convulsive interaction pattern. The detailed examination of a tape-recorded session revealed the adaptive function of this more circumscribed occurrence of the complaints, and the phenomenon of "electroshock dependency" was not observed in subsequent group meetings. �-13. 23rd to 9hth daz: During relaionship this period stable psychotherapeutic patient became more independent a more apparent. The and discussed problems of compliance and self-assertiveness. Although her attitude remained positive and collaborative, her gross adulation of the therapist diminished. In one session she said, "Maybe I won't get better unless I get angry was at you.“ She was less elated. She moved from a closed ward to an open cottage, and began to work in the hospital library. Occasional episodes of overt disturbance were handled by the therapist without solicitude. His attitude was one of interest, support and detachment. Patient and therapist discussed plans for discharge and outpatient treatment. The patient was discharged six weeks later. Comment: Subsidence of the changes in brain function resulting from convulsive therapy permitted a new integration of the doctor-patient relationship. The pattern of a conventional psychotherapeutic situation appeared. This differed both from the original negative and the artificially induced positive transference relationships. �WW Therapist's notes as an index of relatedness: Following the conclusion of the study, another index of the psychotherapeutic relationship was investigated. Rioch (9) has described the use of the volume of staff progress notes as an index of staff-patient interaction. The therapist had kept his notes in a standard stenographic notebook throughout the treatment. A gross count of the number of pages of notes per session could be made. This is represented graphically on the chart. As no written notes were taken during the occasional tape-recorded sessions, these were omitted from the chart. The change in the therapeutic relationship is apparent from the abrupt and sustained increase in note-taking from the hhth day on. This coincided with the first gross change in the electroencephalogram. The notes taken by the two other psychiatrists in the supervisory meetings followed a similar pattern, although with peaks of note-taking at the onset and again at the waning of induced neurophysiologic change. �DISCUSSION: primary purpose of this report is to demonstrate the value of a detailed investigation of psychotherapy when somatic therapies are temporarily introduced as adjunctive procedures. One of the difficulties in the objective study of transference and countertransference phenomena is the The absence of a quantifiable and controllable variable. Adjunctive therapies, somatic or pharmacological, provide such a variable. They produce alteration in behavior as well as concomitant, measurable neurophysiologic changes (3, h). This opportunity has been utilized in the present project. For example, one of adaptation to altered brain function is a euphoric type of relatedness (5). The occurrence of the phenomenon in this case permitted us to observe how the induction of mode positive and negative transferences called forth similar countertransference attitudes in therapist and supervisor. Another illustration of this technique was our discounting of the earliest clinical change during the Bhth to h2nd day of somatic treatment. The electroencephalogram gave evidence in favor of the significance of this beginning change in the relationship. The fact that it was minimized demonstrates the obscuring effects of staff expectancies. Finally, the alteration of brain function in this course of psychotherapy was accompanied by a change of the pattern of complaints i;g. from physical symptoms to memory difficulty. This resulted in a modification �-16.. of the dependency relationship (h3rd to 63rd day). The new form of the relationship was experienced differently by the staff, with resultant change in their feelings about the patient. This effect was observed in the patient's family group as well as in the supervisory group. observations illustrate several other phenomena of interest. One is peculiar to supervision in group settings. We have called attention to the emotional atmosphere of the group, which seemed to fluctuate in accordance with the therapeutic relationship being described. Hora (7) believes that the supervises may communicate the affective aspects of his experience with a patient by non-verbal means. His formulation is that "the supervises unconsciously identifies with the patient and involuntarily behaves in such a manner as to elicit in the supervisor those very emotions which he himself experiences while working with the patient, but was unable to convey verbally." He also describes the diffusion of this effect in the other participants of a supervisory seminar. Thus he reports that, "This observation has been subjected to repeated tests in seminars where it was possible to verify the supervisor's emotional perceptions by matching them with the emotional reactions of the other participants present." Our work supports such observations and suggests the potential fruitfulness of studies of group dynamics in supervisory seminars. We have noted one change in relatedness resulting from the somatic therapy that had a disjunctive effect upon the The �-17- relationship (hSth day). The patient mentioned familiar topics "as if it were new information." The "uncanny" quality produced in the therapist and supervisor resulted from the temporary feeling that the therapeutic relationship had no history. Rapport in intensive psychotherapy depends to a great extent upon an accumulated body of shared information. Both doctor and patient take this for granted, and the inability to rely upon it may affect rapport adversely. Other patients in the study,nct discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forms of "acting-out," which were disruptive to the concurrent psychotherapy. In each case the induced behavioral change was related to the personality of the individual patient and occurred at the time of changing brain function (3). Also, in each case, there were concomitant changes in behavior in the supervisory group. The limited scope of this study does not warrant general conclusions as to the efficacy of concurrent somatic treatment and psychotherapy. We have confined the discussion, therefore, to the presentation of methodology and description of the types of observations that can be made in such interdisciplinary approaches. Our experience does highlight, however, some of the difficulties that may develop when the two modes of treatment are used concurrently. Intensive psychotherapy is based upon �-18a conviction as to the the improvement of the efficacy of verbal communication for patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interpersonal communication as the therapeutic instrument. When cerebral change was maximal a "social recovery" occurred. This was apparently unrelated to interpretation of psychodynamic factors. No increase in awareness of psychological relationships was verbalised. When the induced neurophysiologic changes subsided, there was a partial recurrence of earlier communication patterns. This was accompanied by a brief period of doubt that the modification of behavior could be perpetuated by interpersonal means alone. To some extent this phenomenon was an expression of the different conceptual and linguistic systems inherent in the two modes of therapy. It is related to the philosophical dichotomy described by Hollingshead and Redlich (6) between practitioners using somatic and analytically-oriented therapies. These considerations also arise in the use of psychopharmacologic agents during the course of psychotherapy (h). �SUMMARY: study of the effects of concurrent somatic therapy on psychotherapy is reported, in which simultaneous observations of serial changes in brain function, the psychotherapeutic relationship, and social A adaptation were made. The observations in a group supervisory seminar reflected the pattern of neurophysiolcgical alteration. It is concluded that the introduction of a measurable physiological variable is a useful method for investigation of the psychotherapy process. �REFERENCES l. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichman, F., and Weigert, E.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis, Psychiatry $1: 103, 195k. 2. Esecover, 8., Jaffe, J. and Kahn, R.L.: Psychotherapeutie Techniques with Electroshock Patients, J. Hillside Hosp. 1: 17, 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. 1Q: 516, 1957. 3. Fink, M.: A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp.g: 197, 1957. Fink, M., Kahn, R.L. and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. 81 . $2: 113, 1958. Hollingshead, A.B. and Redlich, F.C.: Social Class and Mental Illness, J. Wiley & Son, N.Y. T953. Hora, T.: Phenomenology of the Supervisory Process, Am. J. Psychother. $1: 769, 1957. Kahn, R.L. and Fink, M.: Changes in Language During Electroshock Therapy, in Pa cho atholo of ZuSEn, P. 3. §§3., Grune and Communication, Hoch, & Stratton, 1958. Rioch, D. McK.: Research in Psychiatry: Certain Problems and Developments in Multi-Disciplinary Studies, T.W. Salmon Lectures, 1957 (in press). N.Y. Acad. Med. �noditiaation at Pnynhothornputtta frannaettonu By tltnrod Drain Junction "tt‘, H.B.. E. 3.00.7.7, K.D., R. L. “hn, Phonu ‘fid fl. link, 8.D. ‘0 Iron thy aspartulnt a: Bxportuonsal Psychiatry, £111.16. loupttal, 61.“ O‘k.’ L.I., ‘1’. Aided. in part, by tho Foundationn' thud tar Research in Puyehiutry (SénlSl) and grant 3-927 of the rational Inu‘itutc o: nuntnl lualth, laticntl Inutitflna of nculth, v.5. Public loalth aarvtoo. Tho aunt-tango or 31:: 83th.: sander: :nd Hrs. Anita DCIIOI, who participated auttvoly in tho tcatnnra, 1. gratitully acknavludgod. III 10/30/59 �this rlport ta darivnd from a luporvinory suntan: in which thn affect. at convultivc trontncnt upon p;y¢ho~ thornptut1e trananotxanu war. studiud. rho thornpist'u abrcrvntinnl havo boon douoribod in u previous publicattou (2). in: proaoat pups: accorthcu thn pronoun tr.u tho franc at ratcrcaco at tho atporvisor and ouporvinory group. It 1! intondod an n aonplonontnry hot or obaorVItioua at thin nonbinud therapy. In addition, ouncurront neurophyulalogia ant: arc includad, of vhich both thornpiat and supervisor var. unnuuro. this udditiouul tram. of xutorenoo may broaden the underutnndiug or eurtnin phonononu 1n the pattcnt-thcrapint, and therapiltulnparvitcr tatcraottona. to don-natratt that the intraduction a: a unanurablo phyuiologiaul variablo 1: a ncctul Itthod for the turoatixatinn a: tho payehothcrapy pronoun. Our purpaao 13 �xxggan: tho ootttag too o uookhr oulttodiooaplioory ooporvtoovy oontorouoo. Ioalndod in tho group rotor o) tho thoroptot (3.8.), (at tho ttno o senior rootdont in poynhiotrr), who proooutod tho enoo uotortol; h) o ooatol worhor who roportod tho rooponoo at tho yotiont'o fonily; a) o poyoho~ onolyot (3.5.), who doolt mainly with tho d1doct1e oopocto of psychothoropoutte toohniquo; d) o poychologiot (3.3.). who studiod tho eoooo indopondontly3 and o) o nonrepoyohiotrtot (8.!t). who coordinotod tho diocuooion. rho loot tot nooboro wart ovoro of tho connooitont chouxoo 1: phyoioloxtc honouroo, one olthough thlo intorlotton infloouood thotr quoottouo, tho doto woo not introdtcod ot thooo toaforonooo. rho octuol oo-otlo trootoout woo porforood by o phyoioion who not o porticipont ot tho nootingo. Tho pronodoro woo intoruol, with tho thoroptot toktnx tho lood 1a prooonttnx hto vorbotto uotoo of tho poyohothoropy Tho ooootoao. ordor of tho aooo roporto and tho ooount o: tiuo dovotod to oath woo not prooorihod. Iolloring tho opoutohoouo oooo pronoutotion, morn dironttvo quootiouiag II! Introdoood, otood ot choritytnx and rolottns tho intoraotioa proooutod by thoroptot ond ootiol vortor. woo �803130?! the hintertee e! the enhaeate at thte study were reported in e previeee publication (2). In thie report e detailed enelyeie of Gate #3 (0.0.) 1- presented es meet illustretive or the nodixieation of interpereomel trenaeetiene by extered hrein function. This petieut, e hh your old vitae end nether of e 12 yeer old eon, bed been ednitted to the hoepxtel with eyaptone of depreeeion, enxiety, enorexie, varied phyeicel complaints, end feelings é: unreelity end isoletien. In psychotherapy eeeeione she would reiterete her difficultiee in e cenpleining pattern, repetitiouely illustretinx her inedequecy. During e three nonth period an ilpreveaent occurred end A couree at electroehoek therepy wee reeoeeended. At thte Junotute the patient wee included in the preeent study. vsg§;!:c_rnxnarr: cheervetiene eede dertn; the period of eenetxe therepy ere depleted in the euconpenying ehert. During the 9k deye of supervision tee different levee e: eoeetie treetleut were utilieed. This procedure wee pert e: e heepitel-wide eonvuleiveoeubeeavuleive control etedy then in progreee, in which therepiete were enewere at the introduction or enheonvuleive pheeee e: treetnent. Fer the tit-t treeteent period (21 deye) the patient received eebeenvuleive electra-etlaeletiou with pentethel �‘h. pronodiootiou. roolvo oooh trootnonto ooro givon ot tho roto or throo por rook. lo ohonxoo in tho ooohtitotivo looooroo o: 336 olov oovo ootivity (3) woro monitoot during thio tins. fhio poriod oorvod to ootobiioh o booolino for tho hohoviorol oboorvotiooo and tho oxpootonoioo of tho otott. In tho oooond trootnoht porioo (29th to 59th doyo), grand nol oonvoloiono uoro ihduood thrioo wookly for o totol o: 1h trootnonto. In thio ported, nioiaol dogrooo of EEG ohongo ooro rooordod on tho 37th doy, ond uodoroto dogrooo. woro shown on throo oohooqoont rooordingo. foolvo doyo ottor tho toroiootino o: oonvuloivo thoropy, EEG slow wovo ootivity ooooidorohly dioioiohoo. this intoruhtioo woo not ovoilohlo to tho thoropiot or tho ooporvioor until ottor tho ooholuoioa of tho otooy. woo -fi.‘.‘....‘..0fld.fl. Pic. 1 about horo -DO“-....‘..O-.... rho potioot woo ooon in poyohothoropy ooooiono throo tiloo vookly throughout hor hoopitoliootion. Hhilo tho thoropiot II! ovoro of tho ooooorront oonotio trootnoot, ho woo nnovoro that oohoohvoloivo oti-olotion woo givon initiolly, ohd of tho ohonso to convoloivo thoropy on tho 29th doy. thongoo in tho potiont—thoropiot rolotionohip oo roportod in tho ouporvioory lootiogo oro oonnorisod in tho ohort ond oro dotoilod in tho following ohoorvotiooo. �0188371 ;tt ,IS! 2: 12th dgz; firot throo vookl tho thoropiot did not dioeuoo thio potiont in tho ooporvioory group. othor potionto oooupiod tho allottod tino, in opito o: o rooolutioa to ‘ Daring tho conoidor oaoh potiont vookly. Gounonts In totroppoot, tho toiluro to roport this potiont 'o pragrooo coaotitutod o pottoru or ovoidoneo. sonotiu thoropy hod' not Iodiriod tho potiont'o word bohovior or tho doctor-potiont rolotioaohip. Both voro tho onto to in tho initiol Iontho a: hospital- iootion. rho nonrophyoiologio indieoo voro unohonxod. 20th to 22:4 dog: rho oooo history firot prooontod in tho looting on tho 20th doy. rho thoropiot roportod no oltorotion in tho potiont'o clinging, whining, holplooo ottitudo throughout tho proooding throo uontho. Errorto to oxplorovhor problouo in 1171:; uoro blookod by phyoieol oonplointo and by rocitolo of woo Ho woo loft of toiluro. tooling: guilt, oolt-roprooch, littlo oponiag £0» counont. In tho throo ouporvioory nootingo during thio poriod tho group otnoophoro woo ono of diluenrogonoat thou thio eooo too prooontod. the thoropiot roportod inpulooo to oxhort tho oud �.6patient to participate in ward activitiee, and reacted to her prereeeieue e: helpleeeneae with the feeling that *ehe eaan't trying.‘ eoneidered The taniiy reported that the patient her doctor "tee reung,' retleetiac he: attitede e: repreaoh toearde theee who were unable to help her. He, in turn, felt that eke wee 'threeiuc up he: hende and giving up.“ I gelnenta the therapeutic iayaeee eae eapathieaiiy oeuaenicated to the creep by the cane repert. The transactiene during thie peried were typically theee leading to referral of depreeeed patiente for eeaetia (i.e. noncverbel) treataent. they nay be toileee. Verbal nethede ee eharaeterieed er therapy are inceepatible with the affective made at cannunieetien adapted by each patiente (1). The deetor'e atterte to help are not eat by a eellaheretive reepenee, and he feels treetratea. the ineatieble qeaiifiy er the patient“ dean“ a1" «11. berth deteueive veeetiene in the therapiet. Baring thin period the node or eeaatie treetaent wee chanced tree eaheenveieive to eeafileive. The elinieal etatne and therapeutic relatienehip, hetever, eentiaaed unaltered. Perhaps the lack of the expeated reapenee to �.7. eenetie treetnent eentributed te the thereptet'e dieeeuregeuene. le eeee-ed thet cenvuleteue nee been induced from the euteet, end hie peet experienee bed led hie te entteipete e elinieel reepenee by the fourth week e: teeetlent (3). to ytnd 63!. In the aeetinx thet teak pleee en the 38th day, e “alight chenlef wee reverted; Although the,pet1ent tee etill revinxi 1n therepy eeeeiene, it wee elee renting, 'eryinc, neted thet 'ehe pertteipetee 1a eetivlttee e 11$t1e bit note, but net naeh.’ {he therepiet end the group discounted ehie ehenge an eeeiel relet30nehtpe. the tiret eyeateueoee oonpleint at eeeery dittieelty'vee elee reported. «age: cennent: the Sir-t evidenee er eeurephyetelegte eheuge ep’eered et thie tine. the 3E6 teken the any prter ‘0 thin leetlng eheued e Wm eixuitteent inereeee in slew wave eettvxty. In the neeting en the hSth day fine therepiet reyerted e full perehetherepy eeeelee fer the rivet tine. Re deeertbed the pettent ee 'brighter,’ ”with e little eere reuse end lipetteh' end 'eetltng.‘ rue deye lefier her need wee meted ee 'eupheric.‘ Phyeteel eonpleinte eeeeed end were replaced by aenpleinte of forgetting. The therepiet deeeribed thie ee e *oeeeetteu e: ceapleintng.‘ concomitantly, the effective �.8. expreeeien wee repleeed by e eere intelleeteelieed e: pettern. Ineteed e: etetiux “I here to cling to I: nether“ the petieet eeid '1': dependent en ey nether ter may thus" Thie eee deeerihed ee 'telhina ehent her dependency in e different eey.‘ Another cheese in eeneenioetion pettern eveked 'enoenny‘ reeliuge in the therepiet. fie eteted that the petient 'eentiene things we hed telhed ebout ee it it were nee in:ereetien.' With theee ehenzee,there wee e ceneeeitent iaereeee in the petient'e eeeiehility end perthipetien in heepitel eetiritiee, end e dieieetien er her clinging to the teeily end therepiet. whe euporrieory group etueephere eleo changed free one e: hepeleeeneee te well-being, with increeeed aching, eniling end enineted participation. 0n the 52nd dey the therapist reported thet the petient are-led seductively end epplied treeh rehe-up for eede l V her eeeeiene. She expreeeed toelinge or treat end enjoyment e! the neetinge. the doctor experienced einiler eeetiene, end ere eexer to repert the pregreee of this oeee. fhe patient wee new 'upeet' beeeaee ehe couldn‘t resell her prehlene, end the therapiet noted that he wee inclined to e directive “re-ether. He end she of leee coupleined memory role. ettenpted felt in:' to relete in e triendly, reelieticelly gratifying we: to prevent further peyuhologie exploration. A greater deteehlent from her family wee expreeeed. Seeiel ilpreve-eet continued. the felily eteted thet ehe no ' �.9. long-r onunidorud the doctur 'tao 1033;,” but rnihor a 'guiding nasal.“ Gunnontt Eh: ubrupt, groi- ahnngo in tho picturu parnnllud tn. duvolopttnt or anxiaun physiological change. The 61131031 rayorda during this poriod uhovcd u nodcratl ducts. of slaw wavo activity. Tho udvunt or pcn1tsvo tooling: olicitod -ruciprocnl elation: in thn thordpist which 1n thu supervinery cautions. caununicntad utrt tho attoat was alpsthic:11y rotluctod in nonbiru at the conxcrcuoo group. (rho clinical pioturc roaonbltd that at a 'trtunforonac auro.') throo EEO It 10 .! iattraut that I chant. tron "physical“ to *nnncry’ eonplnintt was dolarlbea 1: I ‘uoaustton at oonpluiulnx.’ Pcrhupa the notary dottctt, an expootnd oonconittnt or oonvulntvc thurnpy, 1. nova acacptablo to the lint: becauau 1t 1- underatundablo. Thu: £001 a rnaponaibility for this tynptoa tad nun tuthorttativoly r033Iuro thu putlatt that it will be transiant. in lifteticnuta dapcndoncy any .100 be more tolorah1c thin a hastilt out, when ucconpnniod bi erutifyinz oaeinl oupccinlly improvonant. Tho langungo change: 3:. indicative of a nor. definah‘d, intqlleotnnltacd ooununicntioa �~10» of taniltar content (8). Th. patinat nor ”talked abaut' ruthor thnn cunting or “acting out.“ This nav 1:33:33. patttrn can nor. in kooping with hat background or oulloau uduaataoa, and the thcrtyint's inplioit unpoetutions (9). In contrast to her prior node of cuuuuntcntton 1t canned ta to nor. noipgtiblo with a purchaauulytically-oriontcd approach. The concomitant dovslopnant of honor: difficulty, howovur, perpetuated thc cantnttully nonninalghtrul thorapuutic nitnnticn. 65th to 12nd gig! than ported followod tho termination a: sciatic trontannt. fhe patiout Inverted a ”auddoa £90115: ’1 3011‘ cvnrouuuo.“ Euphorta and gentry attticulty wit! a. 19:10: tbscrvud, tad an amnion. ltlt. :uportcnod. Payohothortpy toutinnu worn nhnrtctor1s¢d by morn crittcal appruisal at hot 11:. uitunttnn. tar tho first txun tho doctor 3:10 tho Thu tho in auctions. tine group voiced ton. txtra pattont unacorn that aha wt. "olippiuc back.9 thn thd patient. .ccactoually talkud positivolr nbout euro-r, cutncipttiou tron lather, 333., the tharnpist tolt called upon to rospond optiniutically, rather thug to explore. Thurs vs; I rtvivul or old canplnintn. At thin paint, tha supervilar tad thortpist roviovod A nuonion. recurrence of tho ourltor a tnruvroeordcd thtrupy �vorbal putt-run could indeed be tdcntitiod. nauuvur, than. coourrod 1n airuuunoribad fashion ruthor than throughout $30 intervinv. The «wont: nutcccdunt to Inch parlodn worn attainad Ind tha adaptivh nature at the racnrront n£tocttvo pnttornu haunt. apparant. coununt: tundra during this patina showed a considorlbla duoranau in slow The EEG activity. tn: : cauconitant rocntabllihnant at IOII of tho connunieutlon pattorna which pracedod tau period or altered brain function. Th0 coutarsnco group responded with nnxtoty rotlootod in the solicitouunnul of tho thortpiat in pralongtnz in: sonoi¢ns. the phononunan obsorvoa ta ta. nnpcrvitory stain, for luck at a bottnr turn, may be callcd 'alcetronhack dupcndoaoy.‘ statoncntn were lid. in tha matting such us 'cho'u slipping buck,” "no.4. ucr- troutnonts* and ”taprovanont not holding up.“ In... Itatcnonts inyly that the hoitilcodcycndaat panama mm being thought a: primarily as a nonalcgie flntity, ”a dopraauiun,‘ rtthor than a node or Bantu ralatodnunn. Porhapa hcuuuac hohuviorul chnngo had not boon attcctod by psychologic Incas a1930, it new conned tottlly dopondout upon thc alteration in acrcbrul function. yaw. Thurs �1-1 a. rha chins. 1n intoraction was «Qneoptltltibd as th: roanlt of the brain syndroan, find not an a function of tho doatcrupntiont relation. Edna. tho graup'h «acacia... on 6h. ahip. sporadic rcappcaranco or praeouvrloivc puttornt. Thu dotatlcd oxnuinattou of I t‘po~racordud caution rqvualod ti. ndqfitvo functtun or this not. circumacribod occurrcnon of the canvlaiatt, tad the phnnancnon of “electroshock dupnndunay' Vt! not obnorvod in Inblcqucnt group nactinga. 12rd to 25th 4:13 baring this ported a not. stubln yuyvhothorupcntxc rtlatitnlhip was upparont. the ptticnt boots. nor. tndcpnndcnt and d£lcnalad prohlcno a! euupltauoo and uolt~aalurtavoucla. Although hot at$1tudo rousinod petitivo and eollnborutivo, hi! tdlllttin a: the thcrapiat diniutuhod. In on. 3.3.1.: ch. :31! *luyho I vantt xnt buttor union. I get that: at run.“ an. ant lens olntad. 5h. ncvcd troy eh. cloned ward so an upon 00:113., and bugnn *u Ibrk_1a the hospittl library. Occulionll Ipinodul of ownrt disturbance war. ‘run‘cd by tho thcrapiut washout salinituda. n1- attitude us: an: of intorant, tappart sud datuchnont. 1a.: dtnouusod plan: tar dischargo and .u‘pntlunt ‘ruutnnnt. �-13. Gemnentz Suhaidanaa at tha chances in brain fanation raaulting tron_cénvulaiva thorapy permittad a not iatagration or the doatnrfi patiant ralationahip. Thu pattern or a céhvanttanal paychotharapaatic attuatiau appeared, which airfarad both fro: the crazinal negative and the artificially induced poaitiva relatianahipa. rharantat'a nataa an an ands: a: relatedness: Following tha cancluaian of tho study, anathar 1ndax at tho payehotharapautie ralattouahip was invaatigatad. flinch baa daaaribad the use of tha volume or stat: pragraaa nataa aa an 134a: at ata£t«patxant intavactian (10). Tha thorapiat had kapt ht. natal in a standard atanoxraphic notahoak thranzho out tha troatnant. 1 grant count or the aunbar of vagaa or nataa par tau-ion vaa mafia, and in rapraaantcé graphically an aha chart. lo written meta. vara takan daring occasional tapa¢raaardad aaaaioaa, and thaaa ara anittad from tho chart. Tho chance in tha ralatienahip is apparant from tha abrupt and paratatant incraaaa finnota taking from tho hhth day. this aoiuuadad with tha tirat groan changa in tha alaatraanoaphalogran. Tho nut-a takon by aha two ethar psychiatriata in tho unparviaory naatinga rallauad a aiuilar pattorn (not illuatratad), although with peaks 6! actoatakinz at tha onaat and again at the waning or inducad naurophwrialagta changa. �.1h. Iscusa I!hso vaport dasnrlbts an tnvonttgatian at vlrrhat&orapy adjunc$1vu procuauru. an intracuucd as to aauugio thcrupy than and dtftiuulty in fiho fbj.¢$1V! Itudy of puyuhotharupcuttc centrallfiblu ana traanaatttaa it tho abnsncn a: I quanttraablt pharnnool¢gtanl. Ind tauntia thurapton. variablo. ,gdduncttvo bohuvior in altorgtioa product gravid. tank 1 varinblo. racy was. h). (3. change: tn wall I! uniqurablu naurophyaiolauic prudent. «#111334 an. in hula In pnunt urw‘utty 1. tunntluu brain altcrud ta Ixtnpln, oat Iona a! tduyta‘ion tho Eh. at coaurrauco (5). r.1ato¢ncsu 0t typo tuphurio I haw %o inducud obicrv. an phfinanouun in this 0:30 purai‘tcd 9511 forth uttifludto ‘nd accltivo altnrantioi .1 pontttv. Anetta: 5nd uupcrviuor. ‘hcruplut tn llnilnr uttitudca 011n1¢:1 unrlxunt 0: tho discounting ti. alluatrnfitoa wt; The Ilcutroa hand or truntlnut. fihth «:1 to ahnauo during thi beginning this .1 an. :tgnatteuueu instantad ouctphnllarun miniutsud 1t thut Th. tau! fill 13 tho ralnttonuhip. chnng. dcnnunfirt‘oo tho intestine «(Stats 0: uttxt .xpcotancicc. by «coup-uni“ um mum.» brain of ”3.111,”: from uyaptcns phywicul 1n fiulplaznt 5¢3,, puttarn. oh‘nxt : the of 3 tern Thin in ruaultcd ant t0 nounxydtstiauzty. which oxportonocd was 63rd day) to (hjrd dcp¢n¢¢u¢y rtlatlonahlp shuns. rcuul‘nnt with tun supervinary otatt, atttortntly hr nine was rhtu 0:3:ct thy p&t1ant. ubant in thoir :nolinsa w unfit“: �pstient'e resily group. The oheervstions else illnetrete e phenoeeaeh supervieion we heve celled in to settings. greep peculiar sttention to the emotional steoephere or the are up, which seemed to fleateste in eoeerdenue with the therepeetie rea Here the (7) described. thst suggests being istieaehip observed in the supervises say eoanunisete the effective sepsete or his experience with the pstient nenaverhsliy in the eupervisevy nesting. his ternaletien is thet *The supervises unconsciously identities with the petient end invelentsriiy hehevee in such s esnner es te elicit in the supervisor theee very esstiens which he himself experiences ehile working sith the petieat, but use unehle to convey verbally.” He elso describes the diffusion at this extent in the other psrtioipenta or e supervisory sesiner. thus he reports that 'rhis ehservetien hse been suhaeeted to repented tests in eeniners where it use possible to vsrit’ the euyervieor'e enetiohel perceptions by sstehinx thee with the eeotiehsl resctiens or the other psrtieipents present.” Our work supports such observetiene sud suggests the patentiel truitrhlnees or studies or group dynsnies in supervisory eeeiuers. we he's noted one ehenss in reletednese resulting tree the seentie therspy that hsd e disasuetive effect upon the rsletiehship (age dsy). the petieet mentioned teeilier tepiee ”es it it were new infatuation.” the 'nnoenny‘ queiity predeeed in the therepiet end supervisor resulted from the �.16. had no the relationship that therapeutic temporary feeling history. Rapport in intensive psychotherapy depends to a great extent upon an accuaulated body of shared inforaatien. loth doctor and patient take this for granted, and the inability to rely upon it nay affect rapport adversely. Other patients in the study, not discussed in this paper, showed different patterns of response. These included transient paranoid episodes, hyperactivity, erotic, exhibitionistic and other forns of 'acting-out' which were disruptive 1 to the concurrent psychotherapy. In each case the induced the behavioral change was related to personality of the individual patient end occurred at the time of changing brain function (3). Also in each case there were conconitant changes in behavior in the supervisory group. Our experience also highlights some of the difficulties that nay develop when the two nodes of treatment are used concurrently. Intensive psychotherapy is based upon the conviction as to the efficacy of verbal communication for iaproveaent of the patient's adaptation. In the case reported a trial period of psychotherapy had been ineffective in altering clinical behavior. The introduction of somatic treatment represented a decision against exclusive reliance upon interWhen communication the instrunent. as therapeutic personal cerebral change was aaxinal a “social recovery“ occurred, apparentlr unrelated to interpretation of psychedynanic factors. When the induced neurophysiologic changes subsided, a recurrence of earlier oonnnnication patterns led the therapist to doubt ‘ , �.17- that in. iapravaaant oeuid ha parpatuatad by intarparaoual aaana aloha. to can. extant thin phanauanan was an expraaaioa a: difllrint aancaptual and linguiatic ayataaa ink-rant in in. two node: a: thorapy. It in ralatad to tho philaaaphiaal dichotomy daacriboi by Haliiaxahaad and nadlieh (6) batwaan practitionara using aoaatic and analyticallyariaatad Sharapiaa. I 8931‘!!! i atady a: concurrant aquatic and payohatharapiaa ia taperiad, in which ainnitanaoua obnorvationa of atrial ”in. brain in function, omgu paychothanpaatio ralatiouahip and social adaptation var. Iada. rho ohaarvationa in a afonp aaparviaory salinar ratlaatad tha yattarn or natty; phyaiologia altaratiou. It ia canciudad that tho introduction or a aaaaarabia phyaialosio variable in a aaatul aathod for investigation at intarparaonai ralaiionahipa. �-13. BEIEREIGES 1. count, 1.1., frusn~801¢hn&un, 3iklf, 0., x.n., and Roigzrt, 3.: A: latch-ido‘stugy c§£r:01vo 1., cases .1 Han ouncprunl vs Pay: as a, Ila a g; 103' 1951‘ cohon, u, o queovor, 3., Jntfo, J. and Kuhn, R.L.¢ Payehnthcrnpoutic foehniquoo with Eloctroahook Pattontl, logz.‘1u 17.>1958. 3. rink, J, Hill-1d. l:hn, R.L.a Relation a: nun bolt: Activity Quantitativo to Inhaviorti Responao in Electronhoak. Soraul stadium, A.H.A. Arch. laurel. & Pnzchtat.lgu H. and 516, 1957. h. rink, Emailed Theory of the nation or Phystodynaaic l l.: ibtrnpiufi, J, Hillside 30.2. g; 197. 1957. 5. Pink, l.‘hxnhn, R.L. and aroon, H.c Bxporinnntnl Studio: of I nloctroahoek Fractal, Bin. Not. all. 32: 113, 1958. 6. lalliaglhand, 1.]. and lodlieh, 1.0.: Social Olunl tad flinttl Illnuln, J. U110: & Son, . ., . 7. Kora, 2.: Phononsnology 0! ‘ho Supurvisory Precast, “O J. chhothor. E" 769, 1957. 8. tuba, 8.L. and rink, x.s chanson 1n Lungnngo During Eltatronhock rhor‘py, 1n Palahgfathologi or connnnieatl n, Inch, P. an I a, . o 3., Gran. E 3!:35‘33, I956. (aha, 3.1.. Polltck, H. and rink, K.: sociopuycholocic Aspects a: Psychiatric rroatnnnt 1a a Volunttry xcntal noupital, 1.3.5. Arch. Gen. Pazehiu . (1n proul). 10. Hal-I ROI-arch 1n Pcyuhiutryt curtain Prohlonu sud Dovclepncntn in Hulttufiiaaiplinary studion, 2.8. Stlnon zocturor, l.!. laud. lad., 1957. kiosk, 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 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 Modification of psychotherapeutic transactions by altered brain function. Am J Psychother. 1961 Jan; 15:46-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-49-015 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 Jaffe J.; Esecover, H., Kahn, R. L.; <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 and two [preprints]. Reprint from AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. XV, No. 1, pages 46—55. January, 1961. 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/8ad71ef7a3c44154da4264a3d36d2625.pdf d939faed36329ffba731bbff9e10004f PDF Text Text An Objective Study of Communication in Psychiatric Interviews Joseph Jeffe, H.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Read at the New York N.Y. Divisional MBeting, A.P.A. November, 1957. Supported by Grant 565561 of the Foundations' Fund for Research in Psychiatry. 14’! 10-1h-S7 �The clinical interview is the psychiatrist's primary tool for the diagnosis of psychopathology, the modification of behavior, and the collection of research data. Only in recent years, however, have the actual transactions which comprise the interview been studied objectively. Investigators of the interview have usually employed systems of content analysis (1), which are based upon various theories of psychodynamics. Currently, there is increasing emphasis upon formal aspects of interaction such as temporal patterns of speech (1h) drastic change of subject (3), PHYSiological relationships of the participants (2), grammatical patterns of language (S, 6, 9), and speech disturbances and silences (10). These aspects, in contrast to content categories, are relatively independent of theoretical preconceptions, and are more readily quantified and studied statistically. In many investigations of these formal variables, however, the total context of the interview. These approaches neglect the fact that the psychiatrist is a participant observer, i.e., a significant variable in the interaction (11). Others have attempted to control this variable by means of structured interviews in.which the doctor's contribution is standardized patient's communications are abstracted from the according to a predetermined experimental design (6, 7, 1h). These structured situations delete the very quality of living relationship that is the ultimate concern of the psychotherapist (7). methods of verbal We are in need of interaction analysis that neither preclude nor prescribe the doctor's clinical responses. The this paper is to present a method of interview a) is objective and quantitative, b) preserves the purpose of analysis which �.2... natural patient-therapist relationship, and c) treats the interview as an integrated system of interpersonal communication. This is accom- plished by including the doctor's usual clinical behavior in the data to be studied. the The raw material is not the patient's speech, but rather total verbal output of the "two person" or "dyadic" group. �Method: tape recorded interview The is precisely transcribed, without regard to the speaker of the words. Careful attention is given to subtle repetitions such as "I - I mean," "well as - as I say," polated expressions such as "you know," The inter"so to speak," "as I said," etc. and to transcript is then arbitrarily divided into consecutive units of 100, 50 or 25 words depending on the discreteness of the phenomena to be investigated. Thus a unit contains contributions of words from either doctor or patient alone, or from both in varying proportions. The measurement applied to these units of dyadic Speech is the typetoken-ratio (TTR). This is an index of the balance between repetition variety of words (12). The TTR is the ratio of the number of different words (types), to the total number of words (tokensL in a sample of language. For example, in a 100 word sample the repetition of the identical word 100 times in succession would produce the lowest and possible ratio of .01 of 1.0 would different result if (l type/100 tokens). The highest possible every one of the 100 successive words were (100 types/100 tokens). These extremes of stereotypy and diversity are rarely encountered, situations (8). The i.e. "word-type," ratio and then only the numerator of the in grossly pathological TTR, is arbitrarily defined. All words are different which are pronounced or spelled differently. Thus, ive, gives, gave, given and gizipgfl are considered different types, as are "know" and "no." Vocalizations not clearly " �.u-‘ identifiable as which is words are omitted, with the major exception of "mmhmm" a frequent utterance of the interviewer in our records. Contractions are retained as single words, but vulgarisms such as "I dunno" are edited to read "I don't know." The TTR scores is calculated for is graphically plotted, additional precision, the units may be advanced 25 words the last half at unit each as and the illustrated in Figures may be first half unit. This often smoothes the resultant curve. is illustrated in Figure 3. TTR have in a single person's language (12). 1 and 2. For overlapped, e.g. 50 word units a time, so that each unit of the preceding and the Previous studies of the pattern of consecutive is composed of of the subsequent The overlapping technique dealt with the overall average The sequential pattern in dyadic language. present method studies the �Observations: In the last eighteen months approximately sixty recorded interviews this method. The material includes forty patients in all diagnostic categories. The dyadic have been inveStigated by found to be sensitive to a variety of clinical TTR patterns have been phenomena (8). This report illustrates the changes in language interaction occurring during the course of hospitalization and therapy, as well as changes in rapport in individual interviews. and defensive operations A - andic TTR Pattern in Clinical Change. first Figure 1 shows the pattern of the three separate 1500 words of interviews during the clinical course of one patient. The doctor is the in each. This case same was selected as an unequivocal example of gross clinical change. In the first interview the patient was agitated and depressed. She refused to be seated and paced about the room, reiterating stereotyped self-recriminations, crying hysterically, with marked pressure of speech. At the time of the second interview, following a course of grand mal electroshock, the clinical picture was grossly altered. She was less agitated and complaining of a memory appeared more deficit. cooperative, although withdrawn and On alert, poised, conversational insightful. She had been The TTR of later, discharge two months and, she at times, surprisingly rated clinically as "recovered." consecutive 25 word units of interaction, for each of the three periods described, is graphically represented in Fig. 1. Consecutive points are connected by lines so that the fluctuations in the graph reflect the difference between successive scores. The mean TTR for �~6- the complete interview from which these samples were taken is represented line through each graph. by a horizontal strates The a The fluctuating equilibrium about the pattern of scores mean. interviews of these three successive stages changes. The mean demon- show a sequence of level of the interaction is seen to increase as the clinical status changes from psychosis to "recovery." There is a concomitant restriction in the amplitude of the pattern, i.e. a decrease in variation about the mean. Comment: The sequence of change in the TTR pattern parallels the progressive in interpersonal communication that improvement clinically. was apparent This suggests an approach to the quantification of clinical change, defined as an altered pattern of verbal interaction in the interview. B - in Communication‘within the Interview: Changes Figure shown 2 is an enlargement of the in Figure 1. first of the three interactions Here the sequence of changes within a.single interview are examined rather than comparing the patterns of successive interviews. As described before, the patient was speaking continuously in a disorgan- ized affective outburst. mflrich The lower line indicates the the interviewer participated. Following remarks, units 3 - 12 fine 25 word units in doctor's introductory represent the patient's uninterrupted speech. Wide oscillations of the pattern are prominent. From samples 13 onwards the doctor made repeated efforts to communicate with the patient. Two independent judges reviewed the transcribed protocol, and both identified three areas in which there seemed to be an understandable, rational �-7interchange between the participants. These periods are labelled "rapport" in the upper line. tions of the pattern are much During these three periods the constricted. Compare oscilla- other non-rapport periods such as 23-2h and 39-hl, in which the doctor's participation amplified the oscillations. Cmmmnh This illustrates a method of quantifying interpersonal phenomena, such as the degree of "contact" with a severely disturbed patient. The affective pattern in this patient represents the psychotic integration, for this reason, the occasional occurnnces of conventional,rational conversation are described as periods of "rapport." The restriction in and the amplitude which characterizes these periods is similar to the overall pattern at the time of "recovery." 0 - Analysis Figure 3 of a Complete Interview. initial demonstrates the dvadic TTR analysis of a complete interview. This interview is the discharge evaluation of a patient had been hospitalized following a months of hospitalization, she who bizarre suicide attempt. After seven had "improved" clinically. This took the form of a hypomanic mood and a gross denial of her severe emotional conflicts. word The interview units advancing by is scored by the method of successive 50 ZS word steps. The mean TTR for the interview is shown by the horizontal line drawn through the graph. The pattern falls into several natural segments. There are two areas in which ten consecutive points fall below the mean (areas h and 7). These are unusual in this interview. There are also areas of gross deviation �~8from the mean (such as area determine our criteria for 2). Thus we allow the phenomena for persistent changes in the TTR to be studied. In general, we look level, gross trends or sudden shifts. Several of the deviant areas are described to The objective pattern to illustrate the method. interview begins with a hypomanic monologue in which the patient visit describes her successful home, her euphoric outlook and plans for a rosy future. Area 2 has been delineated because of gross deviation from the mean. The beginning of this period coincides with a change of topic to her plans is interrupted by a period of confusion as she tries, with some difficulty, to recall one of the details of the job. The end of the gross fluctuation coincides with the rationalization "I don't think I'll have too much trouble." Area h was delineated as one of the two sections in which 10 consecutive for going back to her job scores fall two days hence. Her optimism Its beginning coincides with below the mean. about her depression on admission to the hOSpital. a statement This area ends with the lowest score of the interview which,precedes by only a few words a spontaneous reference to her suicide attempt. This large deviation at the end of area h embodies the main characteristics of the following area. Area 5 The is characterized by large content of this area attempts to prove at the is how much fluctuations above and below the mean. completely on the theme of suicide. She live. The doctor's queries with increasing resistance. In the begin- she now wants to end of the period meet ning of the next segment (area 6) she stubbornly refuses to discuss the subject of suicide further, at which point she changes the subject abruptly. �-9Area 7 was delineated on precipitous drop in the the basis of TTR, criteria. It begins with ”two a followed by 10 consecutive scores below rise. Its the mean, and ends with an equally abrupt beginning coincides with a change of subject by the doctor in the form of a question about her feelings at that the "you-me" relationship, period ends Area 9 when she in the interview. This content area, 1.6. moment is at a very It The of an extremely low score enclosed by two coincides with a brief mention of a meeting with a young man who told her how well she looked. remark and her statement These examples repetitive level. abruptly changes the subject. is delineated because large deviations. pursued "I decided to get illustrate areas him It ends with an embarrassed off the topic." of disturbance or disequilibrium in the verbal interaction pattern. In contrast, areas I 3, 6,,23 and 10 are areas of relative stability or equilibrium in the record. These stable areas are marked by a different quality of communication. They consist either of a euphoric, hypomanic monologue which avoids all stressful areas. or of evasion of the doctor's probing questions by superficial rational- ization and conventional cliches. Comment: Recent reports of objective interview studies using other techniques (10), have noted that the interaction goes through a series of definable phases, which may and successful defense and the events The stressful disorganization correspond to periods of respectively. The phases demonstrated here, that delineate them, suggest an analogous fonmulation. content areas that disturbed the pattern in this final interview �also did so the initial interview seven months earlier. we anticipate that the discussion of a subject that had resulted in disequilibrium but now no longer does so, may constitute an operational on definition of "resolution of an area of conflict." �Discussion and Conclusions: Diverse and highly personal interpretations of interview data limit the growth of psychiatry as a science. Systematic study of the actual transactions may lead to operational definitions of hitherto subjective it is likely that the patterns of verbal diversification presented here constitute part of the subliminal cues to phenomena. For example, therapists affect, etc. which reSpond when.making clinical judgments of anxiety, Objective investigations of the interview must encompass the behavior of both participants since the events observed are interpersonal processes. Gill, Heuman & Redlich (h) define even the initial interview as "the diagnostic evaluation of an interpersonal relationship." Reusch (13) has recently stated have the that “observations made in social situations characteristics of a scientific procedure in which do not one aSpect is studied in detail while all other variables are held constant." The method presented here is an attempt to convert these concepts into practical research methodology. It permits a quantitative statement of various clinical phenomena occurring either within single interviews or in the course of therapy. Disturbances of verbal interaction are defined operationally in terms of the configuration of the Applications to the definition of clinical change and pattern. transactions TTR within the interview have been presented. The TTR is only one of many quantifiable aspects of dyadic speech. interaction, time reference, and relative amounts of participation doctor and patient may also be measured. Further applications of these Pace of by techniques are under investigation. �REFERENCES 1. Auld, F. and Murray, E.J. (1955): Content-Analysis Studies of Psychotherapy, Pslchol. Bull. 2a: 377-395. 2. Coleman, R., Greenblatt, and Solomon, H.C. (1956): Physiological M. Evidence of Rapport During Psychotherapeutic Interviews, Dis . Nerv. 3. Eldred, S.H., sttem, ll: 2-8. E.R., Salzman, L., Meyersburg, Hamburg, D.A., IHWOOd, (l95h): H.A. and Goodrich, G. A Procedure for the Systematic Analysis of Psychotherapeutic Interviews, §§zchiatry, l1: 337-3h5. h. Gill, M., Néwman, R. and Redlich, F.C. (l95b): The in szchiatric Practice. Press. 5. Goldman-Eisler, F. (195h): A New York: Study of Individual Differences and of Interaction in the Behavior of Interviews, Jour.. Rent. Sci. 6. Initial_1ntervigg International Universities Some Aspects of Language in lQQ: 177-197. Gottschalk, L.A., Gleser, G.C. and Hambidge, Behavior Analysis, Arch. Neur. and G. (1957): Verbal ngchiat., 21; 300-311. 7. Grinker, R.R., Sabshin, M., HaMburg, D.A., Board, F.A., Basowitz, H., Korchin, Use m? S.J., Persky, H. and Chevalier, J.A. (1957): The an Anxiety-Producing Interview and Its Meaning to the Subject, Arch. Neur. and Psvchiat., 11: hO6-hl9. 8. daffe, J.: Language of the Dyad: A Method of Interaction Analysis in PBychiatric Interviews, Psvchiat , (in press). 9. Lorenz, M. and Cobb, S. (195h): Language Patterns in PBychotic and Psychoneurotic Subjects, Arch. Neur. and Pszchiat., 1g: 665-673. �REFEREEIJCES lO. Mahl, G.F., (1956): Disturbances and Silences in the Patient's Speech in Psychotherapy, Jour. Abnorm. Soc. Psxcholu §_3__: 1-15. 11. Handler, G. and Kaplan, :‘J.K. (1956): Subjective Evaluation and Re- enforcing Effect of a Verbal Stimulus, Science, l2. Mowrer, O.H. (1953): Verbal Behavior (Ed.) szchotheragz: T1139 1.2143 in Paychotherapy. In 582-583. Mowrer and Research, New York: Ronald Press. 13. Ruesch, J. (1957): Disturbed Commnication, New York: 11.14". Norton. 1h. Saslow, G., Matarozzo, J.D. and Guze, S.B. (1955): The Stability of Interaction Chronograph Patterns in Psychiatric Interviews, Jour. Consult. P§Xcholu 1.2: 14174430. � 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/. 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Title A name given to the resource Joseph Jaffe: An Object Study of Communication in Psychiatric Interviews, 1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-8-009 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 Jaffe, Joseph 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/0a04fd8af8c99e319cfc9e14d05f3ffd.pdf d38bf0d44fbbfe5439d4cca003bd77b2 PDF Text Text CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D., MAX FINK, MD. Reprinted from Tm: JOURNAL or AND ROBERT L. KAHN, PHJ). NERVOUS AND MENTAL DISEASE 130, No. 3, March 1960 Volume Printed in U.S.A. �Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 130, No. 3, March 1960 Printed in U.S.A. CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D.,1 MAX FINK, MD. Repeated interviews with patients under— going convulsive therapy reveal progressive changes in the interpersonal relationship, which are referable to verbal and non-verbal transactions. While non-verbal aspects of communication are difficult to quantify, techniques are available for the measure— ment of verbal behavior. Using such lin— guistic methods, we have observed systematic alterations in language patterns during convulsive therapy, which were related to independent evaluations of behavioral change and to improvement. The description of these language patterns has provided a useful quantitative method for understand— ing interpersonal changes which occur during therapy. In a syntactic—content analysis of recorded interviews during convulsive therapy (6), such changes as denial (negation), qualification (subjunctive and .adverbial modifiers), displacement (person and tense), and cryptic and clichéd remarks were scored. An increased incidence of these changes in the patients’ speech was related both to the degree of induced altered brain function and to the evaluation of therapeutic response. It has been clinically observed that when the language of the patient is affected by neurologic dysfunction, modification of the interviewer’s speech patterns occur. In the syntactic-content analyses, in which a structured interview was used, the examiner’s participation was restricted to statements in the questionnaire. This two-person inter— 1Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. This study was aided by grants 56-151, Foundations’ Fund for Research in Psychiatry, and M-927 of the National Institute of Mental Health, U. S. Public Health Service. The technical assistance of Mrs. Jean Kolodny and Mrs. Ann Horowitz is gratefully acknowledged. 235 AND ROBERT L. KAHN, PHD. view group (or dyad) therefore assumed special characteristics. Interactive effects were minimized. The constraint of the questionnaire interrupted the reciprocal modification of the examiner’s speech. In such a dyad, scoring of the patient’s responses alone constituted an adequate description of changes in the verbal transactions of the two-person communication system. Judgements as to mental status are usually arrived at in less structured conversa— tions between doctor and patient. It was suggested that measurable changes in language patterns would occur even in con~ ventional clinical interviews, and furthermore that such changes would be related to those observed in structured interviews. The methods of dyadic analysis were developed (3—5) to permit a quantitative description of verbal transactions in unstructured interviews (diagnostic, psycho— therapeutic). In this analysis, the speech of doctor and patient is considered as one continuous behavior, and the measurements are performed on consecutive units, irrespective of speaker. The verbal flow of the interview is thus considered as a single out— put, irrespective of speaker. The justification for this maneuver rests ultimately on the correlation of dyadic speech patterns with those obtained by other methods, and is an aim of the present study. These scoring measures of unstructured interviews have been applied to weekly interviews with patients undergoing convul— sive therapy. It is the purpose of this report to 1) determine the pattern of change in dyadic language measures with convulsive therapy; 2) study the relation of these measures to the degree of induced altered cerebral function; and 3) relate the dyadic scores to syntactic language measures ob- �236 JAFFE, FINK AND KAHN tained concurrently in structured inter- repetitive the interaction. For these studies, both the mean and standard deviation of views. the TTR distribution of each interview sam— SUBJECTS AND METHOD ple was obtained. For the syntactic speech analyses the paTwenty-seven consecutive referrals for convulsive therapy in a voluntary mental tient was seen by another examiner during hospital were studied. On a random basis, the same intervals. This interview consisted ten patients were assigned to a control group of a standardized questionnaire composed and the remaining seventeen constituted the of specific items concerning the major comexperimental group. Both groups were com— plaint, reasons for coming to the hospital, parable for age and education; the convul- and temporal and spatial orientation (9). sive group had a mean age of 47 and 11.7 The verbatim responses were analyzed for mean years of education, while the mean the presence of syntactic language changes age of the subconvulsive group was 47.8, previously described as occurring with inwith a mean of 10.5 years of education. The duced cerebral dysfunction (6). Prior to, and at weekly intervals during investigators had no part in the treatment process, and did not know which cases treatment, an electroencephalogram was reserved as controls until data collection was corded in each patient. These records were measured for the per cent time of induced completed. The experimental (convulsive) group was slow wave activity (1). In the dyadic TTR analyses, experimengiven grand mal electro-convulsive therapy three times weekly, under pentothal pre- tal (convulsive) and control (subconvulmedication for a minimum of 12 treatments. sive) groups were compared. In relating The control subjects were treated in identi— dyadic TTR changes to induced slow wave cal fashion except that they received sub- activity and to syntactic language analyses, convulsive electrostimulation while under the mode of treatment was disregarded, all pentothal premedication. patients being considered as a single group. All patients were interviewed prior to RESULTS treatment, and in the week of the 12th 1. Dyadic TTR: A consistent change was treatment. An unstructured clinical diagnostic interview technique was used centered observed in the TTR patterns of the experiabout the patient’s symptoms and life prob- mental group. Scores for consecutive 25 lems. The patient was encouraged to talk word units of interaction in 500 word samfreely, with occasional guiding interventions ples were plotted before and during the by the interviewer. Long silences resulted treatment course (end of the fourth week). in increased interviewer activity. All inter- Figure 1 shows a graph of the TTR patviews were tape—recorded. terns for one patient. Next to each graph is For the formal dyadic analyses (3, 5), the frequency distribution of the 20 consecu— the first 500 words of each interview were tive scores shown. The change in the distranscribed in temporal sequence without tribution for this case was a decrease in the regard to the speaker. This sample of dyadic mean and an increase in the standard deviaspeech was divided into consecutive 25 word tion of the dyadic TTR. This pattern of units. The type-token ratio (TTR) was cal- change was characteristic of the expericulated for each unit. The type—token ratio mental group. is the number of different words (types) Table 1 shows changes in the group mean divided by the total number of words (to- T TR score during treatment. Although there kens). Thus, the lower the TTR the more was a decrease in both groups, the change �237 LANGUAGE CHANGES WITH BRAIN DYSFUNCTION was significant (p < .01) only in the convulsive group and not in the control (sub— convulsive) group. Table 2 shows the changes in standard deviation of the group TTR scores during treatment. There was a significant increase in standard deviation (p < .01) in the convulsive group. In the control (subcon— vulsivc) group the standard deviation was decreased during treatment. The change, however, did not reach statistical signifi— cance. 2. Relation of Dyadic TTR to EEG changes: The changes in dyadic TTR scores were related to changes in brain function as reflected in measurements of the amount of slow wave activity on the electroencephalogram. For this purpose, the per cent time delta activity in the EEG record obtained in the same week as the interview was used. While almost all members of the experimental group developed prominent amounts of EEG delta activity during treatment, none of the control group demonstrated such changes. Using the method of rank order correlation, the change in standard, deviation of the dyadic TTR correlated +65 with the per cent time of delta activity TABLE 1 Change in Mean TTR with Electroshock Subconvulsive Convulsive .92 j .xv-rp/w. p. l— .76 . /. - - with Electroshoclc Subconvulsive Convulsive ,5 3 83 ° .5660 ,0 .92 El e4 ...76 .68 .60 . .68 D—URING TREATMENT / f .76 T” text). .92 Lo 55 5“ 83 m Ea /\T I .56/6068 .76 TTR FIG. 1. .84 fl—I 6 0 10 17 During Difference treatment treatment 8.6 8.1 76 9.2 —0.5 +1.6* *Significant at 0.01 level, using Wilcoxon’s method of paired replicates. TABLE 3 Relation of Syntactic and Dyadic TTR Language ZWeasnres Dyadic Analysis: Syntactic Analysis N Change in Mean Fewer than two changes Two or more changes Change in Standard Dev1at10n 15 —0.8 —0.1 12 —3.0** +1.4* < .01). The greater increase in variability in the language measure was thus associated With the greater degrees of altered brain function. Changes in the mean T TR, however, were not significantly related to the changes in brain function (r = +19). 3. Relation of Dyadic TTR to Syntactic Language Changes: A comparison of dyadic TTR scores with syntactic aspects of the patient’s speech obtained in independent structured interviews was made. The patients were divided into those who showed two or more syntactic language changes, and those who showed fewer than two such changes, regardless of the type of treatment (Table 3). For the patients showing (19 0 N Group Pre— Significant at 0.02 level. ** Significant at 0.01 level. 0’) . —0.8 —2.4* TABLE 2 Change in Standard Deviation of TTR 25 WORD UNITS) E2 80.3 79.2 * ————“‘7 /' 17 81.1 81.6 Significant at 0.02 level, using Wilcoxon’s method of paired replicates. PRE-TREATMENT 1.0 10 treaItirient tiggffiiltegnt Difference * DYADIC TTR PATTERN (CONSECUTIVE N Group .84 .92 LIO Plot of TTR patterns for one patient (see �238 JAFFE, FINK AND KAHN two or more syntactic changes, both dyadic indices showed a significant change during treatment. There were no significant altera— tions in TTR indices for the group showing fewer than two syntactic changes. DISCUSSION These observations indicate a significant difference in dyadic transactions in the experimental (convulsive) and control (subconvulsive) groups—a difference which is referable to a consistent change in the subjects receiving convulsive therapy. The find: ings are consistent with those reported by Weinstein and Kahn (9) in their studies of patients with altered brain function. They observed increased use of the second and third person, non-aphasic misnaming, cli— chés, stereotyped expressions, condensations and neologisms. These language patterns were termed the “language of denial” and were regarded as symbolic adaptations. Kahn and Fink (6) noted similar language changes in patients with brain function al— tered by convulsive therapy. The present observations indicate that verbal transactions during altered brain function are not only more stereotyped qualitatively, as in the use of clichés, but are also more stereotyped quantitatively as in the increased repetition of words. Thus, analyses of the more formal aspects of speech parallel analyses of content. Alteration in brain function was also related to changes in the dyadic indices. The low, but significant correlation between the dyadic scores and EEG delta activity suggests that the two-person communication system as a whole may reflect neurophysio— logical alteration in one of its participants. The low correlation is consistent with previous observations that the dyadic TTR pattern is sensitive to factors other than al— tered brain function (5). Other studies of the dyadic TTR and syntactic language measures during drug administration (2) are consistent with the present findings. Administration of agents which produce EEG hypersynchrony similar to that of convulsive therapy was associated with changes in both language measures in the direction of increased stereotypy and repetitiveness. Agents which produced EEG desynchronization, however, were associated with decreased repetitiveness and a decreased number of syntactic alterations. These observations, though limited to acute drug interviews, indicate that similar changes in language patterns can be antici— pated in subjects following the chronic administration of psychotropic compounds. We anticipate that alteration in patterns of lan— guage may provide cues for the evaluation of behavioral change in drug therapies as well as in convulsive therapy. It is of significance that changes in dyadic speech are measurable when the neurophysiological status of only one of the participants is altered. This observation is consistent with concepts of verbal behavior as a two-person phenomenon, inseparable from its interpersonal context (7, 8, 10). The method and findings also demonstrate that neurophysiologic effects can be investigated in unstructured interviews and that the results may be related directly to those obtained under more structured experimental conditions. Thus, the measurement of formal aspects of language in clinical interviews may be viewed as another tool of neurophysiologic investigation. CONCLUSION Formal language measures in unstruc— tured clinical interviews were undertaken in the course of a study of convulsive and subconvulsive therapies in a hospitalized psychiatric population. Dyadic TTR (Type—Token-Ratio) measures showed a significant decrease in the mean and an increase in the standard deviation in the subjects receiving convulsive therapy, but no differences in those receiv— ing subconvulsive therapy. The degree of change in dyadic indices was related both to the degree of induced delta activity on �LANGUAGE CHANGES WITH BRAIN DYSFUNCTION the electroencephalogram, and to changes in syntactic language patterns obtained in independent structured interviews. Theoretic implications for the understanding of language changes during altered brain function were discussed. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock. AMA. Arch. Neurol. & Psychiat., 78: 516—525, 1957. J. AND KAI-IN, R. L. Drug induced changes in interview patterns: Linguistic and neurophysiologic indices. In The Dynamics of Psychiatric Drug Therapy, SarwerFoner, G., ed. C. C Thomas, Springfield, Ill. 2. FINK, M., JAFFE, 3. In press. JAFFE, J. An objective study of communication in psychiatric interviews. J. Hillside Hosp., 6: 207—215,1957. 239 J. Dyadic analysis of two psychoanalytic interviews. Presented in Symposium on Psycholinguistic Analysis of the Psychiatric Interview, Divisional Meeting of A.P.A., New York City, November 28, 1959. JAFFE, J. Language of the dyad. Psychiatry, 21: 4. JAFFE, . 249—258, 1958. . . KAHN, R. L. AND FINK, M. Changes in language during electroshock. In Psychopathology of Communication, Hoch, P. and Zubin, J ., eds., Grune & Stratton, New York, 1958. SAPIR, E. Language: An Introduction to the Study of Speech. Harcourt-Brace, New York, 1949. .SKINNER, B. F. Verbal Behavior. Appleton— Century-Crofts, New York, 1957. . WEINSTEIN, E. A. AND KAHN, R. L. Denial of 10. Illness: Symbolic and Physiological Aspects. C. C Thomas, Springfield, Ill., 1955. ZIPF, G. K. Human Behavior and the Principle of Least Efiort. Addison-Wesley, Cambridge, Mass, 1949. � 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 Changes in verbal transactions with induced altered brain function. J Nerv Ment Dis. 1960 Mar; 130:235-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-44-010 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 Jaffe, Joseph; <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 Reprinted from The JOURNAL of NERVOUS AND MENTAL DISEASE Volume 130, No. 3, 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/31ade8ace56aaea325e0c1b5774137fb.pdf 34c1dccec8167a1f1d6a23f225341ecc PDF Text Text F , Perception of Eknbedded Figures after Induced Cerebral Trauma Robert L. Kahn, Ph.D. and Max Fink, M.D. 1/? "a From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, M—927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Aided by grant Presented 11—27-57 at American Psychological Association, New York, August, 1957. NJ. �Perception of Embedded Figures after Induced Cerebral.Trauma Studies of complex visual perception man are not always clear or consistent. after cerebral The damage in disagreements may be due, in part, to difficulties in evaluating the extent of the disease process or the degree of alteration in cerebral function. In contrast, conditions in'Which there is control of the degree of brain damage, as in electroconvulsive therapy (ECT), provide a unique opportunity for studying this problem. While investigations of brain-injured populations have focused an the role of location of lesion on behavior, current studies of emphasized the been shown to EDT. have factor of individual differences. marked.variability has for perceptual (l), behavioral (2) and physiological reSPonses In addition, various personality (h) and social factors (5) have 1. C. Landis, D. Dillon and S. Leopold, Changes 2. M. 3. R.L. Kahn, ' ECT in flicker-fusion threShold are in choice reaction time induced by electroconvulsive therapy, J. Psychol., bl, 1956, 61-80. Fink, R.L. Kahn and M. A. Green, Experimental studies of the Electroshock process, J. Nerv. & Ment. Dis. (in press). M. Fink and E.A. weinstein, Relation of amobarbital test to clinical improvement in electroshock, A.M.A. Arab. Neurol. & PWChiato, 76’ 1956, 23-29; Fink and R.L. Kahn, Relation of EEG delta activity to behavioral in electroshock; quantitative serial studies, A.M.A. Arch. response M. Neurol. & Psychiat. 78, 1957, 516-525. h. R. L. Kahn and M. Fink, Personality 5. R. L. Kahn, M. Pollack ahd factors in behavioral response to Electroshock, Conf. Neural. in press). F. Fink, Social factors in.the selection of therapy in a voluntary mental hospital, J. Hillside Hosp., 6, 1957, 216-228. �-2been related to differences In the course of an in reSponse to treatment. investigation of the perceptual and behavioral changes with ECT, a convulsive-subconvulsive control study was undertaken. In this report, performance on complex visual tasks is presented. Specific- ally, the aim.was to determine whether perceptual change induced by ECT is related to the degree of altered brain function and clinical behavioral change; and whether the pretreatment perceptual pattern was related to physiologic changes with treatment. The method used in the study was the perception of embedded geometric figures - a technique which has been Widely studies of perceptual changes accompanying in recent years in cerebral dysfunction (6). employed Lethe: 1) Population: were 22 Fifty-three consecutive patients referred for studied. These included 16 men and 37 women, with ages ranging_fran to 66 with a median of h9 years. into ECT The patients two groups. An experimental group of 29 were divided at patients (Convulsive random A) received grand.mal electrotherapy with pentothal premedication three times a week, using C—h? either a Medcraft alternating current instrument or a Reiter electrostimulator. A minimum of 12 treatments were given. of treatments was determined by the supervising The number psychiatrist in charge of clinical criteria. A control group of treated in similar faShion, except that only subconvulsive the treatment unit on the basis of 2h 6. patients was 5. Battersby, H.P. Krieger, M. Pollack and M. B. Bender, Figure ground discrimination and the "abstract attitude" in patients with cerebral neoplasms, A.M.A. Arch. Neurol. & Psychiat., 76, 1956, 369-379; H. L. Teuber and S. Weinstein, Ability to discover hidden figures after cerebral lesions, A.M.A. Arch. Neurol. & Psychiat., 763 1956, 369-379; F. Pollack, W.S. Battereby and M. B. Bender, Figure-ground discrimination in patients with cerebral tumor, presented at Eastern Psychological Association, 1957. W. �"1 -3stimulation was given following the pentothal. Fourteen patients in the control group were subsequently given a regular course of convulsive therapy (Convulsive B). 2) Perceptual task: In the week prior to treatment and on the day following the 12th treatment each patient was tested with a modifica- tion of Gottschaldt's hidden figures developed The by Battersby subject is presented with a page containing geometric figure, figure is embedded it and below (fig. 1). -a simple a complex figure in which the simple The patient is asked to trace a Specific by geometric figure from the background/outlining ~The two fonns gt 2;.(7). it with a colored pencil. discriminations ranged in complexity from relatively simple to more complex. There were 25 such discriminations. was allowed for each. Performance of errors. To minimize a was A maximum of two minutes scored in terms of total number practice effect two equivalent forms of the test were used. 3) Evaluation of physiologic change: Two the electroencephalogram and the amobarbital tests of brain function - test (8) - were given to at weekly intervals during treatment. each patient prior to, 7. Battersby, Krieger, Pollack and Bender, op. 8. E. A. weinstein, R.L. Kahn, L.A. Sugarman and L. Linn, Diagnostic use of amobarbital sodium ("amytal sodium") in organic brain disease, Am. J. Peychiat., 112, 1953, 889-89h. and cit., The 703-712. �.uelectroencephalogram was evaluated as to the degree of delta activity induced according to criteria previously published (9)° ’The amobarbital test for brain disease was noted as positive or negative according to the standardized criteria (10). The results of these tests obtained during the second, third and fourth weeks of treaunent furnished the criteria for physiological change. A combined physiological index was obtained by ascribing to each high degree delta barbital test a score of one. ranged from zero to six. h) EEG record and each positive amo- The range of Behavior ratings: Each physiological alteration thus patient's behavior was evaluated at weekly intervals. After the 12th treatment, a rating for the degree of behavioral change was made according to »..none. These ratings of four classes: marked, moderate, change were minimal or not value judgments as to the quality of change, but rather quantitative estimates of differences in behavior patterns under similar conditions of observation. vpatterns as euphoria, paranoia or withdrawal might [Thus such behavior all be rated as equivalent degrees of quantitative change, although the implications of each for qual- itative evaluation of 9. 10. improvement were Fink and Kahn, op. cit., quite different. éin~pressl. 37$-5§fin. 'Weinstein, Kahn, Sugarman and Linn, op. cit., 889-89h. �Results: pre-treatment and treatment scores The number of errors with treatment is intragroup analysis shows shown and the mean change for each group that the subconvulsive group in the in Table I. made The significantly fewer errors during treatment, while the combined convulsive patients made significantly more. TABLE I Intragroup Comparisons for Number Before and During ECT Mean No. Type of Treatment Subconvulsive Convulsive A Convulsive B Before E} ECT of Errors Errors During EDT Difference p_* 2h 9.96 7.67 -2.29 4:1.02 29 10.59 12.62 +2.03 NS 7.36 10.1h +2.79 ‘=1.05 +2.28 “=1.02 ** 1h Combined Convulsive h3 ‘ * Intragroup analyses in this and subsequent tables based on Wilcoxon's method of paired replicates. ** Patients originally in control group, then placed on convulsive treatment. group is period. The score obtained during treatment used here as the pretreatment score Prior to treatment. subcgnvulsive patients made in the control for the convulsive approximately the same number of errors as the original convulsive group. During treatment, however, subconvulsive subjects made fewer errors (7.67), while the errors in convulsive patients increased to 12.62 errors - a difference significant at better than the 1% level of confidence. �-6When the data is analyzed with respeCt to physiologic change, significant increases in errors are found only in those patients with the greater degrees of physiologic change. This relationship is present in analysis of the amobarbital tests are test and the combined (Table EEG as separate indices, and when the two II). TABLE II Intragroup Comparisons for Number of Errors Before and After ECT in Relation to Degree of Physiological Change . Physiological Index N Mean Difference in Number of Errors during Treatment Amobarbital Test. or None positive one 13 -O.23 NS 28 +3.714 .01 23 +1.73 NS 18 +3.33 .05 3 21 +1.00 h to 6 us 20 +3.90 .01 Two or three positive Electroencephalogram or None one High Delta Two or three High Delta . . Combined Physiological 0 to The in relationship between number of flue degree errors during treatment is of behavioral change shown with no, minimal or moderate behavior changes difference in made number of errors. in Table III. do not show an and the change Those patients appreciable Those with marked behavior changes, however, significantly more errors during treatment. �TABLE III Intragroup Comparisons for Number of Errors Before and During ECT in Relation to Degree of Behavioral Change Degree of Behavioral Change Difference Nnmber Errors During Treatment Mean N _ marked 2h Moderate 1h p <1.0l +3.58 +1.00 NS -0.h0 NS l Minimal or 5 None Analysis of the pretreatment error scores in relation to the degree of physiological change is shown in Table IV. The results show that subjects with large pretreatment error scores manifest greater degrees of physiolog- ical change during treatment. Patients with little physiological change during convulsive therapy had a mean pretreatment score of 7.88, while physiological effects, had a mean pretreatment score of 13.25 errors. The triserial correlation the .05 level of confidence. is +.3h, significant at those who developed marked TABLE IV Relation of Pretreatment errors to Eventual Degree of Physiological Change During Treatment N Mean Number Errors Prestreatment Physiologic Change: o to 211’ 3/ and my 16 7.88 19 11.21 �Qualitative Data: Alterations in size of figure or in minor aspects of form were common types of error during both testing periods. Certain qualitative patterns were frequently noted during treatment, however, which occurred only or to a lesser extent in the pretreatment period. patients to .was make no It was common attempt to trace the more complex figures. rarely for This response often associated with a generalized withdrawal reaction in which the patient was unreSponsive to any stimulus or procedure. Others became hostile and negativistic toward the testing. l i Patients wifln the greatest amount of physiological change seemed to difficulty following instructions. They would trace the lines indiscriminately without regard for the Specific figure to be outlined, repeated have ‘ a previous figure despite changes in the actually existed, the more complex and impulsively, and showed Such little drew lines where none trace the stimulus figure while ignoring and attempted to test figure. test figure, patients were likely to respond quickly concern about making an error even they might spontaneously comment, "I know that's not right." when ‘ �Discussion: results of this study clearly danonstrate a relationship between the degree of cerebral dysfunction and perceptual alteration. Patients ‘The with subconvulsive stimulation make fewer errors on retesting. A slight decrease or no change in errors occurred in those patients receiving vulsive therapy who showed only minimal physiological changes. vulsive patients, however, with the showed a significant increase in alteration, of errors. This interrelation- number is in accord with studies of patients with altered brain function due to head injury and brain tumor. (ll), The con- most marked physiological ship of brain fUnction and perception and Weinstein con— Teuber applying a similar technique in cases with penetrating ’brain,wounds, concluded that performance was unrelated to locus of lesion but that aphasic patients made significantly more errors than a non- aphasic brain-injured group. Pollack gt §l3(12), using the identical in this study, reported relationship between perceptual errors as no test and the location of lesion in tumor patients. They reported, instead, that defective perception related to the severity of other rental changes, was ‘ such as It disorientation. Should'be pointed out that the all patients referred for to that found by Pollack ECT was 10.35 total pretreatment cit., Teuber and Weinstein, op. 12. Pbllack, Battersby and Bender, op. 13. Ibid. score for errors, a score almost identical gt §l5(13) in thefi‘brain 11. mean 369-379. cit. tumor patients. Since �the two populations are comparable in terms of other parameters as age The and education. defects in figure ground discrimination cannot be ’regarded as reflective of cerebral dysfunction as an isolated entity abstracted from the totality of behavior. Rather than being in a to one relationship, poor performance on such tasks interaction of many there are cases with cerebral many may be due to the factors, brain dysfunction; being only one. not damage who do show one Thus defects. Con- versely, the present findings indicate that the inability to perceive embedded as it is The figures may be related as much to certain types of mental illness to brain disease. ! relationship of perceptual alteration to behavioral is clearly demonstrated. treatment The patients increase in errors during treatment were those pronounced change in clinical behavior. who showed also who change during the greatest showed the most They manifested such behavior patterns as euphoria, hypomania, withdrawal, somatization or paranoia. Comparable to these are the embedded figures test during treatment. related to paranoid was qualitative aspects of performance an evasion The some may as well be was cases, and to a lack of concern in correcting errors associated with clinical patterns of euphoria increase in errors the Failure to attempt the task or withdrawal reaction in hostility in orders. on attributed to and hypomania. change The in motivation or attitude toward the task or examiner as it is to any Specific aSpect of the altered brain function. Changes in performance on this complex perceptual task can thus be understood as one manifestation of changes in the patterns of interaction with the environment. The relation between behavioral this type of task, has been noted and perceptual by Witkin to be patterns, using true of persons without 9 �-11.. demonstrable cerebral dysfunction as well. He individual differences in the perception of embedded be related to personality factors (15). The found that the wide figures (1h) may finding in the present study of the prognostic significance of the pretreatment score to the eventual physiological reaponse is in accord with his observations. 7 Personality factors may thus be related to the degree of changes in In a previous study (16) certain person- brain function.with trauma. ality patterns were associated with the ment following ECT. short term behavioral improve- basic characteristics of persons with a favorable prognosis defined in that study were an inability to think critically The or sensitively about their own or other's needs or feelings, patterns characterized by oversimplified generalizations, ,stereotypy and conventionality. The present data that persons with greater difficulty in making the necessary analysis and figure-ground and response discriminations on embedded figures show a greater alteration in behavior with treatment, is consistent with the previous observations. Witkin,.Individual differences in case of perception of figures, J. Pers., 19: 1950, 1-15. 15. H. A. Witkin, Nature and importance of individual differences in perception, J. Pers., 18, l9h9, 1&5-170. 1h. 16. H. A. embedded Kahn and Fink, op. cit. �.12Summary and Conclusion: 1. Fifty-three consecutive patients referred for electrotherapy were studied before and embedded geometric after treatment figures. An on their ability to perceive experimental group of 29 patients received A. regular grand mal therapy wifla pentothal premedication. control group of 2h patients received subconvulsive stimulation only. 2. The experimental group made significantly more errors following treatment than did the controls. I 3. 'Within the experimental group, however, there was considerable I variability. Increase in errors was found to be significantly related to the degree of altered brain function, and the degree of behavioral change. h. The pretreatment error scores were significantly related to the degree of altered brain function developed during treatment. The significance in terms of personality factors is indicated. 5. Performance in this complex visual task mirrors the pattern of of this behavioral change observed clinically. 6. one It is concluded that performance on a complex visual task is manifestation of a generalized pattern of interaction with the environ- ment. ,4 Lu... �.13- Legend Illustrations of test figures. Fig. 1. used to acquaint the subjects with the task the task is The is preliminary sample shown in a. In d complicated by having the subject determine which of the two simple figures can be found in the complex figure. � 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 embedded figures after induced altered brain function. American Psychologist, 12: 36, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-24-029 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 Kahn, Robert L.; <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]. 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/7bd07b6cfa28408a13dfb7a2b134ee43.pdf 7a8e9dcb7ef041dbb63226e8de460992 PDF Text Text �Reprinted from Psychopathology of Communication Grime & Strstton. Inc., 1958 Printed in. (1.5.4. 9 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY By ROBERT L. KAHN, PH.D., I AND MAX FINK, M.D.* Weinstein and his associates have described patterns of symbolic adaptation in patients with cerebral dysfunction.l The main emphasis in their work has been placed on altered language patterns. Their observations have shown the similarity and relationship between various kinds of behavior which were previously regarded as disparate phenomena. Instead of being isolated defects due to focal brain lesions, these phenomena can be understood as unified aspects of an altered pattern of adaptation under the conditions of a diffuse disturbance in brain function. Some of the factors which determine the particular type of adaptation shown include the premorbid personality and the nature of the environmental stresses. This emphasis on language has been shown to be a useful method of study. For example, the presence of certain characteristic changes in language under the influence of amobarbital sodium, such as disorienta— tion for time and place, denial of illness, and reduplication, has been standardized as a diagnostic test of brain disease in neurological patients?! 3 This technique has application in the study of other conditions of altered brain function, as in the somatic therapies. The electroshock population is of interest for two reasons. It is possible in these patients, as it is not in those with neurological diseases, to manipulate experimentally the stimulus causing changes in brain function. Secondly, the mode of action and the psychological changes associated with electroshock treatment remain poorly understood. In a previous study we have shown that a favorable clinical response to electroshock treatment is related to early and persistent manifestations of language changes with amobarbiN RECENT YEARS * Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Prepared with assistance from the National Institute of Mental Health, Public Health Service and the Dazian Foundation for Medical Research. 126 �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 127 tal sodium characteristic of altered brain function} This finding was considered to support the hypothesis advanced by Weinstein and Kahnl’ 5 that the mechanism of therapeutic action of electrically induced convulsions lay in the creation of a condition of altered brain function in which the patient might express his problems in a new symbolic fashion, particularly in the form of denial. The present investigation is a further attempt to test this hypothesis by studying changes in language that occur with treatment. The following questions specifically were studied: 1. Are there characteristic identifiable changes in language which develop in the course of electroshock treatment? 2. Are these changes related to the clinical response? 3. Are these changes related to the degree of alteration of brain function? 4. Does the administration of amobarbital sodium prior to treatment produce any changes in language which have prognostic value for the eventual clinical response to treatment, the development of altered brain function, and the development of language changes during treatment? METHOD Population: Sixty-five consecutive referrals for electroshock treatment at the Hillside Hospital were studied. The Reiter electrostimulator was used on 49 patients, while 16 were treated with the Medcraft. There were 20 men in the series and 45 women and ages ranged from 21 to 68. Each patient was tested prior to treatment and retested during the second week of treatment after having received 4-6 convulsions, and during the third week after having received 7-9 convulsions. On each of these occasions the patient was first tested clinically and then after amobarbital sodium had been administered at the rate of .05 grams per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward were noted.2 The test consisted of a standardized series of questions concerning orientation and awareness of illness. This study is based, however, on the response to only three of the questions used: (1) What is your main trouble? (2) Why did you come to this place? (3) If you could have one wish, what would you wish for? All responses were recorded verbatim. Observations were also made on such nonverbal aspects as smiling, laughing, gestures, and other bodily movements. �128 PSYCHOPATHOLOGY or COMMUNICATION RESULTS Patterns of Language Change Noted Clinically During Treatment In evaluating the changes in language, the original responses to the three questions given clinically prior to treatment were used as the baseline. The evaluation of what constituted a change was based on explicit objective changes in grammar rather than on subjective or interpretative changes as to affect, mood, feeling, pitch, voice quality, etc. In this manner the following types of language change were noted clinically during the course of treatment: (1) alteration in the syntactical use of person, (2) evasion, (3) verbal denial, (4) qualification, (5) change in tense, (6) displacement, (7) stereotyped expressions and cliches, and (8) smiling and laughing. Alteration in the syntactical use of person. Instead of using the first person singular as in the pretreatment period, 28 patients used the second or third person and, occasionally, the first person plural. To the question concerning main trouble such responses were given as, “It’s what they call a depression,” “They told me I was emotionally and mentally sick,” “We’re having a lot of trouble with my mother-in-law,” “My cousin brought me; she said I was nervous,” “What’s your main trouble, or don’t you know?” and “My Mrs. is sick and I would appreciate it if they would let her in here as soon as possible.” The reason for coming to the hospital was variously given as, “My wife brought me,” “My father told me to come here,” or “My doctor said this was a good hospital.” The wish was given as “Perfect health for my family,” “My children, my husband, and all my good friends should be healthy and happy,” and “There should be peace in the world.” Evasion. Evasion in answering the question about their illness was shown by 27 patients. This commonly took the form of answering this question with another, as, “What do you mean by my main trouble?,” “What do you expect me to say?,” “Well, what it it?,” and “What did I say last time?” Other language patterns considered evasive included such responses as, “I don’t know how to tell you,” “I don’t get what you mean,” “Let me think,” “It’s hard to say,” and “I just don’t know how to express it.’ One patient asked the examiner to give her a hint. Verbal denial. Explicit verbal denial of illness was shown by 23 patients. They either said they had no main trouble, were well or else, after giving evasive ‘I don’t know” responses, denied their illness and symptoms when specifically questioned about them. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 129 Qualification. Qualification of a response in the direction of less commitment was shown by 19 patients. This language pattern was characterized by the use of such words as “guess,” “kind of,” “sort of,” “think,” “apparently,” “probably,” “possibly,” “might be,” “seem,” “assumed,” 9, and “perhaps. Thus such responses were given as, “I guess I have been jittery,” “I seem to be very much depressed,” “Probably that I’m nervous,” “I suffer from anxieties, apparently,” “Possibly worry about the future,” “I have sort of gotten frightened,” “Mentally upset, I assume,” and “I think I’m a little insecure.” Change in tense. In 18 patients there was a change in tense in describing their illness. In most cases the patient used the past tense: “I was depressed when I came here” or “I had been nervous.” In other cases the patient answered the question about his main trouble by putting it in the future tense as a wish. Displacement. In 20 cases there was a displacement of the complaint to something other than originally given prior to treatment. This was invariably less serious than the original complaint. Sometimes the displacement was in the form of a somatic complaint, as saying the main trouble was “diarrhea,” “headaches,” “pain in the feet,” “I slammed the finger in the door,” and “I’ve got an itch.” In other cases the displacement was to some concrete aspect of the hospital situation, as “My main trouble is getting these treatments,” or “I’m upset because I was transferred to another ward.” Stereotyped expressions and cliches. The use of stereotyped expressions and cliches was shown by 11 patients. They gave such responses as “It seems to me under the proper circumstances I’d be all right,” “ [My trouble is] monetary problems with people that are honorary and sincere,” “That’s the root of the whole thing,” “The only thing certain is death and taxes,” “Learn my lesson and be a good boy,” “To be a person of pep and reliability,” and “I just want to stop being a lazy lout.” One woman responded to a question of her one wish with, “I think I should consult my husband before I make a wish because he’s a lawyer and the father of my children.” Smiling and laughing. In 20 cases the patient was noted to smile or laugh either immediately preceding or following his response to the question concerning his illness. Language Changes Shown with Amobarbital Sodium During Treatment The language patterns after amobarbital sodium during the second �130 PSYCHOPATHOLOGY OF COMMUNICATION and third weeks of treatment were similar to those noted clinically. With the drug, however, the changes appeared earlier in the course of treatment. A given language pattern might be noted in the second week of treatment with the drug, but would not occur clinically until the third week. In addition, the reactions to the drug took more extreme forms, which are described as (l) cryptic responses, and (2) withdrawal reactions. Cryptic responses. These were shown by 23 patients. Responses were classed as cryptic when they had no obvious relevance to the test question or when their meaning was obscure, representing a very personalized expression. Thus one patient, when asked his main trouble, said, “Nightmare of the afternoon of the evening of the nightmare.” Others do the know the didn’t “I such problems—couldn’t as responses gave problems,” “Getting my husband to write down what he does,” or “What could I say—you don’t get the crossword.” Withdrawal reactions. Some pattern of withdrawal was noted in 33 patients. This behavior was characterized by incomplete sentences, incoherent mumbling, neologisms, perseveration, the use of a foreign language by bilingual patients, and delay or failure to respond to the questions. These patients would characteristically lie with their eyes open, would smile or turn their heads when the examiner spoke, and would speak clearly and promptly and in English when asked questions not pertaining to their illness. Other Changes in Language Other changes in language were noted both clinically and with amobarbital sodium in response to the other questions of the test battery but not as a part of this study. There was frequent misnaming of the examiner or reference to him as “Mister.” With the drug those patients who had a “positive reaction,” i.e., one characteristic of altered brain function, showed the characteristic patterns of disorientation for place and time and confabulation described in previous communications. (2) Relation of Language Changes to Clinical Response The evaluation of clinical response to treatment was made independently of this study. The patients were rated by the supervising psychiatrist in charge of the treatments, by the patient’s own therapist and supervising psychiatrist, and by the medical director. On the basis of these ratings the patients were classified into three groups: 28 patients were �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 13]. considered much improved, no longer showing the symptoms which had brought them into the hospital; 22 patients were rated as moderately improved, showing some symptomatic relief but still showing disturbing features; and 15 were regarded as unimproved, having shown only equivocal or transient changes at best. The ratings were short term evaluations, being made within two months after completion of treatment. For quantitative purposes the language changes shown during both the second and third weeks of treatment have been grouped together as though the patients had been tested only once. If a particular pattern was shown during both periods, the item was scored only once. Altogether, 89 per cent of the patients showed at least one of these patterns of language change clinically during treatment. Such changes were found in all of the much improved patients but in only 73 per cent of the unimproved group. It was apparent that there was a relation between the degree of clinical improvement and the number of changes in language patterns. When the data are analyzed for the patients who showed three or more language pattern changes, there is a significant difference between the groups (table 1). While 68 per cent of the much improved patients showed three or more language changes, only 20 per cent of the unimproved patients showed this degree of language change. Using Chi-square, the over-all difference is significant at better than the 1 per cent level of confidence. TABLE 1.—Relation of Language Changes Shown Clinically to Response to Treatment Three or more * patterns Fewer than three Change No. Much improved Moderately improved Unimproved 28 19 22 7 32 15 68 15 3 20 12 80 65 29 45 per cent 36 55 per cent Total *X’ = 11.26; P < 68 per cent patterns 9 * 32 per cent .01 When each language pattern is analyzed individually (as shown in fig. 1) it becomes apparent that not all patterns discriminated equally �132 PSYCHOPATHOLOGY OF COMMUNICATION between the groups. In all but one case, a greater percentage of the much improved group was most likely to show denial, use of the second or third person, evasion, and displacement of complaint. The only lanmuch the between found difierence which little was on pattern guage improved and unimproved patients was the incidence of smiling and laughing. Analysis of the changes shown by the difierent groups under amytal is shown for the cryptic and withdrawal reactions only in figure 1. While the crytic responses did not vary much with the different groups, the showing of a withdrawal reaction differentiated the three groups significantlyfi‘ occurring in 71 per cent of the much improved, 45 per cent of the moderately improved, and only 20 per cent of the unimproved patients. Relation of Language Changes to Electroencephalographic Response In a previous communication a method of quantitatively evaluating electroencephalographic records was described.6 Criteoria were established for rating records as showing relatively high, middle or low degree of slowing according to five criteria: average per cent time delta waves (waves of six or fewer cycles per second), the highest per cent time delta waves at any one lead, the lowest frequency in the record, the highest amplitude of delta waves, and the longest duration of a burst of delta waves. In the present study, an electroencephalogram was obtained prior to treatment and in the second and third weeks of treatment. Each record was evaluated according to the dichotomy of showing a relatively high degree of delta activity or not, using these criteria. In table 2 the relationship is shown between electroencephalographic slowing and changes in language. Those patients with the highest degree of cerebral dysfunction, having high degree delta in both the second and third weeks of treatment, show a greater number of language changes both clinically and with amobarbital sodium. Using the withdrawal reaction as an index of the drug effect, however, the difference just fails to be statistically significant. Pretreatment Language Patterns The language patterns described in this study were considered as changes only when they occurred after the original pretreatment clinical test which was used as a baseline. Seven patients, however, showed some " X2 = 10.72, significant at better than the 1 per cent level of confidence. �133 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY TABLE 2.—Relation of Language Change to High Degree Delta on the Electroencephalogram During the Second and Third Weeks of Treatment Withdrawal reactions with amobarhital sodium T Change No. Three or more changes clinically Both weeks high Delta Activity One week high Delta Activity No high Delta Activity 25 16 16 8 50 9 56 24 6 25 8 33 = 7.62; P < TX” = 4.87; P < * X2 * 64 per cent 15 60 per cent .05 .10 M form of these language patterns in the initial clinical test. The manifestation of these same patterns by these patients at any other time was accordingly not scored as a change. When given amobarhital sodium prior to treatment, however, 30 patients (or 46 per cent of the total) showed some language change comparable to that noted during treatment. Table 3 shows the relation between such changes at this time and the eventual clinical response. These changes were found in 68 per cent of the much improved patients, in 36 per cent of the moderately improved, and in 20 per cent of the unimproved groups. TABLE 3.—-—Relation of Pretreatment Language Changes with Amobarbital Sodium to Eventual Clinical Response Change No. Much improved Moderately improved Unimproved 28 19 22 8 36 15 3 20 “ X2 = 10.30; P < .01 Change with amobarhital sodium 68 per cent * �134 PSYCHOPATHOLOGY OF COMMUNICATION In table 4 it is demonstrated that the pretreatment change with the drug was also prognostic of the eventual physiological response to treatment as measured by the degree of electroencephalographic slowing. The over-all distribution just falls short of statistical significance, although when those who showed high delta activity in both periods are compared with all the other cases as a group, the difference is significant at the 5 per cent level of confidence. of Pretreatment Changes with Amobarbital Sodium to High Degree EEG Delta Activity During the Second and Third Weeks of Treatment TABLE 4.———Relation Both weeks high Delta Activity One week high Delta Activity No high Delta Activity "‘X2 = 5.27; Change with amobarbital sodium No. Change P < * 64 per cent 25 16 16 6 38 24 8 33 .10 Finally, the initial response to amobarhital sodium was also prognostic of the degree of language change shown clinically and to the manifestation of withdrawal reactions with the drug during treatment (table 5). Between Pretreatment Language Response to Amobarbital Sodium and Clinical Changes and Withdrawal During Treatment TABLE 5.——Relati0n No. Pretreatment Three or more clinical lan* guage patterns barbital sodium = 4.26; P < 'l'X2 = 6.88; P < "‘X2 .05 .01 tions to amobarbital sodium '1‘ 30 18 60 per cent 21 70 per cent 35 11 31 12 34 response to amobarhital sodium N0 pretreatment response to amo- Withdrawal reac- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 135 DISCUSSION The relationship of the language changes to the development of altered brain function and to the clinical response is consistent with our original hypothesis concerning the mode of action of electroshock treatment. In 6 studies4’ we have shown that the clinical outcome is related previous to the presence and degree of alteration in cerebral function. Using the “amytal test”2 and the EEG as indices, it has been found that those patients with the earliest and most persistent manifestations of cerebral dysfunction were most likely to have a favorable response. Such physiological changes create the milieu which facilitates behavioral change. The present study, analyzing language patterns, clarifies the nature of the behavioral changes that occur with treatment. The language shown originally (prior to treatment) may be summarized in the statement, “I have this particular illness.” The subject of this sentence answers the question “who,” the predicate refers to “what,” and the verb describes the relationship, including the temporal and intensity aspects. During treatment the subject of the sentence may be modified by changes in the use of person, so that the sentence might read, “You [or he, she, or they] have this particular illness.” Changes in the predicate are shown by such patterns as displacement or evasion. In displacement the sentence might read, “I have some other kind of illness,” while, with evasion, it would be, “I have something, but I don’t know what.” Changes in the verb are shown by denial, qualification, or alteration of tense. In denial the statement would be, “I don’t have this particular illness;” a qualified sentence would read, “I might have this particular illnessg” while with alteration of tense the sentence would be, “I had this particular illness.” Some language patterns modify the sentence as a whole. If the patient smiles, or if he introduces his statement by saying, “The doctors tell me that . . . ,” any part or all of the sentence may be modified. In other reactions, particularly those noted under amytal, the patient avoids giving any meaningful statement at all. In the withdrawal reaction he says nothing or omits part of the sentence. In the use of cliches or cryptic expressions no specific referential meaning can be drawn from the language. It is evident from this analysis that the language changes are not random or bizarre, but form a patterned reorganization of communica- �136 PSYCHOPATHOLOGY OF COMMUNICATION tion characterized by an alteration in the patient’s attitudes to his problems and his illness. The patient either says he is not now and never has been ill, displaces his illness temporally, spatially, or personally, is less committed to his awareness of his illness by the use of qualifications, or avoids the whole problem by evasion and noncommunication. These patterns are comparable to those noted previously by Weinstein and Kahn:l in patients with cerebral disorders, and referred to by these authors as the “language of denial.” Similar language changes have also been described following other somatic therapies. Frank“ 8 reports that lobotomized patients avoid talking about the operation, and he states that “the facility and glibness with which they say ‘well I had an operation for my nerves, I guess’ contain the quality of unconscious denial.” Legault,9 working intensively with post-lobotomy patients, found persistent attitudes of denial. One patient, when asked why she came to see the doctor, said it was her relatives’ idea. Many gave qualified responses, saying they “supposed” they had had an operation. Others doubted that the operation was on the brain, or used an evasive, stereotyped expression as “some nerve in there,” or displaced the procedure as in, “Oh, yes, I went to the hospital and got two black eyes.” When asked about the symtoms that led up to the operation, patients gave such response as, “It seems to have gone.” In studying patients who showed clinical improvement following prolonged coma reactions in insulin coma therapy, we have noted similar changes in language. In a case report10 we noted the appearance of reduplicative phenomena, evasion, verbal denial, displacement, increased use of stereotyped expressions and cliches, cryptic responses, and much smiling and laughing, at a time when clinical improvement was most marked. Since these language changes occur most frequently in patients who are clinically evaluated as improved, may not the language patterns themselves be the critical cues that give a favorable clinical impression? There is traditionally much difficulty in rating patients after treatment. Such evaluations are highly variable because of the lack of suitable objective criteria. While there are other objective cues which can be used, such as the amount of sedation required or the quantity of food eaten, the appearance of these language patterns may constitute an operational basis for clinical evaluation in the psychiatric interview. Not all patients, however, who showed at least three of the language changes were regarded as much improved, and not all of the much im- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 137 proved patients showed this degree of change. There may be other aspects of language and communication not covered by this study which are significant. Another explanation is that the use of these language patterns may vary in time or in different situations. On the basis of our previous observations of the “Amytal test” and the electroencephalogram in electroshock patients, we should predict that unimproved patients would show these language changes only transiently, while improved patients would show them persistently. Future work should also be directed toward comparison of language patterns shown when the patient is speaking to a physician with those used when he is with his family or friends. The degree to which members of the patient’s family are made more comfortable by the changed language, and even their inclination to use similar language, may explain the variability in the duration of 11 and Both Kahnl' Weinstein and improvement following treatment. Legault9 have indicated a relationship between the patterns of communication of the patient and those of his family. Finally, our results demonstrate the prognostic usefulness of amobarbital sodium administered prior to treatment. The prognostic value of the drug in the somatic therapies has been noted previously by Hoch12 and others,““14 who felt that patients who became more normal in speech, ideation, and behavior under the influence of barbiturates were most likely to improve with treatment. In the present study the manifestation of a change in language with the drug was related not only to the development of altered brain function and to the clinical outcome, but to the eventual manifestation of these language patterns clinically. On this basis, an operational definition of the goal of electroshock therapy might be described as enduring clinical manifestation of those language patterns which occur initially only with amobarbital sodium. SUMMARY AND CONCLUSIONS consecutive patients referred for electroshock treatment were studied prior to and during the second and third weeks of treatment. Each patient was tested at these times both clinically and with amobarbital sodium with a standard series of questions concerning attitude toward illness. 2. The results showed that characteristic changes in language occurred both clinically and with amobarbital sodium during treatment. These changes were significantly related to the clinical response to treatment 1. Sixty-five �138 PSYCHOPATHOLOGY OF COMMUNICATION M and to the degree of alteration of brain function as measured by the electroencephalogram. 3. The presence of these language patterns with amobarbital sodium prior to treatment was related to the eventual clinical response, the development of altered brain function, and the development of language changes clinically during treatment. 70 a 6050 40 'lo 30 FIG. 1. CLINICAL WITH AMOBARBITAL r-——| I uucu Imovso- Ei Ionmovw Cl ‘ummovso Relation of each language pattern to response to treatment. 4. It is felt that these language changes constitute an operational basis for the evaluation of the clinical response. 5. The results support the hypothesis that the therapeutic mechanism of electroshock treatment is the development of different patterns of symbolic adaptation to the patient’s problems and illness under the conditions of altered brain function. REFERENCES 1. WEINSTEIN, E. A., AND KAHN, R. 2. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, III., Charles C. Thomas, 1955. SUGARMAN, L. A., AND LINN, L.: Diagnostic use of amobarhital sodium (“Amytal Sodium”) in organic brain disease. Am. J. Psychiat. —, —, 112: 889-894, 1953. 3. —-~, , AND MALITZ, 5.: Serial administration of the “Amytal test” for brain disease: its diagnostic and prognostic value. Arch. Neurol. & Psychiat. 71 : 217-226, 1954. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 139 Relation between altered brain function and denial in electroshock therapy. Arch. Neurol. & Psychiat. KAHN, R. L., FINK, M., AND WEINSTEIN, E. A.: 76: 23-29, 1956. 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. FINK, M., AND KAHN, R. L.: Quantitative studies of slow wave activity following electroshock, Electroencephalog. Clin. Neurophysiol. 8: 158, 1956. FRANK, J .: Clinical survey and results of 200 cases of prefrontal leucotomy. J. Ment. Sci. 92: 497-508, 1946. —: Some aspects of lobotomy (prefrontal leucotomy) under psychoanalytic scrutiny. Psychiatry 13: 35-42, 1950. LEGAULT, 0.: Denial as a complex process in post lobotomy. Psychiatry 17: 153-161, 1954. 10. KAHN, R. L., GRAUBERT, D., ll. FINK, M.: Delusional reduplication of parts of the body after insulin coma therapy. J. Hillside Hosp. 4: 134-137, 1955. WEINSTEIN, E. A., AND KAHN, R. L.: Personality factors in denial of illness. AND Arch. Neurol. & Psychiat. 69: 355-367, 1953. 12. HOCH, P. H.: The present status of narcodiagnosis and therapy. J. Nerv. Ment. Dis. 103: 248-259, 1946. 13. HARRIS, M. M., Honwn‘z, W. A., AND MILCH, E. A.: Regarding Sodium Amytal as a prognostic aid in insulin and metrozol shock therapy of mental patients (dementia praecox). Am. J. Psychiat. 96: 327, 1939. 14. GOTTLIEB, J. 5., AND HOPE, J. M.: Prognostic value of intravenous administration of Sodium Amytal in cases of schizophrenia. Arch. Neurol. & Psychiat. 46: 86-100, 1941. ��r i , ‘ 4‘ __ W g 1" ' 3 m' 13 1956 ‘ L g 0 cm In meme: mama wrmsnocx mm! Robert L. mm, mm. (1) m m; 3.9. (2) x a 3 E m the Roman Service, Rama 303mm, f 610:: om, In Ion-k Research Assistant (Psychology). (1) (2) Inmmumrtufflmumrdn : um,upon,bymtmavrmmhmmmmeumwmmum l hum). Instant-a We quiz . .____.,_T f 3 32 I m M“ 7 , , , ‘ of Heath, Public Health Service, and tin mm mum :m' W/we‘bé , . I ��.————n.~— um w-w—w, m , c121: ll‘ynbolié rum“, gamma: in we tan a: mu. m pal-amt imadglfim 1- 5 mm»: «mm t0 tut this Methods by studying changes in 1mm: um. ocetu' wfih transom. speculum, in: quantum war. ”mad: 1) he then numb-nun 1631153113131. chug“ in language in the a: 93.00th tmmu 2) An thug changes routed tn the clinical rum? cm 3) 1;) tho Imm- which develop ‘ mmwmmmadummrmumz 1:.an m <3th no» mum-mum at amour-him swim prior to mm mane pm «no any chaugu Salaam mu tax-tho mutual 611M681 “spams t0 tmtmnt, tho Moment 6:! ahead brain mum, and the m1»- mt of language We! during treatment? �www.— mm Pbpflatim 8mm.” «causative mun-.1- for 0103th mama 3W. n: tho 3:11.146. Hoopim were ha ma Rutter mootmtimlator was used an puma, m: 16 mm trhud with m Index-art. mm was 20 m m that nflaoanthm,andthoagaamngofifm21t068o 1361th mudprbrto What, and nuuuddurxng tbs soc. nadmok o: tmhent arm-hum medMM amen... and man; the third Each Mattel-havingmiv'ud'l-‘P convulsions. am was first team clinically, m and muchatthcnoemiona tbsp“- that after Win]. ”dim had bun mun- mm, slurred speech, dram intend at the at. of .05 Per mm mm sine” and awn 1n counting hackurd was We! (2). m tut consist-d of a. “1m and ”mane” at 111m". a» standardised an» of Question concerning orient» nu stumr in band, hammer, on thg mm” to was a.) flaw in your Iain troublo? 2) Why am you com to this 131100? 3)Ifmcon1dhnve mum, whutwofldmwinhfar? 111 responses was mom 19mm. Mmum am: also on such mam}. only three or . aspects as questions mum, laughing, gestural: and cum- bodily m mu. �._. m- WW.Mmmmmm.m W —...— , "Hwy—n warm munmmgtmmsmmmemom nmaeatothathm questions gm clinically prior to treatment. were and at tho Malina. ufimofwhat mfiWaWmewut a: chug-l, 1) as to affect, mod, um mm: m. mum Amen a: mg. mum m. nag. change wars noud oval- objoeuva changaain gm author than mm” or infierprouuw In mung, pitch, vein. The clinical): during the saw at {amen-at: alumna in ma tynucuml m a: pox-on, 2) 0mm. 3) «M ma. h) Mama, 5) ohms. mu, 6) amt, 7) stereotyped 11: oxpzésum and cliches, and a) 1. Album first pom singular is wing and 12mm. , in tho pmtmttmt Warmingtha patient. used the second or third pom and occasionally the first. person plural. to me question anoaming min trouble such reopen.” ward given us ”It's what they call a depress- 10a.”- 17823.64, 28 Whaytoldmlmmfiomuyandmmliuck,‘ We'mhavingalatef trouble with w mflme-lm,“ my cousinbrnght no; she said I was mus,“ mam troublo, er mm mm,“ and my lira. it sick and I tram tppmciato it bar in how u soon a pas-ibis.” thq mum team for coming to the heapiul m anomaly given a W wife hm: no," "W "What‘s 11‘ tamortaldm to m hora! oriwdeow mid mama mumm.‘ will: an: grim as “Part-rat ' The 3.0% mu: for w M13," W alumna.- my Tho husband and anwgoodfm uhauldbelnnlflvandhappy' mfimmaummmm m Md.“ �“”1 ‘ ~5i I LAW Men Wiring m. m M 2. w 1:: 21 patients. rm- with a question, as ”What. do. mm; m Wm momma the queetioh about their tea: the tom of you new by m main trouble?,' “that do you «poet mo; won, what 1:: m,“ and "What «he 1 may last than?“ Gum-1W patterns considered and" included such responses as ”I don't know how to tell you,“ ”I don’t get what you mean," "Let ale think,“ um hard to any,“ ad “I no to m Just don‘t hint. how to expanse 11:." One patient asked the «minor to give her a W. mutwmmammummwzspu an,” Wm W. 1mm. they either math-y had no um «am or an axing evasive “I don't mow” reapeneeo, denied specifically questioned about. him. ' eomltmont the use their illness and a... arm- mention a: a meme in the dimtion a: 1»- m ohm by 19 patients. a: were. as ”31103:," ably, " "possibly,“ ”man. be,“ were given no '1 gun: I have ”pmbably that I'm This lulguago pattern was characterised by ”kind of, “an,“ been ' , “sort at " ”think " “apparentlyfl "prob- “assumed," and “perhape." That such Jittery,” “I seen to he very ream mammaed,“ mom,” “I suffer from emotion, apparently,“ ”Poenbly early about the fume," ”I have sort or! gotten momma,“ upset, I and ”I think I'a a little inseam..." W. ”W ‘ Inlapntiente therewaeaohangein um,” mum» in; their 1111:)“. In most cane the patient used the past tense, as "I wan depressed when I one here” or 'I had been mm.” In other canoe the patient answered the question about his main trmzble by ' 131%(2mg. In 20 cases mung it in the future there no a diamamnt tense as 3 Huh. of the Wt ‘ W to something other than originally given prior to treatment. This was mummy lest Bonan- than the original comm. Sometimes the dilplacamnt was in the tom of a emetic complaint, as laying the main trouble was ”diarrhea," “headaches,“ �WWWWMI—Fr‘ .6. ' ”pm in the tests," “I slams the rings;- in the door,“ stair case: the displacemnt as ‘33: main form»! m to some mores. aspect or the: itch.” In hospital situation, trauma in getting those treatments," or “I'm upset because I to another 7.} and "I‘vs got. an was trans- wand.” Sufism mania and 011mg. Tho use of stereotyped sxpmssim andsliohumaambyupltisntl. Thsygan-uehnnponauunltmtam undo:- the proper circumstance: Igd be alright," with pupils than. are honorary and sinners,“ “The only '1‘0 be thing «mm is “(my tmblo in) monetary "Tut’- the root of the (bath and taxes,“ "Loam my pmblou whole thing,“ lesson and be a good boy,” person a! pep Ind nhtbility,” and “I just want to stop being a hly lent.“ Muhammlpmbdto‘aqusstimothsrmwishuth, 'Imnkllhmaoonsultw a. W. husband borers 8. laugh I make a wish became ho'a a lawn: and the {nth-r or InfiOcaauthopatimtmmtodtoamoor 01m manuly wounding or following his coming xv childish." suspense to the question can- nu 111m". to. language ”zoom um:- ambarbitsl mom during to. mono and tom: units of treatment. were 11min:- to those noted clmenlly. with the drug, haunt, the changes 5mm earlier in the sour» or treatment. A given Imguags pattern might be noted in the second was]: at insistent with tho drug, but. would not occur annually until the third mt. In Audition, the motions to the drug took more extreme forms, which are ascribed cryptic responses and withdrawal remnants. 1. W. u patients. 3031mm” wars class-sdas cmtiswhmthsyhndmobfim relevance to the testqueetion ormthsir 31118 was shown by 23 m obscure, 1'31)an a very momma-d «pr-union. Thu: ms patient, MWMsMntmnble, ma'mghmoftmuumomofmmmgattm naming night-am.” Others gave such msponsoa an to. problem," ”gutting no husband to you duo‘s get. the naturism." '1 MN. know the pmblsm - cm‘t do ma dm mo he does,“ or firm oouu I uy .. �M_W~«W.“hm... ,Wfir—yyw'V‘amn"WW—wzmw. wm-u.www‘wex"w\’murvxl'ww’byum—lam. 7, am....-.. We. .: . ~ . , V . ... 7 or Wham-x“... .3». > my- a. ~u..r-_..L-r.-‘~w flaw. ,‘m,r__ wry", “Tee ‘11ng reaction. 8m pattern or withdrawal was noted in 33 patients. 2. m: behavior we: ohenoteriled by ineomlete egim, pomemtdon, the use or failure to eve-pond of e totem Manage by bilingual patients, and delay to the questions. meet; patiente would cheruoterietioelly lie m1. with their eyes open, would or turn their heed clearly end promptly and in would speak eentencee, incoherent mumbling, mela- when the miner epoke, and Well when asked motions not pertaining to their illness. comm sodium My endwith ambarbitel oom- changes in hnguege were newborn in neponee to the other qua-time of the tut battery but not part of thie more use frequent dimming of the manner, or uteri-mg to hm :- .‘Eflater.’ with the drug these Intimate who had e “punitive reaction,“ my one characteristic characteristic patterns of acclimation for place and time and contebuhtion deeorlbed in preview! communion! (2) . of altered man Motion, showed the the evaluation of clinioel memo to treatment we mede independently of thie may. The Intimate were mted by the supervising peyohietnet in charge of the teammate, the patient‘fl om therapist end eupenieing peydxiatflat, anaby the director. 0:: the beeie of these ratings the petiente were unsealed “eel into three gmpa: W turned, 28 pmenu um widened much which brought then aiming em into the hoepitel; eynptometio 22 improved, no longer showing the petiente were rated as moderately relief, but still ehowing dimming restore" 15 were ragweed ee mmproved, having elbow: on]: equivocal or trmeient and We at beet. me rating: were abort term evaluations, being ude within two loathe after coupletim of them. �PERCENTAGE SHOWING EACH LANGUAGE PATTERN ACCORDING TO RESPONSE TO TREATMENT 70 60 CLINICAL I—————————-‘ WITH AMOBARBITAL l———_I I MUCH IMPROVED El UNIMPROVED I400. IMPROVED �*8. For quantitative purposes the language change: diam during both the mead third week: of tmtaent have been grouped together“ as though the patient: had been tested only once. If e particular pattern we chm during both periods, the the: me scored only wee. ntegether, 895 of the petiente enabled at least one at and then patterns of We manually dining treatment. Such changes were fomdinullthemch mpmvoepauembntinonly7motuuunmpmdm. It as nmt. and the amber [the patients a: chengee who showed mungmgo patterns. three or more leaguege language change. em a.“ is analysed for Wed petm enlyZOSottbeunimpmedpaflenu ienteehmdthmotmnlmgugechangee, this degree of When We- petum changes, there is a signifi- I). ‘gieent differ-wee between the groups (Table shaved clinieel apparent that. there me e relation between the degru of 681 of the much Bung cm! the menu dietdbufidnie lim- mMatbetmtnmth-uwaercmnm. Relatian of. W m 1mm (28) WW MW (22) W (15) 1‘0“!- (65) Chang" W Shawn 3. Wally to Ream“ to Treatment. lie. lo. 5 1 19 685 9 32: 7 )2! 15 681 3 201 12 895 29 ' W 36 551 :2 - 11.25 1! <m Hheneachlengmge pettemiemelyeedmdivimm,um1nfl¢m1, itbecaneeeppemtthetnotenpe‘btem wcmmequmymmw. Infilbntoaeem,emmmtmeftmmmmdpeumuwmmn ’ �Y «my v m. n.“ .-‘ nmxw “gamma. — yawn , v mama-gm m w“... n- ,.—., »1—0” —W -.~.- - V , , n «Fur run...“ .- - . 17,1,» - . , men-1mm, mottheeecmdormmpeum, Wanda-Newt o! ambush; The afly 1111311130 petum on While}: little airtime was found between mmmmmmmdmmamemdmmmum. .Anuymatmmemwmwrmmmup-meumm termerypueandwithdmel mam anlyinrigun 1. mmaypuc reepeneee did mtnrymeh with the afferent groups, the withdml, moving of e mum differentiated the three gmupe eigfifimm: occurring in 711 of the mach Whfldthemdenflhhpmndmdmmzfiottbmnpmdpauwu. x. : mu.“ Mum of In a e to ., vs; mea new M of qumtitafivm Mam electro- Mama pm ducribed (6). emeMgraphic ' a resend: records an m inning relatively high, middle ,a; criteria 62‘ ~ were established low degree for rating of abnonnliia according to five agitating avenge percent. time delta. wee (waves at :11 cycles per mood or lees), the highest percent time delta. mm at my one low. the lowest tremmney lathe moord,thehigheetamplitudeofdelteme, burst. of delta me. mummumote In the present study, an electroencephelogm wee obtained priortotmmntandm the ”Windmirdmk a: treatment. Each ”comm «alum mending to the dichom at showing eliw er m, using the-e axe-Lurk. In Table ality V and changes the relation-hip 2 in animation, Wag show a 1mm. am reletively h1g1 demo at ebnon'e- mm mm abetroonaeplulognphtc linem. Tho: patients with the in Why of high mate; mm: 18 I. greatest degree at cerebral both the «can! I2 a 10.72, thinner:- at mmt, hmge change- both clinicallyxand with Waite]. and“... the mama. mum at! mime-u: at the drug effect. ' m, was the 3m. ran- to be statistically significant. I» end. Wimt 1% better than the ' 11 level or comm. �fl‘rfiwwwme—wmm. . ‘ermmmfimvfimimmw' TABLE Relation of Language Ghana. ’60 High 3 WW (25) OnMunimzé) ‘ lo 315: Ahnamauw (2h) mm withdrawal Motion! with W191}. Seem: i lo. 1 15 as a 50% 6 255 - 15 601 _ 9 5“ ‘ B 335 . Yoa P < 0°, :2 12 Language when they ._._.r,._r. Eloctmmmalom Dunne , m1: < ‘ Both Weeks 31g: 2h: , of Treatment clinical]: lo. may “at on the or Kan changes m._.—r.m~. 2. 83m and Third flecks the , P pat-Mm «termed in that: stuck wan manned afar tho original ’ has? .19 < midsmd a: change: mmmm clinical test which an and u a. baseline. Bum patients, 11mm, .Ihmd can form of than 1mm puttem in the initial 91.1mm test. me minimum or thus same pattern! bythaeepnuenuatmomrtimmmonnnmnatuconduachmgo. mm gum Wits). actual prior to tmtmt, War, 30 patients", at Wot‘flwmu,mmdmhngmgammnbhmmntnommtmh neat. In‘hbh3thonhumbomahmgamhchmguat mamumhm m'mmmeumm mm». Manfmdméfifidmmw pmdpmmnu, thwzyséiutlmnoammynwdwamozmmmd W. . ‘ , par" .— .V �w :u—v-r—wwxv—mww: Relatim of W W3 Pn-tmmt Language Ghangon autumnal Mun with mm and clinical Mona cm. with Ambarbital mu 1 Ho. Knob Impravod (28) Hodomtely MIMI: W 68$ 19 (28) 8 36% 3 W 30 It“ (15) Tom (65) l :3 - 10.30 P< In Tab}. was I; .01 it 1. “infiltrated that the pm-vtmtmnt change with the also prognostic of tho eventual drug Widow anionic to tmtment as mound ouctmcaphalogmmc abnomanw. Tho mun distribution 3m; tall: chart at statistical lawman, although than who my: almonby m. magic. 01' m mlityinboflpeuoda an conpnrodwiflzall’ehsothor crence is significant at th- 51 1m]. 91‘ canfldonoo. Relation of ma mnuam, thaw:- Pwtmmt Languag- Ghanges with manual. Sodium and High Basra Em Abnomliw Drug the Second and Third Weeks of Tmman‘b Both Wuks High One week mmty (25) M Announnw (16) Chung: With Amobarbital Sodium Ho. 1 16 6&1 6 . 38$ ’ la High Abnormality (2h) 8 335 - 5.27 P<olO 1a �many, the initial degru a! Ianguagl clung. I‘hm cunicamand "actions with the drug during twat-ant (km: S). tho m hcpom to 5 . human at Pro-tantalum sodium.an pregnant?“ at to tho Mutation otirithdmnl response to ambarbital Language . NW mm mm: 5041mm . 1': 011mm Chang“ and Withdrawal Remuom 3 Clinical PatternLeague. 03' Hora lo. Pmtmmm Respom to max-mm Sodium (30) In l’ru—treatment Response to Mammal Soditm (35) 18 , 11 :2 aims 9‘00; Withdrawal Reaction! fio Amour-Mu]. Sodium 1 30. i 601 21 705 311 12 3M - 6.38 P<ll°1 x2 _ �'Iwwa‘v-rI—Ku,WM wc-v— ~33- w".— «my. qzwrr * Discussim the relationship or the language changes to the development of sltsred brain function and to the clinicsl reepcnee is cmistent with our original vaethesie cenceming the nude have shown ct action or electmehock treatment. In previous stmnee that the clinical outcome is related to the (hfié) we presence and degree of alter- ”mm test" (2) and the we as indicse, it has been fomd that those patients with the earliest and most persistent Mutations were met likely to have a favorable response. Such physioof cerebral aticn in cerebral function. Using the mm logical changes create the milieu which facilitates behavioral change. present study, analysing language petteme, clezii’ies the nature a: the beheviorel changes that occur with treatment. the language chem criginelly, mic:- tc. treatment, my be amused in the The statement, "I have this particular illness.” The subject or this sentence answers the questicn 'Who,’the predicate refers to What,‘ and the verb describes the relationship, including the femoral and intensity aspects. During treatment the sub- dectoi’thesentencemybenofltiedbycmngesinthemotpereon, eothntthe sentence night read "You (or he, she or they) have this particular illness." Changes in the predicate are shown by such. fiettem as displacement or evasion. In displncs- nent the eentencc night tied “I have ecu other kind of illness," em... with evasion, whet.” Change: in the verb are it would be, "I have something, but I don't m qualification or alteration of tones. In denial the statement would be, “I don‘t have this particular illnessg' a. qualified sentence would read, “I light have this particular illneseg“ while with alteration or tense the sentence would be, "I as this particular illness,” flown by deniel, Sons language psttems- modify the sentence as a whole. " If the patient mice, or 1: n. introduces his etstewent by saying. "no doctors tell me theta...“ any, pert or all of the sentence my be emailed. Other reactions, particularly those noted under mytcl amid giving any meaningful statemt at ell. In the withdrawal reaction w”... �W, wwcww—mw '-—-—'- ..r.-_m..—w., ”fir .,,,,.:.._._‘,._.. r_.‘-“‘1KvW“fiW——r—W‘w‘wwflwmwwi'w ,_,. WWW .Vw—ya-awwmwnmr an... Wpemsaysnoflfingormiupertottlnsen’om. Intheuseotoliohesot cryptic expxessions no specific referential meshing can be dram free the language. or numemm-WumtwmoW-mmom bot rose mourned him, mrzaniutim a of omioeuon Motorised by so alteration in the petient's attitudes to his problems and his illness. The patient either says he is not now and never has ill, displaces his illness temporslly, or parsmslly, in less committed to his or his illness by the use of quelifioeums, or avoids the whole problem by evasion and These pettems en oonpereble to these noted previously by Weinstein end Kahn (1) in patients with cerebral disorders, and who Memo to than as the "m3. w spam use of detain." Sinus: lsngusge mm” Manon. changes have also been described following other emetic therapies. Frank (7,8) reported that lebotonised ptiente avoid talking sheet the operation, end he states that " the teoility and glibness with which they say Well 1 had so operation for nerves, I guess' contain the quality a! moon-:' scion!» q denial." Benoit (9), working mummy with postnlobotouy patients, some ‘ persistent attitudes a: denial. the patient. when asked why she ems to see the doot-or, said it was her, relatives' idea. new game qulii'ied responses, saying they owned the operation was on the brain, or used an evasive, stereotyped «passion as "sou nerve in there,” or aispleoed the procedure es in “oh, yes, I went to the hospital and got one black eyes.“ when asked “suppose“ they had an operation. Others ' about the symptoms that led up to the eperstioo suoh responses were given as ”it seems to have gone." In stucbring patients who showed clinical improvemt following prelooged om reactions in insulin eons thin-em, we have noted sinilsr changes in lengoege. In a ease report (.10) we noted the sppeerenoe of nduplicetive phenomena, evasion, verbal dermal, displacement, incmsed use or stereotype expressions and cliches, eryptio responses and moh mung and laughing at pmemt was most marked. s. time than clinical ile- �wmmmemMMp‘mmm mmmamuwmmmmpmmmum mmmum nugtammmmmr ‘mmumm mmwuumpmmmm MWmm mmammammwmwmm ultimatum awn'mmamhMMuMdemwmm utyotrmdummwdmmpmmwmututamw mmmrormmumummm um. mapm,m,mmummumwmu unwumwwmmammwpflmm mommd'm mummommdhwudmmmm . mmwmsmméhmummt. Wruflmflmumtflnm amewma-wmmmwmmnmm. fathom deflumflmdtfl‘WM’udm-Wm an,uwmmtmmpmmmmg mmwtm.mwpmmmmmupem may, WMWMMWMWWRWM n- wtbpmsnumammmmmuummmorm. mumwtbpmvammyummnmmbnbymmm, mammmmmwmmm,mmmnmmhmwdm duration of tone-mg and ! 1 Wt hmt(9)mmmamumummpmmammam mutant; nmmmrumv Both Hon-ma Km (1, n) and ' ' m.mmquWWde-ob iummmummg mpwmamwmmmm ‘ ’ mmmmmupmmwmm)uomm.mmmz mtmmmmmumgw,mmnmwmurwm i �”mm “mm“..m—wwaww—lw""" , A m. wl’vr-w—w-‘mx'r- :46nnuanco at barbiturates were most likely to 1W0 with treamnt. In the pumt at. chum mmguagowieh‘mdmgm nut-daetenlyto an Mom's a! alum bmn sanction and to the clinics]. but to the av. mmwamum 5mm mutation of then 1mm puttom' clinically. mm. this built, an aparauaml definition at the god of electroshock therapy night be «scribed an enduring On mm museums: of than mm natural which only occur initially with no. humui main. ' �v." 77—79». mm? - , WW. W'm“wu}—r¢ MN '-v" r 0.: navy—w ' , _ , 4 “aw—Ia W.wmv3ww,wmx-. WW,'—-‘W ~01” my iyg‘w 'w-w Hunwyw—m...“ 4.7.» may 1. , GWI saw-an ammunw mums rotomd for!" platteflmck What an tmtasnt. Mmfient’ ammwwmmmmmmu clinicallymdwith m umummww suburbia). BOMflthiltflndu, am: at Mom mooning unwa- mm 1111mm. 2. mo result: :1th that. ahamoteriatia chug“ an language We both 01mm and after gum-mm ”dim during mums. mm ohmgu we. sign“- and 1canfly ”hudtothe chainsaw-panes to tmtmntmdtaflmdegreoufalund mum at maund by thc alwmlogm. 3. Tho presume at then 1mm mam with ambit-him ”(than pain:to tmtmt was directly mum to th- mntml clinical aspen-e, tho Malay-sent bruit: ' otaltendbrainfmcfim. undthadmlomntutlanguagcchmgu clinicallydnring treatment. that than language éhangu What. an opomtim bun m- m mluntim of the clinical 5. the mum: ‘n'mport an hypoflmia that tho thanpeutio or oloctroshoak Mama“. in the develomt of walnut putt-m at symbolic adapt. 1;. It. in $311: mm. mum to the pntiont'u problem and 111m” talcum. am. _ War the conditions a: slum brain .w-wm. __..,‘ ’n’rr' 2-}— �1o “sustain, E. A. and Kuhn, R. L. AW, Springticld, 2. , 1111mm, 8mm, , . W cum: of L. A. and Man, ("mm Sodium") 39am. I maul! Evacuated. mm, 1955. L. : Dwain Us. at Ambaxbitul 6. argma Brain 1n Symbolic and maul, Ann-1m J. meant... $183943?!» 1953.. ”J 3. _____, and mm, Psychintg, E: Serial Administration at the for ”Am/ta]. Test." “mm, MILL. Arch. 217.226, 1951;. 1!. and Yul-match, E. A. s h. mm, R. 1... Pink, cation and x It: Diagnostic and Prognostic Vila, Brain 131mm: a: 3. mm in Ebotroflxock Therapy, 361.31% Between Alum: Bran rm- L114. Arch. ”enrol. G: ' Pageant... in press. 5. Renown, E. It: am: 1., L. and Kuhn, B. Linn.» Kantian be the of Timmy La Psychosis During Electmhock Shock Ehex'npy, Am. J. Paychiatu ' 14. and mm, 3. Lu Quantitative Studies mammm. m. cm 7. Frank, J. I clinical Survey J. fluent. 301., 8. 23! 1;th, 0.: Dani-.1 161. 1994. 10. ram, R. Body at 1956. , 7 (Putnam mom) Under Psychoanalytic u a comma m” in Post know, yummy, u: 1531 1mm 0m 11.: morally. a. 11. Hem-tan, E. A. and Kuhn, R. In: Arch. Activity Founding 354:3. 1950. I... Gmubert, n. and Fink, Am:- - mm o: 200 Cm: or Putnam Macaw, of lobotomy Scrutiny, Psychiatry. 9. (mm). Heumphysiol. g: 158 and Slow wave ”7-508. 13%. Some Aspects I 01‘ mt ' 22-26, 1952. 6. Pink, Burk» mm. a: Pawn»... éi‘ Delusional Redupliaation of Parts at th- mum. Wm, Personality Eastern b; ”Iv-1&7. 1955. 1:: Denial of ’ 355-367, 1953. Inna”, �"fl..- v.w-m,.__wWR—v~.....,1,..e..r.»-w.q.w,__ v7 Koch, P. 313., n. : no Prognostic n W “F" _~—,w .— Mm vunw H.‘ r u-vn ~..»u-,Ww—~wwwwnw~. WVWVWW ,wuwyfl—w ”Maw—v.4. 1911.6: Roma, 3. A. and men, n. 4.: lid in Insulin and Home]. Shock mgammg ‘I‘hompy (was Pmeox), m. a. Paychitt" 2g: 327. 3.939. 11;. ‘swa ant. Status as Memo-1- and Thoupy, J. Harv. Mont, m8 W59; 13. Harris, :4. a... , scum was. as a of Inantal Patients Mm», a. s. and Hop-,4. u. ! Pragmatic van; ,0! 1:11.va amusmum at Mm W]. in ease: of Schisommin, Arch. 3mm}... & Wt.f 5g: 86400. ' 191.1. ' um" , l u, ,, � 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 Changes in language during electroshock therapy. In P.H. Hoch and J. Zubin (eds.), Psychopathology of Communication. Grune and Stratton, New York, 1958: 126-139. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-27-002 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 Kahn, Robert L.; <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 Psychopathology of Communication Grime & Stratton. Inc., 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/cd19f1b46d47e649344f387e918358a2.pdf 402d7d717080af9c10d773a24db00fb9 PDF Text Text Reprinted from Journal of Neuropsychiatry, Vol. I, No. 1, Sept-Oct. 1959. Personality Factors in Behavioral Response to Electroshock Therapy ROBERT L. KAHN, PH.D., and MAX FINK, M.D. In previous studies”,7 we found that patients who were most likely to improve from electroshock treatment exhibited persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital test for brain disease.10 We reported, furthermore,7 that patients who improved with electroshock treatment had developed a language pattern similar to- that previously described by Weinstein and Kahn}3 in their studies of neurological patients with cerebral dysfunction. Weinstein and Kahn described a language pattern which they called “language of denial” and demonstrated the relationship of this language pattern to the premorbid personality of the patient. On the basis of these observations, we assumed that the patients most likely to benefit from electroshock treatment would be those who most closely approximated the “explicit verbal denial” personality.11 To test this hypothesis, we studied 63 consecutive patients referred for electroshock therapy. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. Thepatients ranged in age from 20 to 66, with a mean of 47, and included 21 men and 42 women. Prior to and during treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient’s 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 than proceedFrom the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented at a meeting of Electroshock Research Association, Chicago, 1957. ing in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the “explicit verbal denial” personality. The number and; type of questions required'with each relative varied according to the degree of spontaneous production and the informant’s capacity to comprehend and communicate. The informant was encouraged to give concrete: examples of all statements. The patients were evaluated as to the pres ence and extent of the following character istics: whether they (1) stressed verbal symbols such as resolutions, homilies, cliches-and rationalization; (2) were prestige and; security conscious, and did not enjoy the in; trinsic benefits of health, work, leisure money and property; (3) regarded illnéSs: as an imperfection or disgrace, keeping it an; , secret from family and neighbors, and were reluctant to seek medical care; (4) tended) to “shake off” their own troubles and to be) regarded as practical persons who advise, others; (5) possessed much drive and coma pulsive energy and felt guilty or uneasy if not occupied; (6) were conscientious, with a high sense of duty and responsibility; (7) were sensitive to criticism, regarding it as an attack on their integrity; (8) were proud and tended to avoid help from others; (9) were reserved rather than openly affectionate or emotional; (10) emphasized being correct; (11) lacked imaginativeness and creativity; (12) were not considered by their relatives as dependent; (13) did not discuss sex openly; (14) did not have temper outbursts; and (15) were not “ludic”—a term taken from Piaget8 and used by Weinstein” and Kahn12 to denote comic, tragic or melodramatic behavior. After the interview, each item was rated on a scale of O, 1 or 2. A score of O was given if the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked ,» . , ' ' �' presence of the pattern. The scores for each item were added and, the resultant score termed the “denial personality score.” 2. Clinical Evaluation: Each patient was interviewed prior to treatment and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient’s behavior in the few weeks following the end of the course of treatment, and was based on the evaluation of the patient’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, following the criteria outlined previouslyf‘ 3. Language Study: In addition to. the clinical interviews, each patient was examined with a standardized series of questions directed at determining his attitude toward his illness. Two of the questions asked were “What is your main trouble?” and “If you 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 Treatment for all patients consisted of grand mal electroshock, using a Reiter elec— trostimulator or a Medcraft alternating-current instrument, on a schedule of three treatments per week. Of the 63 patients, we were able to- interview the relatives of 47; and the present study refers to this group. The denial personality scores ranged from 0 to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the “high denial” group, while those with scores from 0 to 10 were classed as low in denial tendencies. 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 only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as unimproved. ') .« TABLE I Relation of Denial Personality Scores to Clinical Response to Electroshoclc Denial Much Personality Improved Score 11 - 25 0 - 25 14 Total Moderately Improved Unimproved Total 7 9 9 1 7 24 23 21 18 8 47 The difference in the denial scores between the much and moderately improved patients, when compared to the unimproved patients, is statistically significant (at 1% level of confidence by Mann-Whitney U Test). Although the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative Observations: Although there is a relationship between high personality scores and the clinical rating, 30 per cent of the patients with low denial scores were also evaluated as showing a marked improvement. While the group of seven patients is a small one, certain common characteristics can be described. Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or others’ feelings. They relate to the environment primarily by nonverbal forms of communication. They are described by their families as laughing or crying excessively and as showing anger by muteness— “going into a shell,” “walking out of the room in a huff”——or by violent tempers with table-pounding, throwing objects or direct physical assault. Personality Score and Changes in Language: By means of the technique of language analysis described in a previous study,7 the changes in language in clinical interviews ~were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, etc., have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether �. qr nothe showed three or more explicit language 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 is +.71, significant at better than the 1% level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes Daring Treatment Denial Personality Scores 11 - 25 (20) 0 - 10 (20) N 0. Language Changes 0 — 2 3 or more .................................. 8 .................................. 17 12 Total ........................................ 25 15 3 Illustrative Cases Case 1. High Denial Personality Score: A 61-yearold housewife was admitted to the hospital with a 15—month history of insomnia, abdominal. pain and fear of cancer. On admission she was depressed, retarded and seclusive, evincing little interest in her surroundings and wandering aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with much integrity. She had no hobbies or outside interests, and was unable to relax; as a consequence, she busied herself with chores at home. She was “mortally afraid” of doctors, minimized her illnesses and concealed ailments even from her husband. Very restrained, she 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 stubbornness,” 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 was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a “model” patient who, “while reluctant to discuss her personal feelings, asserted that she had no difficulties at home, had a wonderful husband who was very good to her, considered herself lucky and eagerly anticipated her discharge.” She was discharged with a rating of “much improved.” Case 2. Low Dental Personality Score: A 41year-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 it was noted that the patient paid little attention to her personal appearance, cried readily, showed psychomotor retardation and was circumstantial in speech. The patient was described by her husband as a “negative personality” with whom it was not easy to get along because she was opinionated and argumentative. He 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, implying you just don’t know any better.” Although considered a “cold” person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was “naive” and “unrealistic,” believing, for example, that she had a flair for writing although others considered her amateurish. Her personality score was rated as 4. The patient received 18 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 felt it was doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for continued psychotherapy. Discussion The structured family interview was designed to test the Specific hypothesis derived from earlier observations that patients with the “explicit verbal denial” personality are most likely, with electroshock therapy, to show both the language and behavioral changes which are rated as much improved by the examiner. The data support this hypothesis and are also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952.9 They suggest tha “. . . the therapeutic eflicacy of electroconvulsive therapy . . . derives from the production of a. state of brain function in which the mechanism of denial is facilitated in characterologically disposed individuals.” The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. On the basis of the present data and methods of analysis, a broader View of’ personality patterns in relation to improvement with EST is now possible. Those patients who are rated as clinically improved are character- ' �8va — _ ,r-Pff-‘wu ‘:_‘_":':'*'r‘-n-€"L ,V"-~.' -: < ,2 ized as: (a) nonempathic—unable to think critically or sensitively about the needs, feelings or communications of others; (b) nonintrospective—unable to think critically about their own feelings or needs, or to achieve insight even with the collaboration of others in the psychotherapeutic relationship; (0) relying heavily on nonverbal communication—even when they are talkative there is little referential communication, the words being clichéd, stereotyped or representative of feelings and emotions rather than transmitters of information; and (d) highly conventional—without imaginative or creative capacity, and with few resources to deal with stressful or new situations. With this pattern as the common background, two classes of patients who respond to treatment can be defined: the driving, conscientious, independent, successful, emotionally controlled person who can be characterized as the “explicit verbal denial” personality type; and the chronically inadequate, affectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short-term response to electroshock, preliminary followup observations indicate that the “explicit verbal denial” personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function 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. Some show mood changes and denial or displacement of symptoms, and are rated as improved. Others develop paranoid agitated states, become withdrawn or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality factors in those cases whose behavioral response was rated as improved. We have not considered the patients who were 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 4.: in this regard is minimal, as this problem has not been approached with a specific hy-“ pothesis. These observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic premorbid personality. Abraham1 noted that states of depression occur in obsessional persons. Arnot2 described depressed patients as being overconscientious and perfectionistic. Hamilton and Mann,5 reporting various aspects of the personality in involutional depression, included such features as “followed a rigid pattern of behavior . . . displayed a lack of imagination . . . narrow range of interest . . . thorough, conscientious, meticulous devotion to duty . . . lack of feeling for point of view of others . . . hard, uncompromising drivers . . . oversensitive . . reserved.” Cohen et al.,3 in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having little capacity for communicative interchange; and unaware of other persons’ feelings toward them or of their feelings toward others. They emphasized the patients’ inability to communicate verbally and suggested that the therapeutic relationship should be in nonverbal terms rather than emphasizing the intellectual content of the exchange, These studies of the personality background of depression show a pattern that is most similar to those personality aspects which have been described as the “explicit verbal denial” personality. The factor of personality could thus explain the fact that depression is the condition that responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to nonverbal forms of therapy. These factors enable him 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 cat- ' > �.' respOnse in the individual faced astrophic 7 With the loss, of a partner, job, business or u'loiv‘ed 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 To summarize, we believe that our results show that aspects of personality can be differentiated, which are significantly related to the response to treatment. The basic personality pattern of the patients Who respond best to electroshock treatment can be characterized as (a) nonempathic, (b) nonintrospective, (c) communicating nonverbally and ((1) highly conventional and stereotyped, with little imaginative or creative capacity. Within the context of this common care, there are two main subdivisions of improved patients. One group is comparable with the “explicit verbal denial” personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are affectively labile and ludic. The same personality factors 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. . . . REFERENCES Abraham, K.: Selected Papers on Psychoanalysis. (The Hogarth Press Ltd., London, 1949.) Arnot, R.: The Predepressed Personality. Arch. Neural. (G Psychiat, 76:617-618 (1956). Cohen, M. B., et al.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis. Psychiatry, 17 :103-137 (1954). Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock. Arch. Neural. c6 Psychiat, 78:516-525, 1957. 10. 11. 12. 13. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Hoch, P., and Zubin, J. (eds.), Depression, pp. 199-209 (Grune d2 Strattan, New York, 1954). Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neural. c6 Psychiat., 76:23-29 (1956). Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Hoch, P., and Zubin, J. (eds), Psychopathology of Communication, pp. 126. Piaget, J .: Play, Dreams and Imitation in Childhood (W. W. N ortau, New York, 1951). Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109:22-26 (1952). Weinstein, E. A., et al.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112:889-894 (1953). Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol. (Q Psychiat, 69:355-367 (1953). Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. J. Hillside H08p., 3:98-106 (1954). Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. (Charles 0'. Thomas, Springfield, Ill., 1955.) ' ��March 1957 £471.“. Personality Factors in Behavioral Response to ElectroShock Therapy Robert L. Kahn, Ph. D. and.Max Fink, From New WW. M. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by M—92? of the National Institute of Mental Health, National of Health, United States Public Health Service. grant Institutes Presented to the Electroshock Research Association, Chicago, l. , l, , , gnu-H‘SVAmh-fiy, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy variable. noted In previous studies of the factors related to that patients who showed is this variability early, persistent and relatively we marked degrees of altered brain function, as meaSured by the electroencephalogram and the amobarbital test for brain disease (10), were most response which was rated as improved (h) (6) (7). likely to The show a clinical present study is an investigation of the role of personality in the behavioral response. explicit hypothesis concerning this relationship has been derived An from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), patients patterns as explicit denial of illness; who develop such language we reported that personal, Spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) studies of neurological patients with cerebral dysfunction. in their 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- plicit verbal denial" personality (11). the hypothesis was advanced On the basis of these Observations, that those patients this "explicit verbal denial" personality type the behavioral changes The purpose after EST who most closely approximated would be more likely to Show which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reSponse to electroshock therapy can be differentiated; and 2) whether patients with greater "denial" tendencies are more likeLy to show proved. behavioral changes after electroshock therapy which are rated as imp �~2~ POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was asked to describe, in his interests and attitudes.. The relatives patient's usual encouraged to talk about any own were words, the aSpect they wished, and the interviewer followed the trend of rather than proceeding in a serial fashion. The their talk, interviewer asked questions, however, to obtain information in 15 Specific areas which have been described as characteristic of the "explicit verbal denial" personality. and type of questions required with each The number relative varied according to the de- gree of spontaneous production and the informant's capacity to comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence features: 1) stress verbal symbols such as rationalization; 2) are prestige and and extent of each of the following resolutions, homilies, cliches security conscious, intrinsic benefits of health, work, leisure, money and it a and and do not enjoy the property; 3) regard secret from family and neighbors,-and are reluctant to seek medical care; h) "shake off" their own illness as an imperfection or disgrace, keeping �-3troubles and are considered practical persons who advise others; 5) have drive and compulsive energy, and are guilty or uneasy if not much occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive it to criticism, regarding 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; 13) do not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25) After the interview, each item was rated score of O was given if on a scale of O, 1 or 2. A the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the each item were added and the resultant score pattern. The scores for is termed the "denial personal- ity score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The evaluation was determined by clinical the patient's behavior in the few weeks follow- ing the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: proved, following the much improved, moderately improved, or unimp criteria outlined previously (6). 3. lgnguagg §t_gy: In addition to the clinical interviews, each patient was examined toward his with a standardized series of questions determining his attitude illness. Two of the questions asked were, "What is your main trouble?" and ”If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim reSponses were anal- ized for changes in language according to the method previously described (7). �V «hRESULTS The relatives of scores ranged from h? patients were interviewed. to 25, with a O O denial personality statistical comparison Patients with scores ranging from 25 were consiRered the "high denial" group, while those with scores from to to For median of 11. the patients were divided into two groups. 11 The 10 were classed as low in denial tendencies. Patients with high denial 1. Personality score and clinical reSponse: personality scores in these family interviews were most likely to be as much improved, and only one case was considered unimproved (Table patients with a chance 30% I). In clinical reSponse rating occurred low scores, however, the basis, with rated on of the patients being regarded as unimproved. I TAJLE Relation of Denial Personality Scores to Clinical Response to Electroshock Moderately Much Unimproved Total 9 1 2h 9 7 23 18 8 h? Improved Improved Personality Score - 25 1h 0 ~ 10 7 11 Total . 21 The proved difference in the cenial scores between the patients, significant. % when compared to the unimproved much and moderately im- patients is statistically Although the much improves patients have a higher mean score than the moderately improved group, this Jifference is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores she the clinical rating, low denial scores * Significant at ‘1 30% of patients with were also evaluated as showing a marked improvement. 'Hhile 1% .0 ' level of coniidence by HannAWhitney U Test. �-5the group of seven patients be described. and security is a small one, certain common characteristics can Although these Subjects lack the competitive drive, prestige ne ds of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings» They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or bv violent tempers with table-pounding, throwing objects or direct physical assault. patients are "ludic," - a term used These by Heinstein and Kahn (12) to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were compared with the denial personality scores. patterns of language change, such as explicit denial of illness or Nine symptoms, displacement, qualification, 323' have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial personality scores showed a greater ality scores ality scores number of language changes, than those with low (Table II). The denial persen- coefficient of correlation between the person- and the number of language Chan es is + .71, significant at better than the 15 level of confidence. * This terizwas taken from Piaget behavior of young children (8). who pplied it to the play and imitative �-6- II TABLE Relation of Denial Personality Dcores to Clinical Language Changes During Treatment Number Language Changes - 0 2 3 or more Personality Scores 11-25 (20) 8 12 0-10 (20) 17 3 Total 25 15 h. Illustrative Cases: Case 1. A month High Denial Personality Score: élayear-old houswife was history of insomnia, abdominal nain admitted to the hospital with a 15 and fear of cancer. she was depressed, retarded, and seclusive, evincing On admission little interest in her surroundin s, and uaneering aimlessly about the ward. The patient was described responsible person with and was unable to home. She was much relax. by her husband as a conscientious, dependable, integrity. She had no As a conseguence, she hobbies, outside interests, busiee herself with chores at "mortallv afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she onenly showed no affection or emotion, never 6iscusse€ sex had "a long memory for little "streak of stubborness," sible for her mistakes." than borrow or take things and would if she and felt that According to the denial She she was wronged," a "just as soon hold another person She was proud ane would money from rarely lost her temper. "rather go reSponu without food" others. criteria, hrr score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor �-7called her a "model" patient feelings, asserted that band who was very good her discharge." who, "while reluctant to discuss her personal difficulties at home, had a wonderful husto her, considered herself lucky and eagerly anticipated she had no She was discharged with a Case 2. Low "much improved." Denial Personality Score: hl-year-old housewife A rating of 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 showed attention to her personal appearance, cried readily, psychomotor retardation and was circumstantial in speech. The whom He little noted to pay patient it was was described by her husband as a "negative personality" with not easy 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 ative person, she liked to sations. When put herself out for others. engage An excessively talk- in long, intellectual, pretentious converu angry, however, she would become either completely mute, or "very nasty, implying you just don‘t "cold" person, she was able to know any better." Although considered a talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "un- realistic," believing, for example, that she had a flair for writing although others considered her amateurish. rated as h. Her personality score The patient received eighteen electroshock treatments, which were term» inated at her was frightened to take any more,, At the time of her discharge her doctor noted her as "quite depressed," but felt that ital. it was own insistence because she was too doubtful that she could benefit from further treatment at the hosp- She was discharged with the recommendation for continued psychotherapy. �-8- . 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 havioral Changes the examiner. show both the language and be- to electroshock therapy which are rated as The data supports this hypothesis and much improved by 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 Linn and Kahn in 1952 (9). They suggest function in which the mechanism of denial is facilitated in characterologically disposed individuals." The degree of explicit verbal denial is, however, only aspect affecting the behavioral reaponse to treatment. one personality the basis of the On present data and methods of analysis a broader view of personality patterns in relation to improvement with rated as clinically empathic - ~ improved are unable to think EST is now possible. Those own who are characterized by such features as: 1) non- critically or sensitively about the needs, ings, or communications of others; 2) non-intrOSpective critically about their patients - — feel- unable to think feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic relationship; 3) rely heavily on nondverbal Communication little referential -- even.when they are communication, the words being cliched, stereotyped, or .representative of feelings and emotions action and h) highly conventional .. .. rather than transmitters of informp withoutimaginative or creativecapacity, y'and,with few resources to deal with stressful or With talkative there is this pattern as the common new situations. background, two classes of patients who "‘respond to treatment can.be-defined: a) the driving,.conscientious, independent, �.9can be successful, emotionally-controlled person who plicit verbal denial" personality type; b) the chronically inadequate, coming from an impoverished ively labile and ludic, dependent person, cultural background. characterized as the "ex- 'While both types are rated as improved affectsocio- in their short term reSponse to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical reSponse, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change'with electroshock therapy. The kinds of behavioral change shown with however, vary marcedly in different patients. denial or diSplacement of symptoms and paranoid agitated states, become withdrawn, altered brain function, Some show mood changes and are rated as improved. Others develop or show ory complaints, and are rated as unimproved. In additional somatic or memp this study we have stressed the personality factors in those cases whose behavioral reSponse was rated as improved. We have not considered the patients who were rated as only moder- ately 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 These this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic predepressed personality. Abraham (1) noted of depression occurred in obsessional persons. Arnot (2) describes that states depressions as being overly Conscientious and perfectionistic. Hamilton and Mann (5), reporting various aSpects of the personality in involutional depress- ion, include such features as "followed a rigid pattern of behavior....dis~ played a lack of imagination...narrou range of interestS..thorough, conscientious, �.10.. meticulous devotion to duty...1ack of feeling for point of view of others... hard, uncompromising drivers...oversensitive...reserved." Cohen, §t_§l'(3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having communicative interchange; and unaware of self or of his feelings toward others. to be little capacity for other persons' feelings toward him- They emphasized the patients' inability that the therapeutic relationship should in non-verbal terms rather than emphasizing the intellectual contents of communicate verbally and Suggested the exchange. studies of the personality background of depression Show a pattern that is most similar to those personality aspects whidh have been described These as the "explicit verbal denial" personality. The factor of personality could thus explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to non-verbal forms of therapy. These factors enable him 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, convention- ality, 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. �.11SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for e1ectro~ shock therapy were studied by means of a structured family interview. 2. which are 3. be The results show that aspects of personality can be differentiated significantly related to the reaponse to treatment. The basic personality pattern of the patients who respond characterized as a) non-empathic, b) non-introspective, c) non-verbally, and d) highly conventional and stereotyped, with best can communicate little imagin- ative or creative capacity. h. ‘Within the context of of improved personality, patients. One showing such and emotional control. ically inadequate grounds, uho are this group is core, there are two main subdivisions comparable to the "explicit verbal denial" common features as drive, conscientiousness, independence The oflaer group and dependent, coming consists of persons apt to be chron— from deprived Socio-cultural back- effectively labile and ludic. 5. The relationship between these personality patterns and descriptions of the personality of depressed perSOns is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of which altered brain function following electroshock therapy is evaluated as improvement. �.12.. FERENCES 1. Abraham, K.: Selected Papers on Psychoanalysis. London: Press Ltd., 19h9. Arnot, R.: The chiat., 3. Cohen, h. Fink, Predepressed Personality, Zé: 617—618, 1956. A.M.A. Arch. The Hogarth Neurol. & Psy- B., Baker, G., Cohen, R. A., FrommpReichmann, F. and Ueigert, An Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 11: 103-137, l95h. H. E. V.: M. and Kahn, R. L.: Quantitative Studies of Slow wave Activity EEG Clin. Neurophysiol., Q; 158, 1956. Following Electroshock, Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychosos, in Depression (Hoch, 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, A.M.A. Arch. Neurol. Kahn, R. 7. Language During Electroshock Communication (Hock, P. and Zubin, Psychopathology of Kahn, R. L. and Fink, M.: Therapy, in Changes in Eds.) in press. Piaget, J.: Play, Norton, 19 51. Dreams and Imitation in Childhood. New J., York: N. W. 9. Weinstein, E. A., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Pey- chiat., 193; 22-26, 1952. 10. ‘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., 11g} 889-89h, 1953. 11. E. A. and Kahn, R. L.: Arch. Neurol. & A.M.A. ness, neinstein, Personality Factors in Denizl of Psychiat., éfi: 355-367, 1953. Ill- 12. Ueinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp., 2; 98-106, l95h. 13. Ueinstein, E. A. and Kahn, R. L.: Denial of siological Aspects. Springfield, Ill.: Illness: Symbolic and Phy- Charles C. Thomas, 1955. �--.f\ ._ Personality Factors in Behavioral Response to Electroshock Therapy Robert L. Kahn, Ph.D. and From Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented to the Electroshock Research Association, Chicago, May 5/59 195”. �INTRODUCTION .The behavioral response of patients receiving electro— shock therapy is variable. In previous studies of the factors related to this variability we noted that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital most likely to show a test for brain disease (10), clinical response were rated as investigation which was present study is an of the role of personality in the behavioral response. An eXplicit hypothesis concerning this relationship has been derived from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), we reported that improved (h) (6) (7). The develop such language patterns as explicit denial of illness; personal, spatial and temporal displacement of symptoms; and qualification, 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 characterized this behavior as the patients who "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "explicit verbal denial" personality (11). On the basis of these observations, the hypothesis was advanced that �-2- closely approximated this "explicit verbal denial" personality type would be more likely to those patients show who most the behavioral changes after EST which are rated as improved. purpose of the present study, therefore, was to determine: The - 1) whether personality characteristics related to the behavioral response to electroshock therapy can be differ- entiated; and 2) whether patients with greater "denial" tendencies are more likely to show behavioral changes after electroshock therapy which are rated as improved. EQPULATION: Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was 1. �-3asked to describe, in his interests and attitudes. own words, the The relatives patient's usual were encouraged to aspect they wished, and the interviewer followed the trend of their talk, rather than proceeding in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the "eXplicit verbal denial" personality. The number and type of questions required with each relative varied according to the degree of spontaneous production and the informant's capacity to talk about any comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence and extent of 1) stress verbal symbols each of the following features: resolutions, homilies, cliches and rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and such as regard illness as an imperfection or disgrace, keeping it a secret from family and neighbors, and are reluctant to seek medical care; h) "shake off" their own troubles and are considered practical persons who advise 5) have much drive and compulsive energy,.and are others; guilty or uneasy if not occupied; 6) are conscientious property; 3) with a high sense of duty and responsibility; 7) are sensitive to criticism, regarding it as an attack on their �-u- integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly.af£ectionate or emotuonal; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25). After the interview, each item was rated on a scale of 0, 1 or 2. A score of O was given if the aspect was noted 13) do to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant scoretns termed the "denial personality score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. into three groups: much improved, unimproved, following the Patients were classed moderately improved, or criteria outlined previously (6). Study; In addition to the clinical inter~ views, each patient was examined with a standardized series 3. Language �-5of questions determining his attitude toward his illness. Two of the questions asked were, "What is your main trouble?" "If you 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 and according to the method previously described (7). �-6RESULTS relatives of interviewed. The denial personality scores ranged from O to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the "high denial" group, while those with scores from O to 10 were classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews The likely to were most patients h? rated as be were only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as much improved, and unimproved. TABLE I Relation of Denial Personality to Clinical Response to Electroshock Much Moderately 25 1h 9 1 2h to 10 Total 7 9 7 23 21 18 8 h? Improved Improved Total Unimproved Personality Score 11 0 to The difference in the denial scores between the and moderately improved unimproved * patients, when compared much to the patients is statistically significant.* Although Significant at 1% level of confidence by Mann-Whitney U Test. �-7the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with low denial scores were also evaluated as showing a marked improvement. While the 2. group of seven patients is characteristics a small one, can be described. certain common Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings. They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying 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) a term used to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were the denial personality scores. Nine patterns of language change, such as explicit denial of illness or compared with * This and term was taken from Piaget imitative behavior of young applied it to the play children (8). who �-8displacement, qualification, 323. have been described as characterically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial symptoms, personality scores showed a greater number of language changes, personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is + .71, significant at better than the 1% level of confidence. than those with low denial TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Language Changes 0 - 2 Personality Scores 11-25 0-10 (20) (20) ' Total h. Illustrative 3 or more 8 12 1? 3 25 15 Cases: gigh Denial Personality Score; A 61-year-old housewife was admitted to the hospital with a 15 month history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her surroundings, Case 1. aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with and wandering much �-9- integrity. hobbies, outside interests, and was a consequence, she busied herself with She had no unable to relax. As chores at home. She was “mortally afraid" of doctors, minimized her illnesses and concealed ailments, even from her husband. Very restrained, she openly showed no affection 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 or emotion, never discussed sex and another person reaponsible 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 was 20. electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a "model" patient who, "while reluctant to discuss her personal feelings, asserted After that she 20 had no difficulties at home, had a wonderful husband very good to her, considered herself lucky and eagerly anticipated her discharge." She was discharged with a rating who was of "much improved." Denial Personality Score: A 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 aetivities, found it increasingly difficult to take care of her Case 2. Low suicidal thoughts. On admission the patient was noted to pay little attention to her personal appearance, cried baby and had �readily, showed psychomotor retardation and was circumstantial in speech. patient was described by her husband as a "negative personality" with whom it was not easy to get along because The she was opinionated and argumentative. He 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. excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, An either completely mute, or "very Just don't know any better." Although however, she would become nasty, implying you considered a "cold" person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "unrealistic," believing, for example, that she had a flair for writing although others considered her amateurish. personality score was rated as h. The patient received eighteen electroshock treatments, which were terminated at her own insistence because she was Her too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed," but felt that it doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for was continued psychotherapy. �-11- Elialfiilgli structured family interview was designed to test the specific hypothesis derived from earlier observations that patients with the "explicit verbal denial" personality The are most likely to show both the language and behavioral changeswfiflxelectroshock therapy which are rated as much data supports this hypothesis and is also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952 (9). They suggest that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial improved by the examiner. The is facilitated in characterologically disposed individuals." 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 The of analysis a broader view of personality patterns in relation to improvement with EST is now possible. These patients who are rated as clinically improved are characterized by such features as: l) non-empathic - - unable to think critically or sensitively about the needs, feelings, or communications 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 the psychotherapeutic rely heavily on non-verbal communication they are talkative there is little referential relationship; even when 3) - �-12communication, 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 new situations. this pattern as the common background, two classes patients who respond to treatment can be defined: a) the driving, conscientious, independent, successful, emotionallycontrolled person who can be characterized as the "explicit verbal denial" personality type; b) the chronically inadequate, effectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short term response to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. of Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change slacwn with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms and are rated as improved. Others develop paranoid agitated states, withdrawn, or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality become �-13- factors in those cases as improved. We whose behavioral response have not considered the patients was rated who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relation~ ship 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. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic These 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 Mann (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior.... diaplayed a lack of imagination... narrow range of interests.. thorough, conscientious, meticulous devotion to duty...lack of feeling for point of view of others...hard, uncompromising drivers... intensive study of manic-depressive psychosis, reported their patients oversensitive...reserved." Cohen, sflngg (3) in an as being highly prestige-conscious; problems of little concerned with interpersonal relatedness; stereotyped; conventional; little capacity for communicative interchange; and unaware of other persons’ feelings toward himself or of his having �~1h- feelings toward others; They emphasized the inability to verbally communicate therapeutic relationship should be patients' that the in non-verbal terms rather and suggested than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a pattern that is most similar to those personality "explicit verbal personality. The factor of personality could thus the fact that depression is the condition which responds electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are aspects denial" explain best to which have been described as the those which make him responsive to non-verbal forms of therapy. These factors enable him 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 prestigeconsciousness, 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. �-15SQMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electroshock therapy were studied by means of a structured family interview. 2. The results show that aspects of personality can be differentiated which are significantly related to the reSponse . to treatment. 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 little imaginative or creative capacity. h. Within the context of this common core, there are two main subdivisions of improved patients. One group is comparable to the Wkplicit verbal denial" personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to 3. The chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are effectively labile and Indie. 5. The relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors 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. be �116REFERENCES 1. Abraham, K.: SelecteguPafiers on The Hogarth Press Ltd.,‘l9h9. 2. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. and Psychiat., 1g: 617f618, 1956. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichmann, F. and Weigert, E.V.: Antintensive Study of Twelve Cases Psychosis, Psychiat., 11: 103-137, 1ofsfianic-Depressive 9 3. Psychoanalysis. London: 5 o R.L.: Quantitative Studies of Slow Wave Activity Following Elastroshock, EEG Clin. Neurophysiol., g: 158, 1956. Fink, M. Hamilton, and Kahn, The_Hospita1 Treatment of D.M. and Mann, W.A.: Involutional Ps choseg, in Depression (Hash, J., 6. 933.5, New Stratton, FT and Zubin, 199-209, 1952. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Kahn, R.L., Fink, A.M.A. Arch. 7. York: Grune E M. Neurol. & Egychiat., lé‘ 23-29, 1956. Kahn, R.L. and Fink, M.: Changes in Language During Electro— shock Therapy, in Psychopathology of Communication (Hoch, Zubin, J., eds.) New York: Grune & Stratton, 1958, P.6and 12 ~139. fi J.: Play) York: W.W. Piaget, 9. Norton, l9Sl. Imitation in Childhood. New Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, 10. Dreams and Am. J. Psychiat., 109: 22-26, 1952. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbitai Sodium ("Amytal Sodium") Am. inSOrganic Brain Disease, ""‘ J. Psychiat., 112: 889-89h, 19 3. 11; Weinstein, E.A. and Kahn, R.L.:’Personality Factors in Denial of Illness, A.M.A. ArCh. Neurol. & Psychiat., £2: 355-367, 1953. 12: Weinstein, E.A., Kahn, R.L. and Sugarman, L.A.* Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. 2: 98-106, 195h. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects. Springfiél’, 111.: Charles i 13. UT Thomas, 1955. � 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 Personality factors in behavioral response to electroshock therapy. J Neuropsychiatr. 1959 Sep-Oct; 1:45-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-41-007 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 Kahn, Robert L.; <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 Two [preprints] and one reprint. Reprint fromJournal of Neuropsychiatry, Vol.I, No.1, Sept-Oct. 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/9a3312b18cdf6e7ffc1390135fa8f24f.pdf 7ebf0740040bf69f9525e1f11a533ee3 PDF Text Text 20 Soci0psychological A3pects of Psychiatric Treatment A Report of Treatment in Three Voluntary Hospitals ROBERT L. KAHN, PhD, NEW YORK; MAX FINK, MD, ST. LOUIS; AND NATHANIEL SIEGEL, PhD, BETHESDA, MD IN THEIR STUDIES of the New Haven treated primarily by psychotherapy, and repsychiatric patient population, Hollingshead ceived poorer discharge ratings. These and Redlich reported significant relation— clinical factors were also related to a measscale.""5 California F the of in the individual’s stereotypy, ure position ships between an social—class structure and the incidence of Higher F scores, ie, greater stereotypy, were treated illness, types of diagnosed disorders, often found in patients diagnosed as inand kinds and duration of psychiatric treat— volutional psychosis who were referred for ment administered.1 The influence of the convulsive therapy, hospitalized for shorter economic status of the patient on the avail- periods, and were more often rated as much recovered. improved or of however, was personnel, treating ability It was suggested that differences in psy— not excluded. should chiatric hospitals treatment in the social factors of among Studies of the role social factors of influence in— similar reflect a of hospitalized patients treatment Hos— Hillside within noted for patients dependent of their financial status and the as decided it to this To was test suggestion pital. undertaken of treatments were availability 1957 Hillside the of the procedures 1957. employ this In in hospital, at Hillside Hospital Hosinstitutions—Hillside in three instudy a variety of treatment modes, including dividual psychotherapy, pharmacotherapy, pital, the C. F. Menninger Memorial Hosand convulsive therapies were available to all pital, Topeka, Kan, and the Massachusetts inThese Boston. Health Mental Center, patients regardless of their ability to pay. In our surveys 2'3 we observed that patients stitutions were selected with the expectation hospitalized for the shortest periods were that diverse treatment modalities were older, had less education, and were more equally available to populations of different often of foreign birth. These older, less- social classes. Each provided short—term educated patients were predominantly treated treatment of voluntary patients and did not by convulsive therapy and received more provide custodial care. Each is a residency favorable clinical discharge ratings. In con- training center with a full—time supervisory trast, younger, native—born, more—educated staff and active research units, emphasizing patients were hospitalized for longer periods, psychoanalytically-oriented psychotherapy. This study was designed to determine the Submitted for publication June 21, 1965. From the Department of Experimental Psychiatry, Hillside in— three the of characteristics population Hospital, Glen Oaks, Long Island, NY 1959-1962. Currently at the Department of Psychiatry, University of Chicago, social with class, to stitutions age, respect the of at the Psychiatry Department Chicago (Dr. Kahn); Missouri Institute of Psychiatry, University of Missouri and F score; and to relate these education, School of Medicine, St. Louis (Dr. Fink); and the National characteristics to treatment variables of type Institute of Mental Health, Bethesda, Md (Dr. Siegel). Reprint requests to 5400 Arsenal St, St. Louis, Mo 63139 of duration of hospitalization, treatment, (Dr. Fink). ' Arch Gen Psychial—Vol 14, Jan 1966 �EPIDEMIOLOGY—DUNHAM Small City,” in Epidemiology of Mental Disorder, B. Pasamanick (ed), \Vashington, DC.: American Association for the Advancement of Science, 1959, publication No. 60. 46. Hollingshead, AB, and Redlich, F.: Social Class and Mental Illness ew York: John Wiley & Sons, Inc., 1958. 47. Morris, ].N.: ealth and Social Class, Laneet 12303—305 (F 1959. 48. Dunham, Dis— “Anomie and Mental .. order,” in Anom and Deviant Behavior, M. B. Clinard (ed.), Ne k: The Free Press of Glencoe, a division of the acmillan Co., 1964. 49. Buck, C.; Wanklin, M.; and Hobbs, G.E.: Symptom Analysis of Ru l—Urban Differences in First Admission Rates, ] erv Ment Dis 122 280-82, ].A., and Kohn, M.L.: Social Isolation and Schizophrenia, Amer Soc Rev 20:265— 58. Clausen, 273 (June) 1955. 59. Stein, L.: Social Class Gradient in Schizo- phrenia, Brit J Prev Soc Med 11:181-195 (Oct) 1957. 60. Carstairs, G.M., and Brown, G.\V.: A Census . (July) 1955. M.B.: Al native Hypothesis for the Explanation of Some f Faris and Dunham’s Re— sults, Amer J Soc 47 48-52 (July) 1941. 51. Schroeder, C. : Mental Disorders in Cities, Amer Soc 47 :40-47 ( 1942. 52. @degaard, (3.: E igration and Insanity: Study of Mental Diseas Among Norwegian Born Population in Minnes , Aeta Psychiat Neural, 50. Owen, suppl 4, 1932. 53. @degaard, Incidence of Psychoses 0.31m in Various Occupations, Soc Psychiat, vol 2, No. 2 (Autumn) 1956. 54. Ekblad, M.; Psychiat c and Sociologic ‘ 19 , of Psychiatric Cases in Two Contrasting Communities, J Ment 5 ' 72—81 (Jan) 1956. 61. Dunha r .W.: Community and Schizo— phrenia : Epidemiological Analysis, Detroit: Wayne Sta University Press, 1965. 63. Leig lot: Comm Psychiatry, , lisher, 1960. 64. Leigh ger, New Y. 65. LClgh the Epidemi demiology bank Memori b , .H.: “A Proposal for Research in y of Psychiatric Disorders,” in Epi— ental Disorder, New York: Mil‘ o Fund, 1950, pp 128-135. 66. Krame M.; “Discussion of H. W. Dunham’s article”. 'n Causes of Mental Disorders: A Review of miologieal Knowledge, 1959, New York: Milban emorial Fund, pp 271—273, 1961. 67. Miles, H.C., et A Cumulative Survey of All Psychiatric Expe nce in Monroe County, New York: Summary of ata for the First Year (1960), Psychiat Quart 3| ‘ 58-487 (July) 1964. 68. Dohrenw , B., and Dohrenwend, B.: The Problem of Valio in Field Studies of Psychological Disorder, ] Abn Psyehol 70 :52-59, 1965. 69. Benedict, P.R., nd Jacks, I.: Mental Illness in Primitive Societie Psychiatry 17 :379—390 (Nov) . . ’ E.: Mental Ment Hyg (April) 1935. 55. \Vinston, M.; Compa t e Study of Disease Incidence in Admissions to ase Psychiatric Hospi— tal in Middle East, Men ei 922118—127 (Jan) 56. Simms, 1946. 57. JaCo, E.G.: The Social Isolation Hypothesis and Schizophrenia, Amer Soe Re-zv 19:567-577 (Oct) 1954. 1954. 70. Hollowell, Philadelphia 1955. : .A.: Culture and Experience, niversity of Pennsylvania Press, Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL diagnosis, and discharge evaluation among the institutions. Method A census of all voluntary, adult patients in residence in the institutions was undertaken in January While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evalua— tion or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their nonvoluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead two-factor index—a weighted score of education and occupation—was used.“’6 The study population consisted of 173 patients at Hillside, 100 at Menninger, and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult, however, because of vari— 1959. ous methodological differences discussed below. These difficulties were most marked in the intrahos— pital comparisons and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, reflected in the tables by the varying population sample sizes. Results I. Methodological Problems—When re— porting studies from one institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. In TABLE 1.—Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction, narcissistic personality Anxiety reaction, narcissistic personality Narcissistic personality Narcissistic personality, alcoholism, chronic infantile personality Passive aggressive personality, alcoholism Infantile personality, schizophrenic reaction, schizoaiicctive type General Classification Psychoneurosis Psychoneurosis Personality trait disturbance Sociopathic personality disturbance Sociopathic personality disturbance Schizophrenic psychosis 21 gathering comparable data from multiple in— stitutions, however, the differences between institutions are accentuated. While these in— stitutions were selected as comparable in teaching, research, and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designa— tion of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. Designation of Type of Treatment: The criteria for designating that a patient , received “psychotherapy’ differed among the institutions, making comparisons (lif— 1. ficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with a psychiatric resident physi— cian were considered part of routine ad— ministrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising resident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines—psychiatric residents, psychologists, social workers, nurses, and medical students. Formal records of such sessions were not routinely included in the patient’s record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident physi— cian responsible for each case. 2. Diagnosis: Individual institutional di— agnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table 1, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Arch Gen Psychz'al—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL 22 Discharge Ratings of Improvement: Ratings of improvement at the three hos— pitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological, and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table 2). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. II. Interhospital Comparisons—1. Sociopsychological Variables: The distribution of the variables of social class, age, education, and California F scale score among the three institutions is presented in Table 3. A. Social Class. The anticipated differ— ence in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. B. Age. There were no differences in age distribution in the institutional populations. C. Education. The populations also differed in educational attainment, with patients having more years of education at Men— ninger Hospital than at Massachusetts Mental Health Center. While 41% of the patients at MMHC had not completed high school, only 32% at Hillside and 23% at Menninger did not graduate. D. F Score. Differences in the distribution of scores on the California F scale were also observed. Fifty-one percent of Menninger patients had F scores below 30, and only 8% with scores of 50 or above—the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside 31% of the patients had F scores below 30 while at MMHC only 20% were be- 2.—Comparative Ratings of Clinical Condition at Time of Hospital Discharge TABLE 3. low 30. Menninger Hospital Thus, differences in social class, tional attainment, and performance on the F scale were observed. These differences permit a test of the hypotheses relating socio— psychological factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables: A. MM HC Improved Recovered Much improved Unimproved Improved Social adjustment Character structure Recovered Markedly improved Moderately improved Slightly improved Unimproved Unimproved Improved Unimproved Syndrome Complete remission Improved Unchanged (or worse) Selection of Treatment. Among the institu— tions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table 4). B. Duration of Hospitalization. The three institutions differed with regard to patient’s length of stay (Table 4). Patients at Men— ninger Hospital were hospitalized longest, with 65% of the patients remaining for 12 months or more, compared to 31% of the Hillside patients and only 5% at the Massachusetts Mental Health Center. The modal stay of the Hillside group was beComparison: for 'Sociopsychological Variables TABLE 3.——Interhospital ' Hillside Hospital Menninger Hospital N 87 31 % I II III Social class l 17 13 28 28 O 5 20-39 40+ x2= N <12 12-15 16+ 121.5, df = 3.9, dr= 4, 100 23 % 54 23 x2 = 9.7, df = 4, [ F score { I N Arch Gen Psychiat—Vol 14, Jan 1966 x2 51 P % 41 8 = 39.2, (if = <0.001. 173 19 % 58 23 95 15 % 52 33 173 32 % 51 17 91 41 P: NS 92 10-29 30-49 50-70 L P 8, 100 19 % 59 22 <20 education 28 V = 72 3% 2O 1 x2 M M HC 51 IV N Age 133 7% 34 34 L Years of educa— Hillside Hospital 4, P % 49 10 <0.05 163 33 % 50 17 <0.001 76 20 % 38 42 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL TABLE 4.—Inicrhospital Difi‘ercnccs in Treatment Variables Menninger Hillside Hospital Hospital MMIIC 100 Ty pe of treatment Psychotherapy [ Duration of hospitalization Somatic Other 21% 43 36 x2=82.,8 df=4, P <0.001 NMo <7 Mo >11 M0 7- 11 100 22 % 13 65 x3=90.,6 df=4, P RecoveNred,1 % evaluation much1m- proved Improved Unimproved x2=29.3, df= N Discharge diagnosis 80 19 4, 89 24 % 68 8 173 27 % 42 31 67 % 27 172 23 % 88 28 % 5 5 P 62 15 61 171 52 22 S5 54 10 <0001 95 43 % 5 Schizophrenia Affective psychosis Psychoneurosis 52 & personality disorder xa = 23.8, df = 4, P <0.001 % % 17 26 29 tween 7 and 11 months while two thirds of the MMHC patients were discharged within six months of hospitalization. C. Discharge Evaluation. In each hospital, most patients were evaluated at the time of discharge as “improved” (Table 4). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as “unimproved” and only a single patient was scored “recovered” or “much improved.” The highest percentage of “recovered” or “much improved” ratings (28%) and the lowest proportion of “unimproved” (10%) were found at the Massachusetts Mental Health Center. D. Diagnosis. For statistical analysis three diagnostic groupings were made: TABLE 5.—Duration of Hospitalization, by Age Percentage of Age Group Staying Over One Year Age Below 20 20-29 30—39 40-49 50+ Menninger Hillside MMHC 81 73 61 30 36 42 14 6 6 0 0 36 30 20 0 schizophrenia, affective disorders, and psy— choneurosis and personality disorders (Table 4). The diagnostic proportions of patients within these groups were similar for Hill— side and MMHC, as slightly more than half were diagnosed as schizophrenia and one quarter as psychoneurosis or affective dis— order. In contrast, at Menninger Hospital psychoneurosis and personality disorder ac— counted for more than 50% of the popu— lation. III. Intrahospital Comparisons—The lack <0.001 99 Discharge 173 36 % 64 — 23 of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intrahospital comparisons. However, the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Men— ninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals—the younger patients re— maining for the longest periods. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table 5) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. Comment The patients of three voluntary psychiatric hospitals exhibited significant interinstitutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables—duration of hospital— ization, selection of treatments, and dis— tributions of diagnoses and discharge evaluations.7 Expectations based on our earlier intra-Hillside Hospital study were confirmed. The institution serving upperclass patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the Arch Gen Psychiat—Vol 14, Jan 1966 �24 SOCIOPS‘YCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL three institutions. Similarly, the institution serving lower—class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations. The contrasts between in— stitutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, defini— tions of psychotherapy, and the details and amount of recorded data. While these stylistic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater de— pendence on social class variables than ordinarily acknowledged. Such population and treatment variable relationships are interactive processes, de— termined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients present. Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, ie, where objective criteria defining diseases of known etiology are absent, as in schizo— phrenia, psychoneurosis, personality and be— havior disorders. Under these conditions of perceptual and situational ambiguity, the ob— server’s attitudes and expectations become significant aspects of his perceptions, classi— fications, and decisions. A similar situation was clearly documented by Pasamanick et al 7 in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards (lid not differ in type of admission, marital status, education, age, or residence. Significant differences did occur, however, in the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the popula— tions were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners. Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another. Literal adherence to these concepts produces paradoxical results. For example, Menninger Hospital with more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizo— phrenia, and yet, reports the poorest treat— ment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results. In the absence of independent criteria for the quality of care or the assessment of com— parability of populations for degree of ill— ness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions. Since the evalua— tions are based on the institution’s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psy— chiatric characteristics. In our initial Hillside study3 it was postulated that different criteria of improve— ment were utilized for persons of different social background. It was suggested that the higher the person’s social background the more complex the criteria employed. This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutions. Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower—class persons we are apt to assess improvement in relation to symptom relief or the patient’s capacity to resume work, while for upper—class persons the criteria emphasize such complex intangibles as “de— veloping insight,” or “working through one’s problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But dif— ferences in institutional style made it diffi— cult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, di— agnostic classifications, or length of hos— pitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient popula— tions. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labo— ratories, for the lack of confirmation may reflect differences in populations and psy— chiatric criteria as much as errors in the original hypotheses. The use of the terms “schizophrenia” or “psychoneurosis” to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by “objective” criteria rather than our present methods, so highly dependent on institu— tional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. 25 Summary Population characteristics, defined by social class, age, education, and F score; were related to treatment variables in three voluntary teaching hospitals. Treatment vari— ables included type of treatment, duration of hospitalization, diagnosis, and discharge evaluation. Interinstitutional differences were observed in patient social class, years of education, and distribution of California F scores, but not age. The variations in treatment characteristics among institutions were significantly differ— ent in the predicted direction. The institution serving upper-class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses, and more com— plex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions. Similarly, the institution serving lower-class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diag— noses, and the better discharge evaluations. These variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hos— pitalization, and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasized. Aided, in part, by grants MY-2092 and MY-2715, of the National Institute of Mental Health, US Public Health Service and the Nassau County Mental Health Board. Dr. Max Pollack aided in gathering material for this study. REFERENCES Hollingshead, AB, and Redlich, F.C.: Social C lass and Mental Illness: A Community Study, New York: John Wiley & Sons, Inc., 1958. 2. Kahn, R.L.; Pollack, M.; and Fink, M.; Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J Hillside Hosp 6:216—228, 1957. 3. Kahn, R.L.; Pollack, M.; and Fink, M.; Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitali— zation, Discharge Ratings and Diagnosis, Arch Gen Psychiat 1:565—574, 1959. 1. al: The Authoritarian sonality, New York: Harper & Brothers, 1950. 4. Adorno, T.W., et Per— Kahn, R.L.; Pollack, M.; and Fink, M.; Social Attitude (California F Scale) and Convulsive Ther— 5. apy, J Nerv Ment Dis 130 2187-192, 1960. N.H., et al: Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals, Soc Problems 10 :191-196, 1962. 7. Pasamanick, B.; Dinitz, S.; and Lefton, M.; Psychiatric Orientation and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer J Psychiat 116:127-132, 1959. 6. Siegel, Arch Gen Psychiat—Vol 14, Jan 1966 �26 Families of Children Wit nia hi hood SchizoPhr Early Sc ected Demographic Informajion L IS HENDRICKSON LOWE, MA, INDIANAPOLIS PREVIOUS STUDIjS regarding the etiological importance of l‘family background in childhood schizophr ia have produced Kanner4 i ressions. and diverse findings has stated that autistic hildren are usually found to have intellige , sophisticated pareducational attaine high have who 3a ents level. In his populatio 10f autistic patients, grad— school high the we of parents 94% and 49% fathers of while 74% uates, of the mothers had co 'pleted college. In another publication,3 he ‘emarked on a low incidence of divorce :1 ng these families. Bender,1 on the other h d, has noted that 'ong the parents no such trends exist of schizophrenic childre seen at Bellevue, " t " wide variety of backgrou It has also been rep ed that a fairly in is a s common to of ratio boys high these that and ion, schizophrenic pop children are freq fly the firstborn in their male-fe— the lists nder2 sibling group. 1 in a group of 142 male ratio as 7 of under chil age. en years schizophrenic autistic 27 of ulation with a Phillips,6 is which boys, that noted were children, also He 6:1. ratio male—female 0 early a autistic of ition ordina data on presents children. In the general opulation, the ex— is 44.12%.6 children firstborn of rate pected In a group of 635 disturbed (but nonautistic) children, Phillips found that 27 the of while firstborn, 76.38% were autistic children, 81.5% were firstborn. that to data these suggest Phillips interprets autistic children differ from the normal population in matters of sexual ratio and ordinal position as do lesser disturbed chil:1 of the suggestion out dren. He points continuum, with more vere childhood dis— turbances appearing cw comitantly with a higher ratio of boys 'l girls, and with a ‘l stborn children. It higher proportion of should be noted that ny data on ordinal position can be undistood better when viewed in conjunctio with maternal age at the birth of the chi these various re— Discrepancies amo ports of data may be due to disparities in om which samples patient populations were drawn. Bender nd Kanner, however, drew their patient ample from different population groups ,' ith respect to socio‘anner’s probably came economic status. largely from peopl in higher socioeconomic groups in a unive ity community while Bender had a wide population to draw from in New York ci . Since this poten— tial error is compounc d by the relatively low incidence of c'dhood schizophrenia in the general . The p pose of the present paper is to make .available pertinent information collected etween 1955 and 1963 in the Chil— dren’s S :VICC of LaRue D. Carter Me— morial Ho' ital, Indianapolis. The data on children is compared with that schizophre obtained on y-\turbed children given diag— childhood schizophrenia. noses other Since LaRue Hospital is the only nit for disturbed residential treatmen youngsters in the stat of Indiana, the patient population is probably representative of all geographic areas of the state as well as a variety of socioeconomic backgrounds. t Ca Method Subjects.—Included in the study were the children whose preadmission diagnosis was one of emotional disturbance, whether or not the child was admitted Arch Gen Psychiai—Vol 14, Jan 1966 Submitted for publication March 18, 1965. From the Indiana University Medical Center. . Reprint requests to 64 Mercury Ct, West Springfield, Mass 01089. �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts MEntal Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �In their studies of the New Haven psychiatric patient population, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure hand the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to payu In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth, These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingsa In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)c Higher F scores, i.e,, greater stereo— typy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered, In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -‘ Hillside Hospital, the C. F° Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classes° Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho— analytically—oriented psychotherapy, This study was designed to determine the population character— istics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �..2.~ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statuso The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrathospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample sizeso The �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. criteria for differed among At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res~ ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger HOSpital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systemso Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono �Table I Discharge Ratings of Improvement: Ratings of im~ provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)a For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsw Table B. II Inter—hospital Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having mOre years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Manninger did not graduateo c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight per~ cent with scores of 50 or above —- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attain— ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC Hospitalization: (68%) (Table IV), three insti~ tutions differed with regard to patient's length of stay (Table IV)9 Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per-cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization° b) Duration of The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diag— disorders, and �psychoneurosis and personality disorders (Table IV). The diag— nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the population° Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsidec Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods“ While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a yeare The Table —-—\ V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7), The —— Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psy— chiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, gig}, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his per— ceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners, Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions° Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria employedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been great— ly impressed by the methodological problems of studies across in— stitutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hos~ pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis'l to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective'' criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationw Inter—institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted direction. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc \Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. These differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo Such �REFERENCES l. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. Sanford, Brothers, R. N. The New Authoritarian Personality° York, 1950, 990 pp. J. and Harper and 2. Hollingshead, A. B. and Redlich, F. C. Social Class and Mental Illness: A Community Study. John Wiley and Sons, Inc., New York, 1958, 442 pp. . L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. Kahn, R. L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, G Ps h' Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, Sociopsychologic Voluntary Mental Discharge Ratings and is 565-574. Fink, M. Social Attitude (Cal— Scale) and Convulsive Therapy. .lefiflah_lkflflfi_Dlfi,, M. and 1960, lfifl: 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Ameri_la_£sxchiat., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete_Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociogsxchological Variables MEnninger Hospital N I Social Class III Hillside Hospital Massachusetts Mental Health Center IIIIIKEEIIIIIIHIIIIIEIIIIIIIIIIIIIIIHEIIIIIIII 31% 7% II 51 20 III 17 34 . . IV 1 34 V O 5 X 2 = 121.5; df=8: p<.OOl IIIIIIIIIIIIIIIIHNIEIIIIIIIIIIIHHIIIIIIIIIIIIIIIJBHIIIIIIII 19/ Ag e 20- 39 IIIINIIIIIlllllflflddflllllIIIIIIIHHEIIIIIIIIIIIEHIIIIIIIII Years of Educatio < 12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables jMenninger N Treatment Massachusett Mental Healt Center .m-m-mHospital Type of Hillside Psychotherapy Hospital Somatic Other =82 8 Duration of , Hospitallzatlon 7 df= 4 . .001 months 7-11 months ~11 months Discharge Improved Evaluation Unimproved X = Schizophrenia 29.3' df=4' .<.001 ' Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 52% 54% 22 17 26 29 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 30 40-49 30 20 50+ 36 MMHC 14 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Agg Below 20 Hillside 81 20-29 73 30-39 61 30 ho-h9 30 20 50 + MMHg �TABLE IV Interhospital Differences in Treatment Variables Menninger Hillside Massachusetts .m---Hospital N Psychotherapy Somatic of Treatment Type WW Other l Duration of Hospitalization Hospital Mental Health Center 9 21% 36% 2b% h3 6h 68 36 -- 8 » . _ . _..W.xi:82-8:.§_£:-hz P<-001 mud-Mm...“ w...» W 7-11 months x2=90.6; df=h; p<.OOl Recovered, Improved Discharge Evaluation f ‘> . 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Thane imfitndmmumfwfinbcmfiamlumpmdfln Wmmmdmbmmdmmmwmd. obtain mm Mammuammfinpmblmofflumdaulm 65.1ch data. But in style made it difficult to mmblc ofmantiwstafiatim,apocidlyinfiuommimofmmimie Mics. Mmofdismmfim,dimficfludflafimsor Mdmitmufimumminmmmwfiu to extensive of warm imtitutims mien countable popuhflms the m clan-1y m swim mm m for staff attitudn cad styhumllusocialclasspaminpatimtpomlafiom. cholicve mmfmmmommfiufaflmofmimfisummflm mbmmrmdmmimmmmmmmw sdmbmduudbymmiwmulu. Manudobmatimtobo Whamlnbomtmy,ttnmfimdsmmtavaflablctodaym mmmmmmmmrwmmmm. �-13- Inam‘asod attunticn must ho paid to tho althodblogiaal prcblumn of classifying mjom mlthads, so highly dnpgndant an m criteria institutional by ”objcativa" than the present and obonrvur attitudul mmmmmmmammm-pmmm. �Wmmnsxm 1. Infimowydmmic-mmmmgmfitnn, WWmmammmmmtm-hbm. Populatimsmdcflmdbyaomlelus,m,adumtimmfsm. mmmhmmtypoofumt,dmfimofhmpitmadm. Wwflmmmflm. 2. 3191131121“: inurhwfitutianl diffm m obscured in Wflmofpatimtsoahlelus,ymofodmutimm diuudbufimofcuifwml‘m,butmtago. mmmmmwummmum timmfmmbouigflfimflydifimtinmpmdicmd 3. dim. It. mmmmymammmnmnm mumtwithmmclusdflfmwmgimflmdmsmdm thuidiosynmtie. 5. matrmmmmmmummmof W,mumof)mpimnmim,mdmammultnbam mmwfimdtmmm,mmmdfmmobjwdw «imamimdmofmmfimsismim. �REFERENCES 1. Adorno, T.w., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New Brothers York, Harper R.N.: The Authoritarian Personality, 1950. Two-Factor Index of Social Position, Hollingshead, A.B.: mimeo— graphed publication. Mental and Class Social F.C.: Redlich, & New John Sons, Inc., Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: §g_p., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: 565—57h, 1959- (CaliM. M.: Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, fornia Scale) Kahn, 122: 187-192, 1960. Pasamanick, B., Dinitz, Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: tion and Its Relation to Diagnosis and 1959. 127-132, Amer. J. Psychiat., llé: Hospital, Siegel, N.H., Kahn, R.L., Pollack, and Treatment in Three M. and Pink, M.: Social Class, Diagnosis Psychiatric Hospitals, Social Problems, 10: 191—196, 1982. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved ~W‘_ Improved Moderately Improved Unimproved Slightly Improved Improved Unimproved Unimproved Syndrome .._.W Complete Remission Improved Unchanged (or worse) Markedly Improved W- �III TABLE InterhosEital Comparisons for SocioEsychological Variables Hillside Menninger ; Hospital Hospital Education 17 ’ (92) N 3 Score 1 i ’ F Massachusetts Mental Health ; 10-29 1 3o-h9 W7 51% i ’41 g (163) 33% 50 10 g i 76 20% 1 '1 38 } 50-70 8 1 i 17 g M �TABLE IV Interhospital Differences in Treatment Variables Massachusetts lHillside iMenninger Mental Health Center IHospital ‘Hospital ‘Psychotherapy of Treatment Type Somatic h3 Other Duration of Hospitalization 36 ’ 7-11 months 1 months Recovered, Improved Discharge Evaluation Much Improved 61 ’ . 'Unimproved 10 % I 9 . - _ mw.,,__,‘<2=29-3s df=1v fianQwawiwflj I Discharge Diagnosis tr-‘a-m-th-A _ ...-A.Wn‘.m Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde .W--- 85 Sh% 1? 26 29 ”- -.- —-”“— w- �TABLE V Duration of HosEitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside Below 20 81 h2 20-29 73 36 30-39 61 3O hO-h9 3O 20 50+ M9 �‘— ‘7 -w vuwlr-u'rflmmm —-u-- “Tm—“vii W Hm: W. 21, man 911.13. Hill-M- Wu}. P. 0. Dan: 33 man Odes. the You: W81 , mm. mm mmmlht: MWWIMBWMbyaWo-n I whammmm'mmmmmmrmunm. Midwinbutlmzldlfluewrymm IMMMM Mtfizhfwwblmw . Wumflulntdmfimfm Wh.metMtoajml,ImflAlihto$smm-d Hm,I mmmmwmuwmmm. singlubmmtittoamoffiujwmmmwm to . 81 FILE. ‘ ‘ mm,mmmqumummxwmt mwmumwtm-mmdtmjmw. WWW. ma: �flv psychiatric treatment, haMflm and research December 2h, l96h Dr. Max Fink Missouri Institute of Psychiatry Shoo Arsenal St. St. Louis, Missouri Dear Max: (E) / (:> let, the have reread I In reply to your letter to and objections my original paper on sociological aspects the skirts I feel no altered. it in way this paper are whole problem of diagnosis which Nat in a previous paperwhich and than social class, has shown to be more ;important True, variable. be crucial a VA showed to I in the paper disturbed more severely younger same institution within the of time period a and longer for kept patients are treated and all this is relative to the philosophy of the the in not reported at all is This viewpoint institution. paper. form. in present its of in publishing favor not it I am Should you have some specific need for seeing it published, removed. was name my providing no objection I would have collaborate to want should you authormanship, of Speaking variables and psychological EEG and psychiatric on the findings I would have no objection. My best wishes to you, Martha and the kids for a Joyous New Year. have him I and Turan to tell Please give my regards ordered a copy of his book. Sincerely yours, of the 10m»; MP:gp Pollack, Ph.D. Senior Research Associate Max �m 21, 196‘! mmmrmtmmmgm-ormw;md fdfluMdmmm-Jmlofwmommfia Mfllhdmlafhyuhhm. mfiwmhfin ”magma-mum. hmmhmyw. and: Enema-mu cc: Pollack Ph.D. Nathmial siegel, Ph.D. Max �MONTEFHMHCHUSPVRHJAND MEDHLMACENTER 111 EAST 210TH STREET. BRONX, NEW YORK 10467. TELEPHONE: 212/TU 1-1000 January 19, 1965 Fink, Director max M.D. Missouri Institute of Psychiatry suoo Arsenal Street St. Louis, Missouri 63139 Dear Max: I think the paper is fine, and would touch it as little as possible. Your choice of Journal is excellent. For my part, go ahead and submit it. The only change concerns the here - "Mbntefiore Respital and Mbdical Center" and the revised address as revised name shown on this letter. It to see you and I pleased that you are doing well. was good am Best regards to Martha. Sincerely, RLK:FB Rdbert L. Kahn, Ph.D. Head, Section on Psyology Division of Psychiatry �DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 December 31, 1964 NATIONAL INSTITUTES OF HEALTH AREA CODE aoI TEL: ass—mo In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink, Director Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: I was pleasantly surprised to see the paper on "Sociosociological Aspects of Psychiatric Treatment in Three Voluntary Hospitals" again. I was really delighted that you resurrected it and have taken responsibility of submitting it to one of the journals that you listed. I have no real preference for one of various journals that you mentioned. I would think it would be most unlikely to be published in Psychiatry, but I am sure you share this opinion since you listed it last in your order. In all honesty, in rereading the manuscript, I found it to be much better than I remember it. Most of my comments are of a stylistic nature. Here, however, I would bow to you as the collator of the document to use the style that you prefer. My own penciled comments are, however, on the paper. V/ I think the main contribution that this paper has to make, and should make, has to do with the methodological problems that are involved in doing cross-hospital studies or in doing hospital studies within the same institution over a period of time. As you indicate in the paper, on page 4, that when one reports studies from one institution, the structure of the hospital is either taken for granted or ignored. Cer— tainly, we should be elaborating on this in great detail, and the methodological aspects of doing a study, such as the one we have done, Should occupy a major area of the report in its own right. For this reason, I am not sure I would report methodological problems as we have done on page 4. I think that it should either occupy a place of its own in the discussion or might indeed exchange status with "AH Interhospital Comparisons on page 4, and become the "A" category, or interchange and make Interhospital Comparisons the "#1" category. Most of the things that we want to say are in the paper but, as I have indicated, I am a �2. little unhappy about interweaving our "findings" with the "methodological not being our intent in the original investigation in the also, report. more I, important the I being think ...and, yet, would I of the author be try to should senior paper. believe that you own in and autonomy right its give problems it methodological the spotlight Section." 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MWuwa-mw. mammmmwmmummw m.mawunuum.newmum mmmtum.mmmmmwmdw B. wwwmmamnw �REFERENCES 1. and D.J. Sanford, Levinson, Adorno, T.W., Frenkel-Brunswik, E., & New Brothers York, Harper R.N.: The Authoritarian Personality, ' 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo— graphed publication. 3. Hollingshead, A.B. and Illness: A Community Redlich, F.C.: Social Class and Mental & New John Sons, Inc., Wiley York, Study, 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a Hos2., g: 216-228, 1957. S. R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: and Diagnosis, Ratings Discharge of Duration HOSpitalization, Kahn, Arch. Gen. Psychiat., 6. l: 565—57h, 1959- (CaliAttitude Social R.L., Pollack, & Ment. Nerv. F J. Dis., and Convulsive Therapy, Scale) fornia M. Kahn, and Fink, M.: 129: 187—192, 1960. 7. Pasamanick, B., Dinitz, tion Hospital, and 8. and to Diagnosis Relation Its Amer. J. Psychiat., 116: 127-132, l9S9. Siegel, N.H., Kahn, R.L., Pollack, and Treatment Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: M. and Pink, M.: Social Class, Diagnosis in Three Psychiatric Hospitals, Social Problems, 10: 191-196, 1962 �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered A Markedly Improved Much Improved Improved A ! Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved Moderately Improved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociopsychological Variables i I Social Class Years of Education III Menninger Hospital Hillside Hospital : I Massachusetts Mental Health �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health iHospital Center ' of Treatment ‘Psychotherapy Type 68 Somatic 8 Other 1 . _fl, __ Duration of Hospitali— zation 7-11 months 1 months Improved .--a-—u.~...w Much Improved 61 Unimproved lO a,” Discharge Diagnosis , months Recovered, Discharge Evaluation ~__imiu_i_.,i_.__.::- . ”13:29-33 W Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde df=h~ 5,1001 I ‘ ”WWW” 85 22 1? 26 29 ! I S2 1 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £52 Below 20 Menninger Hillsidg 81 he 20-29 73 36 30-39 61 30 ho-h9 30 20 3422219. �' > %> This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hespital, Glen Oaks, L.I., N.Y., 1959-62. Pal/sue aux! KIRIM“ cooperation of the staffs of the Massachusetts Health Center the is The acknowledged. and C.P, Menninger Memorial Hospital Mental gratefully Aided, in part, by grants MY—2092 and MEI—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. ** Present Address: Division of Psychiatry, Montefiore Hespitalaw* ’ ' {hxxfirtfiF-itfifr IO‘NAZI g“ QM? 1.14: 0M yNL nan : National Institute of Mental Health, 'M, -flflqmam pn--~~r~Ognv m. Bethesda, Md. Department of Psychiatry at the Missouri Institute of Psychiatry ef-the-SChool of Medicine, University ot’ Missouri, suoo Arsenal Street, St. Louis) an, Ma, 6399'"! ,4 :9, �In their studies of the psychiatric patient population, Hollingshead and Redlidh have reported significant relationships between an' individual's position in the social class structure and the of treated New Haven illness, types of diagnosed disorders administered.(;%. treatment patient . The and kinds and duration W of psychiatric influence of the economic status of the the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized on #‘Ffi‘ . ' IflL srflwu‘ patients independent of pateent‘s finances and the availability of treatments were undertaken at Hillside Hespital in 1957. In this hospital, a variety of treatment modes, including individual psydhotherapy, pharmacotherapy and convulsive therapies were available to . . . . all patients regardless of their ability to pay. (Eglgé In these surveys we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth. These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings. These clinical factors were also related to a measure of stereotypy, the ' California F ’15’ Scale (1333. Higher F scores, i.e., greater stereotypy, were often in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized fOr shorter periods, and more often were rated as much improved or‘recovered. hen, (gram) e' In thzs surveyglit was suggested that differences in psychiatric treat— ment among hospitals should reflect the influence of social factors as noted f0und fbr the patients within Hillside HOspital. To test this suggestion it was �decided to employ the procedures of the 1957 Hillside study in three institutions Hillside Hospital, the C.F. Menninger Memorial Hespital in Topeka and the Massachusetts Mental Health Center in Boston. These institutions were selected mm» Ww-Mans.:qum-W nag-MW : with the expectation that they served patients of different social classes.and- provide custodial care. Each supervisory staff and is a residency training center with a full active researCh units) time emphasiqgugsychoanalytically— They oriented psychotherqua This study was designed to determine the population characteristics of the three institutions with respect to social class, age, education and score; F to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the in— and stitutions. M'MWW,.,L..««Ila-mm?” W/ “”‘MW‘WWW ”‘W “’ m "' “ t4" "M" ‘flwwmwww ”‘ W “m «a , N, WWW‘W,MM —— �/ A METHOD census of all voluntary, adult patients in residence in the institu— in January, 1959. While Manninger and Hillside Hospitals had voluntary patients only, a small number of those at the MassaChusetts Mental Health Center (MMHC) were assigned by the courts for psydhiatric evaluation or tions was undertaken of a chronic schizophrenic state hospital group transferred for a from because excluded the These study were researdh patients project. specific of their non—voluntary status. The California F scale was scored for each were members patient on the census day. Eighteen months examined were of records the disdharged patients later to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingihead 2—factor index a.weighted score of education used(g;ii;.The and occupation was study population consisted of 173 patients — — at the Massachusetts Mental Health Center. social of the to the The study included examination.of the relations psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra— hcspital comparisons, and accordingly, in the analyses of psydhiatric variables emphasis will be placed on the differences between institutions with citation of at Hillside, 100 at Manninger and 95 intrainstitutional trends. These difficulties also led to missing infbrmation 1&6/34 6, #2, for some data, whidh is reflected in th varying population sample sizeslénrthe 4fififlxeu �RESULTS I Methodological Problems A‘ When reporting studies from one institution, the structure of the hospital maybe taken forgranted and either ignored or mentioned briefly. 'W 1,, e comparable gathering gr; m, _ M ”1111111....” institutions While were selected as these data from.multiple institutions, . in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific-problemscygf4LAt-Lk* comparable were prominent tions, in the designation of type of treatment, diagnostic classifica- and the evaluation of treatment outcome. criteria for designating that differed among the institutions, making come Designation of Eype of Treatment: 1) a patient received ”psychotherapy" [Sous parehti=ay The difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a patient was Charged a fee. staff psychiatrist for whidh the Sessions with the psychiatric resident were con— sidered part of routine administrative patient care. 'At Hillside Hospital psydhotherapy was defined as treatment sessions with Staff psychiatrists did not treat patients, but No additional resident physicians. restricted their activities to supervising a psydhiatric resident. fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated aucha‘ functiggrof psydhiatric residents, psydhologists, social workers, nurses and medical students. Formal records of such sessions as the many disciplines -— �which ascertain and record to in the included patient's were not routinely team members the of study for was received necessary psydhotherapy it patients to interview the resident responsible for eadh case. made comparisons diagnostic styles Individual institutional Diagnosis: evaluative the multiple employed diagnoses At Menninger Hospital difficult. 10 dlil the American Psydhiatric Association)while both followed different unitary systems. Several examples of scheme recommended by Hillside and MMHC conversions with Table suggested in our I, diagnoses from.Menninger are listed con— These two institutions. other of the that into categories comparable to versions provide a source of distortion. at the detail. The discharge rating at Menninger and format varied in three hospitals Hospital was tripartite with a separate evaluation for social, characterological 53) e Rat' Disc s of rovement: Ratings of improvement Hillside Hespital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome and syndrome Changes. rating 3. jfiflv was compared to the global ratings of the other institutions. "A, .16 (’30 waft/mm Co I. Sociopsychological Variables The distribution of the variables of social class, age, education �and California F Scale score among the three institutions is presented in Table III. a) Social Class: The institutions composition of the three the population anticipated difference in social class was observed. was predominantly upper At Menninger Hospital class; at Hillside Hospital, middle Massachusetts Mental Health Center, predominantly lower class; and at class. There were no differences b) ége; in age distribution in the institutional populations. c) Education: The populations also differed in educational attain- ment, with patients having more years of education at than at MassaChusetts Mental Health Center. While Ml patients at per cent of the had not completed high school, only 32 per cent at MMHC Hillside and 23 per cent at Menninger did not graduate. d) F Score: Califbrnia F patients had 50 or above below 30. Differences in the distribution of scores on the Scale were also observed. Fifty—one per cent of Menninger F —- of stereotypy. patients had Menninger Hospital F scores below 30, and only eight per cent with scores of the higher F scores being associated with higher degrees In contrast, at Hillside thirty—one per cent of the scores below 30 while at MMHC only twenty per cent were �Thus, thl=a=pa===d.differences in social attainment and performance on the #40; F class, educational Scale were observed. RELA'H u a. These differences permit a test ofkhypotheses oamannrnngdflxrirfiefifixwrtn? sociopsychological factors to the treatment variables among these institutions. 12. Psychiatric Treatment Variables a) Selection of Treatment: Amongfiinstitutions, significantly at Menninger Hospital (”3%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). fewer patients b) DUration of H05pitalization: The three institutions differed with regard to patient’s length of stay (Table IV). Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per cent of the Hillside patients and only per cent at the MassaChusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were disdharged 5 within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger Hospital, however, a higher percentage (19%) of were rated as "unimproved" and only a single patient "recovered" or "much improved". or "much The was patients scored highest percentage of "recovered" inproved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found d) Diagnosis: groupings were made: at the Massachusetts Mental Health Center. For statistical analysis three diagnostic schizophrenia, affective disorders, and psycho- neurosis and personality disorders (Table IV). The diagnostic propore tions of patients within these groups were similar for Hillside and MMHC, �as slightly more than half were diagnosed as schizophrenia and one- In contrast , at Menninger quarter as psychoneurosis or affective disorder. Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. 6. Intra—Hospital Comarisons lack of meaningful criteria for the subdivision of populations, 1......an size and 1:: the sample each within institution homogeneity their dgghb A $31“ Lou-T precluded adequate intra—hospital comparisons . everal groupings were The WW Jr”) W obtained which had fewer than five cases) . . . . 94 z 5/ the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher more and somatic therapy), receiving frequently F P score patients score alone at Hillside. both the related at and were chronological of age hospitalization length Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these MMHC V) where no (Table noted the was at trend similar two hospitals, a Menninger and patients over 40 , but 1% of patients under the age of than a year. ————_———_—— 20 remained longer �DISCUSSION Q , M daM SOClal variables—95 1:11: differences in Significant interinstitutional of distribution in not but age; years of education/W97 ; F ? {”1238 MN 3 WI } kw of eva‘aaeed periods shorter lower class patients the institution serving Eta and fieportions diagnoses of low psychoneurotic “better , hospitalization, discharge evaluations. \ ment are fiuw $7, memm‘ ; (M I and complex more diagnoses of psychoneurotic of stay, a higher proportion a forms somatic receiving of patients diagnostic schemataalower proportion “in Similarly, yere-eaeh-eonflmed. ratings and discharge of therapy, poorest r“ “3 {2/ MW W , ”fl 033°” “5: f Wtuw W —variables treatment the each of and F in California Scale scores; duration of hospitalization, selection ff treatments and distributions “MM: Mafia—5’ in— e of diagnoses and discharge evaluations. ..._v,.__~__~_.'/l\——".~W-v J! A . . . . duration the longest class patients stitution serVing upper ' f""\ 9’ «mean related Ato differences in staff attitudes than—to— “errences in populations . 'Ihe contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic and of evaluations psychotherapy, formulations , discharge , definitions lflese differences recorded data. amount and stylistic of details the W wwfi‘sfissed as slinky idiosyncratic1am they follow a pattern M, W related to social {W WW; meabmx/Wm fig “W434. differences] consistent7with . �-10- Such population and treatment variable relationships are Cf the physician attitude the both determined by interactive processes , and the administrative staff and by the Such constellation of symptoms or relationships are marked most history which patients present. least are criteria where diaglostic conditions those in psychiatric known of diseases defining criteria where objective i.e. specific, , fl personality schizophrenia, in psychoneurosis/ etiology are absent, as AAA-0L of conditions perceptual a: Under these disorders. and behavior and expectations attitudes observer's the situational ambiguity) Ak444~0u4, become 5 I4 v "uufi situation was Eris his perception classification) 6 . . . . study their and (1) lefton in Dmitz Pasamanick, clearly emanated-by observed They institution. within a single of variations in diagnosis in did differ wards not type different to assigned“ that patients g4en¢bh ' o dew S ’and' ~qu réaedéup _ M ’1 Significant residence. education, or age marital status, of admission, diagnostfié Cewif‘UI-Lflvarious of incidence differences did occur, however, in the among the three wards and m ' believe thefi reflect the among differences attitu W ward. one on administrators three As (“E in the populations/ we es 0 the examiners. ”atclinical evaluation Present psychiatric concepts of diagnosis par” another. to institution have little For results . roduces paradoxical literal adherance to these concepts meaning when example, Menninger transferred from one M mhighly trained personnel Hospital has—themes; con— 3% has “fewest the for longest patients its keeps time/and ducting treatment, the poorest Ad reports yI.’ yet, as diaglosed schizophrenia, patients I i I �-11- treatment results. ,fit'MMHC, in contrast, whiCh is most inclusive in defining a therapist, which keeps patients for the shortest periods, and whéeh-has a higher-proportion of the population classed as schizophrenia, OV’ quality of carefnnop the assessment of comparability of populations for degree of illness among the institutions)‘ Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of rather than.§gy intrinsic psychiatric Characteristics. In our criteria of initial Hillside it was postulated that different utiliZed fer persons of different social suggested that the higher the person's social improvement were It baCkground. study (‘) improvement was the more complex the cr1ter1a.enm3i?:§é*£lgis has‘::§&;1 background literally confirmed in the present study, WithAMenninger‘EluSIng a to the global rating of the other two institu— considering the syndrome rating on whidh our comparative tripartite rating tions. Even statistical compared analyses were based, it is our contention that fOr lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize sudh complex intangibles as "developing insight", or "working through one's problems." �-12_ demonstrated the role of While these investigations have again social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These selected for their educational leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable institutions were data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of disdharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. fikrtefiéeve——— difficulties also extend to the failures of scientists to clinical or laboratory observations made in other laboratories, lack of confirmation may reflect differences in populations and criteria as much as errors in the original hypotheses. The use confirm ’Ehese for the psychiatric of the terns "schizophrenia" or "psychoneurosis" to explore changes in psydhological and biological features of mental illness has led to-;:;1mnanadrthgr 6;Z;é science burdened by negative results. a valid observation to be “40W reported from one laboratory{ the methods armhamfiaafieélable—teéay to Judy.” «(no—c..- (adeduately)describe psychiatric populations for an=adiqnuta==nnfinm==éan. //*~—~.“www.m“imm. “WM.,.,.--M—«~~WW" c M 4;,Aaanéigzgedai7 . : 54; fggfi"JR;¢”;' 2%;7*"/;? E �~13. fzar Increased attention must be paid to thenaathedniogéoairprebiemSuei—-V4-’ 3 w, a by "objective" criteria rather than the present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. $nn“ g cla881fyiag sub ects ‘ . o a 9 a �-1u- WW SUMMARY and “Wu-I 2 @1 MW VoLu u'! three CONCLUSION MWHw.» m...» (A a. teaching hospitals, W,~.mm~__1_ ""“"Wm.m...“ mmwv— vm l.»/ fiopulation characteristicsjig-ererelated to treatment variables W ,.. . ., wwmm MN defined by social class, age, education and F score , W type of treatment, duration of hospitalization, TfZM (W Washed-#0 W diagnosis and discharge evaluation. Z interinstitutional :da— differences were observed in patient social class , years of education and California F scores , but not age. distribution of @ variations in treatment characteristics among institutions were found—$0.435; significantly different in the predicted ‘2, The direction. '% 6 “Q variations in psychiatric practices follow a pattern among’f‘institutions withgocial and are consistent class differences These not regarded as idiosyncratic. 6g ‘Eae differences in institutional style make comparisons of between and treatment duration results of diagnoses, hospitalization, institutions difficult and tenuous , and the need for more objective criteria 4w 4C1 ff classification ( 0 ne‘kfi‘m‘v) emphasized. is pppulations A �REFERENCES Adorno, T. W., Frenkel-Brunswik, Authoritarian Personalitz. The 990 pp. 3. Communit238tudz. J. and Sanford, R. N. Harper and Brothers, New York, 1950, D. Class and Montal Illness: John Wiley and Sons, Inc., New York, T933, KHZ pp. Hollingshead, A. B. and A E., Levinson, delich, F. 0. Social L., Pollack, H. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Montal Hospital. J. Hillside Hos ., 1957, Q; 216Kahn, R. 228. h. Kahn, R. L., Pollack, M. and Pink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Montal Hospital: Duration of Hospi- talization, ;: 565-5714. Discharge Ratings and Diagnosis. Arch. Gen Ps hiat., 1959, S. Kahn, R. L., Pollack, M. and Fink, H. Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Mont. Dis., 1960, 1;_: 187—192. Pasananick, 3., Dinitz, s. and Lofton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. P hiat., 1959, gig: 127-132. 7. Siogel, N. H., Kuhn, R. L., Pollack, M. and Fink, H. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 19: 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved -WM_W_ Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE InterhosEital III Comparisons for Sociopsychological Variables Menninger Hospital I Hillside Hospital 1 Massachusetts Mental Health s 2 § a 3 1 1 Social Class III E 17 3b ‘ z g i g 1 i i 3 i l ! z ~, Years of Education llZ—lS ; % i a 3 I F Score 5h '13 �TABLE IV Interhospital Differences in Treatment Variables ;Menninger [Hillside Massachusetts {Hospital [Hospital Mental Health of Treatment Type 'Psychotherapy Somatic 68 Other 8 I Duration of 7-11 months Hospitali— W zation months WWW..-”— mmm -w - 1 *- Recovered, Improved Discharge Evaluation Much Improved 61 Unimproved 10 . i Discharge Diagnosis . , I mewmm 001 -.......’32_.L.__.......B< _.... Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde (95) (171) I (85 5h% 17 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR l» mm Below 20 Menninger Hillsidg 81 he 73 36 61 30 3O 20 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 195941962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " Hospital is gratefully acknowledged. The ‘ Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York *9': Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, New Haven Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay“ In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birthc These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings, These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.e,, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered. In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -— Hillside Hospital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston» These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classesc Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions” education and F �-2“ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statusc The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center» — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends" These difficulties also led to missing information for some data, which is reflected in.the tables by the varying population sample The sizes, fl... �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institu~ tions, however, the many differences between institutions are accentuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study, Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome; When *— 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult, At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident“ Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians, No additional fees were charged, At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho~ was necessary for members of the study team to interview therapy it the resident responsible for each case. 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemsa Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono MMHC �Table I 3. Discharge Ratings of Improvement: Ratings of imr provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. Table B. Inter-hospital II Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table in. a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduatec c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2a among these institutions. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). a) three institutions differed with regard to patient's length of stay (Table IV)Q Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside b) Duration of Hospitalization: The group was between seven and eleven months while two—thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV)o At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved” ratings (28%) and the lowest proportion of "unimproved” (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV)w The diag— nostic preportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per—cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothere Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundo It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapiese The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables included type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions, ~Simi1arly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasized° These �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, Brothers, R. N. The New Hollingshead, Mental Inc., York, 1950, 990 pp. A. B. and Illness: A Redlich, F. C. Community Study° New York, 1958, 442 pp. Social Class and John Wiley and Sons, L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., . 1957, 6: 216-228. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and G Ps Diagnosis. A a ., 1959, A; 565—574. Kahn, R. Kahn, R. ifornia F L., Pollack, Social Attitude (CalScale) and Convulsive Therapy. ligjfiuabhlkuug_jn§,, M. and Fink, M. 1960, 13Q5 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 1959, 116: 127—132. Hospital. Whig” Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comgarisons for Sociogsxchological Variables Menninger Hospital I Class "I“ Hospital 7% II 20 III 34 IV 34 V 5 x2 = 121.5; df=8: I Massachusetts Mental Health lllllflaiflllllllIlllflflflflfllllll N Social Hillside _ p:(.001 “M“-0__-____—_‘-.i-____.__..1-____—___ 19% 20- 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4g p<.001 �TABLE IV Interhospital Differences in Treatment Variables §Menninger N T Massachusett Mental Healt Center mum-.mHospital Type of Hillside Psychotherapy Hospital 36% re atment Somatic Other =82 8 df=4 100 N Duration of Hospital— ization 7 months 7-11 months . ~11 months Recovered, Much .001 173 95 22% 27% 67% 13 42 27 65 31 5 90. 6 df= 4 X2= . .001- Improved Discharge Improved Evaluation Unimproved X = Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 2903' df=4. U<n001 52% 54% 22 17 26 29 23.8' df=4° .<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40—49 3O 20 50+ 36 MMHC 14 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. Pollack and the staffs of the Massachusetts Mental Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The co.operation of Dr. Max Aided, in part, by grants My—2092 and MY-2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excludeda Studies of the role of social factors in the treatment of hosPitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay, In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingso In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsm These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i;gf, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredu In the survey reported here, it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital» To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions -- Hillside Hospital, the C. F, Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classeso Each provided short-term treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapya istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutionsa education and F �METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non-voluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center, — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions, These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1, Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a fee, Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedu At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical studentso Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemso Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono MMHC �‘1 Table I Discharge Ratings of Improvement: Ratings of imw provement at the three hosPitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 39 institutions. Table B. II Inter—hospital Comparison 1. Sociopszchological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduate, c) Education: The Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— the higher F scores being assoc— cent with scores of 50 or above iated with higher degrees of stereotypya In contrast, at Hillside thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30, d) F Score: —— Thus, differences in social class, educational attainfi ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychological factors to the treatment variables among these institutionse 2. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c a) three institutions differed with regard to patient's length of stay (Table IV)O Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center, The modal stay of the Hillside b) Duration of Hospitalization: The group was between seven and eleven months while two—thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: PA In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved", The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disorder, In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter'institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)¢ The ,r‘ Expectations based on our earlier intra—Hillside Hospital were confirmedo The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions” Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations° The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, 3223, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorders, Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to another, Literal adherance to these concepts produces paradoxical results, For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions, Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria em— ployed, This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating In our compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statis— tical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �f’. leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies, The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psychoneurosis" to explore changes in psychological and biological fea— tures of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in" cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso »Similar1y, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the stitutions and are not regarded as idiosyncratic. These in— differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasizedo Such �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, R. N. The Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., . A. B. and Illness: Redlich, F. C. John Wiley and Sons, Community Study. New York, 1958, 442 pp. A Social Class and L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and G PS h 565—574. 15 Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1- Scale) and Convulsive Therapy. .lLJkflubnlkflug_DLi-, 1960, 139; 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Am£I4_Ja_2£¥£hiaL., 1959, 116: 127—132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 195 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosRital Comparisons for Sociogsychological Variables Menninger Hospital N I Social Class ‘“ Hillside Hospital Massachusetts Mental Health Center IllllflliillllllllIIIIIIIHEIIIIIIIIIIIIIIIIZIIIIIIIII 31% 7% II 51 20 III 17 34 IV 1 34 V 0 5 x2 = 121.5; df=8: p<(.001 “M 1IIIIiIifliiIIinjflfiniiiiifliiiifliijfiiiiiiIIIIIIIMIBIIIIIIIII 19/ 20- 39 = Years of Educatio 3. 9; df= 4; p=n. s. < 12 41% 12-15 49 16+ 10 x2 = 9.7; df=4; p<.05 IIIIEIIIIIIIIIIIIEIIIIIIIIIIIIIIIIIIIIIIIIIIIIIEflIIIIIIII F Score x2 = 33% 20% 50 38 17 42 39.2; df=4; p<.001 �W TABLE IV Interhospital Differences in Treatment Variables {Menninger Hospital N Type of Treatment Psychotherapy Somatic Other Duration 0t Hillside Hospital Massachusett Mental Healt Center 21% 36% 24% 43 64 68 36 -— 8 7-11 months Hospitallzatlon ~ll months Recovered, Much Improved Discharge Improved Evaluation nimproved X = Schizophrenia 2903. df=4.'<0001 52% Discharge Diagnosis Affective Psychosis 22 Psychoneurosis and Personality Disorder 26 X = 23.8. df=4. .<0001 54% 17 29 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40-49 30 20 50+ 36 MMHC 14 �Herch 12. 1965 Dr. Hetheniel Siegel. Ph.n. lecionel Institute of Hentel Beelth Bethesde. Ketylend Deer nets: I have sooepted ell your recommendations end heve redone this report. Enclosed ere e for copies which, while they still may hsve e typographiosl error, ere in e for: which ooold he sent to s publisher. I have taken the liberty of running this off on Colitho pletos. so the: if it is not published, we may still have some copies for our friends. Unless I hes: from you or receive s stop order. I will send e copy of this to the Archives of Geoersl Psychiatry. My best regards. Sincerely yours. Me: Pink. H.D. H131- Professor of Psychiecry �Hutch 12. 1965 Dr. Robsrt L. Kuhn, Ph.D. Division of Psychiatry antstiora Hospital and Medical Cents: Ill Esau 210th 8tssst Riv York, flaw York 10667 Dear Bdb: Following all tha recommendations in our last discussion, I have accepted the full responsibility for this draft. Recognizing the snotionsl problems involvsd. I hsvn deleted nsas. In this drsft. I have sssuusd tbs senior authorship insofar as you seen to be ralactsnt to do anything with the doeumsnt. It you would lihs, I will has. the first psgs radon. sad hsvs this subnictsd to tbs Archivss of Gsuarsl Psychiscry. with you ss senior author. st's It I tsctory. My do not has: from you. and submit ss is it it I will assume that this drstc is satisto Dr. Grinksr. best rsgsrds. Sincerely yours, Iink, H.D. frofsssor of Psychistry Ms: 31:3: �MONTEFIORE'HOSPPTAL.AND MEDICAL UHETHR 111 EAST 210TH STREET. BRONX. NEW YORK 10467. TELEPHONE: 212/TU 1-1000 March 15, 1965 Fink, M.D. Professor of Psychiatry Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5h00 Arsenal Street St. Louis, Missouri Max Dear Max: Thank you for sending me the draft of the "Three Hospitals" paper. I can understand your deleting Max's name since he never seemed able accept this organization of the material. I would appreciate however, if my name were restored as senior author when the paper is submitted for publication. I do not, in fact, feel "reluctant" it, to handle it, and if you wish, I am quite prepared to arrange for publication. I have no objections, however, if you wish to submit it to Dr. Grinker first with myself as the senior author. I notice from your letterhead that you are now a professor at the university of Missouri. I hope this change will be beneficial to your professional interests. You certainly have my best wishes. Regards to Martha. Sincerely, 34;, Hebert L. Kahn, Ph.D. Head, Section of Psychology Division of Psychiatry RLK:DCS to �April 1, 1965 Robert L. Kain, Ph. D. Division of Paydmiatzy Hmtefiom Hospital and Hndical Cantor 111 East 210th Strut Bronx, Haw York 10%? DurBob: Mummftisenclmod.andithasgmctonn Wrinthisfom Idohopohaceeptait,becauseit is me of tho intcmsting nm-biolofieal studies in m participated. MWMWMW.mImfindmlf inapooitimsimilartomatmichlheldinmsa. whidx we have Waterman burdms The are minimal and palate exclusively to mymstudiu. Immhawadaiewdawdmofindepondmca fwmamhwithamatdulofauflmvityoverpatimtn. staff.md£acilitius. WMIcm-mhemflxingofthis Ihaveafew excellent oomrkcm,but mlytimwill tell. have none the stimulation and imginatim that you exhibited. Max 14?: fun Fink, PLD. Professor of Pug/wintry �DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 NATIONAL INSTITUTES OF HEALTH AREA aoI TEL: ass—mo coo: March 17 2 1965 In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink Professor of Psychiatry Missouri Institute of Psychiatry ‘ University of Missouri 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: for the colitho copies of the "Sociopsychological" It looks fine and I hope that it will be accepted by Thank you paper. the Archives of General Psychiatry. I have been in touch with some of our training grantees in Missouri, making the Missouri Institute of Psychiatry more visible to them as a research source. I hope that some cooperative endeavor may result in the not too distant future. Please keep in touch, and give my best regards to Martha. Sincerely, Nathaniel H. Siegel, Ph. D. Acting Chief, Social Sciences Section Training and Manpower Resources Branch National Institute of Mental Health �April 1. 1985 Mamie). a. 31.91, PM). Acting Chief, Social 801m Sectian Training and Hammer Ramon Bunch National Institute of bats). Health Dapu'mmt of Health, Edtmtim. md Welfm Bethesda, Maryland Dar Nat: After- scnfing copies of the aociopsychological paper to Bob, he indicated apnfomce forbeing the scalar auflm. Implmodtocxooodtohiswish,mdmcloeediaaoopy offite “pm wiflatmmvisod fact sheets. Ampysimmrto this has gone to the Amhim. 811ml}; yaks, Max HP-zjn Pink, 1-1.1). Manor of. Psychiatry �March 30. 1965 lobbins, stis Msdicsi Dirscror Hillside Hospital Dr. P. O. Box 38 Glsn Oaks, Haw K. D. York Dost Lev: During ths wists: usstings discussed this study and esrion. we Bob Xshn, I for publi- Nst Sisgcl and ssrssd to prepsrs it linsl drsft is enclosed for your infornstian. Vs hsvs tsksn rhs liberty of sabnirring this to Dr. Grinksr for his A consideration for publication in tbs copy I! to Agghgve . it sdvissbls. I would be plesssd to ssnd you dssl snyons you sugzsst st tbs Heaninxsr Foundation. Sincsrsly yours. link, H. D. Protsssor of Psychiatry Ms: first, s �Hatch 30. 1965 Dr. Jack Ewslt, H. D. Prefessor of Psychistry Massachusetts Hunts! Esslth Cantor 72~76 Yenwood Rosd Boston, Hassschnsstts Dear Dr. Ewslt: s conpsrsttve study was undertsksn with the Massachusetts Mental Baslth Conner as s coopsrstins institution. A finsl copy of tbs ropes: of thst study is sneloscd. we have tsceLvsd psruisston to publish this inforustion from Sons years ago, Dr. Grssnblstt. WW- I an writing to tell for consideration I would bu by tho you tbs: us hsvs submittsd this drst: plssssd to hsvs your con-sacs. Sinesrsly yours. Ms: rink, u. D. Profsssor of Psychiatry lltkp �March 30, 1965 as. Roy R. Grinkar, Sr. lbpartnent of Psychiatry Michael Reese Hospital micago, Illinois 60616 Dear Dr. Grizflcer: I the opportmity to enclose two copies of a report "Socioysychological Aspects of Psychiatric Tmatmnt in Emma Voluntary Hospitals" for your consideration for publicatim in the Archives. am tall-dug We report mmmts a study mdertaken some years ago by my associates and myself at the Hillside Hospital. We have decided to submit 'ti'xis for publicatim, in View of the continued interest in the social aspects of diamonis and manhunt. Sincerely yours, Max Pixflc, M. I). Professor of Psychiatry 3‘? �Harvard Medical School Department of Psychiatry Boston Fenwood Road, 021 I 5 74 l l l Massachusetts Mental Health Center [plllllllllllllllllll3M“; ljlllllllllll!!llfllH . ugfifirflifi a: g 2:” l (Boston Psychopathic Hospital) ill Department of Mental Health W” ”H" u: ‘ Flak-.215 .-:::.!'1| " x2.mumuillméw JACK R. EWALT, M.D. 3mm PROFESSOR or PSYCHIATRY SUPERINTENDENT April 5, 1965. Dr. Max Fink Professor of Psychiatry Mi ssouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: Thank you for the copy of your study of the Hillside Menninger's MMHC. I found it very interesting and, considering the differences particularly between this place and Menninger's, I am impressed with the way you could tease out comparable elements. I would hope some energetic person would about ten years after the first study do a repeat on the same three institutions, using as near as possible the same criteria to see what directions or shifts if any had taken place be would directional changes that there I them. strongly suspect among in all three but the differences you found would probably persist. Si ely �w. -. m. .V 1n: vv “ quI’V—nw W", waw w':——'-1.17W . VF... s ”pamn— w...“ -mrmwmwv 4w-uw1-w‘rr ,_....v , . — Jun. 3, up. lbbart 1.. New . .4, , .«.—-~w "w ‘v.'rr .. «q many 1965 Rain Division of Psychiatry Hawaiian Win). and 1.11 East 210th 3m“: M York, ”fin—“W. hated. Cantor York 16%? DaanublndNat: Hm: Firm, 1!. 1). Professor of Paydfiatry many an: HAW Sign. Hm}. Mimi Imam of m1 Knuth m, mm a“ m:«mv-:~,<muvw; vn‘w‘u‘w‘rv v V .. ,... �PROCESSING OF ACCEPTED MANUSCRIPTS Each accepted manuscript is processed in the Chicago Editorial Offices of the Archives of General Psychiatry bringing together all elements of the printed pages of the final published article. You will receive a reproduction of the typescript, edited according to the official AMA Style Book, for final review and approval. There will be no galley proof. is accepted with the understanding that it may be necessary to make minor revisions, or to request changes in illustration or text. Your manuscript The Editors �SAMPLE DETACH SAMPLE AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and .I. P. Utz 1200 Blank Street, Chicago, Illinois 60610 TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �w DETACH . INVITATION...TO PREPARE AN ABSTRACT OF YOUR COMMUNICATION WHICH WILL BE CONSIDERED FOR PUBLICATION .IN THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. Suggestions: .7. 1. Type name(s) of author(s) (also address of one of the authors), title of article and name of journal in which the original article appears. 2. 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Type abstract on attached card and mail promptly: a) Indicate purpose, extent, kind of study, materials and methods used. b) Refer chiefly to new data—the high points—informational, not descriptive; e.g., new statistics,new apparatus, new technics, new diagnostic criteria, new evidence, new preventive measures, a new theory,new treatment.Do not use abbreviations. 3. The abstract should not exceed 200 words. NOTE: Accepted article. PLEASE TYPE abstracts will be printed concurrently with publication} of the original THIS IS THE ONLY REQUEST PLEASE RUSH �SAMPLE DETACH SAMPLE ——————————-———————‘_ AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and J. P. Utz 1200 Blank Street, Chicago, Illinois 60610 V. TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �*Kahn, R.L., Fink, , dd d THOR s *‘blijvisioé 3f(?3yc?1'i%€ryf°figntefiore “ M. and Siegel, N. 10467) Hospital, St., TFFLE:Sociopsychological Aspects of Psychiatric Treatment in Three JOIHHWAL: Archives of General Psychiatry Voluntary HOSpitals. Population characteristics, defined 5y social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals, Hillside Hospital (N.Y.), C.F. Menninger Memorial 111 E 210 NY Hospital (Topeka), and Massachusetts Mental Health Center (Boston). Treatment variables included type of treatment, duration of hospitalizaThe and evaluation. institutions differed in discharge diagnosis tion, of education and distribution of California class, years patient social 1 but not age. EF scores, had the The class longest g patients serving institution upper p psychoneurotic diagnoses > quration of stay, a higher proportion of lower of patientg Idand a schemata, complex proportion more diagnostic (I) the dischar e of fo oorest an somatic ther rati receivi Eamong tfié three instfgfitions. €¥§i1ariy, thg institution sgrving “gs m of had the shorter hospitalization, periods class patients glower m lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. Psychiatric treatment and management practices differ among institutions according to the prevailing social class characteristics of their populations. �F‘ . “‘ ““ <4, FIRST CLASS Permit No. 1876 CHICAGO 10, ILL. VIA AIRMAIL MAIL REPLY BUSINESS No Postage Necessary if Mailed in the U.S. Postage . W111 be paid by— . American Medical Association 535 North Dearborn Street Chicago, Illinois 60610, U.S.A. Z. Danilevicius, MD _ — '— — — — — — — — — — — _ ~ �ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American M€dical ASSOCiation June Institute for Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EATON W. BENNETT, M.D., San Antonio EUGENE L. BLIss, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD I. LIEF, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco 3 , 1965 Fink, M.D. University Of Missouri Max Medicine 5400 Arsenal Street St. Louis, Missouri JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS SChOOl Of GILBERT S. COOPER, Managing Editor T. F. RICH, Assistant Managing Editor 63139 ' re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I am very pleased to inform you that your paper has been accopted by the Editorial Board for publication in the ARCHIVES OF GENERAL PSYCHIATRE, Yours very ROY truly, R. GRINKER, 311., NJ). Chief Editor iknczbr �’ ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American Medical ASSOCiation Institute to: Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EUGENE L. BLISS, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD 1. LEE, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco June 149 1965 Max Fink, M.D . JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS Department Of PSYChiatry Executive Managing Editor GILBERT S. COOPER, Managing Editor T. F. RICH, Asszstant Managmg Edttor ROBERT W. MAYO, Missouri Institute Of Psychiatry University Of Mi ssouri 5400 Arsenal Street St. Louis, Missouri 63139 re: Manuscript SOciopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I Number 3326 very pleased to inform you that your paper has been accepted by the Editorial Board for publication in the ARCHIVES am OF GENERAL PSYCHIATRY. Yours very ROY truly, R. GRINKER,SR., M.D. Chief Editor RRG3br P.S. We will, Of spaced throughout. Course, need three cepies of the manscript, doubled �re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Dear Author: et a1 Your paper has been received and is being considered by the Editorial Board. A decision will be given to you as soon as possible. Yours very truly, ROY R. GRINKER, Sr., MD. Chief Editor ARCHIVES OF GENERAL PSYCHIATRY �IS ROYR. GRINKER, Sr., M 5 c) Pan ‘ _HIS 29th STREET AND ELLIS AVENU CHICAGO, ILLINOIS, 60616 SIDE OF CARD FOR ADDRESS Fink, M.D. University of Missouri Dept. of Psychiatry at Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Max �June 15, 1965 Dr. Roy R. Grinkcr, Sr. , Chief Editor- Archivna of General Psychiatry Institute for Paymomtic and Psychiatric Paaeamh 29th Strut and Ellis Avenue Chicago. Illinois 60616 Dnar Dr. Grinkcr: Enclosed am thme copies of thc mmcxipt entitled "Sociopsycl'nlogical Mpocts of Psychiatric '15:!th in That. Voluntary Mitch," as mmtcd in ymr recent letter. I am also enclosing the Mical abstract card. I have pmvimuly cm to Dr. Dmilevicim, as he had rcqunstcd this about ten days ago. mt man: you very much for your interest. Sincamly yours, Pink, H.D. Professor of Psychiatry Max Hrzkp encloms �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �w. .-..w‘ww.."“mmmmn—pw MWCALWSOP WCWWWWWW mm L m. 31.9... ”I! My Katmai.“ Sing-1. Rub)“ “ODD... �Wt Oaks, Thisutudyunduuwmmnutmmassocimdatthe Hillside Hospital. Glen of L.I. Expodmul Pawmutry, New Yak. 1959452. MWmdfluataflsoffln meimofIr. CJ‘. «ad 1:): Manta). Henningnr Cantor hath Mutant“ mm l-bmitnl in gratefully W. Aidcd, in part. by grams M24092 and HY~2715. of the National Hulth, 0.8. Public malt}: Serving; and tho Instituu of mun Bond. Rum County mm m1 O Pun-mt Adams” East 210th York 1mm. “ I’m-mt Adan": W SM. mvidm of Psychiatry, Hmmfim 111 0mm, New Howitd and Wt ram New York. of Psychiatry at the Instituu o: Psyehhuy, Missouri School of of Mmity sum m1 Strut. Win... 8t. Inuit, Missouri 63139. no HIP 2/1/65 Present Adda-u; Nutimal Institutc of brutal Knuth, Wadi. mma. �. V.— ,___‘V ... auvn-m. rm. .whwwvr... _w.. .vaw.‘w 3w.-- - .-.—u--r.. .'>rlm' 'v' r q— “n... v-A‘Hnwwvwv‘V-vvv' )w-p—w' vrwumwrl—‘"W':"'V"V""-*‘VL'I'W-lw-v ‘.'._.,.._wv mmmdfluflummmcmmpop- ulntim. 8011111351356 and hdlich Imported significant relation- Mphmnmhmm'spmldminmsodalchssnmmtm mmmddmceofmatndillmas,typesof¢iagmoddism mmmmotmudammtmmmm. mainflumceoftmmcstmoffiumientmthe availabilityofmating pummel. m,mmtmm¢ Stmiasoffinmbofaodalfwminthomxmnof of their fixmial status and tho hospitalized paints Wt m mast-tam at Huma- Hospital in availability of mutant: 1957. In this hospital, anxiety of manhunt modes, incluling individual payabafinmpy, were WW thompiu available to all patients regardless of melt” ability to pay. and convulsive hmamys (mummizhat patimts hospitdiudforfln Wm‘iodsmmoldar.hadlmedtmimmdmmoftm 011mm. Mom,mmwmimmpm inmtlymmdbyomvulsiwfinmpymdmoeiwdmfavumbh WWW. mum W Myhypaydaathu‘pyujdmiwdpoomdim mm mm.mr.miv¢m. mhoopitlliud for Impurioda, tmtad ratings. Thuclmimlfwmwnmmmamof‘sumtypy, mmmnmrSa-hu.s).mwrm.w Mrstomn mmmofmmmdinmlmtadimduinvolutiaalpmis WWWMMWDMN thrupyfltocpitaliud‘fom amt- m,mmmmmumwwm. �_-..‘._ i It as ,. m." .... 7.." ‘r».:- — -~~-- um» 7.“ , suggested that differences in paydxiatr-io treatnmxt afloat a similar influence of social factors along hospitals should as noted for patimts within Hillside Hospital. To ewtion it was decided to wloy the Hillside study in three institutions cm. lhmin'ger Mental Health mm enter in - test this procedures of the 195? Hilleide Hospital, the Hospital in Topeka and the Maoeadmoetta Boston. Those with the expectation that diverse available to population of institutions were selected tnataent modalities diffemt social classes. were equally Each provided ohm—ten treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active march mite, mixing peydnomalytioallycoriented psychotherapy. 'Ihia study wm designed to detemine thepopulatim character- ietioe of the three inetitutim with respect to social class. age, echoatim and 1' some; lid to relate these dmmcteriatios to treatment variables of type of treatment, duration of hospitalization, diamoeia and discharge evaluation mg the inetitutiom. tvwrw— w v �w J"- -A.».—. v ...v. m-uwwa. ... ,ur» In.‘,._(...._,..n .,.‘,.“___,‘ .- warm—Mr...“ . .VN.... .v- , ‘ ,7...” .... .... NM”, x..." ‘rwm'.tq'(1.'rm'“>1flr-r.ny\w ”rm—"w.“fivn v..._ mu Ammofmwlmtuy.am1tpafimtsinmimin mum adminidnflonpitalslndvolmtuypafimsmly,amnnmr WWquuminmeylaso. ofthoocatfluWMthfimethflflQmm mimdbyfinmtsprsymcovalmfimormm dadmionwimmicnmmitummfmdfwn specifiampmjwt. Mmflmflmmmfmflu studybocmofthcirmwmuy 3m. mmimeIMwasmndformImtimtmm mundu.‘ memmofdismdmimfi mummmmmmmwmmcrma 1110M. PornmofsoddclumflnfloWZ-fwtw im-aWMsdemmmmim-mmd of Hillside, at patients (3.“,7). mist-d M MORWWDSKWWWWMmCmtw. mmmmmflmoffinnmofflusml The W 173 mmmdmcmiabluwifldnmmnimflmumnm batman institutions. mu. maxim mm difficult. lunar, MmeofvuMBquiffWWbem. W www.mmwymoepaymcvamm diffimltiu were most mined These in the intm-hospital will be placid on the diffomw batman imtitutiau with citatim difficulties also no to o: mwmmmm m m. mummfomdmfwm‘dau,mfhmdintbeubmbythé ' vmpawmimsaploaigs. ‘ pvt—u u �A. WMCAL mums M Rpm ofthehoapitalis r studies from an. instituticn, tho stmctm fwmtedmdeimrimdorm~ tel-am timed bflafly. In suturing amenable data from nultiplc institutimo, hmwr, the durum between institutions are «mutated. R111- thele institutims were sol-cred as mental: invading, mom and Mt m. unlflm in ways which inflummd the data they a! the m 8m. fmctimdly Specific Mt, mutant «Item. differences were manhunt in the deeimtim of type of (lunatic mutants. and th- evaluation of m Raw designating that a pationt miwd of 1. the institutim, making 01' Mutant: The ”1:”de cum-rim difficult. oxitcria for diffemd mg hazing-r Hospital psychoflmpy was duimatod as mutant basis by a staff psychiatrist for Want-d on a At Mum mmpafimtwudmmdafui Wwithapsyddmic ruidunt physicim wen midst“ part a! rmtino mutmiw paint an. arm a Hillsid- ibopitn payMampy was mutant main»! with a psychiatric mid-at. Staff poydmictrim did not A1: matplthnta, mmmactivitiutowpoming midmtphysicim. Nomitimdfmwemmd. W mm MW 3 At tht th- mtivity Hum: Gutter pnyehothcrupy was ofmy disciplines --~- We �“am < -v u w“ -w “KN..." .... ,.. v... -. .7 r,r.,,..-....r...m~ rm.“ \w‘wur-m 7.. , .mvmwvrwmw—w ”v, w... H r. v. -_.'wm.-_..r.,.“,...m_,,‘,,.._w_..,. ,,._r_~‘l.,,_. w mm,pydnlosisu.sochlm,nms wwwwdzmsimmnmtmflmlyimmainm mdmdioal students. mt'smmmmmmummmm Witmmmfwmoffluammminm unmidmtplmidmmpmnibh farewells... W: Wm: 2. and. Indivichal imtitutimal difficult. At diamtic styles cums WWtal Whmlflphuvmmiwsmmdbytmmdw and music:we row mum diffmtufimaym. Scwnlmwofdimm W. W Wmmudinhbul,wmhmmsumutodmmm thWmMflfiWmhflmfim. Mmmmamflmm. 3- m WW=WMW mummmitmmwinrmmmm. m WWatWpritnmtdpar-dtewitham «31min: Max:111, W011 and syndm W. mmmimmmmmmmmmmam difficult to assess the ammunim of cad: it tutor offinlhminearsymfl'nblan). Pwfifiss‘mdyflnmmw rating making smmmmmmmmotwm intimation. m A... 7w.. �, .,__n..-. 7‘..-‘._._.‘._..-..W‘..v...‘ w...—,.,-v.,mx-,~_..V“-.."w.u "Wm.”w r9.w‘_v . .r,_..-——w.w ”w. ._»,.,.r,, — ._.__ .m‘...-..v..‘~,.\" »......—-....—-v— "m..- w w ——.~.. ".V...», v...“ - mmmmumoruummamum,m.m mmmrmmmmmmuumm in III. W Table I) W mattinmfiaipuaddflfnmin mm" mommmmormmmmmw. ”Wm-pimfiupwflaflmmpmuywm; «mumm.mm;mnmmmmm www.muymam. b) msnmmmdifminmdimibutim ammumwmmm. Wammmaflu‘dhm _mmm.mmmummmamdm «WWmmummmmnmmmm. mulmmammummmmmw 3M.uuya2parmtdtmmidcmd23permtatfllmimr c) didmtm. d) Wswfminmdlstfibutimat mmfinmifthSed-mmmd. Fifty-em mmtdmmmrmhlwm.mmy oimtmmwimmofSOwabw-wmhlmfm hum InWt. �, ”.7 . v Nv‘,—' ~ v , v... v. ‘v" —.~,~.~..-m ”11"!“ “we ,-.. ~.<.., .._ ~--r“~..,—a,<.»~mprv-. —. ~~pw~mmmw-w~mn m.” a... j." -r..-‘...,.1~.v» nymI-rznu at Hillside thirty-me per cent of the patients had 1" scores 30 while at WHO only twenty per mt mm belcw 30. mus, differences in social perfume: an the below clan, edumtional attaimxt P Scale were observed. and These diffexemee permit test of the hypotheses relating sociopsydsological factors to the mam-at variables mg these institution. 2. gleam-1c Than-ant Variables a n) Selectim of rm uimifimtly W: Manna the institutions, patimts at Naming” Hmpitel 043*.) received sciatic therapy than at Hillside (6%) or 11116 (68$) (Table IV). 1:) V Wm at Hoegiteliznticn: ‘lhe three insti— tutims differed with mm: to patient's length of my (m1. IV). Pedant: it Hlminw Mini was hospitalized lamest, with 65‘ cf patients mining far twelve month: or mated to m. alparwrtofflnflillnidepatientsMmlySpercmtatthe Pin-mm Hentnl thalth Center. 'Ihe mdal stay of the Hillside mmbetweeneemmdelmmfiu while tm-thirds ofthe WC patients were a) W Evalutim: diam Diem within six In and! petients were evaluated at the time of (Table IV) . At (191!) thinger Hoapitel. of patients wen rated patimt was a of hoapitelizatim. mini, mot dimmer-3e no "iuprmd" however, a higher percentage “miwmved” and only a single scared ”uncured" or “max iwmved." The percentage of ”mounted" an "mm harmed" rating him (2810 and the �_ _ v. “v ~_.v_..‘._.......p.r "anv “:wu—"mw-nr -17.": WNWV. ”.wuwwn mm My .-.._‘ n-wwn-y—wy ..~—r 7— —-,__.y vwri'ai.W"YV-wwmrnw. Mmportimofwumwd”(mt)wmfamdnmmuo mwmmm. W3 minimum: W, d) nostic For satiation analysis uffccdw Mmmiamdpomuuntymnflabh than: diag— diam, IV). Trading- Mamdmmmmmmm mmmm.usum1ymmmenaiW "Wmmrwmmhwdfwdw centrist. at paydmmia WW1“). disorder. In and memmdfwmflmfiftypwmdm W161. c. ’ m W.» mmammmmmmmmmmf ”Alum W.finflrhmpmiflwifldnudaimfituflm.mdm mm m].- siu (neural mine Maud: had was («or than than was) maimed significant intru-l’mpital mn- pm. Humor-.mmappomummtommmm thou-lineman MMmeMnWmm ulwddefatWHo-piulwwwhiMF accumumfmmuymaimwmm‘py).md Pamalematlfllhide. mamimmmm~ Wmmmnmnmmmmmmm Wm~mwmmmfmetm. mmmmmummtmmmmmm, �asmmmndwamudummmbuwmmmmn mummusotpmmmummmonomm Mam. W m DISCUSSIW mmormmmymmnmcmm mind significant inter-institutional cum in social mwmofmum.mtmtm;indiatflbutimof ammrsmammmmmormmmm win~mmothosp1unudm.ahctimo£mmts mammarmmamwmum maul-mm“. Hmpitnlatudy WWmmmmr (7). marina-d. 'nuimtitutimmvingwmpatiom mmmmmwmyummw paydmdodimmdmmdiwflcm,a �-rw .-,. a... h -... w ‘ purvm .. “.V 7—-.. w. tux—0.... V" - ,7". "7‘-.. - "\‘w' . -. -h. -Vw—l m.—....‘——wn~. V . m .w._-—zu—«——~....'_~Wm,- u...“ -10.. form of therapy. mtic mim and the poorest discharge ratings mg the three institutims. smmxy. the 1:31:in serving mg. class patients did have Mr proportion of patients the shorter pew of hoe:pi.t:eliaa1:i.tm,~ peydmmtic diamond, ad lover proportions bf the better discharge evaluations. Itumiwmeimflmtmdflfeminpeydumc W durum in staff ettitudes and are related more to lock]. alas variables than peydniatric differences in populetiom. The are We greet. as between m the mututime in dwetim 0f hapitaliutim mucky of climatic foundations. diam-rye evaluations. deflnitima of peydwthempy, and the detail- md aunt of differences W date. mm. these stylistic idiosynmtic, they follow! a social related to diffemoes, aid finir'miemncy mum with emeoteticm laments e meter dependence on social class may be dismissed as Wiedgad. Sud! mulatim and metnnt variable variables than outwardly intemtive processes, physicim and the of an 15th determined both by mum‘s staff relatimships are the attitude of the me! by the matellatim or history which patients present. Such relationships mined mat in than psychiatric conditions where diwtic criteria are leeet specific, a,an fining diseases of Imam etiology where objective criteria de- absent. as in schizophmie. peyoimmuis, personality md beluvior W. Under these �- ——-»~.—.. . 0 . .... Twp... -‘-- ~vv-ul'~w 5" 1m -.——.rw~‘~_.r “mp—m...“ "m”. . v~-_.v...‘.. ... m «um”www.m—mrwv.r.w-‘.,r-r.—,.m.~ Nut-aw..." I"-~nr~rl’-' Irav’r VW'FV‘wW-Pf'lm‘"- ._ mmwpomwthainiguity.m¢oh«mr's mmwmmmuwmumormm classified“, «Md-claims. osmium. 1:313:11»qu chalydoamudbyl’umidc,mnitxmdhfm (6)1ntha1r studyafmiatimiadimiuwithinasinghimtitutim. 'nuyobuzwdflutputiummimdatrmmdiffcmtm admtdifhrintypoofmm,mitalm,e¢mim. mermaid-non. Simiflcmtdiffcmasdidm,m,in “demmicwvimfimmm Mm “wwwmmmmwm. wtmmmmmmmmm.mumwm wmmammotdimmmmmitmIoffln W. WWWofmmismdmniml mmnnhmwmmfcmdmmimb tutimmmflm. unmmmammaemm mimic-insults. Farminlhmimmtdwiflxm Wyudmdpcmlmmfingmmnknpcimpmmto fwfinlamttiu,huflufmtpatiem$mdu W.mm.mflupmatmtmulu. Arm,inmt.miahismstimlmiwindufininga Wat.kmpaflmufwfindmtpoflw.Mhma mmamWWme Whhaatmammults. �mmmotmmmmmmqmny olmwflnmmtofmwutyofpopumamfw dogmofilhmsmgmeimtimfims, these {Wand We «fleet the mhtiva efficacy of the institutions. Simfincvalmfimsmbaudmtmmfimdm’sommfings, arm Mfmmmofimmmmrfiminmicpsyw- we mum that tho rennet variaticm in the criteria Mam“. Inwinimlfiflhidoatudym)itmpoamhmthat M WWW. mam criteria of were utilized {or mom of Itwmsuggastedfimttmmmr flumm'asodubwmdfinmmlexflthefiaw ployad. with mmmumlymmmmmtsm. flu cuff of flaming-r ibupital min; a tripartite rating Em Wmmemmgdmmmmum. mmmemmfingmmmmmmtiwamim fimnlmmbmd.itisourmumtmtorlmr duapommwapttcumiwinnuumto Wamfwfinpafimt's mpmitytomm wrigmile for uppor ulna panama the criteria aphasia: such mien intangiblmm”avnloping insight,"or"mfld.nng‘a pmbm." mmmmmmmmmmmmu ofwdnfminpaymem.mhmbemgrufly mmwmmmmmormm_mumm. �Midesmmwamedmflmllnad-nhip mamamimmmmmwmmnucmuy defined. But diffm in instituflmal style and: it diffimlt toebtlincmpambhdata. Mmdmisnmmmpmblm Wiml Wu meofwdxinmcmm. memormm of the use of statistics, «Many in W,mewmwlmnthm umitwiainmmwalmmwmidmfiflmimof Whpopuladmmauhdecttomiwmmnum institutions m charly mm for staff attitudu md atyla wmlluminmminpafimrtwpumm. Thu-o diffimltiwalaouflndtoflnfdlmdscimflahmomflm mmwmymmmmmMuMm-m. mmmammmwmmmu. mmmdfimmmuMqummm hypotm. flamofthcm”adfiaophmnia"or”paydw- W18” to explore chm in paydnologial and biological futuresofmtdfllmnhulodmascimww Manama oboewatimtobanpoma Mmmwzoday,mmmthmmmtom negatiw malts. paydkalc munitions Manly fwamfm tut of the be must paid, to the elusificutim Imam Music. mum m, wmymmmmmmmmnflmm of aubjwts by "abjectiw" criteria tamer than our present the oodnpoydxologiml aspects of fin unmist-padom: Wm. �v. ...., A. n. ‘v ....._.—ur————‘.v—. muw ‘ «m Two—u..— -..—.—v. .r. vvn<~>ww~wmfl‘rmew~——uir—I .—~ . am WMWW Was, Mmmdrsm,mm1mammamntvaflablaoin dufimd by social class, age, Fopuluflm on. ”may tanning hospitals. typo of mm. W variablas incluad dmutim of hmpitulimtim, diagnosis md diuduma evaluation. Imimtitmimal diffaranous mm in mint nodal class, yum of and distri- m mam Monofculifmiufums,butmtsga. Wins Thu tions m in W Gamma“ mg institu- uimifioumly diffamt in the pmdictad dimctim. The imtitutim sawing class patients did have the longest Minn of stay, a higher pmportim of paydxmam'otic diagnoses and W m min: diagnostic am, W, a lower proportion of diam and the poorest too-Mag mastic fans of ratings can; tho imtttutim. Similu‘ly, the m patina imitutim ummmmmdidmmmrpemcr houpitulisutim, 1m proportion of psydxmamdc diagnoses, and the discharg- evaluations. Wvariation on ma mm m muss with W mm not and Such dim, Wm hum institutimo objwmdam is in psychiatric practices followed u pattern class <11!qu mg thu momma. as idiosyncratic. in institutions! style make madam of of houpitalizatim and treatment mats {:1th ma tea-nuts, and the mad for m «item m:- the classification: of psymiati'ic populu~ mind. �REFERENCES and D. J. T. Levinson, Frenkel-Brunswik, W., E., Adorno, and The N. R. Harper Authoritarian Personality. Sanford, Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., A. B. and Illness: Redlich, F. C. Community Study. New York, 1958, 442 pp. A Social Class and John Wiley and Sons, M. M. and Social Factors in Fink, Pollack, L., the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., 1957, 6: 216—228. M. M. and Sociopsychologic Fink, Pollack, L., Mental in Treatments a Voluntary of Psychiatric Aspects and Ratings of Discharge Duration Hospitalization, Hospital: Diagnosis. Argh, Gen Psyghia§., 1959, A; 565-574. Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1— Scale) and Convulsive Therapy. J4_Nexy&_mgntg_flls,, 1960, 1395 187—192. . Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 116: 127-132. 1959, Ameza_J‘_£a¥£hiat., Hospital. 7. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191-196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved ______.____——————-——— Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved �TABLE Interhosgital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Hospital N Class WM” Massachusetts Mental Health Center IllllfliilllllllIIIIEEEEHIIIIIIIIIIIIflflZflIIIIIIII I Social III 31% 7% 3% II 51 20 28 III 17 34 13 H IV 1 34 28 V 0 5 28 ”'1‘" " x2 = 121.5; df=8: p<{.001 ,,_-_1_A_s-__1.______ 19% 20— 39 =3. 9; Years of Educatio <12 41% 12-15 49 16+ 10 --—--—-— x2 = F Score df= 4; p=n. s. = 9.7; df=4; p<.05 §3z 20% 50 38 17 42 39.2; df=4; p<.001 �TABLE IV Variables Treatment in Differences InterhOSpital EMBnninger Hospital Treatment Psychotherapy 21% 36% 24% Somatic 43 64 68 Other 36 -— 8 x2 Duration . 0? HOSpltal— lzat1°n Hospital Massachusett Mental Healt Center IlfiflflflflllllIIIlflEflIIIIIIIIZIIIIIII N Type of Hillside = 82.8- df=4 -m** 7 months 7-11 months ' .11 months 22% 27% 67% 13 42 27 65 31 5 Discharge Improved Evaluation nimproved X = 29.3' df=4' -<.001 85 54% Schizophrenia Discharge Diagnosis Affective Psychosis 17 Psychoneurosis and Personality Disorder 29 X = 23.8' df=4‘ -<.001 �Duration of HOSpitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �AMA SPECIALTY JOURNALS ' ' lC ' Am 6 r1 C a n M e d al A S S O C l at] O n 535 NORTH DEARBORN STREET - ' CHICAGO, ILLINOIS 60610 wa— AREA CODE 312 527-1500 910-221-0300 November 2 , 19 65 Archives of Dermatology . um 0 an i:Chialldr:n Sinse;ses Archives Of Envir nrnent al Heal I h .° Archives °f General Psychiatry Archives of internal Medicine Archives of Neurology Archives of Ophthalmology Arc ives o ‘0‘ o l a ‘V n g o ‘ o 3’ "_ Arcthes of Pathology A'c h'was ° f S“ '3 eW JOHN H. TALEOTT, MD, DIRECTOR DIVISION OF SCIENTIFIC PUBLICATIONS ROBERT W. MAYO, EXECUTIVE MANAGING EDITOR NORMAN D. RICHEY, MANAGING EDITOR Fink , MD Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5400 Arsenal St. St. Louis, Mo. 63139 Max Dear Doctor Fink: edited copy of your manuscript entitled, ”SociopsychoA Treatment: of Aspects Report of Psychiatric logical Treatments in Three voluntary Hospitals,” is enclosed for your final checking and approval. Also enclosed is a layout that shows placement of title, copy, and illustrations. Please indicate any necessary changes in a covering letter rather than on the edited typescript. we will be responsible for checking your material against proofs. An manuscript has been edited according to present AMA style. For example, most abbreviations appear without periods. The are currently striving for brevity in article titles. If the modified title of your paper is not satisfactory, please \/ supply another that will fit into two lines of no more than 40 characters and Spaces each. we L ,ZU Chi, for reprint purposes, the one Is address at end of article, you will be using on a relatively long-termlaasis? 1 Specialty Journals publish acknowledgments only to personsbfi1p P have aided in that a a study or organizations major way, as, for example, by supplying drugs or funds, making statistical analyses, or doing pathological studies. AMA references have been renumbered to conform to our rule requiring numerically consecutive citation. Your �Fink, St. Louis, Max MD -2- Mo. 11/2/65 According to our calculations,the paper will occupy 6 printed pages. Please note that any new material you may wish to submit at this time will be acceptable only if it can be compensated for by deletion of an equal amount of copy now included. have retyped the references so that an accurate copy estimate could be made. Although we have reread the typescript, we request that you also check for any errors of omissions that may have slipped through. we correction and return of your typescript will help us get it into print as fast as possible. Please return it, along with the layout, in the enclosed self-addressed envelope no later than November 9. For your convenience we are also enclosing a reprint order form with the correct number of pages indicated. Prompt Yours very amh , udith M. truly, Kiolbassa �. "luau—“new .- , . H- MW. -1 ~ »~v - we. w re ,-_....‘--—-~~w—~- «V... WP v,“ mm“- "WWW. w. 1“. - -.. .. . 5. 1965 Judith H. Kiolbesse Mariam Medical Association 535 North Deerbom Street Chicago, Illinois 60610 Dear flies Kiolbesse: Myouwrymdafcrymmletterofflovemrz. I shelltrytomreechitenineeqmnoe. The article title is satisfactory, elthcugh I think the "A Mt sub-heed should reed in Three Voluntary Report of Hospitals.“ 'me word "treetlsents" end "treetsent" are probably interminable, but in this inetmoe, I think the singular {on is preferable. However, both eve acceptable. While the address at the end of the erticle is one that will be used for e lmg~tem basis, I would prefer that you and that is the Depertnmt of change this for Dr. Psychiatry. University of axioego. Chicago, Illinois. m. edmouledgmt included the name of Dr. Max Pollack. In ell the studies done at Hillside, Dr. Pollack was e coper'tioipmt. In this study he was one of the three people she visited eech of the institutions. Hmever, in writing this report, there were some disagreements as to the omclusims, mdheelectednottobeeoo—euthoroftheetudy. Hy essccietes and I. wild, however, like to indicate his assistance, and for this meson, I think a statusent, "me cooperation of Dr. Mex Polleok is gratefully edmwledged" “me would be appropriate. met. numbered refermces are I m assuming thet the Jamel limits the timer of authors to three, and The metthieisthereesmmythatintwooftheoitetions the co~euthore are omitted. If this is not e gmerel rule, perhaps in this instance the oo—wthcrs could be listed. page la, in addition to the notation regarding the coopemtim of Dr. Pollack, would you please damage the address of Dr. Kern from Hontifiore Hospitel to: Department of Psychiatry, University of Omicego, Chicago, Illinois. On .uw vs.— ‘ =. 2.. .: “may.“ . .,.. �Miss Kiolbassa -2- Also, the dates 1959-1952 , which follow the statement donoeming the origin of the study, are immutable by themelvee. In our original report, we used the sentence, "his study was dorm when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital. 19594962." If 30m full sentence offluiekindionottobeinoluded,thmlwmldouggestthat the dates 1959-1982 be omitted. I have read the text carefully, and find two small corrections midxlhavemked. mm2,naarfimbotton, theoomotimo putaolashlinethmwfithemwerS, mdthiemaybemolmto 1’ the printer. It should read "the California Scale. 03,5) page 10, mfemoe 7 should be number 6, and mmked this copy. cm I have so is a table. and them is a symbol which I do not mderatmd. In the first oolm."omplete remission"is aplit with a synbol mien to me would indicate that the word “mission” should be under "ooeplete." If that is so, this may be molear. I do not know how this will be not, but ”oanplete minim," "amicedly homo," "mdemtely normed” are each word pairs that should not be split. If this is too long for the oolmn, than I hope you will indicate féthat "markedly mmved” fit Page 19 together by appropriate spacing. Tfiis is the first time that I have had the opportunity to edit a mmxmoz-ipt in this fashion, and I must say that I found it quite helpful. opportunity toworkwithyou, andI Myouforthe look forward to the final results. Sincerely yours . Pink, NJ). Professor of Psychiatry Max HP : in �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �~ This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 19591-1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " is acknowledged. Hospital gratefully The . ‘ Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine,-University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich hast reported significant relation— ships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paye In anr thsae surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings, In contrast, younger, native born/aim? more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsa These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.eo, greater stereotypy, were often found in patients diagnosed as involutional psychosisf who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredo in-ehe-survey—rEpUTtEd-hETE)[it was suggested that dif— "’4”“’A“' ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for iht patients within Hillside Hospitala To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -¢ Hillside HosPital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston, These institutions were selected with the Fr:ec£3£ipn that hing-had diverse treatment modalities h’&Y‘ available,;d££:eoi¥ed-paeients of different social classeso equally Each provided short—term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo This study was designed to determine the population characteristics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �_2_ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status? The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult/however, because of various methodological differences discussed below. These difficulties were most marked in the intraehospital comparisons/.and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra-institutional trendso These difficulties also led to missing information for some data, which—ie-reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems repgfting studies from one institution, the structure of the hospital guanine taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institu~ tions, however, the.mnny;differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcomeo When l. Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making comparisons difficult, At Menninger Hospital psychotherapy was designated as basis by a staff psychia- treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the ‘2 psychiatric residentfiyere considered part of routine administrative patient care. fkysa4.¢ Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychowas necessary for members of the study team to interview therapy it the residentgresponsible for each case. fkjsKJAu Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems, Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono 2° Diagnosis: �Table I Discharge Ratings of Improvement: Ratings of improvement at the three hosPitals varied in format and detaily The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsa Table Q M’s _———"’ Inter-hos ital <:; B.fi~~,»n--__ "M..- {§_‘ 10 The Com II arisonSN Sociopsychological Variables distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed, At Menninger Hospital the population was predominantly upper class; /AE Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—” cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo 0) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fiftynone per cent of Menninger patients had F scores below 30, and only eight per— cent with scores of 50 or above -- the higher F scores being associated with higher degrees of stereotypy, In contrast, at Hillside thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables \“"2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside b) Duration of (64%) or MMHC Hospitalization: (68%) (Table IV), three insti— tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"o The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perncent of the populationo zx Table IV ‘“ CLJLRS ."” C: Intra—Hos s-‘wa. ~~ r“ e~ ital Com arisons ‘h53 lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisons, However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodst While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The Table V �DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)“ swudy Expectations based on our earlier intra—Hillside Hospitaufifi;;:’ confirmed. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl— istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, Egg}, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersq Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward“ As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundc It was suggested that the higher the person's social background the more complex the criteria em— ployedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined, But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hos— pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionse Similarly, the institution serving lower class patients did have the Shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the in— stitutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo These �REFERENCES 1. Adorno, T. W., Frenkel—Brunswik, E., Levinson, D. Sanford, R. N. The Authoritarian Personality. Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., Illness: New Redlich, F. Community Study. A. B. and A C. J. and Harper and Social Class and John Wiley and Sons, York, 1958, 442 pp. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. . L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, Diagnosis. Arch, Gen Psychia;., 1959, Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Sociopsychologic Voluntary Mental Discharge Ratings and 1; 565—574. Social Attitude (Cal- Scale) and Convulsive Therapy. 14_lkuahhlkuxLL_Disu, 1960, llQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. AmeIa_J4_E£¥£hiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 1Q; 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comparisons for Sociopsxchological Variables Menninger Hospital I Class 31% 7777 7 7 7% II 51 20 III 17 34 IV 1 V O 34 . 5 l||||||||||||||||||||||||||||||||||||||||||||||||||| x2 77 Hospital Massachusetts Mental Health IIIIIflBiflIIIIIIIIIIIIIIEIIIII N Social Hillside 7 7N7 777—777 7 = 121.5; df=8: p’{.001 7m__-— -77777777—77 20 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hospital Treatment Psychotherapy 36% 21% Somatic Other um— =82 8' N Duration 0? Hospital Massachusett Mental Healt Center IIIIIIIHIIIIIIIIKIIIDIIIHIIIIIIJJIIIIII N Type of Hillside 7 months 7—11 months Hospitallzat1°n .11 months df= 4 . .001 Z ' A 70 13 42 27 65 31 5 52% 54% 22 17 26 29 Discharge Improved Evaluation Unimproved Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20—29 73 36 30-39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance ‘Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �:0". mm»... can“ b. awn-u a mi: “tum-Ma in a M an“ ”MI "in“ am: tm‘nt It“ ”mm van-mm pap-nun ”humbly! m trams m um to but! up»: u “mun" pram-I. «Wu! h by no “at: m pints“: m “um. a n manna" u. wanna» .1 Wm at hum: mu 1 ”tint up mm“. In! mumm- Irin h nut mm in m than Mm m. pmmuu I!" ”not“ Mt “am“: Mm hut with, $1334, than “I “scan" ufinu «flung «In». or knu- uum Mum-mt an that. a n W“ mchm“ ”than”2le at numb”, nnflnn. “than” an and «mutton o: a“ nun»’M“” a: citation! «yuan-n tum v3.01: 2» a» mu pmmuu «a «mausuun. In. an flatly Imam“ hr tun-much, an“: and um (7) u that it“: of «than: as “was: um: a am. in“. huh. 3.; than“ it“. ”mm mum}! animal! to 551’:an an m mm in m. t: await», mm: sum, man, an 0: awn-mt «um-«m m mm. m m mthmulnhhiutmummd. u “unawaI“ am, bum, 11:01: «In “no in “and“ it. and. as! “St-rm mu tub-rut 1: m ywmfln. �SociopsydholOgical Aspects of Psydhiatrie Treatment in Three Voluntary Hospitals ;R0berrt L, .lfiahn, 1311313332! Nathaniel Siegel, Ph.D.*** ‘— NEIIIIiiiiIIiE§E¥§ �-7- ’4‘, DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter—institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -— duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations {7}, The Expectations based on our earlier intra—Hillside Hospital were confirmeda The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded datae While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i;gf, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.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 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 Sociopsychological aspects of psychiatric treatment in three voluntary hospitals. A.M.A. Arch Gen Psychiat. 14:20-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59b-002 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 Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Siegel, Nathaniel 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], drafts, letters, review board postcard, 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/4092f702c20d2db606a33fb51b3082e2.pdf eb5e272391290df4e9e5af41a15c37b2 PDF Text Text THE “AMYTAL TEST” IN PATIENTS WITH MENTAL ILLNESSl ROBERT L. KAHN, Ph.D.,2 MAX FINK, M.D.,3 EDWIN A. WEINSTEIN, M.D.4 and Recent studies have demonstrated the value of utilizing amytal sodium as a diagnostic test for the presence of brain damage (9, 10, ll) . Under the influence of this drug, certain changes in orientation and awareness of illness occurred in patients with brain disease that rarely appeared in persons without demonstrable brain pathology. These changes included patterns of disorientation for place, time, and person, and verbal denial of illness and incapacity. In addition to disorientation and denial of illness, other changes in verbal pattern and the nonverbal aspects of behavior occur in both patients with brain disease and in normals.l5 All of these aspects of behavior have contributed to an understanding of the relationship of the psychological and physiological effects of the drug and the role of language in adaptation to stress. Until now the normals have consisted of patients with peripheral nerve, spinal root and cord lesions and miscellaneous medical and surgical conditions. There has been no systematic investigation of patients with mental illness unassociated with demonstrable brain changes. 1From the Neurological Services of Hillside Hospital and The Mount Sinai Hospital, New York. 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-49-007-MD-376 and by a grant-in-aid from the Lilly Research Laboratories. Dr. Max Fink was aided by a fellowship from the National Foundation for Infantile Paralysis. 2 Research Assistant, Hillside Hospital, Glen Oaks, N. Y. 3 Research Director, Hillside Hospital, Glen Oaks, N. Y. 4Consultant, Neuropsychiatric Division, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C. 5 Normal is used here to refer to patients without evidence of brain disease. 3 �4 KAHN—FINK—WEINSTEIN The purpose of this study is, by the administration of the test to a series of patients hospitalized for mental illness, to: (l) evaluate further the diagnostic validity of the procedure; and (2) compare the patterns of altered symbolic expression found in mental patients with those shown by other groups. METHOD Consecutive admissions to Hillside Hospital were selected. Patients who had recently received electroshock treatment or who were clinically disoriented were excluded. Sixty-eight interviews were essayed: eight patients refused the test, three showed insufficient physiological effects, and one patient was grossly disoriented in the pretest interview, leaving a total of fifty-six patients who were adequately studied. No attempt has been made to classify the patients according to clinical diagnosis, although most were considered to have schizophrenic or depressive reactions. Thirty-four women and twenty-two men were tested, the ages ranging from sixteen to sixtyfive, with a median of thirty-six years. TEST PROCEDURE Immediately before and during the administration of amytal sodium, each patient was examined systematically for orientation and awareness of illness. These questions were based on previous observation of certain patterns of disorientation and denial observed in patients with brain disease (6, 7) and are as follows: What is your main trouble? Why did you come here? Where are you now? What do you call this place? What kind of place is this? Where is this place located? How far from here do you live? Have you ever been in any other hospital of this name? Where were you last night? What is today’s date? What month is this? What year is this? What time is it now? What part of the day is it? Who am I? Have you ever seen me before? Along with the routine test, the patients were asked two additional questions to obtain further material for the study of patterns of symbolic expression: If you could have one wish what would you wish for? Can you think of a joke? The amytal sodium was given intravenously in a solution of 0.5 �“AMYTAL TEST” IN MENTAL ILLNESS 5 gm. in 10cc. of distilled water at a rate of 0.05 gm. per minute. As the drug was administered the patient was asked to count backwards from 100 to l. The injection was continued until the patient showed rapid nystagmus on lateral gaze in each direction, slurred speech, errors in counting backwards and drowsiness. These were regarded as indicators of the physiological effects of the drug. The total amount injected depended on the appearance of a maximal effect of the drug. In this study the quantity given ranged from 0.2 gm. to 0.5 gm. When the physiological action of the drug was manifest, the patient was interviewed with the same series of questions. If an error was made, the question was repeated immediately to determine its persistence. Only persistent errors have been regarded as indicative of brain disease since it has been found that normal controls may make transient mistakes (9). RESULTS Prior to Administration of Drug These patients as a group showed many overt indications of fear and distrust in the test situation. This was shown by the large number who refused the test altogether. Some wanted to consult their doctors or their families first, while others were too frightened to enter the examination room. Even among those who took the A. Behavior test there were numerous manifestations of distrust. Several were reluctant to lie down—one sitting up throughout the entire procedure, one constantly keeping one foot on the floor, and several keeping their heads raised. Many patients asked for specific details of the test—its purpose, what drug they were getting, why they were selected, whether this was a “truth test,” whether the results were confidential and, commonly, whether they would go to sleep or not know what they were saying. One patient asked if he were going to be killed. Another asked that a nurse be present. Some patients asked us to postpone the procedure or said, “I shouldn’t have come.” These manifestations of evasion and suspicion were much more marked than were encountered when the test was administered to patients in general hospitals. Unlike patients with physical diseases who usually gave as a “wish" a statement about getting well or leaving the hospital, these patients gave many more wishes outside the immediate situation, such as “that all men in the universe should live in peace and harmony” or “good health for the �6 KAHN—FINK—WEINSTEIN sick world,” or “my daughter should marry a nice fellow.” Further, there was a greater tendency for patients to answer the questions using syntax involving the third and second person as “you might say I had a slight nervous breakdown” or “my main trouble is my stepmother.” Patients with physical ailments are much more apt to limit the expression of their difficulties to the first person as “I have diabetes.” B. Changes in Behavior Accompanying Amobarbital Sodium Persistent Errors: Positive Reactions Five of the fifty-six patients showed persistent changes of behavior similiar to those found in brain disease. In a previous report (10) positive reactions were graded from one to four plus, depending on the number of manifestations of disorientation and denial shown. On this basis, the five positive cases in this study showed a one plus reaction. The test was repeated in three of these cases and showed a persistence of the one plus result in two and a negative result in the third. Of these five patients, three showed evidence of brain disease by other methods of study. One, a boy of eighteen, had a positive face-hand test (2), an abnormal EEG record, and an elevated spinal fluid protein on two occasions. Another was a case of Parkinsonism. The third showed a memory defect on psychological tests. One was a sixty-four-year—old man who persistently referred to “Sydenham Hospital” while under the influence of the drug. He had a normal EEG and no presumptive evidence of brain disease. The other patient located the hospital in “Oakland Park” after having placed it correctly in Glen Oaks prior to receiving the drug. The second administration of the test in this man gave a negative result. 1. Transient Errors Transient errors (i.e., errors which were either spontaneously corrected or corrected when the question was immediately repeated) in orientation and awareness of illness have not been regarded as diagnostic indices of brain damage. In persons with physical incapacities, the incidence is low, having been found in 16 cent per of the original series of fifty control subjects (9). In the present study, however, eighteen patients, or 32 per cent, made such errors. These included giving the incorrect year, naming the place as “Hillside Oaks" and “Psychiatric Institute” and confabulating having 2. �“AMYTAL TEST” IN MENTAL ILLNESS 7 been at home or in a friend’s house the night before. Some patients used euphemisms such as “a place to help people get well,” “a place for recuperation,” “a place to teach health to sick people,” “a clinic,” and “the greatest hospital with the most stupendous doctors,” whereas prior to receiving the drug they had simply stated that they were in “Hillside Hospital.” When the questions were repeated, however, the original response was again given. Other Alterations in Language The use of the second or third person in response to questions about illness and hospitalization was noted twice as frequently as in the pre-drug interview. Another person became the subject of the sentence or another person performed the action or became involved in an experience, whereas previously the patient had described his symptoms in the first person. Thus the reason for hospitalization originally given by one patient as “I was getting worse and desperate for help” was changed to “the hospital had a lovely reputation.” Another patient who had detailed his problems in the first person before receiving the drug talked about a friend who had cancer. The change frequently took the form of concern over the health of relatives. The wish “that I never get sick" was changed to “I wish that my kid would stay well.” There was more of a tendency to employ clichés as “nothing to fear but fear” and ”not for publication.” There was also more selective specificity in answer to questions. Thus patients who had originally said that they had come to the hospital for some illness replied that they had come because their doctors had sent them. Other patients gave their location in a more precise way, stating for example that they were in “a treatment room leading off the corridor.” Cryptic remarks were occasionally given, as in the instance of the patient who, when asked for a wish, said “If you could help me out then I wish you wouldn’t, and if you could then I wish you would.” These patterns were not qualitatively different from those used by patients with physical incapacities where displacement to the third or second person, greater specificity and selectiveness of response and increased use of clichés and slang also occur. 3. 4. Jokes In many patients the response to the request to tell a joke seemed to be a symbolic representation of some problem relating to illness, hospitalization, the procedure itself or their interpersonal relations. �KAHN ——FINK—WEIN STEIN 8 The content of these responses in relation to the illness will be considered in a separate paper and only the pattern will be reported here. Of fifty-three patients, fifteen did not respond either before or during drug administration. Eleven patients answered by referring literally to their difficulties as “It would be a good joke if I could go home,” or “The joke is my being here." Six patients used this type of personal reference both before and during the administration of the drug, while five responded in this fashion only after injection. Thirty-two patients gave the usual form of structured joke, the account of the action or experience of some third person symbolizing some aspect of the patient’s problems or motivation. Usually patients who responded to the question in this fashion in the pre-drug interview used the same pattern after the injection. Seven told the same joke, while different stories were related in fifteen instances. Here the tendency was toward a more allegorical representation of the problem. Eight patients told a joke before receiving the drug but not after, while eight related a story only with the drug. Psychomotor Reactions These changes included withdrawal, overactivity, alterations in mood and the appearance of comic or melodramatic “ludic”6 behavior. Twelve patients showed withdrawal reactions. In the extreme form the patient failed to respond to any questions for periods ranging from several minutes to half an hour. In other instances the questions had to be repeated several times to elicit a response, there was incoherent mumbling or neologisms, and incomplete sentences were used. As such times the withdrawal appeared to be a selective process, since the inadequate response occurred primarily with questions relating to the patient’s illness. When questions of a more innocuous nature were asked, such as the date or time of day, the patient often answered quickly, clearly and completely. Marked withdrawal has been unusual in control patients in general hospitals but has occurred frequently in patients with brain disease. Ten patients were overactive during the test. Usually this consisted of restlessness, shivering, rhythmic movements of the head, hips or legs, eye blinking, or repeated fussing and adjusting of clothing. One patient showed behavior which resembled catatonic posturing. 5. 6Ludic is the term used by Jean Piaget (5) to describe the play, imitating and pretending aspects of behavior in young children. See also VVeinstein et a1. (8)- �”AMYTAL TEST” IN MENTAL ILLNESS 9 Alterations in mood were noted in sixteen patients. The predominant change was in a euphoric direction, although in two cases the patient became tearful and depressed toward the close of the interview. Euphoria was shown by increased smiling, giggling or laughing, joking and expressions of well-being. Some patients commented that they thought they had “one drink too many." Paranoid attitudes as indicated by threatening remarks and gestures and cursing were sometimes intermingled with euphoric manifestations. Thus one patient, who said he felt good and “would like this more often,” answered with such expressions as “What do you think it is, you goddamn fool” and “How the hell would I know.” The incidence and degree of these euphoric and paranoid reactions was comparable to those previously found in both normal control and brain diseased groups. Varying degrees of ludic behavior were shown, but were especially prominent in sixteen patients. In several cases this behavior was noted in counting backwards while the drug was being injected by variation in tempo, alternately slow and fast, or use of a sing-song rhythm. One patient barked out the numbers in a staccato fashion, while another overemphasized the pronunciation in telephone operator fashion. One patient responded throughout the interview with an exaggerated syllabic accent and dramatic pauses. Another used “French” expressions such as “00, la, la.” Several staggered excessively when brought back to the ward, particularly when they were in sight of the other patients. One patient, who acted in a dramatic, comic manner throughout the test, spontaneously remarked, “I need applause.” Such ludic behavior is difficult to grade statistically but was in general more marked than had been observed in the previously studied control groups. Six women patients showed some form of altered sexual behavior under the influence of the drug. This ranged from holding the examiner’s hand and such remarks as “dear” to the behavior of one patient who tried to kiss the examiner. A few others manifested hip movements suggestive of sexual activity or partly exposed themselves in restless leg movements. DISCUSSION The results of the study provide further evidence of the validity of the procedure as a diagnostic test for the existence of structural brain disease. Of the fifty-six patients tested, “positive” results were �10 KAHN—FINK—WEINSTEIN obtained in five. The others showed behavior more like that of patients without evidence of brain damage in that they did not develop enduring patterns of disorientation or persisting delusional denial of illness and incapacity. In a previous study of psychotic patients in a state hospital (9) , only one of twenty-five, a sixty-fouryear—old woman hospitalized for thirty-five years, had a positive result, a one plus response. This compares with a figure of 1 to 2 per cent positive in over one hundred and fifty normal controls and an incidence of 65 per cent in over four hundred patients with brain disease tested in two general hospitals. It may be concluded that while it is possible for a patient without demonstrable brain disease to yield a positive result, the difference between patients with brain disease and other groups is statistically significant. In three of the five cases giving positive results, there was other evidence of brain disease. One patient had Parkinsonism, in another the clinical history and finding suggested a chronic encephalitis, while in the third, degenerative or arteriosclerotic disease of the brain was likely. One of the other positive results was found in a patient over sixty years of age. Adequate control studies on the effect of age on the results of this test have not yet been completed. It is possible, however, that positive reactions may occur in older persons comparable to the finding of slow waves in the EEG record (1) and to changes in the perception of simultaneous tactile stimuli (2, 3). These results suggest that in a group of patients with “functional” psychoses there are some with disease of the brain which of methods of the be demonstrated by appropriate application may examination. The amytal procedure and the face-hand test of perceptual function introduced by M. B. Bender and associates (2) are examples of such techniques and should be employed as part of the diagnostic work-up of a mental hospital. In considering the alterations in symbolic expression shown by these patients it is necessary to review some data relating to the mechanisms of disorientation for place and time and denial of illness. These phenomena are not defects directly attributable to brain damage in the sense that they are the manifestations of the loss of a functional modality represented in some area of the brain. They are, rather, forms of adaptation or defense that the patient uses in situations of stress in a milieu of altered neural function. In disorientation, the misnamed time or place is the symbolic representation of some motivation of the patient, usually related to his illness, not a manifestation of memory defect. Thus the patient �“AMYTAL TEST” IN MENTAL ILLNESS 11 is apt to state a time antedating his illness; to give the name of a small hospital or a place where he has been for some trivial illness; to locate the hospital near his home; or to confabulate that he has left the hospital. In effect, the patient is expressing his problems in another language where places, persons and times are not used in their original referential context but as vehicles for the expression of the individual’s own motivations. Although an impairment of brain function is necessary to provide the type of neural organization for the maintenance of this new symbolic system, the behavior itself is the result of the interaction of a number of factors—what Wilder (12) has called the organism-environment-observer complex. This includes not only the neural organization, but the fact of the disability itself, the patient’s motivation to be well, the interpersonal situation of the interview, and the patient’s previous life experience and personality. For example, if the interview is carried out with sterile water, there are very few changes in language. Patients with similar brain lesions may show markedly different reactions under amytal sodium because of different types of personality and attitudes toward incapacity. It is quite conceivable that if this test were carried out under very stressful conditions as in a concentration camp, then disorientation and delusional denial might occur in persons without evidence of brain damage. In interpreting the effects of barbiturates one must distinguish between purely neurophysiological manifestations such as nystagmus and alterations in the EEG record, which occur universally, and adaptive symbolic changes such as withdrawal, ludic behavior, humor, disorientation and changes in syntactical tense and person. It has been pointed out that even such indubitable neurological manifestations as drowsiness and ataxia operated as language as well. The amytal procedure is a stressful one and, contrary to popular belief, the drug does not “abolish” anxiety but rather provides a milieu where it is converted much as a schizophrenic uses a delusional system or a dreamer expresses a problem in hallucinatory personifications. The relation of humor to other forms of symbolic adaptation was of interest. Some of the jokes given used the mechanism of disorientation as in the case of the patients who referred to a hospital (West Hill) as “Mess Hill,” or to “Hillside Cabaret.” Others used verbal denial, as stating that the reason for coming to the hospital was “because I’m well.” In the usual structured joke the patient represented his problems in language involving third persons, more �KAHN—FINK—WEINSTEIN 12 material symbols (often relating to sex, food, death and violence) and the past tense. From this study one cannot state that mental illness is or is not an “organic” condition. What can be stated is that these patients exist in a very stressful environment. This is evident not only by behavior before receiving the drug but by the larger number of transient errors in orientation and awareness of illness, the greater occurrence of ludic behavior and withdrawal and the more frequent use of clichés, euphemisms and expressions involving the third and second person as compared to the responses of patients in a general hospital. SUMMARY The amytal test was given to fifty-six patients in a mental hospital. Five patients, three with other evidence of brain damage yielded a positive result. The results are interpreted as giving further evidence of the value of the procedure as a diagnostic test for brain damage. 2. Mental hospital patients showed more transient disorientation and denial, more withdrawal and ludic behavior and more changes in the syntactical aspects of language than did a group of patients with physical disabilities, but without evidence of brain damage previously studied in a general hospital. 3. It is considered that this greater use of means of symbolic adaptation is additional evidence that patients with mental illness operate in a milieu of greater stress than patients with physical 1. incapacities. REFERENCES Barnes, R. H., Busse, E. W., and Silverman, A. J.: Prevalence and Significance of Electroencephalographic Abnormalities in Normal Old People, Third Inter. Congress of Electroencephalography and Clinical Neurophysiology, 79. (2) Bender, M. B.: Disorders in Perception. Springfield, 111.: Charles C. Thomas, (1) 1952. Fink, M., Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (4) Green, M. and Bender, M. B.: Cutaneous Perception in the Aged. A. M. A. Arch. Neurol. (9 Psychiat., 69:577-581. 1953. (5) Piaget, J.: Play, Dreams and Imitation in Childhood. New York: W. W. Norton, 1951. (6) Weinstein, E. A. and Kahn, R. L.: Syndrome of Anosognosia. Arch. Neurol. <5. Psychiat., 64:772-799. 1950. (3) �“AMYTAL TEST" IN MENTAL ILLNESS (7) (8) (9) (10) (ll) (12) 13 Weinstein, E. A. and Kahn, R. L.: Patterns of Disorientation in Organic Brain Disease. J. Neuropath. & Clin. Neurol., 1:214-225, 1951. Weinstein, E. A., Kahn, R. L., and Sugannan, L.: Ludic Behavior in Patients with Brain Disease. This Journal, 3:98-106, 1954. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Brain Disease. Am. ]. Psychiat., 109:889-894, 1953. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Malitz, 8.: Serial Administration of the “Amytal Test” for Brain Disease: Its Diagnostic and Prognostic Value. A. M. A. Arch. Neurol. (S- Psychiat., 71 :217-226, 1954. Weinstein, E. A. and Malitz, 8.: Changes in Symbolic Expression with Amobarbital Sodium (“Amytal Sodium”). Am. ]. Psychiat., 111:198-206, 1954. Wikler, A.: Opiate Addiction. Springfield, 111.: Charles C. Thomas, 1952. �u. «a... as "am; W' I! ’51!” um MM.» 1m. L. tell. ”.3. mm: LB. 0 III A. "mun. mt:nu. leuelegloel mm e! Innu- lealul beetle lent um halal. lee reel. and W1 me. the _Mlmulgetmmiapnmu mtnmmmzm e! the” tau-teen m Develop-at lee“. eum e! le. WM‘MWIQH‘. tummmwu tree the hilly meme “metal... mu by e teller-up tree the hum). mum tel- Intent“. um mm». 1' �-L. IOC.‘C utudicfl unfit daunuutlntod $ht thll .2 I‘llllinu nnytul social in n atasunntte it‘s for $h0 990...». o! Irtta dn-ugo. (1) (I) (a). ends: the tazluouat a! this drug. olrtntn chnaat- tu aria-Sutton uni usnrunnsu a! allnouu ocuurrod 1a pattoutn with brain «titan. tint rural, appotrod 1n.p¢:soaa without Innmnn%rublo brutn pathology. 1!... eunuch. tnoludnd‘pattowan a! asaowttntnttoa tar plint. tin. uni pariah an! vtrhul dauttl at 111...! “In incapacity. studs... «tint pattatts a! alturod nyuboxto nzpvtnnton turn found in addition to tin «hangs: in ortaatntion Ind umnrououu 01 11150.: oaaurrtns in tin pronanan a! hrtta dtiitli. It Inthnao II. indicatod that thaiq «tannin in vurbu: p$ttara :ad nonpvcrbul Impact. 01 bahtvtor tantrihatod ta II Indornt‘ndtag at tho psychophyltologtanl cttnots a! tin drug and ti. 203’ 01 ltlcuugo 1n &dnp~ an... ‘0 until no. tho control cramp. it's colltntnd a! puttnuta with yortphcr:l atria. cptnsl root In! our! lotion: ant Ilaccllnanoun Indian: uni aarglaul cauda‘anun. that. In: boon no IyItOIttlo tuvnut- am. “me. a: ”that: an aunt unu- Wat“ can mm» Ital: chain's. It. pntpoactot a! tit tant to n Intton 01 pnxtoutu Inuvitaltaod In! unatal £11.»... to: 1) ovuluntc turthnr tho dtucuncttc validity at tho pcooo‘uro. 3“ this study in, by the administration “to ”tum o: um «smug W1“ tom 1We units: 3&ttoat- with than; lhfl'! otlur a) fig Omnnflcustv. putt-3t. udltltlous t6 grunts. lllllidt lonpltul v.39 lcloatod. i£d vacantly rocutv.‘ olnatmoachoot trtatnnax or who v.90 alt-teal}: diaorinntoi tor. IIBII‘O‘a $11t1~tifiht satcrvltun U‘f. 0:33:06. night ytttauta twinned tho taut. thruc alumna innutttctou‘ who �«i- an unattaiul “1mm. m m ”that m puny (Wham m pro-um utmm. than; a to“; a! to nun“ m m: mm“); “in“. I. “W m m and. u “but, tho 3““th «mam iuhtsam ta cltntail diucaoati. u1*&auci flout ttri caln$dtru£ $6 is?! and 13 I» mm mutton. nutptm at pm“ tum: W“. a.“ mum Inn 16» u. «an with a “can at :1 m mn. him and data; m taunts-anon a mu]. owl-taunt); a: mm. «a ”that u: «and tutmumuy tar ”atom. at “luau. W muons an band on ”aim anor— nuou at «mun ”km a! amtntnun n4 «aux ohm“ n ”tints um um. “um (42 (a) m m u sum: laminae-1y an truth? It: am you cm W? "on mahmnutmpw Wimotymutm? me grammar? 1: your mum mutuapuu MM? ”iu'tmhmumuuv mm but a m at!» man: at an W? M «It you an this? night? Int M W's «in? Int mill 1. ti“? “at ya: it 1- st? u. n I!“ m a! the that “no n It an" Inn put «or ms In “in" a: m Am vi.“ ti. mtm Mt. tho ”$1.31! m and «udtuml mum to out“: turn“ mum: to: at um 01 5mm 0! "about: cat’s-«Mon: I! you that 0! n m on“ haw Mu mu mt mu m ”at In? a» 39“? m mu: mm an aim mum}: 1: a «mum at «utum mm at a an a! 0.0! h at! mm”. tho ”that m and to «on» A. a. manta“ I“ m no: 109 to 1. m tumult us mum“ at“ no pun.“ am up“ ”um a am: use an m “mu“. “m“. an“. as cm" a: own“ mm“ m mun». nu. ma «sum 0.5 in 1. 10“. of W“ �*3. “amm- o: u. mum: «tau a: no a... no tout mt injnotod anyondcd on tin apptsrnnno a! u naslnnl uxtcnt at tho trig. In tut! atudy tan qfinntttr 311:3 rascal iron 0.! an to 0.5 03. than tan phyulaloflianl nation .1 ti. drug was nunttosfi. tic pgttoat In. xitcrvtvvud with t). nguo tartan o! quoutitufl. I! an ¢rror was main fin. quanttnn.van rtpuutod aluodiutcly to actor-tn. its parttatinaa. a;1y porutntant armor: Igru boon rngnvdod an tudtsattvo u! truth dtuouou 31am. 3% hi. but: tound that tarsal auntrolu any unit ttuamiant nintulou (1). . Inhavtar . in» t9 . 13$: uttan a: . rtcnc paticut. us I grow» filowud Inn, owurt tfidlaattanl a! tour Iii Ctnfirtflt in tit tilt iitlutttu. fhti was shall. by tho titan :nlbcr vb» 2633.06 tho tout nltogntlor. Son. iua&cd ta calault that! doctor: at tint: inntltan 1131:. watt. othsru war. tau frightenud to .fitfl? tho caantnattoa soon. 3"» 3.3:; than. via tcotilhu its: that! unit nalbcraus naniloatnttonu at dintwuat. Savnrul flirt raiuotaat at 1:. 401a - on. flitting up throughout the cutaro procedurc. on. Gonna illtll Utopia: all fact on tin 1100:. ktuptlt that! than tttaad. Inns patients tutti tor apoettta Gettilu a! tit tout - it: ’II’OIO, Ihlt drug thaw tut. ;n%tlug. why the: It?! uoln¢t0d. Ihnthnr this II! a ”truth tant”. Ibuthor ti. results var. euniidnntlll and. unusual}. vhnthnr that would 30 ta slut; at not hunt want ti.) Ilrt nsgtuc. an. putaoat Into: 1: ho vIrQ '91-; to h. hillod. Aunthnr 3330‘ thtt : turn. be pruunnt. I... tatttntn ‘33ud an to potty-nu and acvarul tun granular. or 3‘1: "I abouldn't 5": ¢nnn.” than. u:a110ututtona o: ovation sad tuapaeton vars haul an». marina than unto announsqrud thin tun tout 1‘s tdiifliutCtOd to putIQntu 1: stunts! Inu3ttnls. BIltkn pntiontu with phyttaul alsoasu: vim usuully 3:1: ti s "stat” a st;tunnnt than: Ifl‘tllt will or tnavta: It: houpttul. thQfli puttonsg �'T ant: taro Uilhll autitda tn. tumullnta nttnsti‘g. Inch ll “tilt :11 3‘: in tin IIIVirflO should 11'. in punau an: h:rnouy* tr ”good intlth 1.! tin ntct unfit? II ”I; lifl‘ht‘t nhnuld flirty a lion tollut.' turthurunmt. titan vat & [rcattr toxicity in tit: group in czar... tilt: gnu. distthXttnu in turns .1 aqua athnr pcraan :3 ”13!.Iiflht an: I but a llxaht Iorvcuu trashinvn” OH “I, uni: trout}: in ny‘ugglagthtr.” Alfihtthtta1_sndtuu. 1) lorntutcna gyrornz fithttvo Innattona 11'! a! ti. ‘0 pattnust nhnuod pcruzatant ohms... of Io~ hgvtor stutlir co tin-c could in hrtlu flaunt... it u IIU'IOII rarest (l).puuattvu tauntinn: that gvnlud tron an» to soar plus anpculinc en ti. lumbar at nuntloatuttoan a! itnursoattttoa nah 6.33:1 chain. on tbtt 5.31.. tho lava pontttvo «use: 1: :81: study thou-d a an; plus roasting. it. tout was rcpoutud tn turn: at those «:30: sud-nbolod a ports-tuna: a! th. an. plan rauult in tun and n Ingnttvc ranalt 1n tho thlrd. a: than: £11. putxnntn. turn: lhfllid «vidnnoc of hrtln taunts. by athnr nothads oi atudy. Out. a haw 01 It. had a pauittvu Inoonhlnl fitnt (6). ti 33:09:51.356 toourd. sun nu titrated uptunl fluid protoil on two Oflflhfitflll. Anetta: it! u «an. o: Paritnnantnn. r30 thtrt attuan psych-mun mu. mam: at tho u. a in: vus$ttvn an... had 0th.: fliflll of br‘tn difitllfl. an. In: t 64 run: 91‘ Inl‘vho porbtltontly tOIOWROd to ”Byflnahnl annpttnl" ‘hili ands! tho inslumauo at tho drug. It had a nnrnnl BEG :34 no prouu-pttwu Ovtdtiui a! brain dtloan¢. fit. othtr puttnut loath4 1h; Ioaptt‘l ti "auklaua.snrlfi altar h‘vtnc pinata it narroatlv in exam Oahu proav to rtoutving tho drug. Tin flaccid tautntntrttaon at tho toit in this has ' , m , .-‘ , .. at»: unvb n.3oust110 mum litflltn a) trgggtnut Irrorns 1r£anxcns array: (a.¢§ iVFORfl 'hiflh var: otthot $90.30 ulnouuly corrected or oowrnotod who: tn» ancatian nun iuuodttttly rn’nntnd) tn cranniatlnn and :nurvaaas a: titans: haw. not bat: ra~ �ubm mm u «W‘u u but; «an. :3 ampmm: nun. .mm:Oriflfllfll a! ti. untowar. II unaxrol.tfibsn¢tu (1). In the preaeat «tidy. Icaad nclttou. tin zlcilnnno in luv. hxvais b¢tn aortas of no £3 19% includod ¢$Viit tho luaorroct puttomnn, or 33%. III» neat trworx. rant. eats" au‘ *fltyuhtntrtn Initituad' ti"”l111l$dl 91:30 in. Iflhlfil than. fifi hunt or 1‘ a friend’s blunt ‘hn utult hon: tiring ochlttulnt1:¢ tat such I» "t plaoc to but. .0033. boxorc. Ian. pustunau «nod cuphauttul ”a piaan t¢ tctah honlth to bank rtcnpcrnttan," tar "a plan; vu11.* not hospital with tun not: ntmaunduuu panama.” ”u “Ilhtfl” tad “thy cronttst drag char but simply tut rocctvin: to print shnranu I!!! dilitrfl.” mm “at thy um “I 331th ”pittl.” M flan motion! m Bivtfl. rtponxtd. tunnvnr. tun arisinnl rampant. run anti: tbs lacuna at third airman in rtuponun to was Intod twist it lrcqummh and hospitaltnttion i11n¢as about qunuttaun booth. in» iflhaoct 0! pinion anothir tuttrviov. yrcudvuc tin 1: 1: as or stain. turalvod tcttau the patterned parucn santhar or tbs statnan: had dynaribufi it: tun patio-t prcvtauuxy 'hnr¢xa exportnnoo 1: an for huapttnltnutmu: ayuntuun in it! first action. Tins til ratio: Thu ‘ at. at mm m mum «umxu :19“ by an ”aunt u «z umhad”um ’ 1 lowly "mum.” "the mun. in law In abused to uobnll in tho mm mm n: «mud m m “tun am m Thu Qfifllll drug tnlknd thaut a tritnd who htd onnaor. 0N0! filo htnlth a! tolnttvos. tho aonauru at for: tha toot trcqnoutly vuuld ohuugud to "t ui¢l that my on: tie!“ Invue jut “thnfi t Isak tiaalrtac tho ill ntny unit.“ Thar. "anth&ac mo was tare Qt 1:32 but taut? and eliahlitii an ?Iot tar yubllcntten.* that. in: tits ;.tondna¢y ta 0:919: ¥uun puttanss It. stloattva spoctitatty in audit! to quantlaun. for non. 111:..hanpttul tho ca has oust tan: that said had originally doowtrs ha! tilt $hfll. Git“! rtrllo‘ thtt tbs! had noun inaiuat tbttr Iowa �cxuupla finalists guru that: Ififlltibt tn t not. ’Uflaiifl way stuttn‘ tar that tic: ivy. In ”t traatngut roe. lindins at! thc corridor." in tho Lustunaa at tho cryptic tilt!!! taro ocaasleually [1103 I! could help :0 out thin p;t1¢nt who. who: 13306 :0: a 11.». 3‘14 ":1 you I with you 3: you «call than I with you wasti‘. Thifli pattorna Ifift net aititrant 12am thus. used fly itnlau‘t. ti! tho tutti-or patient: vtth-phynsnnl.tnaa'ooittcl that. dtnplnetntut to Ind atonnd yoxuau. gruntnr apoetliaity and .alnctzvonou: a: ruppoulu at tn¢rosaod use of aliahfii and filtflfl tor. notud uadmr tbs tnfluttcc tn. drug. 4» 12w. In I311 pstttntn thfl rouyoano to thc rtflflflit in tall 3 prfibluu rulnttng John doc-Id to-ba & tribulia rupwosuntntson of nuns inaction. $0 illnous. houpttalinstion. tn: procedurc ttaclt or tint: centidnrcdv finial rolttxuns. 1h: aoutont at tats. rfiiwfiflfltl will bu at “ hint. rcpartud b. vtll p&t$ara and 9.17 it. papa: Iipttttfl udllutnn 53 pntiauts, 16 did not roapond cathnr hetero or flaring dru; 4111£~ trutian. llovun pattcnt- aavvcr-d hyirntorrtn; ta thsir can x! :nltiua 1n tun {first yuruon.uu¢h a. “:t would b. a spot int. I anal could no hunt? or “thy Join in my bctns but.." at: pafituttn adulntna thin try: at purnaanl rctcronan both taint. gut dating tin tr;tton $1 tun drug '31:. 11v: runpondnd tn thln~£aahtnn only titar utructurdd Alénottob. titrtrwtvo pattuats guru thn asunl turn at an a ' a: tilt third 303:. In theta. tho taaouax a! tin unttnn.ur umpnrtonn; tritium: or par-on :ppnutcd to nyutalauo not. :upnct a! £3. pnttnmt‘a ‘hau nottvuttog. annuity pttzalas who rcupondod to tho «nosttoa a: ch. 1133103 in tin primdntg antirvxcv unad tho ‘5‘; pattutn nitat wail. ‘lfiflflliti indaatxon. aovoa 01 than. patlnntn told tho I!IO John It: tovird float} might pattonta problem. th. at reprouontatton u not. ulltgnrtcal static: war. rolatod in 15 tantsaats. In?! tho tnaluley : ”John” bum mum m» m m an aura ran. um: um“ " �1 47“ 2.13th 3) Gianna. tualudod withfiruuul, avarauttvtty. ultaruttouu. u'pnnrunnn 91 unite er lixodrnuttta ”ladle” hohavtor. an... in loot uni tit it: Cruz. th: rulntud a story 011, with Tvtlvu pataontn thaw-d Itil‘rllII rcaattous. Ia tho lfltlflll for. tho puticut tuilod ca rosyend to any quantaonn tow ported: 13:11.. luau novtrnl innntdn co halt II hour. In othnr anutnuaau tho quouttunn had rntpnauo; tint. In: tn:ohorou‘ Innhltagi or analogiaua and tuna-plat. Icutcnunu Iflrfl ulna. At finch tans. tin withdrawal sayqarcd t: to u solauttvu pruuocs s‘nuc tin tu§d¢QIuto roupous¢ oocurrvd 9:133:11: with qn3;ttona rotating O0 tit ptttont’u illnonu. what quatttoun a! u fifi!‘ tuaoaunnn tfltflrfi via. to no rapdutna,novurnl tin.» ta filiait int. or its. a! n tin pattnlt often unnuoraé unwakly. «13:91: and aauplntcty. quknd Itthlrmlal in: not: unnuunl control puxlontu ta ulnar:l hospitnln hut in: oaaurrod tttqucntly tn taint. such an tho dag, LI patxcntn ittl hrt13.d1:0uno. Tb: patient: unto ovorlutivn aural. tho 303:. Infinity tit: countutod 0d *hyttuta uncut-at: of tan baud. at»: or Inna. a}. bliskiuu, a? v.9uxtod ifilfiiflfl and adaasttt' at elatitla. taunting: tho pttitnxu boos-n vary riitlaan. nut up in 5.6. sud Inliltti on having a algnrottu. an. unison: sinned prolalcou uhtvurinc at It: Uliil. bcdy tor nlvurll Iiifllfifl. titular thuvud bthnvtnr vital roan cabana ontntostc ponawtnc. uponttnaoualy balding an. urn in it: at! law atvbrnl utuutou and thin holdtu. 1t 1: vnrtnu$ paitttain pliant by tho Usualllr. (stilts: 11%.?t‘tfill 1n toad taro nottd in 16 putlontu. it. pr.» aunt‘s was an “uuptnrtc diruction, lithouch in its 0...: ‘DG pgttuut itann. tanrlul sad Quartilud tawgra tun alone at tho 1n$¢rvtau. Implawta in: slow: by tactanlod untltic, fltltltit'or laughtng. 5ohuu| Ind larvalfltalt a! vullabltlc. I... pitttttu Gauntltad thtt tho! KIII‘I thoucbt tho! hut ”on. GU!!! ‘00 I031.“ fihranotd attituinu In tattontod �.3. w tantalum min mm mm and mm m mum at”. utnclod~vith ouphnrta unntfoutattann. it»: on. pattuns, who till I! :alt 330‘ and “vtuld 1110 than unto otttu.” antvmmtd quanta... with such tzpwnanlauu us “that «a you tat-k it in. IE“ dealt-n 10.1” and “not boll fiflfll‘ 1 tauv.” Thu iactdnnoa :nn anuvau a! thil. oaptartc ranutxoun was cougarghln tn than. pravtausly tau-d in both nor-n1 it. «0.12.1 sad ital: dilussud cvuuva. Vurvtng ingrown a! suit. inhuviac var. Ihfliu, but IOU. ill patxonln. In ntvbru1.oaaan this hohtvtur it. until in tint! stunting baakaurd; Ihili tin drag It; 301:: imitatod. I... vurtod in. tango o1 th¢ir oonattac. altnrnntcly filfi' sun 1.3:, at tuna a tiuzwaanc rhythm. an. patient bartnd out tit IHIDUII it m aaaoaiullr vauntntnt in 16 mm» mm“ um» mtm mwmam m wmntm :- ‘ollphonn aparttor annulus. ga. pntitnt rcopouaol tittaghnut tin tstnrvtuv wit! nxxugnrntud nyllnbta unacnt gun druuutic pant... tn0$lr flflfi‘ ”triath“ oxprofintens Inch an "an. 1:. 1:.” low «In! uttsunro‘ mainly ma brought m: to m ward. platinum” um an in in stgtt at tho ether pstiaats. out Bitiltt, who actod in s art-nth: tin taut. upongannaunly tauntini *1 li.‘ applause.” Inch ladle huha'tor is diffiuult to grad. stutlctlonlly but it. In contra! not. ItrlOd thin 3:6 30.. abuarvtd in tin prtvtouuly ntullol control Iron... 81: canon puttuntu ibfl'fld saw. for. of filitrfld count; it» hatter and»: In. anxlutncc at tho crux. thia raaaod tron tilting ch! onnninug’u It‘d and Vbrhtl rauurln can: a: calling than “dust" to tho huhuvtor or an. putlatt uh. triad to Etna ti. nunuiulr. A for atlnru ratatou‘od It: Invoucnt: Ilcguatlvn at fituual activity at ynrtly-oa’0001 tin-n.1th in rattloul 10c Invclcntc. gnu «nude unannr throughout axncuasxal the tumult: a! tin Itfiflr gravid. :uritur duta ro'nrlilc �.9- "1““, u imam tut far can «tum. a a! the prwodum tho at tho M of aluminum: In“: “at“. mun: nu. chum a flu. the ”an“ mud ”yo-tun" mo nu um um Mint” ma ‘W 1- “ti up: in an «item 0!. Malay Mum ”am“ of imam-gm or mama. «luau: mu). «1’ film: as may. :3 a ”cum “W a! ”you“: ”that: in a at“. butt“ (1). only an o! a. n a you on “at a! put-«tn without m M manna“ for 8! ms, and n mitt" m1: 0! «a 31m. is» I “an a: 1 «u ”out” m1“ u our no m1 mmh m n inseam. 01 m 1- m m ”cm“ with ma “mu mm 1: ma «mu mmn. It my be 0.01““ an nth it is with]; as! n ”that without mwu mm diam to ”on I; ”out" mum. at “um ham “than with ma a nutuuully Ituutmt. “mu and «w In that. a! m 11" um [um mitt” rm!“ W W um "um 0! mm dam...umon patient t” In mum-um, 1n 1mm “warm I am“ cumulanu. an. u: an um. “mu” «- Wlmlmua am» 1.at the mm «a $13013. with. malt nu cm a on ”flat this study a ”11 u u m at tho ”than panama mac n a man an «11.5.»: “um A “no mun who m cm to you: at an. uncut. «um: “mm an have not ant to» a no on.“ a: u- n the min a!tutthismm.” mum In new mum. It a with)... to no than: u um am a tit m 1: on,» mm. “I not“ (7) m t. a th- wart“. if imlfim a! nun! ”in.“ with an“). “no m1“ «can! tut in g 0! flu in“ Ilth ~mum1" Wm thin II! to m '1“! «17 by tin ”pliant“ 0! nun a: in I“ m tam-nu tut utm a: ommtm. a» “muby and minus: (a) Ll. at ”mutual {mun m min a! mu Manna» an autumn he ”any“ 1: wt a: th W. man W cm man“ new m W.W W Watt �VF . «10~ "T diacloottc Iflrknl’ or ;.ann$n1 hanpttgx. 1‘ annitdbriac tun nltatfitiuna in mytholis czprunatoa about: by than. pltliitu it in noccuuary an raviiw you: grovioua fittn t01n¢tll‘ mo tho Ianlsnlsuu a! luu;:tcntnttol for place tad ttloihnd 6.31:1 at tllnnat. It hit but: 589*! tit: thouo phanouana 3!! an: 60:06:: Iaroain I: nttrthutuhlo ta brill using. 1113!. runs; that tiny arc tun mafitfilu rattan: or tut In“: or u :uaaiiennl 001.11%: rcprcn-ntod 1: I... tent at tho brain, Thur arc. rtthnr. tor-a at ninytutton or fiotcnsn that It. pntltut usnn in situations a: Itvcsa in n niltau of altcrcd luaral inacttnn. In dxnurinututiau, ti. stanuuqd tine-at plan. in tha uylhtiaa ruprcuontutxum or new; letifttifll a¢_thn ynttunt. usually thst a! hdbu GOItI¢ null and iota: homo ant a nanatoatntlou at 19:: a! unwary. That it: gattnnt in apt to stttn a tint untoautiuc :1: 11130.33 to .11: tit a... a: a small hospital at & vixen that. hs'hn- but: far noun-tttvtnl illnnia; ta least. tum hospital 33:: hit noun: at to uohxniulaxc tint ha has 10:: the knapittl. In cltnet, the ytttans 1n oxygenatus his 1: mt»: when puma. pinata: us than no no: in that: «algxn‘l retornnttul aunuoxt but it vuhielsu tor in: exproslanl WM a: the 1W muamva mu manta“. 1mm: ‘.. 1mm at mu {aunties in noeoasary to prnvid. can typo a: neural orgnnisttton in! ‘hn nuantonanee of this new synbolie synten the behavior 113.11 a: tin tOtult a: tin tuturtntton or t numb.» at ttatort u vhtt 1331.! (I) It! cull-d tn. orgnutuumvnviranmaat—ohfiurvur euuplnx. wax: tualud0t not «:1: tbs antral arznnt:at1an. but the ltct $1 tau disability ttucll. tho putlogt'n untivltion ta b: I'll, tn. tnturpnrooatl tituttton a! $I. intaxvicv. and the paticnt'a 11!. axpcriauct and parsoaaltty. tar .i‘nplo. 1! tin interview in warriod out with utcrxli I;to: that. am. In ch33... 8| lungsmtp. 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LL. and . l»: mu ”no: 3: “cm. with It“: Mum. 3. It In“ mung. 1. m ”that: LMWW ‘r �Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume IV January, 1955 Number 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 The “Amytal test" in patients with mental illness. Journal of the Hillside Hospital., 4: 3-13, 1955. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-15-019 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 Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Weinstein, Edwin 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, Volume IV, January, 1955, Number 1. 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/d4673cc7ac4d3b5481723b3db49559a7.pdf 7cd1e7dcb45e0955ceb3d6c8e6eafcd7 PDF Text Text Relation of Amobarbital Test to Clinical Improvement in Electroshock Robert L. Kahn, Ph.D., Max Fink, M.D. Glen Oaks, N.Y. and Edwin A. Weinstein, M.D. Bethesda, Md. Submitted for publication February 23, 1956. Hillside Hospital (Drs. Kahn and of Research (Dr. Weinstein). Fink). Walter Reed Army Institute supported in part by the Medical Research and of the Surgeon General, Department of the Office Development Board, and grant M-927 from the DA-h9-OO7-MD-376; No. under Contract Army, of the Mental National Health Institutes of of National Institute Health Public Service. U.S. Health, This investigation was �\ theories about the mode of action of electroshock therapy have been offered, the relationship among neurophysiological and psychological factors remains poorly understood (1,2). Although While many changes in brain function may be demonstrated on electrical recording, such evidence of impaired function has not been correlated with the degree of psychiatric improvement. Similarly, although memory defects learning ability are common manifestations following the administration of electrically induced convulsions, their severity is not an index of therapeutic outcome. It would appear that the results of ordinary clinical and laboratory procedures and psychological tests do not furnish adequate criteria for a correlation of the alterations of behavior with the changes in brain function. In previous studies (3) it has been suggested that the therapeutic action of electroshock therapy was related to the production of a milieu of brain dysfunction in which denial of illness (anosognosia) might occur. A concept of anosognosia was advanced which included not only denial of hemiplegia and blindness but denial of many other aspects of illness and problems of living. It was indicated that anosognosia was not explicable as a focal deficit but was, rather, a manifestation of a reorganization of perceptual symbolic function in which the patient represented his problems in an altered language pattern. In the verbal sphere these language patterns included explicit denial, disorientation for place and time, reduplication (reduplicative paramnesia), paraphasia, and confabulation. The patient's feelings about his illness and incapacities could also be manifested in nonverbal aspects of behavior, such as selective and impaired �-2withdrawal, inattention, and muteness (akinetic mutism), altered sexual behavior, and euphoric, manic states. The particular form of symbolic adaptation that was used was of the premorbid personality. closely related to features These changes in behavior were found commonly with infiltrating neoplasms, with acute vascular lesions, particularly when associated with subarachnoid bleeding, and following lacerating brain injury. electroencephalographic records showed diffuse slow-wave rhythms, and it appeared that the lesions affected the diffuse projection systems rather than any specific discrete projection area. Similar forms of behavior may appear after the operation of prefrontal lobotomy and, in more transitory form, after the administration of electroshock convulsions. When the degree of brain damage was insufficient to permit the elicitation of explicit denial and disorientation on ordinary clinical examination, these phenomena might be observed when the patient was interviewed after the intravenous administration of amobarbital (Amytal) sodium. This observation furnished the basis for the "Amytal test" for brain damage, in which the persistence of certain patterns of denial and disorientation are considered as evidence of impaired function (h,5,6,7). It was reported that in some patients receiving electroshock treatment for intractable pain, the amobarbital test, which was previously negative, became positive after a number of convulsions. Others received as many as 18 shocks without change in the results The of the amobarbital test. It was noted that in patients who gained �-3- relief from their complaints of pain, the amobarbital positive, whereas in those patients tests became continued to complain of pain the amobarbital tests remained negative. The purpose of the present paper is to determine the relationship between the clinical response to electroshock treatment and the results of the amobarbital test in patients hospitalized for psychiatric illness. who METHOD patient was given a series of amobarbital tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the awareness of illness. The drug is then administered intravenously in a 0.5% solution at a rate of 0.05 gm. Each cc.) per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward are noted. The same questions are then repeated. The following changes, when persistent,are called "positive" and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness. (1 hospital, either its proper name or in terms of some euphemism, such as "rest home". h. Displacement of the location of the hospital, such as to another city3. Misnaming the 5. Confabulated journey. Reduplication of the hospital, such as the patient's stating that he is in another hospital of the same or similar 6. �name. 7. Disorientation for time of day with confusion of day and night. 8. Gross him a 9. The misidentification of the examiner, such as calling "lawyer" or an "entertainer". Disorientation for year. patient was given his first test prior to treatment and was retested at weekly intervals. All patients in the series had negative amobarbital tests prior to the flfitiation of therapy. Treat— ments were administered three times a week, so that the patients were generally tested after every third treatment. A test was given two days after a treatment and was continued at weekly intervals after the termination of therapy until the result had become nega- tive. Electroencephalographic records and standard tests of memory and learning ability were also given, but will not be considered in detail in this paper. POPULATION patients at Hillside HOSpital receiving electroshock with the Reiter Electrostimulator were studied. The patients were not selected by us but were taken on the basis of consecutive referrals by the clinical staff. Some patients were necessarily excluded because their treatment was terminated or interrupted before they were adequately studied. Another patient was omitted because he had manifestations of brain disease and a positive amobarbital Twenty—four �-5- test prior to electroconvulsive therapy. The number of treatments varied from 9 to 33. Patients who showed clinical improvement tended to receive fewer treatments. Some of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. One patient decided for himself that he had had enough treatment and eloped. Diagnostically, the patients consisted of lh with depressive reactions, 9 with schizophrenia, and l with manic reaction. There were 15 women and 9 men, and the ages ranged from 2h to 68, with a median of h? years. Evaluation of Response to Electroshock Therapy: All patients were observed for at least eight weeks after completion of treatment. Determination of the patient's response to electroshock was made on the basis of the resident psychiatrist's impression, staff opinion, the nurses' notes, and the clinical evaluation of one of us (M. F.), who supervised the treatments but was not aware of the amobarbital test results. On this basis the patients were divided into three groups. 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 felt they were better, and the nurses noted them as being able to sleep without medication, eating better, getting along with the other patients, and participating in hospital activities. A. Markedly Improved: The 11 Moderately Improved: The six patients in this group showed some improvement but continued to manifest indflations of mental B. �-5- illness. patients typically showed symptomatic relief; ELEL’ acute depressive features might be gone, but the dramatic change, so evident in the first group, was not apparent. Each patient continThese noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. ued to show some C. seven Minimally Improved or Unimproved: patients in whom change was not showed only equivocal or In this group was clearly noticeable or transient improvement. placed who Some showed fluctu- ations in behavior, at times appearing somewhat improved. But the change was not sustained, so that by the end of treatment they appeared much as they did before. We are aware of the difficulties in evaluating improvement. Others may have differed in the estimates of changes in these patients. In any case, by using this threefold classification, the differences between the first and the third group will be distinct. OBSERVATIONS Distribution of Positive Reactions: The number of amobarbital tests given to each patient during the course of electroshock A. to 13, depending on how long treatment was maintained. In Table l the data are shown for the number of tests given during treatment and the number and percentage positive for all the patients ranged from 3 in each group. The markedly improved patients showed many more positive reactions than the unimproved group, with the moderately improved patients between these groups. Every markedly improved patient had at least one positive amobarbital reaction during �-7the other hand, one of the moderately improved patients and five of the unimproved patients never showed a positive result. A comparison of the results in each group, using the x2 test, is statistically significant at better than the 1% level of treatment. 0n confidence. B. Positive Reactions at Each Stage of Treatment: In the Figure the groups are compared for the percentage of patients in each group who had positive results at each stage of treatment. Almost half the markedly improved patients had positive reac- tions after only three treatments, and all had positive reactions after seven to nine treatments. In the unimproved cases, on the other hand, the number of positive reactions was small and there was no consistent increase during the course of treatment. Again, the moderately improved group tends to fall between the other two. Fig: Percentage of positive amobarbital test reactions occurring in each group at different stages of treatment. patients received more than 15 treatments, the data are not presented beyond this point because the number in each Although some group became too small for purposes of comparison. Four of the unimproved patients received more than 20 treatments, with consis- tently negative amobarbital test results. One of the moderately improved patients received over 30 treatments, with only an occasionally positive reaction. �-8- variations in the persistence of positive reactions from week to week. With at least two consecutive positives as the criterion of persistence, 0. Duration of Positive Reactions: There were nine of the markedly improved, two of the moderately improved, and only one of the unimproved group showed persistent positives. After the termination of treatment all patients but one had negative amobarbital reactions nine days after the last convulsion. The remaining patient developed a negative test during the second week after treatment. Factor of Age: Since the patients in the markedly improved group tended to be older persons suffering from depressive reactions, it is conceivable that the difference in amobarbital test results D. related solely to age and only coincidentally to clinical improvement. Underlying this is the assumption that the older person is more likely to show signs of altered brain function when given electroshock. In Table 2 the mean age for each group is shown. It is apparent that the first two groups were older than the may be patients. Yet, while the mean age of the moderately patients is slightly higher than that of the markedly group, these patients still had significantly fewer positive unimproved improved improved reactions. the number of positive reactions during treatment is for each group when the analysis is limited to patients more In Table shown 3 years of age. In this Table the relationship of positive reactions in the different groups remains unchanged from that when than hO �-9the groups are considered as a whole. OTHER ASPECTS OF BEHAVIOR Apart from explicit denial of illness and disorientation, there were changes in behavior that occurred both under the influence of the drug and clinically during the course of treatment in signifi— cantly progressive fashion in those patients who improved. These aspects may be divided into verbal and nonverbal communication. A. Changes in Verbal Language: These changes consisted of denial expressed in evasion, in negative expressions, and in the use of a syntactical pattern involving the third and second persons. 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 to tell me." The change in syntactical pattern is When asked about illustrated their symptoms, "It's they call a depression", or "I'm afraid somebody will get hurt", or answering the question "What is your main trouble?" with "What is your main trouble?" by such remarks as what patients would talk of a relative who was sick. In patients who improved there was a notable development of such patterns in a nondrug interview. One such patient, for example when asked prior to the start of treatment what his main trouble was, said, "I’m depressed." 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 mean"; after eight, "I get sick; that's all I know." After 10 treatments he said, "Right now, it's that I don’t see my wife," and after 11 treatments he said, Sometimes �-10"In what way do you mean?" and "I don't know how to explain it." termination of treatment, his main trouble was given as "I want to get home", followed by an account of how "good" his wife At the was. the other hand, the increased use of these language patterns did not occur. They were not present in In the unimproved group, some and were on minimally or inconsistently noted in others. In some patients there were actually fewer such language patterns under the effects of the drug than there had been in the of the unimproved preamobarbital interview. B. Changes in Nonverbal Behavior: reactions occurred frequently in the markedly Euphoric in both clinical and drug interviews most improved group, less often in the moderately improved group, and least often in the group which were considered unimproved. In the patient classed as manic, euphoric behavior present in his clinical behavior and was not changed by amobarbital. Changes in sexual behavior appeared during the amobarbital interviews of four of the markedly improved patients but in only one patient in each of the other categories. This took the form of trying to hug or caress the examiner, making remarks with sexual content, or engaging in masturbatory activity. A patient in the unimproved group showed this behavior both during pre-drug interviews and under the influence of amobarbital. unimproved Withdrawal or markedly improved "selective inattention" was was shown by patients, particularly during the 9 of the ll drug phase of the �amobarbital interview. This behavior consisted of failure to answer the questions about illness and hospitalization or responding in dysarthric and cryptic fashion. This reaction under the drug occur— red only once in each of the other groups. It was of interest that two patients in the unimproved category who appeared withdrawn before the test became more responsive under the influence of the drug. COMMENT results of the amobarbital tests in these patients indicate that there is a relation between clinical improvement and the production of brain damage or an altered state of brain function as determined by this particular method of examination. In patients The who improve, the amobarbital test becomes consistently positive early in the course of treatment. In moderately improved or unimproved patients there are fewer positive reactions and their frequency does not increase with more treatments. With other methods of evaluating brain function such close correlation was not present, all patients abnormalities in the electroencephalographic record and impaired learning was found as frequently in patients who improved as in those who do not. The significance of this relationship may be more clearly appreciated by a consideration of the changes in symbolic function that occur in states of altered brain function. It has been useful in studying the behavior of patients with alterations in brain function to distinguish between defects in the as showed formation of symbol patterns and changes of language patterns which �-12- interaction in the environment. In the first category may be included many types of memory defects, dyscalculia, topographical disorientation, and aphasia. A patient with such a memory defect cannot select elements of experience, classify them into significant units, and arrange them into a temporal pattern. These defects are observed with diffuse cortical lesions and probably occur universally after shock treatments in transient fashion. They are, however, related very remotely, if at all, to therapeutic outcome. Alterations in the mode of interaction in the environment are exemplified in the various patterns of disorientation and denial and in the amnesias that are noted with lesions of the diffuse projection systems, in chronic barbiturate intoxication, and following electroshock convulsions. Here there is no defect in memory, awareness, or perception as such, but the patient selects or rejects certain aspects of the environment for the expression of his own motivations. In disorientation for place, for example, the misnaming and mislocating of the hospital serve as symbolic representations of the patient's feelings about his incapindicate abilities shift in the a and problems be well and go home. mode of as the manifestation of his need to not that the patient is unaware of his -- often It is is in an absolute sense. He of the hospital and expresses "aware- problems and does not know where he commonly "remembers" ness" of his unawareness the name difficulties in other contexts of language. The is, rather, of the far greater degree to which he is expressing his own motivations in his perception of the temporal, �-13- aspects of the environment. In considering what constitutes therapeutic improvement, it is evident that the evaluation that is commonly made by a hospital spatial, personal, and somatic the particular types of symbolic adaptation and defensive operations that are used. If the patient denies that he has any problems or that he is troubled by them, or if he cannot recall any, he is rated as improved. Such patients characteristically appear affable and uncomplaining, their manner reinforced by cliches and banalities, themselves adaptive forms of staff large part depends in on that general memory impairment does not persist after electroshock but that there is a selective "forgetting" of traumatic material in the patient's life. This does not mean that he has developed a better understand— ing of his interpersonal relationships or has acquired "insight“. The observation is also significant in explaining why, although electroshock may have a short-term beneficial effect, evaluation of long-term results shows little difference between treated and untreated cases. Also, the fact that therapeutic improvement did not result in patients with negative amobarbital tests suggests that methods of administering electroshock by minimally affecting brain function, such as a unilateral seizure, will not prove generally efficacious. From the immediately practical standpoint, the amobarbital test given after the third or fourth treatment may be of language. Many studies (8,9,10,11,12) have shown prognostic value. The amobarbital test is not in itself a direct index of brain �-114- in that it measures some particular modality of dysfunction or brings out a specific defect. Rather, under the conditions in which it is given, one deduces impaired neural function by reason of the change in the organization or pattern of language in which the patient expresses himself. A positive result requires not only damage certain degree and type of impairment of brain function exist but that the patient employ verbal denial and disorientation as adaptive mechanisms. It would be expected that among patients with equivalent degrees of brain damage the highest incidence of positive that a amobarbital tests would occur among those who characteristically use denial as an adaptive mechanism in stress. In relating these findings to the mode of action of electroshock and other somatic therapies, several considerations seem of importance. There is a combination of an added stress and a change in brain function. The milieu of brain function determines the pattern or organization of the adaptive behavior which can be most clearly formulated in terms of language. These include not only verbal patterns of denial and disorientation, elicited with the aid of the drug, but changes in syntactical patterns indicative of an altered relationship of the self in the environment. There were also indications that in the improved patients there were more all types of symbolic adaptation, nonverbal as well as verbal. Thus, a patient who appeared withdrawn both in the predrug and in the drug interview had a poorer prognosis than the patient The who became withdrawn only under the effects of the drug. changes in �-15- patient who showed altered sexual behavior under the effects of the drug had also exhibited this behavior during the clinical question- ing as well and did not improve with treatment, whereas the four patients manifesting sexual behavior only under effects of the drug did improve. It is likely that the faculty of changing symbolic patterns regardless of content is a factor in therapeutic improve- ment. SUMMARY patients referred consecutively for electroshock treatment were given amobarbital (Amytal) tests before and at regular intervals during and following the course of treatment. There was a close relationship between the short-term response Twenty-four to treatment and the results of the amobarbital tests. The much patients showed early, persistent, and increasingly positive reactions during the course of treatment. Unimproved patients showed no positive reactions, or showed them infrequently and inconsistently. An intermediate group, who showed moderate clinical improvement, showed more positive reactions than the unimproved group but fell far short of the much improved group in the incidence of positive reactions. Changes in language and nonverbal forms of behavior related to denial were most consistent and pronounced in the improved group, improved interviews not employing drugs. These observations indicate that clinical improvement in elec— troshock requires the creation of conditions of altered brain function in which new patterns of symbolic adaptation can be maintained. even in �TABLE 1 Distribution of Positive Amobarbital Tests During Treatment No. of Tests Given During Markedly improved Moderately improved Unimproved (7) (11) (6) No. % Treatment Positive Positive 50 38 76 39 15 38 hS 6 13 �TABLE 2 Relationship of Clinical Improvement To Age Mean Agez Yr. Markedly improved Moderately improved Unimproved (7) (11) (6) h7.6h 50.00 35.29 �TABLE 3 Distribution of Positive Amobarbital Tests in Patients More Than ho Years of Age No. of Tests Given During Markedly improved Moderately improved Unimproved (3) (10) (5) No. % Treatment Positive Positive h6 35 76 3h 15 hS 17 �REFERENCES 1. Gordon, H.L.: Fifty Shock Therapy Theories, Mil. Surgeon, 192: 397, 19h8. Kalinowsky, L.B., and Koch, P.H.: Shock Treatment, Psychosurgery and Other Somatic Treatment in Psychiatry, Ed. 2, New York, Grune & Stratton, Inc., 1952. 2. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, I11., Charles C. Thomas, 3. Publisher, 1955. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbital Sodium in Organic Brain Disease, Am. h. J. Psychiat., 112: 889-89u, 1953. Weinstein, E.A., 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., 11: 217-226, S. 195k. Weinstein, E.A. and Malitz, 3.: Changes in Symbolic Ex— pression with Amobarbital Sodium ("Amytal Sodium"), Am. J. Psychiat., 6. lll= 198-206, 195h. 7. Kahn, R.L., Fink, M. and Weinstein, E.A.: The "Amytal Test" in Patients with Mental Illness, J. Hillside Hosp., Q: 3-13, 1955. 8. Carter, J.T.: Type of Personal Life Memories Forgotten Following Electra-Convulsive Therapy, Am. Psychologist, g: 330, 1953. 9. Janis, I.L.: Psychologic Effects of Electric Convulsive Treatments: I. Post-Treatment Amnesias, J. Nerv. & Ment. Dis., 111: 359, 1950. �-210. Korngold, M.: An Investigation of Some Psychological Effects of Electric Shock Treatment, Am. Psychol., g: 381-382, 1953. 11. Teicher, A.: The Effect of Electroconvulsive Therapy on the Visual Reactions of Schizophrenic Patients, Am. Pszchol., hhS, 1953. 12. Person, Alexander, L.: Am. J. Psychiat., Effect of Electroshock 109: 696-698, 1953. on a "Normal" Q: �Reprinted from the A. M. A. Archives of Neurology and Psychiatry July 1956, Vol. 76, pp. 23—29 Copyright 1956, by American, Medical Association lee/whorl .725! to o/flmoéaréita/ C/inica/ E/ectrodhocé jm/orouement in ROBERT L. KAHN. Ph.D. MAX FlNK. M.D.. Glen Oaks. N. Y. and EDWIN A. WEINSTEIN. M.D.. Bethesda. Md. lllllllllll|l||[|[|IllllllllllIlllllllllllllll|IIIlIllIlllllllIlllIll|||l||llIll||l|lllllllllllllllllllIlllllllllllllllllllllllllllllllllllIllllllllllllllllllU While many theories about the mode of action of electroshock therapy have been offered, the relationship among neurophy— siological and psychological factors remains poorly understood.* Although changes in brain function may be demonstrated on electrical recording, such evidence of impaired function has not been correlated with the degree of psychiatric improvement. Similarly, although memory defects and impaired learning ability are common manifestations following the administration of electrically induced convulsions, their severity is not an index of therapeutic outcome. It would apclinical of results the that ordinary pear and laboratory procedures and psychological tests do not furnish adequate criteria for a correlation of the alterations of be— havior with the changes in brain function. 3 it has been suggested studies In previous that the therapeutic action of electroshock therapy was related to the production of a milieu of brain dysfunction in which denial of illness (anosognosia) might occur. A concept of anosognosia was advanced which included not only denial of hemiplegia and Submitted for publication Feb. 23, 1956. Hillside Hospital (Drs. Kahn and Fink). Walter Reed Army Institute of Research (Dr. Weinstein). 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—49—007—MD—376; and grant M-927 from the National Institute of Mental Health of the National Institutes of Healthy U. S. Public Health Service. * References 1-2. blindness but denial of many other aspects of illness and problems of living. It was indicated that anosognosia was not explicable as a focal deficit but was, rather, a manifestation of a reorganization of perceptual symbolic function in which the patient represented his problems in an altered lan— guage pattern. In the verbal sphere these language patterns included explicit denial, disorientation for place and time, reduplica— tion (reduplicative paramnesia), paraphasia, and confabulation. The patient’s feelings about his illness and incapacities could also be manifested in nonverbal aspects of behavior, such as selective withdrawal, inat— tention, and muteness (akinetic mutism). altered sexual behavior, and euphoric, manic states. The particular form of symbolic adaptation that was used was closely related to features of the premorbid personality. These changes in behavior were found commonly with infiltrating neoplasms, with acute vascular lesions, particularly when associated with subarachnoid bleeding, and following lacerating brain injury. The elec— troencephalographic records showed diffuse slow—wave rhythms, and it appeared that the lesions affected the diffuse projection systems rather than any specific discrete projection area. Similar forms of behavior may appear after the operation of prefrontal lobotomy and, in more transitory form, after the administration of electroshock convul— sions. When the degree of brain damage was insufficient to permit the elicitation of explicit denial and disorientation on ordi— nary clinical examination, these phenomena might be observed when the patient was in— terviewed after the intravenous administra— tion of amobarbital (Amytal) sodium. This �observation furnished the basis for the “Amytal test” for brain damage, in which the persistence of certain patterns of denial and disorientation are considered as evi— dence of impaired function.T It was reported that in some patients receiving electroshock treatment for intractable pain, the amobarbital test, which was previously negative, became positive after a number of convulsions. Others received as many as 18 shocks without change in the results of the amobarbital test. It was noted that in patients who gained relief from their complaints of pain, the amobarbital tests became positive, whereas in those pa— tients who continued to complain of pain the amobarbital tests remained negative. The purpose of the present paper is to determine the relationship between the clinical response to electroshock treatment and the results of the amobarbital test in patients hospitalized for psychiatric illness. Method Each patient was given a series of amobarbital tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the awareness of illness. The drug is then administered intravenously in a 0.5% solution at a rate of 0.05 gm. (1 cc.) per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward are noted. The same questions are then repeated. The 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 its proper name or in terms of some euphemism, such as “rest home” 4. Displacement of the location of the hospital. such as to another city 5-" 6. 7. 8. 9. 1' Confabulated journey Reduplication of the hospital, such as the patient’s stating that he is in another hospital of the same or similar name Disorientation for time of day with confusion of day and night Gross misidentification of the examiner, such as calling him a “lawyer” or an “entertainer” Disorientation for year References 4-7. The patient was given his first test prior to treatment and was retested at weekly intervals. All patients in the series had negative amobarbital 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 was given two days after a treatment and was continued at weekly in— tervals after the termination of therapy until the result had become negative. Electroencephalographic records and standard tests of memory and learning ability were also given, but will not be considered in detail in this paper. Population T wenty-four patients at Hillside Hospital receiving electroshock with the Reiter Electrostimulator were studied. The patients were not selected by us but were taken on the basis of consecutive referrals by the clinical staff. Some patients were necessarily excluded because their treatment was terminated or interrupted before they were ade— quately studied. Another patient was omitted because he had manifestations of brain disease and a positive amobarbital test prior to electroconvulsive therapy. The number of treatments varied from 9 to 33. Patients who showed clinical improvement tended to receive fewer treatments. Some of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. One patient decided for himself that he had had enough treatment and eloped. Diagnostically, the patients consisted of 14 with depressive reactions, 9 with schizophrenia, and l with a manic reaction. There were 15 women and 9 men, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of Response to Electroshock Therapy. ——All patients were observed for at least eight weeks after completion of treatment. Determina— tion of the patient’s response to electroshock was made on the basis of the resident psychiatrist’s im— pression, staff opinion, the nurses’ notes, and the clinical evaluation of one of us (M. F.), who supervised the treatments but was not aware of the amobarbital test results. On this basis the patients were divided into three groups. 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 felt they were better, and the nurses noted them as being able to sleep Without medication, eating better, getting along with the other patients, and participating in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but con~ �tinued to manifest indications 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 ob— sessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally Improved or Unimproved: In this group was placed seven patients in whom change was not clearly noticeable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing some— what improved. But the change was not sustained, so that by the end of treatment they appeared much as they did before. \Ve are aware of the difficulties in evaluating improvement. Others may have differed in the estimates of changes in these patients. In any case, by using this threefold classification, the differences between the first and the third group will be distinct. TABLE Markedly improved (11)-__ Moderately improved (6)-Unimproved (7)____________ Treatment 50 39 45 Amobarbital No. % Positive Positive 38 15.93 6 .4, 76 38 13 treatments, and all had positive reactions after seven to nine treatments. In the unim-proved cases, on the other hand, the number of positive reactions was small and there was no consistent increase during the course of treatment. Again, the moderately improved group tends to fall between the other two. IOO 90 80 Observations ._ MUCH IMPROVEDUI) ---- UNIMPROVEDU) .\/ '-—MOD.IMPROVED(6) 70 AMYTAL A. Distribution of Positive Reactions.— group, with the moderately improved pa— tients between these groups. Every markedly improved patient had at least one positive amobarbital reaction during treatment. On the other hand, one of the moderately improved patients and five of the unimproved patients never showed a positive result. A comparison of the results in each group, using the X2 test, is statistically significant at better than the 1% level of confidence. B. Positive Reactions at Each Stage of Treatment—In the Figure the groups are compared for the percentage of patients in each group who had positive results at each stage of treatment. Almost half the markedly improved pa— tients had positive reactions after only three Tests During Treatment No. of Tests Given During REACTIONS The number of amobarbital tests given to each patient during the course of electroshock range-d from 3 to 13, depending on how long treatment was maintained. In Table 1 the data are shown for the number of tests given during treatment and the number and percentage positive for all the patients in each group. The markedly im— proved patients showed many more positive reactions than the unimproved of Positive l.——Distribution 60 50 POSITIVE 4O 3O 20 PERCENTAGE 5 4-6 NUM BER 7-9 lO-IZ I3-I5 0F TREATMENTS Percentage of positive amobarbital test reactions occurring in each group at different stages of treat— ment. Although some patients received more than 15 treatments, the data are not pre— sented beyond this point because the number in each group became too small for purposes of comparison. Four of the unimproved pa— tients received more than 20 treatments, with consistently negative amobarbital test results. One of the moderately improved patients received over 30 treatments, with only an occasionally positive reaction. C. Duration of Positive Reactions.— There were variations in the persistence of positive reactiOns from week to week. With at least two consecutive positives as the criterion of persistence, nine of the mark— edly improved, two of the moderately im— proved, and only one of the unimproved group showed persistent positives. After �the termination of treatment all patients but one had negative amobarbital reactions nine days after the last convulsion. The remaining patient developed a negative test during the second week after treatment. D. Factor of Age—Since the patients in the markedly improved group tended to be older persons suffering from depres— sive reactions, it is conceivable that the difference in amobarbital test results may be related solely to age and only coincidentally to clinical improvement. Underlying this is the assumption that the older person is more likely to show signs of altered brain function when given electroshock. In Table 2 the mean age for each group is shown. TABLE 2.——Relationship of Clinical Improvemen To Age Markedly improved (11)_______-____-___-___________ Moderately improved (6) ___________________________ Unimproved (7) ____________________________________ Mean Age, Yr. 47.64 gggg it is apparent that the first two groups were older than the unimproved patients. Yet, while the mean age of the moderately improved patients is slightly higher than that of the markedly improved group, these patients still had significantly fewer positive reactions. In Table 3 the number of positive re— actions during treatment is shown for each is limited to pa— when the analysis group tients more than 40 years of age. In this Table the relationship of positive reactions in the different groups remains unchanged from that when the groups are considered as a whole. Other Aspects of Behavior Apart from explicit denial of illness and disorientation, there were changes in be— havior that occurred both under the in-fluence of the drug and clinically during the course of treatment in significantly progres— sive fashion in those patients who improved. These aspects may be divided into verbal and nonverbal communication. A. Changes in Verbal Language—These changes consisted of denial expressed in evasion, in negative expressions, and in the use of a syntactical pattern involving the third and second persons. When 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 to tell me.” The change in syntactical pattern is illustrated by such remarks Amobarbital Tests in Patients More Than 40 Years of Age TABLE 3.——Distribution of Positive No. of Tests Given During Markedly improved (10)--Moderately improved (5)-Unimproved (3) ____________ _ Treatment 46 34 17 N0. % Positive Positive 35 15 0 76 45 0 as “It’s what they call a depression,” or “I’m afraid somebody will get hurt,” or answering the question “What is your main trouble P" with “What is your main trouble?” Sometimes patients would talk of a relative who was sick. In patients who improved there was a notable development of such patterns in a nondrug interview. One such patient, for example, when asked prior to the start of treatment what his main trouble was, said, “I’m depressed.” 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 mean": after eight, “I get sick; that’s all I know.” After 10 treatments he said, “Right now, it’s that I don’t see my Wife,” and after 11 treatments he said, “In what way do you mean?” and “I don’t know how to explain it.” At the termination of treatment, his main trouble was given as “I want to get home,” followed by an account of how “good” his wife was. In the unimproved group, on the other hand, the increased use of these language patterns did not occur. They were not present in some and were minimally or inconsistently noted in others. In some of the unimproved patients there were actually fewer such language patterns under the �i L’ effects of the drug than there had been in the preamobarbital interview. B. Changes in Nonverbal Behavior.— Euphoric reactions occurred in both sistently positive early in the course of treatment. In moderately improved or unimproved patients there are fewer positive reactions and their frequency does clinical and drug interviews most fre— not increase with more treatments. With quently in the markedly improved other methods of evaluating brain func— group, less often in the moderately im— tion such close correlation was not presproved group, and least often in the ent, as all patients showed abnormalities group which were considered unim— in the e1ectroencephalographic record and proved. In the unimproved patient impaired learning was found as fre— classed as manic, euphoric behavior was quently in patients who improved as in present in his clinical behavior and was those who do not. The significance of this relationship may be more clearly not changed by amobarbital. Changes in sexual behavior appeared appreciated by a consideration of the during the amobarbital interviews of four changes in symbolic function that occur of the markedly improved patients but in states of altered brain function. in only one patient in each of the other It has been useful in studying the becategories. This took the form of try— havior of patients with alterations in ing to hug or caress the examiner. mak— brain function to distinguish between ing remarks with sexual content, or en— defects in the formation of symbol pat— gaging in masturbatory activity. A terns and changes of language patterns patient in the unimproved group showed which indicate a shift in the mode of this behavior both during pre—drug inter- interaction in the environment. In the views and under the influence of amobar— first be included many category may bital. types of memory defects, dyscalculia, Withdrawal or “selective inattention” topographical disorientation, and aphasia. was shown by 9‘ of the 11 markedly im; A patient with such a defect memory proved patients. particularly during the cannot select elements of experience, drug phase of the amobarbital interview. classify them into and significant units, This behavior consisted of failure to an— them into a temporal arrange pattern. hos— the about illness and questions swer These defects are observed with diffuse pitalization or responding in dysarthric cortical lesions and uni— probably occur and cryptic fashion. This reaction under versally after shock treatments in tran— the drug occurred only once in each of sient fashion. They are, however, related the other groups. It was of interest that if at all, to therapeutic remotely, very two patients in the unimproved category in the mode of inAlterations outcome. who appeared withdrawn before the test teraction in the environment became more responsive under fluence of the drug. the in- Comment The results of the amobarbital tests in these patients indicate that there is a relation between clinical improvement and the production of brain damage or an altered state of brain function as de— termined by this particular method of examination. In patients who improve, the amobarbital test becomes con— are exemplified in the various patterns of disorientation and denial and in the amnesias that are noted with lesions of the diffuse projection systems, in chronic barbiturate intoxication, and following electroshock convulsions. Here there is no defect in memory, awareness, or perception as such, but the patient selects or rejects certain aspects of the environment for the expression of his own motivations. ln disorientation for place, for example, the misnaming and mislocating of the �hospital serve as, symbolic representa— tions of the patient’s feelings about his incapabilities and problems—often as the manifestation of his need to be well and go home. It is not that the patient is unaware of his problems and does not know where he is in an absolute sense. He commonly “remembers” the name of the hospital and expresses “awareness” of his difficulties in other contexts of language. The unawareness is, rather, of the far greater degree to which he is expressing his own motivations in his perception of the temporal. spatial, personal, and somatic aspects of the en— Vironment. In considering what constitutes thera— peutic improvement, it is evident that the evaluation that is commonly made by a hospital staff depends in large part on the particular types of symbolic adaptation and defensive operations that are used. If the patient denies that he has any problems or that he is troubled by them, or if he cannot recall any, he is rated as improved. Such patients char— acteristically appear affable and uncom— plaining, their manner reinforced by clichés and banalities, themselves adap— tive forms of language. Many studies: have shown that general memory impairment does not persist after electroshock but that there is a selective “forgetting” of traumatic material in the patient’s life. This does not mean that he has developed a better understanding of his interpersonal relationships or has ac— quired “insight.” The observation is also significant in explaining why, although electroshock may have a short—term bene— ficial effect, evaluation of long—term results shows little difference between treated and untreated cases. Also, the fact that therapeutic improvement did not result in patients with negative amobarbital tests suggests that methods of administering electroshock by minimally affecting brain function, Such as i References 8-12. a unilateral seizure, will not prove gen— erally efficacious. From the immediately practical standpoint, the amobarbital test given after the third or fourth treat— ment may be of prognostic value. The amobarbital test is not in itself a direct index of brain damage in that it measures some particular modality of dysfunction or brings out a specific defect. Rather, under the conditions in which it is given, one deduces impaired neural function by reason of the change in the organization or pattern of language in which the patient expresses himself. A positive result requires not only that a certain degree and type of impairment of brain function exist but that the patient employ verbal denial and disorientation as adaptive mechanisms. It would be expected that among patients with equivalent degrees of brain damage the highest incidence of positive amobarbital tests would occur among those who characteristically use denial as an adaptive mechanism in stress. In relating these findings to the mode of action of electroshock and other somatic therapies, several considerations seem of importance. There is a combination of an added stress and a change in brain function. The milieu of brain function determines the pattern or organization of the adaptive behavior which can be most clearly formulated in terms of language. These include not only verbal patterns of denial and disorientation, elicited with the aid of the drug, but changes in syntactical patterns indicative of an altered relationship of the self in the environment. There were also indications that in the improved patients there were more changes in all types of symbolic adaptation, nonverbal as well as verbal. Thus, a patient who appeared withdrawn both in the predrug and in the drug interview had a poorer prog— nosis than the patient who became withdrawn only under the effects of the drug. The patient who showed altered sexual behavior under the effects of the drug had also exhibited this behavior during �the clinical questioning as well and did not improve with treatment, whereas the four patients manifesting sexual behavior only under effects of the drug did improve. It is likely that the faculty of changing sym— bolic patterns regardless of content is a factor in therapeutic improvement. REFERENCES Gordon, H. L.: Fifty Shock Therapy ories, Mil. Surgeon 103 2397, 1948. 1. The— 2. Kalinowsky, L. B., and Hoch, P. H.: Shock Treatment, Psychosurgery and Other Somatic Treatment in Psychiatry, Ed. 2, New York, Grune & Stratton, Inc., 1952. Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springfield, Ill, Charles C Thomas, Publisher, 3. Summary Twenty—four patients referred consecu— tively for electroshock treatment were given amobarbital (Amytal) tests before and at regular intervals during and fol— lowing the course of treatment. There was a close relationship between the short—term response to treatment and the results of the amobarbital tests. The much improved patients showed early, persistent, and increasingly positive reactions during the course of treat— ment. Unimproved patients showed no positive reactions, or showed them in— frequently and inconsistently. An inter— mediate group, who showed moderate clinical improvement, showed more posi— tive reactions than the unimproved group but fell far short of the much improved group in the incidence of positive re— actions. Changes in language and nonverbal forms of behavior related to denial were most consistent and pronounced in the improved group, even in interviews not employing drugs. These observations indicate that clinical improvement in electroshock requires the creation of conditions of altered brain function in which new patterns of symbolic adaptation can be maintained. 1955. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbi— tal Sodium in Organic Brain Disease, Am. J. Psychiat. 112:889-894, 1953. 4. Weinstein, E. A.; 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. 71 1217— 5. 226, 1954. \Neinstein, E. A., and Malitz, 8.: Changes in Symbolic Expression with Amobarbital Sodium (“Amytal Sodium”), Am. J. Psychiat. 111:198-206, 6. 1954. Kahn, R. L.; Fink, M., and Weinstein, E. A.: The “Amytal Test” in Patients with Mental Ill— ness, J. Hillside Hosp. 4:3-13, 1955. 7. Carter, J. T.: Type of Personal Life Memo« ries Forgotten Following Electro—Convulsive Therapy. Am. Psychologist 8 :330, 1953. 8. Janis, I. L.: Psychologic Effects of Electric Convulsive Treatments: I. Post—Treatment Am— nesias, J. Nerv. & Ment. Dis. 111:359, 1950. 9. Korngold, M.: An Investigation of Some Psychological Effects of Electric Shock Treat— ment, Am. Psychol. 8:381—382, 1953. 10. Teicher, A.: The Effect of Electroconvulsive Therapy on the Visual Reactions of Schizophrenic Patients, Am. Psychol. 8:445, 1953. 11. Alexander, L.: Effect of Electroshock on a “Normal” Person, Am. J. Psychiat. 109:696—698, 12. 1953. Printed and Published in the United States of Amerira � 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 amobarbital test to clinical improvement in electroshock. AMA Arch Neurol Psychiatry. 1956 Jul; 76(1): 23-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-17-021 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 Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Weinstein, Edwin 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 July 1956, Vol. 76, pp. 23—29. 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/f36132b2b1eb8c86e51e7a9456e9e17d.pdf aca2be98c9971c66ad807e1d64ee1b8a PDF Text Text Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume IV July, 1955 Number 3 ��DELUSIONAL REDUPLICATION OF PARTS OF THE BODY AFTER INSULIN COMA THERAPY1 ROBERT L. Ph.D.,2 N. GRAUBERT, M.D.,3 and MAX FINK, M.D.4 KAI-IN, DAVID In recent years studies of behavioral changes occurring in altered states of brain function have gone beyond the description and interpretation of isolated phenomena. Emphasis has been placed on such factors as the particular environmental situation in which the behavior occurs, the total constellation or syndrome of associated behavioral changes, and the influence of the premorbid personality. Using these additional methods of study it has been demonstrated that many types of behavior found in brain disease are not defects, such as impairment of perception or memory, but represent forms of adaptation to the stress of illness (16). It has also been shown that various phenomena are not bizarre curiosities or unrelated fragments of neurological dysfunction, but form part of an orderly and meaningful pattern of an altered interaction with the environment. This report of a single case is presented because of the unusual opportunity it provides to study some of these behavioral changes. First, the patient was in a psychiatric hospital, under observation and in psychotherapy for four months, which made it possible to have an accurate and comprehensive picture of his behavior prior to brain damage. Secondly, the neurological symptoms were of rapid 1From the Research Service, Hillside Hospital, Glen Oaks, New York. This investigation was supported in part by grant M-927 from the National Institute of Mental Health of the National Institutes of Health, Public Health Service and by a fellowship of the Dazian Foundation for Medical Research (Dr. Kahn). This paper was read, in part, at a meeting of the New York Society for Clinical Psychiatry at Hillside Hospital, on March 10, 1955. 2Research Assistant, Hillside Hospital, Glen Oaks, New York. 3Resident Psychiatrist, Hillside Hospital, Glen Oaks, New York. iDirector of the Research Service, Hillside Hospital, Glen Oaks, New York. 134 �REDUPLICATION OF BODY PARTS IN I.C.T. 135 onset and actually developed in the presence of the examiners. Finally, it was possible to observe the patient intensively for a prolonged period afterwards, so that the subsequent changes in behavior could be adquately studied. It is the purpose of this report to evaluate (1) the significance of the alterations in behavior, particularly the delusion of having extra parts of the body, and (2) the implication of the subsequent change in behavior for the understanding of the mechanism of somatic therapies. CASE HISTORY Present Illness The patient, a 34-year-old man, became acutely ill the night of September 25, 1954. Standing with clenched fists, gritting his teeth and without saying a word, he kept his wife in a corner of their bedroom for hours. The patient's family summoned a psychiatrist who referred him for immediate hospitalization. He received 15 electroshock treatments in a three~week period with some improvement. On transfer to Hillside Hospital, however, the patient was lethargic and failed to answer many questions. He said that he had come to the hospital for such reasons as “stomach disease,” “to talk over something with my wife,” and “to prepare myself for an examination." He felt he was being watched; that he was influenced by voices coming through the heating system; was being poisoned from a distance; and that there were changes in his body. He said he knew the exact minute when his wife was being unfaithful to him and expressed feelings that the world was coming to an end. There were frequent auditory hallucinations of being called unpleasant and derogatory names. Past History and Premorbid Personality This was the patient’s first recorded psychotic episode. He is the youngest of five siblings, being the only boy. His father and mother were continually busy running a candy stand, and the patient was cared for primarily by his sisters. As a child he was dependent, demanding, and sought to be the center of attention. He developed a flair for comedy and playing the clown to the extent that he was expected to have a career as a comedian, and on one occasion won second prize in an amateur show. At 12 years of age he became interested in playing drums. This became his sole preoccupation, for he devoted every spare moment to them. The patient suffered episodes of rheumatic fever at 10 years of age and again at 20 and, �136 KAHN—GRAUBERT—FINK at these times, was pampered by his family. During his late adolescence he was withdrawn, spending much of his time at his parents’ candy stand. He became overly concerned with his appearance and masculinity, brushed his hair for lengthy periods, exercised to acquire a good build, worried about his chest expansion and, according to his family, stared at his reflection in a mirror “kind of waiting for hair to grow on his chest." He spent much time exercising his left arm because he wanted it to be as strong as his right. He was concerned about a tooth that had not developed fully on the right side of his mouth. To prevent people from noticing this he developed the habit of talking and laughing out of the left side of his mouth, giving the appearance of facial asymmetry. He never enjoyed or settled down to any work. Besides his efforts as a comedian and drummer, he worked in a pocketbook factory, in a ladies apparel concern, and wrote songs and short stories. He was discharged from one position because he clowned all day long amusing his co-workers. He became a beautician after a friend interested him in it. He wanted to quit this too, but remained at the insistence of his fiancee. He was not ambitious for money, but very much wanted to find a place for himself, needing reassurance about his sense of belonging. Although he comes from a secretive family where each member keeps things to himself, the patient was de— scribed as warm and friendly and drawn to the cause of people he considered the underdog or discriminated against. He was sentimental, being quite upset when having to visit someone in a hospital. He was overly sensitive and easily hurt, though not argumentative. The family reported a change in his behavior during the past six years. He had become more secretive about his friends and activities. He went with his fiancée for more than a year before anyone in the family knew about it. He developed many somatic complaints so that frequent visits were made to his physician, without his family’s awareness. Similarly, he told no one that he was in psychiatric treatment, and maintained his secret even though he found it necessary to steal money from his mother’s store to for pay this. He also kept secret his difficulty in hearing for many months. During the war he was drafted into service, became worried about having to go overseas, and sought and received a medical discharge because of rheumatic heart disease. Since 1948 he has been in intermittent psychiatric treatment. This was begun at the persuasion of a friend who was in therapy. The psychiatrist stated that the main effect of the therapy was to get him to look for some �REDUPLICATION OF BODY PARTS IN I.C.T. 137 kind of work, although he confirms the patient’s inability to hold one job for any length of time. During this period two of his sisters have been under extensive psychiatric treatment for severe phobic reactions. He has been married for 21/2 years, never having dated much previously. His mother believes this the result of his being “pretty much of a home boy” and his fears about his rheumatic heart. His sister, on the other hand, reports that the mother made him feel guilty about leaving her alone in the store. She said he felt the responsibility of helping his mother ever since his father’s illness and death, and that he expressed feelings of guilt in leaving her to get married. The patient met his wife in 1951 at a party, and was married in 1953. During the first two years of their marriage, the patient’s wife had two miscarriages. The second one in particular affected the patient. Soon thereafter he complained that there was something wrong with him, that he was not enough of a man, and that there must be a sickness in his body causing his wife to have abortions. He became increasingly depressed, withdrawn and fearful. Later, he became convinced his wife was unfaithful to him and that his wife and brother-in-law were conspiring against him. Course in Hillside Hospital During his hospitalization he became more withdrawn, and careless in his appearance and in the care of his room. He had little contact with other patients, and was preoccupied with his delusional thoughts and hallucinations. Physical examination revealed a presystolic and systolic murmur at the apex and a systolic murmur at the base without accentuation of the pulmonary sounds, or signs of enlargement of the heart. His blood serology was negative. There were no neurological findings except for right facial asymmetry and bilaterally diminished hearing. An electroencephalogram shortly after admission showed well-modulated, occasional random 5-7 cps activity, with 90% alpha. It was interpreted as showing minimal abnormality, consistent with drowsiness or a history of recent electroshock therapy. An amytal test for brain disease (13) was done on November 24, 1954. There was no change in orientation or awareness of illness, but he became more communicative and showed less overt tension during the procedure. Insulin coma treatment was instituted on December 8, 1954, and he had his first coma on December 30. During the course of 18 coma treatments there was no significant change in �138 - KAHN—GRAUBERT—FINK behavior until the morning of January 27, 1955. On that day he had his 19th treatment, was given 370 units of insulin, and went into coma for an hour and 50 minutes, comparable to his previous reactions. Following gavage he did not respond in the usual time, and he was given glucose intravenously. He awakened promptly, and was responsive, but a marked right hemiplegia was noted. He lay in bed with his head and eyes deviated to the left. There was no evidence of aphasia when tested for naming objects. He had a right facial paresis and a right homonymous hemianopia on confrontation. Reflexes were diminished on the right with a positive Babinski, and there was a right hemisensory syndrome with extinction on simultaneous stimulation tests. He raised his left arm on command but failed to respond when told to move his right arm. When his right arm was raised by the examiner and he was asked to identify it, he looked at it for some moments and said it was a “stranger” and “an intruder.” He reported smilingly that there was an extra arm on the right. He was unable to move his right leg on command, and he asked if it were his own. saying that he had seen him sometime in the past. The patient consistently showed this phenomenon of the reduplicated arm for the next hour. He referred to it as an “extra arm,” “a third arm,” and “a bootleg arm,” or personified it as a “stranger,” "this intruder” and “that fellow.” When his right arm was shown to him, he denied knowing whose arm it was, asking one of the attendants, “Did you slip me this arm—did you pick this old at an up auction in the neighborhood?” Another time when asked to whom it belonged, he said “I’m willing to pay a reward for it, and you’re asking me point blank.” He said he was sure that the arm was not his because “it doesn’t extend from my body” and “the dirt under the fingernail is not recognizable.” The patient denied any disability of his own right arm, but said he’d never seen the extra arm work. He said, “My arm I can move with a brain impulse; this one I have to move manually since it isn’t mine.” During the course of questions about weakness in his right arm he said, “If that extra arm belongs to me, then I’m sicker than I thought I was.” The patient did not react to painful stimulation applied to his �REDUPLICATION OF BODY PARTS IN I.C.T. 139 right arm or leg. Even with his eyes open and his attention directed to the point of stimulation, he denied perceiving any stimulation on the right arm, saying “You’re not fooling me—you’re not touching me—you’re touching this third arm, that intruder.” He correctly identified stimuli applied to the right shoulder, but from the elbow down the touch was displaced to the extra arm. The patient lay with his head and eyes deviated to the left throughout the examination. He had difficulty perceiving any stimulus in the right side of space, a phenomenon which has been termed “spatial inattention." When given phrases to read he ignored the right side, reading only the material on the extreme left. Thus, “GOOD HUMOR ICE CREAM” was read as “GL.” When his right arm lay at his side he had trouble finding it. Once, when he was asked to show it to the examiner, he looked over his left side only and said, “I think I’ve been robbed—where is it?” A lumbar puncture was done and a clear, colorless fluid obtained. The fluid was under increased pressure even though the patient was relaxed. The pressure was recorded as 300 mm., the total protein was 32 mg. per cent, and there were two white cells per cubic mm. During the ensuing hours the patient continued to be euphoric and loquacious. He recited long-forgotten lessons and parts of neurological texts whose source was unknown to him. For instance, he gave a complete description of the course of the facial nerve, and described the muscles of the face, calling them by their correct Latin names. He laughed frequently, and recited cryptic remarks as “in the instrument—insulin—instrument—insulin—instrument ward.” Disturbances in memory or recall were not elicited. The delusional “extra arm” disappeared. An electroencephalogram obtained that afternoon was flat in all leads on the left side and showed random 5-7 cps activity, chiefly on the right side. Both alpha and beta were prominent on the right side only. The record was interpreted as showing diffuse dysfunction with left-sided accentuation. In the afternoon the patient was subdued. The weakness of the leg and arm showed some resolution. His relationship to his therapist was completely changed compared to his previous behavior. There was a complete absence of anger, negativism, withdrawal and depression. He clung to his doctor, shook hands, held him back and did not want to be separated from him. He was pleasantly preoccupied with the morning’s episode and joked about it. He was eager to communicate, and even his hearing seemed to have improved. The next morning the patient was depressed, restless, bewildered, �140 KAHN—GRAUBERT—FIN K slow in answering questions and failed to respond when asked about his illness. He spoke in a low voice, at times inaudible. He was disoriented for time of day and was aware of “numbness” in his right arm. He spontaneously asked, “What happened to me—why am I taking all this depletion?" Minimal weakness of the right arm and leg were noted. There was astereognosis in the right hand, but tactile stimuli were correctly localized, and there was no evidence of hemianopia or inattention. When asked about the extra arm the patient was vague and evasive, but did say, “Evidently somebody else was with me and it was their arm I picked up." That afternoon the patient was given 0.5 gm. amytal sodium. Besides its use as a test for organic brain dysfunction, the drug was given in an attempt to elicit the delusion again (14). At this time there was neither a change in orientation nor a recurrence of the reduplication. There was, however, a marked change in mood and language. The patient became very euphoric and talkative. His speech was characterized by ornate, circumstantial, pedantic, histrionic, and cryptic features, with much use of clichés. For example, asked about the extra arm, he said, “I think it will come looking for me when and if the occasion is propitious, as it were.” When asked why he was here, he said, “On the recommendation of the right honorable Dr. Fink, most distinguished doctor on the eastern seaboard Atlantic area whose fame has spread far and wide." Several times he blurted out the cryptic remark—“transference of aggression." When asked what he meant, he said, “If you can’t kick your mother-in-law in the head, you try your father-in-law.” When asked about his arm the patient was evasive, circumstantial and jocular. For example, asked how the extra arm was different from his own arm, he said, “How was it different? For one reason, in the sensitivity of feel. I raised up my left arm and that was all right. When I went to raise up what I thought was right my arm that was all right. But when I went to raise this third arm I did not feel any sensitivity when raising it, lifting it, touching it or otherwise in no manner could I relate it to my corpus—.” When asked about weakness in his right arm, he said, “It feels little less a dynamic in its volition, and I’m tempted to believe in its delivery, as it were.” While the delusion was not present at this time, the patient insisted that there had been an extra arm the day before, saying, “I was lying in bed and it came to my aware the presence of another arm in my bed.” When he was told that the extra arm was really his own right arm, he said, “Well, I’ll tell you. I never argue with �REDUPLICATION OF BODY PARTS IN I.C.T. 141 facts. You see if you’re surmising that it was, and I were to agree, it would be only for professional courtesy’s sake.” Or at another time, when the possibility of the extra arm was being questioned by the examiner, the patient said, “I don’t think it was mine. It might have been mine, you see, but then I would have to have a comprehensive knowledge of the numerous preponderous volumes of ancient history in associated situations. And then I might be even able to volunteer that extra leg which you spoke of before—and beyond. I might even—be able to extend some photographs of the uterus which I own. If I could have the extra arm, the additional leg, and as I said, other things.” For the next two days he continued to be depressed, spoke slowly in a low voice, and showed no spontaneity. He complained of feeling “depleted.” There was no difficulty getting him into a conversation and he would elaborate in a circumstantial way about the pain in his head and the numbness in his hand. He refused to get into conversation about his extra arm, saying, “You're making fun of me." Neurological examination was completely negative. An electroencephalogram on February 2, 1955 showed a resolution of the asymmetry and abnormality of the previous record. It was similar to that obtained on admission. The patient was given amytal again on February 2 and 9. On both occasions he showed a similar response to that obtained on January 28, with euphoria and changes in language. His attitude, however, toward the extra arm and to the weakness of his right arm was altered. He now said that the extra arm might have been a hallucination due to the drugs he was receiving. He also admitted having had weakness of his right arm, saying, “To the best of my recollection there was a general weakness which might have had a specific attenuating dilemma in the appearance of an arm which might have been, to some degree, in a state of difficulty.” On March 2, he was given amytal again. This time his reaction was more like that seen on admission, although he became slightly euphoric and loquacious toward the end. In the weeks following the eventful insulin coma, there was a change in his clinical behavior. He appeared more sure of himself, and was co-operative and friendly. He started to press for his discharge. He said that there were things to be done which he, and not somebody else, should do, but would not specify these things. His wife visited him and told him she had decided to divorce him and would not accept him back in his home. The patient took this announcement without overt emotion. He was unable to give any reason for his wife’s plans, and stated that he forgot to ask her why. �142 KAHN—GRAUBERT—FINK He still wanted to be sent home as soon as possible because, he said, he was ready to take up some kind of business. He felt that he had failed up to now because of reasons unclear to him, but that if he were careful, it would not happen to him again. This behavior was markedly different from that shown admison sion. In contrast to hisprevious aggressive, uncommunicative and withdrawn behavior, he was co-operative, ingratiating, overanxious to please, and made attempts at socializing with other patients. His of a psychiatrist. DISCUSSION The delusion of reduplication of parts of the body has rarely been reported. The earliest reports are by Bechterev (1) in 1926 and Ehrenwald (3) in 1930. In 1935, Schenderov and Gamaleja (9) described six cases and suggested that more might be found if the phenomenon were better known. In these early studies the phenomenon was regarded as a neurologic curiosity and was explained on the basis of sensory disturbances. In the work of Critchley (2), who reported a similar case in 1952, it was considered as a manifestation of disturbance in “body image" due to a parietal lobe lesion of the nondominant hemisphere. In 1954, four cases were reported by Weinstein et al. (14) demonstrating that the phenomenon could not be explained on the basis of sensory impairment, and was not dependent on a focal parietal lesion. They interpreted the delusion as a symbolic phenomenon rather than a sensory or perceptual disturbance, and showed that it occurred only in a setting of diffuse cerebral dysfunction. indiThey cated that parts of the body were redupli‘cated which were defective in some way, regardless of whether or not there was any neurological involvement. It was pointed out that the delusional reduplication of body parts is but one manifestation of reduplicative phenomena. Thus reduplication for time, place and person has also been reported (11). In reduplication for time the patient confabulates that a present experience has also been experienced at a time in the past. For example, a patient identifies members of the staff as old friends or relatives. Reduplication for place is the confabulation that two or more places with the same name and similar attributes exist, when actually. there is only one. Thus, a patient may say there are two �REDUPLICATION OF BODY PARTS IN I.C.T. 143 hospitals with the same name and same staff, but locate one closer to his home and describes it as a hospital which treats convalescent or minor cases only. In reduplication for person the patient confabulates the existence of two persons when there is actually only one. One woman, for instance, said she had two sons, one named “Bill,” and the other “Willie," when actually she had one son named William. It was shown by Weinstein et a1. (14) that reduplication was usually expressed in more than one modality. All patients with delusional reduplication of body parts showed, in addition, reduplication for time, place and/or person. In the present case the patient also expressed temporal reduplication, describing one of the examiners as someone he had known prior to his hospitalization. The symbolic importance of the various phenomena of reduplication is evident in their motivational character. In the perception of a doctor as an old friend or a relative the patient is reassuring himself that he has less to fear than he would from a total stranger. In reduplication for place the patient who locates the extra hospital near his home or describes it as treating only convalescent or minor cases is minimizing his illness. The patient who confabulated having two sons, while denying her own illness, complained that poor “Willie" was in an accident and was afraid that something terrible had happened to him, thus displacing her concern from herself to the extra person. The delusion of reduplication of parts of the body also is a mechanism facilitating denial of illness. While the patient states that there is nothing wrong with his own body, it is the reduplicated arm or leg which is said to be weak or impaired. In the present instance the patient, who in his premorbid behavior was excessively worried about bodily ailments, was unconcerned about his severe disability. Instead, by denying having any trouble with his arm and saying it was the ”extra” arm that didn’t work, he was able to maintain his euphoria and jocularity. While reduplication is shown mainly as a symbolic adaptation to the problem of illness, it may also be a symbolic expression of other wishes, needs and feelings. For example, a patient with intractable pain had been noisy and demanding and had aroused the antagonism of members of the staff. Following a course of electroshock therapy her complaints of pain were gone and her relations with the staff were considerably improved. Along with other changes in orientation, she confabulated that there were two Mount �144 KAHN—GRAUBERT—FIN K Sinai Hospitals, the old one where people were mean to her, and the new one where everybody was so nice (12). The delusional reduplication of parts of the body appears to be related to certain aspects of the premorbid personality. In the present case, and in those reported by Weinstein et al. (14), all the patients demonstrated a special concern with the symbolic importance of physical characteristics. Our patient was concerned with his build, the strength of the muscles of his left arm and the presence of hair on his chest. He was also sensitive about a tooth which had not come out fully and attempted to conceal it. In the earlier study (14) a patient who had developed the delusion of multiple heads following a craniotomy, had been preoccupied with his baldness and had engaged in numerous extramarital affairs to prove that he was capable of attracting women. A patient, who confabulated having three eyes, was very sensitive about a prosthetic eye and would face people directly forward so that divergence Of his eye would not be noticed. He was also preoccupied with his build and physical appearance, engaged intensively in Yogi and Judo, and was concerned with his ability to satisfy his wife sexually. In recent writings on “spatial inattention” (16, 17) it has been indicated that this, too, represents a form of symbolic adaptation. In this case the patient consistently avoided looking to the right side, was unable to find the “extra” arm when it lay at his side, and only read the extreme left part of phrases shown to him. This behavior facilitated the denial of weakness of his right arm as well as helped maintain his delusion of the extra extremity. His personality also showed features that have been described as characteristic of persons with “spatial inattention” (17). He was very secretive, especially in recent years, and seemed overly concerned with the symbolic significance of violence, as shown by his discomfort on visiting hospitals, his fear of going overseas and by an apparent confabulation that he had once been a secret witness to a murder. The marked ludic behavior shown by the patient during the period of his delusion and during the later amytal tests is also related to his premorbid personality. He was described as having been a good mimic with a flair for clowning. Ludic behavior has also been regarded as a form of adaptive behavior (15) in which the patient acts out a feeling of well-being, implicitly denying his illness. It is of theoretical interest that the delusional reduplication and “spatial inattention” occurred with right-sided symptoms. Disorders of the “body image” and spatial awareness have been regarded as characteristic of nondominant lesions. In this case, with apparent �REDUPLICATION OF BODY PARTS IN I.C.T. 145 dominant hemisphere involvement but without aphasia, it was possible to study these behavioral changes as clearly as with nondom— inant lesions. One must conclude that in the usual case of a dominant lesion, pathology which is sufficiently extensive for these changes to occur, will also result in an aphasic disorder which masks the phenomena. The neurologic lesion which was the basis for the reported of diffuse behavior in alteration dysfunction a and was phenomena the cerebrum with accentuation of the left hemisphere. Such disturbances in neurologic function are not uncommon in insulin coma therapy, and are the result of persistent cellular dysfunction despite restoration of the glucose level of the blood. While one may ascribe etiological importance in the production of this patient’s hemiplegia to the history of rheumatic fever and the cardiac murmurs, this is not warranted considering the absence of other rheumatic phenomena either before or subsequent to the event. It is more meaningful to regard this incident as one manifestation of the central nervous system damage incurred by prolonged hypoglycemia. Such manifestations include all aspects of nervous system functions including seizures, transient hemiplegia and aphasia, confusional syndrome and Korsakoff psychoses, prolonged coma and death (6). Recent studies of the electroencephalographic changes during prolonged coma (18) and minor neurologic signs following insulin coma treatment (19) amplify the variety of neurologic sequelae of this treatment. The importance of cerebral damage in the mechanism of somatic therapies has recently been re-emphasized by Weinstein and Kahn (12, 16). They suggest that improvement following somatic therapies is characterized by manifestations of denial in a milieu of altered brain function. A study in this laboratory (5) has supported this hypothesis concerning electroshock therapy; Improved patients showed significantly earlier and more persistent alterations in brain function as measured by the amytal test (13) and by serial electroencephalographic studies (4), and more changes in language and behavior indicative of denial, than did patients who failed to improve. Recent case reports of the effects of prolonged insulin coma by Revitch (8), Kwalwasser and Caplan (7), Shagass and Rowsell (10), and Yeager et a1. (18) point to the behavioral improvement and discerebral when of damage superschizophrenic symptoms appearance venes. In this patient, too, there was an immediate, marked and cerebral with concomitant behavior damage. in change persistent �KAHN—GRAUBERT—FINK 146 It was possible here to demonstrate not only explicit verbal denial of illness, but other aspects of denial as reduplication, spatial inat- tention and changes in mood and language. Thus, the observations in his case are consistent with the hypothesis of Weinstein and Kahn. Further studies of the role of premorbid personality in denial, and on the mechanism of somatic therapies are now in progress. SUMMARY AND CONCLUSION A case history is presented of a 34-year-old man with a fourmonth history of acute mental illness who was placed on insulin coma therapy. After his 19th coma he developed a right hemiplegia, hemianopia, hemisensory syndrome and “spatial inattention,” and became ludic, euphoric and loquacious.'At this time he showed delusional reduplication of body parts, expressing the conviction that while there was nothing the matter with his right arm, there was an “extra" arm in his bed which did not belong to him and which did not work. 2. The significance of reduplication is discussed in terms of a symbolic adaptation to illness. This phenomenon, as well as his other changes in behavior such as “spatial inattention" and ludic behavior, is considered to be related to his premorbid personality. 3. The presence of these phenomena in a case with right-sided symptoms is considered with reference to anatomical localization. These findings contradict the traditional view that “body image" disorders and “spatial inattention” depend on a nondominant hemisphere lesion. 4. The subsequent changes in the patient’s behavior, in which he showed complete recovery from his illness, is discussed in terms of its implications for the mechanism of action of insulin coma therapy. The results are considered to support the theoretical view that improvement in the somatic therapies is characterized by manifestations of denial in a milieu of altered brain function. 1. REFERENCES Bechterev, V. M.: Obozr. Psikh., 1926, cited by Schenderov and Gamaleja. Critchley, M.: A Phantom Supernumerary Limb after a Cervical Root Lesion, Arq. Neuro-Psiquit., 10:269-275. 1952. (3) Ehrenwald, H.: Altered Perception of the Body Image with Consequent Psychosis in Left Hemiplegia. Mschr. f. Psychiat. u. Neurol., 75:89-97, 1930. (4) Fink, M. and Kahn, R. L.: Relation of Electroencephalographic Changes and Improvement in Electroshock Therapy. In preparation. (1) (2) �REDUPLICATION OF BODY PARTS IN I.C.T. 147 Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation Between Altered Brain Function and Denial in Electroshock Therapy. In preparation. (6) Kalinowsky, L. B. and Hoch, P.: Shack Treatment, Psychasurgery and Other Somatic Treatment in Psychiatry (2nd ed.). New York: Grune 8c Stratton, (5) 1952. and Caplan, M.: A Case of Prolonged Insulin Coma: Treatment. This Journal, 1:145-155, 1952. Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Following Protracted Insulin Coma. Psychiat. Quart., 28:72-92, 1954. Schenderov, L. I. and Gamaleja, K. N.: Peculiar Disturbance of Body Scheme in Hemiplegics (Pseudomelia). J. Nevrol. Psihhiat. i Psikhogig., 4:361-372, (7) Kwalwasser, S. (8) (9) 1935. and Rowsell, P. W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma. A.M.A. Arch. Neural. (‘5' Psychiat., 72:705-711. 1954. (11) Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Phenomenon of Reduplication. A.M.A. Arch. Neural. & Psychiat., 67:808-814, 1952. (12) Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat., (10) Shagass, C. (13) (14) (15) (16) 109:22-26, 1952. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium") in Brain Disease. Am. J. Psychiat., 109:889-894, 1953. Weinstein, E. A., Kahn, R. L., Malitz, S., and Rozanski, ].: Delusional Reduplication of Parts of the Body. Brain, 77:45-60, 1954. Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. This journal, 3298-106, 1954. Weinstein, E. A. and Kahn, R. L.: Denial of Illness. Springfield, 111.: Charles C. Thomas, 1955. (17) Weinstein, E. A., Kahn, R. L., and Slote, W.: Withdrawal, Inattention and Pain Asymbolia. A.M.A. Arch. Neural. (9 Psychiat., in press. (18) Yeager, C. L., Simon, A., Margolis, L. H., and Burch, N. R.: Electroencephalographic Studies in Posthypoglycemic Coma. J. Nerv. & Ment. Dis., 118:435-441, 1953. (19) Ziegler, D. K.: Minor Neurologic Signs and Symptoms Following Insulin Coma Therapy. J. Nero. (3' Ment. Dis., 120:75-78, 1954. �6&3»; a; M '4 ’ u ��an m w ‘~ w m at m w m was. M M , ' , .. ”MW; mm a; m. . M3mg, W M §F mm man—5.... ������������mmmmmwwmmmiw- mummmuummmnmmmmm~' hag-6“} m IZLv*"' ,-Mv.-..‘w+,w A .w ~ ��' ~19- a We "a u ' of W M w W m M a -::.,.; m m mm mm M m u m . ���WW*WWMWW“WWMMWW ‘ WMWNWWWQfliwwm‘ a m. m m mm m mm w - Wmmwgmmwwmamwmw . *meummmim «WM W W M Wm w w m «mm W (X); . mammary In wmmmmmmwmwmm �,, m w W» m W mm m m ��m mM m - , �Vt,“ ~ m as. a. m » ~ ~ ‘ - � 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 Delusional reduplication of parts of body after insulin coma therapy. Journal of the Hillside Hospital, 4: 134-147, 1955. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-16-020 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 Kahn, Robert L.; Graubert, David N.; <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 Volume IV July, 1955 Number 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 http://exhibits.library.stonybrook.edu/mfp/files/original/c8041bb911b27dd176a67a53d9ba080c.pdf 51e8ec2d2ba520c72d5afb41bd417d27 PDF Text Text Prognostic Application of Psychological Techniques in Convulsive Therapy Robert L. Kahn Ph.D. and From Max Pollack Ph.D. the Department of Experimental Psychiatry, Hillside Hospital, L.I., N.Y. Aided, in part, by grants M-927 and MY-2092 of the National Institute of Mental Health, National Institutes of Health, U.S. Glen Oaks, Public Health Service. Read at the Eastern Psychiatric Research Association, October 25, 1958. IV: 10-2h-58 New York, �Prognostic Application of Psychological Techniques in Convulsive Therapy One of the more important clinical applications of psychological testing techniques is the prediction of the has there In treatment. in particular, results psychiatric been a considerable effort to determine valid psychological The to results somatic the for therapies. criteria prognostic date, however, have not found clinical acceptance. Using the Rorschach, for example, Rabin (1) has stated that ”single Rorschach factors cannot serve as indices or as has Piotrowski In contrast of improvement." predictors published a number of papers on the prognostic use of the Rorschach in insulin coma and convulsive therapy (2, 3, h, S, 6). Unfortunately, his criteria, as reported in successive papers, are vague and contradictory. In l9h1 he reported six explicit prognostic signs which were applied in predicting clinical months the termination of several after a over period response of treatment. But Rees and Jones (7), in a study of schizophrenic found somatic that of a therapies, receiving variety patients Piotrowski's signs were related to the results on a chance basis only. The differences in the studns of various investigators can be accounted for by methodological variables. These variables include factors of population, number of patients observed, the method of analyzing data, the kind of somatic therapy utilized, and the criteria for evaluating improvement, �-2made in evaluation is which the clinical time the at including incon— Another for basis treatment. of relation to the course sistent results may be the lack of an adequate theretical framework. in been have we engaged several years past These were studies convulsive of therapy the process. studies mode action of the concerning a to hypothesis test initiated of convulsive therapy which was derived from observations on a hypothesis of the to brain-damaged pepulation. According Weinstein and Kahn (8, 9) the therapeutic effect of convulsive function brain of altered the induction to therapy was related of symbolic a new type for conditions the creating necessary adaptation, mainly denial, in characterologically disposed shown altered that have Our already studies previous persons. change behavioral for condition a function is brain necessary (10, 11) and that the manifestation of denial language patterns with treatment is related to the evaluation of improvement (12). The purpose of the present report is l) to summarize the the and demonstrate 2) to on personality factors, findings application of these findings as prognostic criteria for convulsive therapy. For the �Method: studies were conducted at Hillside Hospital, a non-profit, voluntary, mental hospital, admitting patients who are considered as having early and curable illnesses. Psychotherapy is the principal treatment employed, with somatic therapies available when needed. The material presented was collected in a series of studies during a period of three and a half years. While a total of 180 patients have been investigated, varying numbers were tested with each of the techniques of personality evaluation. The patients ranged in age from 20 to 66, with a median of hS, and included twice as These many women as men. All patients received convulsive therapy administered three times a week, using either a Medcraft alternating current instrument or a Reiter C-h? electrostimulator. A minimum of 12 treatments was given, with the total course determined by the supervising psychiatrist in charge of the convulsive therapy unit. All psychological procedures were adminstered in the week prior to the start of treatment. The determination of the patient's response to treatment was based on the medical director's evaluation at the time of discharge, usually within six to eight weeks following treatment. �Procedures and Results: 1. Family Interviews. According to the original theory, it was considered that persons showing characteristics of the "explicit verbal denial" personality, as described by Weinstein and Kahn (13) would be most likely to show a behavioral change rated as improvement following treatment. This was tested in a standardized interview with members of the patient's family, eliciting information on the patient's attitudes, mode of communication and reactions to stress. Fifteen areas of behavior considered to be related to denial tendencies were scored from the interview material. A score of O, 1 and 2 was given for each item, depending on whether the designated behavior was minimally, moderately or markedly shown. The sum of the scores thus obtained was used as the denial score. The relatives of h? patients were interviewed, and denial personality scores ranged from O to 25, with a median of 11. The patients were divided into two groups: those with scores from 11 to 25 were classed as "high denial," and those from 0 to 10 as the ”low denial" group. results of this analysis were significant, showing that of the patients with high denial scores, 58% were in the much improved group and only one patient was unimproved. Of the patients with low denial scores, on the other hand, only The 30% were much improved and an equal number were unimproved (1h). �-5- results based on family interviews felt that our conceptions of prognostic Although these were promising, we personality factors could be extended and made more amenable to practical application by the use of standardized psycholog- ical procedures. For this purpose the Rorschach test 2. The Rorschach Test: We used. have obtained Rorschach was protocols in 87 patients receiving convulsive therapy. The & of the to records were scored according Klopfer criteria Kelley (15). Only those components were analyzed which were considered related to the personality aspects under study. It was found (16) that the much improved patients had significantly fewer total number of responses, and a significantly greater per cent of whole and form responses than did those The who rated as unimproved. were stereotypy and patients limited imaginative capacity of the much improved patients was also shown by their giving a greater percentage of popular responses, with little diversification of content categories. They were less likely to have any kind of shading response. Those patients who had human movement (M) responses had the poorest clinical responses, while those with no movement of any kind had the best results. With respect to color, an F6 response was associated with a poor clinical result, while those with no color at all did very well. Combining some of these factors tended to sharpen the differentiation in terms of outcome. Thus, of those who had �.6. In much improved. as rated both M much 66% improved FC, were with nor neither those of contrast, and only one patient was unimproved. We have converted these results into prognostic criteria, M and FC, only as shown in Table I. 17% In one column are listed those Rorschach closely related to a favorable In the other column are those factors which are factors which have been prognosis. were most For example, outcome. unfavorable clinical of an prognostic 67% much were of those patients with ten or less responses 16 more with or those of 28%, responses however, Only improved. had a good result. �TABLE I Prognostic Rorschach Indices of ImErovement Favorable Prognosis % Unfavorable Prognosis Much % Ingroved Improved of Responses Number Movement Color F and FC less (67%) 16 or more (28%) present present (28%) None (63%) M No FC (60%) FC - 75 a: Shading M 10 or ~ 100 None Much (21%) (59%) o - 59 (27%) (58%) Present (33%) Neither Present (66%) Both Present(17%) �’8- It should also be noted that comparison of post treatment Rorschach records with those obtained prior to treatment failed to show any significant change. This confirms similar observa- tions by others (6, 17, 18, 19) and indicates that the Rorschach pattern is probably a reflection of the basic personality rather than transient aspects of the disease process. 3. Social Attitudes: The F Scale. While these Rorschach results amply confirm the concept of the relation of personality factors and results of treatment, further data was obtained in application of measures of social attitude such as the California F Scale. This scale, originally developed in studies of ethnOa centrism and authoritarianism (20) has been increasingly used in the study of more central psychological processes. In our laboratory the F Scale has been regarded primarily as a reflection of stereotyped thinking and communication. It has been observed that patients who receive convulsive therapy at Hillside Hospital P scores than those given psychotherapy higher significantly alone (21). In these studfls a ten-item modification of the F Scale (22) has been used. The test is rapidly administered, taking no longer than 10 minutes in most cases. The subject reads 10 ambiguous statements and indicates whether he agrees or disagrees with each statement, and to what extent. The score given for each item ranges from one to seven and the range of total scores is 10 to 70. The greater the agreement, the higher the score have �-9- statements themselves are extreme, conventional or stereotyped expressions. For example, one of the statements is: "If people would talk less and work more, everybody would obtained. be The better off." This test patients prior to score of ho as a cut-off point,we has been given to 96 convulsive therapy. Using a found that of those patients with scores of ho or more 71% were rated as recovered or much improved. In contrast, only 36% of those with scores below ho were so rated. In general, the higher the score, the better the clinical result. We have also tested an additional 13 patients, referred for convulsive therapy, but who either refused treatment or terminated it of their own accord prior to completion. Of these, eleven had F scores below ho, an observation consistent with the general expectation that such persons haVB a poor response to convulsive therapy. �-10- Discussion: These observations have shown that in the course of the investigation of theoretical problems of convulsive therapy, certain standard psychological procedures have provided data which is significantly related to the therapeutic outcome. This data can now be applied to the practical problem of clinical prognosis. that favorable improvement rating is given to those patients who develop euphoric, hypomanic or denial modes of adaptation following treatment (23). Such behavioral change is most likely to occur in persons whose premorbid personalities may be characterized as non-empathic, non-introspective, nonverbally communicative and highly conventional and stereotyped with little imaginative or creative capacity (1h). On the Rorschach prior to treatment these patients give few reaponses, fail to show human movement, shading or integrated color responses (F0) and have little variety of content. 0n the F Scale, their scores were apt to be over b0, showing a high degree of stereotypy in their communication. In contrast to such patients, others are either unchanged by convulsive therapy or develop such modes of reaction as panic, paranoid behavior, or increased somatic concern, such as We have found a complaints about their memory. These patients are rated as unimproved. While this latter group of patients showed diverse patterns in their premorbid personality characteristics, they were more apt to be imaginative, introspective and less stereotxnd in their communications. On the Rorschach they gave human �-11movement, integrated color and shading responses, and were more On good than the prognosis patients. diversified in their content the F Scale their scores were most likely to be under ho. finding that meaningful prognostic criteria can be derived on the basis of personality constellation rather than in terms of nosological entities has important implications. For one thing, this conception leads to the use of further psychologSuch application is for prognostic ical techniques purposes. laboratory Secondat Hillside under in Hospital. our way currently mental of increased an understanding derive to is possible ly, it disorders, their management and prevention. Thus, we have previously noted (1h) that the same personality factors which are related to a good prognosis with convulsive therapy, are etiologof of psychiathe certain types development in important ically tric disorder. Studies of patients with psychiatric depression, for example, demonstrated a prominence of premorbid personality patterns characterized by the inability to communicate verbally (2b), and rigidity and lack of imagination (25). Such persons and verbal conventional to techniques are generally refractory require non-verbal therapeutic techniques. It seems that the same personality factors which make a person responsdve to nonverbal forms of therapy are involved in his susceptibility to a depressive reaction. The same stereotypy and conventionality which lead to a catastrophic response in the individual faced by the sudden loss of a job or close relative, permit the develop-. t ment of denial, minimization and displacement under the conditions of altered brain function and are considered "improved" by the family and the therapist. The �-12- that in the course of investigation of theoretical problems of convulsive therapy, certain standard psychological procedures have provided data which is significantly related to the therapeutic outcome. This data can now be applied to the practical problem of clinical We have shown prognosis. On the Rorschach test, those patients without human movement, shading or integrated color (FC) responses, few total responses, and with little originality or variety of content have the best prognosis. On the F Scale, a score of less than no is prognostic of a poor clinical reaponse. The theoretical conception developed in these studies leads to the application of additional psychological techniques for prognostic purposes, and to an increasing understanding of the etiology of psychiatric syndromes with its implications for management and prevention of such disorders. �-13- W REFERENCES 1. Rabin, A.I.: Effects of Electric Shock Treatment Upon Some Aspects of Personality and Intellect, Am. Psychol. 23 28,4, 19b7o 5'1 Rorschach the of Possibilities Z.: Prognostic Piotrowski, Method in Insulin Treatment, Psychiat. Quart. $3: 679, 1938. 3. Piotrowski, Z.: Rorschach Manifestations of Improvement Med. Psychosom. in Insulin Treated Schizophrenics, 508’ 1939. 6. l: A the Device for Experimental Z.: Single Piotrowski, in Prediction of Outcome of Insulin Treatment19h0 Schizophrenia, Psychiat. Quart. lg: 26?, Aid in Method a Prognostic Rorschach as 2.: Piotrowski, the Insulin Shock Treatment of Schizophrenics, 19h1. 807, Quart. lg: Psychiat. Effects N.D.C.: Z. and Lewis, Piotrowski, B.L., Pacella, of Electric Convulsive Therapy on Certain Personality 10h: Am.J. in Psychiat. Traits Psychiatric Patients, 83, 19h7. An Rorschach of the A.M.: Evaluation Jones, Test as aPrognostic Aid in the Treatment of Coma Therapy, Electronarcosia Insulin by Schizophrenics & Leucotomy, J. Ment. Sci. Therapy Electroconvulsive Rees, W.L. and 21:681, 1951. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat. 109: 22, 1952. Weinstein, E.A. and Kahn, R.L.: Denual of Illness: Symbolic and Physiological Aspects, Springfield, Ill. C.C. Thomas, 1955. 10. 11. 12. of M. E.A.: Relation and Weinstein, Fink, R.L., Amobarbital Test to Clinical Improvement in Electro& 1956. 23, Neurol. Arch. shock, lg: Psychiat. EEG M. of Delta Activity and Relation R.L.: Kahn, Fink, to Behavioral Responses in Electroshock: Quantitative & 1957. 516, Neurol. Arch. Psychiat.1§: Serial Studies, Kahn, Kahn, R.L. and Fink, M.: Changes in Language During Electro- shock Therapy. In Psychopathology of Communication, & New Grune York, Roch, P. and Zubin, J. Eds., Stratton, 1958. �~1h— 13. Factors in Weinstein, E.A. and Kahn, R.L.: Personality & Neurol. Arch. Denial of Illness, Psychiat. Q2: 355, 1953. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press). Kahn, R.L. and Fink, M.; New The Rorschach D.: Technique. Kelley, Klopfer, York, World Book Co., 1§E§. Kahn, R.L. and Fink, M.: Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Paper read at Electroshock Research Association meeting, San Francisco, 1958. Beck, S.J.: Effects of Shock Therapy on Personality as Shown by the Rorschach Test, Arch. Neurol. & Psychiat. fig: h83, 19h3. Kelley, D., Margolis, H. and Barrera, S.E.: Stability of the Rorschach Method as Demonstrated in Electric Convulsive Therapy Cases, Rorsch.Res.Exch. 5: 35, 19b1. B. and 16. 17. 18. 19. 20. 21. 22. 23. Kisker, G.W.: A Projective Approach to Personality Patterns During InsulinéShock and Metrazol-Convulsive Therapy, & Soc. Psych. 21: 120, 19h2. Abn. J. Adorno, T.W., Frenkel-Brunswick, E., Levinson, D.J. and New The York, Authoritarian R.N.: Personality, Sanford, Harper, 1950. R.L., Pollack, M. and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental HOSpital, J. Hillside Hosp. g: 216, 1957. Levinson, D.: Personal communication. Fink, M. and Kahn, R.L.: Behavioral Patterns in Induced States of Altered Brain Function. Paper read at Divisional meeting, American Psychiatric Association, Kahn, New York, 1957. . A a A. N a__..... ..- Cohen, M.B., Baker, R.G., Cohen, R.A., Fromm-Reichmann, F. and Weigart, E.V.: An Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Ps chiatr , 11: 103, 195h. .A-aL.......;.—..M.u ~.~ , i Hamilton, D.M. and Mann, W.A.: Hospital Treatment of In Depression, Hoch, P. and & Involutional Psychoses. Zubin, J. Eds., New York, Grune pp. 199-209- Stratton, 1952, j 5 E t i 2 1 s � 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 Robert L. Kahn and Max Pollack: Prognostic Application of Psychological Techniques in Convulsive Therapy, 1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-14-013 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 Kahn, Robert L.; Pollack, Max 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/2e0c07f8713070c07cedfceccd13935e.pdf f963256ba3adedd04d38ff5d4403fc1f PDF Text Text Social Factors in the Selection of Therapy in a Voluntary Mantel Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max From Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant Me927 of the National Health Service. 10-8-57 N.Y. Institute of Mantel Health, U.S. Public j M M 3:) �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and illness (3, 5, 6, and and incidence of mental psychiatric disorder with respect to type therapeutic selection 13, 1h), outcome (10). The and maintenance of treatment (2, 6, 15), present study is concerned with social factors in the selection of therapy in a voluntary mental hospital. In the studies reported by Bollingshead, Redlich and their co—workers (3, 5, 6, 13, 15), the population of classes New Haven was divided into five social basis of weighted criteria of education, occupation on the of residence. Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. was entirely restricted to the two upper Social class was the predominant determinant of the type of treatment selected even as follows: when the diagnosis "..... it is found was held constant. They summarize their results that treatment does not and medical determinants alone, but on the well. the lower classes. depend on psychological status position of the patient as degree Psychotherapeutic methods are applied in disproportionately high to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �- 2 - extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting therapeutic techniques and services are available to where the same This requirement is met all patients. at Hillside Hospital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. are admitted regardless of their and ability to criteria for accepting patients is their "ability to of the main One who non- participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the when needed. primary method of treatment with organic therapies The average length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of In previous work several years of study it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study from those was to determine whether electroshock receiving other forms of treatment in regard to cultural background, including such factors as education and personality as measured by the California F and place of birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hoSpital services. �m: Population: as of March 7, The 1957 was entire in-patient adult population of Hillside Hbspital studied. This constituted a total of ranging in age from 16 to 68 with a mean 172 of 3h.6, and including patients, 58 men and 11h women. 1) The population was subdivided Procedure: into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. I 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been The F scale The patient reads ten statements indicates whether he agrees or disagrees with each statement tent. The and score given for each item ranges from one to seven and the score range is tained. is a question- related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item.modification The 10 to 70. The to what ex- total greater the agreement the higher the score ob— statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subJects. * All patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical compar- ** As part of ison since treatment. an ongoing study all the EST it had been found that EST significantly affects the score during �-uh) The population was subdivided in regard of certain adjunctive services in the hospital. Among to utilization such services available are group activities, occupational therapy, psychological testing therapy. The latter is a diagnostic and and creative therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a specific referral from the therapist. �RESULTS: data The 1) comparison of the treatment was analyzed as follows: scores and place of groups for age, education, F scale where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia- -tions for the Table I. F scale scores, The EST group had age and years of schooling are presented in higher P scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was treatment groups were subdivided into difficult to evaluate accurately. When number of eight years of education, the difference was patients above and below significant at the .01 level. not differ statistically for The insulin any of these and psychotherapy groups did factors. �Hague uwumuom auom $5 $5 nMfimnom m mo 2 $3 Agooav muwam awamuom .nuom no modem m>fiuaz nvuwm amousm a m m 383 “somv 33$ mm mfl 8 $8 Afloav no qmfiwuom $8 anon a nowpwoscm um anon can muaam wkfid .ummm 3me nuhum o nahwm m $fi>u% ma once $8 .mw< H 6m- .cm no auhoom we 0 b made» How 0 8H $5 Ammv :5 m H .~ m; w.m *Réudx .cm am Ho unmanamua ma aonm mqmdg masono a. $8 Afimmv mummy cams 8.3 «a 0.3 H.ma 8;: m.: can: mi m.mm 3m am 93 m.ma 9.: gums 3: am p ***om.w dfia m.w N.H a ***mm.a ***ww.m m:.~ mm.” H.H m>.H pnmnwuhan mw¢ can: .33 ~.m o.m >.:H mo nomwnmmsoo a **Aa.m mm. m>.m Hm>ofi amped Hm>ma no. do. «a pa pa pauu««Hanm aguofiqumfiw endowmfinwam macaw m can: 9.3 9% m.Hm ado: .&B ~.m o.ma so: ”om“ G3 nonu naasmnu 9% Hoe. uonuhmmanwaamnm madamnH.amm nacho m.m Rama» mm -onohnm.emm mgauon» ammumnp * ** K *** �- - 7 Both somatic groups had a higher percentage of foreign born patients than the psychotherapy group, with the electroshock group being highest of Among the foreign born patients, those who came from all. Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe reneived psychotherapy alone. II. Comparison of Treatment Groups in Relation The to Diagnosis: diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital population (12). Of the fl72 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and two with other diagnoses. portion of the depressed patients with other diagnoses. To (52%) As expected, a larger pro- received electroshock than did those control for the factor of diagnosis in choice or treatment, the psychotic depression patients were subdivided into those received electroshock and those are shown who were given psychotherapy alone. .02 The results in Table II. While the two groups were comparable shock who patients had a much level of confidence. higher It is mean F for age and education, the electro- score, a difference significant at the also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. �‘hmavo afimv as: a a Agmmv :83 nunwm no nnmpmmm muonsm ma unusuauua m #moi madam Afimmv mo m>apaz 333 u, whom ma NN mm mumwa 0903 $8 anoumhuwn Aaawv.wm .usdm no w Mo cwbaoumm mm Pm...” m Ammmv mama» soamm 3?: u m a NN 3.: a p cams. m.o~ 0.2 am :.mH .92 spas gum: 0.0: 9S mpnuupdm am 0a: HH .ust IQ- mm mama noummohmmn no uuaow $03 .MHS p canonohmm mad omd mN.o mmm. m.ma {3 m.om 0.3 9602 33.3 v No.0 *m:.m muoom mo m can: 502 .935 0N6 Hm>oH nomuhdmaco mo. pa as pnwowgfiamum namv 3203393 -ongmmm.amm hmdhmfi. 9mm b it; * �-9. III. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment: While the electroshock from those receiving insulin or psychotherapy, there intra-group differences. postulated that the To account While most of the less than three months for some were who EST scores and were older were treated Place of birth h0% months were born earlier than the is also a significant factor. cance, although 28% in the U.S. The were also compared according Patients who had on higher younger and lower F scale While hh% of those all patients referred after data was referred after a period were III the patients are within three months were foreign born, six it were placed on treatment to the period of hospitalization prior to electroshock. groups. considerable of these differences received after admission, about In Table to differ patient was referred for electro- which a given patients of three to twelve months. F still shown factors involved in selection of treatment same related to the readiness with shock. patients, as a group, have been education Just treated a period of fails of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adignctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is clear that of these procedures had significantly lower more education and more were for these services. F and psycho~ those referred for either scores, were younger_in age, had native born than patients who were not referred �.350 Agmv m Agmmv nuHHm cumwmmm 0935 Mo NH o o haemv o m *ma.m pamapmmne madam 0p “away Afiowv ma w AgooHv u m>wuwz anon Ha N x nownm 933 Ammuv Afiomv mm m no m mo nofipduwawpwmmom Aaooav HH mafipwuscm made» w mm.: 0 Agmmv Agoav m H an >.m m.m o.m gm: m.m ».ad m.mH 333 mo a N x HHH nnwan '0‘"- no mqm¢9 on p aw.” mm.o mm.o aoavmosu mama» cams mm.H .Muaa Hm.a Po.nw*wm.m mnwcnoou< am m.ma m.ma m.oa 30E m.m; w.mm H.om u FH.H Hw.H mm¢ Hp.m mpqmwgwm m~.m swag».meg ‘ ~:.mnwrmw.m mm 9mm o.:a w.HH a m.~H mm.a mm.a , _ macaw mo m new: H.a: ~.N: m.mm mama .Mqu m:.m m~.m ma.ma nomwuwmaco ncwpcufiawpunmom .moa Hmpmfl mo. Ho. pa 96 AHHV Ammv angdwha Hm>oH Aoflv .mos : u .moa .woa .noa .moa n m mo nvmumq m m .moa on nova gang swap mama w m 0p m mama can» pnaowwflnmfim pqaofimfinmfim nun» can» m on mama m m .moa on mnoz mama mm .moa whoa «nos m * ** �nmnpo hmmnmna $8 Away m m Asmav m Aamv m npuwm a3 Amwmv Afimv cnmpmdm # muonsm m>wpwmuo A mo mm Afimav ma *mm.m *mm.® $3 mqwam cam hfimwv Agapv Afimpv u u m>w¢dz upon mwfipmme 3 a» flame Amway Aapmv “*pmv 8 mm my mm MN am H» «x whoa no Haowwoaonommm m mo *mm.: mowpmosum *mm.m mndow m mo soamm :5 Awmav Afimv a A$MHV n H ma mtm H.: Nx m «x ma >H p mwuw>hmm am IHHI mgm¢H m.m mm.m mo ***>.m m».H aowpwuscm mama; can; 3; aw v.0“ «.mH m.HH m>fiponmmd¢ m.mw**om.: mm no“ O.H h%fi add m.ma 5mm m.mm m.HH p :.ma mm.m om¢ o.> cams. p.0m p.»m mam: .men H.oa***mm.m a dmunmwmm am 3: m.m~ cum: 9mm p.m: w.:~ m.ma r*wm.m choom mgqmwpwm m H.mm $.H: can: .umfin m.w m.:a rm>¢r amped Ho>oa mo mo. Ho. :8 pa pa pa amoavhmanona Appv newwnwmabo 3239 mumua «CC. Ammv .a.o pnmUHuHamHm pacuHMwumHm * ** HQNUfiMHanm oz mmsouo .Hoaohmm m>wpmmuo mummy :.Honommm 8385 .Honoamm oz oz .a.o oz *** �DISCUSSlON: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such who were younger, patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated were most likely to be and foreign born, referred for EST. particularly in Eastern Europe, These patients infrequently were referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hbllingshead, Redlich and their co-workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. that social factors are The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criteria of therapeutic selection and of therapy are equally available to the With financial aspects and the where all forms entire population. availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations factors may of therapy. may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �such persons respond best to adequate since 13 - this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to ‘choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communi- cation. Thus, a patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 EE' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic rela- tionship. In the present study, similarly, the patients who received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education was over 20. * The 18 therapists had a mean F �-1ushown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are patterns appear to be likely to receive electroshock (7, 8). more frequent Such language in persons with poorer socio-cultural back- grounds. Social and cultural factors, in addition to their effect on cation patterns, that, has noted may communi~ also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in among symptoms are related to differences in cultural background. Frank gg'gl. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had ideational shock patients (8) we In a study of personality factors in electro- have noted that certain patterns of symbolic value The F scale and likely to be associated with the development of a The indicates that symptoms re- symptoms. communication were more depressive psychosis. who relationship between communication pattern symptoms themselves are a mode and of communication. furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �- 15 - Preliminary observations from a study in progress indicate that lowbscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing new their social differences, by matching them more birth. 0f possible greater importance is the modes of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process~oriented definitive answers. * See Esecover's presentation of this topic in this issue. research to provide �- 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score on the California F scale were significantly related to the type of therapy received and to the utilization of adJunctive hospital services. 2. Patients and were be who were older, poorly educated, had higher foreign born, particularly in Eastern Europe, referred for electroshock. those patients who most were most F scores likely to Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient 5. was It is were same factors found to be also related to the readiness with referred for electroshock. postulated that treatment selection is the result of the communicative interaction between patient and be important insofar as they are therapist. Social factors may related to different modes of communication. �- 17 - REFERENCES Adorno, T.W., FrankeloBrunswik, (1950): & The E., Levinson, D.J. and Sanford, Authoritarian Personality, New R.N. York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. Am. Leave Psychotherapy, A.M.A. Arch. Psychiat., 11; 283-299. & Freedman, L.Z. and Patients Hollingsheadfij. (1957): Neurosis J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. and Social Class, J. Psychiat., 110: 695-701. Social Class and Psychiatric Ecllingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank MEmorial Fund, pp. 195-208. -3 Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Roch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: 82h-830. �-18. REIFEEENCES ll. Opler, Schizophrenia and Culture, Scientific American, M.K. (1957): .. 191: 103-110. 12. Rachlin, H.L., Goldman, 6.8., Gurvitz, (1956): ll}. Redlich, F.C., Hollingshead, A.B., Roberts, 33., Robinson, H.A., KJ. (1953): Social Structure and Psychiatric Disorders, Am. J. Psychiat., fl: 729-73h. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Am. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Tougas, R.R. (19511): Urban J. Psxghia‘b” 3.3;: 831-837. Robinson, H.A., Redlich, F.C. and Myers, J .K. (195M: Psychological Research: 17. Rachlin, L. Freedman, L.Z. and Meyers, and 16. A. and J. Hillside Hospital, 2: 17-40. 1950, Life and Mental Health, 15. Lurie, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. 14., Social Structure J. Orthopsychiat., g5: 307-316. The California F Scale 1950—1955, P331301. Bu11., Ethnocentrism as 8. it: in 147-64. Limiting Factor in Verbal Therapy, In Psychotheragy and Personality Change, C.R. Rogers and R.F. Dymond, 18. Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (1956): of Creative Activity, Am. Structure and Therapeutic J. Psychotherapy, i3: Utilization 11833519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY I AGREE A I I LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, When it, 6. the youth needs most is will to wOrk and is best for strict discipline, fight for family Nowadays when so many much, a person has an it him not to but to keep busy with more cheerful things. What and the a person has a problem or worry, rugged determin- and country. different kinds of people mix together so to protect himself especially carefully against catching infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. �-20.. 8. is to The best teacher or boss is the be done and how 9. the strong. go about to get over them and tells us exactly what it. Young people sometimes up they ought 10. to one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak and �Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Discharge Ratings. and Diagnosis ROBERT L. KAHN. Ph.D.; MAX POLLACK. Ph.D.. AND MAX FINK. M.D. GLEN OAKS. N. Y. �Reprinted from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574 Copyright 1959, by American Medical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAHN, Ph.D.; MAX POLLACK, Ph.D., and MAX FINK, M.D., Glen Oaks, N.Y. The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community,12 private practice,29 and outpatient clinics.24'2” In the studies reported by Hollingshead, Redlich, and their co—work— ers ”'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa27 well.” tient as Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high-income pop— ulation. Similar findings have been noted in studies of outpatient facilities. Myers and Schaffer 2" showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychia— try, Hillside Hospital. Aided, in part, by Grants M-927 and MY-2092, National Institute of Mental Health, National In~ stitutes of Health, US. Public Health Service. found almost a linear relationship between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonprofit institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate profit— ably in psychotherapy.” 11 Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,“ it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign-born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the final diagnosis. Population Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, with a mean of 35 years. Procedura—The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a lO—item modification of the California F Scale.20 The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much,” or “very much.” The score for each item ranges from 1 to 7, and the total score range is 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one state— ment is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, With a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 1.—Dnration of Hospitalization: Total TABLE Months in Hospital No. to 5 to 9 or more 49 04 58 1 6 10 F Score. Mean 43.9 Age, Mean Yr. 45.5 32.5 27.9 40.1 31.0 Education. Mean Yr. ForeignBorn 10.0 11.9 12.8 41% 19% 10% x’=l5.0 I Moan Mean Difi'i r- Difi‘eiences Differences 13.0 § 1.9 T § ences to 1‘s. l to 5 vs. more 6 to 9 vs. more 1 0 lo 10 10 9 3.4 Mean or 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 or P<0.05. t P<0.02. I P<0.01. § P<0.001. * the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in beLween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table .3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of significance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classiVol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2.—Dnration of Hospitalization: Patients Receiving Convnlswe Therapy Months in Hospital F Score, No. Mean to 5 6 to 9 10 or more 15 1 to 5 vs. 1 to 5 vs. more 6 to 9 vs. more 1 “ T 1 § 17 25 to 9 10 or 6 58.2 45.6 34.9 . Mean Yr. 51.7 42.2 32.1 Yr. Born 6.5 12.3 13.2 67% 24% 16% x2=12.0 I Mean Difier- ences ences ences 12.61 9.5 ‘ 5.81 1 of Hospitalization: Patients Receiving Psychotherapy Only Education, Mean Foreign- Mean Difier- Months in _ 1 6 10 or § 19.6 § * 10.1 t NO- t0 5 to 9 or more 33 43 6.7 to 5 (is. to 5 vs. more to 9123. more 1 * 11-4 11.7 12.4 30% 16% 8% Mean to 9 10 or 6 1.6 12,4 10 * Difl‘er- Differ— ences ences 14.1 * 0.3 18.4 * 1.0 or 10.8 Mean 4.3 0.7 . . almost definlte, a hnear, relat1onsh1p be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the wide variability within each group, however, only the factor of age reached a level of statistical significance. Education also sig— nificantly differentiated the groups when dichotomized according to those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS TABLE 43-2 29.1 24-8 ForeignBorn P=0.001. . fied according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were characteristic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There 40-2 38-6 27-8 Differences 0.9 p<omL Mean Yr. Mean § P<0.05. P<0.02. P<0.01. F Score, Mean Education, Mean Yr. 26 Mean Difler- 6 10.7 HOSDltal Age, x’=5.4 1 23.3 10 Age, TABLE 3.——Dui*a_tion _ _ 4.—Duration of Hospitalization in Patients Classified According to Diagnosis Diagnosis Months in Hospital F Score, Mean Mean Yr. Involutional psychosis ___________________ 1-5 58.2 50.9 35.0 58.8 54.5 52.3 9.6 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 27.1 8.7 12.5 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 10% ‘ 6—9 10+ Manic-depressive psychosis .............. 1-5 6-9 10+ Psychoneurosis ........................... 1-5 6—9 10+ Schizophrenia ............................ 1-5 6—9 10+ Kahn et al. Age, Education, Mean Yr. 7.1 Foreign-Born 57% 43% 0 0 8% 12% 39/ 567 �M a? A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 5.—Discharge Evaluation No. 17 82 63 9 F Score, Mean 42.9 39.0 36.1 31.1 Age, Mean Yr. Education, Mean Yr. Foreign-Born 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 41% 22% 16% 11 % x 2=6.1 Mean Differences Recovered vs. Much Improved Recovered vs. Improved Recovered vs. Unimproved ............................. .................................... ................................. Much Improved 08. Improved ............................. Much Improved vs. Unimproved ........................... Improved vs. Unimproved ................................. 3.9 6.8 11.8 2.9 7.9 5.0 Mean Differences 8.9 * 13.3 I 13.4 4.4 4.5 0.1 * T Mean Difl'erences 0.5 0.5 2.5 0.0 2.0 2.0 ' P<0.05. P<0.02. t P<0.01. 1‘ years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By X2—analysis these results were significant at the 5% level of confidence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensified (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically significant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE 3. Diagnosis.~—The relation of sociopsy- chological factors to diagnosis is shown in Table 8. Those patients classified as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classified as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving Convnlsive Therapy Evaluation N 0. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Mean Differences Recovered vs. much improved ______________________________ Recovered vs. improved and unimproved___________________ Much improved vs. improved and unimproved _____________ 11.3 13.4 ‘ 2.1 Age, Mean Yr. Education, Mean Yr. 51.6 43.8 32.3 9.4 10.6 12.3 Mean Foreign-Born 50% 35% 17% x *=3.5 Differences Mean Difierences 7.8 19.3 I 11.5 t 1.2 2.9 1.7 * ’ P<0.05. P<0.02. I P<0.001. ’r 30/568 Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.——Discharge Evaluation in Patients Receiving Psychotherapy Only F Score, Mean N 0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 54 32-6 38.1 39 33.5 9 Age, Mean Yr. Education, Mean Yr. Foreign-Born 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% x '= 1.8 Mean Differences .............................. ................... ............. Recovered us. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also significantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such results were obtained in a survey of private practitioners, as in the Weinstock report,29 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of'treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Mean Differences Mean Differences 6.0 6.3 0.3 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important because they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the influence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist-patient interaction. Current data both from this laboratory 14 and from others 12'24’27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8,—Diagnosis Diagnosis N 0. F Score, Mean Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 52.3 40.8 36.9 32.8 Age, Mean Yr. 56.7 41.9 29.4 26.1 Education, Mean Yr. 8.9 , 11.5 11.9 12.7 Foreign~Born 46% 26% 22% 10% x’=14.2 I Mean Involutional vs. Manic-depressive psychosis ................ Involutional psychosis vs. psychoneurosis __________________ Involutional as. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia_______________ Psychoneurosis vs. schizophrenia ___________________________ Mean Mean Differences Differences Differences 11.5 I 15.4 I 19.5 § 14.8 27.3 § 30.6 § 3.9 8.0 4.1 12.5 15.8 3.1 § 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 T § § P<0.05. T P<0.02. 1 P<0.01. § P<0.001. * Kahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural' background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the par— ticular function and philosophy of the insti— tution. In studies of outpatient clinics which have a psychoanalytic orientation 24,28 it has been observed that persons from the higher social classes, determined by educa— tion or income, are treated for a longer period. In contrast, in state mental hospitals, patients with the least education are kept longer and form a higher proportion of the chronically hospitalized groupfi'l'fi23 The state—hospital therapist, viewing the in— stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients who come from a background most like his own. The observation of the relation between sociopsychological factors and improvement rating, particularly in those patients receiving convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for theolder, less educated pa— tients than he does for the younger, more sophisticated ones. In the patient with littl/ education and with modes of expression different from his own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. 32/570 . Thus, the rating of recovered is defined at Hillside Hospital as “the reasonable ex— pectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill.” 11 The therapist’s perception of the patient’s premorbid functioning may be influenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For ex— ample, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratification, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical significance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convul— sive group. The outpatient study by Rosenthal and Frank 28 also failed to find a relation between social factors and improve— ment rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willing— ness to attend treatment after he had been accepted. The marked relationship between socio— psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connota— tion. Landis and Page,19 in 1938, stated that age was the “most important single deter— Vol. 1, Dec., 1959 . �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of first admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the .present study, however, we have also shown that education, place of birth, and F score significantly differentiate the major diagnostic groups in the hospital. In View of these findings, we have postulated that a psychiatric diagnosis is not just a one—to—one reflection of a specific type of behavior pattern but is also a value judgment in terms of social interaction. Thus, both in our own studies and in the work of 12 it has been noted that patients others with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating socio~ psychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower-class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argu— ment. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found significant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, compliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were diffi— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan22 noted that hospitalized schizophrenic son patients exhibited significant social—class difference in symptomatology. Lower-class patients showed a predominance of “motoric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt thatthe lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms Would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general populatio-n.2v4'8'10 This de— crease, in our view, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 26 has Rees inhibited sexually.”6 reported that those British soldiers who had hysterical symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cataleptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difficult to find today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with de— pressive psychoses, we have frequently noted a pattern of premorbid behavior characterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other authors.3'5""21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that while the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the specific findings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle-class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa— tient is said to be “hostile” or “resisting psychotherapy” may reflect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful-oriented therapeutic approach a difficult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Significant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more edu— cated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were significantly related to age, the older ' . Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classified under involutional or manic—depressive psychosis. It is postulated that these relationships reflect the influence of social background on psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel-Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. Arieti, S.: The Decline of Manic—Depressive Psychosis: Its Significance in the Light of Dynamic and Social Psychiatry, paper read at 113th Annual Meeting of American Psychiatric Association, Chicago, 1957. 3. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. & Psychiat. 76 :617-618, 1. 1956. 4. Chodoff, P.: A Re-examination of Some Aspects of Conversion Hysteria, Psychiatry 17: 75—81, 1954. Cohen, M. B.; Baker, R; Cohen, R. A.; Fromm—Reichmann, F., and Weigert, E.: An Intensive Study of 12 Cases of Manic—Depressive Psychosis, Psychiatry 17:103-137, 1954. S. H. W., and Meltzer, B. N.: Predicting Length of Hospitalization of Mental Patients, Am. J. Sociol. 52:123—131, 1946. 7. Freyhan, F. A.: The Impact of Somatic Therapies on Course and Clinical Profile of the Schizophrenias, J. Clin. & Exper. Psychopath. 19: 6. Dunham, 195-201, 1958. Frumkin, R. M.: Occupation and Major Mental Disorders, in Mental Health and Mental 8. Kahn et al. Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136—160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199—209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty-Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, 11.; Israel, R. H., and Johnson, N. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Office, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.; Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, J. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital, edited by M. Greenblatt, D. J. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psychiatric Study, Psychosom. Med. 3:410—426, 1941. 22. Miller, D. R., and Swanson, G.: Defense Against Conflict and Social Background, paper 15. 35/573 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, Disorder, New York, Milbank Memorial Fund, 1953. 23. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Morgan, N. C., and Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: 307-310, 1954. 25. Opler, M. K., and Singer, J. L.: Ethnic in Behavior and Psychopathology, Internat. J. Soc. Psychiat 2:11-22, 1956. 26. Rees, J. R.: in discussion on paper by Gruenberg, E. M., in Epidemiology of Mental Differences 36/574 1950, pp. 51—52. 27. Robinson, H. Treatment, Am. J. Orthopsychiat. 24:307—316, 1954. 28. Rosenthal, D., and Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127 :330343, 1958. 29. Weinstock, H. 1.: Report of the Central Fact—Gathering Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathological Association, New York, 1958. Prénted and Published in the United States of America ��J. Hillside Hospital, 6: 216-228, 1957. SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type and incidence of mental illness (3, 5, 6, l3, l4), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present study is concerned with social factors in the selection of therapy in voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into five social classes on the basis of weighted criteria of education, occupation and place of residence. Of the residents who were under psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the psychotherapies, psychoanalysis was entirely restricted to the two upper groups. Social class was the predominant determinant of the type of treatment selected even when the diagnosis was held constant. They summarize their results as follows: ". . . it is found that treatment does not depend on psychological and medical determinants alone, but on the status position of the patient as well. Psychotherapeutic methods are applied in disproportionately high a 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. 8. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Scnior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4 Director, Department of Experimental Psychiatry, Hillside Hospital. ‘ 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 ‘ degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient’s financial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonprofit, k, h . ....-_.._...-.,...v..... nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms" (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their “ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in, regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. mum METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups, according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.‘5 5All patients are seen in psychotherapeutic sessions during ’hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. .... “.4. na. ._‘....-..—._4.,_....—««... . gbnyw. C) �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modification of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to what extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psychological testing and creative therapy were selected for this study because both require a specific referral from the therapist. RESULTS The data were analyzed as follows: (1) comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) significance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These differences were statistically significant for F score and age but failed to reach statistical significance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F In the case of those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during treatment. scale prior to treatment. �SOCIAL FACTORS IN SELECTING THERAPY .850 :wmuuom Eon $5“ 82m 39.7114? $.32 o ammokoh we 219 55 ..fi.:namo cwMuSh .ummmfiuom omen”.— fiamr: $.85“ $83 :25 .PEaZ x0 3:: 3:: Eom $.8va $532 fivawm 55m mo .minamo 82m -fimuuoh Eon @EE $3“ fimmIv $.32 Agar: :otugfim 985 .me .3— $.8va now .«o 0 .Ssnamo .Eeum 988w fl ”55H. K $5; ax? 3?: Gm 3. ea mm 532 2: 2: qfi wzofiom ‘8.“ $336 6m mow—mo? “2253‘; a 532 .59 ...23 3 2, N.— o o . ~23»me «I m5.— Gm q: 3 2;. n: gm 3” a :32. .8.” mi ed 3 ow< x0 532 :82 a5 n: a a tantamwficc Gm 92 ”.2 a: mi. 3» 3m . :2.» tmhd £5 E2 BE 3:: 38mm 532 :82 .En 3: 3 hm any .3. 8. So. a an 3 38%?2.85:»; Esscma .o&u>m&.::=n=— aozéemfi 335-5“ 585-98— -OH—U smvhmm $5.19 r7305 .53.: uh .382: . .. 2.. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difficult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was significant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are comparable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference significant at the .02 level of confidence. It is also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .550 $.23. ax”: 5.3m 538mm jigli‘l EuEEEh we “Egan $53” «Rana— .Sauamu REE Kc .0332 50m §$§ $53“ EOENN §£Vmw awash 208 39$me a; How no con—8.6m 938» name Bwamwunfi exam; 15.3. Gm 3. 3 532 3: 3: Gm wfi n2 :32 3:. 9:. Ga 3: «.2 h :32 new q: wzogum 0:3 N .vm 38C. somnufifium we mama? :32 . 86 £5 85 utofibfi 5.3» a mud ow< 582 a3 and 3:»..qu kc . é.“ 38m :ontfiwEoU :32 ea BE 3m 8. «liq. a $6 . ‘ . :3 Hammama .ofirmémm -onuwnm ha. , . 2!!!!) .. , ‘ W 7 832: . ,1" w 322: , 221 �KAHN—POLLACK—FIN K 222 ., .550 @va c o sin uo .£6 . 33mg 583m uncuzm $53 m o $53 figs: a : Mano cum—m 2.25355 -0322 50m 3 @932 3.2% 308 $.83 $5me : mm new “o :otuggxwmom QUE :oumusvm wweflamo “26> w Afiwua 32:: c 3015 kc m Ewnud 45 55H. S a 85 :2 85 £5 a: 8.... a; 9 :4 :3.” 3» :82 .En E...“ 2.2 N: ms: a 8; :3.“ 5* 3... Gm 5.. am 3.. 38> 582 am hi 3.; Gm 3: mfi 2: 532 93 mg Gm q: 582 2:. mo can: mEEouuV Szuzcm 8.. uw< :3 Sam \0 . m3 38m zowtuiEeU h mo as 3 .88 him -mNSSEmo: 52: Susannah. sum—SA €3.88... no: 4 w. $04 ,w ‘ 8 e5 $6 kwoa :2: o m 532 c: m Gan—u .85 0.82 c 33 o2 2.2 e 2 » .22 me. 8. aa -608 .88 ~22 m Ema—u 30..— 288 :2: 308 .85. 3 n 285:? 385:”; 52: o 308 88¢ . 2. . �SOCIAL FACTORS IN SELECTING THERAPY 223 Shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a significant factor. \Vhile 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of significance, although 28 per cent of those treated earlier had less than eight years of education. .,,. ,, . mug-r; Adjunctive Hospital Services Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had Significantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. 4. Use of DISCUSSION .. "155' . , The results indicate that the factors of education, age, place of birth, and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services‘ in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, 13, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations maybe considered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is ' �KAHN—POLLACK—FINK 224 .850 fin“; $me Amwutch 35:30 533mm «@055 A03: Afimwvmw H 1%: 35:2 @33 @3: @8va §§8 .mwmuamo «50 853 .25“ «:8 $63 .23 2:5 go ARE; 50m aways $95: $.38 138% Z MFGSK. 805 1%» 3w .uo H ~838va PfimSafibfi .Nmenamu mud“; «Eu 3?: $.27: 33“ $.32 Gm fl. 3 a.» 38> 582 3: 2: 3“ N: mic—om kc v 8.938% .Um 35? we 8.“ :82 a octhd £5 QN m5 3 , uptuzzbuv. . .Sx 2: we a: E: 532 SN 3». 5.8 5.3 Gm 2: ”.2 a: 2: 3w 5.3 3» ASV 32v Gm .tnowJ. ....ewm "A: S. vw< Vutfiwm :8: . 2:».zum Kc a5 tooomd :8.” ~22 3,2 no. 8. 38m h 582 532 £5 Nfiu «.3. 2 :32 so. a3a :ofluEwEoU st 333.5 3380 u>tmuu0 332:. REEF oz 285:?“ 285:»; ..H..U .._oau>mm .355 38.“. Saucmcmmm .355 Amaze... oz uhu OZ 0z . .3 2. �,amr»: . “ ‘ .. SOCIAL FACTORS IN SELECTING THERAPY 225 , .. new... 4.. ,wu referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 . Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on communication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et a1. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those, who remained had ideational symptoms. In a study of personality 7 The 18 therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was over 20. , .vr" �KAHN—POLLACK—FINK 226 factors‘in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an etlmocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. Preliminary observations from a study in progress indicate that lowscorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating patients who are refractory to conventional psychotherapeutic ap1 proaches. While epidemiological studies have clearly structured some of the problems involved in selection of treatment,‘and have indicated the direction of further. study, it still remains for more processoriented research to provide definitive answers. SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth, and score on the California F scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital 1. servrces. ’ Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �. . p *Wflg g “A 4““ .. )WA-W.~»‘,.I_~HWW‘W« "r .t. SOCIAL FACTORS IN SELECTING THERAPY 227 ment of choice for those patients who most closely resembled the therapist in these aspects. 3. These relationships were present even when diagnosis 'was held constant. 4. Among the electroshock patients the same factors found to be significant in choice of therapy were also related to the readiness With which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX “Wadwfl a F SCALE FORM . Below are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I AGREE A LITTLE I AGREE PRETTY MUCH I AGREE VERY MUCH 3),." glue»: ‘. 1. No sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. 4. When a person has a problem or worry, it is best for him not think about it, but to keep busy with more cheerful things. to 5. What the youth needs most is strict discipline, rugged determination, and the will to work and fight for family and country. 6. Nowadays when so many different kinds of people mix together so much, a person has to protect himself especially carefully against catching an infection or disease from them. 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one who tells us exactly what is to be done and how to go about it. 9. Young people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down.‘ . \4 I DISAGREE A LITTLE I DISAGREE PRETTY MUCH I DISAGREE VERY MUCH �\‘ KAHN—POLLACK—FINK 228 People can be divided into two distinct classes: the weak the and strong. 10. REFERENCES (1) (2) (3) (4) (5) (5) (7) Adorno, T. W.; Frenkcl-Brunswik, E.; Levinson, D. J. 8c Sanford, R. N.: The Authoritarian Personality. New York: Harper 8.: Brothers, 1950. Frank, J. D.; Gliedman, L. H.; Imber, S. D.; Nash, E. H. 8: Stone, A. R.: Why Patients Leave Psychotherapy. A.M.A. Arch. Neurol. (9' Psychiat., 77: 283-299, 1957. Freedman, L. Z. 8: Hollingshead, A. B.; Neurosis and Social Class. Am. J. Psychiat., 113:769-775, 1957. Hillside Hospital: 29th Annual Report, 1956. Hollingshead, A. B. 8: Redlich, F. C.; Schizophrenia and Social Structure. Am. ]. Psychiat., 1102695-701, 1954. Hollingshead, A. B. Fe Redlich, F. C.: Social Class and Psychiatric Disorders. In: Interrelations Between the Social Environment and Psychiatric Disorders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kalm, R. L. 8: Fink, M.: Changes in Language During Electroshock Therapy. In: Psychopathology of Communication, ed. P. Hoch 8: J. Zubin. New York: Grune 8: Stratton, 1957. Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (9) Levinson, D. J.: Personal Communication. (10) Morgan, N. C. 8.: Johnson, N. A.: Failures in Psychiatry: The Chronic Hospital Patient. Am. J. Psychiat., 113:824-830, 1957. (11) Opler, M. R.: Schizophrenia and Culture. Scientific American, 197:103-110, - (8) 1957. Rachlin, H. L.; Goldman, G. S.; Gurvitz, M.; Lurie, A. 8: Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950. This Journal, 5:17-40, 1956. (13) Rcdlich, F. C.; Hollingshcad, A. B.; Roberts, B. H.; Robinson, H. A.: Freedman, L. Z. 8c Meyers, J. K.: Social Structure and Psychiatric Disorders. Am. ]. Psychiat., [09:729-734, 1953. (14) Rennie, T. A. C.; Srolc, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. (15) Robinson, H. A.: Redlich, F. C. 8: Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 24:307-316, 1954. (15) Titus, H. E. 8c Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. (17) Tougas, R. R.: Ethnocentrism as a Limiting Factor in Verbal Therapy. In: Psychotherapy and Personality Change, ed. C. R. Rogers 8: R. F. Dymond. Chicago: University of Chicago Press, pp. 196-214, 1954. (13) Zierer, E. 8: Zierer, E.: Structure and Therapeutic Utilization of Creative Activity. Am. ]. Psychother., 10:481-519. 1956. (12) . �Social Factors in the Selection of Therapy in a Voluntary Mantal Hospital Robert L. Kahn, Ph.D. Max Pollack, Ph.D. Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Grant M-927 of the National Health Service. 10-8-57 Institute of mental Health, U.S. Public N.Y¢ �Social Factors in the Selection of Therapy in a Voluntary Mental Hospital Recent investigations have indicated a relationship between social class and psychiatric disorder with respect to type illness (3, 5, 6, and therapeutic and incidence of mental selection and.maintenance of treatment (2, 6, 15), 13, 1h), outcome (10). The present study is concerned with social factors in the selection of therapy in.a voluntary mental hospital. In the studies reported by Hollingshead, Redlich and (3, 5, 6, 13, 15), the population of classes on the of residence. New Haven was their co-workers divided into five social basis of weighted criteria of education, occupation Of the residents who were under and place psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care Of was more common among the psychotherapies, psychoanalysis groups. Social class selected even as follows: when " was was held constant. They summarize is found that treatment does not and medical determinants alone, but on the well. entirely restricted to the two upper the predominant determinant of the type of treatment the diagnosis ..... it was the lower classes. their results depend on psychological status position of the patient as Psychotherapeutic methods are applied in disproportionately high degree to the upper social levels. The data of this study would most psychotherapy takes place in a setting seem to indicate that where the background of the patient is similar to that of the therapist" (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the �extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques This requirement is met and services are available to all patients. at Hillside HoSpital. It is a non-profit, sectarian institution for the treatment of voluntary patients with "early curable mental symptoms" (h), pay. of the main One who non— and are admitted regardless of their ability to criteria for accepting patients is their "ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy available is regarded as the primary when needed. The average method of treatment with organic therapies length of hospital stay is six months, al- though some patients remain for as long as a year. The present investigation is of electroshock therapy. an outgrowth of several years of study In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose patients differ of the present study was to determine whether electroshock from those receiving other forms of treatment in regard cultural background, including_such factors as education and personality as measured by the California F and place of to birth, scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. �Mame: Population: as of March 7, 16 entire in-patient adult population of Hillside Hospital studied. 1957 was ranging in age from llh The This constituted a to 68 with a mean total of 172 of 3h.6, and including patients, 58 men and women. Procedure: 1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only. * 2) The groups were compared for age, education and place of birth. 3) of the California naire (see F All patients were tested scale suggested by Levinson (9). Appendix) which has been indicates whether tent. The scale is a question- The patient reads ten statements he agrees or disagrees with each statement and to what ex- score given for each item ranges from one to seven and the total score range is tained. The F related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). and ** with a ten-item modification The 10 to 70. The greater the agreement the higher the score obs statements themselves are extreme, uncritical or stereotyped expressions. patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data was included in both groups. In the results this makes a total of 179 subjects. * All part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of those patients who were actually on EST on march 7th their pre-treatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during ** As treatment. �- h h) The population was subdivided in regard to of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing therapy. The latter is and be analogies life experience (18). Psychological testing and creative therapy selected for this study because both require a specific referral therapist. creative a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to of utilization were from the �RESULTS: data The was analyzed as follows: 1) comparison of the treatment groups for age, education, F scale scores and place of where diagnosis is held constant, prior to treatment, birth, 2) comparison significance of length of hospitalization 3) and h) comparison between groups referred for adjunctive hospital services. I. Comparison of Treatment Groups: For each of the three treatment groups the means and standard devia— tions for the Table I. F scale scores, age and years of schooling are presented in The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. differences reach were statistically significant for statistical significance for education. cation to differentiate the groups electroshock group contained many was due, F These score and age but failed to The failure of years of edu- in part, to the fact that the foreign born patients whose education was difficult to evaluate accurately. When number of eight years of education, the difference was patients above and below significant at the .01 level. not differ statistically for The treatment groups were subdivided into insulin any of these and psychotherapy groups did factors. �*** ** fig * $3qu dumumww 33mg. menwmwowOa mmwnwOu macaw mmeanmcpwn Humcfiuamov Hamcwwuawmwoan mnmunHnmUd md .oow mumbwwwomsw 309 mwmuwwwomud ma ma .OH .ow 38 w.w ma Hw.o 83.. Emma wrm flaw ES. Emma w macaw Hm<ww ooavaHmOd Hm<mw Hm<mw .mm whw w.ww** firm a 5:0. 55 mu ow .msa mb H:.< 9%. saws wma 35 5....“ Emma pmm wawmumba P.4m r.mm**+ d m.w 92.. EL mu Fm :78 Pmmiiw.» H.H w.:m fmm m.wo**x a xm" Emma “Po Wm 5L Pm Emma 8.0m ammum aummwfimuw 0% Fe mu mm. mwocvm : 2% m prbw wow wwwos ESE Ems .70.? pom E. m xmmum w m ow macaw. on Hmeé ma. 8% Gm§ pmm. Scam 5 xv." 53$ macomdwou moumumb wwmom moan Si: .39. mm 3 Gwé 8&3 m 5 mfiow‘ngmamoé ow mum wwwau wows xmu zwdH<m wwmom ow moan. mcwoww wowmums 3% mfiooé mwmnm 333 mmma. Pd: wuwfiw 5 o ow m wonmumu Smfi 3% wean woumumu Carma wwwdw H �f 7 ' Both somatic groups had a higher percentage of foreign born patients than the psychotherapy group, with the electroshock group being highest of Among the foreign born patients, those who came all. countries from Eastern European received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. II. Comparison of Treatment Groups in Relation to Diagnosis: The diagnostic categories of the patients in this study are comparable to those reported in previous studies of the heapital population (12). 172 32 patients, as psychoneurosis and two with other diagnoses. with other diagnoses. To (52%) As expected, a larger pro- received electroshock than did those control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those received electroshock and those shown who were given psychotherapy alone. .02 The who results in Table II. While the two groups were comparable shock the 78 were classed as schizophrenic, 60 as psychotic depression, portion of the depressed patients are Of patients for age and education, the electro- had a much higher mean F score, a difference significant at the It is also that a significantly higher level of confidence. demonstrated proportion of the electroshock patients were born in Eastern Europe. �* mug $0.33 mmHImeoUOI wfiduogmumg $5 mHmUManmfiw $8 ma .Om ooswmuwmom Hm<mw 9mm waw. Emma 5.0 8Q Emma w ow mnoum m}? 9mm a mafia. 5.: 2mmb ab 5.m 55 Sh ”5.: mu mmdwmmdm Emma audr mmm 0.8 0.8 9% a cwmw. ma wmwaUOdwo Emma a 8.0 Hob 9m fr Emma MmmHm ow unmammmwos prfim mu Waco. xm u : w 2:3 3&3 HH :30 waves «mmum m H.mu mmomu<ma 0% m mm 0H 8253 @050. 25% Uumwmnmua Beam vamm xm u mm pm Smé 383 wowu wwmom #.0w * 0% zmaw<m w pm Hammaamsa mcwovm mmmdmun 30,3 ow 3me wwudw p H 3&3 GE oawmw �- 9 - III. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment: While the electroshock from those receiving insulin or psychotherapy, there intra-group differences. postulated that the same To account While most of the less than three months for some have been shown were patients who received after admission, about EST h0% was to differ considerable of these differences patient which a given of three to twelve months. In Table it was were also referred for electro— were placed on treatment were referred after a period III the patients are to the period of hospitalization prior to electroshock. F still factors involved in selection of treatment related to the readiness with shock. patients, as a group, compared according Patients who had higher scores and were older were treated earlier than the younger and lower groups. Place of birth is also a significant factor. within three months were foreign born, six months were born cance, although 28% in the U.S. The While hh% of those all patients referred after data education just on F fails scale treated a period of of signifi- of those treated earlier had less than eight years of edu— cation. IV. Use of Adjunctive Hospital Services: Comparison of the logical testing is shown patients referred for creative therapy in Table IV. It is of these procedures had significantly lower clear that those referred for either F more education and more were native born than for these services. and psycho- scores, were younger in age, had patients who were not referred �** * w Beam Bowm bmmm fio m Em: «was dams mumuwwwomba m 3 w Hmmm 308m m ma mw w 0 gem. Bow. Bow. 80m. o n ma Hm<mw mHMou bmmmaw do 38. ow w $8 38. awwmdamua momvwdmwwumawon 32 “Hwy .OH 5% arms wsmu u Bow. 3 m dumb 38. 80m. mwmbHWHomUd w .Om Hm<mw ooswmwwmos m.4m 3.5 95 Emma UH%H. ww.m 5.4 SL Ewan w ow macaw Ema H.Mm H4.w d Fm tro ww.m Sam mme mu m.mm**.wm.5 mu} $.4H Tme UMWfi. wo.H .zmmu mmwwmbam bmm v.5 H.mw d Ho.w Hm.“ 53 mu >ooowawum wamxwmbu v.8 H.mw UHHH. Kama Hm.m fl; mb Emma Mmmwm ao mocnmawou o.wm PS 0.3 ebwfiw om d m.o Pm “.4 mb u Ho Hammaw HHH N m H H 0 m ow waves 323 333 m :.mm ammwm manomdwoa HP AHOO$V m mw 60ch SR3 momvwdmwwnmawou m ow on Baum wHHow xm PH n AHOO$V a Hm 393 3&3 wows do zmdw<m wwmom m.wm* Hammdams¢ w o 383 0 0 pm ow mcuowm mmmdmus 395 wwuwu m R§ oawmu u �zo *** ** * ac n.e. zo 593. wanWOH.u - oummdw<m ammflm wmwauou. mammaw<m zo mwmuwwwnmbfi mHmuwanmbd owocwm mumswwwombd Awmv o.e. Sea gamumww mw 2.: m» ma oosvaumOb ewmuquawomv Amqv .ow .Om ow .OOH‘Hmamu wm<mw wm<mw m.w up.» uwww. Emma :H.: w: :w.4 mm.“ Saws w wmdeUdm mooam Hm.w a w.wm*4 arm Hm.w po.m mu wmwmwuma m.wm***po.w cwww. Emma w&.4 we; Wm.m mm.a Emma 4.0 bmm % m.mm**.w.o Hw.: a 5.» Hm.m 5.» Ho.a wow Ho.p mu :.mo**wm.w >aucundwdo fiuww smmu Hp.m rw.m Emma wmmwm wacnmdwou H.4w m.<*** & m.wm ow E p.» w.“ Bbmbm mu mmH<Hnmm H< N» u Hm prwv m 33 mm ww p mmwot ow u Awmfiv Am$v m «mmdm m.mw* macomduon r.mm* mw d mm Am4$v 3.33 Ammfiv mm m ow mmRnwowomwoww 0% Amway Beam ammfiwmm xm 4H mp u N» Q: my moan zmdu<m u Aqmav 8% A4H$V “mpgv mum wwmnm m.wm* m.mm* Hm v mw H ow mcuowm owmmaw<m mmmdmwu prfiv Q: “MN$V Amfiv wwudw m m m m Amfiv :3: Amfiv Ammv akumnm OdWmH �-12.. DISCUSSION: results indicate that the factors of education, age, place of birth The and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients better educated, native born and had lower F scores. Such were younger, who patients were also referred more frequently for the auxiliary hospital services of psychological testing creative therapy. Conversely, those patients were older, poorly educated likely to were most be and foreign born, referred for EST. who and had higher F scale scores, particularly in Eastern Europe, These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich and their co—workers (3, 5, 6, 13, 15) who demonstrated related to the type of therapy received in a community. The present study that such factors are also significant in a hospital setting demonstrates ability to that social factors are is not a criteria of therapeutic selection pay and where all where forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, factors may of therapy. two alternative interpretations may be considered. The social relate directly to the empirically established criteria for choice On this basis a patient is referred for electroshock because older, poorly educated or foreign born, clinical experience having shown he that is �- 13 such persons respond best to adequate since this type of treatment. This explanation is in- half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional cation. Thus, a modes of therapy, such as mode of communi- patient is not referred for electroshock because he is foreign born or poorly educated, but rather, these factors provide the difference in cultural background between patient and therapist which makes successful communi» cation less likely in the psychotherapeutic relationship. Robinson 33 Ei' (15) in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic tionship. In the present study, similarly, the patients who rela— received psycho- therapy alone were more like the therapists with regard to the factors studied.* Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations haVe therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen percent were born in Eastern Europe. Their mean years of education * The 18 was over 20. �-11).shown that verbally and use of uncommunicative persons, prone to denial, evasion, stereotypy cliches are likely to receive electroshock (7, 8). patterns appear to be more frequent in persons with poorer Such language socio-cultural back- grounds. Social and cultural factors, in addition to their effect cation patterns, that, has noted may among on communi- also determine the manifest symptomatology. Opler (11) patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank 33 a}. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those mained had shock ideational patients (8) we symptoms. symptoms likely to The indicates that The F In a study of personality factors in electro~ hare noted that certain patterns of symbolic value and communication were more depressive psychosis. re~ who be associated with the development of a relationship between communication pattern symptoms themselves are a mode and of communication. scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital lation, Levinson (9) found that high—scorers were popuu less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. study the F scale was In the present the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. �Preliminary observations from a study in progress indicate that low—scorers the scale have a poor response to electroshock, and that those with high F on F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing closely for age and place of necessity for developing their social differences, by matching birth. new modes Of them more possible greater importance is the of communication when treating patients who are refractory to conventional psychotherapeutic approaches.* While epidemiological studies have clearly structured some of the problems involved in selection of treatment, and have indicated the direction of further study, it still remains for more process-oriented research to provide definitive answers. * See Esecover's presentation of this topic in this issue. �_ 16 - SUMMARY: 1. In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of therapy were equally available, education, age, place of birth and score F on the California scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital services. 2. who were older, poorly educated, had higher F scores foreign born, particularly in Eastern Europe, were most likely to and were be Patients referred for electroshock. those patients who most Psychotherapy was the treatment of choice for closely resembled the therapist in these aspects. were present even when diagnosis was held 3. These relationships h. Among the electroshock patients the constant. significant in choice of therapy which a patient S. was were factors found to be also related to the readiness with referred for electroshock. It is postulated that treatment selection is the result of the communicative interaction between patient and be important same therapist. Social factors may insofar as they are related to different modes of communication. �m 17 - REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N. (1950): & The Authoritarian Personality, New York: Harper Brothers. Frank, J.D., Gliedman, L.H., Imber, S.D., Nash, E.H. and Stone, A.R. (1957): Why Neurol. & Patients Leave Psychotherapy, A.M.A. Arch. Psychiat., 11: 283—299. Neurosis and Social Class, Freedman, L.Z. and Rollin gsheadfifi. (1957): Am. J. Psychiat., Hillside Hospital, 29th 113: 769-775. Annual Report, 1956. Schizophrenia and Social Hollingshead,A.B. and Redlich, F.C. (l95h): Structure, Am. J. Psychiat., 110: 695-701. Social Class and Psychiatric Hollingshead,A.B. and Redlich, F.C. (l95h): Disorders, in Interrelations Between the Social Environment and Psychiatric Disorders, New York: Milbank Memorial Fund, pp. 195-208. Kahn, R.L. and Fink, Therapy. Zubin, M. (1957): Changes in Language During Electroshock In Psychopathology of Communication (Hoch, P. and J. Eds.), Kahn, R.L. and Fink, M.: New York: Grune & Stratton. Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol., in press. Levinson, D.J.: 10. Personal Communication. Morgan, N.C. and Johnson, N.A. (1957): Chronic Hospital Patient, Am. Failures in Psychiatry: J. Psychiat., The 113: Sen-830. �_ 18 _ REFERENCES 11. Schizophrenia and Culture, Scientific American, Opler, M.K. (1957): £91: 103» 110. 12. Rachlin, H.L., Goldman, G.S., Gurvitz, M., Lurie, (1956): J. Hillside Hospital, 2: 1950, and Psychiatric Disorders, Am. Social Structure J. Psychiat., Am. J. Psychiat., 109: 729-73h. Titus, Psychiatric Treatment, Am. H.E. and Hollander, E.P. (1957): Urban 113: 831—837. Robinson, H.A., Redlich, F.C. and Myers, J.K. (l95h): and 16. l7—h0. Rennie, T.A.C., Srole, L., Opler, M.K. and Langner, T.S. (1957): Life and Mental Health, 15. L. Redlich, F.C., Hollingshead, A.B., Roberts, B.H., Robinson, H.A., Freedman, L.Z. and Meyers, K.J. (1953): 1h. Rachlin, Follow-up Study of 317 Patients Discharged from Hillside Hospital in 13. A. and Social Structure J. Orthopsychiat., g3: 307-316. The California F Scale in Psychological Research: 1950-1955, Psychol. Bull., 53: h7-6h. 17. Tougas, R.R. (195%): Ethnocentrism as a Limiting Factor in Verbal Therapy, In Psychotherapy and Personality Change, 0.3. Rogers and R.F. Dymond, 16, Zierer, E. and eds., Chicago: University of Chicago Press, pp. l96-21h. Zierer, E. (l956): of Creative Activity, Am. Structure and Therapeutic Utilization J. Psychotherapy, lg: h81-519. �- 19 - APPENDIX F SCALE FORM Below are a number of statements. For each statement we give us your personal opinion of whether you agree or disagree. want you to Answer each statement according to one of the following: I AGREE A I I I DISAGREE A LITTLE AGREE PRETTY MUCH I DISAGREE PRETTY AGREE VERY MUCH I DISAGREE VERY LITTLE 1. No MUCH MUCH sane, normal, decent person could ever think of hurting a close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and work more, everybody would be better off. h. think about 5. ation, an it, a person has a problem or worry, it is best for him not to but to keep busy with more cheerful things. What and the 6. much, a When the youth needs most is will to work and strict discipline, fight for family Nowadays when so many rugged determin- and country. different kinds of people mix together so person has to protect himself especially carefully against catching infection or disease 7. from them. Sex crimes, such as rape and mere imprisonment; such criminals ought to attack be on children, deserve more than publicly whipped, or worse. �”"1 ‘ -20.. 8. is to The best teacher or boss is the be done and how 9. to go about 10. the strong. tells us exactly what it. Young people sometimes up they ought to get over them and one who get rebellious ideas, but as they settle grow down. People can be divided into two distinct classes: the weak 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 Social factors in selection of therapy in a voluntary mental hospital. J Hillside Hosp., 6: 216-228, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-25-030 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 Kahn, Robert L.; Pollack, Max; <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 4 items. 1: [Preprint]. 2: Reprint from the A. M. A. Archives of General Psychiatry December 1959, Vol. I, pp. 565—574; title: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital. 3: Xerox of J. Hillside Hospital publication. 4: Another [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/b97c9ed1045d743c104ef57163e90f61.pdf cca8258a1cb2c00bbe3baaafbd7ccf91 PDF Text Text Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Qis‘éttarge Ratings. and Diagnosis ROBERT L. KAHN. P|1.D.; MAX POLLACK. Ph.D.. AND J’ MAX FINKI M.D. GLEN OAKS. N. Y. �Reprinted from the A. ill. .4. Archives of General Psychiatry December 1959, Vol. 1. pp. 565—574 Copyright 1959, by American .llca’ical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAI-IN, Ph.D.; MAX POLLACK, Ph.D., and The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community}? private practice,29 and outpatient clinics.24’2" In the studies reported by Hollingshead, Redlich, and their co—workers “'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa— tient as well.” 27 Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high—income pop— ulation. Similar findings have been noted in studies of outpatient facilities. Myers and Schaffer 24 showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by Grants M-927 and MY—2092, National Institute of Mental Health, National 1n— stitutes of Health, US. Public Health Service. MAX PINK, M.D., Glen Oaks, N.Y. found almost a linear relationship, between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonprofit institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate profit11 in ably Individual psychotherapy.” psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,14 it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign—born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the final diagnosis. Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, ' i with a mean of 35 years. Procedure.——The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a 10-item modi— fication of the California F Scale.” The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much," or “very much.” The score for each item 1 to 7, and the total score from range is ranges 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one statement is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, with a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients Who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 of Hospitalization: Total Population TABLE 1.——Dnrati0n Months in Hospilal to to 1 6 No. 5 S) or more 1.0 49 64 58 l 6 to 51‘s. filo?) to 5 vs. 10 or more to 9 vs. 10 or more Education. Mean ForeignYr. Born F Score. Mean Mean Yr. 43.9 31.0 45.5 32.5 27.9 10.0 11.9 12.8 Mean M can Difl'e- Mean Differ- ences ences 13.0 § 1.9 T § 40.1 Difi: reneos 1 Age, 3.4 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 41% 19% 10% x ’=15.0 I P<0.05. P<0.02. I P<0.01. § P<0.001. * 1‘ the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in be;ween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table 3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of significance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classi— Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2,—Dnration of Hospitalization: Patients Receiving C onvnlswe Therapy F Score, N0. Mean Months in Hospital to 5 6 to 9 10 or more 15 1 17 25 58.2 45.6 34.9 ences to 5 vs. 1 to 5 v8. more 6 to 9 vs. more * T 1 § to 9 10 or 12.61 6 Differences 9.5 Education, Mean ForeignYr. * ‘ Months 1” Hospital Born 67% 24% 16% x2= 12.0 6.5 12.3 13.2 Mean or 1 '50 § 19.6 § * 10.1 1 t to 5 vs. to 5 vs. more to 9173. more 1 § 0.9 Education, Mean Yr. ForeignBorn 11-4 11-7 12.4 29-1 24-8 30% 16% 8% x2=5.4 istic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There to 9 10 or 6 1.6 12.4 10 ences * Mean Differences 141* 0.3 * 1,0 18.4 or 10.8 4.3 0.7 a definite, almost linear, relationship be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the Wide variability within each group, however, only the factor of age reached a level of statistical significance. Education also sig— nificantly differentiated the groups when dichotomized according to- those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS fied according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were character— Mean Difier- P=0.001. . - . . . 4.—Duration 0f Hospitalization in Patients Classified According to Diagnosis Diagnosis Involutional psychosis ___________________ Manic-depressive psychosis .............. Months in Hospital F Score, Mean 1-5 6-9 58.2 150.9 10+ 1—5 6-9 10+ ........................... 1-5 6-9 10+ ............................ 1-5 10+ Kahn et al. 432 Differences * Psychoneurosis 40-2 38-6 27-8 Mean OHCES 6.7 Mean Yr. 26 Mean Difler5.8 F Score, Mean 33 43 5 Age, 1 P<0.05. P<0.02. P<0.01. P<0.001. TABLE N 0- to 9 or more 6 10 6 10.7 Schizophrenia of Hospitalization: Patients Receiving Psychotherapy Only 1 23.3 10 Mean Yr. 51.7 42.2 32.1 Mean Difier1 Age, TABLE 3.———Dnration Age, Mean Yr. Education, Mean Yr. Foreign-Born 35.0 58.8 54.5 52.3 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 8.7 12.5 27.1 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 7.1 9.6 57% 43% 0 0 10% 8% 12% 39/567 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE 5.—Discharge Evaluation No. Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 17 ' 82 63 9 F Score, Mean Mean Yr. Education, Mean Yr. 42.9 39.0 36.1 31.1 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 Mean Mean Differences M ean Differences Recovered vs. Much Improved _____________________________ Recovered vs. Improved Recovered vs. Unimproved Much Improved vs. Improved Much Improved vs. Unimproved Improved vs. Uni mproved 3.9 6.8 11.8 2.9 7.9 5.0 .................................... ................................. ............................. ........................... ................................. Age, 8.9 13.3 * 13.4 * 4.4 4.5 0.1 T Foreign-Born 41% 22% 16% 11% x2=6.1 Differences I 0.5 0.5 2.5 0.0 2.0 2.0 ‘ P<0.05. t P<0.02. 3 P<0.01. years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By x2—analysis these results were significant at the 5% level of confidence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensified (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically significant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE relation of sociopsychological factors to diagnosis is shown in Table 8. Those patients classified as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classified as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. 3. Diagnosis.‘—The Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving C onvnlsive Therapy Evaluation No. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Foreign-Born 51.6 43.8 32.3 9.4 10.6 12.3 50% 35% 17% x '=3.5 Mean Differences Recovered vs. much improved ______________________________ Recovered ”8. improved and unimproved ____________________ Much improved vs. improved and unimproved _____________ Mean Yr. Education, Mean Yr. Age, 11.3 13.4 " 2.1 Mean Mean Differences 7.8 19.3 I 11.5 T 1.2 2.9 1.7 Differences * ‘ P<0.05. P<0.02. 1 P<0.001. 1 30/568 Vat. 1, Dee, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.—Discharge Evaluation in Patients Receiving Psychotherapy Only N0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 9 54 39 F Score, Mean 32-6 38.1 33.5 Mean Diflerences .............................. ................... ............. Recovered vs. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also signifi— cantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such re— sults were obtained in a survey of private practitioners, as in the Weinstock report?9 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Diagnosis N 0. Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 .................. ForeigmBorn 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% Mean Differences 6.0 6.3 0.3 x '= 1.8 Mean Difierences 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important be— cause they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the influence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist—pa— tient interaction. Current data both from this laboratory 14 and from others 19'24'27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8.—Diagnosis F Score, Mean Mean Yr. 52.3 40.8 36.9 32.8 56.7 41.9 29.4 26.1 Mean Mean Differences Involutional vs. Manic-depressive psychosis ________________ Involutional psychosis vs. psychoneurosis Involutional vs. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia _______________ Psychoneurosis us. schizophrenia___________________________ Mean Yr. Education, Mean Yr. Age, 11.5 15.4 19.5 3.9 8.0 4.1 I i § ’r Age, Education, Mean Yr. 8.9 11.5 11.9 12.7 Differences 14.8 27.3 30.6 12.5 15.8 3.1 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 § § § § 46% 26% 22% 10% x==14,2 r Mean Differences § Foreign-Born P<0.05. T P<0.02. I P<0.01. § P<0.001. * K ahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the, hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the particular function and philosophy of the insti— tution. In studies of outpatient clinics ' Which have a psychoanalytic orientation 2438 it has been observed that persons from the higher social classes, determined by education' or income, are treated for a longer period. In contrast, in state mental hos— pitals, patients with/the least education are kept longer and form a higher proportion of the chronically hospitalized group‘.6'17"23 The state—hospital therapist, Viewing the in— Stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients “who come from a background most like his own. The observation of the relation between sociopsycholo-gical factdrs and improvement rating, particularly in those patients receiv— ing convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for the;older, lesseducated pa— tients than he does for the younger, more sophisticated ones. In the patient with littlr education and with modes of expression different fromhis own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. _ 32/570 Thus, the rating of recovered is defined at Hillside Hospital as “the 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.” 11 The therapist’s perception of the patient’s premorbid functioning may be influenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For example, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratification, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical significance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convulsive group. The outpatient study by Rosenthal and Frank 28 also failed to find a relation between social factors and improvement rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willingness to attend treatment after he had been accepted. The marked relationship between socio~ psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connotation. Landis and Page,19 in 1938, stated that age was the “most important single deterVol. 1, Dec., 19.59 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of first admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the present study, however, we have also shown that education, place of birth, and F score significantly differentiate the major diagnostic groups in the hospital. In view of these findings, we have postulated that a psychiatric diagnosis is not just a one—to—one reflection of a specific type of behavior pattern but is also a value judg— ment in terms of social interaction. Thus, both in our own studies and in the work of others 12 it has been noted that patients with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating sociopsychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower—class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argument. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found significant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, com— pliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were diffi— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan— '22 noted that hospitalized schizophrenic son patients exhibited significant social-class difference in symptomatology. Lower—class patients showed a predominance of “mo— toric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich 12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt that the lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general population."-”4'8'10 This de— crease, in our View, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 2‘6 has reported inhibited sexually.”6 Rees that those British soldiers who had hysteri— cal symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cata— leptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difficult to find today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with depressive psychoses, we have frequently noted a pattern of premorbid behavior char— acterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other .authors.3’5"”'21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that While the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the specific findings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle—class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa~' tient is said to be “hostile” or “resisting psychotherapy” may reflect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful—oriented therapeutic approach a difficult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Significant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more educated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were significantly related to age, the older Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT . patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psycho— neurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classified under involu— tional or manic-depressive psychosis. It is postulated that these relationships reflect the influence of social background on psychological processes, such as the habitual patterns of communication, modes of eXpression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel—Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. Arieti, S.: The Decline of Manic—Depressive Psychosis: Its Significance in the Light of Dynamic and Social Psychiatry, paper read at 113th Annual Meeting of American Psychiatric Association, Chicago, 1957. 3. Arnot, R.: The Predepressed Personality, AMA. Arch. Neurol. & Psychiat. 762617—618, 1. 1956. 4. Chodoff, P.: A Re-examination of Some Aspects of Conversion Hysteria, Psychiatry 17: 75-81, 1954. E; Baker, R; Cohen, R. A.; Fromm-Reichmann, F., and Weigert, E.: An In— tensive Study of 12 Cases of Manic—Depressive Psychosis, Psychiatry 17:103-137, 1954. 6. Dunham, H. W., and Meltzer, B. N.: Predicting Length of Hospitalization of Mental Patients, Am. J. Sociol. 52:123—131, 1946. 7. Freyhan, F. A.: The Impact of Somatic Therapies on Course and Clinical Profile of the Schizophrenias, J. Clin. & Exper. Psychopath. 19: 5. Cohen, M. 195-201, 1958. Frumkin, R. M.: Occupation and Major Mental Disorders, in Mental Health and Mental 8. Kalm et al. Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136-160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199-209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty—Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. N europsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a. Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, H.; Israel, R. H., and JohnsonpN. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Office, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.: Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, I. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hos— pital, edited by M. Greenblatt, D. I. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psy— chiatric Study, Psychosom. Med. 3:410-426, 1941. 22. Miller, D. R., and Swanson, (3.: Defense Against Conflict and Social Background, paper 15. 35/573 V �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, 1953. 23. Morgan, N. C., and Johnson, N. Disorder, New York, Milbank Memorial Fund, 1950, pp. 51-52. 27. Robinson, H. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Treatment, Am. J. Orthopsychiat. 24:307-316, A.: Failures in Psychiatry: The Chronic Hospital Patient, Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127:330— L.: Ethnic I.: Report of the Central 307-310, 1954. 25. Opler, M. K., and Singer, J. Differences Internat. J. 26. Rees, Gruenberg, 36/574 in Behavior and Psychopathology, Soc. Psychiat 2:11—22, 1956. J. R.: in discussion on paper by E. M., in Epidemiology of Mental Printed and Published 1954. 28. Rosenthal, D., and 343, 1958. 29. Weinstock, H. Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathologi— cal Association, New York, 1958. Fact—Gathering in the United States of Amerm �a. "—1 “‘1 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** __..1 Fl l I J2 P ] �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen L.I. Oaks, New York, 1959—1962. The cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. ' " Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, York MIP 10467. New York, New ** Present Address: Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** Present Address: National Institute of Mental Health, 2/1/65 Bethesda, Maryland �their studies of the psychiatric patient popsignificant relationships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2)9 The influence of the economic status of the patient on the availability of treating personnel, however, was not excludedo ulation, In New Haven Hollingshead and Redlich have reported Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paya In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i429, greater stereotypy, were often fOund in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredg it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospitala To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions Hillside In the survey reported here, —w F. Menninger Memorial Hospital in Topeka and the Hospital, the Massachusetts Mental Health Center in Boston, These institutions were selected with the expectation that they had diverse treatment modalities C. equally available, yet served patients of different social classeso Each provided short—term treatment of voluntary patients and did not provide custodial careo Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho- analytically—oriented psychotherapyo This study was designed to determine the population characterof the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, istics �METHOD A census of institutions all voluntary, adult patients in residence in in January, 1959. While Menninger and patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status. The California F scale was scored for each patient on the census the was undertaken Hillside Hospitals had voluntary day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation - was used (3,4,7). The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends. These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample Sizes. �RESULTS A. Methodological Problems When of the hospital reporting studies tioned briefly. from one institution, the structure be taken for granted and either ignored or men— In gathering comparable data from multiple institu— may tions, however, the many differences between institutions are accen- tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. 1. Designation of Type of Treatment: designating that the institutions, a The criteria for patient received "psychotherapy" differed making comparisons difficult. among Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychia— trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. At Menninger At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was Individual institutional diagnostic styles At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a 2. Diagnosis: made comparisons source of difficult. distortion. �Table I 30 Discharge Ratings of Improvement: Ratings of imw provement at the three hOSpitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings.making it difficult to assess the contribution of each factor of the Menninger system (Table II), For this study the Menninger syndrome rating was compared to the global ratings of the other institutions, Table B. II Inter—hospital Comparison lo Sociopsycholqgical Variables The distribution of the variables of social class, age, among the three institutions education and California F Scale score is presented in Table III. Table III . a) Social Class: The anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age distribution in the institutional populationso �populations also differed in edu_” more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo c) Education: The cational attainment, with patients having d) F Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight perm cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy, In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 309 Thus, differences in social class, educational attainment and performance on the F Scale were observed. These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c b) Duration of Hospitalization: The three insti~ tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two—thirds of the patients were discharged within six months of hospitalizatione MMHC 1,—— c) Discharge Evaluation: In each hospital, most were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"a The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachu— patients setts Mental Health Centera d) nostic groupings Diagnosis: For statistical analysis three diagwere made: schizophrenia, affective disorders, and �psychoneurosis and personality disorders (Table IV)» The diag~ nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one~quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perucent of the populationo Table Co IV Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier studyg Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The — Table V �-7DISCUSSION The patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var~ duration of hospitalization, selection of treatments iables and distributions of diagnoses and discharge evaluations (7), Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions“ Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower preportions of psychoneurotic diagnoses, and the better discharge evaluations, —— It is our impression that these differences in psymore to differences in staff attitudes and social class variables than psychiatric differences in populations, The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl~ istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. chiatric treatment are related Such population and treatment variable relationships interactive are processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presente Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i£§,, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersw Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothero Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. In our initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background° It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would clearly defined. But differences in institutional style made to obtain comparable data. This experience is a cue difficult it to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationsc These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative resultsa Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction, be �-10_ SUMMARY AND CONCLUSION Population characteristics, defined by social class, and F score, were related to treatment variables education age, in three voluntary teaching hospitals. Treatment variables in~ cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationo Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso a-Similarly, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of The institutions were psychoneurotic diagnoses, and the better discharge evaluations, These variations in psychiatric practices followed a with the social class differences among the inconsistent pattern and are not regarded as idiosyncratic. stitutions Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula- tions is emphasizedo �REFERENCES 1. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. J. and Sanford, R. N. The Authoritarian Personality. Harper and Brothers, New York, 1950, 990 pp. . and Redlich, F. C. Social Class and Community Study. John Wiley and Sons, Illness: New York, 1958, 442 pp. Hollingshead, Mental Inc., A. B. A . Kahn, R. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. . Kahn, R. L., Pollack, and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. Arch, Gen Psychiat., 1959, 15 565—574. M. Kahn, R. L., Pollack, M. and Fink, M. Social Attitude (Ca1— ifornia F Scale) and Convulsive Therapy. J4_Akuabhlkuugkjlui., 1960, lfiQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amari_Jm_EfixnhiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �III TABLE InterhospitaI Comparisons for Sociopsychological Variables Menninger Hillside N (87) (133) 1 31% 7% Hospital Social Class Massachusetts Mental Health Center Hospital (72) 3% 11 51 20 28 III 17 34 13 , 1v 1 34 28 v 0 5 28 x2 = 121.5; df=8: p:<.001 Age N (100) (173) ”(95) < 20 19% 19% 15% 20—39 59 ‘58 52 40 + 22 23 33 : x2 = =~ 32% 41% 12-15 54 51 49 16+ 23 17 10 7 = (91) 9.7; df=4; p<.05 (92) (163) (7%) 10-29 51% 33% 20% 30—49 41 50 38 8 17 42 N s °°re “—— 23% x2 F —= (173) -<12 Education -——'———“:=;= (100) N Years of 3.9; df=4; p=n.s. 50—70 1 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hillside (100) (173) Hospital N Type of Psychotherapy Treatment Somatic Other X2 = Duration 0? Hospital— lzat1°n Hospital Massachusett Mental Health Center (89) 21% 36% 24% 43 64 68 36 —- 8 82.8; df=4; p(.001 N (100), (173) (95) *7 months 22% 27% 67% 13 42 27 65 31 5 7—11 months 511 months Xzf 90.6; df=4' p<.001 N Recovered, Much Improved Discharge Evaluation Improved Unimproved XZ'= N Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder x2 = (99) (172) (88) 1% 23% 28% 80 62 61 19 15 10 29.3; df=4; p<.001 (95) (171) 4185) 43% 52% 54% 5 22 17 52 26 29 23.8; df=4; p<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age. Menninger Hillside 81 42 20-29 73 36 30-39 61 3O 40—49 30 20 50+ 36 Below 20 MMHC l4 �� 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 Sociopsychologic aspects of psychiatric treatment in a voluntary mental hospital: duration of hospitalization, discharge ratings, and diagnosis. AMA Arch Gen Psychiatry. 1959 Dec;1:565-74. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-42-008 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 Kahn, Robert L.; Pollack, Max; <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 General Psychiatry December 1959, Vol. 1. pp. 565—574 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/d30b69ef69a8cf00c194481df0db03be.pdf 468179c0544d033b07449c4407b71b92 PDF Text Text Reprinted from THE JOURNAL OF Volume 130, NERvots AND MENTAL DIsEAsE No. 3, March 1960 Printed in (ISA. SOCIAL ATTITUDE (CALIFORNIA F SCALE) AND CONVULSIVE THERAPY ROBERT L. KAHN, PH.D.,1 MAX POLLACK, PH.D. . ,\— AND MAX FINK, M.D. improved was most likely in those who were Studies of the mode of action of convulsive therapy in altering behavior have been under investigation by a variety of experimental methods in our laboratory for several years. Early studies demonstrated a relationship between clinical evaluations of improvement and the degree of altered brain function as measured by the amobarbital test (15) and the electroencephalogram (5). Personality patterns related to a favorable therapeutic outcome have been defined by family interviews (13) and projective techniques (14). Behavioral changes have been measured by complex visual and tactile perceptual tasks (6) and by analyses of changes in syntactical aspects of language (12). More recently we have become increasingly aware of the relation of sociopsycho— logical factors to differences in both referral for, and response to, convulsive therapy. In a study of the entire adult iii-patient population of Hillside Hospital it was found that those patients referred for convulsive therapy were significantly older, more likely to have been foreign-born, had less education and higher scores on the California F Scale than those patients who received psychotherapy alone (17). Of those patients receiving convulsive therapy, a favorable therapeutic evaluation of recovered or much older, more poorly educated, foreign—born and with higher F scores (18). The aim of the present investigations was to study the convulsive therapy process further by the use of the California F Scale (1). Although promulgated in a setting where interest was focused on prejudice and au— thoritarianism, the F Scale was designed to evaluate psychological aspects, such as con— ventionalism, rigidity and stereotypy, related to the manifestation of these social attitudes. It was our specific purpose to determine: 1) what the F Scale measures in a psychiatric population, and 2) how response to the F Scale varies with change in brain function. METHOD Population: These studies have been conducted at Hillside Hospital, a private, nonprofit 200-bed psychiatric hospital in New York City admitting voluntary patients with “early and curable mental illness.” Psychoanalytically—oriented psychotherapy is the treatment of choice for all patients, with somatic therapies (convulsive, insulin coma and drug therapies) regarded as ancillary, but available when needed. The in—patient population consists mainly of middle-class Jewish patients, with a high school education. between the ages of 18 and 40. Most patients are classified into the diagnostic categories of schizophrenia, psychoneurosis, manic-depressive and involutional psychosis. In these studies we have used a ten-item modification of the standard F Scale (8). Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. This investigation was supported in part by grants M-927 and MYw2092 from the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. This paper derives from a presentation given at the Annual Meeting of the Eastern Psychological Association, Philadelphia, 1 April, 1958. 187 �188 KAHN, POLLACK AND FINK TABLE 1 Scores on Conventional and “Reverse” F Scales Dichoto— (grilled I‘OU p S M chzi: iN Cpnv erll— iona Scale hi3: ‘Reverse”' _ Diff. t 51.5 48.1 +25.2 +0.7 20.3* : Scale I 10—37 38—70 * 79' Significanti _ at .001 0.6 level The procedure consists of having the subject read ten statements and indicating to what extent he agrees or disagrees with each, i.e. a little, pretty much, or very much. The score for each item ranges from one to seven, and the total score range is 10 to 70, with high scores indicating greater agreement with the statements. The statements are extreme, uncritical or stereotyped expres— sions, such as: “No sane, normal, decent person would ever think of hurting a close friend or relative” and “If people would talk less and work more, everybody would be better off.” RESULTS ment with the statements. In contrast, the patients who made high scores initially showed little change on retesting, indicating that they agreed with the statements to the same extent even when their meanings were reversed. Change in F Score with convulsive therapy. In a second study, 69 consecutive hospitalized patients referred for convulsive therapy were given the F Scale in the week prior to treatment, on the day following the 12th treatment, and two weeks after the termination of treatment. These patients were divided into two groups; an experimental group of 59, and a control group of ten patients randomly selected from the referrals. In the experimental group all patients received grand mal convulsive therapy, while the control group received subconvulsive electro-stimulation only. All patients were treated three times a week, for a minimum of 12 treatments. The degree of physiologic change during treatment was determined by quantitative analyses of delta activity in the EEG, using techniques previously described (5). EEG records were obtained weekly and the records taken nearest the 12th treatment were measured for the degree of induced slow wave activity (the per cent time occupied by waves of 6 cps or slower for 66 seconds of recording from the anterior temporal—vertex leads). The changes in F score during convulsive treatment are shown in Table 2. There was a mean increase of +5.7 in F score during What the F Scale measures in this population: the “reverse” F Scale. In this study the entire in-patient population was first tested with the conventional scale, then retested one month later with a “reverse” scale (2). In the “reverse” scale the same items are used, but stated in opposite terms to the original. Thus, the first example cited above is changed to read, “A sane, normal, decent person might have to hurt a close friend or relative.” The “reverse” scale is scored in the same manner as the regular scale, with TABLE 2 Efiect of Convulsive Treatment on F Score high scores reflecting greater agreement. The relation of the scores on the convenMean F Score tional to the “reverse” scales is shown in N PreTable 1. The patients were divided into two Mean During t Treatment Difference 22:? the to median groups according score on the conventional scale. Those patients who made Convulsive 59 45.3 51.0 2.02* +5.7 low scores initially, indicating predominant Group 10 48.7 disagreement with the statements, showed a Control 49.2 +0.5 0.02 Group significant increase in score on the “reverse” * scale, indicating that they were now in agreeSignificant at .05 level �189 SOCIAL ATTITUDE AND ECT treatment, a difference significant at the five the of confidence. In level cent contrast, per control group showed a statistically insignificant change during the same period. The effect of convulsive therapy on the F score was further demonstrated by an analysis of seven patients, originally in the control group, who were subsequently placed on a regular course of convulsive therapy. On retest after 12 control treatments their scores were unchanged, with a mean difference from the pretreatment score of +0.1. After 12 convulsive treatments, however, these patients showed a significant mean increase of +9.1. Adequate EEG records at the time of the 12th treatment were obtained for 54 patients. For this analysis the records were divided into two groups according to the degree of slow wave activity: a high delta index group in whom slow wave activity appeared in 40 per cent or more of the selected leads, and a low delta index group in whom the slow wave activity was less than 40 per cent. Changes in F scores during treat— ment for the two groups are shown in Table 3. TABLE 3 Change in F Score and Degree of Induced Cerebral Dysfunction Mean Treatment Treatment Difference Pre- During 27 43.9 52.5 +8.6 23* 27 45.6 49.0 +3.4 0.8 Degree of Slow Wave Activity High Delta Index Low Delta Index * 15 Significant at .05 level The patients with high degrees of slow wave activity had a mean increase in F score of +8.6, significant at the five per cent level of confidence. Those patients with low delta indices showed a relatively small increase of +3.4. While the increase in scores in the low delta activity group was statistically insignificant, it was greater than that of the control group (Table 2). TABLE 4 Pre-Treatment and Post—Treatment F Scores Pre— Post— 21 42.2 40.6 —1.6 0.4 16 42.6 42.1 —0.5 0.1 N High Delta Index Low Delta Index .Mean Treatment Treatment Diflerence I F scores were obtained in 44 patients two weeks after the last treatment (Table 4). The mean difference between pre— and posttreatment scores was statistically insignificant. Furthermore, the same pattern of a small decrease in score was found for both the high and low delta activity groups. DISCUSSION These observations demonstrate the relevance of the F Scale to the convulsive ther— of these An understanding apy process. relationships requires examination of the psychological factors reflected by the F Scale in our population. The observations on the “reverse” F Scale indicate that those patients who disagreed with the original statements (low F score) were responding to the content of the state— ments. This was shown by the high degree of agreement with the reverse statements. Those patients who agreed with the original statements (high F score), however, continued to agree when the statements were reversed. Evidently, these patients were not responding to the content of the statements, but demonstrated a more generalized reac— tion. There have been several studies on non— psychiatric populations using a “reverse” F Scale, with conflicting results. Thus, Chris— tie, Havel and Seidenberg (3) have found a consistent response to content in original and reverse scales, e.g., agreeing to one and disagreeing with the other, while Jackson, Messick and Solley (10) report a positive correlation between agreement on the two scales. In part, these differences may be accounted for by differences in the form of the reversed �190 KAHN, POLLACK AND FINK scale. Jackson and Messick (9) indicated that Christie ct al. (3) modified the language form of the original scale and reversed the content, while Jackson et al. (10) retained the extreme, cliché—ridden style of the origi— nal scale. Jackson and Messick indicate that the response pattern to the F Scale may be interpreted in terms of response style rather than specific item content. On the basis of the data from our population there is a difference between the high and low scorers with respect to the extent that cognitive style affects their response. The high scorers who agree with both forms of the scale show a consistent style of response acquiescence, overgeneralization and conforming to so— cially desirable standards. Those who scored low on the original scale, however, did not show the converse—a consistent pattern of negativism or social non-conformity. Rather, they altered their style to agree with the con— tent when the statements were reversed. Thus, low F score patients were characteristically more critical and discriminating persons, While those with high F scores were more undifferentiating and stereotyped in their reactions. With this conception of the F Scale, the findings in convulsive therapy may be considered. In the selection of treatment in this institution, those patients receiving convul— sive therapy had significantly higher scores than those receiving psychotherapy only (17). That this observation is not simply a reflection of diagnosis is seen in the differentiation by the F score of the selection of treatment even among those patients classi— fied as psychotic depression. The selection of treatment thus seems related to psycho— logical processes reflected in the F Scale. Subjects with high F scores, with stereotypy of thinking and difficulty in introspection, often present a behavioral pattern incompatible with the establishment of the type of interpersonal relationships required in psychoanalytically-oriented psychotherapy. The favorable evaluations of therapeutic response to convulsive therapy in patients with high F scores may be related to personality attributes. The psychological processes reflected in the F Scale are similar to those personality factors previously found to be related to a favorable response to such treatment. In structured family interviews it was observed that the favorably rated patients had personality patterns characterized as nonempathic, nonintrospective, nonverbally communicative, and highly conventional and stereotyped, with little imagi— native or creative capacity (13). Consistent patterns have been shown in Rorschach studies indicating that good prognosis is re— lated to a small number of responses, absence of human movement and little diversification of content (7, 14). The F score increases significantly with convulsive therapy with the extent of in— crease related to the degree of altered brain function, as measured by the degree of induced EEG slow wave activity. This relation of change in behavior to physiological change is an observation that has been consistently noted in convulsive therapy patients (5). The increase in F score during treatment may have been even more marked than actually observed. Several patients of foreign birth and little education had maximum or near maximum scores prior to treatment, thus eliminating or reducing the possibility of an increase on retesting. The change in score with altered brain function is consistent with previous observations on the behavioral effects of convulsive therapy. In accord with our conceptual framework, greater agreement with F Scale items during treatment is related to increased stereotypy and difficulty in discrimination, as well as to increased acquiescence. This is part of a general process which has been noted in linguistic, perceptual and clinical behavioral measures. In their language, convulsive therapy patients show increased denial, evasion, qualification and use of clichés and stereotyped expressions �SOCIAL ATTITUDE AND ECT (12). They also manifest increased repetitiveness of words (11), difficulty in complex visual and tactile perception (6) and figureground discrimination (16). Clinically, they are characteristically more compliant and acquiescent and try to please the examiner (4). SUMMARY A measure of social attitude, the California F Scale, has been utilized in studies of the convulsive therapy process. In a voluntary psychiatric hospital it was noted that patients referred for convulsive therapy had significantly higher F scores than those re— ceiving psychotherapy only. Among the patients receiving convulsive therapy, those with the higher initial F scores were evalu— ated as showing the best clinical results. With treatment there was a significant increase in F score, with the increase related to the degree of altered brain function. Follow— ing treatment the scores returned to their original level. Comparison of results with a conventional and “reverse” F Scale demonstrated that patients with low F scores respond to the content of the questionnaire, while those with high F scores showed a generalized of the con— of independent agreement pattern tent. These results are interpreted in terms of the psychological processes measured by the F Scale. High—scoring patients are considered to be stereotyped in their thinking and to have difficulty in introspection—behavior which is incompatible with psychoanalytically-oriented psychotherapy, rendering them more liable to referral for convulsive therapy. With treatment, such patients are also more likely to develop the language patterns of denial and use of clichés which are the cues for evaluations of clinical improvement. The increase in F score with treatment is comparable to other types of behavioral change, such as increased acquiesin figure-ground increased difficulty cence, 191 discrimination, and increased stereotypy of language. REFERENCES 1. ADORNO, T. W. ET AL. The Authoritarian Personality. Harper, New York, 1950. 2. BAss, B. M. Authoritarianism or acquiescence? J. Abnorm. & Social Psychol., 51: 611—623, 1955. 3. CHRISTIE, R., HAVEL, J. AND SEIDENBERG, B. Is the F Scale irreversible? J. Abnorm. & Social Psychol., 56: 143—159, 1958. 4. FINK, M. AND KAHN, R. L. Behavioral patterns in induced states of altered brain function. Paper read at Divisional Meeting, Am. Psychiat. Ass., New York, November, 1957. 5. FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock: quantitative serial studies. AMA Arch. Neurol. & Psychiat., 78: 516—525, 1957. M., KAHN, R. L. AND KORIN, H. Effects of diffuse altered brain function on perception. Internat. Congr. Psychol, Proc., 15: 6. FINK, 238—239, 1959. 7. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to con— vulsive therapy. J. Nerv. & Ment. Dis, 128: 243—248, 1959. J. AND ERLICH, I. Some sociopsychological characteristics of patients and their relevance for psychiatric treatment. In The Patient and the Mental Hospital, Greenblatt, M., Levinson, D. J. and Williams, R. H., eds., pp. 357—379. Free Press, Glencoe, 111., 1957. 9. JACKSON, D. N. AND MEssroK, S. J. Content and style in personality assessment. Psychol. Bull., 55: 243—252, 1958. 10. JACKSON, D. N., MESSICK, S. J. AND SOLLEY, C. M. How “rigid” is the authoritarian? J. Abnorm. & Social Psychol., 54: 137—140, 8. GALLAGHER, E. B., LEVINSON, D. 1957. J., FINK, M. AND KAHN, R. L. Com— munication patterns with altered brain function. J. Nerv. & Ment. Dis., 130: 235—239, 11. JAFFE, 1960. 12. KAHN, R. L. AND FINK, M. Changes in language during electroshock therapy. In Psy— chopathology of Communication, Hoch, P. and Zubin, J., eds., pp. 126—319. Grune & Strat— ton, New York, 1958. 13. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock therapy. J. Neuropsychiat., 1: 45—49, 1959. 14. KAHN, R. L. AND FINK, M. Prognostic value of Rorschach criteria in clinical response to convulsive therapy. J. Neuropsychiat. In press. 15. KAHN, R. L., FINK, M. AND WEINSTEIN, E. A. Relation of amobarbital test to clinical im- �192 KAHN, POLLACK AND FINK provement in electroshock. A.M.A. Arch. Neurol. & Psychiat., 76: 23—29, 1956. 16. KAHN, R. L., POLLACK, M. AND ure—ground discrimination FINK, M. Fig— after induced altered brain function. A.M.A. Arch. Neurol. In press. 17. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a vol— untary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. 18. KAHN, R. L., POLLACK, M. AND FINK, M. Sociopsychological aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 1: 565—574, 1959. , �Social Attitude (Californin 3 Scale) and convulsivo Ihornpy Robort L.Kahn Ph.n., Kn: Polluek Ph.D. and flux rink H.D. Dcpurtnont a! Experimentnl Psychiatry, Hillside Hospital, 61"! 0.1(3' litre, 3.1. ~ IX; 11/10/59 �mu. 1: part, at t» mun run-hum. tannins“. nuuczym, April, ”58. 3*91‘1 1» try at “.2092 «a put. at um, an” “tuna menu» a: mm mu. “an“ Influx“: of Inn“. was. ”In.“ mm: aunt“. �3.3111 Attitude and E0! �Boeial Attitude (Galifornia I Scale) and Convnleive Therapy Studies of the node of action of convulsive therapy in altering behavior have been under investigation by a variety of experimental methods in our laboratory for several years. Early studies demonstrated a relationship between clinical evaluations of inproveaent and the degree of altered brain function as measured by the aaobarbital test (12) and the electroencephalogram (h). Personality patterns related to a favorable therapeutic outeone have been defined by fanily interviews (13) and projective techniques (15). Behavioral changes have been neasured by eeaplex visual and tactile perceptual tasks (6) and by analyses of changes in syntactical aspects of language (16). recently we have become increasingly aware of the relation of seeiopsyehelegieal factors to differences in both referral for, and response to, convulsive therapy. In a study of the entire adult in-patient population of Hillside hospital it was found that these patients referred for convulsive therapy were significantly older, more likely to have been foreign-born, had less education and higher scores on the Californi I Scale than these patients who received psychotherapy alone (17). Of those patients receiving convulsive therapy, a favorable therapeutic evaluation of recovered er much iapreved was nest likely in those who were older, aore poorly educated, foreign-born and with higher 7 scores (18). Here �1h. 31: 0: ts. pr.nunt tavcnttanttonl.wun to turtle: 'utniy tho convulntvo thorny: pronoun h: £3. at. or «p. 6.113.231: r Saul. (1). Althotgh prcanllt‘nd 1: a cutting white tn‘iroat at: located an prtandicc tad luthnrttnrtanxln, tho I Ital. wt: d-utgnod to it‘lxuto paychcloginnl napocto, such a: convontilnlltun, rigidity and Itarcnfiyyy, rclutcd to thy n;nt£cn#n$t¢n a: tin:- :0aiul attitudes. I It wan OI! apuctltc ptrpnna to how und 2) pnychtatrta poyuzntiou, t acaln 1.210: with Chllg! in brain function. 83:19 acanurul 13 rtiptnao $0 it. I naturist. 1) tint tho �KBIEOD: Pepnlationt These studies have been conducted at hillside Hospital, a private, nanoprerit 200 bed psychiatric hospital in New York City adaitting relentary patients with Iearly and enrahle aental illness". rPsyeheanalytiosllyu oriented psychotherapy is the treatment of choice for all (convulsive, with senatie therapies patients, insulin cans and drug therapies) regarded as ancillary, but available when needed. The in-patient populatien epneiste mainly of niddleclass Jewish patients, with a high school education, between the ages of 18 and ho. Most patients are classified into the diagnostic categories of schieophrenia, psychonenrosis, manicdepressive and invelntienal psychosis. In these studies we have need a ten its: aeditieation e! the standard scale (8). The procedure consists of having the subject read ten stateaents and indicating te‘Whet extent he agrees or disagrees with each, i.e. a little, pretty each, or very such. The score for each item ranges tron one to seven, and the tetal sears range is 10 to 70, with high scores indicating greater asreenent with the otatenents. The statenente are extreme, uncritical er stereotyped expressions, such as: "No sane,neraal, deeent person would ever think or hurting a close friend or relative‘ and "If people would talk less and work acre, everybody would be better air.” �RESELISs the 1 Scale Heaenree in our Po nlatione The i'ne'nn-ae'“ F Scale In this stat: the entire in-patient population was tiret tested with the contentional eeale, then reteeted one nenth later with a 'reveree' eeib (2). 'In the "reverse" scale the sane items were need, but stated in opposite terms to the original. Thus the liret example cited above was ohanged to read, ”A aane, normal, decent person night have to hurt a The close friend or relative." 9reverse'eea1e was scored in the eane manner as the regular scale, with high score: reflecting What greater agreement. the relation of the eeoree on the conventional to the “reverse“ eealee 1e ehovn in table I. The patienta were divided into two group: according to the nedian aoore en the conventional eeele. Those patiente who node low eeeree initially, indicating predoninant dieagraeaent with the etatenente, ehoved a significant innfeaae in score on the 'reveree“ scale, indicating that they were not in agreement with the statements. In contrast, the patients who aade high eeoree initially showed little change on retenting, indieating that they agreed with the etatenente to the sane extent even when their meanings were reversed. -u-abfiooogqfi‘mmn—tun‘m Table I about here Dun-Qn-uueembebuufiua-Oepn. �TABLE I Scar-a on Conventional and 'Rovorao' Dichotonisod Graugs Kcan Scorn conventional Soul. ~!_ I fiction noun Score “levcrao' Se&lo Dirt. .£_ 20.3‘ 10-37 76 26.3 51.5 +25. 2 36.70 79 h7.h h8.1 + ”Signitietnt at .001 luvol 0.7 0.6 �.5- I score with cenvuleive theregz. In e eeoond etody, 69 eoneeoutive heepitelieed petiente referred for eonvnleive therepy were given the r seele in the week prior-to treetwent, on the dey following the 12th treetwent, end two weeke etter the terninetion er treeteent. Theee pdiente were divided into two groupe,en experimentel group of 59, end I control group or ten petiente tenderly selected from the reterrelea In the experieentel group e11 petiente reeeived greed eel oeuvuleive therepy, while the control group received enbeonvuleive electro-etieuletien only. All petiente were treeted three tieee e week, for e nininne Change e1 12 in treeteente. , physiologic ohenge during ‘lreetnent wee deterrined by queutitetive enelyeee of delta eotivity in the EEG, neing teehniquee previoneh deeerihed (h). EEG reoorde were ebteined weekly end the reeerde token neereet the 12th treetnent were neeeered for the degree of induced elow were 6 wevee o: by cent ocoopied ope or (the tine eetivity per elewer for 66 eeeonde of recording from the enterior tenperelvertex leede). The ehengee in r eeore during oonvuleive treetnent ere ehewn in Tehb 2. There wee e ween increeee of +5.? in r eeore during treetwent, e difference eignificent et the 55 level of confidence. In contreet, the control group ehowed e etetietieelly iheighitioent chenge during the eeee period. The degree of �.6. it. attics if nouvnlntvt thorny, an in. r atnvn vat tnrihur dcnouatrafiua by a: ina1ruaa if aovoa pattcltug' originallyjtn the nautrll crux», vi. wart t‘§u¢.u¢ut11 plant: ffltfififi 33%.: an «mutilatvu of neuron $hurtyy. rcculur a a: 13 anntral trunthaut: that: Iqurca utrn tuuhauucu. ‘1‘» a mans ditftruuao :tcn tut protrcatunut tutti Q3 «9.1 errorn. Altar 12 nnuvulntvo trtatlcuta, fiauuvur, than. ptiiia‘t unavod :1mm». a: 09.1 anew. “want u» tibla 5h but. it. its. at tin 12th irontntat pflttflt‘fl. In! $htt tnnlyttn tho Instant Adogua§a BIB roaorda var. ubtntnoa tor a about 3% Itvtdndjin£o tut nauupo'nno.r¢ina ‘9 it. 1.33%. at Ilia var. ntilvltyu a high dixfic 13am: group‘tn ulna slaw unvrunttvtty Ip’cntod 1n ho: or nor. 0: ti. stlcutod Ionic. Qua a lll‘lfl‘fi ludax (ran; 1: that th. III! II'. nafilvtty u:Xcal than 801. Gianna. in I lifivflfl fl!rtll $2¢usnoat fur fit. in. groups .9. shut: in rabid 3. warn ‘ .C'OOUMfiOWQ‘fiQD‘OOO‘ Inhla 3 thont but. fl. “’.*“*Q*&.*QOOQQU In. ytfiiunta with high 4.3!!!! a: axon any! aattvity had n o: «8.é. significanfi tt tho 5! 10'01 at conttdtnnc. than. putianta with 10v 401‘: iadlceu uhluud lama ilerillt 1a 9 t¢¢ru �TABLE 2 Effect of Convulsivo Treatnent on r Score Raga P Saute 1 Pre~ treatnont During Treatment Convuluive Group 59 h5.3 51.0 control Group 10 h8.7 h9.2 ‘ Significant at .05 lovcl noun Difference 3 + 5.7 2.02* + 0.5 0.02 �TABLE 3 Chan 0 in r Scare and chroo or 31.u Huvc ctivit De roe o: Induood Cor-bral Pro» ‘g During front-out rroatnont D stunctioa noun Differenco t ligh molt. Index 27 h3.9 52.5 +8.6 2.3“ Lov'nolta Indox 27 h§.6 h9.0 +3.h 0.8 G Significnnt 1t .05 level �-1- relatively small inereuso of +3.h. Hhilo the increase in scores in the low delta nativity group was stutiatioally insignificant, it ran grout-r thtn that or the control a (table 2). 1 score: were abtainod in hh patient: two racks utter the 1tat troatnnnt (T‘ble h). The noun ditfcrnnec botvccn pro~ tad ponttruatncnt scorcs fill statistically insignifictnt. Furthermore, tho 5.30 puttsrn or a 3:111 door-nae 1n acor$gw found 1nd both the for high delta totittty group: v:a graup .--Q-‘-~-"-..-flfifi-.. Table h thout hora .‘..--*-‘Cfl-‘-‘-~‘-fl‘ �an: t Index Low Delta Indox ttrontncnt 1 Score: Prc~ Pout— Kean Trautnent Trontnent Difference 21 h2.2 h0.6 16 h2.6 h2.1 3| High Delta h ~1.6 «0.5 0.1 �DISGU8SION: These observations demonstrate the relevance of tho to the oonvnleivo therapy proooea. in understanding of theeo relationships requiroe oxanination of the payoholegioal factors reflected by the 7 Scale in our population. The obeorvationa on the reverse F scale indicatee that those pationte who diaagroed with the original etatonente (low r eoore) were responding to the content or the otatonente. Thie nae shown by the high degree or agreement with the rarer-o statoaente. However, thoee patiente who agreed with the original etatononto (high I eoere) continued to agree when the etatenente were revereed. Evidently, these patient: were not reephnding to the oontent e! the atatonente, but deaenatrated a noro generalised reaction. There have been several otudioo on nenpeyohiatrio populations neing a reverse I soelo, with conflicting reenlte. Thno, Christie, floral and Seidonberg (3) have found a coneiatont roeponeo to content in original and rovoreo ooaloe, o. ., agreeing to one and disagreeing with the other, while Jackson, Heeeiok and Selley (9) retort a positive correlation between agreement on the two eoalee. In part, theoe dittoronooe nay be accounted for by difference: in the tern of the rovoreod eoalo. Jackson and Heeeiok (10) indicated that Chrietie gt 3;. (3) modified the language fora of the original scale and reversed the content, while Jaokeon et a1. (9) retained the extreao, olioho1ridden etyle e: the original eoalo. Jackson and noeeick indicate that the reeponoo pattern to 7 Scale �«91- the 1 Scale nsy be interpreted in terne of response style rsther then specific item content. 0n the besis or the dots from our popnlsticn there is s difference between the high end low scores with respect to the extent thst cognitive style effects their response. the high scorers who egree with both ferns or the sonic lion s consistent style of response ecqniescsnoe, evergenerelisetien end contorning to secislly desireble stendsrds. Those who scored low on the originsi sosie, however, did not shoe the converse -. s consistent psttern or negotivisn or sociel nenvcentornity. they eltered their style to egree with the content when the ststononts were reversed. ‘Thns, low I score petients were cherscteristicsily nore critical snd.decrildnsting persons, while these with high I scores were norc nndittcrontieting end stereotyped in their resctione. With this conception of the r Seth, the findings in convulsive thorspy may be considered. In the selection or trectnent in this institntion, those psticnts receiving convulsive therapy had significantly higher scores then those recciving psychotherapy only (17). That this observs~ tion is not Just e reflection of diagnosis is seen in the dittorsntietion by the F score of the selection of trestnent oven snong those pstients clsssitied es psychotic depression. The selection of treatment than scone related to poyohologicsl processes reflected in the r Scale. Subjects with high I �-10. scores, with etereetypy of thinking end difficulty in introepectien, often preeent a behavioral pattern incompatible with the eatebliehaent of the type of interpereenal reletien~ ehipe required in peycheanalytically-eriented psychotherapy. The favorable evaluatiene of therapetic reopenee to eonvulaive therapy in patienta with high I acoree nay be related to pereenality attributee. The psychological prov eeeaee reflected in the I Scale are similar to those pereonality factors previeuely related to a favorable rcepenae to each treatment. In structured family intervieea it vat observed that the faverabl! rated patients had personality patterns characterised as neuenpathic, conintrespectivc, nenverbally eeamenicative, and highly conventional and stereotyped, with little nonnative or creative capacity (13). Genaistent patterns have been aheen in Rcrachaeh etudiee indielting that good prognosis in related to a small number of reepeneee, absence of human movement and little divereifieatien of content (15; 7). The F acere increecee significantly with cenvuleive therapy with the extent of increase related to the degree of altered brain function, as measured by the degree of induced EEG slow wave activity. This relation of change in behavior to physiological change is an observation that has been coneietently noted in cenvulaive therapy patients (h). The increaee in I accre during treataent may have been even �nere marked than eetnelly observed. Severel patients of tereignobirth and little edneetion hed retina: er nee: nexinnn eeeree print to treatment, thne elinineting or reducing the peeeibility er en increeee en retenting. The ehenge in eeere with altered brein function is eeneietent with previous obeervetiene on the behevierel effects 0: convulsive therapy. In eeeerd with our oeueeptnel trenewerk, greater egreenent with I Scele items during treete tent in related to inereeeed etereetypy and difficulty in dieerininetien, ll velx ee increeeed eeqeieeeenee. rue 1e preeeee whieh hee been noted 1n‘11ngn1et1e, e e! general pert neeeuree. and In their behavierel clinieel perceptual language, cenvnleive therepy patient: shew inereeeed deniel, cliche: end etereetyped end er use eve-inn, qualification expreeeiene (16). They elee nenifeet increased repetitiveneee of words (11), difficulty in aenplex Vienel end tectile per— eeptien (6) end figureggreund discriminetien (1h). Clinieelly, eke they chereeterieticelly here oeup}1ent end ecqnieecent and try to pleeee the exeniner (S). �-12- annular: neaenre e: social attitude, the California 1 Scale, has been utilised in etadiee o! the convulsive therapy proceee. In a voluntary psychiatric hoepital it wee noted that patients referred for oonvnlaive therapy had eigniticantly higher I A aoorea than theee receiving psychotherapy only. Anon; the patiente receiving convulsive therapy, theee with the higher initial 7 ecoree were evaluated ae showing the beet clinical reellta. With treatment there waa a significant increase in r ecore, with the ineroaae related to the degree or altered brain function. Following treataent the ecoree returned to their; original level. comparison of reenlte with a conventional and "reverne'l r eoale concentrated that low I acore patiente respond to the content or the questionnaire, while these with high I eoeree ahowed a generalized pattern or agreement independent of the content. There results are interpreted in tern: of the psychological proceeeee neaenred by the F Scale. High 1 score patients are coneidered to be aterectyped in their thinking and to have ditticnlty in introspection ~- behavior whih is incompatible with peychoanalytioally-oriented psychotherapy, rendering than acre liable to referral for convnleive therapy. With treatnent, enoh patients are aleo acre likely to develop the language patterna of denial and nee o: cliche} which are the one: for evalnatione or clinical improvement. the inoreaae in I score with treataont is conparahle to the other types of behavioral �ohnnxo, such :- 1n figure—around of lungntga. inerouocd noqniouconcc, increased ditticnlty disarininntign, tad incroalod stereotypy �Reference- 1. Aderno, !.H., Frankel—Brunswick, 3., Levin-on, D.J. and Sanford, 1.3. The Antheritarian Pereonalitz. Harper, low rerk, 1950. 2. ‘Baee, B. n. Antheritarianion or aeqniooeenoe? J. Abnern. & scan Pezeho1., 5;. 611~623, 1955. 3. chriotie, 3., Havel, 3., and Beidenberg, I. II the P Scale irreversible? J. Abnorn. flee. Pezche1., fig: I 1h3~1§9, 1958. Fink, H. and Kahn, R.L. Reletion of EEG delta activity to behavioral reeponee in electroshock: quantitative eerial etndiee. 1.x.i. Arch. Henrol. & Po ehiat., 1Q; 516-525, 1957. 3.2. and 3ehaviora1 patterno in induced Kahn, n. Iink, etetee or altered brain function. Paper read at Diviaional Meeting, Aner. Peyohiat. Lee., low York, levenber, 1957. 6. Fink, H., Iahn, R.L. and Kevin, 3. Effects of diffuse eltered brain tnnntien en perception. Proc. 1? Int. sonar. szohel. Anatordans Northelolland Pnb1., V pp. 238-239, 1959. Fink, x., Kahn, R.L. and Pollack, Psychological factors attenting individual ditteronoee in behavioral response to convuleive therapy. J. lorv. & lent. Dio., M. 128: 2h3~2h8, 1959. �-2Referancoa Gallagher, E.B., Ltviason, D.J. and Erlich, I. Some sociopsycholcgical chaructoriatics of patiants and their rclavuneo tor paychintric treatnont. In Groonblntt, 9.5. Lovinlon und 3.x. Williams (Edl.) The Pttiont und the Hpntnl iosgittl. The Pro. Prosl, H. alencoo, 111. pp. 357-379, 195?. Jack-on, 3.3., Herrick S.J., and Bailey, c.n. 30v “rigid“ is the autharitnrinn? J. Abnorm. soc. Pnzchol. fig: 137~1h0, 1957. 10. Junk-tn, 9.1. and Herrick, 5.3. content and style in personality anion-none. Patchol. 3‘11., 2;: 2&3-252, 1958. 11. antic, 3., Fiat, R.L. Communication pattorns with ulterod brain function. J. Harv. & Rent. 313., H. and Kuhn, in prons. 12. 8.1., link, E. 3nd WeinttOin, E.A. Relation of anobarhital tent to clinical inprovonont in oloctro¢ Kuhn, shook. A.H.A. Arch. Konrol. Pazchint., 1g. 23»29, 1956. 13. Inna, 1.1. ind link, x. Personality factor: in bohuvior¢1 response to olootraahook thornpy. J. learn I ehiut., l3 h5-h9, 1959. Inna, R.L., Pellaek, l. £34 rink, H. Figaro-ground dinorininaticn after indueod ultcrod brain inaction. A.H.A. Arch. louroi.,fiiu pron: �15. rink, H. Prague-tie value at hereohaeh criteria in clinical response to convulsive therapy. Kuhn, R.L. and Paper read at Bleetreeheck Reaeareh Aee., san Francisco, 1958. 16. Iahn, R.L. and link, H. changes in language during oleetroeheck therapy. In P. flesh and J. Znhin (Ede.), Pazehegatholegz et columnieatien. Grune and stratten, l.‘ Yorke ppe 126‘139e 1958a R.L., Pellaek, H. and link, H. social tactora 1n the selection at therapy in a veluntary mental helpital. J. Hill-1h Hung. Q: nos-:20, 1957. 18. Iahn, n.L., rellaek, H. and rink, u. seexepeyehelexieal aepeete at fieyehiatrie treatleut. Arch. Gen. Pezchiat., in press. 17. Kahn, �Social Attitude Questionnaire (F Scale)* Below are a number of‘statements. For each statement we want you to give us your personal opinion of'whether you agree or disagree, and how much. .3 g 5 8 >3 am :> o (I) :4 fi g >> +3 43 m a {34 m (D M m r1 9 +2 'H H c6 w 0) 3 3 vi H 8 E g 5’ S pm (D ((3 Q1 L" w m a) m a) m m p ’ 0 h w (6 m aw £6 m better When talk less ho w no a -H "-4 rd 0 F1 Pi F4 F4 F1 +4 H U U ................... and work more, everybody would be offOOCOICOOOOOQ. OOOOOOOOOOOOOOOOOO OOOOOOOOOOOOOOOOOOOOOOOO . think about it, it is best for him not to but to keep busy with more cheerful things ....... a person has a problem or worry, the youth needs most is strict discipline, rugged determination, and the will to work and fight for family and country ...... What I different kinds of people mix together to protect himself especially carefully infection or disease from them ............... Nowadays when so many so much, a person has against catching an crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse....... . Sex ................... ..................... best teacher or boss is the one who tells us exactly what is to be done and how to go about it. ...... . The ..................... people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down Young People can be divided into two the strong.... ..... ... *From ...................... distinct classes: the weak and .................. ........................ . Gallagher, Levinson and Erlich (1957). Scoring: I agree very much ....... +7 I agree pretty much.....+6 I agree a little ........ +5 I can't say ............ I disagree very much ....... +1 I disagree pretty much ..... +2 I disagree a little +3 +h 43 ho w ....................................... people would h aw m -H 5-4 Science has its place, but there are many important things that must always be beyond human understanding If h a $4 sane, normal decent person could ever think of hurting a close friend or relation.. No 8 ........ $3 as �Appendix Social Attitude Questionnaire (F Scale)* Felow are a number of statements. For each statement we want you to give us your personal opinion of whether you agree or disagree. Answer each statement according to one of the following: I AGREE A LITTLE I DISAGREE A LITTLE I AGREE PRETTY MUCH I DISAGREE PRETTY MUCH I AGREE VERY MUCH I DISAGREE VERY MUCH 1. sane, normal, decent person could ever think of hurting a close friend or relation. No 2. Science has its place, but there are many important things must always be beyond human understanding. 3. If better off. that people would talk less and work more, everybody would be a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things. tion, A. When 5. What and the the youth needs most is will to strict discipline, rugged determina— fight for family and country. 6. Nowadays when so many different kinds of people mix together much, a person has to protect himself especially carefully against catching an infection or disease from them. work and so 7. Sex crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicaly whipped, or worse. is 8. The best teacher or boss to be done and how to go about is the it. one who tells us exactly what people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down. 9. 10. Young PeOple can be divided the strong. into two distinct classes: the weak and -————————————.__.__—_—______ * Gallagher, Levinson and Erlich (1957). Scoring: Agreement is scored as +7 (agree very much), +6 (agree pretty much), and +5 (agree a little); +h for no response or uncertain; +3 (disagree a little), +2 (disagree pretty much), and +1 (disagree very much). The ten items are summed for a single F—Scale Score. From �CONVULSIVE THERAPY PROJECT — INTERNATIONAL ASSOCIATION FOR PSYCHIATRIC RESEARCH, INC. §gpia1 Attitude Questionnaire {F ScaIe) aha a numbed 05 Atatemcnia. Fox each Ataiemeni we want you to give uA gout geaéonafi Opinion 05 whethea you agaee Befiow on disagree, and .C.‘ 0 how much. g much m G) very H 94 muc 3 >5 JJ U little - much 4-) a H 1—! pretty very CE! cisagree agree say t can I I sane, normal decent person could ever think of hurting a close friend or relation. ..... ‘u.......... ..... No Science has its place, .............,... but there are many important things that must always be beyond human understanding................ If people would talk less and work more, everybody would be better off.................................................... I ‘ then a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things.... I If I the youth needs most is strict discipline, rugged determina— tion, and the will to work and fight for family and country... What different kinds of people mix together to protect himself especially carefully infection or disease from them ..... ....... Nowadays when so many so much, a person has against catching an I crimes, such as rape and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse................... .. Sex I ......... ............... . The best teacher or boss is the one is to be done and hOW tells us exactly what to‘go about ituu'oonltocconcoct-cocooooowho Young people sometimes get rebellious ideas, but as they grow up they ought to get over them and settle down................ People can be divided into two distinct classes: the weak and the strongOIOOIIOOIOOQOOOOOCOOIIOIOOIOIICOOCIOIOOCOOIIOICI I “"“'{' I i, 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 Social attitude (California F Scale) and convulsive therapy. J Nerv Ment Dis. 1960 Mar; 130:187-92. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-46-012 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 Kahn, Robert L.; Pollack, Max; <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] with questionaire and reprint. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 130, No .3, 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/bf0b6905f6c2b44054f0b8c530666cd5.pdf b11f5eee6a69d331f4c3c98cd7961516 PDF Text Text Reprinted from the :1. M. :1. Archives of Neurology May 1960, Vol. 2, pp. 547—551 Copyright 1960, by Aerircm Medical Association F igure-Ground Discrimination After Induced Altered Brain Function ROBERT l.. KAHN, Ph.D.; MAX POLLACK, Ph.D., and Studies of complex visual perception with altered brain function in man have not always yielded clear or consistent results. The disagreements may be due to many factors, such as differences in population studied, types of procedures employed, and difficulties in evaluating the degree of alteration in brain function. Electroconvulsive therapy (ECT), however, provides a unique op portunity for studying the effects of cere— bral dysfunction in that more accurate control can be maintained over the degree of induced cerebral dysfunction and its measurement. While most investigations of brain—injured populations have focused on the role of the locus of the lesion on behavior, current studies of ECT have emphasized individual differences. Marked variability has been shown for perceptual}2 behavorial,7 and physiologic 5'8 responses to ECT. Various personality 6'11 and social factors 9'10 have also been related to differences in response to treatment. In the course of an investigation of the perceptual and behavorial changes with ECT, a convulsive—subconvulsive control study was undertaken. In this report, the performance on complex visual tasks is pre— sented. Specifically, the aim was to deter— mine whether perceptual change induced by ECT is related to the degree of altered brain function and clinical behavioral ‘ Accepted for publication Jan. 18, 1960. From The Department of Experimental Psy— chiatry, Hillside Hospital. Presented at the American Psychological Association, New York, August, 1957. Aided by Grants M-927 and MY-2092 of the National Institute of Mental Health, National Institutes of Health, US. Public Health Service. MAX FINK, M.D., Glen Oaks, New York change, and Whether the pretreatment perceptual pattern is related to physiologic changes with treatment. The method used in the study was the perception of embedded geometric figures—— a technique which has been employed in recent years in studies of perceptual change in head trauma and brain tumor pa- tients.1'“"'14 Method Population—Fifty-three consecutive patients referred for ECT were studied. These included 16 men and 37 women, the ages ranging from 22 to 66 years, with a median of 49 years. The patients were divided at random into two groups. A convulsive group, of 29 patients, received grand mal electrotherapy with thiopental (Pentothal) premedication three times a week, using either a Medcraft alternating-current instrument or a. Reiter C-47 electrostimulator. A minimum of 12 treatments was given. The total number of treat— 1. ments was determined by the supervising psychia— trist in charge of the treatment unit on the basis of clinical criteria. A subconvulsive group, of 24 patients, was treated in similar fashion except that only subconvulsive stimulation was given after the thiopental. Fourteen of the subjects in the 'subconvulsive group were subsequently given a regular course of convulsive therapy. 2. Perceptual Task—In the week prior to treat— ment and on the day following the 12th treatment each patient was tested with a modification of the Gottschaldt hidden—figure test developed by Bat— tersby et al.1 The subject is presented with a page containing two forms—a simple geometric figure, and below it a complex figure in which the simple figure is embedded (Figure). The patient is asked to trace a specific geometric figure from the background by outlining it with a colored pencil. The discriminations range in complexity from relatively simple to more complex. There are 25 such discriminations. A maximum of two minutes is allowed for each. Performance is scored in terms of total number of errors. To minimize a practice effect, two equivalent forms of the test were used. The forms were alternated with 77/547 �A.M.A. ARCHIVES OF NEUROLOGY Comparisons for Number of Errorr Before and During EC T TABLE 1.———Intragr0up Type of Treatment Subconvulsivo Convulsive Before No. 24 43 ECT During Differ— ECT once 1’ 7.7 11.8 ~2.3 +2.3 <0.02 10.0 9.5 * (0.02 Intragroup analyses in this and in subsequent tables are based on Wilcoxon’s method of paired replicates. * Results \VAVI ‘7"7V 'AL A AL‘ Figures in hidden-figures test. The preliminary sample used to acquaint the subjects with the task is shown in a; b and c are examples of test figures. In (1 the task is complicated by having the subject determine which of the two single figures can be found in the complex figure. successive patients in pretreatment testing. During treatment the patient was reexamined with the form different from that given initially. 3. Evaluation of Physiologic Change. Two measures of brain function——the electroencephalo— gram and the amobarbital test15—were given to each patient prio1 to and at weekly intervals during treatment. The electroencephalogram was evaluated as to the degree of induced slow-wave activity according to criteria previously published.5 The amobarbital test was noted as positive or negative for brain dysfunction according to standardized criteria}5 The results of these tests during the second, third, and fourth weeks of treatment furnished the criteria for physiologic change. A combined physiologic index was obtained by ascribing to each high—degree slow—wave EEG record and each positive amobarbital test a score of one. The range of physiologic altera— tion thus ranged from 0 to 6. 4. Behavior Ratings.—Each patient’s behavior was evaluated at weekly intervals. After the 12th treatment, a rating for the degree of behavioral change was made according to four classes: marked, moderate, minimal, or none. These ratings of change were not value judgments as to the quality of change but, rather, quantitative estimates of differences in behavior patterns under similar conditions of observation. Thus, such behavior patterns as euphoria, paranoia, and withdrawal might all be rated as equivalent for degree of quantitative change, although the implications of. each for the qualitative evaluation of improvement may be difi'erent. 78/548 The pretreatment and treatment scores and the mean change in the number of er— rors with treatment are shown for each group in Table 1. Intragroup analysis shows that the subconvulsive group made signifi— cantly fewer errors during treatment, whereas the convulsive patients made sig— nificantly more. Prior to treatment, subconvulsive patients made approximately the same number of errors as those in the convulsive group, a mean difference of 0.5 error. During treatment, however, the difference between these bet— at significant (4.1 errors) was groups ter than the 1'% level of confidence. When the data are analyzed with respect to physiologic change, significant increases in errors are found only for those patients with great— er degrees of physiologic change. This re— lationship is present in the analysis of the amobarbital test and the EEG as separate 2,—1ntragroup Comparisons for Number of Errors Before and After EC T in Relation to Degree of Physiologic Change TABLE 3 Mean Difference in No. of Errors During Treatment Physiological Index N Amobarbital Test None or one positive 13 —0.2 Two or three positive Electroencephalogram None or one high delta 28 +3.7 23 +1.7 Two or three high delta Combined Physiologic 0 t0 3 18 +3.3 21 +1.0 20 +3.9 4 to 6 1’ Not significant <0.01 Not significant <0.05 Not significant <0.01 V 01. 2, May, 1960 �FIGURE-GROUND DISCRIMINATION 3,—Intragronp Comparisons for Number of Errors Before and During ECT in Relation to Degree of Behavioral Change 4.—Relation of Pretreatment Errors to Eventnal Degree of Physiologic Change TABLE Degree of Behavioral Change Marked Moderate Minimal or none N Treatment 14 5 ——0.4 Physiologic Change 1’ 0 3 5 <0.01 Not significant Not significant indices, and when the two tests are bined (Table 2). to 2 and N 16 4 and 6 19 8 Mean N o. of Errors Pretreatment 7.9 11.2 13.3 logic change had frequent difficulty following instructions. They would trace the lines com— The relationship between the degree of behavioral change and the change in num— ber of errors during treatment is shown in Table 3. Those patients with minimal or moderate behavior changes did not show an appreciable difference in number of er— rors. Those with marked behavior changes, however, made significantly more errors during treatment. Analysis of the pretreatment error scores in relation to the degree of physiologic change is shown in Table 4. A significant relationship is shown between the pretreatment error scores and the degree of physio— logic change during treatment. Patients with minimal physiologic change during convulsive therapy had a mean pretreat— ment score of 7.9 errors, while those who developed marked physiologic effects had a mean pretreatment score of 13.2. The triserial correlation of pretreatment score and physiologic change is +0.34, significant at the 0.05 level of confidence. Qualitative Data—Alterations in size of figure or in minor aspects of form were common types of error during both testing periods. Certain qualitative patterns were frequently noted during treatment, which occurred only rarely in the pretreatment period. It was common for patients to make no attempt to trace the more complex figures. This failure was often associated with a generalized withdrawal reaction in which theipatient was unresponsive to any stimulus or procedure. Others became hos— tile and negativistic toward the testing. Patients with the greatest amount of physio— Kalm ,et al. During Treatment Mean Difference for Number of Errors During +3.6 +1.0 24 TABLE indiscriminately, without regard for the specific figure to be traced, repeat a previous figure despite changes in the test figure, draw lines where none actually existed, and attempt to trace the stimulus figure while ignoring the more complex test figure. Such patients were likely to respond quickly and impulsively, and showed little concern about making an error even when spontaneously commenting, “I know that’s not right.” Comment This study demonstrates a relationship between the degree of cerebral dysfunction and the degree of perceptual alteration as measured by errors on the embedded-figures test. Patients with subconvulsive stimulation made fewer errors on retesting. Patients receiving convulsive therapy, in whom only minimal physiologic changes were recorded, manifested slight increase or no change in errors. The convulsive patients, however, with the more marked physiologic altera— tions, showed a significant increase in ‘ errors. This interrelationship of brain func— tion and perception may be related both to the perceptual patterns with neurologic dis— orders and t0 the mode of action of con— vulsive therapy. It is evident that perceptual responses systematically vary with the degree of dif— fuse cerebral dysfunction. In relating these patterns to concepts of localized pathology, the role of generalized, nonspecific cerebral dysfunction must be considered. For ex— ample, unilateral spatial “inattention,” fre— quently attributed to parietal lobe lesions alone?!4 has been reported with a variety 79/ 549 �AM. A. ARCHIVES OF NEUROLOGY of lesions provided there was a somato— sensory defect and an associated generalized mental impairment."""16 Teuber and Wein— stein 1“ found that performance on an em— bedded—figures test was unrelated to locus of lesion in cases with penetrating brain wounds, but that aphasic patients made significantly more errors than a nonaphasic group. Pollack et al.,13 using a test identical with that in this study, reported no rela— tionship between errors and the location of lesion in tumor patients. They noted, instead, that the number of errors was related to the severity of general mental changes, manifested as disorientation for time and place. The present observation that perception of embedded figures is re— lated to the degree of diffuse brain dys— function is in accord with these studies of patients with head injuries and brain tu— mors. In previous investigations of the mode of action of convulsive therapy, we have shown that clinical behavioral change is related to the degree of altered brain func— tion.5'7'8 The present study reinforces this observation, the objective criterion of per— ceptual errors being used as an index of behavioral change. As a group, the patients who showed the greatest increase in errors with treatment were those who also showed the most pronounced change in clinical behavior, as assessed by conventional psychiatric evaluation. There appeared to be considerable comparability in the type, as well as the degree, of clinical behavioral change and the quali— tative aspects of performance on the em— bedded-figures test. Failure to attempt the task characteristically accompanied with— drawal or paranoid hostility. A lack of con— cern in correcting errors was associated with clinical euphoria or hypomania. From these behavioral observations, the increases in errors may be attributed to a change in attitude toward the task or examiner, as well as to a specific defect. The altered brain function modified the total pattern of interaction with the environment, of which 80/550 the performance on a complex perceptual task is just one aspect. Previous studies have shown that there is a relationship between the clinical response to convulsive therapy and aspects of personality, defined as the habitual or characteristic modes of response and adaptation.“v1°'11 In this study it has been shown that the pretreatment perceptual performance is related to the physiological response during treatment. This finding suggests that the indi— vidual differences in the development of physiologic change may also be related, in part, to personality factors. Summary and Conclusion Fifty—three consecutive patients referred for electrotherapy were studied before and after treatment on their ability to perceive embedded geometric figures. An experimental group of 29 patients received a course of grand mal therapy with thiopental (Pentothal) premedication. A control group of 24 patients received submnvulsive stimu— lation with thiopental premedication only. The experimental group made significant— ly more errors after treatment than did the controls. Within the experimental group there was considerable variability. Increase in errors was significantly related to the degree of altered brain function and to the degree of behavioral change. Qualitative aspects of perceptual behavior mirrored the pattern of behavioral change observed clinically. Pretreatment error scores were signifi— cantly related to the degree of altered brain function developed during treatment. The significance of this observation in terms of personality factors is indicated. Department of Experimental Psychiatry, Hillside Hospital. REFERENCES l. Battersby, W. S.; Krieger, H. P.; Pollack, M., and Bender, M. B.: Figure-Ground Discrimi— nation and the Abstract Attitude in Patients with Cerebral Neoplasms, A.M.A. Arch. Neurol. & Psychiat. 76 2369, 1956. Vol. 2, May, 1960 �FIGURE-GROUND DISCRIMINA TION Battersby, W. S.; Bender, M. B.; Pollack, M., and Kahn, R. L.: Unilateral Spatial Agnosia (Inattention) in Patients with Cerebral Lesions, Brain 79:68, 1956. 3. Critchley, MacD.: The Parietal Lobes, Baltimore, Williams & Wilkins Company, 1953. 4. Cobb, S.: Amnesia for the Left Limbs De— veloping into Anosognosia, Bull. Los Angeles Neurol. Soc. 12:48, 1947. 5. Fink, M., and Kahn, R. L.: Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 2. 78:516, 1957. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Affecting Individual Differ— ences in Behavioral Response to Convulsive Therapy, J. Nerv. & Ment. Dis. 1282243, 1959. 7. Fink, M.; Kahn, R. L., and Green, M. A.: Experimental Studies of the Electroshock Process, Dis. Nerv. System 19:1, 1958. 8. 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, 1956. 9. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 6. 216, 1957. Kalm cl 0]. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital, A.M.A. Arch. Gen. Psychiat. 1:565, 1959. 11. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiat. 1:45, 1959. 12. Landis, C.; Dillon, D., and Leopold, 8.: Changes in Flicker-Fusion Threshold and in Choice Reaction Time Induced by Electroconvul— sive Therapy, J. Psychol. 41:61, 1956. 13. Pollack, M.; Battersby, W. S., and Bender, M. B.: Figure—Ground Discrimination in Patients with Cerebral Tumor, read at Eastern Psychological Association, 1957. 14. Teuber, H. L., and Weinstein, 5.: Ability to Discover Hidden Figures After Cerebral Lesions, A.M.A. Arch. Neurol. & Psychiat. 76: 10. 369, 1956. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 112 2889. 1953. 16. Weinstein, E. A.; Kahn, R. L., and Slote, W. H.: Withdrawal, Inattention, and Pain Asymbolia, A.M.A. Arch. Neurol. & Psychiat. 74:235, 15. 1955. rrmccu’ and l’ublinhed in the United State: 0] America 81/551 ��liguruwaruuua ntncrtainn‘aau Artur Induaod Alsorud Irwin luuat£an "M‘ In ”I. than. m ,“1333' "on. II‘ “‘3 'Ilk Kc”. $ at Savorinnuinl Payuhaitry. Islanido Ilqpitul. tron ti. ‘3... 0th, 31$. '0!ttdod I: (933‘! 3‘91? and uz-noya .8 1h: rattanal Igs¢tiutn at lialfih ’ublta v.3. 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Ila UQIOIC nut 05:! poattiv. anotnrhttal tnnfi a lanai a: nut. 1h. rang. at phwitaloatcnl a1&nrat1nn thuu test: ruagnd tron h) atra'io nix. la tr *1: It Bash pctaaufi's hchnvtor In. cvnlnatud 3‘ wtokly intarvals. Artur ‘3: 12th trcn‘uant, a rtttal for it. dugvnu a: bnhtvinral thing. It: and. ¢os.vdll¢ ta tan! clnsucut unwind, nod¢rnto. Iantunl or menu. Th... rating: at «hang. vura ant VIII. audgnnnutu ta ta tho unaatty �.5. u “than“ in“ “my «unaba- uuntu‘ in boinvtov pu‘tnrau unit: tintlar mandatsana at uhocrv.‘10u¢ than. tuch‘bolnvtur psi$urua nu «upharsa, viruautn or withdrawn: usgl‘ .11 ha astod as aqutvnlcnt to: ‘OCIOI u: an minute“ or out chum. thy qunlt£nttvu cvnluutsna a: tlprcwuuuat um; to dartornut. at than, wanna“ am» in �mu» nud-truatnoét ae¢r¢t uni tic luau :3. pretrtatuaut ¢hanzc in *5. 31:30! at or!.ra I1$h trnntutnt Ara uncut {fir caah group in 1.31. X. 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"by 9.: Wk mug-ma um m an.“ u 3. n g m an: m tn um» Hm. «I: u “I“ an at“ m was “we. W m �«1 3a References I. Inttarahy, w.s.. traccnr. x.r., reliant, n. and nundlr. 3.3.: figuruogrcmnd ¢£unr£uannt1nu and the abatrtut uttitncn 1n putatuta with narchrax neayltnna. 5,555, ‘4 xi, '_'_, gaig.~;k;w., 19; 369, 195$. 2. rink. I. and Kuhn, Into: leln‘ttn Qt ita ficltl anivtty ‘a behavioral raapouao an electrouhaaks quantitnfiivn ' sorts: utiliaa, ewe .'o 1!? a 516. 1951. J. rink. h. m. I.t. tucturc vayuhnlnnzaal l.u rlmllsh, l.. Ittecttng individual attrcrlacus In hohtvanrtl filviiii Kata. and a. «man mm. mg... m: m. 1939. m. rm, M... and arm. ma... Mora-um mm. ' 0! the alaotveuhaek prune... Egg, leggg 51p., l2! 1. 1958. 5. mm. 2.3... rm, 1:. mt manna, 1m... lemma .3 Innhtrbttaa tout to altfiifill inprrvoann‘ in cleatrclhatk, 1.mt.,‘1§I 83. 1956. 6. Kuhn, 3.3.. Pollnel, fl. and tint, n.a auutul flatari 1n ‘ho taxonfiauu at thtvlwy ta 3 valuntear ninth: hanpttal. ,. 7. .fi _. , uI. go :16”. 1997. Iain, I.L., Pulltnk, and risk, 3.: atatapuylhaluuto firtntlnut an I reinstary ninth! haspt‘tl. 5.x.n. trot. flan. Payer. (In preto). I. tenets, 6.. 3111‘», a. and beeper; 8.! damage: 3: little:lliinn thrtlhfild and in until. vtnnfitlu $1.! Indtotd 1956. by 61. that-pr. a: magenta ‘3 paguhtttrso “wanna“ W... �...L 1.1.23.1...LL hunt. I... ground tuna”. 10. rum, Id. I). 8.3.: W and 'nnna W M. ‘ 5.: woman. attu- {W “any hunt, mm 1;.»- m. 1m. to hunch, 3a.. uh. IJ...‘ Guam. ammo m a a man“ in“ than. 1953. 1!. mm. Wumm M, 1‘va mu“ mm: 11. ma. m4 itltrfintnlttui in pttllut: itth carthvll at Panama“). Amati“. m. m 1957. ‘ mm. 3.4.1. “It. in: m: 889. on «an (Inn: want) ’ . «mm». 8.5.: .1 unhaido‘ tiguruu, g, rugg.. in £23 «u a! 1, 1936. swam mm»: um Wu 3.9M. um. 1M. pot-«yam. a a: W" LA... um .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 Figure-ground discrimination after induced altered brain function. Arch Neurol. (Chic.) 1960 May; 2:547-51 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-47-013 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 Kahn, Robert L.; Pollack, Max; <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 and [preprint]. Reprinted from the A.M.A. Archives of Neurology May 1960, Vol. 2, pp. 547—551 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/fdd65cffa7365ba9ca6ade8a0f3f6e8b.pdf 60ce7c5bb093bf1402d25c650f359a34 PDF Text Text PROCNOSTIC VALUE OF RORSCHACH CRITERIA IN CLINICAL RESPONSE TO CONVULSIVE THERAPY ROBERT L. KAHN, PH.D., and MAX FINK, MD. ABSTRACT In this study of the relationship between premorbid personality factors and clinical responses to convulsive therapy, the Rorschach test was admin— istered to 87 unselected patients prior to the beginning of EC T. A favorable clinical response to ECT was observed in subjects whose Rorschach records revealed a basically conventional and unimaginative personality, generally lacking in empathy, introspectiveness or facility of verbal communication. Post-treatment records (of 41 patients) showed no significant changes. It is therefore concluded that Rorschach patterns reflect basic personality rather than prevailing mood or type of illness. These results indicate that Rorschach patterns can be useful adjuncts in the selection of patients for convulsive therapy. In a series of studies of convulsive therapy we have observed marked individual differences in behavioral response. It has been shown that the induction of a behavioral change is related to the presence of altered brain function;5 Yet, among those with equivalent degrees of physiologic change, there are still differences in the clinical patterns of behavior. While some patients become hypomanic, others show paranoid reactions, withdrawal, increased somatization or expressions of fear.3 We have postulated that personality is one of the significant factors affecting this variability. This hypothesis was tested in a previous study,6 in which each patient’s premorbid personality was evaluated by means of structured interviews with members of his family and with the patient himself. We found that the patients who were rated as recovered or much improved after electroshock treatment were those with the follow- From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 'This study was supported in part by Research Grant M—927 from the National Institute of Mental Health, US. Public Health Service. Presented at meeting of the Electroshock Research Association, San Francisco, May 11, 1958. ing personality pattern: they were generally nonempathic, nonintrospective, verbally noncommunicative, highly conventional and stereotyped, with little imagination or creative capacity. The concepts derived from these observations lend themselves to study by other methods. In the present study the Rorschach test, another measure of personality, was used. The Rorschach technique has particular advantages in that it is both an instrument for testing the patient directly and, at the same time, a standardized procedure providing data which can be verified by others. The specific purpose of the present study was to determine: (1) the relationship between Rorschach findings and personality aspects previOusly fOund to be significant in family interviews; and (2) the applicability of Rorschach criteria in the prognosis of the clinical response to convulsive therapy. METHOD The population consisted of 87 consecutive, unselected patients referred for convulsive therapy in a voluntary mental hospital. All patients received electroconvulsive therapy (with either unidirectional or alternating-current instruments) three times a week. A mini242 Reprinted from Journal of Neuropsychiatry, Vol. I, No. 5, May—June, 1960 �l 960 mum Of 12 treatments was given, with the staff psychiatrist in charge of the treatment determining the final number on the basis of clinical criteria. The improvement evaluation, made by the staff psychiatrist, was based on the patient’s behavior in the hospital setting during the period of two to four weeks following termination of treatment. In this manner each patient was rated as either much improved, moderately improved Or unimproved. As previously described,5 patients were rated “much improved” if they no longer showed the symptoms which had brought them into the hospital; if, in addition, their doctors felt they were better; and if the nurses’ notes confirmed such aspects as ability to sleep without medication, better appetite, and improved capacity to get along with other patients and participate in hospital activities. “Moderately improved” patients typically showed some symptomatic relief (i.e., acute depressive features might be gone), but not the dramatic changes so evident in the first group. Each of these patients continued to show some noticeable disturbance such as obsessional thinking, paranoid ideas or somatic preoccupation. In the “unimproved” patients, change was either not clearly noticeable or only equivocal or transient. Some showed fluctuations in behavior, at times appearing somewhat improved; but the change was not sustained, so that by the end of treatment they appeared much the same as before. The Rorschach test was given to each patient prior to the beginning of electroconvulsive therapy and, in 41 cases, two weeks after electroconvulsive therapy. The Ror— schach records were scored according to the criteria of Klopfer and Kelley.9 Only those common components were studied, however, which could be analyzed quantitatively. These included: Total number of responses. 2. Per cent whole responses (responses in which a subject uses all of a card for the formation of a concept). 3. Per cent form responses (responses in which the shape of the blot is the sole determinant in the concept formation). 1. 243 JOURNAL OF NEUROPSYCHIATRY Number of content categories included in the responses. 5. Number of movement responses (references to any action or movement). 6. Per cent popular responses (responses statistically given most frequently to a particular blot area). 7. Presence or absence of shading responses (responses in which a subject incorporates the darker and lighter aspects of a blot into his description). 8. Type of movement responses (e.g., human movement, animal movement, etc.). 9. Type of color responses (responses in which the color in a blot plays a recognizable role in the concept formation; when form and color are both significant, color-form [CF] or form-color [FC] is scored, depending on the predominant influence). 4. RESULTS The relation of the various Rorschach factors to clinical changes following ECT is shown in Tables I-IV. In Table I, comparison is made between those patients who were rated as having a good clinical response and those whose response was moderate or poor. The much improved patients had significantly fewer total number of responses, and significantly more per cent whole and form responses. TABLE I RELATION OF RORSCHACH FACTORS TO CLINICAL RESPONSE IN CONVULSIVE THERAPY (NUMBER, PER CENT WHOLE, PER CENT FORM RESPONSES) Number of Responses Much Improved (38) Mean S.D. 13.0 6.7 Moderate or Unimproved (48) 19.5 12.8 Per Cent Whole Responses Much Improved (38) 87.6 21.0 Moderate or Unimproved (48) Per Cent Form Responses Much Improved (38) Moderate or Unimproved (48) Significant at .05 level ** Significant at .01 level * 24.4 18.2 71.8 19.0 61.9 21.4 Diff. t, 6.5 2.7 *" 13. 3.0 H 9.9 2.2 * �244 JOURNAL OF NEUROPSYCHIATRY An analysis of content categories, move- ment responses and popular responses (presented in Table II) reveals that there were significantly fewer content categories and movement responses, and a greater per cent of popular responses in the Rorschach records of the much improved patients, as compared with the records of the unimproved and mod— erately improved groups. As shown in Table III, the much improved patients were also less likely to have any kind of shading response. This table also presents an analysis of the different types Of movement and color responses. Those patients who gave human~movement (M) responses had the TABLE II RELATION OF RORSCHACH FACTORS To CLINICAL RESPONSE IN CONVULSIVE THERAPY (CONTENT CATEGORIES, MOVEMENT AND PER CENT POPULAR RESPONSES) t. Mean Diff. SD. Number of Content Categories Much Improved (38) 3.8 Moderate or Unimproved 4.9 (48) Number of Movement Responses Much Improved (38) 2.3 Moderate or Unimproved 4.9 (48) Per Cent Popular Responses Much Improved (38) 37.7 Moderate or Unimproved (48) 26.6 2.2 2.7 5.1 21.6 poorest clinical responses (28% much improved), while those with no movement of any kind had the best clinical results (63% much improved). Patients with animal-movement (FM) or inanimate-movement (In) responses were rated better than those with human movement but not as well as those with no movement at all. With respect to color, those patients with form-color (FC) responses had the poorest results; those with no color at all, the best—although patients with CF or C responses did almost as well. In Table IV the patients are grouped according to combinations of human-movement (M) and form-color (FC) responses. Of those who had both M and FC, only 17% were rated as much improved; 25% were considered unimproved. In contrast, of those with neither M nor FC, 66% were much improved and only 3% were unimproved. The ratings of the group with one or the other of these determinants (M or F C) fell in between. As 2.3 11.1 2.8 14.3 * Significant at .05 level "* Significant at .01 level MAY-JUNE mentioned, post-treatment records were obtained from 41 patients. Comparison of the pre—treatment and post-treatment records of these patients revealed little change in the types of responses found. With respect to human movement (M), for example, 34 of the records showed no change. In four cases patients with M responses prior to treatment H showed none afterward; three other patients with no M response had such response following treatment. These small changes could be expected on a chance basis. TABLE III RELATION OF RORSCHACH FACTORS TO CLINICAL RESPONSE IN CONVULSIVE THERAPY (SHADING, MOVEMENT AND COLOR) Total No. Much Improved Moderately Improved Un improved Shading 46 15 (33%) 20 (43%) 11 (24%) No Shading 40 23 (58%) 15 (38%) 2 ( 5%) x2 = 8.12 p<.02 Human Movement (M) Animal Movement (FM) and/or Inanimate Movement (In) 39 11 (28%) 19 (49%) 9 (23%) 29 16 (55%) 9 (31%) 4 No Movement (14%) 19 12 (63%) FOrm-Color (FC) 7 (37%) X2 = 10.49 p<.05 Color-Form (CF) and/or Pure Color (C) 34 7 (21%) 18 (53%) 9 (26%) 27 16 (59%) 8 (30%) 3 No Color (11%) 26 16 (62%) . (35%) 1 ( . _ > x2 = 14.98 p<.01 4%) �JOURNAL OF NEUROPSYCHIATRY I960 TABLE IV RELATION 0F RORSCHACH FACTORS To CLINICAL RESPONSE IN CONVULSIVE THERAPY (HUMAN MOVEMENT AND FORM-COLOR) Much Total Moderately Human Improved Unimproved Movement (M) and Form-Color No. Improved (FC) 24 25 4 (17%) 10 (40%) 14 (58%) 9 (36%) 6 (25%) 6 (20%) 38 25 (66%) 12 (32%) 1 FC Neither M nor FC M or M and FC vs. M or FC vs. Neither M nor F0: M and X2 WC vs. Neither M nor FR: .‘(1’ = -: 17.82 12.26 ( 3%) p<.01 p<.00] EPICBISIS The results of this study confirm the findings previously reported concerning the relationship of personality to clinical response after convulsive therapy. Patients who had a good clinical result showed Rorschach records characterized by few responses and little variety of content, no shading or movement or color responses, and a high percentage of whole, form and popular responses. This kind of record indicates a personality pattern which is nonempathic, nonintrospective, verbally noncommunicative, highly conventiOnal and stereotyped and with little manifestation of imagination or creative capacity. These characteristics are identical with those described in the previous study based on interviews with family members.6 The prognostic value of the Rorschach as a clinical instrument is demonstrated by these data. While there are a number of studies in the literature on the prognostic value of the Rorschach in somatic therapy, the results have not been consistent. Rabin,13 for example, states that “single Rorschach factors cannot serve . . . as predictors of improvement.” On the other hand, Piotrowski12 describes specific prognostic criteria. It is likely that the difference in point of view, as well as in the varying criteria offered, reflects differences in the type of population and the variety of somatic treatment observed. Despite these problems, however, those studies 12’ 14 with the largest series of patients have obtained results similar to those of the present study. For ex— ample, their data show that the absence of 245 human movement (M) is more often associated with a favorable clinical response, and that patients with form-color (FC) responses are more likely to have a poor result.14 The significance of our findings might be questioned on the basis that we have demonstrated a relationship merely between clinical response and type of illness, rather than between clinical response and personality pattern. This objection would appear to be sup1“ 4’10'1‘1 the studies ported by numerous which have reported that depressed patients. the most likely candidates for convulsive therapy, show no human-movement or color responses. Our observations, however, substantiated by other studies,1’7!8’“’ Show a constancy of the Rorschach before and after treatment, and indicate that the response pattern reflects aspects of the basic personality rather than transient features such as the prevailing mood or type of illness. REFERENCES l. Beck, S. J.: Arch. Neurol. & 1943. 2. Fink, M., and Kahn, R. L.: 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Psychiat. 50:483. AMA. Arch. Neurol. i7 Psychiat, 78:516-525, 1957. Fink, M., and Kahn, R. L.: paper presented at meeting of A.P.A., New York, 1957. Cuirdham, A.: Brit. J. Med. Psychol., 16:130— 145, 1936. Kahn, R. L., Fink, M., and Weinstein, E. A.: AMA. Arch. Neurol. b Psychiat, 76:23—29. 1956. Kahn, R. L., and Fink, M.: I. Neurop.sychiat., 1: 45-50, 1959. Kelley, D. M., Margolis, H., and Barbera, S. E.: Rorsch. Res. Exch., 5:35-43, 1941. Kisker, C. W.: I. Aim. (J Soc. Psychol., 37:120— 124, 1942. Klopfer, B., and Kelley, D.: The Rorschach Technique, World Book Co., New York, 1942. Levy, D. M., and Beck, S. J.: Am. J. Orthopsy— chiat., 4:31—42, 1934. Pacella, B. L., Piotrowski, Z., and Lewis, N. I). G: Am. J. Psychiat., 104:83-91, 1947. Piotrowski, Z.: Psychiat. Quart, 14:267-273. 1940; 15:807—822, 1941. Rabin, A. 1.: Am. Psychol., 2:284, 1947. Rees, W. L., and Jones, A. M.: J. Ment. Sc., 97: 681-689, 1951. H.: Psychodiagnostics, Crune & Stratton, New York, 1942. 16. Varvel, W. A.: Bull. Menninger Clin., 5:5-12, 15. Rorschach, 1941. �Pragmatic Value of Rorschach Criteria in Clinical Beeponse to Convulsive 'Iherapy Robert L. Kahn Ph.D. and From Max Fink M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., NJ. Aided, in part, by grant Public Health Service. M 927, National Institute of Mental Health, U.S. Presented at the Electroshock Research Association, San Francisco, May 11, 1958. 5-5-58 �Prognostic Value of Rorschach Criteria in Glynical Response RObert L. to Convulsive Therapy W Phone and Max Fink In a series of studies of convulsive therapy MOD. we have observed marked individual differences in behavioral response. It has been shown that the induction of a behavioral change is related to the presence of altered brain function (2, 5). Yet, among those with equivalent degrees of physiologic change, there are still differences in the clinical patterns of behavior. While some patients became hypcmanic, others show paranoid reactions, withdrawal, increased somatization or expressions of fear (3). we have postulated that personality is one of the significant factors affecting this variability. This hypothesis has been tested in a previous study using structured interviews with members of the patient's family (6). It was reported that patients who were rated as recovered or much improved following treatment were generally non-empathic, non-introspective, non- verbally communicative, highly conventional and stereotyped, with imagination or creative capacity. The concepts derived from these observations lend themselves to study by other methods. used little in this study. The Rorschach test, another The Rorschach measure of personality, technique had the advantages both of testing the patient directly and of being a standardized procedure providing data which could be verified by otherS. The specific purpose of the present study was to determine: 1) the relationship between Rorschach findings and personality aspects previously found to be significant in family interviews, and was �.2.2) the application of Rorschach criteria in the prognosis of the clinical response to convulsive therapy. METHOD: The population consisted of 86 consecutive, unselected patients referred for convulsive therapy in a voluntary mental hospital. All patients received electrocommlsive therapy three times a week, using either midirectional or alternating current instruments. A minimmn of 12 treatments was given, with the supervising psychiatrist in charge of the treatment determining the final number on the The improvement exraluation was made by basis of clinical criteria. the supervising psychiatrist the patient's behavior in the hospital setting in a period to four weeks following the termination of treatment. In this and was based on of two patient manner each was rated as either much improved, moderately improved criteria previously described (5). Each patient was given the Rorschach test in the standard mnner in the week prior to treatment. This data constituted the main focus of this or unimproved, using study. To determine however, the of treatment. test was stability of the Rorschach pattern with treatment, readministered two weeks following the termination �RESULTS : A. Relatim of Rorschach Factors to Clinical The Rorschach records were scored according to the criteria of Klopfer and Kelley (9). (July these however, which could be analyzed total Change: common components were studied, quantitatively. These included of responses, 2) per cent whole reSponses, 3) Per cent form responses, )4) number of content categories included in the 1) number responseS, 5) number of movement responses, 6) per cent popular responses, 7) presence or absence of shading responses, movement reaponses, and 8) type of 9) type of color responses. In Table I the comparison is made between those patients who were clinical response and those whose reSponse was moderate or poor. The much improved patients had significantly fewer number of responses, and significantly more per cent whole and form rated as having a responses . good �TABLE I Relation of Rorschach Factors to Clinical Response in Convulaive Therapy: Number, Per Cent Whole, Per Cent Form Responses Number Mean §_:_D_o (38) 13.0 6.7 (h8) 19.5 12.8 of Resmnses Much Improved Moderate or UnimProved Diff. 6.5 L 2.7 *‘hL Per Cent Whole Resmnse Much Improved (38) 37.6 21.0 Moderate or Unimproved (ha) 2h.h 18.2 (38) 71.8 19.0 (ha) 61.9 21 .h 13 .2 3.00 *4:" Per Cent Form Resoonse Much anrorved Moderate or Unmproved 9.9 2.2 * as Significant at .05 level *"‘ Significant at .01 level �-5significantly fewer content categories in the Rorschach records in the much improved patients. (TableJI). They also demonstrated There were fewer movement and a greater per cent of popular responses, than the unimproved and moderately improved groups. TABIEII of have kind to less any likely patients shading responses, as shown in Table III. In this table the comparison is also shown for the different types of movement and. color responses. Those patients who had human movement responses (M) had the poorest clinical were also The much improved had the best results inanimate movement movement improved), while those with no movement of any kind (28% much reaponses (63% much (m) improved). Patients with animal (FM) or reaponses were rated better than those with human but not as well as those without any movement at all. With respect to color, those patients with form color (F0) reaponses had the poorest results, “those with no color at all the best, although patients with CF or C responses did almost as well. TABLE III �.6. TABLEII Relation of Rorschach Factors to Ciinical Response in Convulsive ’Iherapy: Content Categories, Movement and Per Cent Poplgar Responses Number $.13. (38) 3.8 2.2 (he) h.9 2.3 Diff. of Content Categories Much Improved Mod Mean erate or Unimproved ifl, 1.1 2.1 2.6 ** 2.7 11.1 * Number of Moveme‘ot Responses Much Improved (38) 2.3 2.7 Moderate or Unimproved (hi3) h.9 5.1 (38) 37.7 21.6 (h8) 26.6 1h.3 Per Cent Pomar Responses Much Improved Moderate, or Unimproved * Significant ** 2.8 V. at .05 level Significant at .01 level �$3 g 3 35 N 8.V. $8 335 m a m $8 o menu;H m Amaav 305 m H SVQ ”ummnony wmbommfiH NH.w 32 n n 0 «N «x NM QQOJH mmeazpaoo gs ca Nampwhmcos $5 €09 “Rm: N. 3 a m Ammmv Ammov Amawv Ammmv HH ma NH N 0H RS Amwv 8d Amos fig: “many 3.5 ma 3 m 383 Rammv ,mH mu $5 85 8 noaoo omcbmmmm HHH cam [chlmnm¢fl Hmowawao unmsmboz on \xfimmmV cabommgH Awmev myopowm finfim sou: ma nomnomnom mo mbwpmamm I! RE AEhv Aumv upmafiuu¢m pumsmboz Amuv ASV chum 303%: on such pamembnx gamma pmoswboz wfiuflm 02 g noaoo hoaoo_suom n0\unm noxnnm amewq< noaoo hoaoo oz oz �-8In Table IV the patients were grouped according to combinations of H and rated as FC responses. 01‘ those who had both much improved and 25% were of those with neither M nor M and PC only 1775 were considered mimproved. In contrast, EC, 66% were much improved and only 3% were improved. The ratings of the group with one or the other of these deteminants fell in between. unnuumm TABLES IV W...‘. B. chnErison of Pre- and Posttreatment Records Posttreatment records were obtained from hl patients. These showed little difference from the types of responses found prior to treatment. .fith respect to human movement (M), for example, recorfls shared no change. In four cases patients with none afterwards; follow-ring three other patients with no treatment. M M 3h of the responses showed response had such response �«a. TABLE IV Relation of Rorschach Factors to Clinical Response in Convulsive Therapy: Human Movement SM) and Form Color $130) Rorschach ___N__ M and M or FC F0 Neither M M nor FC and FC/Neither Mmr Much Improved (21:) h (25) 10 (ho%) (38) 25 (6655 FC (17%) Moderateg ImEroved W 6 (25%) (36%) 6 (20%) (32%) 1 (3%) 1h (58%) 9 12 x2 = x2 - 12.26 17.82 p < p.<; .01 .001 �.10.. DISCUSSION: this study confirm the findings previously reported concerning the relationship of personality to clinical response after convulsive therapy. Patients who had a good clinical result showed The results of Rorschach records characterized by few responses and content, no shading or movement or little variety of color reaponse, and a high percentage of whole, form and popular reSponses. This pattern indicates a personality pattern which i s non-empathic, non-introspective, non-verbally cormunicative, highly conventional and stereotyped and with little manifestation of imagination or creative capacity. These aspects are identical with these described in the previous study based on interviews with family members (6). The prognostic value of the Rorschach as a clinical instrument is demonstrated by this data. ifhile there are a number of studies in the literature on the prognostic value of the Rorschach in somatic therapy, the results have not been consistent. T:Jhile Rabin (3), for example, has stated that "single Rorschach factors cannot serve ... as predictors of improvement ," Piotrowski has described specific prognostic criteria (12). It is likely that the difference in point of view, as well as in the varying criteria offered, reflects differences in the type of population and the varieties of somatic treatment observed. Despite these problerns, however, the results of those studies with the largest series of patients report similar observations to those in the present study. For example, their data shows that the absence of human movement (M) is more (12, 114) often associated with a favorable clinical response, and that patients �.uwith F0 responses are more likely to have a poor result (1h). The that significance of these results might be questioned on the basis clinical response and type of illness rather than flue personality pattern. In this regard numerous studies have reported that depressed patients, the most likely candidates for convulsive therapy, show no human movement or color we have demonstrated a reSponses (h, 10, 15, 16). by other relationship Our studies (1, 7, 8, 11), after treatment, between observations, however, substantiated show a constancy of the Rorschach before indicate that the reSponse pattern reflects aspects of the basic personality rather than transient features as the and prevailing mood and or type of illness. �SUMMARY.AND CONCLUSION: 1. Eighty-seven unselected cases referred for convulsive therapy were administered a Rorschach test prior to, and two weeks following, treatment. 2. A favorable clinical response was observed in subjects with pretreatment records characterized by few responses, a small number of content categories, absence of shading, movement and color responses (particularly lack of human movement and form color), and a high percentage of whole, form and popular reSponses. This data confirms previous observations on the 3. personality factors to clinical outcome relation of in convulsive flierapy. favorable evaluation is most likely in patients who A are predominantly non-empathic, non-introSpective, nonaverbally communicative, highly conventional and stereotyped, with little imagination or creative capacity. significant change in Rorschach records obtained There was no A. It is that pretreatment Rorschach patterns in this population reflect the basic personality rather than the prevailing following treatment. mood concluded or type of illness. 5. can be patterns, by providing a set of prognostic criteria, useful adjuncts in the selection of patients for convulsive therapy. Rorschach �.13- 2.‘ Fink, 3. and Katm, R.L.: Relation of Electroencephalographic Delta Activity to Behavioral Response in Ele ctroshoclc, A.M.A. Arch. Neurol. 8: P_s,zchiat., IQ: 516-525 (1957). A M. Behavioral Patterns with Induced States of tered Brain Function, Div. Meeting A.P.A. (New York 1957). : 14. Guirdham, A.: Diagnosis of Depression by Med. Psycho . _1_§: 130-115 (1936). 5. Kahn, the Rorschach Test, Brit. J. R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Bnprovement in Electroshock, A.M.A. Arch. Neurol. and Psychiat. 1g: 23-29 (1956). ,: Personality 7. 8. 9. 10. 11. 12. Factors in Behavioral Reaponse to Electroshock Therapy, Conf. Neural. (in press) Kelley, D.M., Margolis, H. and Barbara, S.E.: of the Stability Rorschach Method as Demonstrated in Electric Comrulsive Therapy Cases, Rorsch. Res. Exch., 5: 35-143 (19M). Kisker, G.W.: A Projective Approach to Personality Patterns During Insulin-Shock and Metrazol-Convulsive Therapy, J. Abn. & Soc. 21: 120“12)4 (19112). mo: Klopfer, B. and Kelley, D.: The Rorschach Technigue. (World Book Co. , New York 19h2). levy, D.M. and Beck Psychosis, Am. S.J.: Rorschach Test in Manic-Depressive J. Orthops‘gchiat” ll: 314:2 (19311). The Pacella, B.L., Piotrowski, Z. and Lewis, N.D.C.: The Effects of Electric Convulsive Therapy on Certain Personality Traits in Psychiatric Patients, Am. J. Psvchiat. 1011: 83—91 (19M). Piotrwski, Z.: A Simple Experimental Device for the Prediction Quart., lg: 267-273 (1910); Aid in the Insulin Shock Treatment of Schizophrenia, Psychiat. Quart. 15: 807—822 (19141). �REFERENCES 13. Rabin, A.I: Effects of Electric Shock Treatment upon Some Aspects of Personality and Intellect, Am. PsEhol. g: 281; (1911?). lb. Rees, W.L. and Jenes, A.M.: An Evaluation of the Rorschach Test as a Prognostic Aid in the Treatment of Schizophrenia by Insulin Coma Therapy, Electronarcosis, Electroconvulsive Therapy and Leucotomy, J. Ment. Sci. 97: 681-689 (1951). 15. Rorschach, H.: Psydhodiagnostics (Grune Stratton, The Rorschach Test in Psychotic and Manninger 01111., S: 5'12 (19,41)- 16. Varvel, MtA.: Bull. & New York, 19h2). Neurotic Depressions, � 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. 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Kwalwasser: Confin. neurol. 16, 88, 1956 Printed in Switzerland From the Research Service of Hillside Hospital, Glen Oaks, New York Relation of Changes in Memory and Learning to Improvement in Electroshock 1' ** Max FINK *, KORIN By Hyman and Simon KWALWASSER *** Read by title. This investigation was supported in part by a research grant M-927 from the National Institute of Mental Health, Public Health Service. Received the annual $ 100 prize awarded by the Electroshock Research Association. * Research Assistant (psychology). ** Director of Research. *** Associate Medical Director. T �In the course of studies of the relation between altered brain function and improvement following electroshock therapy, the present investigation of memory functions was undertaken. By serial testing of learning and recall variables, an attempt is made first to study and quantify memory changes; and then to determine the relationship between therapeutic outcome and such changes. Amnestic effects during electroshock therapy are commonly observed, and are both of practical and theoretical interest. Although differences in methodology, materials, subjects and electroconvulsive techniques make direct comparison difficult, a few conclusions related to the questions of concern in this study can be derived from published investigations. The majority of investigators state that no significant memory loss or other intellectual impairment remains two or three weeks after treatment 1—4. One study 5, however, noted that 5 patients, otherwise fully recovered, reported defects affecting long familiar names of 6 and Zubin places, found no indication lasting a year or more. persons �Korin, Fink and Kwalwasser 89 that electroshock destroyed memory traces, and concluded that where memory loss persists, the progress is one of slow recovery rather than obliteration. In studies of personal memories selective circumscribed amnesias at least four and five weeks after therapy are described for material elicited in pretreatment interviews 7' 8. The amnesias, however, are construed as due to subtle emotional factors, rather than permanent 8 memory loss. From such observations, Janis postulates that memory impairment facilitates repressions and thereby reduces affective disturbances. Regarding the question of memory impairment as a prerequisite for improvement, Wilcox 9 notes that three techniques of electroconvulsive therapy, namely, the “organic shock”, the “standard” or Cerletti and the “brain-facilitation” techniques, are based on concepts which attribute varying degrees of importance to amnestic change. Studies based on the “brain-facilitation” technique where the low current type Reiter and “brief-stimulus” electrostimulators are used, emphasize the diminished memory change induced as compared to the “standard technique”, although reported therapeutic results are analogous 1°. Hoch and Kalinowsky 11, believe the “standard” technique to be the most effective therapeutically; and numerous clinicians using the “organic-shock” method hold that a 12. is for of electroshock essential success therapeutic regressive type 13 Wilcox of In a specific study this problem, recently found no relation between improvement and either the treatment induced confusion seen immediately following an initial Reiter electroshock, or after a series of ten electroshocks. Method and Materials The subjects are 40 consecutive patients referred for electroshock treatment and 21 untreated controls at Hillside Hospital. The clinical diagnosis in the electroshock patients include involutional depression, 7; manic depressive psychosis, 18; reactive depression, 4; paranoid schizophrenia, 3; catatonic schizophrenia, 5 and hebephrenic schizophrenia, 3. The depressed patients tend to be older — between 40 and 68 years of age; the schizophrenic patients are younger, between 24 and 40 years. For the untreated group, patients designated as possible electroshock candidates were selected. They are a representative sample of the electroshock group matched proportionately with respect to diagnosis, age, education and previous electroshock treatment. The Reiter CW 47 C electrostimulator was used in all cases. Treatment was administered on alternate days 3X per week, and was reduced after the second week depending on the clinical condition of the patient. 8 Confinia Neurologica, Vol. 16, No. 2/3 (1956) �90 Korin, Fink and Kwalwasser, Relation of Changes Methodologically, the study involves a test of the ability of patients to recall an original learning of lists of eight, three letter common words, at weekly intervals under two conditions: (a) immediately after an interpolated learning of a list of nonsense syllables; (b) after a ten minute rest period during which a copy of “Life” magazine is read. The choice of testing method and materials was based on studies in retroactive inhibition which indicate that the degree of retention of a learning task varies with the type of activity interposed between an original learning and the later measurement of retention. Thus, by interpolating nonsense syllables and the reading of a magazine on separate test days each week, two indicators of recall function of varying sensitivity are obtained. In the test procedure lists of common words and nonsense syllables are arranged according to established experimental procedures respecting successive consonants and vowels 14. Each list of words was presented manually on flash cards by the examiner. The time interval of exposure was not definite during learning and seldom exceeded five seconds. For recall, however, 10 seconds was uniformly permitted. In the presentation of the lists for the interpolation condition the common words were presented for a maximum of ten trials; or less if the list was learned earlier. The list of nonsense syllables was then similarly presented. In the no-interpolation condition the learning procedure was similar, except that reading “Life” magazine was substituted for the nonsense syllables. Each condition was tested weekly on non-electroshock days, alternating between successive treatments. The control group was tested in the same way, twice weekly for five weeks, to simulate the testing for 12 electroshock treatments. Following completion of treatment, ratings of improvement were determined independently by the supervising psychiatrist on the basis of observations of ward behavior and psychiatric interviews. The improved patients were those in whom there was a marked change in behavior, and whose acute symptoms had subsided. In the moderately improved The behavior but in persisted. transient there change symptoms a was group, unimproved patients were those in whom symptoms persisted or increased and in whom there was no change in behavior. Results (I) Original and Interpolated Learning. Impairment in learning function occurred during treatment in the electroshock group. This was seen in the increased mean number of failures to learn the words and syllables as the number of treatments increased (Fig. 1). The decrement in learning is maximal in the 4—6 and 7—9 electroshock periods. In the 10—12 treatment period this decrement in learning ability decreases. This decrease may be the result of a change in therapy from three to two treatments weekly in many of the patients. Considerable recovery in learning function 3—4 administered when at day intervals. treatments are occurs �in Memory and Learning to Improvement in Electroshock 9]. RELATION OF ERRORS IN LEARNING TO ELECTROSHOCK TREATMENT 50 \ / +/_____ n‘ + 0Z 40 2 E 30 Lu .1 E U) (I O ELECTROSHOCK GROUP 0—4- 0—0 LEARNING 0F NONSENSE SYLLABLES LEARNING OF COMMON WORDS UNTREATE o GROUP + o---+ + 0—--o LEARNING LEARNING or Nonsense POST POST TREATMENT 3 WK. SYLLABLES or connou wonos 20 O: 5 IO 0 PRE TREATMENT I «3 4 -6 7-9 IO-I2 POST TREAT— MENT I WK. TREATMENT ZWK. INTERVAL OF TREATMENT Fig.1 Following termination of therapy, the decrement in learning is completely reversible, so that the mean errors are significantly fewer than pretreatment. For the untreated group, the errors decreased in each of the simulated intervals of electroshock (Fig. 1), probably due to the factor of practice. These data for original and interpolated learning indicate therefore that a significant decrement is obtained during electroshock which is reversible after termination of therapy when intra-individual comparisons are made. This observation confirms previous reports 1—4. (II) Recall-Interpolation and N o-Interpolation. On tests of recall of learned words after interpolation, the decrement from pretreatment was significant at the l per cent level for all intervals of treatment in the electroshock group. In contrast with the original and interpolated learning which was first significantly altered during the 4—6 treatment period, the recall function was significantly impaired within the 1—-3 interval (Fig. 2). When evaluations are made of recall of the learned word lists after reading “Life” magazine (“no-interpolation”), the changes are similar �92 Korin, Fink and Kwalwasser, Relation of Changes . RELATION OF RECALL OF COMMON WORDS TO ELECTROSHOCK TREATMENT RECALLED WORDS COMMON a "°__-_ .—a o——--""° MEAN ELECTROSHOCK GROUP +——+ no INTERPOLATION o mrenpounou UNTREATED GROUP 4----+ o---c PRE TREATMENT l-3 4-6 7-9 IO-IZ POST TREATMENT l WK. POST TREATMENT 2 WK. N0 INTERPOLATION INTERPOLATION POST TREATMENT 3 WK. INTERVAL OF TREATMENT Fig. 2 to those obtained for original and interpolated learning. These observations indicate that the type of activity interposed between an original learning and a later measurement of retention is an important and useful factor in eliciting subtle changes in function. Post therapy, the decrement is reversible for both interpolation and no-interpolation recall. The foregoing results indicate that a significant memory change occurs within the 1—3 treatment period and that recall following interpolation is a more sensitive measure of change in function than learning. (III) Relation of Recall and Learning Responses to Improvement. In the analysis of individual data for the relation of recall function to clinical improvement, the scores of 38 patients, treated three times 3 Of assessed. week for least weeks, these, twenty-nine were at per showed a pattern of decrement in recall function (scores of zero or below pretreatment). Of the matched controls, four showed the same pattern of decrement in recall in a similar testing period while seventeen showed no decrement. �in Memory and Learning to Improvement in Electroshock 93 The treated patients were then characterized as to improved, moderately improved, and unimproved by the supervising psychiatrist in charge of the electroshock treatment unit. The number of subjects in each group are tabulated according to memory loss in Table 1. ' TABLE 1 Decrement and No Decrement Groups During Recall Compared with Respect to Degree of Improvement Improved Moderately Improved Unimproved Decrement No Decrement l2 2 4 1 13 6 To facilitate statistical study the improved and moderately improved groups are combined, and compared with the unimproved group. A chi square of .22 indicates that no significant difference between these two groups exists. Thus, there is no indication that clinical improvement is necessarily related to decrement on interpolated recall tests. Following this analysis for recall, the data for the learning of common words is similarly evaluated. Of the 38 patients, 26 showed a pattern of decrement in learning function (number of errors above pre-treatment), and 13 showed no decrement (errors below pretreatment score). In the control group of 21 subjects, only one subject was in the decrement range. When these patients are grouped according to their psychiatric ratings, there is an apparent relationship between improvement and decrement in learning (Table 2). This relationship, however, is not statistically significant by the chi square test. It is concluded, therefore, that no relation exists between clinical improvement and decrement in the pattern of learning. The above patterns of response are based primarily on changes during the 4—6 and 7—9 intervals of treatment. For the majority of patients, these are points of maximum decrement, and at such times electroshock therapy was reduced or discontinued. Five patients, however, were treated three times per week for 18 or more treatments. Clinical changes during this period were minimal and following . �Korin, Fink and Kwalwasser, Relation of Changes 94: TABLE 2 Comparison of Degree of Decrement During Learning with Ratings of Improvement Decrement +++ ++ Improved 7 (44%) 3 Moderately Improved 2 (40%) 0 Unimproved 4 (24%) 3 No Decrement — —— + (18.5%) 2 (12.5%) l (20%) (18.5%) 3 (18.5%) 2 (12.5%) 2 (12.5%) 1 (20%) 1 (20%) 1 (6%) 6 (35%) termination of therapy, all were rated as unimproved. The learning patterns in these patients remained at a minimal or no decrement level throughout. For recall following interpolation, however, these patients showed a decrement during treatment with scores below both pretreatment and also post therapy. Thus, these patients did show evidence of brain dysfunction by the more sensitive recall interpolation variable. Nevertheless, failure to develop changes in the learning function after relatively prolonged treatment suggests that improvement is unlikely when there is minimal brain dysfunction. This interpretation of the data is supported by the findings of Kahn and Fink 15 who, in this laboratory, used the electroencephalogram and Amytal tests 16 as indices of cerebral change, and found a high correlation between degree of brain dysfunction and improvement. Discussion In similar investigations of memory function with lists of words and syllables, the learning task was completed before therapy and recall was tested at varying intervals after termination of therapy. In this study serial measures of change in learning and recall obtained on the day following treatment are assessed. As group data, they verify the findings of other investigators that significant decrements in learning and recall functions occur during electroshock which are reversible by the third week following termination of therapy. Recall after interpolation is the most sensitive indicator of dysfunction. For this variable, a significant pattern of decrement is evident in 29 of 38 of the electroshock group. Thus, the majority of these patients show some quantifiable memory change during treat- �in Memory and Learning to Improvement in Electroshock 95 in the occurs impairment significant a memory ment. Furthermore, 24 hours measurable is 1—3 which the treatments between week first electroReiter the is This though EST. even true after the single stimulator used here is reported to minimize amnestic efi'ects. During and second the is during only significant the impairment learning, week 7—9 4th the In and interval). (4—6 of weeks treatment third This of the scores. less is learning there impairment (10—12 interval) of method treatment of is artefact particular a an however, change, clinical favorable reduced is a as electroshock frequency whereby 7—9 interval, the the between Thus, becomes apparent. response 20 others are on reand discontinued is 12 of patients treatment of the mefor peak most patients Nevertheless, duced treatment. ninth and treatments. fourth the between reached is decrement mory time. this derived is benefit at therapeutic Seemingly, greatest When the patients categorized according to individual patterns of their with ratings and compared recall are both learning in response of improvement, a relatively high proportion with marked memory brain that dysfunction This finding fail suggests to improve. changes induce sufficient is a to recall and not measured learning 36 by as per Wilcox her in reached conclusion A by similar was effect. therapeutic 13. this in The data study confusion of to relation of therapy the study further indicate that when only minimal memory impairment deveresult. is to likely no improvement after prolonged treatment, lops While some of the patients in this study seemed to benefit thera- peutically with minimal memory impairment within ten treatments, of indices brain dysother with marked showed changes usually they 15. As these patients are and EEG test the Amytal such function as in rather treatdiscontinued early reduced or frequency placed on receivwith them patients is to there no opportunity compare ment, similar fashion, basis. In week times three a 20 a on treatments ing also has and of lack improvement no between change a relationship been observed in a study of eosinophile levels following electroshock 17. is here measured not as induced the impairment Although memory subtle remains that the possibility related to improvement, directly 7» 3 memories selective of the facilitate repression changes memory reinforce which such denial, reactions defensive as of or the emergence mechanisms defense 15. these induced by behavior in Changes changes used in this those than other with measurable be techniques may study. �Korin,Fink and Kwalwasser 96 Summary and Conclusion Studies of changes in learning and recall function during electroshock were undertaken. Group data indicated: (1) a significant decrement in the recall of common words following the interpolated learning of nonsense syllables which persisted during all intervals of treatment (P = .01) for both intra- and inter-group comparisons; (2) a significant decrement in learning at the 4—6 and 7—9 interval of treatment where change from intra-individual pretreatment scores was maximum; (3) the return of both learning and recall functions to the pretreatment level or better within 3 weeks of termination of treatment. Analysis of individual patterns of response indicated that 29 of 32 patients showed a pattern of decrement following recall with interpolation during treatment. When the improved and unimproved patients were evaluated res P ectin g the P resence of memorY imP airment, no si gnificant difl'erence was obtained between the two groups. It is concluded that electroshock with the Reiter CW 47 C electrostimulator (1) induces memory change as measured here and that such change is reversible; (2) that marked memory changes are not a prerequisite for improvement but that (3) the lack of marked memory changes with 20 treatments is associated with lack of improvement. Bibliography 2 — 1947. abnorm. 206, Brower, D., and S. OppenP.: J. soc. Psychol. 42, heim: J. gen. Psychol. 45, 171, 1951. — 3 Luborsky, L. B.: J. nerv. ment. Dis. 107, 531, 1948. - 4 Michael, S. T.: Arch. Neurol. Psychiat. Chicago 71, 362, 1954. — 5 Brody, M. D.: J. ment. Sci. 90, 777, 1944. 6 Zubin, J.: J. Personality 17, 33, 1948. 7 Janis, I. L..' J. Personality 17, 29, 1948. — 8 Janis, I. L., and M. Astrachan: 9 — 1951. Wilcox, K. W.: Papers of Michigan abnorm. 501, 46, Psychol. soc. J. 1“ Liberson, W. T., and — 1949. Arts and of Letters 35, 357, Science, Academy P. H. Wilcox: Digest Neurol. Psychiat. 13, 292, 1945. 11 Hoch, P. H., and L. B. Kalinowsky: Shock Therapy: Psychosurgery and Other Somatic Procedures in — 12 Kennedy, C. J. C., and D. Anchel: & 1952. New York Grune Stratton, Psychiatry. 13 — 1942. Wilcox, K. W.: Confin. neurol. 14, 318, 1954. 317, 22, Psychiat. Quart. 14 Stevens, S. S.: Handbook of Experimental Psychology. J. Wiley & Sons, N.Y. 1951. — 15 Kahn, R. L., and M. Fink: Relationship between Altered Brain Function and Denial in Electroshock Therapy. Presented at American Psychiatric Association Meeting in Atlantic City, May 1955. — 1“ Weinstein, E. A., R. L. Kahn, L. A. Sugar17 1953. Amer. L. Alexander, S. P., and J. and Linn: 109, 389, J. Psychiat. man F. Neander: Arch. Neurol. Psychiat. (Chicago) 69, 368, 1953. 1 Stone, C. — —— —— —— �April 15, 1955 Relation of Changes in Memory and Learning to Improvement in Electroshock* by Hyman Max Korin, M.S. (1) Fink, rm”). (2) and Simon Kwalwasser, M49. (3) From the Research Service of Hillside Hospital, ulen Uaks, New York *This investigation'was supported (in part) by a research grant from the National Institute of HA92? Mental Health, Public Health Service: (1) Research.Assistant (peychology) (2) Director of Research (3) Associate Medical Director �Relation of Changes in Memory and.Learning to Improvement in Electroshock In the course of studies of the relation between altered brain function and improvement following electroshock therapy, the present investigation of memory functions was undertaken. variables, an attempt is made serial testing of learning By first to study and quantify and recall memory changes; and then to determine the relationship between therapeutic outcome and such changes. effects during electroshock therapy are commonly observed, and are both of practical and theoretical interest. Although differences in methodAmnestic ology, materials, subjects and electroconvulsive techniques make direct compar- ison difficult, a few conclusions related to the question of concern in this study can be derived from published investigations. The majority of investigators state that no significant other intellectual impairment remains study, (5) however, noted that two memory loss of or three weeks after treatment (l-h). patients, otherwise fully recovered, reported defects affecting long familiar names of persons and places, lasting a year or more. Zubin, (6) found no indication that electroshock destroyed.mems One 5 cry traces, and concluded that where memory loss persists, the progress is one of slow recovery rather than obliteration. In studies of personal memories selective circumscribed amnesias at least four and five weeks after therapy are described for material elicited in pretreatment interviews (7) (8). The amnesias, however, to subtle emotional factors, rather than permanent vations, Janis (8) postulates that are construed as due loss. From such obserb facilitates repressions and memory memory impairment thereby reduces affective desturbances. Regarding the qestion of memory impairment as a prerequisite for improv- that three techniques of electroconvulsive therapy, " " the the standard or Carletti and the "brain-facil"organic shock", namely, ement, Wilcox (9) notes itation " techniques, are based on concepts which attribute varying degrees of importance to amnestic change, Studies based on the "brain-fanilitation" tech» �-2nique where the low current type Reiter and 'brief-stimnlus' electro-stimulators are used, emphasize the diminished memory change induced as compared to the "stand~ ard technique", although reported therapeutic results are analogous. (10) Kalinowsky (11), believe the "standard" technique is Koch and the most effective therap- clinicians using the "organic-shock" method hold that a therapeutic of electroshock is essential for success (12). In a regressive type eutically; and numerous specific study of this problem, Wilcox (13) recently found no relation between either the treatment induced confusion seen immediately following initial Reiter electroshock, or after a series of ten electroshocks. improvement and an METHOD AND MATERIALS. The ment and 21 subjects are ho consecutive patients referred for electroshock treatuntreated controls at Hillside Hospital. The clinical diagnosis in the electroshock patients include involutional depression, 7; manic depressive psychosis, 18; reactive depression, h; paranoid schizophrenia, 3; catatonic schizophrenia, 5 and hebephrenic schizophrenia, 3. The depressed patients tend to be older - between to and 68 years of age; the schizophrenic patients are young- years. For the untreated group, patients designated as possible electroshock candidates were selected. They are a represenative sample er, between 2h and he of the electroshock group matched proportionately with reSpect to diagnosis, age, education and previous electroshock treatment. The was Reiter CW h? C electrostimulator was used in all cases. Treatment administered every day, and was reduced after the second week depending on the clinical condition of the patient. test of the ability of patients to recall an original learning of lists of eight, three letter common words, at weekly intervals under two conditions: (a) immediately after an interpolated learning of a list of nonsense syllables; (b) after a ten minute rest period during which a copy of "Life" magazine is read. Methodologically, the study involves a �The choice of testing method and materials was based on Studies in retro- active inhibition which indicate that the degree of retention of a learning task varies with thetype of activity interposed between an original learning and the later measurement of retention. Thus, by interpolating nonsense syllables and test days each week, two indicators of recall function of varying sensitivity is obtained. In the test procedure lists of common words and nonsense syllables are the reading of a magazine on separate arranged according to established experimental procedures respecting successive consonants and vowels (1h). Each cards by the examiner. The time list of words was presented manually on flash interval of exposure was not definite during learning and seldom exceeded five seconds. For recall, however, 10 seconds was uniformly permitted. lists for the interpolation condition the maximum of ten trials; or less if the list was In the presentation of the words were presented earlier. The list for a common learned of nonsense syllables was then similarly presented. In the no-interpolation condition the learning procedure was similar, except that reading "Life" magazine was substituted for the nonsense syllables. Each condition was tested weekly The on non-electroshock days, control group was alternating between successive treatments. tested in the same way, twice weekly for five weeks, to simulate the testing for 12 electroshock treatments. Following completion of treat- ratings of improvement were determined independently by the supervising psychiatrist on the basis of observations of ward behavior and psychiatric interviews. ment, The improved patients were those in whom and.whose acute symptoms had subsided. there was a marked change In the moderate improved group, there was a transient change in behavior but symptoms persisted. were those in in behavior. whom symptoms in behavior, persisted or increased and The unimproved in whom patients there was no change �RESULTS 1. Original and.Interpolated Learning - in learning function occurred during treatment in the electrogroup. This was seen in the increased mean number of failures to learn the and syllables as the number of treatments increased (Fig.1). The decrement Impairment shock words in learning is maximal in the h—6 and 7-9 electroshock periods. In the 10—12 treatment period this decrement in learning ability decreases. This decrease be the result of a change in therapy from three to two treatments weekly in of the patients. \ Considerable recovery in learning function occurs when at 3-h ments are administered day mean many treat. intervals. Following termination of therapy, the decrement reversible, so that the may in learning is completely errors are significantly fewer than pretreatment. For the untreated group, the errors decreased in each of the simulated intervals of electroshock (Fig. 1), probably due to the factor of practice. This'data for original and interpolated learning indicates therefore that a reversible which obtained significant-decrement is during electroshock after is termination of therapy when intra-individual comparisons are made. This obser- _vation confirms previous reports (l—h). II. Recall—Interpolation and no-Interpolation Ontests of recall of learned.words from pretreatment'was significant at the l after interpolation, the per cent level for decrement all intervals of treatment inThe electroshock group. In contrast with the original and inter- polated learning which was first significantly altered during the h-6 treatment period, the recall function'was significantly impaired Within the 1-3 interval. (Fig. 2) When evaluations are made of recall of the learned word lists after reading "Life" magazine ("no-interpolation"), the changes are similar to those obtained for original and interpolated learning. These obserbations indicate thatthe type �later of activity interposed between an original learning and a measurement of re- tention is an important and useful factor in eliciting subtle changes in function. reversible Post therapy, the decrement is for both interpolation and no-interpolation recall. foregoing results indicate that a significant The in the 1-3 treatment period sensitive measure of change III. occurs with- that recall following interpolation is in function than learning. and a more Relation of Recall and Learning Responses to Improvement In the analysis of individual data for the relation of recall fun- ction to clinical improvement, the scores of week memory change for at least 3 weeks, were assessed. Of 38 patients, treated three times per these, twenty-nine showed a pattern of decrement in recall function (scores of zero or below pretreatment). of the pattern of decrement in recall in a similar matched controls, four showed the same testing period while seventeen showed no decrement. The treated patients were then r‘cate'gorizled. as to improved, moderately improved, and unimproved by the supervising psychiatrist in charge of the electro~ unit. The number of subjects in each group are tabulated accordloss in Table 1. shock treatment ing to memory Table I. Decrement and No Decrement Groups During Recall Compared with Reapect to Degree of Improvement. Decrement Improved 12 Moderately Improved h Unimproved To No 13 facilitate statistical study the Decrement 2 ’ 1 6 improved and moderately improved groups are combined, and compared with the unimproved group. A chi square of .22 indicates that no significant difference between these two groups exists. Thus, there is no indication that clinical improvement is necessarily related to decrement on interpolated recall tests. �this analysis for recall, the data for the learning of common words is similarly evaluated. Of the 38 patients, 25 showed a pattern of decrement in Following learning function (number of errors above pre-treatment), and (errors below pre-treatment score). In the control group of ment only one subject was When is 13 showed no in the decrement range. relationship between improvement and decrement in learning (Table 2). is not statistically significant This relationship, however, concluded, therefore decrement subjects, 21 these patients are grouped according to their psychiatric ratings, there an apparent It is decre- that by the chi square relation exists between clinical no test. improvement and in the pattern of learning. Comparison of Degree of decrement During Learning with Ratings of Improvement. Table 2: Decrement +++ 7(ML%) 3(1805%) Improved 2(h0%) 0 Unimproved h(2h%) 3(18.5%) Improved Moderately ++ - + No Decrement - 2(12 05%) 2(1205%) 2(1205%) 1(20% l(20%) l(20%) 3(18.5%) 1(6%) 6(35%) patterns of response are based primarily on changes during the and 7-9 intervals of treatment. For the majority of patients, these are The above h—6 at such times electroshock therapy was reduced or discontinued. Five patients, however, were treated three times per week for 18 or more treatments. Clinical changes during this period were minimal and points of maximum decrement, and following termination of therapy, all were rated as unimproved. patterns in these patients remained at a minimal or For recall following interpolation, however, these no decrement patients The learning level throughout. showed a decremhnt during treatment with scores below both pretreatment and also post therapy. these patients did show Thus, evidence of brain dysfunction by the more sensitive re- call interpolation variable. 1“evertheless, failure to develop changes in the learning function after relatively prolonged treatment suggests that improvement is unlikely when there is minimal brain dysfunction. This interpretation of the �data is supported by the findings of Kahrland Fink (15) who, in this laboratory, used the electroencephalogram and Amytal tests (16) as indices of cerebral change, and found a high, correlation between degree of brain dysfunction and improvement. DISCUSSION In similar investigations of the learning task memory function with lists of words and syllables, before therapy and recall was tested at varying was completed intervals after termination of therapy. In this study serial measures of change in learning and recall obtained on the day following treatment are assessed. As group data, they verify the findings of other investigators that significant decrements in learning and recall functions occur during electroshock which are reversible by the third week following termination of therapy. Recall after interpolation For is the most this variable, a significant pattern of sensitive indicator of dysfunction. decrement is evident in the electroshock group. Thus, the majority of these patients show memory change in the first the single some of 38 of quantifiable during treatment. F'urthermore, a significant memory impairment occurs week between This EST. is reported to 29 the 1-3 treatments which is true even though the Reiter minimize amnestic effects. measurable 2h hours after electrostimulator used here During learning, the impairment significant only during the second and third terval). In the hth is is weeks of treatment (h-6 and 7-9 in, interval) there is less impairment of the learning scores. This change, however, is an artefact of a particular method of treatweek (10-12 ment whereby electroshock frequency becomes apparent. is reduced as a favorable clinical response Thus, between the 7-9 interval, 12 patients are discontinued and 20 others are reduced. Nevertheless, for most patients the peak of memory decrement is reached between the fourth and ninth treatments. Seemingly, greatest therapeutic benifit is derived at this time. When the patients categorized according to individual patterns of response in both recall and learning are compared with their ratings of improvement, a �relatively high proportion with marked memory changes fail to improve. This finding suggests that brain dysfunction pg; §g_as measured by learning and recall is not sufficient to induce a therapeutic effect. A similar conclusion was reached by Wilcox in her study of the relation of confusion to therapy(13). The data in this study further indicates that when only minimal memory impair- after prolonged treatment, of the patients in this study ment develops no improvement While some seemed is likely to result. to benefit therapeutically with minimal memory impairment within ten treatments, they usually showed marked test changes with other indices of brain dysfunction such as the.EEG and.Amytal (15). As these patients are placed on reduced frequency or discontinued rather early in treatment,'ueiris no opportunity to compare then with patients re- ceiving 20 treatments on a three times a week basis. In similar fashion, a relationship between lack of change and also been observed. in a study of eosinophile levels following electroshock (17). no improvement has Although the induced memory impairment as measured here related to improvement, the possiblity remains that subtle ilitate is not directly memory changes fac- the repression of selective memories (7,8) or the emergence of de- fensive reactions such as denial, which reinforce changes in behavior (18). Changes induced by these defense mechanisms may be measurable with techniques other than those used in this study. �SUMMARY AND CONCLUSION Studies of changes in learning and recall function during electroshock were undertaken. data indicated: (1) a significant decrement in the recall of common words following the interpolated learning of nonsense syllatles which persisted Group all intervals during of treatment (P = .01) for both intra parisons; (2) a significant decrement in learning at the and h—é enter group and 7-9 comp interval of treatment where change from intra-individnal pretreatment scores was max(3) the return of both learning and imum; level or better within 3 weeks recall functions to the pretreatment of termination of treatment. Analysis of individual patterns of response indicated that 29 of 32 pat- ients Showed a pattern of decrement following recall with interpolation during treatment. When the improved and unimproved patients were evaluated respecting the presence of memory impairment, no significant difference was obtained between the two greups. It is or induces 2) that that electroshock with the Reiter CW h? C electrostimnlat-“ change as measured here and that such change is reversible; concluded memory prerequisite for improvement but that'changes with 20 treatments is associated with lack marked memory changes are not a 3) the lack of marked memory of improvement. �[REFERENCES l. Stone, C.P.: Losses and Gains in Cognitive Functions as Related to Electroconvulsive Shocks, Journal of Abnormal and Social Psychology, ha: 2-6-21u, (April) 19u7. 8.: Effects of Electrcshock Therapy on Mental Functions as Revealed by Psychological Tests, Journal of General Psychology, g5: 171-188, (April) 1951. Brewer, D. and Oppenheim, ,The Luborsky, L.B.: Psychometric Changes During Electric Shock Treatment, JOur. Nerv. and Ment. Disl, 191: 531-536, (June) l9h8. - Michael, S.T.: Impairment of Mental lfunction During Electric convulsive Therapy, A.M.A. Arch.Neurol. and Psychiat. 11:362-366, 195k. Brody, M.D.: Zubin, J.: Prolonged Memory Defects Following Electrotherapy, Jbur. Ment. Sci. 90: 777-779, (July) 19hh Functioning in Patients treated with Electric Shock Therapy, Journ/ pf Berspnality, 17: 33-h1, (April) l9h8. Memory Janis, I.L.: Fellowing “lectroc Convulsive Treatments, JOurn. of Personality, 11: 29-32, (April) 19h8. Memory Loss Janis, I.L.and.Astrachan, M.: The Effect of Electroconrulsive Treatments on Memory Efficiency, Journ. Abner. and boc. Psych., fig; 501511, (October) 1951. 9. wilcox. . K;W;: Psychological Studies in filectroshock Therapy, Michigan Academy of Science, Arts and J«etters, 357-368, l9h9. ii: Electric Uonvulsive Therapy: 10. Liberson, W.T. and wilcox, PlH.: Comparison of Brief Stimuli Technique with the Friedman Wilcox - Reiter Technique, ”igest Neural. and Psychiat. 12; 292-302, l9h5. — L.B.: Shock Therapy: Psychosurgery and Uther Somatic Procedures in Psychiatry, Grune and Stratton, New York Hoch, P.H. and Kalinowsky, 1952. 12. Kennedy, C.J.C., and Anchel,D.: Regressive Electric Shock Thur: Treatment in Schizophrenics Refractory to Other Shock Therapies, Psychiat. Quart. fig; 317, 19h2. 13. Wilcox, K.W.: finia S.S. Stevens: 1951. 15. Confusion and Therapy in Electroconvulsive Treatment, ConNeurologica, lg; 318-326, l95h. Handbook of Experimental Psychology, J. Wiey and Sons, N.Y., Fink,M .: Relationship Between Altered Brain unction and Denial in Electroshock Therapy, Presented at American Psychiatrifl Associatimn, May 1955. Kahn, R .L. and - �.12- 16. Whinstein, E.A., Kahn, R.L., 5ugarman, L.A., and Linn, L.: The Diagnostt Use of Amobarbital Sodium ("Amytal Dodiumf') In Brain Disease, Amer. Jour. Psych. ;92: 889-89h, (June) 1953. 17. Alexander, S. P. and Neander, J.F1: Adrenocortical Responsivity to Electic Shock Therapy and Insulin Therapy, Arch. Neurol. and Psychiat. 92: 368-371;, (March) 1953. �up“ ELECTROSHOCK RESEARCH ASSOCIATION DFF'GERS 1954‘1955 DR. PHILIP a. REED, (Ex-Plaza.) 1800 E. TENTH S12, INDIANAFULIS 1. IND. on. TITUB H_ HARRIS, 316 STRAND, BALVESTDN, TEXAS DR. HOWARD D. FAEINB 2314 AUBURN AVENUE, CINCINNATI 19. :1th DR. ERNEST H. PARSONS DR. BERNARD L. PAGELLA, FEES. a. 5131. 57.. New YORK 21. N. Y. DR. WILLIAM L. HOLT, dflq VICE-FEES. ALBANY HOSPITAL. ALBANY, N. Y. DR. PAUL H. WILCDX, SEC'Y-TREAI. 526 w. TENTH 5T.. TRAVERBE ClTv. MIGHi us (“dun“) nggg; may PRLLE AWARD 8, 1955 Atlantic City, m.J. Prize Paper: at on of Uh 'earnin to es ‘n memorr nd in electroshock 1m rovement by Korin, a.S. Fink, M.D. Hyman max and Simen nwalwasser, m.D. hillside Hospital, Glen Oaks, m.r. the Prize Committee, wish to congratulate the authors on their excellent paper. Our decision was made because this paper is based on a carefully worked out research design and reports the development of a sensitive measure of the transient mental impairment occurring following elecfipshock convulsions. We anticipate that this method will have broad ap;licatmon in the evaluation of the various physiodynamic We, therapies." Enclosed herewith is a check for $100.00 to be divided among the authors. iguana liBernard L. Pacella, m.u. i M; ta ”William L. «4 /,/% 7w, 3m. nolt, dr., :7 7v - . ~p . MIA/Mb» PM Paul Wilcox, H. m.u. The Electroshock Research Association is incorporated under the laws of Michigan as a non-profit corporation to promote and coordinate research and clinical investigations regarding electroshock therapy and related therapies in mental diseases. �w.-b :: m and Clinical threats 0: New Wattle amdmguith maptic pregame: aniline-ta theme: Sam Medias have iadieatad meme}, its nee thnnuwith untrusel and in aativeting the m. pnamt away emeem r _ _ ephrenia and suspected that tint 1a” aypmhmian mm it in a safer and antler drug Heginida also has an enema-barbiturate an evaluatim with ta use effect. a» at these properties at agenda. ho patients with meal aim”, chiefly achie- invelatiml «pneum, as well as more}. We brain disease, mm studied. with definite er gums mid. it is available in sciatica: for m. mention at a mum. emu-sum a: 0.5% (5 mg. in Ice). Itmmmmuamtemedmbedyunight. This ranged flames is a eyelie derivative ef truth tam eaparninnta 03‘20 to 95m. perms. 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Psmgs tho stage at metabolism at museum in the tether stats muted or barbiturate 11:12th «mime! is the pmestt than. study is éiftwent in the am]. Wimto poisoning. negate has Maptic 1.. pm 193a appmmum than mm“). ta in mutating gamma. appears to page 2. properties statue:- ta these es and mm)... It my be an W drag mmtsnmtagmmtemmemsimmmmsfmm ital. Its eg the use Maui». ‘ tht I at barbiturate panning m further in.» � 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 changes in memory and learning to improvement in electroshock. Confinia Neurologica 1956;16(2-3):88-96. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-19-023 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 Korin, H; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kwalwasser, 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 publication. Confinia Neurologica. Proceedings of the Eleventh Annual Meeting of the Electroshock Research Association Atlantic City, New Jersey, May 8, 1955. From the Research Service of Hillside Hospital, Glen Oaks, New York. 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/a0dd669fe6ef80d3f920fa82ad004579.pdf 922f3407ada0d1bf7f975f2fcd3d0f5a PDF Text Text From the Journal of the Hillside Vol. VI October, 1957. I1oslojfoait, ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M—927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK unclear. In a review of the problem (3) consideration was given to hypotheses ascribing significance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink of the organization “no explains that adequately theory one note this pattern. Learning and maturation are probably factors, but it brain with of studies In inherent.” be patients to mostly appears disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed significance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted specifically that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sucking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an second holds it wherein and appendage tension-relieving exploring place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic view was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patloss of alteration there when or was an only terns were apparent the that demonstrated exfurther discrimination. They two-point tinction of the hand stimulus by a stimulus to the leg could be cheek the of dominance hand. The the stimuli four to overcome by the stimuli altered to be ten by however, could hand the not, to hand in their subject. The basis for these phenomena is” �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 3%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained affixed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (I) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were first determined. At a frequency of .3 cycles /second, and a pulse �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Increments of 5 volts were applied to the hand and increments of 1 volt to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both parts were stimulated simultaneously, or one part singly, in a mixed order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical significance. Variability of the threshold is considerably greater in the hands and legs than in the cheeks. There is virtually no overlapping of thresholds, however, Where the cheeks and the hands are concerned. A. �STIMULUS INTENSITY IN PERCEPTION 245 I Mean Thresholds and Standard Deviations of Body Parts TABLE Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not significant (Table II). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a significant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE II Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Significance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek Difference Significance Threshold .39 .45 .06 N.S. Both Cheeks at Suprathreshold Right Cheek at .18 .37 .19 NS. .96 .14 .82 p<.05 .03 1.28 1.25 p<.01 Both Cheeks at Suprathreshold and Left Cheek at Threshold Left Cheek at Suprathreshold and Right Cheek at Threshold therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the dilferences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical significance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a significant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION TABLE 247 IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold“ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek B-Hand 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 A-Left Cheek B-Right Cheek * Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. extinctions are elicited when homologous parts are stimulated. These findings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction followingelectrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the findings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in Simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of affixing electrodes to the skin. The findings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supin differences inference, By hypothesis. stimulus-intensity a ports threshold also play a significant role. That an intense stimulus elsewhere can raise the pain threshold and Wolf demonstrated been has by Hardy, 35 much cent as as per Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators how however, still remains, The stimuli 9). problem (8, other using it is that a pattern of dominance may be elicited when presumably stimuli. touch stimuli by are applied equivalent The results of this study suggest an explanation. Stimuli of for sensation threshold elicit a to intensities are required differing various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivastimuli the two body in parts, touching clinically lent. In contrast, are disproportionate relative to the threshold value although apthe of Because their in of application. intensity equal proximately differences in threshold for the hand and cheek, the tactile stimulus the than threshold the above is more cheek the proportionately to stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not double the elicited order by dominance the to strictly correspond simultaneous stimulation tests. Most difficult to reconcile is von which the of threshold penis, glans the that Frey’s finding pressure is second in dominance rank only to the cheek in a group of ten the while millimeter; 111 is tested, grams per square body parts 12 is is least dominant, only which at the grams of hand, threshold per square millimeter. feand male for the in area thresholds genital Unfortunately, thresholds of list Von determined. Frey’s been seldom have male (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the and warmth of the pain, perception clitoris, although or penis glans cold is well developed. It is quite possible that the punctate presthe where touch with genital area correlate does threshold not sure is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These findings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a definite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no definite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultaneous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not significant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a significant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springfield, 1952. (2) 111.: Charles Thomas, Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. é» Psychiat., 66: 855-362, 1951. �KORIN—FINK 250 (3) Bender, M. B.; Green, M. A. 8c Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. (5" Psychiat., 72:233-255, 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. 1. Nero. (5. Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Significance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Influence of Pains. Psychol. Forseh, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8: Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. ]. Nerv. 63'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. 8: Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46—58, 1952. (13) Hardy, J. D.; Wolf, H. S. 8: Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. 1. Clin. Invest., 19:649-658, 1940. (14) Linn, L.: Some Developmental Aspects of the Body Image. Int. ]. Psychoanal., 3621-7, 1955. (15) Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. ]. Invest. Derm., 18:447-451, 1952. (15) von Frey, M.: Beitrage zur Physiologic des Schmerzsinns. Ber. Sdchs. Ges. Wiss., 462185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47:166-184, 1895. �JOURNAL of the HILLSIDE HOSPITAL VOL. VI, No. 4 l . l OCTOBER, 1957' * . . CONTENTS Papers» from the Department of Experimental Psychiatry A UNIFIED THEORY: OF THE ACTION‘OF- PHXSIODYNAMIC- THERAPIEs—‘——Max Fink - ’ A 19.7 AN OBJECTIVE STUDY OF COMMUNICATION .IN‘ PSYCHIATRIC, INmRyIEws—Jbseph Iafle 207‘ SOCIAL FACTORS IN THE SELECTION OF THERAPY IN TA—RY MENTAL HOSPITAL—Robert and Max Fink L Kahn, Max Pollack SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN TO ELECTRosHOC'x—Martin A. Green A VOLUN- EEG .216 RESPONSE 229 ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTAN'EOUS‘ ELECTRICAL CUTANEOUS STIMULI—Hy‘mqn Max Fink Korzn and "241 ‘ NEWS AND NOTES -- "I ' ' I " " —— ——-——————_—. V , , V Published quarterly for the Hillside HOspit-al, Glen Oaks,- N. Y., by 7 ‘ 251 ' THESOCIETY 0F HILLSIDE HOSPITAL Copyfight_1957, The Society OE Hillside HOSpital, Inc. v” "V ' �Hillside Hospital is a nonsectarlan, nonprofit mental hospital for the treatment Of voluntary patlents sufferlng from early and curable mental illne-SS; regardless o'E the1r ability to pay. A special department for adolescents1's 1ncluded:1n the Hospital program. The Hospital teaches and trains" phys1c1ans ‘;in‘ psychiatry and psychotherapy, and also prOVidEs graduate training to graduate students1n psychology, social service and psych1atr1c nursing. Research programs are in progress in psychiatry, med1c1ne and1n the laboratories. The teaching and training program carefully organized and integrated with the clinical serv1ces and 1nvolves the participation of the administrative staff, a staif of superv1sors and the cooperation of a large psychiatric attendmg staff almost entirely psychoanalyti— cally trained. In addition to all the usual inpatient adjunctive therapies, the Hospital condiu‘cts anact’e extramural program including an aftercare clinic, an outpat1et1c11n1c affiliation with Adelphi College for the tralnmg'of’ psychologists, nurses and social workers, an organization of formerpatients; lectures to the general public, and a close affiliation with the LongIsland Jewish Hospital. The Hospital traces itsbegmmngsto orgamzatlonal meetings in 1917 held under the sponsorsh1p of Dr Israel Strauss which led to the formation of the Committee for Menta 'iI-Iealth among Jews, in 11919. Hillside Hospital was opened anddedlcated in 1927. Its original location was in Hastings-on-Hudson, mQVing' to its present location in 1941. It is an afliliate of Federatlon ofi Jewish Philanthropies of New York, and has been growmg stead1lyin bed capacity, the present size being 200 beds. is " ' �JOUBNAL of the HILLSIDE HGSPITAL Published as a function of the Publications Committee of the Medical Board. The Hospital is an agency of The Federation of Jewish Philanthropies of New York. VOL. VI, No. 4 OCTOBER, 1957 Editorial Advisory Board MORRIS B. BENDER, M.D. DUDLEY SANDOR LORAND, D. SHOENFELD, M.D. MD. Editor SIDNEY TARACHOW, MD. Associate Editors M.D. JOSEPH S. A. MILLER, M.D. ABRAHAM S. LENZNER, M.D. M. DAVID EPSTEIN, M.D. SYLVAN KEISER, M.D. EMANUEL KLEIN, Distributed by INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street, New York 11, N. Y. �Information to Contributors Manuscripts—Original manuscripts should be sent to Sidney Tarachow, M.D., 123 East 80 Street, New York 21, N. Y. All parts of the manuscripts should be typewritten, double-spaced, on one side of bond paper. References should conform to the style of this Journal. Reprints—Orders for reprints should be addressed to International Universities Press, 227 West 13 Street, New York 11, N. Y. ANNUAL SUBSCRIPTION, $3.00, SINGLE ISSUES, $1.00 Editorial communications should be addressed to Sidney Tarachow, M.D., Editor, Journal of the Hillside HosPital, 123 East 80 Street, New York 21, N. Y. Business communications, remittances, subscriptions and advertising material should be addressed to the Administrator’s Office, Hillside Hospital, Glen Oaks, N. Y. �EDITORIAL NOTE The Editors are happy to devote this issue to the work of one of the Hillside Hospital research departments, the Department of Experimental Psychiatry. While from time to time the pages of this Journal have carried reports of the various research activities within the Hospital, this is the first time that an entire issue of the Journal has been given over to presenting a comprehensive picture of the activities of a single department. Future issues will carry reports of our other research activities, in different spheres and carried on with varying methodologies. In our next issue we expect to present a large report on the many activities of the in-Hospital and attending staffs in professional and public education. We turn this issue over to the Department of Experimental Psychiatry. It is a young department, its workers are searching for scientific measurable factors in psychiatry, and hope by their findings to contribute to the multidisciplinary approach in psychiatry. 195 �PREFACE The reports in this issue of the Journal are representative of studies now in progress in the Department of Experimental Psychiatry. The Department was established in September 1954 upon the initiative of the late Dr. Israel Strauss. The goal of its full-time research personnel was defined as the study of psychologic and physiologic aspects of behavior. In establishing the operational, experimental principles of the Service we have leaned heavily on our previous experiences with Drs. M. B. Bender and E. A. Weinstein at the Bellevue and Mount Sinai Hospitals of New York. These studies are supported financially by the Board of Direc. tors of the Society of the Hillside Hospital. In 1954 the United States Public Health Service, National Institute of Mental Health established their support of the program, which has continued. Funds have also been obtained from the Dazian and Kaufmann Foundations, and recently from the Foundations’ Fund for Research in Psychiatry. The Staff has shown rapid growth, and at the present time includes: Martin A. Green, M.D. Joseph Jaf‘fe, M.D. Robert L. Kahn, Ph.D. ' Hyman Korin, Ph.D. Max Pollack, Ph.D. Assistant in Neurophysiology Assistant in Psychiatry Senior Assistant in Psychology Assistant in Psychology Senior Assistant in Psychology —— —- — — — Technical assistants include Mrs. Hannah Mosquera (EEG), Mrs. Jean Kolodny (Psycholinguistics) and Mrs. Janet Bowie (Secretary). During the past year Dr. Harold Esecover, Senior Resident in Psychiatry, has been associated with the Department on a half-time basis. October 10, 1957 Max Fink, M.D., Director Department of Experimental Psychiatry 196 �A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES1 MAX FINK, MD.2 The proper role of the physiodynamic therapies (convulsive, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neurophysiologic-adaptive View of electroconvulsive therapy has been presented (41, 32, 38, 1). This view ascribes the therapeutic process in electroshock to a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. The type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, an awareness of a similar mode of action in insulin coma (31) and lobotomy (40) has developed. During the past four years we have studied the relation between alteration in various indices of brain function and the behavioral response of psychiatric patients to therapy. The neurophysiologicadaptive view of electroshock has been supported and amplified (1 l, 12, 13, 19, 21); evidence for a similar view of insulin coma has been presented (22); and recently the concept has been extended to the newer “tranquilizers” (9). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the experimental evidence to determine whether or not the mode of action of each of these thera1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the 2nd International Congress of Psychiatry, Zurich, September 6, 1957. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 2Director, Department of Experimental Psychiatry, Hillside Hospital. 197 �MAX FINK 198 pies may result from their ability to induce sustained alteration in cerebral function; and the corollary question, whether measurable alteration in cerebral function is a necessary condition for the effi— cacy of these therapies, or a “complication” or “untoward effect.” The indices of brain function used in these studies have varied. These include memory scales (26), visual (20) and tactile (10) perceptual tasks, and changes in language patterns of orientation both clinically (19‘) and after intravenous amobarbital (21). In electroencephalographic studies of this problem, changes in the delta index, both in routine records (11, 12) and after activation by intravenous thiopentone (32, 33), and in the beta index (16) have been applied successfully. For this review, two indices will be stressed: changes in the delta index of the unactivated EEG, and clinical neurologic signs. These indices have been selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities. OBSERVATIONS (a) E lectrosh ock The following notes summarize our experimental studies of the role of changes in EEG delta activity in the response of subjects to electroshock (11, 13). In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. Grand mal treatments were administered three times a week, for twelve to twenty treatments. The EEG records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of “high,” “moderate” and “low” degrees of delta activity. At the end of treatment, the patients were independently rated for their shortterm clinical response into the categories of “much improved,” “moderately improved” and “unimproved.” In the initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of “much improved” was observed. Eighty per cent of the records in the much improved group were high degree delta by the fourth to sixth treatment; and the percentage was sustained at 90 per cent in the third and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the first three weeks, and only 20 per cent of the records in the fourth week were so classified. In a subsequent predictive study, the EEG records during the �THEORY OF PHYSIODYNAMIC THERAPIES 199 second and third weeks of treatment were analyzed. Of the patients who had high degree delta records on both occasions, 67 per cent were rated as much improved, while of the patients without such records, 70 per cent were in the unimproved and moderately improved categories. Roth (32, 38), studying the EEG delta activity evoked by intravenous thiopentone after electroshock, has related both the stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. He concluded that patients not attaining a specified delta activity level “have not acquired an adequate physiological basis for recovery,” and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of delta activity that vary from low to high, subconvulsive therapy rarely alters EEG patterns or induces low degrees of delta activity (13). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demonstrated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (13) recently completed here, twenty-seven patients received a course of subconvulsive therapy. Electroencephalograms, taken at weekly intervals, demonstrated minimal changes—none of the records were scored as middle or high delta activity. Of the twenty-seven patients, no change in behavior was noted in twenty-three, and of these, nineteen were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranquilizing Drugs When the newer drug therapies are studied from the viewpoint of their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electroencephalographic patterns. Based on observations made in chronic admin- �200 MAX FINK istration of drugs in adult psychiatric patients, the EEG changes may be classified according to predominant changes in the frequency spectrum. There are three broad types: 1. Increased slow wave activity with hypersynchrony (“bursts”)——“delta shift” 11. Desynchronization with voltage and frequency irregularity and irregular theta activity—“desynchronization” III. Increased high voltage fast activity—“beta shift.” Of the group of drugs inducing a delta shift, the phenothiazine derivatives chlorpromazine, promazine, and perphenazine are clear examples. Each drug induces seizures in nonepileptics or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). Each drug induces clinical parkinsonian neurologic patterns when given in adequate dosage. In our laboratories, we have induced parkinsonism in all patients receiving chlorpromazine (14) and have observed seizures in 10 per cent of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, was observed in more than half the patients in this series. Reserpine also evokes delta activity when given in large doses (2). At high dosage levels, it exaggerates seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in all patients. EEG changes were limited to desynchronization only, without delta burst activity. The primary response of two other drugs, mepazine and benactyzine, is the induction of EEG desynchronization. Mepazine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity (7). Delta activity has not been described, nor have we found reports either of seizures or parkinsonism in the clinical literature. Benactyzine, a potent anticholinergic compound, induces a blocking of alpha, flattening of the record and occasional theta activity (5, 17). Neither seizures nor parkinsonism have been described for this agent. Meprobamate is the clearest example of the group of drugs inducing a beta shift in the EEG (3). This agent further differs from the phenothiazines and reserpine in not producing parkinsonism and not only are clinical seizures not induced, but definite antiepileptic activity has been described (30). Habituation is readily �THEORY OF PHYSIODYNAMIC THERAPIES 201 achieved, and withdrawal phenomena of agitation and seizures have been observed (42). In these actions, meprobamate is more like barbiturates than like the other new tranquilizers. If we determine the clinical efficacy of these agents, we note a parallel between the induced EEG effects and their potency in altering behavior. The drugs that most readily induce a delta shift in EEG frequencies—the phenothiazine compounds—are those with the greatest clinical efficacy in the therapy of psychoses. The compounds with lesser activity in this direction are less efficacious clinically. Insulin Coma Therapy The effects of insulin coma therapy on the nervous system are well documented. During each coma, EEG delta activity is induced, which usually persists for minutes to a few hours after gavage. Not infrequently, in approximately one third of patients receiving deep coma therapy in this hospital, seizures, aphasia or prolonged coma results. After such events, EEG changes of delta activity persist for days, and in cases of prolonged coma, for weeks and months (43). The relation between prolonged coma, altered brain function and behavioral response has been discussed at length. Revitch (31) reported eight cases of prolonged coma and concluded that improvement may be attributed to the induction of organic brain damage, similar to lobotomy. Yaeger, Simon, Margolis and Burch (43), describing twelve cases of prolonged insulin coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (34), emphasizing EEG data, and Kwalwasser and Caplan (27) presented individual cases to support the same conclusion. We reported a similar relationship between prolonged coma and behavioral response in a case study (22). A 34—year-old schizophrenic patient with paranoid ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. He became lucid, loquacious and denied his illness. His former paranoid-withdrawal type pattern was replaced by a friendly cooperative attitude. These changes were accompanied by delta changes in the EEG, as well as language changes after amobarbital indicative of altered brain function. The neurologic symptoms resolved, but the behavioral changes persisted so that he was discharged two months later as “much improved.” (c) �202 MAX FINK (d) Lobotomy While we have not had the opportunity to study lobotomy patients from the point of view of this summary, the reports of numerous observers clearly document a similar relationship. EEG changes of delta activity are present in all subjects postoperatively (6) and persist for varying periods. Walter et a1. (40) in a study of 150 patients, found an 80 per cent persistence of abnormal EEG activity after three years. These authors also noted a relation between clinical improvement and the degree and extent of postoperative Slow wave activity. Postoperative seizures are a frequent “complication,” being variously reported as occurring in up to 20 per cent of subjects (25). Furthermore, there is a relationship between the extent of brain tissue cut and the therapeutic outcome. Circumscribed surgical lesions, regardless of locus, have an improvement rate lower than unilateral lobectomy; and these latter are frequently inadequate and are “improved” upon by a bilateral procedure (36). DISCUSSION When the various physiodynamic therapies are essayed from the point of View of an alteration in brain function, a common mode of action becomes apparent. These therapies represent devices which induce appreciable changes in brain function, with resultant change in behavior. Convulsive therapy and lobotomy induce measurable diffuse changes in brain function directly; insulin coma primarily when complications ensue; and the phenothiazine and reserpine groups of tranquilizers when given in adequate dosage. How persistent changes in cerebral function affect behavior is not clear. Psychotic behavior is not “reversed” or “obliterated.” Rather, with an alteration in the central nervous system milieu, there is an alteration in all aspects of behavior including perception, mood, affect, memory, judgment and attitude. The specific adaptive is and is each for variable dependent on numerous subject response historical and environmental factors. Premorbid personality (18), environmental situation and expectations (13), and the duration of the alteration in brain function (12) have recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the psychiatrist, administrator or family as to the degree of “improvement.” These ratings are value judgments, based upon such factors as the tolerance environmental the behavioral of induced response, type �THEORY OF PHYSIODYNAMIC THERAPIES 203 and the observer’s expectations. In this context, the physiodynamic therapies do not induce “improvement”-—rather they induce behavioral change which is secondarily evaluated as improvement. The alteration of cerebral function is therefore not a “complication” or an “untoward effect” but the desired goal of these forms of therapy. Of the many “organic" therapies introduced during the past thirty years, none apparently has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not spe— cific for a type of psychosis. The early enthusiasm that reserpine or chlorpromazine was specific for schizophrenia, or hypotheses that ascribe significance to an antagonism between these drugs and “psychosis” or “schizophrenia” are not tenable. Similar enthusiasm claiming a specificity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine-insulin coma control study (14). EEG analysis of these therapies permits a more explicit definition of the induced alteration in brain function. Changes in cerebral function reflected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as “bursts” or “hypersynchrony” provide the change in milieu that is more effective in altering behavior. The significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the tranquilizers. That a delta shift has some specificity is seen in the analyses of the drug effects. Those drugs that induce the delta shift—the phenothiazines and reserpine—have been consistently reported as effective modifiers of psychotic behavior. Changes in brain function reflected by EEG desynchronization only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior.3 The significance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when compared to convulsive electroshock in the management of psychoses. Another aspect of the alteration in brain function which may be defined is the change in seizure threshold. With the delta shift in These observations suggest the application of EEG screening of new chemotherapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. 3 �MAX FINK 204 the EEG, an increase in clinical seizures would be anticipated. This is indeed true. Seizures have been described following electroshock (4, 24); they are prominent after lobotomy (40) and a common “complication” during and occasionally following insulin coma therapy (23). With the tranquilizers, the parallel of clinical efficacy and seizure induction is most striking. Phenothiazine compounds induce seizures commonly; reserpine rarely; benactyzine not at all; and meprobamate is a potent anticonvulsant! The lowering of seizure threshold parallels the extent of the EEG delta shift induced by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism—both potent indices of an alteration in cerebral function. The neurologic basis for the delta shift and increase in seizure frequency is unclear. Whether this represents a persistent change in function of some specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a delta shift, with or without hypersynchrony, it appears more likely that the EEG changes reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. SUMMARY The neurophysiologic and clinical neurologic aspects of convulsive therapy, “tranquilizers,” insulin coma and lobotomy, are 1. reviewed. The efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the EEG spectrum and an increase in 2. incidence of seizures are two indices. 3. Alteration in cerebral function is an essential prerequisite of behavioral change with each of these therapies. Such alteration is neither a “complication,” nor an “untoward effect,” but is the sine qua non of the mode of action of these therapies. 4. No evidence has been educed in these studies that the physiodynamic therapies are specific agents for the relief of psychoses; nor do they affect a specific segment of the nervous system; nor do they induce specific behavioral changes. 5. The therapeutic process of convulsive therapy, insulin coma, lobotomy and tranquilizers may be ascribed to the induction of a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. ' �THEORY OF PHYSIODYNAMIC THERAPIES 205 REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hernoff, M. K. 8c Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. A.M.A. Arch. Neural. (9 Psychiat., 75:371-378, 1956. (2) Arellano, A. P. 8: Jeri, R.: The Effect of Reserpine on the Scalp and Basal Electroencephalogram. EEG. Clin. Neurophysiol., 8:150 (abst.), 1956. (3) Berger, F. M.: The Chemistry and Mode of Action of Tranquilizing Drugs. (1) Arm. N. Y. Acad. Sci., 67:685-699, 1957. (4) Blumenthal, I. J.: Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy. J. Nerv. é» Ment. Dis., 122:581-588, 1955. (5) Coady, A. 8: Jewesbury, E. C. 0.: A Clinical Trial of Benactyzine Hydrochloride (“Suavital”) as a Physical Relaxant. Brit. Med. J., Mar. 3, pp. 485487, 1956. (5) Cohn, R.: EEG Study of Prefrontal Lobotomy. Arch. Neural. & Psychiat., 53:351-357, 1945. (7) Denber, H. C. B.: Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia. Second Int. Congress of Psychiatry, Zurich, 1957. (8) Fabisch, W.; Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients. J. Neurol., Neurasurg., (5» Psychiat., 20:185-190, 1957. (9) Fink, M.: Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior. Presented Second Int. Congress of Psychiatry, Zurich, 1957. (10) Fink, M.; Green, M. A. 8c Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (11) Fink, M. 8: Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophysiol, 8:158 (abst.), 1956. (12) Fink, M. 8: Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neural. (5» Psychiat., 78:516-525, 1957. (13) Fink, M.; Kahn, R. L. 8: Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. 6} Ment. Dis. (in press). (14) Fink, M.; Shaw, R.; Gross, G. 8c Coleman, F. 8.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Am. Med. Assoc. (in press). (15) Hankofi', L. D.; Kaye, E.; Engelhardt, D. M. 8c Freedman, N.: Convulsions <16) Complicating Ataractic Therapy, Their Incidence and Theoretical Implications. N. Y. State J. Med., 57:2967-2972, 1957. Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, G.: Changes in Electroencephalogram and in Excretion of 17-Ketosteroids Accompanying Electro-shock Therapy of Agitated Depression. Psychosom. Med., 8:246-251, 1946. (17) Jacobson, E.: Suavitil, et Nyt Stof Med Specifik Virkning pa Centralnervesystemet. Ugeskrift for Laeger, 117:1147-1151, 1955. (18) Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). (19) Kahn, R. L. 8c Fink, M.: Changes in Languages During Electroshock Therapy. In: Psychopathology of Communication. New York: Grune 8c Stratton, (in press), 1957. (20) Kahn, R. L. 8c Fink, M.: Perception of Embedded Figures After Induced Altered Brain Function. Am. Psychol., 12:361 (abst.), 1957. (21) Kahn, R. L.; Fink, M. Sc Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. A.M.A. Arch. Neurol. (5- Psychiat., 76:23-29, 1956. (22) Kahn, R. L.; Graubert, D. Fink, M.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy. This Journal, 4 :134-148, 1955. 8: �MAX FINK 206 (23) Kalinowsky, L. B. 8: Hoch, P.: Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry. New York: Grune 8c Stratton, 1952. (24) Karliner, W.: Epileptic States Following Electroshock Therapy. This Journal, 5:258-263, 1956. (25) Klotz, M.: Incidence of Seizures, with EEG Findings, in Prefrontal Lobotomy. A.M.A. Arch. Neurol. 65- Psychiat., 742144-148, 1955. (26) Korin, H.; Fink, M. 8: Kwalwasser, S.: Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol., 16:88-96, 1956. (27) Kwalwasser, S. 8c Caplan, M.: A Case of Prolonged Insulin Coma: Treatment. This Journal, 1:145-155, 1952. (28) Liberson, W. T.: Effect of “Tranquilizing” Drugs on EEG. EEG Clin. Neurophysiol., 8:523, 1956. (29) Liddell, D. W. 8c Retterstol, N.: The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy. J. Neurol., Neuro(30) (31) (32) (33) (34) (35) surg., (g. Psychiat., 20:105-107, 1957. Perlstein, M. A.: Miltown, Its Use in Convulsive and Related Disorders. ]. Am. Med. Assoc., 161:1040, 1956. Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Following Protracted Insulin Coma. Psychiat. Quart., 28:79-92, 1954. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Significance for the Theory of ECT Action. EEG Clin. Neurophysiol., 3:261-280, 1951. Roth, M.; Kay, D. W. K.; Shaw, J. 8c Green, 1.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electro-Convulsive Treatment. EEG. Clin. Neurophysiol., 9:225-238, 1957. Shagass, C. St Rowsell, P. W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma. A.M.A. Arch. Neurol. 65Psychiat., 72:705-711, 1954. Sigg, E. B. 8c Schneider, J. A.: Mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine. EEG. Clin. Neurophysiol., 9: 419-426, 1957. (35) Simon, A.; Margolis, L. H.; Adams, J. E. 8c Bowman, K. M.: Unilateral and Bilateral Lobotomy: A Controlled Evaluation. A.M.A. Arch. Neurol. (‘5' Psychiat., 66:494-503, 1951. (37) Stewart, L. F.: Chlorpromazine: Use to Activate Electroencephalographic Seizure Patterns. EEG Clin. Neurophysiol., 9:427-440, 1957. (38) Ulett, G. A.; Smith, K. 8c Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. ]. Psychiat., 112:795-802, 1956. (39) Wachspress, M.: Blumberg, A. G.; Fink, M. 8: Miller, J. S. A.: Evaluation of High—Dose Reserpine Therapy for Relief of Anxiety. This Journal, 5 :67-77, 1956. (40) Walter, R. D.; Yaeger, C. L.; Margolis, L. H. Simon, A.: The EEG Changes in Unilateral and Bilateral Frontal Lobotomy. Am. J. Psychiat., 111:5908c 594, 1955. (41) Weinstein, E. A. 8: Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, Ill.: C. C. Thomas, 1955. (42) Wikler, A.: Personal Communication. (43) Yaeger, C. L.; Simon, A.; Margolis, L. H. 8: Burch, N. R.: Electroencephalographic Studies in Posthypoglycemic Coma. ]. New. 6’ Ment. Dis., 118: 435-441, 1953. �AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS1 JOSEPH JAFFE, The clinical interview MD.2 is the psychiatrist’s primary tool for diagnosis of psychopathology, the modification of behavior, and collection of research data. Only in recent years, however, have actual transactions which comprise the interview been studied the the the ob- jectively. Investigators of the interview have usually employed systems of content analysis (1), which are based upon various theories of psychodynamics. Currently, there is increasing emphasis upon formal aspects of interaction such as temporal patterns of speech (14), drastic change of subject (3), physiological relationships of the participants (2), grammatical patterns of language (5, 6, 9), and speech disturbances and silences (10). These aspects, in contrast to content categories, are relatively independent of theoretical preconceptions, and are more readily quantified and studied statistically. In many investigations of these formal variables, however, the patient’s communications are abstracted from the total context of the interview. These approaches neglect the fact that the psychiatrist is a participant observer, i.e., a significant variable in the interaction (ll). Others have attempted to control this variable by means of structured interviews in which the doctor’s contribution is standardized according to a predetermined experimental design (6, 7, 14). These structured situations delete the very quality of living relationship that is the ultimate concern of the psychotherapist (7). 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the New York Divisional Meeting, A.P.A. November, 1957. Supported by Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 2Assistant in Psychiatry, Department of Experimental Psychiatry, Hillside Hospital. 207 �208 JOSEPH JAFFE We are in need of methods of verbal interaction analysis that neither preclude nor prescribe the doctor’s clinical responses. The purpose of this paper is to present a method of interview analysis which (a) is objective and quantitative, (b) preserves the natural patient-therapist relationship, and (c) treats the interview as an integrated system of interpersonal communication. This is accomplished by including the doctor’s usual clinical behavior in the data to be studied. The raw material is not the patient’s speech, but rather the total verbal output of the “two person” or “dyadic” group (8). METHOD The tape-recorded interview transcribed, without regard to the speaker of the words. Careful attention is given to subtle repetitions such as “I—I mean,” “Well as—as I say,” and to (i i, such “so as “you know,” to speak, interpolated expressions as I said,” etc. These have a tendency not to be heard since they are irrelevant to the content. The transcript is then arbitrarily divided into consecutive units of 100, 50 or 25 words, depending on the discreteness of the phenomena to be investigated. Thus a unit contains contributions of words from either doctor or patient alone, or from both in varying proportions. The measurement applied to these units of dyadic speech is the type-token-ratio (TTR). This is an index of the balance between repetition and variety of words (12). The TTR is the ratio of the number of diflerent words (types), to the total number of words (tokens), in a sample of language. For example, in a lOO-word sample the repetition of the identical word 100 times in succession would produce the lowest possible ratio of .01 (1 type/ 100 tokens). The highest possible ratio of 1.0 would result if every one of the 100 successive words were different (100 types/ 100 tokens). These extremes of stereotypy and diversity are rarely encountered, and then only in grossly pathological situations (8). The “word-type,” i.e., the numerator of the TTR, is arbitrarily defined. All words are different which are pronounced or spelled differently. Thus, give, gives, gave, given and giving are considered different types, as are know and no. Vocalizations not clearly identifiable as words are omitted, with the major exception of “mmhmm” which is a frequent utterance of the interviewer in our records. Contractions are retained as single words, but vulgarisms such as “I dunno” are edited to read “I don’t know.” is precisely �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 209 The TTR is calculated for each unit and the pattern of consecutive scores is graphically plotted, as illustrated in Figures 1 and 2. For additional precision, the units may be overlapped; e.g., 50word units may be advanced 25 words at a time, so that each unit is composed of the last half of the preceding and the first half of the subsequent unit. This often smoothes the resultant curve. The overlapping technique is illustrated in Figure 3. Previous studies of the TTR have dealt with the over-all average in a single person’s language (12). The present method studies the sequential pattern in dyadic language. OBSERVATIONS In the last eighteen months approximately sixty recorded interviews have been investigated by this method. The material includes forty patients in all diagnostic categories. The dyadic TTR patterns have been found to be sensitive to a variety of clinical phenomena (8). This report illustrates the changes in language interaction occurring during the course of hospitalization and therapy, as well as changes in rapport and defensive operations within individual interviews. TTR Pattern in Clinical Change Figure 1 shows the pattern of the first 1500 words of three separate interviews during the clinical course of one patient. The doctor (a) Dyadic DYADIC TTR PATTERN WITH CLINICAL CHANGE (CONSECUTIVE PRE-TREATMENT T53 I. 25 WORD UNITS) POST-TREATMENT# I2 0N DISCHARGE .92 .84 .76 M M .68 ."-' — ‘ .60 I lo 20 30 40 UNIT NUMBER 5060 I I0 20 30 40 UNIT NUMBER FIGURE 1 5060 I I0 20 30 4O 50 60 UNIT NUMBER #40 #49 #59 I957 �210 JOSEPH JAFFE in each. This case was selected as an unequivocal example of gross clinical change. In the first interview the patient was agitated and depressed. She refused to be seated and paced about the room, reiterating stereotyped self-recriminations, crying hysterically, with marked pressure of speech. At the time of the second interview, following a course of grand mal electroshock, the clinical picture was grossly altered. She was less agitated and more cooperative, although withdrawn and complaining of a memory deficit. On discharge two months later, she appeared alert, poised, conversational and, at times, surprisingly insightful. She had been rated is the same clinically as “recovered.” The TTR of consecutive 25-word units of interaction, for each of the three periods described, is graphically represented in Figure 1. Consecutive points are connected by lines so that the fluctuations in the graph reflect the difference between successive scores. The mean TTR for the complete interview from which these samples were taken is represented by a horizontal line through each graph. The pattern of scores demonstrates a fluctuating equilibrium about the mean. ' The interviews at these three successive stages show a sequence of changes. The mean level of the interaction is seen to increase as the clinical status changes from psychosis to “recovery.” There is a concomitant restriction in the amplitude of the pattern, i.e., a decrease in variation about the mean. Comment: The sequence of change in the TTR pattern parallels the progressive improvement in interpersonal communication that was apparent clinically. This suggests an approach to the quantification of clinical change, defined as an altered pattern of verbal interaction in the interview. (b) Changes in Communication Within the Interview Figure 2 is an enlargement of the first of the three interactions shown in Figure 1. Here the sequence of changes within a single interview is examined rather than comparing the patterns of successive interviews. As described before, the patient was speaking continuously in a disorganized affective outburst. The lower line indicates the 25-Word units in which the interviewer participated. Following the doctor’s introductory remarks, units 3-12 represent the patient’s uninterrupted speech. Wide oscillations of the pattern are prominent. From samples 13 onwards the doctor made repeated efforts to communicate with the patient. Two independent judges reviewed the transcribed protocol, and both identified three areas �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 211 in which there seemed to be an understandable, rational interchange between the participants. These periods are labeled “rapport” in the upper line. During these three periods the oscillations of the pattern are much constricted. Compare other nonrapport periods such as 23-24 and 39—41, in which the doctor’s participation amplified the oscillations. DYADIC TTR PATTERN (CONSECUTIVE 25 WORD UNITS) —— 'RAPPORT" TTR 36 DOCTOR'S PARTICIPATION l 5 l0 IS 3035 4045 20 25 UNIT NUMBER FIGURE 2 50 #40 I957 Comment: This illustrates a method of quantifying interpersonal phenomena, such as the degree of “contact” with a severely disturbed patient. The affective pattern in this patient represents the psychotic integration, and for this reason, the occasional occurrences of conventional, rational conversation are described as periods of “rapport.” The restriction in the amplitude which characterizes these periods is similar to the over-all pattern at the time of “recovery.” Complete Interview Figure 3 demonstrates the initial dyadic TTR analysis of a complete interview. This interview is the discharge evaluation of a patient who had been hospitalized following a bizarre suicide at(c) Analysis of a �JOSEPH JAFFE 212 tempt. After seven months of hospitalization, she had “improved” clinically. This took the form of a hypomanic mood and a gross denial of her severe emotional conflicts. The interview is scored by the method of successive 50-word units advancing by 25-word steps. The mean TTR for the interview is shown by the horizontal line drawn through the graph. The pattern falls into several natural segments. There are two areas in which ten consecutive points fall below the mean (areas 4 and 7). These are unusual in this interDYADIC TTR ANALYSIS TTR OFA PSYCHIATRIC INTERVIEW (OVERLAPPING so woao UNITS) .98 .94 .90 :3: ::2 I.I—'i—'.I—'Ij== .70 .r. III -. v. 255- -/1-’1 I II ~ JUL—I- ---.r I 4I—I—I—I----I----—I——-—I-—I—|*I—---|—I—I I 3 4 7 5 9 8 l0 II I2 it 54 |957 FIGURE 3 There are also areas of gross deviation from the mean (such as area 2). Thus we allow the objective pattern to determine our criteria for phenomena to be studied. In general, we look for per- View. sistent changes in the TTR level, gross trends or sudden shifts. Several of the deviant areas are described to illustrate the method. The interview begins with a hypomanic monologue in which the patient describes her successful visit home, her euphoric outlook and plans for a rosy future. Area 2 has been delineated because of gross deviation from the mean. The beginning of this period coincides with a change of topic to her plans for going back to her job two days hence. Her optimism is’interrupted by a period of confusion as she tries, with some difficulty, to recall one of the details of the job. The end of the gross fluctuation coincides with the rationalization “I don’t think I’ll have too much trouble.” ‘ �COMMUNICATION IN PSYCHIATRIC INTERVIEWS 213 Area 4 was delineated as one of the two sections in which ten consecutive scores fall below the mean. Its beginning coincides with a statement about her depression on admission to the hospital. This area ends with the lowest score of the interview, which precedes by only a few words a spontaneous reference to her suicide attempt. This large deviation at the end of area 4 embodies the main characteristics of the following area. Area 5 is characterized by large fluctuations above and below the mean. The content of this area is completely on the theme of suicide. She attempts to prove how much she now wants to live. The doctor’s queries at the end of the period meet with increasing resistance. In the beginning of the next segment (area 6) she stubbornly refuses to discuss the subject of suicide further, at which point she changes the subject abruptly. Area 7 was delineated on the basis of two criteria. It begins with a precipitous drop in the TTR, followed by ten consecutive scores below the mean, and ends with an equally abrupt rise. Its beginning coincides with a change of subject by the doctor in the form of a question about her feelings at that moment in the interview. This content area, i.e., the “you-me” relationship, is pursued at a very repetitive level. The period ends when she abruptly changes the Area 9 is delineated because of an extremely low score enclosed by two large deviations. It coincides with a brief mention of a meeting with a young man who told her how well she looked. It ends with an embarrassed r'emark and her statement “I decided to get him off the topic.” These examples illustrate areas of disturbance or disequilibrium in the verbal interaction pattern. In contrast, 3, 6, 8 and 10 are areas of relative stability or equilibrium in the record. These periods are marked by a different quality of communication. They consist either of a euphoric, hypomanic monologue which avoids all stressful subjects, or of evasion of the doctor’s probing questions by superficial rationalization and conventional cliches. Comment: Recent reports of objective interview studies using other techniques (10) have noted that the interaction goes through a series of definable phases, which may correspond to periods of stressful disorganization and successful defense respectively. The phases demonstrated here, and the events that delineate them, suggest an analogous formulation. The content areas that disturbed the pattern in this final interview also did so on the initial interview seven months earlier. We anticipate that the discussion of a subject �214 JOSEPH JAFFE that had resulted in disequilibrium, but now no longer does so, may constitute an operational definition of “resolution of an area of conflict.” DISCUSSION AND CONCLUSIONS Diverse and highly personal interpretations of interview data limit the growth of psychiatry as a science. Systematic study of the actual transactions may lead to operational definitions of hitherto subjective phenomena. For example, it is likely that the patterns of verbal diversification presented here constitute part of the subliminal cues to which therapists respond when making clinical judgments of anxiety, affect, etc. Objective investigations of the interview must encompass the behavior of both participants since the events observed are interpersonal processes. Gill, Newman and Redlich (4) define even the initial interview as the “diagnostic evaluation of an interpersonal relationship.” Ruesch (13) has recently stated that “observations made in social situations do not have the characteristics of a scientific procedure in which one aspect is studied in detail while all other variables are held constant.” The method presented here is an attempt to convert these concepts into practical research methodology. It permits a quantitative statement of various clinical phenomena occurring either within single interviews or in the course of therapy. Disturbances of verbal interaction are defined operationally in terms of the configuration of the TTR pattern. Applications to the definition of clinical change and transactions within the interview have been presented. The TTR is only one of many quantifiable aspects of dyadic speech. Pace of interaction, time reference, and relative amounts of participation by doctor and patient are also being measured. Further applications of these techniques are under investigation. REFERENCES (l) Auld, F. 8c Murray, E. J.: Content-Analysis Studies of Psychotherapy. Psychol. Bull., 52:377-395, 1955. (2) Coleman, R.; Greenblatt, M. 8: Solomon, H. C.: Physiological Evidence of Rapport During Psychotherapeutic Interviews. Dis. New. System, 17:2-8, 1956. H.; Hamburg, D. A.; Inwood, E. R.; Salzman, L.; Meyersburg, H. A. 8c Goodrich, G.: A Procedure for the Systematic Analysis of Psychotherapeutic Interviews. Psychiatry, 17:337-345, 1954. (4) Gill, M.; Newman, R. 8c Redlich, F. C.: The Initial Interview in Psychiatric Practice. New York: International Universities Press, 1954. (3) Eldred, S. �COMMUNICATION IN PSYCHIATRIC INTERVIEWS (5) 215 Goldman-Eisler, F.: A Study of Individual Differences and of Interaction in the Behavior of Some Aspects of Language in Interviews. ]. Ment. Sci., 100:177-197, 1954. (6) Gottschalk, L. A.; Gleser, G. C. 8c Hambidge, G.: Verbal Behavior Analysis. A.M.A. Arch. Neural. 63'» Psychiat., 77:300-311, 1957. (7) Grinker, R. R.; Sabshin, M.; Hamburg, D. A.; Board, F. A.; Basowitz, H.; Korchin, S. J.; Persky, H. 8c Chevalier, J. A.; The Use of an AnxietyProducing Interview and Its Meaning to the Subject. A.M.A. Arch. Neural. (5* Psychiat., 77:406-419, 1957. (3) Jaffe, 1.: Language of the Dyad: A Method of Interaction Analysis in (9) (10) (11) (12) (13) (14) Psychiatric Interviews. Psychiatry (in press). Lorenz, M. 8c Cobb, 8.: Language Patterns in Psychotic and Psychoneurotic Subjects. A.M.A. Arch. Neurol. (5. Psychiat., 72:665-673, 1954. Mahl, G. F.: Disturbances and Silences in the Patient’s Speech in Psychotherapy. ]. Abn. é» Soc. Psychol., 53:1-15, 1956. Mandler, G. 8c Kaplan, W. K.: Subjective Evaluation and Re-enforcing Effect of a Verbal Stimulus. Science, 124:582-583, 1956. Mowrer, O. H.; Verbal Behavior in Psychotherapy. In: Psychotherapy: Theory and Research, ed. 0. H. Mowrer. New York: Ronald Press, 1953. Ruesch, 1.: Disturbed Communication. New York: W. W. Norton, 1957. Saslow, G.; Matarozzo, J. D. 8: Guze, S. B.: The Stability of Interaction Chronograph Patterns in Psychiatric Interviews. J. Consult. Psychol., 19: 417-430, 1955. �SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL1 ROBERT L. KAHN, PH.D.,2 MAX POLLACK, PH.D.,3 and MAX FINK, M.D.4 Recent investigations have indicated a relationship between inci— and with to disorder class and type social respect psychiatric dence of mental illness (3, 5, 6, 13, 14), selection and maintenance of treatment (2, 6, 15), and therapeutic outcome (10). The present in of selection the in factors social therapy is with concerned study a voluntary mental hospital. In the studies reported by Hollingshead, Redlich, and their coworkers (3, 5, 6, 13, 15), the population of New Haven was divided into five social classes on the basis of weighted criteria of education, under who residents the Of were residence. of and place occupation freclasses social more were the from those upper psychiatric care, quently treated with psychotherapy, while organic treatment or custodial care was more common among the lower classes. Of the the restricted two to was entirely psychoanalysis psychotherapies, of the determinant the class Social was predominant upper groups. held conthe when was diagnosis selected even of treatment type is that “. found it follows: results . . as their summarize stant. They determedical and psychological does on not depend treatment well. the of as the patient status but position minants alone, on Psychotherapeutic methods are applied in disproportionately high 1 Glen Hillside Hospital, of Psychiatry, Experimental the From Department Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, U. S. Public Health Service. 2Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3Senior Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 4Director, Department of Experimental Psychiatry, Hillside Hospital. 216 �SOCIAL FACTORS IN SELECTING THERAPY 217 degree to the upper social levels. The data of this study would seem to indicate that most psychotherapy takes place in a setting where the background of the patient is similar to that of the therapist” (15). It is possible to relate the results obtained from these community studies to such selective factors as the patient's financial resources or the extent and type of treatment facilities available. A more critical test of the importance of social factors affecting choice of treatment would be in a setting where the same therapeutic techniques and services are available to all patients. This requirement is met at Hillside Hospital. It is a nonprofit, nonsectarian institution for the treatment of voluntary patients with “early and curable mental symptoms” (4), who are admitted regardless of their ability to pay. One of the main criteria for accepting patients is their ”ability to participate profitably in psychotherapy.” Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. The average length of hospital stay is six months, although some patients remain for as long as a year. The present investigation is an outgrowth of several years of study of electroshock therapy. In previous work it has been shown that certain aspects of personality were significantly related to patient selection and therapeutic efficacy of electroshock (8). The purpose of the present study was to determine whether electroshock patients differ from those receiving other forms of treatment in regard to cultural background, including such factors as education and place of birth, and personality as measured by the California F scale (1); secondly, whether these factors were also related to referral for adjunctive hospital services. METHOD Population: The entire inpatient adult population of Hillside Hospital as of March 7, 1957 was studied. This constituted a total of 172 patients, ranging in age from 16 to 68 with a mean of 34.6, and including 58 men and 114 women. Procedure: (1) The population was subdivided into three groups according to type of treatment received, (a) electroshock therapy, (b) insulin coma therapy, and (c) psychotherapy only.5 5All patients are seen in psychotherapeutic sessions during hospitalization. Electroshock and insulin coma are administered as a supplement to this management. Seven patients received both EST and insulin and their data were included in both groups. In the results this makes a total of 179 subjects. �KAHN—POLLACK—FINK 218 (2) birth. The groups were compared for age, education and place of (3) All patients were tested6 with a ten-item modification of the California F scale suggested by Levinson (9). The F scale is a questionnaire (see Appendix) which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity (16). The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to What extent. The score given for each item ranges from one to seven and the total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. (4) The population was subdivided in regard to utilization of certain adjunctive services in the hospital. Among such services available are group activities, occupational therapy, psychological testing and creative therapy. The latter is a diagnostic and therapeutic service consisting of a series of controlled painting procedures which are considered to be analogies of life experience (18). Psycho— logical testing and creative therapy were selected for this study because both require a specific referral from the therapist. RESULTS The data were analyzed as follows: comparison of the treatment groups for age, education, F scale scores, and place of birth; (2) comparison where diagnosis is held constant; (3) significance of length of hospitalization prior to treatment; and (4) comparison between groups referred for adjunctive hospital services. (1) Comparison of Treatment Groups For each of the three treatment groups the means and standard deviations for the F scale scores, age and years of schooling are presented in Table l. The EST group had higher F scores, was older and had fewer years of formal schooling than either the insulin or psychotherapy groups. These difierences were statistically significant for F score and age but failed to reach statistical significance for education. The failure of years of education to differentiate the groups was due, in part, to the fact that the electroshock 1. 6As part of an ongoing study all the EST patients were tested with the F scale prior to treatment. In the case of‘ those patients who were actually on EST on March 7 their pretreatment scores were used in the statistical comparison since it had been found that EST significantly affects the score during treatment. �SOCIAL FACTORS IN SELECTING THERAPY 219 - .550 ammvaom §3« 50m $.32 o ammuuoh mo REE 55 :Eduamo fiwmouom onesm .ummm.50m $32 Afioozw fivwwvm £me 50m -0332 «a fivgvmm $592 fiaéww :25 83m mo .Esnamo 8m: 35 -Gwmuuom Son $52 $55“ fimwvvv $392 $82 “Staggm 088 .vm GMV @8va How mo .Ssflamo 658% 98on H 53H. h mBOBm J/ SK $2; $5: fix: l/i If!!! 3320 6M Gm «0 28> 582 EwEuufih 3 3 g NM 2: 2: OS "~on .qu :53 9: «E MN S 2 :33. 1&3 fill!!! “59$th Qm q: 3 3; n: 3w mum u w? um< x0 :82 Gav: £5 .2: 3w a 3%...“ 3 :oflkfificu Gm 92 3; 2: ::.m m2. :32 E2 28m h 582 3% fine: 2m we”. a5 3 3: mm mo. 8. 32 So. 3 a a so: 8% 385:me 285:? 385:3 t 1 .onoxmmézsmcu £35me 339% @380 532: -onuwmm Saga -935-.me 38% 3&2: 1:. �220 KAHN—POLLACK—FINK group contained many foreign-born patients whose education was difficult to evaluate accurately. When treatment groups were subdivided into number of patients above and below eight years of education, the difference was significant at the .01 level. The insulin and psychotherapy groups did not differ statistically for any of these factors. Both somatic groups had a higher percentage of foreign-born patients than the psychotherapy group, with the electroshock group being highest of all. Among the foreign-born patients, those who came from Eastern European countries received somatic therapy predominantly, while the majority of those from Western Europe received psychotherapy alone. Comparison of Treatment Groups in Relation to Diagnosis The diagnostic categories of the patients in this study are com— parable to those reported in previous studies of the hospital popution (12). Of the 172 patients, 78 were classed as schizophrenic, 60 as psychotic depression, 32 as psychoneurosis and 2 with other diagnoses. As expected, a larger proportion of the depressed patients (52%) received electroshock than did those with other diagnoses. To control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are shown in Table 2. While the two groups were comparable for age and education, the electroshock patients had a much higher mean F score, a difference significant at the .02 level of confidence. It is also demonstrated that a significantly higher proportion of the electroshock patients were born in Eastern Europe. 2. Comparison of Electroshock Patients According to Length of Hospitalization Prior to Treatment While the electroshock patients, as a group, have been shown to differ from those receiving insulin or psychotherapy, there were still considerable intragroup differences. To account for some of these differences it was postulated that the same factors involved in selection of treatment were also related to the readiness with which a given patient was referred for electroshock. While most of the patients who received EST were placed on treatment less than three months after admission, about 40 per cent were referred after a period of three to twelve months. In Table 3 the patients are compared according to the period of hospitalization prior to electro3. �SOCIAL FACTORS IN SELECTING THERAPY .830 ax”: $.va vacuum 133$ $2; fihm “225355 «0 583m ainamo 83m «so .033 50m $32 @5th $.ng @8va Z ”REE 208 23$th a; how «0 comumuswm Envy. Mano Sign“ waofium N fig; @E: 23 .vm HEM—NH =32»:qu Qm 3 can: 3: mo $3on 3 2: GNU: a $5 a5 86 a mg umucxuafim Gm mi «NH 3.2; vm< 582 3:“ Gm 32 3* Que: mg £5 fitubum kc a fl: *Nwm 88m goutumwficu h 532 3* non 5N0: Em: a5 8d me. a as 3% 285:? -ofiwmmémm -oauwmm 322: 382: Ha a. 221 �KAHN—POLLACK——FINK 222 fié .850 N a o .83 5.85 $me mo 583m @888 uneasm 8 8me H o m «Eu EuEEush -0332 3 58m $88 $85 $8: 2 5 2 fig $89 $83 mm a : BER 988 How we tetanacfifiwem 8.8 H 8098sz any? «Eu 183 wBBom x0 $2: a m m SMEVN 6mm 559 3 Qm E :82 3 «o 928% 3 ca 5.: 8.8 8 88 :2 8.8 :82 .85 cm: Sn a; fill!!! Mfifikouuvx Gm 8.2 25.36% 98 8.2 a :4 :88 gm :82 .85 83. $4: 8...: a 8.8 :8.“ :2 %< 8.8 582 8% :3 Ram 88 Qm Q: w: mm; 38m :ofltificu BE :52 :8 rm :32 Sim -mNzflmmmom “cued—88H. 622.: aa dawned .88 :05 8.8 a; 9 mo E« $va .88 m m .85 $8 288 EMS“ 2c m 52: o 3 :82 88 who: 8 $04 a; 2.2 8 288 .88 8 8 m 8. S. 8. m 52: 80A .89: 5:: 988 885.85 88:88.,” Gmflu .888 c 8 m UHOE .888 a.“ I �SOCIAL FACTORS IN SELECTING THERAPY 223 shock. Patients who had higher F scores and were older were treated earlier than the younger and lower F scale groups. Place of birth is also a significant factor. While 44 per cent of those treated within three months were foreign-born, all patients referred after a period of six months were born in the U. S. The data on education just fails of significance, although 28 per cent of those treated earlier had less than eight years of education. 4. Use of Adjunctz've Hospital Sewices Comparison of the patients referred for creative therapy and psychological testing is shown in Table 4. It is clear that those referred for either of these procedures had significantly lower F scores, were younger in age, had more education and more were nativeborn than patients who were not referred for these services. DISCUSSION The results indicate that the factors of education, age, place of birth, and F scale score were significantly related to the type of therapy received and to the utilization of adjunctive services in this hospital. Psychotherapy was the treatment of choice for those patients who were younger, better educated, native-born and had lower F scores. Such patients were also referred more frequently for the auxiliary hospital services of psychological testing and creative therapy. Conversely, those patients who had higher F scale scores, were older, poorly educated and foreign-born, particularly in Eastern Europe, were most likely to be referred for EST. These patients were infrequently referred for psychological tests or for creative therapy. Furthermore, these relationships were still significant when diagnosis was held constant. These observations are compatible with those of Hollingshead, Redlich, and their co-workers (3, 5, 6, l3, 15) who demonstrated that social factors are related to the type of therapy received in a community. The present study demonstrates that such factors are also significant in a hospital setting where ability to pay is not a criterion of therapeutic selection and where all forms of therapy are equally available to the entire population. With financial aspects and the availability of therapeutic facilities eliminated in accounting for the relation of social factors to the selection of treatment, two alternative interpretations be conmay sidered. The social factors may relate directly to the empirically established criteria for choice of therapy. On this basis a patient is �KAHN—POLLACK—FIN K 224 550 .35an «REE $5; $5.: @2va $5: 153$ $3: Axwwvwa $.8va @583 $.me @me $3 5me «0 532%.“ vacasm fiw: fivfivmw H awwuamu «Eu 82m 323.5 -0332 3:3 1E3 Eom a wumtuh EOE $38 kg How «0 N £038st *Nmenamo man“; ~e£m£o£uaam «Eu . 33:5 ARR“: waofium fiéw fiévfi u8 w. 8.9.5wa it’ll; .wm 539 if} 3. m.» Qm a.» a 8N ***h.w mm: mo 28> 2: 3: :82 wfi w: :82 a5 A: AWN 233::va .8“ Qm 2: 3: «.2 :82 EN 3m Sun «.2 a mg :52 .Em ***©N.m fwawowé om< wmtukum 0.“. fioa Scwtek it$©m6 Gm kc 2: QB inomfi H as 2: :32 :32 28m h :82 982 3w 5.3 soy 32V 3.» iv 55 m.w mg: A5 s. so. a a a 23.23%:80 O>UNQHU mo. :52 Esme? 385:? $3389 385:? Aonuwmm 3:80 .rH.U 03330 322? 3225 Oz Jonowmm .Hoaowmm and. oz -Hd OZ * oZ i I; �SOCIAL FACTORS IN SELECTING THERAPY 225 referred for electroshock because he is older, poorly educated or foreign-born, clinical experience having shown that such persons respond best to this type of treatment. This explanation is inadequate since half the patients with psychotic depression received psychotherapy alone, even though electroshock is generally considered the treatment of choice for this illness. An alternative interpretation is that social factors are related to choice of treatment because they also affect certain psychological patterns of behavior fundamental to conventional modes of therapy, such as mode of communication. Thus, a patient is not referred for electroshock because he is foreign-born or poorly educated, but rather these factors provide the difference in cultural background between patient and therapist which makes successful communication less likely in the psychotherapeutic relationship. Robinson et al. (15), in a study of psychoneurotic patients, have pointed out that psychotherapy is most likely to take place where the cultural background of the patient is similar to that of the therapist. Conversely, patient-therapist differences in systems of value and communication may hamper the establishment of a therapeutic relationship. In the present study, similarly, the patients who received psychotherapy alone were more like the therapists with regard to the factors studied.7 Apart from the problem of patient-therapist differences, certain patterns of communication exhibited by the patient may be intrinsically incompatible with the establishment of conventional psychotherapeutic relationships, particularly psychoanalytically oriented psychotherapy. Thus, our previous observations have shown that verbally uncommunicative persons, prone to denial, evasion, stereotypy and use of cliches are likely to receive electroshock (7, 8). Such language patterns appear to be more frequent in persons with poorer sociocultural backgrounds. Social and cultural factors, in addition to their effect on com— munication patterns, may also determine the manifest symptomatology. Opler (11) has noted that, among patients diagnosed as schizophrenic, differences in symptoms are related to differences in cultural background. Frank et al. (2), studying psychoneurotic patients, reported that patients whose symptoms were expressed in somatic complaints were likely to leave psychotherapy, while those who remained had ideational symptoms. In a study of personality The therapists had a mean F score of 21.8 and a mean age of 33.9. Sixteen per cent were born in Eastern Europe. Their mean years of education was 7 20. 18 over �KAHN—POLLACK—FINK 226 factors in electroshock patients (8) we have noted that certain patterns of symbolic value and communication were more likely to be associated with the development of a depressive psychosis. The relationship between communication pattern and symptoms indicates that symptoms themselves are a mode of communication. The F scale furnishes a quantifiable index of attitude and communication patterns related to treatment selection. In a study of a mental hospital population, Levinson (9) found that high-scorers were less receptive to entering a psychotherapeutic relationship and were more likely to receive electroshock. Tougas (17), using an ethnocentric scale similar to the F scale, found that psychotherapy was more effective in patients with low scores. In the present study the F scale was the most consistent factor differentiating the treatment groups. These results have clinical as well as theoretical significance. lowthat indicate in from observations study a progress Preliminary scorers on the F scale have a poor response to electroshock, and that those with high F scores respond poorly to psychotherapy alone. Another clinical application may be in maximizing the communicative interaction between therapist and patient. This may be done by minimizing their social differences, by matching them more closely for age and place of birth. Of possible greater importance is the necessity for developing new modes of communication when treating conventional psychotherapeutic apwho to refractory are patients proaches. While epidemiological studies have clearly structured some of the indicated have and of selection in involved treatment, problems the direction of further study, it still remains for more processoriented research to provide definitive answers. / SUMMARY In a study of social and personality factors affecting selection of therapy in a voluntary mental hospital, in which all forms of and of birth, education, place available, age, were equally therapy score on the California F scale were significantly related to the type of therapy received and to the utilization of adjunctive hospital 1. services. Patients who were older, poorly educated, had higher F scores and were foreign-born, particularly in Eastern Europe, were most likely to be referred for electroshock. Psychotherapy was the treat2. �held constant. 4. Among the electroshock patients the same factors found to be significant in choice of therapy were also related to the readiness with which a patient was referred for electroshock. 5. It is postulated that treatment selection is the result of the communicative interaction between patient and therapist. Social factors may be important in so far as they are related to different modes of communication. APPENDIX F SCALE FORM Below are a number of statements. For each statement we want you to give us your personal opinion of whether disyou or agree agree. Answer each statement accordi ng to one of the following: I AGREE A LITTLE I DISAGREE A LITTLE I AGREE PRETTY MUCH I DISAGREE PRETTY MUCH I AGREE VERY MUCH I DISAGREE VERY MUCH I. No sane, normal, decent close friend or relation. 2. Science has its place, but there are many important things that must always be beyond human understanding. 3. If people would talk less and wor k more, everybody would be better off. pe and attack on children, deserve more than mere imprisonment; such criminals ought to be publicly whipped, or worse. 8. The best teacher or boss is the one wh 0 tells us exactly what is to be done and how to go about it. 9. Young people sometimes up they ought to get over them and settle down �KAHN—POLLACK—FINK 228 weak the classes: distinct into divided two be 10. People can and the strong. REFERENCES 8c Sanford, R. N.: D. Levinson, J. E.; Frenkel-Brunswik, (1) Adorno, T. W.; 8: Brothers, 1950. York: New Harper The Authoritarian Personality. St: Stone, A. R.: E. H. S. Nash, D.; L. Imber, H.; (2) Frank, J. D.; Gliedman, (33» 77: Neurol. Arch. Psychiat., A.M.A. Leave Psychotherapy. Why Patients 283-299, 1957. (3) Freedman, L. Z. 8c Hollingshead, A. B.: Neurosis and Social Class. Am. ]. Psychiat, [13:769-775, (4) (5) (5) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) 1957. Hillside Hospital: 29th Annual Report, 1956. 8c Redlich, F. C.: Schizophrenia and Social Structure. A. B. Hollingshead, Am. ]. Psychiat., 110:695-701, 1954. Disorders. Class and Social Psychiatric 8: C.: F. A. B. Redlich, Hollingshead, Disand Psychiatric Environment Social the Between In: Interrelations orders. New York: Milbank Memorial Fund, pp. 195-208, 1954. Kahn, R. L. 8c Fink, M.: Changes in Language During Electroshock Therapy. 8c J. Zubin. New York: P. Hoch ed. Communication, In: Psychopathology of Grune 8c Stratton, 1957. to Behavioral in 8c Response Factors M.: Personality L. Fink, R. Kahn, Electroshock Therapy. Conf. Neurol. (in press). Levinson, D. J.: Personal Communication. 8c Johnson, N. A.: Failures in Psychiatry: The Chronic HosC. N. Morgan, 1957. 113:824-830, Am. Patient. ]. Psychiat, pital 197:103—110, American, Scientific Culture. and K.: M. Schizophrenia Opler, 1957. 8: Rachlin, L.: A. Lurie, M.; Gurvitz, G. S.; Goldman, Rachlin, H. L.; 1950. in Hillside from Hospital 317 Patients Discharged of Follow-up Study This Journal, 5:17-40, 1956. Redlich, F. C.; Hollingshead, A. B.; Roberts, B. H.; Robinson, H. A.; Disorders. and 8: Social K.: Structure Psychiatric Z. L. J. Meyers, Freedman, Am. J. Psychiat., 109:729-734, 1953. Rennie, T. A. C.; Srole, L.; Opler, M. K. 8: Langner, T. 8.: Urban Life and Mental Health. Am. J. Psychiat., 113:831-837, 1957. Robinson, H. A.; Redlich, F. C. 8c Myers, J. K.: Social Structure and Psychiatric Treatment. Am. ]. Orthopsychiat., 242307-316, 1954. Titus, H. E. 8: Hollander, E. P.: The California F Scale in Psychological Research: 1950-1955. Psychol. Bull., 54:47-64, 1957. In: Verbal in Factor Therapy. Ethnocentrism as Limiting a R.: R. Tougas, 8c R. F. Dymond. C. ed. R. Rogers and Change, Personality Psychotherapy 1954. 196-214, Press, of Chicago pp. University Chicago: Creative of Utilization 8c and E.: Therapeutic Structure E. Zierer, Zierer, Activity. Am. ]. Psychother., 10:481-519, 1956. �SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK1 MARTIN A. GREEN, MD.2 The assumption 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. Differ- ences 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. Such an assumption may not be warranted, however. Perhaps another factor in the variability of response under these conditions is an individual variability in neurophysiological reactivity or responsiveness. The initial “base line” may not be similar in all individuals. The possibility of different inherent patterns of reactivity has been suggested by the studies of the alterations in the EEG during electroshock. We have been impressed by the high degree of variability in such 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. The present report concerns a description of the changes in the EEG during electroshock in the Hillside Hospital material. The concept of neurophysiological reactivity is presented and studies that may clarify this problem are suggested. MATERIAL AND METHODS Eighty-nine patients who received electroshock for psychiatric illness were studied. The patients were voluntary admissions to 1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 2Assistant in Neurophysiology, Department of Experimental Psychiatry, Hillside Hospital. 229 �230 MARTIN A. GREEN Hillside Hospital and the majority had not received electroshock previously. The diagnostic groups included psychotic depression, manic-depressive psychosis and schizophrenia. The largest group was patients with depression. Ages ranged from 20 to 68 years with a median of 47 years. Treatments were given three times weekly, each patient receiving at least twelve treatments. The Medcraft instrument (alternating current) was used for twenty-eight patients and the Reiter instrument (unidirectional current) for sixty-one patients. Electro— encephalograms were taken prior to, at weekly intervals during, and two weeks following the course of treatment. Patients Whose pretreatment EEG was abnormal were specifically excluded from study. Tracings were done on a nontreatment day (from 24 to 36 hours following the previous treatment) with an eight channel Medcraft machine using needle electrodes. Frontal, motor, parietal, occipital, anterior temporal, posterior temporal, vertex and earlobe placements were employed with scalp to scalp and scalp to earlobe combinations. RESULTS Delta Activity A. Quantitative Difierences: The delta activity was analyzed according to the method described by Fink and Kahn (7). The duration of burst activity, the lowest frequency, the average delta index in several leads, the highest amplitude, and the highest per cent time delta in one lead were measured. Records were classified as showing a low, middle or high degree of delta activity (Fig. 1) according to criteria previously described (7). All patients developed delta activity during the course of twelve treatments, but differences in the amount of the slow activity and its rate of development were very apparent (Table I). Some patients developed “high delta activity” early in treatment, whereas other patients showed only “low” or “middle” changes even after twelve treatments. These latter patients were followed further with serial EEGs. As treatment was continued, a high degree of delta activity did not develop in some of these patients until twenty or more treatments, or until treatments were given on a daily basis. They were resistant to neurophysiologic change. This individual variability in EEG response was independent of the type of electroshock current employed, being present both with alternating and with unidirectional current applications. 1. �INDIVIDUAL VARIABILITY IN EEG UPON ECT 231 WWW WWW WWW’VW’WW WWW WWW WWW "WWW WWW-«MW WWW WWW LF-LO RF-RO .,, LC-LMT RC-RMT RP-E LAT-LPT WWWWWWWVW ”W ISECOND RAT-RPT PRE- ELECTROSHOCK FIGURE la 24 HOURS AFTER EST 150 W 4%: l2 Degree of Delta Activity—Low From Fink and Kahn (7) Qualitative Diflerences: Although the total amount of delta activity may be similar, records differ as to type, frequency and voltage of delta activity. One prominent qualitative difference is the ratio of irregular delta activity to bursts of slow activity. Nearly all B. W WW LF‘ LO WWWMWMWW LC-LMT R C -R MT L P-E RmANWMMW-E LAT- LPT ' WNW/“WWW WWW/MW Ison "WWW WWW WWIMMMMMMWNVWMMWWMMMMMHM £59932. RAT-RPT PRE-ELECTROSHOCK FIGURE 1b 24 HOURS AFTER EST #10 Degree of Delta Activity—Middle From Fink and Kuhn (7) �MARTIN A. GREEN W W W mm 232 LWW WWW «WWW - L MT T ELEM“ Mwmwwaw MR LP'E RP-E ”WWW “H” WWW lSECOND RAT- RPT' PRE-ELECTROSHOCK 24 FIGURE 1c {5,on HOURS AFTER EST =11:” Degree of Delta Activity—High From Fink and Kuhn (7) records show burst activity during a course of twelve treatments. In some patients the initial delta change is in the form of bursts which become more frequent, slower and of higher voltage as treatments are continued. The irregular delta activity in such records is much less prominent and usually occurs at faster frequencies. In other patients the reverse occurs. Delta activity appears chiefly in an irregular and scattered form. Although burst activity is also present, it is not conspicuous. In a third group of patients the amounts of irregular delta activity and bursts are approximately equal (Fig. 2). These differences in the form that the delta activity assumes are usually constant during the course of treatment. At times, TABLE I Degree of Delta Activity in Serial Electroencephalograms during Electroshock (2-4 records were taken for each patient) No. of Records in Each Treatment Period EEG Activity No change Low delta activity Middle delta activity High delta activity EST 1-3 4-6 7-9 10-12 5 l 1 37 0 21 7 20 28 22 45 10 25 16 3 1 �INDIVIDUAL VARIABILITY IN EEG UPON ECT 233 however, burst activity will become more prominent 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. WWWW A HH I486 WWW AT‘VERTEX R 5 HH F-VERTEX 1392 WWWNWWVWWW R WWWWWWWWW ‘3 HH l599 AWWWWWWWMMMMWNWWW D HH 50 mv. I572 |____ SEC. l FIGURE 2 Qualitative Changes in Delta Activity A—Irregular Delta C—Rhythmic Runs B—Delta Bursts D—Asymmetry The slow activity is maximal at the anterior temporal and frontal electrodes and less pronounced at the more posterior electrodes. Often it is asymmetric, being of higher voltage, slower, and in greater amounts at the left anterior temporal and frontal electrodes as compared to the right (Fig. 2). Only rarely is the reverse true, i.e., accentuation on the right side. This asymmetry occurs during treatment both with alternating and with unidirectional currents. Another type of abnormality is the appearance of rhythmic runs of delta activity which may continue for 10 to 20 seconds (Fig. 2). �MARTIN A. GREEN 234 The regularity of the frequency and voltage of the slow waves in these runs is very striking. 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 portions of a record may appear nearly normal, while in other parts of the same record the delta activity may be quite pronounced. This variation is independent of the electrode combinations employed. or Spike-Wave Activity A large number of records show single spike activity of low, moderate or high voltage. Most often such spikes are slower and not as prominent as those present in patients with seizure disorders. A small number of records show spike—wave 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. 3). 2. Spike 3. A lpha 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 proHH A F I40! a ~wvv~uu~vv*1qJJWV’V‘r 0 W “H 3‘ WWW AT-VERTEX TO EARLOBES AT VERTEX '5“ P-EARLOB ”PT 50 mv.| I SEC. FIGURE 3 Spike and Spike-wave Activity �INDIVIDUAL VARIABILITY IN EEG UPON ECT 235 nounced. The frequency will be slowed by 1-2 cps but at times will remain the same as in the preelectroshock tracing. In a small number of patients the amount and voltage of alpha activity increases during treatment. This change persists during the posttreatment period after the slow-wave activity subsides (Fig. 4). F-O HHI484 L R WW PRE-EST HH |597 WWW’WWWWWMMWWWWMAMWMWW L F-O 2 wxs. POST-EST FIGURE 4 50 mv.|_ l SEC. Change in Alpha Activity Beta Activity The fact that many sedatives, particularly barbiturates, induce fast activity in the EEG and the difficulty in controlling the administration of these drugs in the population studied makes it difficult to evaluate changes during the course of treatment. In most instances changes in fast activity are minimal. The most frequent change, when present, is a decrease in the activity. 4. DISCUSSION The problem being raised is that of the individual variability in the type and degree of EEG alteration during electroshock therapy. AS described, this is manifested in: (1) the amount of slowwave activity and its rate of development; (2) qualitative differences in the slow-wave activity (amount of burst activity vs. irregular delta activity, symmetry, fluctuating appearance of slow activity, runs of rhythmic Slow activity); (3) presence of Spike or spike-wave activity; and (4) changes in alpha and beta activity. Previous investigations (2, 4, 5, 10, ll, l2, l4, 17, 18, 19, 20, 25) have stressed possible correlations with age, sex, frequency of treatment, type of current employed, psychiatric diagnosis, and clinical �236 MARTIN A. GREEN change. Increasing the frequency of treatment, for example, will increase the degree of alteration in the EEG. However, when patients of similar sex, age and psychiatric diagnosis are given treatments at the same frequency with the same type of electroshock current, variability in the rate of development of changes in the EEG and their type and 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 the skull, in the distribution of blood vessels and their permeability or in the arrangement of nerve tracts create differences in the pathways taken by the current. Under such circumstances, different portions of the brain may receive more or less current in one patient as compared to another. Differences in the type of electrical activity generated by these variously 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 callosum, has been demonstrated. No further information 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 current reaching different areas of the brain are of minor, if any, importance in the EEG response during electroshock. It is the occurrence of the generalized seizure per se, rather than the passage of electricity, which is the primary factor. During a course of grand mal therapy induced by nonelectrical means such as metrazol, EEG changes occur which are similar, in general, to those seen with electroshock (13, 14). Diffuse slow-wave activity, accentuated anteriorly, and spike or spike-wave activity are described. The amount of slow-wave activity increases during treatment'but shows individual variability unrelated to the number of treatments. Another observation is that electroshock therapy which induces petit mal (8, 18) or focal (3) seizures rather than grand mal does not produce the characteristic �INDIVIDUAL VARIABILITY IN EEG UPON ECT 237 build-up of slow-wave activity. In addition, there is no increase in the degree of delta activity in our patients in whom mal grand therapy is given with high suprathreshold stimuli as compared to those in whom threshold stimuli are used. Factors of current cannot be entirely dismissed, however. Even with grand mal therapy, the type of current employed may influence the EEG change. We have 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 other theory to be considered in explaining the variability in EEG responsiveness, and the one which is probably more decisive, 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, may have these determinants. The type and degree of EEG abnormalities developed during electroshock therapy to be appear the reflection of such inherent individual differences in neurophysiological reactivity. Several types of investigation may serve to test this hypothesis. Methods other than electroshock known to produce 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 Megimide, photic stimulation, or the intravenous administration of drugs such as barbiturate. In addition, perhaps the actual electroshock seizure threshold or the pattern or severity of the seizures may be a measure of nervous system responsiveness. Data from such investigations could be correlated with the degree and types of EEG change during electroshock. In this manner it might be possible to demonstrate different patterns of neurophysiological reactivity and to classify individuals accord- ingly. Such studies may not only help in understanding the variability in the EEG alterations during electroshock but would have wider application to other problems in clinical electroencephalography and neurology. For example, the basis for the development of spontaneous seizures secondary to traumatic, vascular, or neoplastic lesions of the nervous system is not known. Patients with lesions �238 MARTIN A. GREEN comparable in type, size and location may or may not develop seizures. As previously described, some subjects show spike or spikewave activity during electroshock. This suggests an inherent difference in the capacity to develop clinical seizures or EEG seizure activity following “injury” to the nervous system, whether the injury is spontaneous or induced. Differences in this capacity may be reflected in varying patterns of neurophysiological reactivity. Differences in neurophysiological reactivity may also be manifested in the pretreatment EEG. Patients in whom the pretreatment record is abnormal (ll), “instabile” (22), or shows a predominant alpha rhythm (5) are said to develop the greatest alteration in the EEG during electroshock. Other investigators have not confirmed these observations (2, 23). Actually, such correlations depend on the method of analysis of the pretreatment record employed and the 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 investigated. 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 differences in hormonal or other humoral substances produced during the stress of electroshock may serve to “sensitize” or “desensitize” the cerebrum with regard to developing different amounts and types of electrical activity. That such factors may be operative is suggested by the following studies. Trypan red 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 administered during a course of electroshock in man blocked the development of the usual slow-wave activity (24). Electroshock therapy affords an excellent opportunity for the experimental investigation of the problem of an inherent neurophysiological reactivity. One is able to apply studies directly to man rather than animals. The stimulus to the central nervous system can be standardized and the degree of neurophysiological change controlled, within limits, by changing different parameters. Tests of EEG responsivity can be given before such changes are induced as well as during and after treatment. Restudy of patients is often possible when subsequent courses of treatment are necessary. I ‘ �INDIVIDUAL VARIABILITY IN EEG UPON ECT 239 SUMMARY Individual differences, both quantitative and qualitative, in the EEG changes during a course of electroshock treatment in eighty-nine patients are 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 quantitative and qualitative aspects may be the primary determinant of these differences. 4. Variation in skull resistance and in the amount of current reaching the brain appear to be minor factors. 5. Investigations that might serve to test the hypothesis presented are described. Such studies may lead eventually to a classification of individuals as to different patterns of neurophysiological reactivity and clarify other problems in clinical neurology and electroencephalography. 1. REFERENCES Aird, R. B.; Strait, L. A.; Pace, J. W.; Hrenoff, M. K. 8: Bowditch, S. C.: Current Pathway and Neurophysiological Effects of Electrically Induced Convulsions. J. Nerv. (‘5' Ment. Dis., 123:505-512, 1956. (2) Bagchi, B. K.; Howell, R. W. 8: Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders. Am. ]. Psychiat, 102:49-61, 1945. (3) Bergman, P. S.; Impastato, D. J.; Berg, S. 8c Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures. Conf. Neurol., 13:271-277, 1953. (4) Callaway, E. 8c Boucher, F.: Slow Wave Phenomena in Intensive Electroshock. EEG. Clin. Neurophysiol., 2:157-162, 1950. (5) Chusid, J. G. 8c Pacella, B. L.: The Electroencephalogram in Electric Shock Therapies. ]. Nerv. €7- Ment. Dis., 116:95-107, 1952. (6) Delgado, J. M. R.; Alexander, L..& Hamlin, H.: Effects of Electroshock on the Cortical and Intracerebral Electroactivity of the Brain in Schizophrenic Patients. Conf. Neurol., 13:287-294, 1953. (7) Fink, M. Sc Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Re» spouse in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. (‘3‘Psychiat., 78:516—525, 1957. (8) Fink, M.; Kahn, R. L. 8c Green, M. A.: Experimental Studies of the Electroshock Process. J. Nerv. &- Ment. Dis. (in press). (9) Hayes, K. J.: The Current Path in Electric Convulsion Shock. Arch. Neurol. é} Psychiat., 63:102-109, 1950. (10) Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, 0.: Changes in the Electroencephalogram and in the Excretion of 17-Ketosteroids AccompanyElectroshock ing Therapy of Agitated Depression. Psychosom. Med., 8:246251, 1946. (1) �MARTIN A. GREEN 240 Willner, M. D.: Significance of Changes in the Electroencephalogram Which Results from Shock Therapy. Am. ]. Psychiat., 105: (11) Kennard, M. A. 8: 40-45, 1948. ' (12) Klotz, M.: Serial Changes Due to Electrotherapy. Dis. Nerv. Sys., 16:120-122, 1955. (13) Knott, G. R.; Gottlieb, J. S.; Leet, H. H. 8c Hadley, H. D., Jr.: Changes in the Electroencephalogram Following Metrazol Shock Therapy: A Quantitative Study. Arch. Neural. (5" Psychiat., 50:529-534, 1943. (14) Levy, N. A.; Serota, H. M. Sc Grinker, R. R.: Disturbance in Brain Function Following Convulsive Shock Therapy. Arch. Neurol. 1027, 1942. (‘5' Psychiatu 47:1009- (15) Liberson, W. T.: Current Evaluation of Electric Convulsive Therapy. Res. Publ. Ass. Nerv. Ment. Dis., 31:199-231, 1951. (16) Lorimer, F. M.: Sega], M. M. Sc Stein, S. A.: Path of Current Distribution in Brain During Electroconvulsive Therapy. EEG. Clin. Neurophysiol., 1: 343-348, 1949. (17) Moriarity, J. D. 8c Siemens, J. C.: Electroencephalographic Study of Electric Shock Therapy. Arch. Neurol. é» Psychiat., 57:712—718, 1947. (18) Pacella, B. L.; Barrera, S. W. 8c Kali'nowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy of Patients with Mental Disorders. Arch. Neural. E} Psychiat., 47 :367-384, 1942. (19) Proctor, L. D. 8c Goodwin, J. E.: Clinical and Electra-physiological Observations Following Electroshock. Am. J. Psychiat., 101 :707-800, 1945. (20) Proctor, L. D. 8: Goodwin, J. E.: Comparative Electroencephalographic Observations Following Electroshock Therapy Using Raw 60 Cycle Alternating and Unidirectional Fluctuating Current. Am. ]. Psychiat., 99:525530, 1943. Wegener, C. F .: On Electric Convulsive Therapy with Particular Regard to a Parietal Application of Electrodes Controlled by Intracerebral Voltage Measurements. Acta Psychiat. et Neural, 19:529-549, 1944. (22) Sulzbach, W.; Tillotson, K. J.; Guillemin, V., Jr. 8: Sutherland, G. F.: A Consideration of Some Experience with Electric Shock Treatment in Mental Diseases, with Special Regard to Various Psychosomatic Phenomena and to Certain Electra-technical Factors. Am. J. Psychiat., 99:519-524, 1943. (23) Taylor, R. M. Sc Pacella, B. L.: The Significance of Abnormal Electroencephalograms Prior to Electroconvulsive Therapy. J. Nerv. (S; Ment. Dis., (21) Smith, J. W. 8c 107:220—227, 1948. - Johnson, M. W.: Effect of Atropine and Scopolamine Upon Electroencephalographic Changes Induced by Electro-convulsive Therapy. (24) Ulett, G. A. 8c EEG. Clin. Neurophysiol, 9:217-224, 1957. (25) Weil, A. A. 8c Brinegar, W. C.: Electroencephalographic Studies Following Electric Shock Therapy. Arch. Neural. é" Psychiat., 57 2719-729, 1947. �ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI1 HYMAN KORIN, PH.D.2 and MAX FINK, M.D.3 In the course of extensive investigations (1, 2, 3) into the perception of multiple simultaneous stimuli, the pattern of failure of subjects accurately to report one of two stimuli led to a concept of an “order of dominance” in cutaneous perception. Since then, the relationship of the observed pattern of dominance to biologic and psychiatric concepts of body image and body scheme has been the subject of considerable speculation (4, 7, 8, 14). The interrelationship of body areas was initially clearly demonstrated in simultaneous tactile tests of face and hand (2), in which it was noted that the stimuli to the hand were frequently not reported or mislocalized. These phenomena of “extinction” and “displacement” led to the inference that cheek area stimuli were “dominant” to hand stimuli. In subsequent reports (3, 10, ll, 12) a pattern of dominance for tactile stimuli was described in which the face and the primary genital areas were the most perceptive or dominant areas; the hand was the least dominant; and the shoulder, foot, buttock, breast, back, thigh and abdomen fell between these extremes in a mild gradient. These observations were made in normal adults and children and psychiatric patients, but were most clearly discerned in patients with brain disease. Indeed, the major portion of the data relates to a group of patients with severe diffuse brain dysfunction under observation in a general psychiatric hospital. 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service. 2Assistant in Psychology, Department of Experimental Psychiatry, Hillside Hospital. 3 Director, Department of Experimental Psychiatry, Hillside Hospital. 241 �242 KORIN—FINK The basis for these phenomena is unclear. In a review of the problem (3) consideration was given to hypotheses ascribing significance to anatomic, psychophysical, genetic, environmental and neurophysiologic factors. In their conclusions, Bender, Green and Fink note that “no one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent.” In studies of patients with brain disease and normal young children, Cohn (4, 5) emphasized the rostral order of dominance and ascribed significance to “an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain.” He also noted specifically that this pattern was primarily associated with “the over-all sentient function of the brain.” A more extensive elaboration of a maturational and developmental explanation of the order of dominance has been proposed (14). Taking the infantile patterns of sutking and feeding as a model, Linn ascribes dominance to the face as it is the oldest element in the body image; the dominant role of the genital area to the intensity of pleasurable sensation that the infant elicits from masturbation; and the subordinate position of the hand to its role as an exploring and tension-relieving appendage wherein it holds second place in awareness to its stimulation of the more exciting mouth and genitalia. A neurophysiologic View was advanced by Critchley (6, 7), who, after expressing a preference for the term “tactile inattention” instead of “extinction,” emphasized the rostral order of dominance. He stated that “strong stimulation of the healthy side suppresses the attenuated sensations on the impaired side,” and concluded that “tactile inattention in parietal patients is probably no more than an instance of local neglect or disregard, which may be demonstrated at times in many other spheres of consciousness besides the tactile—whether motor, visual or spatial.” A psychophysical explanation was eschewed by Bender, Fink and Green (3, 10, 11), who found no relation between the order of dominance and the tactile threshold for touch or pin prick. DennyBrown, Meyer and Horenstein (8), however, insisted that these patterns were only apparent when there was an alteration or loss of twopoint discrimination. They further demonstrated that the extinction of the hand stimulus by a stimulus to the leg could be overcome by four stimuli to the hand. The dominance of the cheek to the hand could not, however, be altered by ten stimuli to the hand in their subject. �STIMULUS INTENSITY IN PERCEPTION 243 The following data further emphasize psychophysical factors in perception under the conditions of multiple simultaneous stimulation. These studies represent the initial report of an investigation into the application of simultaneous tactile stimulation tests to the problem of measurement of the alteration in brain function induced by electroshock therapy. In the course of this study electrical stimuli were applied to the cheek and hand of psychiatric patients. Stimuli were either at threshold or suprathreshold levels. Two aspects of the data are presented: (a) the effect of alteration of relative strength of stimulus in the order of dominance on facehand tests; and (b) relation of perceptual thresholds to the order of dominance. SUBJECTS AND METHOD The subjects were thirty-four consecutive psychiatric patients referred for electroshock therapy. The range of their ages was between 21 and 65 and the mean age was 45. Eleven patients were diagnosed as involutional melancholia, thirteen as manic-depressive, depressed, eight as schizophrenia, and two as psychoneurosis mixed type. All testing was done prior to a course of electroshock therapy and no patient had clinical or EEG evidence of altered brain function. Each patient was tested in one session for the purposes of this report. Two model S-4B Grass square wave stimulators were synchronized to deliver either single or two simultaneous electrical stimuli. An isolation unit was connected to each stimulator to eliminate artifacts and the output was monitored visually by an oscilloscope. A switch box inserted in the circuit permitted independent selection of the various body parts. An active and an indifferent electrode, required for each body part, were small 5%; inch steel discs placed 1 inch apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. The electrodes remained affixed to the selected body parts throughout the period of testing. The patient was placed on a couch in a relaxed and supine position. To alleviate undue anxiety the nature of the testing was described. It was emphasized that only a slight tap-like sensation would be felt. The electrodes were then placed on (1) the dorsum of the hands, (2) the mandibular area of both cheeks, and (3) the medial calf area of the legs. In the testing procedure, thresholds for the various body parts were first determined. At a frequency of .3 cycles/second, and a pulse I �244 KORIN—FINK duration of 50 milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, until the subject perceived 100 per cent of the stimuli. Incre1 volt of increments and the 5 hand volts to of were applied ments to the cheeks. After a ten-second interval, the voltage was decreased until sensation disappeared. Following another ten-second interval, the voltage was gradually increased by 1 volt each six seconds until the patient again reported 100 per cent of the stimuli. This reading was considered the minimal voltage required to produce threshold sensation. Such stimuli, at threshold and 10 per cent above the threshold, are reported by the subjects as a “tap,” a “prick” or a “sting.” Complaints of painful perception were not elicited at these levels of stimulation. After the thresholds were determined, testing with a series of single and double simultaneous stimuli followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and left cheek (homologous stimulation). Both in mixed singly, a one stimulated or simultaneously, were part parts order for ten trials for each of the following conditions: (1) threshold, (2) suprathreshold (10 per cent above the threshold), (3) one body part at suprathreshold and the other at threshold, and (4) the reverse of (3). The order of presentation of conditions (1) and (2) was alternated for different subjects and the same was done for conditions (3) and (4). Similarly the order of presentation of the heterologous and homologous stimulation was alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. When this change occurred, stimulation was increased until a new threshold was determined and ten trials were started anew. RESULTS A. Threshold Values The threshold stimulation for perception was determined for the hands, cheeks and legs (Table I). The threshold values for the hands and legs are three to four times higher than the thresholds for the cheeks. While the threshold values in the legs are less than in the hands, these differences lack statistical significance. Variabiland hands the in legs is threshold considerably the of greater ity than in the cheeks. There is virtually no overlapping of thresholds, however, where the cheeks and the hands are concerned. �STIMULUS INTENSITY IN PERCEPTION TABLE 245 I Mean Thresholds and Standard Deviations of Body Parts Mean Thresholds (volts) Standard Deviation Right Cheek Left Cheek Right Hand Left Hand Right Leg Left Leg 6.76 7.85 29.25 22.35 24.50 19.52 4.47 4.86 14.88 13.60 13.99 13.64 Extinction Patterns The difference between the number of extinctions of the right hand or the left cheek on stimulation of both parts with either threshold or suprathreshold stimuli was not significant (Table 11). Also, when both cheeks were stimulated with either threshold or suprathreshold stimuli, there were no differences in the number of extinctions in each cheek (Table III). In contrast to these observations, stimulating one body part with a suprathreshold stimulus and the other at threshold resulted in a significant increase in the failure to report the body part stimulated at threshold. Thus the cheek was dominant over the hand, or the hand was dominant over the cheek depending on the body part to which the stronger stimulus was applied (Table II). Altering the relative strength of the stimuli applied to the cheeks resulted in a similar predictable change in the pattern of dominance (Table III). Further analysis of the data in Table II indicates that the hand B. TABLE 11 Mean Extinctions of Cheek and Hand for Varying Conditions of Threshold and Suprathreshold Stimulation Mean Mean Extinctions Extinctions of Hand of Cheek Hand and Cheek at Threshold Hand and Cheek at Suprathreshold Hand at Suprathreshold and Cheek at Threshold Cheek at Suprathreshold and Hand at Threshold Difference Significance 1.55 1.56 .01 NS. 1.02 .59 .57 NS. 2.30 .22 2.08 p<.01 .32 1.36 1.04 p<.01 �KORIN—FINK 246 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.04) for the thresholdsuprathreshold condition. This tendency is also evident when both parts were simulated at suprathreshold. If it is considered that the mean threshold for the hands is approximately 30 volts, while for the cheeks the threshold is 7 volts, the difference in incidence of extinction may be explained. Suprathreshold stimulation was set at 10 per cent above the threshold value. The hand stimulus was TABLE 111 Mean Extinctions of Both Cheeks for Varying Conditions of Threshold and Suprathreshold Stimulation Both Cheeks at Threshold Both Cheeks at Mean Extinctions of Left Cheek Mean Extinctions of Right Cheek .39 .45 .06 N.S. Difference Significance Suprathreshold Right Cheek at Suprathreshold and Left Cheek at Threshold .18 .37 .19 N.S. .96 .14 .82 p<.05 Left Cheek at Suprathreshold and Right Cheek at Threshold .03 1.28 1.25 p<.01 therefore increased by 3 volts and the face stimulus by only 1 volt above the threshold value. Such an increase, although proportionately equivalent, appears to have given greater relative strength to the hand stimulus. Extinction Regardless of pattern, the mean total of the number of extinctions was greater when heterologous body parts were stimulated at threshold than when these parts were stimulated with suprathreshold stimuli (Table IV). For these same conditions of stimulation the diflerences between the mean number of extinctions obtained on homologous stimulation of the cheeks lack statistical significance, but the results are in the direction which indicate that a greater number of extinctions occur when two body parts are stimulated at threshold (Table IV). The failure to obtain a. significant difference in the latter instance is partly due to the fact that relatively few C. Incidence of �STIMULUS INTENSITY IN PERCEPTION 247 TABLE IV Mean of Combined Number of Extinctions For Varying Conditions of Threshold and Suprathreshold‘ Stimuli Both Parts at Both Parts at A-Suprathreshold A-Threshold Threshold Suprathreshold B-Threshold B-Suprathreshold A-Cheek 3.11 1.63 1.68 2.43 .85 .56 1.31 1.10 B-Hand A-Left Cheek B—Right Cheek Differences between the mean number of extinctions at threshold and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. * extinctions are elicited when homologous parts are stimulated. These findings on the total number of extinctions are in agreement with previous observations (2). DISCUSSION The pattern of extinction following electrical stimulation of the skin with threshold and suprathreshold stimuli has been determined. In contrast to the findings of investigators (3) who used clinical (tactile) stimulation, the face stimuli were not reported more frequently than the hand Stimuli. Under the conditions of the method of testing in this investigation, nevertheless, it is clear that the pattern of extinction for any two body parts can be readily altered by varying the relative strength of the stimuli. Thus a suprathreshold stimulus applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimulus intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand, in simultaneous tactile testing, is due to an inherent factor, perceived body image, rostral dominance, developmental principle or a learned factor, are not supported by these observations under our conditions of testing. If any of these factors were involved, a pattern of face dominance should have been elicited when the hand and cheeks were stimulated with equivalent electrical stimuli at threshold and suprathreshold intensities, despite the methodological dif- �248 KORIN—FINK ference introduced by the procedure of affixing electrodes to the skin. The findings in this study, namely that differences in the strength of the simultaneous stimuli can alter the pattern of extinction, supports a stimulus-intensity hypothesis. By inference, differences in threshold also play a significant role. That an intense stimulus elsewhere can raise the pain threshold as much as 35 per cent has been demonstrated by Hardy, Wolf and Goodell (13). This effect of a relatively intense stimulus on the threshold of another stimulus has also been found by investigators using other stimuli (8, 9). The problem still remains, however, how it is that a pattern of dominance may be elicited when presumably equivalent stimuli are applied by touch stimuli. The results of this study suggest an explanation. Stimuli of differing intensities are required to elicit a threshold sensation for various body parts. When these stimuli are increased 10 per cent, the resultant stimuli are proportional and are perceived as equivalent. In contrast, in clinically touching two body parts, the stimuli are disproportionate relative to the threshold value although approximately of equal intensity in their application. Because of the differences in threshold for the hand and cheek, the tactile stimulus to the cheek is proportionately more above the threshold than the stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and has been considered “dominant.” A threshold hypothesis was rejected (3) on the basis that the thresholds obtained by von Frey (16) for pressure and pain do not strictly correspond to the dominance order elicited by the double simultaneous stimulation tests. Most difficult to reconcile is von Frey’s finding that the pressure threshold of the glans penis, which is second in dominance rank only to the cheek in a group of ten body parts tested, is 111 grams per square millimeter; while the threshold of the hand, which is at least dominant, is only 12 grams per square millimeter. Unfortunately, thresholds in the genital area for male and female have seldom been determined. Von Frey’s list of thresholds (16) is based on a single subject. His more detailed observations (17), however, indicate that there is virtually no pressure sense in the glans penis or clitoris, although the perception of pain, warmth and cold is well developed. It is quite possible that the punctate pressure threshold does not correlate with touch where the genital area is concerned but that instead some other sense or combination of senses is involved. �STIMULUS INTENSITY IN PERCEPTION 249 Thresholds for the dorsum of the hand and the cheek obtained by von Frey and other investigators indicate that the cheek is considerably more sensitive than the hand. These findings are in agreement with the thresholds obtained in this study. In a recent study of electrical thresholds at various body sites Sigel (15) reported that “leg areas including thigh and ankle, also dorsum of the hands and the palm showed a definite tendency for higher thresholds. Scalp, temple, forehead and face tended to have lower thresholds. The anterior chest and upper arm and anterior wrist areas showed a tendency for lower thresholds. Neck areas, abdomen and upper back showed no definite trend.” In this statement there is no disagreement with the clinically observed order of dominance. From the experimental results obtained here, it is proposed that the dominance hierarchy elicited under the conditions of simultane— ous testing may be explained on the basis of the relative strength of the stimuli and the stimulus threshold. SUMMARY Using square wave electrical stimuli, the threshold for perception in the hands, cheeks and calves were determined in thirtyfour psychiatric patients. Simultaneous stimuli were applied in random sequence to combinations of cheek and hand and both cheeks, at threshold, suprathreshold and combinations of threshold and suprathreshold intensities. With simultaneous threshold, or simultaneous suprathreshold stimulation, the differences between the number of extinctions in either part were not significant. With stimuli of unequal intensity (one stimulus at threshold and one suprathreshold), however, there was a significant increase in the failure to report the threshold stimulus. The total number of extinctions is greater with threshold than with suprathreshold stimuli; and greater in heterologous than in homologous patterns of stimulation. It is concluded that the observed order of dominance in simultaneous cutaneous tests may be explained by psychophysical relationships. REFERENCES (1) Bender, M. B.: Disorders in Perception. Springfield, Ill.: Charles Thomas, (2) Bender, M. B.; Fink, M. 8c Green, M. A.: Patterns in Perception on Simultaneous Tests of Face and Hand. A.M.A. Arch. Neurol. (9 Psychiat., 66: 1952. 355-362, 1951. �250 (3) KORIN—FINK Bender, M. B.; Green, M. A. 8: Fink, M.: Patterns of Perceptual Organization with Simultaneous Stimuli. A.M.A. Arch. Neurol. 67- Psychiat., 72:233-255 , 1954. (4) (5) (5) (7) (8) (9) (10) (11) Cohn, R.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation. J. New. 6» Ment. Dis., 113:471-484, 1951. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: II—A Study in Rostral Dominance in Children. Neurology, 1:119-122, 1951. Critchley, M.: The Parietal Lobes. London: Edward Arnold 8c Co., 1953. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions. Brain, 72:538-561, 1949. Denny-Brown, D.; Meyer, J. S. 8c Horenstein, S.: The Significance of Perceptual Rivalry Resulting from Parietal Lesion. Brain, 75:433-471, 1952. Duncker, K.: Some Preliminary Experiments on the Mutual Influence of Pains. Psychol. Forsch, 21:311-326, 1937. Fink, M. Sc Bender, M. B.: Perception of Simultaneous Tactile Stimuli in Normal Children. Neurology, 3:27-34, 1953. Fink, M.; Green, M. A. 8c Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects. J. Nerv. 69'» Ment. Dis., 117:43-49, 1953. (12) Fink, M.; Green, M. A. (13) (14) (15) (15) Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. Hardy, J. D.; Wolf, H. S. 8c Goodell, H.: Studies on Pain. A New Method for Measuring Pain Threshold: Observations on Spatial Summation of Pain. J. Clin. Invest., 19:649-658, 1940. Linn, L.: Some Developmental Aspects of the Body Image. Int. J. Psychoanal., 36:1—7, 1955. Sigel, H.: Cutaneous Sensory Threshold Stimulation with High Frequency Square-Wave Current: 11. The Relationship of Body Site and Skin Diseases to the Sensory Threshold. J. Invest. Derm., 18:447-451, 1952. von Frey, M.: Beitréige zur Physiologic des Schmerzsinns. Ber. Siichs. Ges. 8c Wiss., 46:185-196, 283-296, 1894. (17) von Frey, M.: Beitrage zur Sinnesphysiologie der Haut. Ber. Siichs. Ges. Wiss., 47: 166-184, 1895. �NEWS AND NOTES DR. MILLER ANNOUNCES APPOINTMENT OF DIRECTOR OF PROFESSIONAL SERVICES Dr. Joseph S. A. Miller, Medical Director of Hillside Hospital, has announced the appointment of Dr. Lewis L. Robbins of Topeka, Kansas as Director of Professional Services at Hillside Hospital, starting July 1, 1958. Dr. Robbins has been connected for many years with the Menninger Foundation, and has held many senior positions at the Foundation, including the Directorship of the Outpatient Depart ment, and up to about a year ago, the Directorship of the Department of Adult Psychiatry. During the past year, he has been Senior Psychiatric Consultant and Chairman of the Psychotherapy Research Project at Menninger’s. Born in Chicago, Dr. Robbins was graduated from the University of Chicago and received his medical training at the Rush Medical School. He interned at the Michael Reese Hospital, Chicago; and had his psychiatric residency training at the latter hospital as well as at the Menninger Sanitarium. He graduated from the Topeka Institute for Psychoanalysis. He is a Diplomate of the American Board of Psychiatry and Neurology and also holds the American Psychiatric Association’s Certificate as a Mental Hospital Administrator. Dr. Robbins has been an instructor in psychiatry at the Washington School of Medicine and a lecturer in psychiatry at the University of Kansas Medical School, the Menninger School of Psychiatry as well as a training analyst at the Topeka Institute for Psychoanalysis. He is a member of numerous national and regional societies, including fellowship in the American College of Physicians, the American Psychiatric Association, American Orthopsychiatric Association, the Group for the Advancement of Psychiatry; and he also holds important offices on the executive and other committees of the American Psychiatric and American Psychoanalytic Associations, and is currently the Secretary of the American Psychoanalytic Association. Hillside welcomes Dr. Robbins to its staff. The position of Directorship of Professional Services will include the general direction of the Hospital’s treatment, teaching, and some of the important research programs of the Hospital. 251 �252 NEWS AND NOTES SPECIAL INSTRUCTION FOR RESIDENTS DURING 1957—1958 We are pleased to announce that we have engaged the teaching services of three prominent psychiatrists and psychoanalysts for the special instruction of our Residents during the 1957-1958 season. These are: (1) Dr. Robert C. Bak, whose course will be on “The Psychopathology of the Psychoses, with Special Reference to the Schizophrenias.” The lectures will be given at the Hospital on Wednesdays from October 1957 through May 1958, from 12:00 to 1:00 P.M. (2)Dr. Paul Goolker, who will be giving the course on “Principles and Practice of Dynamic Psychotherapy for Hospitalized Patients.” This course will be given during the same period on Fridays from 12:00 to 1:00 RM. (3) Dr. I. Peter Glauber will be in charge of the course on “Important Readings in Psychoanalytic Psychiatry.” This will be given at the Hospital on Thursdays from 11:45 A.M. to 12:45 P.M. As has been the custom, these lectures to the total Resident staff will be preceded by three hours of special conferences including group preceptorship of a number of Residents and their particular Supervisor. A SPECIAL COURSE OF LECTURES ON GROUP PSYCHOTHERAPY We have the pleasure of announcing that Dr. Aaron Stein, the Director of the Group Psychotherapy Program at the Hospital, will be giving an introductory course of lectures to our Resident staff; and that all members of the psychiatric Attending Staffs and the Clinical Assistants of both the Manhattan and Queens Clinics are cordially invited to attend. The lectures will be held at the Hospital in Glen Oaks on Saturday mornings from 9:00 to 10:15 A.M., beginning Saturday, September 28 and up to Saturday, December 21. Dr. Stein is an Associate Attending Psychiatrist at the Hospital and an authority in group psychotherapy. He plans to cover the important practical aspects of the subject, including general principles, selection of patients, group psychodynamics. the role of the group therapist, relationship between group and individual psychotherapy, etc. J.S.A.M. �Recent and Forthcoming Publications INSTINCTIVE BEHAVIOR The Development of a Modern Concept Translated and edited by CLAIRE H. SCHILLER Introduction by KARL S. LASHLEY With contributions by Konrad Lorenz, Paul H. Schiller, Nicholas Tinbergen, Jakob von Uexkiill 120 illustrations, $7.50 EROGENEITY AND LIBIDO Some Addenda to the Theory of the Psychosexual Development of the Human Psychoanalytic Series, Volume I By ROBERT FLIEss $7.50 YOUTH AND CRIME Proceedings of the Law Enforcement Institute Held at New York University Edited by FRANK J. COHEN $6.00 ON THE UTILITY OF MEDICAL HISTORY Institute on Social and Historical Medicine, Monograph I The New York Academy of Medicine Edited by IAGO GALDSTON $2.00 ON NOT BEING ABLE TO PAINT New Revised Edition By MARION MILNER Foreword by illustrated, $4.50 ANNA FREUD or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. At your bookstore 1] �THE INDEX OF PSYCHOANALYTIC WRITINGS ALEXANDER GRINSTEIN, M .D. 5 Volumes, sold as set only, $75.00 Volumes I and II, now available Volume III, Fall, 1957 The Index covers the entire psychoanalytic literature through 1952. Every book, article, review or abstract is listed in alphabetical sequence according to authors and titles. There are approximately 37,500 listings drawn from 25 psychoanalytic publications and some 75 journals containing articles by psychoanalysts or about psychoanalysis and closely related subjects. Psychoanalytic books and articles, published in 21 languages, have been included, and foreign-language titles have been translated into English. The most invaluable feature is a separate subject index with some 30,000 topical entries. In addition, there are a number of appendices. One of them lists nonanalytic books reviewed in psychoanalytic journals. The others are devoted to a chronological listing of the writings of psychoanalytic pioneers. Among them is the first complete bibliography of Sigmund Freud’s writings and published letters. Dr. Heinz Hartmann says: “Psychoanalysis has reached a stage at which a truly comprehensive index of analytical literature has become a necessity. Many questions of principle had to be decided, on the methods of listing, on the degrees of inclusiveness, etc., in order to make this Index a valuable tool for research workers in psychoanalysis and related fields. Dr. Grinstein made these decisions with considerable wisdom and objectivity, guided by a lucid understanding of all the rather complex problems inherent in his tremendous task. This task might well have looked forbidding and frightened off many a less courageous man. Having become accustomed to using Volume I of The Index of Psychoanalytic Writings (other volumes are to follow soon), I can say that the obvious difficulties of this comprehensive venture have been successfully overcome and that this imposing work has proved of the greatest value to me, and without doubt to very many others.” At your book store or order directly from INTERNATIONAL UNIVERSITIES PRESS, INC. 227 West 13 Street New York 11, N. Y. . 1] �JOURNAL of the HILLSIDE HOSPITAL VOLUME VI 1957 NUMBERS 1-4 CONTENTS Scientific Papers Blane, Howard T. and Glad, Erik—THE PSYCHOLOGIST AND THE PSYCHIATRIC TEAM IN A RESPIRATOR CENTER . Boyer, L. Bryce—THE MEANING SCHIZOPHRENIC PATIENT Desmonde, William H.—THE ANIMAL SACRIFICE . . OF INSULIN THERAPY TO A . . 24 . . . . . . ORIGIN OF MONEY IN THE . . . . . . . . Devereux, George—THE CRITERIA OF DUAL CO‘MPETENCE IN PSYCHIATRIC-ANTHROPOLOGICAL STUDIES . 87 Fink, Max—A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMIC THERAPIES . . . . . . . . . Glynn, Eugene—THE THERAPEUTIC USE ADOLESCENT PAVILION . . . OF SECLUSION IN AN . . Green, Martin A.—SIGNIFICANCE OF INDIVIDUAL IN EEG RESPONSE TO ELECTROSHOCK . . Jafie, Joseph—AN OBJECTIVE 1 9‘7 . . . . 156 VARIABLIITY . 229 . STUDY OF COMMUNICATION IN . 207 FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL . . . . . . . . . . 216 PSYCHIATRIC INTERVIEWS . . . . . . . Kakn, Robert L.; Pollack, Max; and Fink, Max—SOCIAL Karin, Hyman and Fink Max—ROLE OF STIMULUS INTENSITY IN PERCEPTION OF SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI. . . . . . . . . . . . . 241 �Locke, N orman—REMARKS PSYCHOLOGY AND THE ON THE GROUP PSYCHOTHERAPY OF THE HARD OF HEARING 100 . M eerloo, ]oost A. M .—Kos AGAINST KNIDOS: AMBIVALENCE AS THE PSYCHIATRIC OUTLOOK ON MAN . . . . . 67 M ullan, H ugh—GROUP PSYCHOTHERAPY IN PRIVATE PRACTICE: PRACTICAL CONSIDERATIONS 34 Nz'ederland, William G.——THE SYMBOLIC RIVER-SISTER EQUATION IN POETRY AND FOLKLORE Reider, N OTman—TRANSFERENCE PSYCHOSIS Slap, Joseph William—PSYCHOTHERAPY 91 131 . WITH A CASE OF 43 MALADIE DES TICS Slap, [oseph William—SOME CLINICAL AND THEORETICAL 150 REMARKS ON CHESS Clinical Symposium OUTPATIENT TREATMENT VIA PSYCHOTHERAPY OF A CHARACTER NEUROTIC WITH IMPOTENCE Part 1: Case presentation by Lionel Blackmcm Part II: Discussion Book Review News and Notes 107 160 180 . . . . . . . . 55,121,182,251 �NO and YES on the genesis of human communication By RENE A. SPITZ $4.00 Dr. Spitz, well known for his original studies of the psychological ‘ i development of infants, devote-s a monograph to the beginnings of com~ munication. He tackles this most important problem from a broad basis, using the theoretical framework of pSychoanalysis; direct ob’servations of infants, both normal and abnormal; and the newest findings of animal ethology, experimental psychology, embryology and physiology. Skillfully integrating the dataiobtained by thesescience'sr Dr. .Spitz presents a most fascinating and thought-provoking theory of, the roots of communication, both verbal and nonverbal. Dr. Spitz eXa-mines the inherited or preformed motor behavior patterns whiCh have a function in the earl1est nursing situation. Both negatiOn as well as affirmation have such early motor prototypes, which in the Course of deve10pment undergo a change of' function. Divorced, fromthe behavior they originally subserved, these motor patterns can now be utilized exclusively as signals of communication. Later, endowed with semantic meaning which the child acquires through identification with the adult’s “No” gesture, they are used for communication proper. Though drawing upon the data and theories of other sciences, the framework of this monograph rests upon Freud's fundamental insights into human pSychological development. Its, major contribution is the minute examination of some of; the building blocks of‘Freud’s theory. This proc'edUre permits the author to throw light on hitherto unexplored interrelations between speCIfic aspects of behaviOr1n infants. these findings emerges the generally applicable concepts of From ‘ “organizers of psychic development" as well as a description of the origins of the Selfin infancy. These findings have the widest implications for clinical psychoanalysis as well as the study of human relations in general. . . ‘ .< .. .1 2...: .J _ ‘ ’ —.—___‘_____________________ At your bookstore. or order directly from ‘ 1] INTERNATIONAL UNIVERSITIES PRESS, INC. 227. West 13 Street 'New York 11, N. Y. . , ' �M THE PS’YCHOANALYTIC STUDY OF THE CHILD Volume XII, $8.50 Contents. of the Newest Volume ERNST KRIS, 1.9004957 Contributions to Psychoanalytic Theory Nature and Development of the Concept of Repression in Freud's Writings PHYLLIS GREENAcRE—The Childhood of the Artist EDITH JACOBSON—On Normal and Pathological Moods Pathoand Normal JEANNE LAMPL—-DE GRoor—On Defense and Development: ‘CHARLES BRENNER—The logical RUDOLPH M. LOE-WENSTEIM—eSomt} Thoughts on Interpretation in the Theory and Practice of Psychoanalysis SEYMOUR L. LUSTMAN—Psychic Energy and Mechanisms. of Defense ’ Aspects of Early Development CAsusoe-Anxiety Related to the Discovery of the‘Penis': An Observation. With an Introduction by ANNA FREUD MARIANNE KRIS—The Use of Prediction in :1 Longitudinal Study WILLIAM G. NIEDERLAND—The Earliest Dreams of a Young Child GABRIEL _ ‘ ANNEMARIE SANDLER, ELIZABETH DAUNTON and ANNELIESE SCHNURMANN— Inconsistency in the Mother as a. Factor in Character Development: A Comparative Study. With an Introduction by ANNA FREUD V Clinical Contributions PETER BLos—Preoedipal Factors in the Etiology of Female Delinquency ERNA FURMAN—Treatment of UndefiFiV'es by Way of Parents ELISABETH GELEERD—Some' ASPects cents of Psychoanalytic Technique in Adoles- BELA MITrELMANN—‘Motility in the Therapy of Children NATHAN N. ROOT—A Neurosis in Adolescence MARGARETE and Adults RUBEN—Delinquency; A Defense Against Loss of ObjeCts and Reality LISBETH J. SACHS—On Changes in Identification frOm Machine to Cripple ‘ Applied Psychoanalysis the Salamander’ StanislaVsk-i PHILIP WEISSMAN—The Childhood and Legacy of ROBERT PLANK—On ‘fSeeing ______—__‘_____._______———————————or- order directly from {I At your bookstore INTERNATIONAL UNIVERSITIES PRESS, INC. 0 New York 11, ‘N. Y. 227 West 13 Street, . . �jam; Rah at smug/1n Pox-caption of Simultaneous mm. swam Pub}! m 2 Karin $.13. and 3"!“ Fink Kenn ”amt at emu“ in “armament until. puma“: ha m been the object at midst-able discussion was. it: «napalm by Bender and common and matron: wlmtim hm bun errand. Ema: 12h. threshold for perception 9150mm maand “mm, 3!; mm w psychiatric putienta. «in: mm, simianeoua stimuli are applied in madam nqumo to lamination: o! cheek md hand and both check: at 111mm, mthruhold and mama” cf throdwld and mmthruhold human. Bung aqua-o in ’01:. hands, Results: 40de 3mm: cinnamon” or supnthromold «imam, wmw, the differences between the number of “auctions in aither part. were not. nigaifiunt. Him «ml: or mummy (m sum“ at thmhold and one supmthmshold), Mater; then m a significant meme in the £13,1an ta «part tho thruhom. with W Cancyuam Thou data suppert tho 1:: simultaneous cutaneous ‘o‘ono " ”Ix/57 mmnm: tint the obnmd nrdor of Wm mm are pmd upon paydmfiysieal anaemia“. � 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 Role of stimulus intensity in perception of simultaneous cutaneous electrical stimuli. J Hillside Hosp., 6: 241-250, 1957. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-26-001 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 Korin, Hyman; <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 Journal of the Hillside Hospital,Vol. VI October, 1957. Full copy of the Journal of The Hillside Hospital, Vol VI, No. 4, October 1957, Table of contents: A UNIFIED THEORY: OF THE ACTION OF PHYSIODYNAMIC- THERAPIEs by Max Fink; AN OBJECTIVE STUDY OF COMMUNICATION IN PSYCHIATRIC INTERVIEWS by Joseph Jaffe; SOCIAL FACTORS IN THE SELECTION OF THERAPY IN A VOLUNTARY MENTAL HOSPITAL by Robert L Kahn, Max Pollack and Max Fink; SIGNIFICANCE OF INDIVIDUAL VARIABILITY IN EEG RESPONSE TO ELECTROSHOCK by Martin A. Green; ROLE OF STIMULUS INTENSITY IN PERCEPTION 0F SIMULTANEOUS ELECTRICAL CUTANEOUS STIMULI by Hyman Korin and Max Fink; NEWS AND 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 Published http://exhibits.library.stonybrook.edu/mfp/files/original/f9143989b4f022343ed9672f34b2d359.pdf 1500dfbcc8282737a3c8c3677182eaf9 PDF Text Text WITHDRAWAL SYMPTOMS FOLLOWING DISCONTINUATION 1 OF IMIPBAMINE THERAPY JOHN C. KRAMER, M.D.,2 DONALD F. KLEIN, M.D.,3 AND MAX FINK, M.D.‘ [Reprinted from THE AMERICAN JOURNAL OF PSYCHIATRY, V0]. 118, No. 6, December, 1961] �, . 0 i ~ I I‘NG- DISCONTIN'UATION OFIMIPRAMINE THERAPY 1 . V IOHN _'.-KHAMEH, M.D;,2 c: DONALD “E KLE‘I‘NQMD.) mMAXFIN‘K, Mgn.4 r v I ' �1961 1 CLINICAL NOTES 549 WITHDRAWAL SYMPTOMS FOLLOWING DISCONTINUATION 1 OF IMIPRAMINE THERAPY JOHN C. KRAMER, M.D.,2 DONALD F. KLEIN, M.D.,3 AND MAX FINK, M.D.4 On discontinuation of imipramine 5 treatment some psychiatric patients reported nausea, vomiting, dizziness, coryza, muscuAided, in part, by grant MY—2715 of National Institute of Mental Health, National Institutes of Health, USPHS. 2 Post Doctoral Research Fellow, USPHS, 19601 1961. Mental Health Career Investigator, USPHS. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I., N. Y. 5 The cooperation and assistance of Ceigy Pharmaceuticals is gratefully acknowledged. 3 4 lar pains and malaise. The symptoms were first regarded as conversion phenomena, but after several repetitions were considered due to physiological withdrawal. Of the patients treated with imipramine 45 had been observed within the hospital during withdrawal of medication. Treatment was instituted with oral doses of 75 mg. daily and usually increased each week in 75 mg. steps. The daily maintenance dose was 300 mg./day in 34 patients, more than 300 mg./day in 3 patients, and less than �550 CLINICAL NOTES 300 mg./day in 8 patients. We reviewed our interview records and the daily nursing notes, noting reports of withdrawal symptoms within 48 hours of cessation of medication in 25 of the 45 patients. Most prominent were nausea with or without vomiting—16 subjects, headache— 10, giddiness—lO, coryza—8, chills—6, weakness and fatigue—5, and musculoskeletal pain—4. Twenty—two of 26 patients treated for 2 months or longer reported withdrawal symptoms, while only 3 of 19 patients treated less than 2 months reported similar symptoms (p< .001). The 25 patients who had been treated for more than 2 months were rated for severity of symptomatology. The reaction was scored as “marked” if subjects reported more than 2 different symptoms with significant distress and as “minimal” if they reported fewer than 2 symptoms causing minor distress, or no symptoms. Of 13 patients with a medication tapering and termination period of less than 2 weeks, 8 had marked withdrawal symptoms and 5 mini— mal. Of 12 with a medication termination period longer than 2 weeks, only 2 subjects demonstrated marked withdrawal symptoms (p:.05). These results are in keeping with the general experience that the intensity of physiological withdrawal symptoms is directly proportional to the duration of drug administration and the abruptness of withdrawal. We could not relate the withdrawal syndrome to the size of the maintenance dose, since our range was too small. However, our modal schedule of 300 mg. per day is larger than the usual clinical schedule of 100 to 150 mg. per day and may account for the inconspicuousness of this phenomenon in other studies. We observed that allowing a period of 2-4 weeks for withdrawal was prophylactically effective. When symptoms on imipramine discontinuation occurred they could readily be treated by resuming imipramine at 50 mg. daily and gradually decreasing over a 1-week period. [ December DISCUSSION A physiological withdrawal syndrome following the termination of treatment with opiates, demerol, barbiturates, glutethimide, alcohol, chlorpromazine and meprobamate is well known. Recently withdrawal symptoms with methaminodiazepoxide(2), nialamide(1) and alpha-ethyltryptamine(5) have been reported. Kuhn( 3) and Mann and Macpherson(4) have also reported symptoms on abrupt imipramine withdrawa1. Until recently the physiological withdrawal syndrome was considered restricted to CNS “depressants” such as opiates, barbiturates and alcohol. This was confirmed by the absence of such a syndrome with “stimulant” drugs such as cocaine, d-amphetamine, marijuana, mescaline and LSD. The occurrence of such a syndrome with imipramine, nialamide, and alpha-ethyltryptamine is of considerable interest, therefore, since these drugs have been loosely referred to as “psychic energizers” with energetic effects similar to “stimulant” drugs. It is apparent that a simple depression—stimulation dimension is inadequate to describe the complexity of drug effect both physiologically and behaviorally. The withdrawal syndrome complicates the evaluation of patients after drug discontinuation since both patients and physicians often interpret the onset of symptoms as an upsurge of “anxiety” related to incipient relapse, and resume treatment with the gratifying subsidence of the “anxiety.” This may cause both patients and physicians to overvalue the importance of the medication to the patient’s stability. BIBLIOGRAPHY 1. Hollister, L. E., Motzenbecker, F. P., and Prusmack, J. J. : J. Clin. Exp. Psychopath., 21 : 212, 1960. 2. Hollister, L. E., Motzenbecker, F. P., and Degan, R. 0.: Psychopharmacologia, 2: 63, 1961. 3. Kuhn, R: Schweizerische Medizinische Wochenschrift, 87: 1135, 1957. 4. Mann, A., and Macpherson, A. : Canad. Psychiat. Assoc. J., 4: 38, 1959. 5. Turner, W. I., and Merlis, S. : J. Neuropsychiat., 2 : 1961. ��Htth¢r¢wnl Symptonu ralluvtnz Discontinuation at In1pran1uo fhurtpy {can 6. {rt-st, H.D.#, nonald and r. Kissn, x.n.u‘ In: link, 3.9. from tho Departnont of Exporincntal rayohigtry, 3:110:40 lalpltal, Olen 00kt, 5.1., [.1. floatorll Raconrch fallow, 88,38, 1960~1961. oqnontnl lunlth euro-r Iavuatagutor, ssrus. Aided, in part, by grant l1~2715 or Intionul Institute 01 Hantnl Health, Int1¢n¢1 Iu|t1tutoa at laulth, yarns. the caoportttou and aauiutanoo ot_6.1¢y Pharancauttcal: O P98? 52.301111: nekuuvlcdaod. VI: 6/29/61 13 �discontinuation of iliprsniss trsstnsnt sons pstissts, ands: obssrvssisa ts: s vsristy a: psychistric sysdrssss, rsportsd nsssss, vssiting, dissinsss, ssryss, ssscslsr psins sad Islsiss. Ens sysptsss ssrs first rsgsrdsd ss osmvsrsisa phsnousns, but stisr ssvsrsl rspstitisns vs sonsidsrsd thsss to be dss to physiological withdrsssl sad an sttolpt vss nsds to dotsrsins their trsqusaoy sad varisty. o: the pstisats trsstsd with isiprssins during sn sightoon nsnth psriod, forty-11's hsd bssn observed within the hospitsl sstting during withdrawal of ssdissties. In thsss subsects trsstnsnt was instituted with arsi dosss st 75 s; dsiiy sad ssnsliy issrssssd sssh sssk in 75 as stsps. Ins dsiiy‘ssistsnsaes dsss ass zoo aglsay in thirty-tour puss-ntsg loss than 300 ltldly in tires pstisass; and loss thin 300 Is/dsy in sight 0n pstisats. rsvisssd our intsrviss rssords and fits dsily ssrsiac notss, noting rspsrss o: uithdrsssl symptoms within k8 hours of ssssstisa or sodiostion in 25 of tho h! pstisnts. (rsbls I) Vs n“.-.IABLE I -D.-”- �2.510 I aynptonl Within an Intro 01 cunna$1on or Iniprnnino therapy’ Pnttontl conning theft?! Patients reporting Iynptonu hS 25 azggtons l:unou (and/or vomiting) 16 Houdnoho 10 GiddinOII . 10 Darya: chill: taintnuuu HIIoqu-Ikolotsl pain Hoaknosu or rmma �.29 ovidoat whoa tho aurorolottonohip otguitioont ttoo o: trootlont and tho oppooroaoo of orlptono oro oomporod. (Toblo I!) toasty-too of tvonty-otx patients trootod for two ooutho or longor roportod withdruvol oyuptono, whilo only throo of ntnotoon potionto trootod loo: than too nontho roportod otnilor oynptono. 1o A II O .‘O--.. fAILB to dotornino tho rolotion of tho obouptaooo ot nodiootton withdrovol to indoood oyuptouo, tho twentyrtvovpottonto who bod boon trootod for noro thou two ooutho ooro rotod to: oovortty o: oynptoootoloay. rho rooottoo woo ooorod oo 'norkod' 1: lobaooto roportod ooro thou two dittoroot oynptono with otgaitioont diotrooo and to "minimal“ at tho: roportod towor than two oyoptono oonoins lino: atotrooo, or no symptolo. Too groupo ooro doriaod according to otothor tho poriod or Iod1oot1on rodootton woo looo thou too rook: or too uooko t or longoo. (foblo III) “-Qfl‘..-. TABLS III �Ink}: 1! nurution of Iniprnltno Therapy w1%hdr¢vn1 Symptoms It Withdrawal Symptonu (lubaootl) (subjects) in. isn‘t. I 16 fun South: or hangar 22 h Lon. thin x9 .- 23.91. P < .001 2gblo £51 rurtod or 3:3: Gestation In Patients rruatcd st Lcnlt fro abnthn Withdrawal 8232t¢nl lurked . Lon. than rug minimal VIDEO 6 5 fun with: or Long.» a 10 p ~ .05 (Fisher) (h) �~3- !haaa raaalta art in kaaping vita fiha can-val asparianaa ihat tho iataaaity a: phyaiolocical withdrawal aylptoua is directly proportional in tho duration at drug adaiaiatration and tha abruptaaaa at vifihdraaal. Va scald not ralata tha appaaranaa of at: withdrawal ayndroao to tho aiaa o: tho aaiatauanea doaa, ainoa our ranaa uaa too shall. flovavar. our natal aahadala a! 300 I; ha: day in largo: than tho aaaal clinical aahadala a: 100 ta 150 a. par day and nay account for an. inaauapioaaaaaaaa a: thin phaaaaaaaa in Qatar atadiaa. It Iaat ha aataa that withdrawal aylpiaaa was. unvaried by aaa patiaat aha III traataa la: tua lantha at 75 In; par «7. a marina. daaa at abaarvad that alluviag a parted at 3-h wacktar withdrawal ran prayhylaatiaally attaetiva. ihan ayaptaaa an iaipraaiaa diaeoatinaatiaa acaurrad they coal! readily be treated by raaaaing iaipraaiaa at Ha , 56 a; daily aid gradually aaaraaains era: a parted. one tack �9h. accurrcauc a: a vhf-1010:1931 utthdrnnal lyndronc tollcrtlg the tor-tnutton o: troninoat with optntcl, duu.rol, burhtiurltcn. all$othilado and 1100301 1! wall kntln¢ looantly withdrlvul Irlgten- attachlsrptonnsaao (2), Isthnatnodinuapcxtlo {1). nialnuldo (5}, alpha-oihyittyp‘anlno (9) and nuptniiluto (1,3,6) lav. icon rcporfiod. tan: (8) ha; ciao obstrvod lyuyton‘ on abrupt znlprnltno withdraanlo Until riotatly it. phytiologteal iithdruu:1 cyadrono was coalidtroi routrtetcd to 618 'dcpréunsatn' Inch OI splat... barblfiurnsos and alcohol. this was contirnod 57 Sh. tbacnco of such a cyndruno with “stannlsnt‘ drugs tank .3 cocgtno, d-tlphotanino, unhealino and £39. In. accurronoc at such antisulan, a syndrcnn with tulprlltnu,43131anldn, and alpha.ihrltryptaazno 1- or etalldnrahll Satori-t, ‘horutorc. can-o thus. drug: havn baa: 1.90.17 rtrorrcd to a: 'payuhao 0303:1302.“ 11$) unaruo‘tc o£1¢ctn 01-11:: ' human an to u .1»:am... It 1.- .pnmt Canto-liaa-stxlnlatioa dincnulun 1: tnnlcquat. to donoribu tho.¢olploxtty or drug effect hath phyuso« logically and behaviorully. in. at withdrawal 9:362:30 conpl1oatbn tho avnlunttou pcttcutn utter drug dicooutsnuatton, both oltniually . �hoth and patina“ an” maximum, punch:um 1“.»er tn ant a mu», (mans, to. u a: spur" a: ‘uuaotyfl "1am to menu“ "up“. and hum a mum ”amt an m ”any“. «bum» a: a. 'mtoty'. m. any at!" ”a and plantain: to ova-van tho moral» of a. plum“ noun“... to tho grunt“ gummy. and �m 1. no taunts-u at «1pm» ”um“ product. phyutoIocto-l withdruwnl uynptonu, which arc rolutod to luasth of ‘rontnaut and abruptuocn o: withdrivui. aylptonn may also be rolntad to douaco luv-1o I. H1thdrar¢1 lyyptons any h. militia-d qr oltntuutod by running fitchuaquol. I it. aneurraaac of : withdranul syndrong lath tnlprgnluo to porttnoafi ta tn. coucoptunltus$1.: or its paynhowhnrnaaolocical notiviflr, and to 3. prabltna I: clinical Isaac-hunt. �1. mu, 3.1., at. an... Ida W. ’- 33.3,. 1. 1023, 1955. Inch. 3-.» 9.3.: Mac, 3.3. and 833. 1958. lulu, 1.3.: m: a, J, 931. 1959. 'mnfi: MI 801301, id. 8.. vgumMe autumn, m ncfirtI-ltll, It! tort, 1956, 96. 5. lanai", In!” ”summer”, hr. and Pam-suck, 3.3.: 3 lmhflnfih, 3;: 212, 1960. g, nun: L“ 6- lolltltor, L.R. and fllcsanar, !.8.s £3!3§22§£££££2¥3‘§2& 196°. 3”, ;. 7. amour, In!” Runabout», LP. and Baa, the” It. ”that, BA” in W a W. I. ma. M 2- ‘3: 1951. 1135, 1957. 9. Mar, m1. ad lit-r110, 373, 1961 (app)... 1) 8.1 J, Inn-3mg; . g: 9.1: � 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 Withdrawal symptoms following discontinuation of Imipramine therapy. Amer J Psychiat, 118:549-50. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-56-022 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 Kramer, John C.; Klein, Donald F.; <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 (Clinical notes) and [preprint]. Reprint from THE AMERICAN JOURNAL OF PSYCHIATRY, V0L. 118, No. 6, December, 1961 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/0f6719a23fdc7ec86b84e3ad0121dcb7.pdf 2c174223139f67b6ca449ef570bd2067 PDF Text Text SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY K MAX POLLACK, PH.D. Reprinted from THE Vol. 132, N0. L 2 Copyright © AND MAX FINK, M.D. JOURNAL OF NERVOUS AND MENTAL DISEASE by The Williams Printed in U.S.A. 1961 & February, Wilkins C0. 1961 �JOURNAL or NERVOUS AND MENTAL DIsEAsE Volume 132, No. 2, February 1961 Reprinted from THE Printed in U.S.A. SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY MAX POLLACK, PH.D.1 The growing recognition of the relation of social factors to referral for and response to somatotherapy in psychiatric treatment has stimulated increased study of “drop-outs”— patients who refuse to start or to continue treatment. Although the problem of “dropouts” is a major one in somatotherapy, it has received little attention. In convulsive therapy it is considered one of the most fre— quent “complications” of treatment (1) yet it is infrequently discussed (3, 7) and no systematic studies have been devoted to it. Systematic studies of “drop-outs” have been limited for the most part to patients in psychotherapy in out—patient facilities (4, 5, 9, 19, 20). These studies have consistently shown marked differences in social and psychological characteristics of patients who remain in psychotherapy and those who fail to continue. Those patients who remain in therapy have more years of education and who those class social than of higher are leave. In addition, their social attitudes, as measured by the California F Scale, show “less so—called conventionalism, stereotypy and less of an uncompromising insistence that ‘right’ and ‘wrong’ can be distinguished” (20). In sociopsychologic studies of the patient population of Hillside Hospital (12, 13) age, education, place of birth and degree of stereotypy, as measured by the F Scale, were related to selection for, and response to, convulsive therapy. Those patients who were older, had fewer years of education, were foreign-born and who manifested high scores on the F Scale were most likely to receive convulsive therapy, be hospitalized for Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 1 and MY—2715, National Institute of Mental Health, U. S. Public Health Service. Aided by grants MY—2092 AND MAX FINK, M.D. a shorter period, and be rated as improved at time of discharge. In contrast, patients who were younger, better educated, native-born and who obtained low scores on the F Scale, most often received psychotherapy as their sole form of treatment, were hospitalized for a longer time, and were more likely to be discharged with a rating of unimproved. Thus, the determination of psychiatric treatment was viewed as an interactive process, and related to the background, cultural values and communicative pattern of both therapist and patient. In view of this relation of psychosocial factors to selection for and response to treat— ment, it was postulated that in a psychotherapeutically—oriented hospital patients who refuse or fail to complete convulsive therapy would be significantly younger, better educated, and be less stereotyped and conventional than patients who completed a course of therapy. This study was undertaken to test this hypothesis. PROCEDURE The seventy-five consecutive iii-patients (27 males and 48 females) referred for con— vulsive therapy at Hillside Hospital during the one year period from October 1, 1957 to September 30, 1958 were included in this study. Hillside Hospital is a non-profit institution for the treatment of voluntary patients. Psychoanalytically-oriented psychotherapy is regarded as the primary method of treatment, with various somatotherapies available when necessary. All pa— tients are seen for individual psychotherapy three times a week, with psychotherapy continuing when other treatment, 6.9., convulsive therapy, is administered. Three social (age, education and nativity) and one psychological measure (the Cali153 �154 POLLACK A ND FINK fornia F Scale), were employed. A ten-item modification of the F Scale (6, 14) was administered to 53 referrals prior to treatment. In this task, the subject reads 10 statements and indicates whether he agrees or disagrees with each statement, and to what extent. The score given for each item ranges from one to seven and the range of total scores is ten to seventy. The greater the subject’s agreement, with the statement, the higher the score obtained. The statements themselves are extreme, conventional and stereotyped expressions. lr‘or example, one statement is, “If people would talk less and work more, everybody would be better off.” Patients were referred for convulsive therapy by the psychiatric resident with the ap— proval, frequently at the suggestion, of his supervisor. The referral form requesting treatment was sent to the psychiatrist in charge of the convulsive therapy unit for medical examination and the institution of treatment. Thus, it was possible to determine those patients who were referred for treatment but who refused to start. Convulsive therapy was generally administered three times a week, and grand mal convulsions were induced with the standard Medcraft alternating current instrument. RESULTS Of the 75 referrals for convulsive therapy, 13 refused treatment. Of these, seven failed to start and six refused to continue treatment. In the latter group, the number of treatments ranged from three to eight— short of the generally prescribed course of at least twelve treatments. TABLE 1 Mean Age, Education and F Score by Group N Group ' Acceptance Refusal Mean Difference (One—tailed t p< test) 62 13 (figs) Educa- 0:325) 40.3 11.6 29.7 13.7 — 10.6 +2.1 2.5 1.9 .01 .025 F Score 48.7 37.7 — 10.0 2.2 .025 Social and Psychologic Factors: The group of patients who accepted a full course of convulsive therapy was significantly older, less educated and manifested a higher mean F score than the group that refused treat— ment (Table 1). Furthermore, 37 per cent of the acceptance group were foreign-born as compared to eight per cent of the refusal group. While there was considerable overlap between groups with respect to these factors, the refusal group was more homogeneous than the acceptance group. Thus, there were no patients in the refusal group who had less than ten years of education (69 per cent of the group had attended college) and none were over fifty years of age. In contrast, 27 per cent of the acceptance group never went beyond grade school (eight years or less) and 31 per cent were fifty years or older. Differences in occupation between groups paralleled the differences in education. Thus, none of the patients in the refusal group were unskilled or manual workers. They were in clerical, professional and business vocations, Whereas ten subjects in the acceptance group were unskilled workers. Housewives were excluded from this tabulation. Relation to Diagnosis: The discharge diagnoses of seventy-three patients fell into four major categories: psychoneurosis, schizophrenia, manic-depressive, or involutional psychoses. Two patients were classified as “psychotic depression” without further specification. Although there was no statistically significant difference in diagnostic composition between the group accepting and those refusing treatment, the groups were dissimilar with respect to the incidence of the involutional psychoses (Table 2). No patient in the refusal group was discharged with a diagnosis of involutional psychosis, whereas 24 per cent of the acceptance group were so diagnosed. There was also a high positive correlation between this diagnosis and the sociopsychological factors studied. Thus, the mean age (56.7 years) and F score (61.4) were higher while the years of educa- �155 REFUSAL OF CONVULSIVE THERAPY tion (9.2 years) was lower than that for the total refusal group (Table 1). Relation to Improvement Ratings: At the discharge conference held by the Medical Director each patient is assigned one of four improvement ratings: recovered, much improved, improved or unimproved. The incidence of recovered and much improved ratings was significantly lower in the refusal group (Table 3). Six patients, all in the ac— ceptance group, were rated as recovered. The hospital discharges were more closely associated with refusal or discontinuation of treatment in the refusal group. DISCUSSION The present study confirms and extends previous findings in this laboratory (2, 12, 13) in demonstrating the importance of social factors and their psychological correlates in the selection for and response to psychiatric treatment. It supports the hypothesis that in a psychoanalytically-oriented hospital patients who refuse convulsive therapy would more closely resemble those who remain in psychotherapy and differ from those who are selected for and treated with convulsive therapy. The lower 1“ scores in the refusal group than in the acceptance group are correlated with a less compliant attitude toward authority and a more analytic approach in interpersonal activities. Review of the patients’ hospital records revealed that negativism, belligerence, uncooperativeness and attempts to manipulate the staff were more common in the refusal group. For example, 38 per cent of the refusal group as compared with only 17 per cent of the acceptance group formally petitioned the Medical Director for discharge from the hospital. (Almost all these patients withdrew their request for discharge shortly after the initial request). Referral for convulsive treatment was more often associated with problems of management, e.g., disturbing the ward or eloping from the hospital, than for depressive or confused thinking. In contrast, a higher TABLE 2 Discharge Diagnosis by Group Group Manic. Depressrve Psychosis Schizo. - Psychoneurosls phrenla Acceptance7 (11%)25 (40%) 2 (15%) 7 (54%) Refusal X2 13 4 Involu. tlonal Psychosis (21%) 15 (24%) (31%) 0 (0) = 2.28, p = n.s. TABLE 3 Discharge Improvement Ratings by Group Group Acceptance Refusal X2 Recoveredfi Much Improved 34 (55%) 3 (23%) Improved Unimproved (31%) 5 (38%) (15%) 5 (38%) 19 9 = 6.41, p = .05 percentage of the acceptance group were referred for convulsive therapy for alleviation of depressive symptoms. There is increasing evidence that accept— ance or rejection of psychiatric treatment is related to learned attitudes toward treatment by both patients and therapist (8, 9, 16, 17, 21). Most often these attitudes which correlate with socio-economic status are formed far in advance of treatment, and are most likely an intrinsic part of the person’s repertoire of behavior. Thus, patients from lower class backgrounds more frequently view psychiatric treatment as nonverbal and in physical terms whereas typically “the middle class patient is predisposed toward the acceptance of psychotherapy even before he arrives at the clinic” (9). In the sample studied there were many expressions of a negative attitude toward convulsive therapy long before the referral for convulsive therapy had been made. One patient, in treatment for several years prior to her current hospital admission, terminated treatment and transferred to another psy— chiatrist on each occasion when convulsive therapy was recommended. Another patient asked to sign the voluntary certification form on admission, appended the following note. “P.S., If I am given shock treatment �156 POLLACK AND FINK I’ll either kill myself or leave the hospital.” Other patients, particularly those who have been in individual psychotherapy prior to hospital admission, state that their previous therapists instructed them not to submit to convulsive therapy in that it would be harm- ful. Perhaps more important than either attitude of the patient or the psychiatrist is the factor of consistency of attitudes. Klerman et al., (17) have reported that young resident psychiatrists with psychoanalytic orientations frequently have unfavorable attitudes toward somatic therapy and are ambivalent about prescribing such treatment. In the present study there were many indications that referral for convulsive therapy was not the “free” choice of the resident physician but was made only after considerable pressure by administrative and nursing person- nel. A recent study by Kaplan and Lefkowits (15) of staff and environmental factors associated with referral for drug therapy in this hospital demonstrated that the psychiatrist’s tolerance for disturbed behavior was much higher than that of nurses and other personnel. Frequently the resident physician placed a premium on helping the patient modify his behavior without resort to somatotherapy. A similar observation was made by Sabshin and Ramot (21) and by Klerman (17) who found that “psychiatrists treating a patient with psychotherapy were unusually reluctant to add drug therapy.” Such attitudes may be conveyed to patients either overtly or covertly. Such observations reinforce the findings of Pasamanick, Dinitz and Lefton (18) that “despite protestations by clinicians that their reference is always the individual patient, clinicians, in fact may be so overly committed to a particular psychiatric school of thought, that the pa— tient’s diagnosis and treatment is largely predetermined.” The studies here would suggest that the psychiatrist’s ambivalent attitude toward treatment is not a general attitude but is related to the “social distance” of the patient to himself. The psychiatric resident frequently has less difficulty in recommending somatotherapy for a lower class patient but is indecisive when it comes to making a similar treatment referral for a patient who is culturally more like himself. The findings that objectors to convulsive therapy were more often discharged from the hospital as clinically unimproved is consistent with previous observations (7). Gordon (7) classified objectors into two categories—poorly oriented catatonic subjects who offered resistance to the treatment and responded with clinical improvement; and a better oriented group who objected to treatment on an attitudinal basis claiming they were “not in need of them.” This latter group were refractory to the clinical benefits of the treatment. Almost all of the patients in the refusal group of the present study could be classified in the latter group. It is of interest that most of the patients who refused convulsive treatment were prognostically poor selectees for convulsive treatment. In previous studies (2, 10, 11) we have shown that the incidence of ratings of improvement at discharge in young, welleducated, low F score patients was signifieantly lower than in the older, less educated, more stereotyped patients. The refusal group is part of that group of patients who are neither “ideal” patients for convulsive treatment nor are they very responsive to milieu treatment and psychotherapy. While referral for convulsive therapy in this and other hospitals has been markedly reduced within the past few years, the problems associated with attitude toward treatment, of which treatment refusal is but one aspect, are of persistent importance. In the absence of specific therapies for the majority of psychiatric disorders the further study of decision-making in psychiatric treatment may help delineate the forces associated with selection of therapy. �157 REFUSAL OF CONVULSIVE THERAPY SUMMARY 8. HAEFNER, D. 1’., SACKs, REFERENCES Treatment of Mental Disorder, p. 223. Saunders, Philadelphia, 1953. 2. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to convulsive therapy. J. Nerv. Ment. Dis., 128: 243— 1. ALEXANDER, L. 248, 1959. 3. FLESCHER, J. The “discharging function” of electric shock and the anxiety problem. Psychoanal. Rev., 37: 277-280, 1960. 4. FRANK, J. D., GLIEDMAN, L. H., IMBER, S. 1)., NASH, E. H., JR. AND STONE, A. R. Why patients leave psychotherapy. A.M.A. Arch. Neurol. Psychiat., 77: 283—299, 1957. 5. FREEDMAN, N., ENGELHARDT, D. M., HAN— KOFF, L. B., GLICK, B. S., KAYE, H., BUCHWALD, J. AND STARK, P. Drop-out from outpatient psychiatric treatment. A.M.A. Arch. Neurol. Psychiat., 80: 657—666, 1958. 6. GALLAGER, E. B., LEVINSON, D. J. AND ERLICH, I. Some sociopsychological charac— teristics of patients and their relevance for psychiatric treatment. In Greenblatt, M., Levinson, D. J. and Williams, R. W., eds. The Patient and the Mental Hospital, pp. 263—285. Free Press, Glencoe, Ill., 1957. 7. GoRDON, H. L. ()bjectors to electric shock treatment are refractory to its therapy. New York J. Med., 46: 407—410, 1946. AND MAsoN, A. S. Physicians’ attitudes toward chemotherapy as a factor in psychiatric patients’ As part of a continuing investigation of the relation of sociopsychological factors to psychiatric treatment, the present study was concerned with the sociopsychological characteristics of patients who refused to start or to continue convulsive therapy. Thirteen of the 75 consecutive voluntary patients referred for convulsive therapy refused treatment during a one year period in a psychoanalytically-oriented institution. These patients were younger, better edu— cated and had lower scores on the CaliforniaF Scale than the group that accepted convulsive therapy. The diagnosis of involutional psychosis was absent in the refusal group, and patients in the refusal group were more often discharged as unimproved. The acceptance or rejection of psychiatric treatment is discussed in terms of learned attitudes toward psychiatric treatment by both patient and doctor. J. M. . responses to medication. J. Nerv. Ment. Dis., 131: 64—69, 1960. IMBER, S. D., FRANK, J. 1)., (,iLIEl)MAN, L. H NASH, E. H. AND SToNE, A. R. Suggesti— bility, social class and the acceptance of psychotherapy. J. Clin. Psychol., 12: 341— 344, 1956. 10. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock 11. therapy. J. Neuropsychiat., 1: 45—49, 1959. KAHN, R. L. AND POLLACK, M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. Syst., supp. 20, pp. 180—184, 1959. 12. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a voluntary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. R. L., POLLACK, M. AND FINK, M. Sociopsychologic aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 13. KAHN, 1: 565—574, 1959. L., POLLACK, M. AND FINK, M. Social attitude (California F Scale) and convulsive therapy. J. Nerv. Ment. Dis., 14. KAHN, R. 130: 187—192, 1960. 15. KAPLAN, A. AND LEFKOWITS, H. J. Influence of staff attitudes and environmental factors on treatment selection. J. Hillside Hosp. In press. Staff attitudes, decisionmaking and the use of drug therapy in the mental hospital. In Denber, H. C. B. Research Conference on the Therapeutic Community, pp. 191—214. Thomas, Springfield, 16. KLERMAN, G. L. 111., 1959. 17. KLERMAN, G. L., SHARAF, AND LEVINSON, D. J. M., HOLZMAN, M. Sociopsychological characteristics of resident psychiatrists and their use of drug therapy. Amer. J. Psy- chiat., 117: 111—117, 1960. B., DINITZ, S. AND LEFTON, M. Psychiatric orientation and its relation to diagnosis and treatment in a mental hospital. Amer. J. Psychiat., 116: 127—132, 1959. 19. ROSENTHAL, D. AND FRANK, J. D. The fate of psychiatric clinic out-patients assigned to psychotherapy. J. Nerv. Ment. Dis., 127: 18. PASAMANICK, 330—343, 1958. 20. RUBENSTEIN, E. A. AND LORR, M. A. A com- parison of terminators and remainers in outpatient psychotherapy. J. Clin. Psychol., 12: 345—348, 1956. J. 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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 Sociopsychological characteristics of patients who refuse convulsive therapy. J Nerv Ment Dis. 1961 Feb; 132:153-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-54-020 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 Pollack, Max; <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 and [preprint]. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Vol. 132, N0. 2 February, 1961 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/10dd96ea03d444a3545ca7a104bdf5fe.pdf a67bc54ff65c228d90099b2591e160d9 PDF Text Text SOCIAL FACTORS AND COMMUNICATION IN PSYCHIATRIC PATIENTS I: 11: III: From Pollack Ph.D. Choice and Results of Therapy - Duration of Hospitalization and Diagnosis - Robert Observations in an Interview Setting - Joseph Jaffe Max L. Kahn Ph.D. . M.D. the Department or Murmantal Psychiatry, Hillside Hospital, Glen Oaks, L.I. , NJ. Presented October 19, 1958, at Hillside Hospital. �III: 9-29-58 Social Factors and Commmication in Psychiatric Patients 1: Choice and Results of Therapy Recent investigations by Hollingshead, Redlich, Frank, Levinson and others have indicated a relation between social class and psychiatric disorder with respect to type and incidence of mental illness, selection be present and maintenance of treatment and therapeutic outcome. report is concerned with the role of social factors in the . selection and efficacy of therapy in Hillside Hospital. me most intensive analysis of the relationship of social class to mental illness has been recently reported by Hollingshead, Redlich and their coworkers. In their studies the population of New Haven was divided into five social classes on the basis of weighted criteria or education, occupation and place of residence. or the residents who were under psychiatric care, those from the upper social classes were more frequently treated with psychotherapy, while organic treatment or custodial care was more comm among the lower classes. Of the psychotherapies, psychoanalysis was entirely restricted to the We upper groups. Social class was the predominant determinant of the type of treatment selected even when the diagnosis was held constant. They summarize their observations as follows: I'.... it is found that and does treatment not depend on psychological medical determinants alone, but on the status position of the patient as well. Psychotherapeufic in disproportionately high degree to the upper social data of this study would seem to indicate that most methods are, applied levels. The �in a setting where the background of the patient is similar to that of the therapist." It is possible, however, to relate the results obtained from these commity studies to such selective factors as the patient's financial psychotherapy takes place resources or the extent and type of treatment more critical test of the facilities available. A importance of social factors affecting choice of treatment would be in a setting where the same therapeutic tecrmiques and services are available to all patients, regardless of their ability to pay. is at Hillside Hospital. the of the main criteria for accepting patients is their “ability to participate profitably in psychotherapy." Individual psychoanalytically oriented psychotherapy is regarded as the primary method of treatment with organic therapies available when needed. Thus a patient is seen in This requirement met regular therapeutic sessions throughout his hospital stay even when undergoing a course of caustic therapy. The average length of hospital stay is six months, with some The purpose patients remaining from of the present report is 12 to 16 months. to smnmarize the relation factors of age, education, place of birth, and social attitude (as measured by the California F scale) to the selection or between the treatment and the ratings of improvement at time of discharge in this environment. muons 1957 was The entire in-patient adult population of studied. This consisted of 171 patients, March 7, 57 men and 111; women , ranging in age from 16 to 68 years, with a mean of 35 years. �Procedure: The patients were tested with a ten-item modification of the California F scale suggested by Levinson. The F scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism and rigidity. The patient reads ten statements and indicates whether he agrees or disagrees with each statement and to what extent. from one to seven and the The score given for each item ranges total score range is 10 to 70. The greater the agreement the higher the score obtained. The statements themselves are extreme, uncritical or stereotyped expressions. For example, one of the statements would be is: "If people would talk less and work more, everybody better off." Choice of Therapy: will first take up the relation of these social and psychological factors to selection for treatment. During the period of this study, (Table I) approximately one-third of the patients received convulsive The small with and two-thirds treated psychotherapy were only. therapy group of patients who received insulin coma and drug therapies are not We represented on the slide. When compared to psychotherapy patients, the convulsive group were older, had fewer years of education not completed grade school also had a higher F - - many had and were frequently foreign born. They score, which indicates that these patients tended to agree with social stereotypes. At this time, the psychiatric residents and their supervisors were also tested. Their average F score was 21.8 with a mean age of thus more closely approximating the psychotherapy group than the 33 .9. �electroshock group. This figure has dealt with group averages for each of the factors mentioned. There was however marked at the patients is variability within each of the groups, with patients each end of a wide range. grouping shown group with reSpect to length of convulsive therapy. As One method in the analysis of the electroshock hospitalization prior to receiving illustrated in the next table electroshock patients were divided into three groups: were and (Table II), the 1) those who after admission, 2) between three after six months. There is a definite correlation treated within three six months, and 3) of sub- months prior to convulsive therapy and F score, age, education and birthplace. It is of interest that there is a gradient for each of the social factors. As a group the patients referred for between length of stay convulsive therapy after six months of hospitalization are most similar to the psychotherapy patients with respect to each of the factors. Che set of data not shown in the slide is the ratio of male to female patients referred for somatic therapy during each of these hospitalization periods. Although the ratio of females to males in the hospital population is two to one, hh per cent of the patients in the group treated within three months were male. In the group hospitalized for six months prior to convulsive therapy, however, only 7 per cent are males. Thus, male patients are referred for electroshock earlier in their hospital stay than As patients. expected, a larger proportion of depressed patients female ~ 52 cent - received electroshock than did those with other diagnoses. per To �-5. control for the factor of diagnosis in choice of treatment, the psychotic depression patients were subdivided into those who received electroshock and those who were given psychotherapy alone. The results are the next slide (Table III). While the two groups are comparable age and education, the electroshock mean F shown in for patients had a significantly higher score and a higher percentage were foreign born. Thus, it may that persons classified as having a psychotic depression are not necessarily referred for electroshock because they are older or less educated, but rather that they come from cultural backgrounds that are be more commonly associated with psychologic processes that make successful in the psychoanalytically oriented psychotherapeutic relationship less likely. These findings are consistent with previous studies which have shown that patient-therapist differences in systems communication of values may hamper Redlich note: "We therapeutic relationship. As Hollingshead and are not sure what attributes a good patient must have, but they include sensitivity, intelligence, Social and intellectual standards similar to the psychiatrist‘s, a will to do desire to improve one's personality and status in life, attractiveness and charm. Rarely will such standards one's best, a youth, be admitted by psychiatrists. On the contrary, psychiatrists claim that the selection for treatment is based on purely psychiatric criteria....." Results of Therapy: Social factors are as significantly related to treatment result as they are to treatment selection. hospital treatment on To the 171 patients, analyze the effects of the we selected the discharge �evaluation as the criterion of improvement. At time of discharge a patient is classified in one of four categories: recovered, much improved, improved or unimproved. relation of social factors to the discharge evaluations is presented in the next slide (Table IV). There is a definite, almost The linear relationship, between the improvement rating and these four social factors. The recovered group of patients had the highest F scores, were oldest, least educated and of foreign birth. In contrast, showed the highest incidence the unimproved group had the lowest F scores, were younger and better educated - almost all having gone to college - and were primarily native~born. for patients treated with convulsive therapy the improvement ratings parallel those for the total population. Analyzing the data (Table V) Again, the recovered group had the highest mean F scores, was the oldest, most poorly educated with the highest incidence of foreign birth. The illustrates the relation of these observations next slide (Table VI) to time of referral for treatment. Within the electroshock group 67 per cent of those who were treated early in the course of hoSpitalization were rated as recovered or those treated after six these two groups. were more much improved, whereas months only 30 per cent were As was noted earlier, patients in this latter similar to the psychotherapy group It is classified in WEUh respect to these not surprising, therefore, that they were treated with somatotheragy only after an extensive course of social factors. psychotherapy. group �.7In summary, the observations that social factors are related to type of therapy received as well as therapeutic outcome are consistent with the studies of Hollingshead, Redlich and their coaworkers. their findings in demonstrating that these factors are also significant in a hospital setting where where and selection of not therapeutic criterion to a is pay ability all forms of therapy are equally available to the entire population. Furthermore, the present studies extenii While the relation between social factors and treatment selection are clear, and are consistent with previous findings, the relation of these factors to improvement ratings appears paradoxical. observations that those patients with high and less educated, more F scores, The who were older often received convulsive therapy and were discharged more frequently as recovered are consistent with the results reported in 1956 in a follow-up study of Hillside Hospital patients conducted by Rachlin, Goldman, Lurie, Gurvitz and Rachlin. It is possible that the differences in communication between therapist patient that result in referral for convulsive therapy may also influence the discharge rating. Thus, Kahn and and Fink have previously to denial, evasion, and benefit most receive to and of cliches use are likely stereotypy from electroshock. Such language patterns appear more frequent in shown that verbally uncommunicative persons, prone persons in the lower socioeconomic groups. Because of the differences therapist and patient, the therapist may set different criteria for improvement for the older less educated patients than he does for between the young, sophisticated ones, �class patient The lower may also set goals for himself that are The from class patient's the different patient. upper qualitatively aspirations for himself and the therapist's expectancy for the patient of time of hospital improvement at Ratings an interactive are process. discharge are relative in that they refer to a baseline of premorbid functioning. Thus the rating of recovered is defined as, "the 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." therapist's perception of the patient's premorbid functioning may be influenced by the distance between his value system and that of the patient and both influenced by their social class. ‘The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change. Fer example, for older, lower class patients, ability to resume work may loom as the major criterion The of improvement. For the upper class patient work adjustment only one of a may be host of criteria, including such intangibles as work gratification, ease of sociability, etc.. This presentation has dealt with a few of the relationships between social factors and psychiatric treatment in a voluntary, psychotherapeutically-oriented hospital. The other speakers will deal with many of the questions left unanswered in this report. �THERAPY SELECTION F Score Yrs. of Education Foreign gMeanz Age {Mean} Electroshock (Ii-57) 14306 ’40.3 11-2 26% Psychotherapy 36.1; 32.6 11.8 9% Groggs (Na102) SMean) % Born �.10TABLE II LENGTH OF HOSPITALIZATION PRIOR TO ADMINISTRATION OF ELEBTROSHOCK F Score gMeanz Groygs Less than 3 {N-Bh) 3 mos. to 6 mos. (N-IO) More than 6 mos. (N~13) Age (Mean! Yrs. of Education Ween! % ForeignBorn 148.3 M45 10.1 1:173 he. 7 39.8 11.7 30% 32.9 29.5 13.14 �-11TABLE III SELECTION OF THERAPY IN PATIENTS WITH PSYCHOTIC DEPRESSION Yrs. of Education Foreign— Born F Score SMean! Age SMean) Electroahock (N'Bl) 50.3 h8.6 10.6 1:253 Psychotherapy h1.0 h7.6 10.0 2h% GrouEs (n-29) SMean)___ % �-12TABLE :1 SOCIAL FACTORS AND DISCHARGE EVALUATION F Score SMean) Age gMean) Yrs. of Education gMeanz 1 ForeignBonn h2.9 Mus 10.7 Much Improved 39.0 35.6 11.2 22% Improved 36.1 31.2 11.2 16% 31.2 13.2 11% Recovered h1% (N-17 ) (n-82) (N'63) Uhimproved (n-9) 31.1 �-13TABLE V DISCHARGE EVKLUATION IN CONVULSIVE THERAPY Yrs.‘of F Score sMeanz Age SMeanz Education % Foreign- SMeanz Born 53.1 51.6 9.u 50% (N-26) h2.0 h3.8 10.6 35% Improved and unimproved (Ni23) 39.7 32.3 12.3 12% Recovered (N-B) Much Improved �-m- M TABLE VI LENGTH OF HOSPITALIZATION PRIOR TO ELECTROSHOCK AND DISCHARGE EVALUATION Recovered Much 8: Iflroved Improved U raved Groggs Less than 32% 6 mos. 70% 30% than 6 mos. 31% 59% (n-Bh) 3 to ms. 68% 3 (N-lO) More (N-13) & �III: 9-29-58 -15- Social Factors and Communication in Psychiatric Patients II: Duration of Hospitalization and Diagnosis Just heard a presentation of factors associated with the selection and results of treatments. I will next conéider the relation You have of these factors to length of hospitalization and to diagnosis. It is obvious that the length of time a patient stays in a mental hospital is related to the particular function and philosophy of the institution. In an institution such as Hillside Hospital which admits only voluntary patients and emphasizes psychoanalytically oriented psychothe In limited. particular of is the hospitalization length therapy, montthin 16 from complete to one was the studied the population range L months. of six over with an stay slightly average hospital, Several factors can.be postulated which might be related to the duration of hospitalization. Since it commonly takes less time to produce behavioral change with convulsive therapy than with psychotherapy, one would expect to find that the consulsive therapy patients are kept in the hospital for the shortest period while the psychotherapy patients are here longer. The data, as presented in Table VII, shows no significant difference between the two groups. If anything, there is a slight tendency for psychotherapy patients at Hillside to be institutionalized for the shorter period. A second possible factor is the severity of the patient's illness. be who will necessarily more intractable those are that patients It maintained in the hospital further to receive additional treatment. Examination demonstrates shown Table in VIII, the however, as data, of those that while patients hospitalized for the shortest period do have may be �Much and Improved, Recovered of of ratings incidence discharge a higher and chance are not significant. variation within a differences are the In the Hillside followhup study of Rachlin there was no relationship EELEE' it was also found that between discharge evaluation and length of time in the hospital. On the basis of the data and discussion presented by Dr. Pollack, be should a relationship there that hypothesis advance the further can we of and duration hospitalization. the background social patient's we oriented psychotherapy psychoanalytically With Hillside's stress on would expect that those patients who are most like the therapists with regard between a to these factors.would be kept The the period. for longest the in hospital data is presented in Table IX. Patients shortest who were period had the highest F scores, were hospitalized for the oldest, had the fewest Conversely, born. of native and smallest the percentage education of years F the lowest had the scores, the who longest the in hospital were those of and smallest the percentage education of most years youngest ages, the foreign born. These differences are statistically significant. In Table X a similar analysis is shown for only those patients receiving electroshock. Again, each of these factors is related to duration of hospitalization. The same results are obtained psychotherapy only is when the data of those patients receiving While XI. shown Table in as analyzed separately, F low have Pollack Dr. scores, are indicated, as these patients as a group, electroshock the than born and native more education have more younger, patients, there is still a significant difference within the group in the the time in hospital. of the to length according direction predicted �These same relationships of social factors to hospitalization are found even when the patients were subdivided according to diagnosis. In Table XII the data is shown for the in the hospital for each diagnostic group. F their final score and months The diagnoses were subdivided into four major groups and include all but three patients in the population studied. For each group there is a significant difference between those in the hospital for the shortest and the longest periods, with those in the longest having the lowest scores. Similar results are shown when the data is analyzed It is also shown for each diagnostic group with respect to age (Table XIII). for education (Table schizophrenic patients stay. It who were who XIV), with the exception of the had about the same education for each length of should be noted, though, that many of the schizophrenic patients here for ten months or more were quite young - around 16 or 17, and so did not have the opportunity to receive education beyond the middle of high school. Analysis of place of hospitalization is shown is associated with a birth for in Table each diagnostic group and length of XV. marked decrease Increase in length of hospitalization in the with the exception of the schizophrenics, number who of foreign born, again as a group, had very few such persons. The previous tables have indicated that not only is there a significant relation between each of the social factors studied and length of hospitalization, but that there are large differences between the diagnostic groups themselves, even when comparing patients with the same period of hospitalization. in Table XVI. The summary It is data comparing the diagnostic groups is shown clear that patients diagnosed as involutional psychosis �have the highest F scores, the oldest ages, the least years of education, highest incidence of foreign born. In contrast, the schizophrenics have the lowest F scores, were the youngest, had the most education and the and the of foreign born. The manic-depressive and psychoneurotic involutionals the to closer with the manic-depressive between, in patients fell least number like the schizophrenics. relationship between these social factors and the psychoneurotics most This marked and diagnosis is not surprising. Certainly the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and What names themselves have a chronological conndstion. in dementia praecox the is unexpected, however, is that age should also be related to the and that the and disorders, psychoneurotic of manic-depressive diagnosis other social factors of education, place of birth and F score should in this hospital. the diagnostic major groups differentiate all significantly we have postulated two hypotheses to account for these relationships. The first is based on the fact that persons from different social backgrounds acquire different habitual and expression. modes of adaptation and patterns of communication Accordingly, under conditions of stress, damaged brain function, or other etiological conditions associated with the onset of mental illness, a person will show those behavior patterns or symptoms his habitual patterns. Thus, a person from background communicate in nonsverbal, to more lower apt social class is a do so in to more while class people likely are physical terms, upper which are of the same type as ideational and verbal terms. Thus, anger may be shown by lower class people by physical violence, while those from upper classes are more and Redlich Hollingshead exhortation argument. to to or resort likely �-19- have noted that these differences among people of different classes lead to different psychodynamic patterns in psychoanalytic terms. Thus, aggressive and sexual behavior behavior variation is is restricted among more acceptable among to lower class parents, while such the upper classes, lending to considerable the different social classes in superego development. Irish Italian patients who were diagnosed as schizophrenic in a V.A. Hospital, found significant differences in their types of symptoms related to cultural differences in their family backgrounds. Patients coming from Irish families in which active expression of emotions Marvin Opler, studying and were frowned upon and with dominant over-protective mothers, were passive, compliant and withdrawn, and fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of showed were assaultive and emotion and were ruled by a dominant destructive behavior, were difficult to father, manage and rebellious against authority. In a comparable study Miller and Swanson have also noted that hospitalized schizophrenics exhibit significant social class difference in symptomatology - lower class patients showing "motoric themes," while middle class patients exhibit "conceptual or ruminative themes." According to our hypothesis, then, we would expect lower social levels would show symptoms sensory or motor patterns. Among that persons from that are non-verbal, expressed in such types of symptoms would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness or paralysis. In this connection it is noteworthy that hysterical symptoms have been reported as the army far men more frequent among enlisted in than officers. In addition hysteria which was apparently so common in‘world.war I was not nearly so notable in wbrld'war II, and, in fact, has been reported �in the general population. This decrease, in our view, is related to the general increase in educational level of the country as a whole. If one finds a classical case of hysteria in New'York today, I on the wane Rican be immigrant Puerto the in likely it population who have the poorest socio-cultural background. (One cannot, of course, ascribe the decrease in hysteria to a greater freedom in sexual will understand that matters; has it is shown, most most common in more poorly educated people who, as Kinsey are least inhibited sexually). In the laboratories at Hillside Hospital the investigations of persons with depressive psychoses have been more intensive. we have noted a common of lack characterized hy these behavior of in people, premorbid pattern imagination, creativity and introspective capacity, and by conventionality and general rigidity. Similar patterns have been noted in a series of studies of such patients by other authors. background, such as that involving little we or believe that a poor cultural no education, spending early and cultural is environment, meager resources, in a illiterate largely years conducive to the development of such a personality pattern. When mentally disordered, such persons tend to react with a repertoire of behavior patterns consistent with their background which A we second hypothesis concerning the term depression. relation of social factors to and between do the with has interaction patient to diagnosis psychiatrist. this hypothesis a diagnosis may not be based on an actual how of the reflection extent a to but behavior great is a pattern, objective psychiatrist perceives or identifies the patient. It has been noted frequently that patients with similar symptoms will be differently diagnosed and treated depending on their social class. For example, we recently studied three According to patients who were admitted with similar symptoms of depression, anorexia and �insomnia. who was All three were referred for convulsive therapy. One woman, 62, born in Russia, of limited education with an F score of 70, was diagnosed as involutional melancholia. this country, with The second, aged hS, born in an F score of 53 and a high school education, was termed manic-depressive, depressed. The third, aged hh, also born in this country, with an F score of 33 and a college education, was diagnosed as psychoneurosis, reactive depression. In conclusion, in the Hillside Hospital population social factors of age, education, birthplace and F score are significantly related to the selection and results of treatment, length of hospitalization and diagnosis. These findings illustrate the importance of social factors in affecting language and communication patterns and the nature of the interaction patient and therapist. Current data, both from our own laboratory and as reported in the work of others, indicates that psychotherapy is most likely to take place with those persons who most closely resemble the therapists between in terms of cultural background and communication pattern. In Hillside, with its emphasis on psychotherapy, it is clear that patients who best meet this criteria are also keptthe longest. This is true for either patients receiving convulsive or psychotherapies alone, and for all diagnostic groups. In the evaluation of clinical improvement there may well be different expectancies towards patients in terms of these social factors. with may little In a person education and different modes of expression than ourselves, we regard, for example, the manifestation of denial as improvement. But in a patient much like ourselves in cultural background, the denial will be regarded as a defense and the patient is showing of considered unimproved. patient,himself, may have different expectancies not only in terms of the type of psychiatric treatment, but for what constitutes improvement as well. The �believe also that the attitude of the patient's family may be crucial in both the patient's and therapist's conception of what constitutes we improvement. relation between social factors and diagnosis was interpreted in affects background cultural one's that indicated was First ways. it The two the type and and accordingly and communication, of expression symbolic pattern the possible type of symptoms a diagnostic statement behavior pattern. patient and is not Rather, it that will be shown. Secondly, we believe that simply an objective evaluation of a given is a reflection of the interaction of the psychiatrist in relation to their respective cultural backgrounds and modes of communication. It is between mind the while relationship that in to keep important social factors and the psychiatric aspects described is probably applicable as a generalized principle, the specific findings may vary in different For example, in a study using the F score at the settings or institutions. Boston Psychopathic Hospital, the same relationship to type of treatment was noted as in our report, i.e., the electroshock patients had higher scores than those receiving psychotherapy. patients there, however, patients is was higher than Since the average score of the at Hillside, their psychotherapy had the same mean score as our electroshock cases. Another example the finding of Hollingshead and Redlich that schizophrenia common diagnosis proportionately among F was a more lower than upper classes, while at Hillside the schizophrenics had the highest education. This discrepancy two of the in composition the variation be accounted by for can probably middle from drawn the largely being the Hillside patients populations, lower classes. social few from the or with upper relatively groups �-23- In Hillside the diagnosis of schizophrenia may indicate an "interesting" same diagnosis the population while State Hospital in a patient, may represent a "hopeless" patient. It be tested to studies these by raised remains for the hypotheses In involved. the psychological of processes studies and for further interaction. communicative of studies on been working have particular we Some Dr. of the details Jaffe. and findings of this work will next be presented by �DURATION OF HOSPITALIZATION AND TYPE OF TREATMENT in Ho§ita1 Months Treatment Grog-pa 1 - 5 6 - 9 10 or more Electroshock (S?) 26% 30% M453 Psychotherapy (102) 32% he}! 25% " 5.73 df " 2 (3112 p - N.S. �-25TABLE VIII DURATION OF HOSPITALIZATION AND DISCHARGE EVALUATION Discharge Evaluation Months in Hoggital Recovered or Much Iggroved Improved or raved EM 1-5 (h9) 69% 31% 6-9 55% 15% 52% 148% (624) 10 or more (58) Chi2 df p - 3-83 2 N.S. �- 26.. TABLE IX DURATION OF HOSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH in Hogi‘bal Months 91-192 - 9 {bl-6h} 10 or more 133.9 10.5 31.0 Mean Age 145-5 32-5 27 .9 Years Education 10.0 11.9 12.8 W 19% 10% 1 ean F Score M Mean 5 Foreign Born - 5 6 ski-582 �-27TABLE X DURATION OF HDSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH IN PATIENTS RECEIVING ELECTROSHOCK Months in Hogaital -5 pm 52 6 Mean F Score 58.2 h5.6 3h.9 Mean Age 51.7 h2.2 32.1 6.5 12.3 13.2 67% 2h% 16% 1 Mean.Years Education % Foreign Born - 9 551-172 10 or more 531-25 2 �DURATION OF HOSPITALIZATION AND F SCORE, AGE, EDUCATION AND PLACE OF BIRTH IN PATIENTS RECEIVING PSYCHOTHERAPY ONLY in HogEital Months 1 - S 6 - 10 or more gN-262 SN‘BB} 9 SN-hB! Mean F Score h0.2 38.6 27.8 Mean Age [‘3 c 2 29 o 1 2,4 0 8 11.1; 11.7 12.1: Mean Years Education % Foreign Born 30% 16% 8% �W TABLE MEAN F XII OF DURATION TO ACCORDING GROUPS DIAGNOSTIC SCORES FOR HOSPITALIZATION Months Diagnostic in Hoggital 3;; L2; 58.2 50.9 35.0 Manic Depressive h0.02 h6.1 33.1 Psychoneuroses h0.05 36.6 36.1 Schizophrenia 36.3 38.5 27.6 Greg Involutional Depression 10 or more K �-30TABLE MEAN AGES FOR XIII DIAGNOSTIC GROUPS ACCORDING TO DURATION OF HOSPITALIZATION 10 or more Diggggstic Gregg 3L;§L £1;;2_ Involutional Depression 58. 8 5h. 5 52. 3 Manic Depressive h6.8 39.1 35.5 Psychoneuroses 141.0 27 .1 27.1 Schizophrenia 27.8 27.8 214. 1 �.31TABLE XIV W OF DURATION TO ACCORDING GROUPS DIAGNOSTIC FOR EDUCATION MEAN YEARS OF HOSPITALIZATION Months in Hogaital 10 or more 1;;;§ 51:113 7.1 9.6 16.0 11.0 11.7 12.3 Psychoneuroses 8.7 12.5 12.5 Schizophrenia 13.3 12.3 12.9 giggnostic Groggs Involutional Dapression Manic Depressive �-3 2.. TABLE Lv OF DURATION TO ACCORDING GROUPS DIAGNOSTIC BORN FOR FOREIGN PERCENTAGE HOSPITALIZATION in Hogital Months Digestic Grougs _1__-_§ 6 - 9 10 or more 0 Involutional Depression 57$ 113% Manic Depressive 39% 23% 0 Psychoneuroses 50% 19% 13% Schizophrenia 10% 8% 12% �TABLE XVI DIAGNOSIS AND F SCORE. AGE: EDUCATION AND PLACE OF BIRTH Dialysis Involutional Depression Mean F Score ' Mean Age Mean Years Education % Foreign Born {NI-21:2 Manic Depressive (NI-322 Psycho- ' neuroses Schizophrenia (Iv-372 $31-68) 52.3 140.8 36.9 32.8 56.7 1:1.9 29.1; 26.1 8.9 11. 5 11. 9 12. 7 146% 26% 22% 10% �-313- Relationship: Patient-Doctor the on Effects of Social.Factors Setting Interview Observations in an illustrate will I In this report how discussed factors the social hypothesis Our interview. clinical the in ommunication c affect morning this and mmunicate, can co that this is why treatment. results of psychiatric and choice the to relevant they are One way to test would hypothesis such a actual an in events, important psychodynamically that he to demonstrate such as age, factors to related significantly are setting, interview of a study the be might A step first and.F score. education, nativity communication of kind the of representative which is event, defined clearly psychotherapy. to relevant that is The phenomenon pattern. communication such one with deals This report e—recording tap the mentioned explicitly the patient no whether or studied is may bear upon transaction spontaneous This interview. during an experimental and interviews rimental in expe develops which transference situation t the well. as in psychotherapy METHOD: The clinical setting in which the observations we re made was an initial of patients edure proc screening the of interview. This was part interviews All hospital. this in therapies sive convul and referred for drug the during Psychiatry, imental Exper of Department the in were performed was It tests. psychological and physiological of battery week as a to asked was The patient and patient. doctor the of the first meeting was procedure unstructured generally and a about his difficulties, tell �.35followed. The purpose was to get an impression of the patient's communication patterns, and to secure a tape recording of the interaction. Several months ago, that the interview it was noted that some patients mentioned the fact was being tape—recorded, whereas nothing about the procedure. Since that time, recorded this data at the conclusion of I other patients said have each session. systematically In addition, the following experimental structure was purposely introduced. A Tanberg tape-recorder was prominently placed beside the desk which the interview took place. This instrument was turned on Just before the patient entered the room, and was clearly in his line of vision. was about at It the level of the desk, at a distance of about seven feet from the patient's chair. The red neon glow bulb, the revolving reels of tape, and the operating noise of the machine could all be observed. An unconcealed mire ran directly from the instrument, across the desk, to a microphone which - lay in clear view between doctor and patient. However, the interviewer no mention of by the made the recording set-up unless the subject was introduced verbally patient. OBSERV£IION33 Since this experimental structure have been recorded. 17 was introduced, 31 initial interviews The tape-recording was mentioned by 1h patients, while others made no such observation. They will henceforth be referred to as the "Mention" and No Mention" groups respectively. a) Qualitative: The patients variety of attitudes. who mentioned the recording expressed a The most common was curiosity, with inquiry as to the purpose of the interview, and the use to which the recordings might be put. �-36A minority expressed overt suspicion, either refusing to proceed with the interview for several minutes, or voicing their fears of humiliating or incriminating uses which might be did'nt know the room was bugged." made A of the recordings. One patient said, "I physician in this group of patients requested that the recorder be turned off for a moment so that he could ask a question as a colleague, "off the record." After a spontaneous mention of the to explore the attitude underlying the remark. recording, an attempt was made This varied from definite hostility and suspicion, through mild objection and uneasiness, to passive acceptance of the procedure. Only one patient expressed delight, saying, "I'm glad this is being recorded, In addition to these subjects who it's like a confession." explicitly mentioned the recording, patient is included in the "Mention" group. to the microphone, shook her head as if She one mute pointed to the recorder, then to say "no," and covered her mouth with her hand. In the "No Mention" group, non-verbal recognition of the recording was often apparent. Most of the patients looked repeatedly at the recorder and microphone , sometimes up furtively. Several of them actually touched or picked the microphone while speaking. I accompanied one patient back to the ward following the interview, and while chatting in a lighter vein she asked way, was that all recorded?" that the flNo-mention" group was aware of the recording. "By the Thus there was considerable non-verbal evidence Quantitative: Quantitative data for the "Mention" and Table-XVILIt is apparent that the group "No—mention" groups is seen in explicitly remarked about the reabout 20 years. They were also better who cording were younger, on the average, by educated, and with only a single exception were native born. They had a lower score on the F scale and I tended to spend more time with them. All the differences between the groups are statistically significant; �.37- TABLE MENTION XVII NO MENTION 53121:). N=17) 26.7 h5.2 1h.1 p< .002 10.9 P<: ~02 93 53 I><: .05 F SCORE 3h.1 11702 DURATION OF INTERVIEW (minutes) 39.6 2900 AGE (years) EDUCATION % (years) NATIVE BORN p‘<:’ .05 �DISCUSSION: Using a single objective index, 3:2. an overt statement about an unexpected experimental procedure, two patterns emerge from patients. The group of this group of subjects mentioning the recording have the same sociological characteristics as those patients from the total Hillside Hospital population are treated by psychotherapy alone. They are who less younger, have some college education, are native born, and are stereotyped in their attitudes. They mention the experimental procedure in a challenging way. Gill, Newman and Redlich have described the anxiety- producing effects of tape-recording psychiatric interviews. This group of patients meet the stress by verbalization of their subjective reactions. talk about it, ask questions, object, 222. The group who do not mention the recording have the same They sociological wharacteristics as those patients in the total Hillside Hospital population who are typically referred for electroshock (i;g. non-venaal therapy) or are hospitalized for the shortest period. They are older, have at most a high school education, are more likely to be foreign born, and are stereotyped in their attitudes as measured by the F scale. These patients the procedure overtly, although they notice the doctor, whatever you do is justified their compliance and what to say, but I'll be glad to it. Their attitude do not question is "You are and should not be questioned." In vauiescence they resemble surgical patients who submit themselves passively to treatment, neither resisting nor actively participating. When asked to tell about themselves their attitude often is, "I don't know The "Mention" group They do answer any questions you may ask." display a different attitude toward the therapist. not treat the physician's procedures as completely outside their �-39- verbalize their resistance, and express their negative feelings directly to the interviewer. The "mention" reaction indicates jurisdiction. They curiosity and the skepticism that Freud felt was required of the analytic patient. In discussing this point, Fenichel notes, that if the patient "is not skeptical at all, the suspicion is warranted that he is repressing negative transferences." It is not surprising that the interviewer, with a psychoanalytic orientation, spent about 10 minutes longer with the "mention" group. This study demonstrates, then, that these sociological factors may be related to actual differences in the quality of patient-doctor relationship. In this one limited aspect of the communication pattern, the sociological background allows us to predict whether the patient will verbalize his reactions or not. If this single stress situation is representative of the general behavior in psychotherapy, we can get some notion of why these related to choice or length of treatment. 'we factors are expect that patients who decline to mention such an obvious situation as a microphone and tape-recorder, will be equally loathe to express the variety of feelings about the therapist which are crucial for analysis of transference. Further studies of the data are in progress which may increase our understanding of the observations reported. For example, a detailed content analysis of the way in which the recording deviant cases. Two of these have already been described. patient, with high F score, who was mentioned sheds light upon the One was an older in contrast to the usual pattern of such persons, did mention the recording. Hewever, he differed from the other older patients in having a medical education. His way of mentioning the �-h0 - recording was to suggest a change in the interview from that of doctorpatient to that of colleagues speaking "off the record." One is tempted to predict the form of his therapeutic resistances from this event. Another patient mentioned the recording,but in an unusual way. She was delighted with the "confessional" aspects. In her sociological characteristics, she too did not fit a clear pattern, being in her 20's, but with a high F score. It is to be noted that she was an ex-Catholic. Other studies of the psychiatric interview, using experimental stresses more characteristic of psychotherapy, furnish additional evidence of the importance of sociological factors. For example, Saslow and Matarozzo research on psychotherapeutic communication. � 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 Max Pollack, Robert Kahn, and Joseph Jaffe: Social Factors and Communication in Psychiatric Patients (research), 1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-11-012 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 Pollack, Max; Kahn, Robert L.; Jaffe, Joseph 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 Joseph Jaffe, Robert L. 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ROTHLIN (Editor) NEURO-PSYCHOPHARMACOLOGY VOL. 2 (1961) Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum IBasle 1960 ELSEVIERPUBLISHINGCOMPANY AMSTERDAM �Reprinted from: E. ROTHLIN (Editor), Neuro-Psychopharmacology, V01. 2 (1961), Proceedings of the 2nd International Meeting of the Collegium Internationale Ne'uro-Psychopharmacologicum, Basle 1960 ‘ NEUROPSYCHOLOGIC RESPONSE PATTERNS OF SOME PSYCHOTROPIC DRUGS MAX POLLACK, ERIC KARP, GEORGE KRAUTHAMER, DONALD F. KLEIN AND MAX FINK Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N. Y. (U.S.A.) PROBLEM This study of the mode of action of some of the newer psychotropic agents was formulated within the framework of a neurophysiologic-adaptive hypothesisl. The concept, derived from earlier work on convulsive therapiesz, views clinical behavioral change as a resultant of the interaction of alterations in brain function and the personality of the subject. The present study emphasizes the question of pattern specificity of drug action and its relation to individual differences in behavioral response. The particular drugs utilized, chlorpromazine3 and imipramine“, were selected on the basis of pilot studies in this institution in which their effectiveness in altering physiologic and behavioral patterns had been demonstrated. This presentation is an interim report of a study currently in progress. METHOD Consecutive referrals for drug administration in a voluntary psychiatric hospital were assigned at random to one of the three drug regimens: (I) chlorpromazine with 1.2% procyclidine added, (2) imipramine, and a (3) placebo. Medication was administered in liquid vehicle in a fixed dosage schedule, to a maximum in four weeks. Chlorproma— zine was begun at 300 mg and increased to 1200 mg daily and imipramine from 75 to 300 mg. Patients continued to be seen three times weekly in individual psychotherapeutic interviews during the period of drug treatment. Analysis of the data is limited to the first 48 cases. These patients are not chronically ill—the majority being admitted for their first hospitalization from the community, and a smaller percentage rehospitalized for a recurrence of their illness. Their mean age was 35.5 years, and years of schooling was 11.9 years. Approximately 57% were diagnosed in the group of schizophrenias, 28% as affective psychoses and I 5 0/5 psycho— neuroses and character disorders. Patients were examined in a four day period prior to drug administration on a fixed schedule of physiological and psychological procedures which was repeated during the sixth week of drug treatment. RESULTS Group changes in some of the measures with drug treatments are shown in Table I. The EEG patterns measured quantitatively through electronic frequency analysis5 References 1). 384. �382 M. POLLACK et al. show that imipramine and chlorpromazine differ significantly from the control group and from each other. There was a significant reduction in the total electrical activity in the imipramine group, while there was an increase both in the amount of slow-wave activity and the slow to fast activity ratios in the chlorpromazine group. TABLE I GROUP CHANGES WITH DRUG TREATMENT EEG Slow/fast ratio Total activity Delta ratio Control I rmpramme Chlarpromazine w it h Procyc l {dine 0 0 co 0| ++ 0 ++ Perceptual Critical flicker fusion 0 Motor Pursuit—rotor Tapping speed Hand steadiness Intellectual WechslerBellevue IQ O O ++ 05 01 —— + O O O + o o Behavorial rating Symptom complaint — 0 Depression + Increase p. + + Increase p. o —- — o No change — Decrease —— Decrease P P 0.05 0.01 The reduction in the critical flicker—fusion (CFF) threshold is noted only for the chlorpromazine group. This test correlated with the increase in EEG slow-wave activity.The motor tests also reflect a differential drug effect with unsteadiness increased by the two drugs, tapping rate unaltered, and pursuit rotor improved only by the imipramine group. The greatest change in intellectual functioning was scored by the no-drug group, present to a lesser degree in the imipramine group and absent in the chlorpromazine group. The lack of equivalent changes for the drug groups may reflect an inhibition of the expected practice effect. In clinical behavior, all groups showed a reduction in complaints on self-rating as measured by the Johns Hopkins Scale, with the reduction being greater for the drug groups. In the Clyde Mood Scale, a Q—sort behavioralrating, there was a quantitative reduction in both the patient’s and the doctor’s ratings of “depression” in the drug group but not for the control group. While these data indicate a pattern that suggests differential drug activity, there was marked heterogeneity within each group on each measure. Table II shows the changes in CFF for each subject. The number within each box refers to the evaluation of a change in behavior, rated on a four—point scale by the evaluating psychiatrist. These are global changes in behavior ratings, and are not necessarily equivalent to References p. 384. �NEUROPSYCHOLOGIC RESPONSE PATTERNS 383 ratings of improvement. (Note that the ratings of behavioral change “3” and “4” were most often associated with changes in CFF of more than one cycle.) Although the difference in mean CFF score between imipramine and the control group was not significant, the difference in variability (F ratio) was significant (P = 0.05). The control group showed a narrow range of change, varying from +1 to ——2 cycles. In contrast, the imipramine group ranged from +2 to ——5 cycles, and chlorpromazine from zero to ——6 cycles. The chlorpromazine group change was in the downward direction only. The individual differences in the alterations of CFF threshold II TABLE CHANGE IN FLICKER FUSION THRESHOLD WITH DRUG TREATMENT Contrél +2 +1 o —1 —2 __3 Imipmmine 2 2 I 4 4 2 I 3 3 1 3 1 1 3 ‘ 2 2 2 I I 3 I I 1 1 3 1 4 2 4 2 ——4 —5 —6 Mean difl. Change in C.P.S. Chlorpromazine Behavorial with Procyclidine change 2 1 4 4 4 4 4 3 2 3 4 4 3 2 ——o.6 ——o.4 TABLE None Mild 3 Moderate 4 Marked I 2 ——3.1 III ‘CHANGE IN EEG (SLOW/FAST/RATIO) WITH DRUG TREATMENT 1mm —.4 ——.3 ——.2 —.1 o +.1 +.2 +.3 +4 +5 2 2 I 2 1 I 4 I 1 3 2 11 1 443111 3 2 322 4 4 3 4 1 3 4 4 3 4 1 1 1 3 3 1 3:22:22“ INone 2 3 Mild Moderate 4 Marked 4 +.6 +-7 4 4 >+-7 Mean diff. Change in slow/fast ratio firearm +.026 +.or4 +.401 are also observable in the electroencephalographic indices. Table III shows the changes in the slow to fast EEG activity ratio demonstrating a wide range in changes for the controls, a similar pattern for the imipramine group, but a change in only one direc— tion—that of increased slowing for the chlorpromazine group. The mean increase in slow-wave activity for the chlorpromazine group was more than I5 times that of the References p. 384. �384 M. POLLACK et al. control and imipramine groups. There was also a significant relation between the increase in slow-wave activity and increasing age with chlorpromazine—older patients being more susceptible to maximum change. DISCUSSION The psychological and EEG findings show that the agents studied affect these random— ly selected subjects differentially, producing drug—specific spectrums of change scores. This demonstration of drug specific profiles based on multiple tests supports previous statements by such workers as WIKLER“, LEHMANN7, and KLERMAN et al.8. It should be noted, however, that these test score profiles are contingent on population characteristics and not solely on the biochemical properties of the agents tested. While no adequate delineation of salient population characteristics is available, two general schemata are in use—the diagnostic nomenclature, and the concept of ”target symp— toms”. Neither scheme adequately reflects population characteristics, and further studies of multivariate behavioral, physiologic and psychologic characteristics are necessary for such delineation. It is thus imperative that drug studies utilize more detailed analyses of pretreatment physiological and psychological functioning. In the absence of such methodological refinements, the present confusing and contradictory data about “drug effects”, “paradoxical reactions”, and imputed specificities will continue. CONCLUSION I. Pattern specificities in various tasks can be identified for group data. 2. Within various groups, individual differences may be great, leading to failure for some group data to achieve significant differences. Further exploration of pattern specifities for subjects is warranted, using some of the more recent statistical techniques of multivariate analysis. 3. Such pattern specificities for clusters of subjects may be a more meaningful way of ordering psychiatric subjects for evaluative studies than conventional nosological methods. 4. Group data for EEG, CFF and behavior are consistent with neurophysiologic— adaptive views of drug therapeutic efficacy. REFERENCES 1 3 3 7 M. FINK, A unified theory of the action of physiodynamic therapies. ]. Hillside Hosp, 6 (1957) 197. M. FINK, Effect of anticholinergic compounds on post-convulsive EEG and behavior of psychiatric patients. Electroencephalog. and Clin. Neurophysiol., 12 (1960) 359. M. FINK, R. SHAW, G. GROSS AND F. S. COLEMAN, Comparative study of chlorpromazine and insulin coma in the therapy of psychosis. ]. Am. Med. Assoc., 166 (1958) 1846. M. FINK, Electroencephalographic and behavioral effects of Tofranil. Cari. Psychiat. Assoc. f., 4 (I959) 166 SG. A. ULET’I‘ AND R. G. LOEFFEL, A new resonator-integrator unit for the automatic brain wave analyser. Electroencephalog. and Clin. Neurophysiol., 5 (1953) 113. A. WIKLER, The Relation of Psychiatry to Pharmacology, Williams & Wilkins, Baltimore, 1957. H. E. LEHMANN AND J. CSANK, Differential screening of phrenotropic agents in man. J. Clin. Exptl. Psychopathol., 18 (1957) 222. G. L. KLERMAN, A. DIMASCIO, M. GREENBLATT AND M. RINKEL, The influence of specific per— sonality patterns on the effects of phrenotropic agents. In Biological Psychiatry, Grune & Stratton, New York, 1959, pp. 224—239. Printed in The Netherlands ��IWEGPSIGIGLMIB RESPGISB ' “runs at sons rsrczonorzc nuns Ha: Fullnek Ph.D., Erie Earp 3.1. George Krauthunor Ph.n., Donald 1. Klein Cad HI! Pink H.D. Ht”. Iran the Dapartnent or Exporinentnl Psychiutry, Hillside Helpital, Glcn Oaks, 3.1., U.I. Prouontod at the Second Meeting of the Gdllogiuu Internationale Houro~ Payehophnrnacologicun, Basal, July 1960. 1?: 7/60 �Probles: _ihis study or the node of action at soae er the never psychotropic agents was teraulated within the tranework of a neurophysielogie—adaptive hypothesis (1). The concept, derived from earlier work on oonvulsive therapies (2), views clinical behavioral change as a resultant of the interaction of alterations in brain function and the personality of the subject. the ,present study enphasises the question or pattern specificity of drug action and its relation to individual differences in behavioral response. The partieelar drugs utilised, ehler» proaasine (3) and iaipranine (h), were selected on the basis of pilot studies in this institution in which their ettectiveu nose in altering physiologic and behavioral patterns had been demonstrated. this preeentatien is currently in progress. an interil report of a study �hethed: VIGonseestiye referrals for drug adninistratien in a voluntary psychiatric hospital were assigned at render to one of the three drug regimens - (1) ohlorpronasine with 1.21 preoyelidine added, (2) inipraaine, and a (3) plaeebo. Hedioatien vas adainietered in liquid vehicle in a fixed dosage schedule, to a saxiaua in tour weeks. chlorproaasine was begun at 300 as. and increased to 1200 :3. daily and iaipraaine tree 75 to 300 as. Patients continued to be seen three times weekly in individual payohotherapeatio interviews during the period of drug treataent. Analysis of the data is liaited to the first us cases. These patients are notohrenioally ill - the majority being adaitted for their first hospitalisation free the ooaaenity, and a saaller percentage rehoepitalised for a recurrence or their illness. Their mean age was 35.5 years, and yeare of schooling was 11.9 years. Apprexiaetel! 575 were diagnosed in the group or sohisophrenias, 281 as affective psychoses and 15S psyche‘ neuroses and eharaoter disorders. Patients were exaained in a four day period prior to drug adainistration on a fixed schedule or physiological and psyche— legieal prooederee which was repeated iering the sixth week of drug treataent. �Results: in cone of the aeaeoree with drug treataente in the figure I. the EEG patterns aeaeored Group changes are shown --~----~--“-. FIGURE I ..—..'.....u. quantitatively through electronic frequency analyeie (5) show that inipranine and ohloryronaeine differ significantly from the control group and from each other. There was a eignificant reduction in the total electrical activity in the inipranine group, while there wee an increase both in the amount of slow ahd wave activity the slow to test activity ratio: in the chlorpronaeine group. -Thc reduction in the critical flickerotueien (CPI) threehold ie noted only for the chlorproxaaine group. Thin test correlated with the increase in EEG elow wave activity. The rotor tests also reflect a differential drug effect with uneteadieeee increased by the two drugs, fiapping rate unaltered, and pursuit rotor inproved only by the igipranine group. The the greatest change in intellectual functionihg rae scored by no-drug group, preeeut to a leeeer degree in the iaipraaine group and absent in the chlorprenaeine group. the lack of equivalent changes for the drug grounsnay reflect an inhibition of the expected practice effect. In clinical behavior, all groups showed a reduction in coupleinte on self-rating ae measured by the Johne napkins Scale, with the reduction being greater for the drug groups. �.h’ 611d. In the load 80:10, 3 Q-Iort bohuviornl rttilg, that. an. a qunatitt‘ivo iodnction in both tho pntaoat'n and tho dfiflttr'. 2:11:33 a: 'dcprocttun' in tn. contrcl fihc drug grvup but ‘ot (tr group. #311. than. du$t indicatc s ptttorn thnt angg-ata dittorontiul drug tcttvlfiy, ‘horo w‘u narkad ho‘crogonuity within tuck grvup an Oneh nonairo. Fitlrc 2 pluts at. ohnngca ------”--‘ FIGURE 2 ouudunouca in ctr tar itch aubaoe‘. rho nunbtr within Ouch ban rotort. the 07:1tatton o: n «inn;- tn bahnviur, rated on t tour-point .031. by sh. ovnlnuting pnynhtutrtnt. it... ‘20 glohnl ch18... 13 bchuvior ratiuga, and gr. not uncocaarily‘oquavglnnt #0 rating. it ingrQVCIdnt. (lot. that £ho ratttan c: habnvtorul '3' tld 'h' IIII aunt often ussoctutcd with ehnngnl 1n err-o: uni. than on. cycle) Althodgh tbs d1£t¢rcnoo in 3033 err near. botviun 'tltpruutno and tho «Chiral group van tot signitiegnt, 6h: atttorcnco 1: vartthtltfiy (1 ratio) III utgnizicgnt (p .o;). admiral It. gran; unused u narruv r.n¢c at chgngo, vnryiu; chaago Iran tron to n! 31:10:. In contrast; tut Slipranlno xrtup :;n¢od +2 tn -5 grains, and chlarpzalnsinn (ran not. to -6 cyclan. Ina chlorprunalinn stump chang- vas a: Shh downward atroction only. the 1nd£v1dnu1 dittorono¢n ta thn t1¢irtiiill If G?! tarantula 1:. .13d ohaorvahln 13 thn olaotro.ncopha10¢raph1¢ «an... run:- 3 an: tho clung“ 1a a. :1» u no «any; +1 an �-5... fi.‘fl---‘fl“.119333 3 O‘flumnabndou ratio demonstrating a wide range in changes fer the controls, a eiailar pattern tor the 1a1praaine group, but a change in enly one direction that of increaaed slewing fer the chlorpreaaaina sweep. The teen increase in elev wave activity for the ehlorpreaaaine group was more than 15 tines that or — the central and 1a1praaine groupe. there was also a aignifieant relation between the increaee in aloe wave activity and increasing age with chlorpreaaaine - elder patiente being late eneceptible te naxinna change. �Dieeeeeion: psychological and £36 findings ehoe that the agente etudied affect theee randomly eeleoted eubjecte differentially, producing drug-epocitio epoctroae or change eooree. This deeonotration or drug epocitic profiles based on multiple tests supports previoue statements by ouch The (7), and Klenaan et al (8). It ehould be noted, however, that theee toot ecore profiles are contingent on population ohareoterietioa and not eolely on the biochemical propertiee e: the agente tested. While no adeqoete delineation of eelient population oheraoterietice ie available, two general eohenata are in nee ~ the diagnoetio neaenclatore, and the concept or I"tax-got eynpteae'. leither ooheee adequately retleete population oharaoterietioe, and further otudiee of multivariate behavioral, phyeiologio end peyohelogio oharaoterietioe are neeeeeary for each delineation. It in thee imperative that drug etodiee utilise more detailed analyses or pretreataent psychological and physiological toentioning. In the abeenoe or euoh aethodological refinements, the present confueing and contradictory data about ”drug effects", "paradoxical reactions“, and iapeted epeoiiicitiee will continue. workere ao Wikler (6), Lohmann �Conclueiefi: (1) ~Psttern speeifieities identified for group dsts. 1n vsrieus tasks can be differencss individusl various Within groups, (2) to dsts sons for group to failure be lesding great, as: of Further explorstien differences. sehisve signifiesnt some using usrrsntsd, is for subjects psttsra speeitities of the nets recent ststistiesl techniques at nultivsrists snslysis. or clusters for Bush (3) pattern speeitieities of psychistrie ordering he nssniugful we: nsre s nsy sabjsets nsselegiesl eenventiensl thsa studies evaluative for subjects methods. . (h) fireup dsts fer use, err and behsvier sre eensistent with nearephysielsgie-sdspt1ts views 9! drug therspeutic etilesey. �‘8REFEREHGES tho Action or of Thoory Enitiod Physiodynonic i Thoropioo. J. Hillaido IOIE. é; 197~206, 1957. 2. link, H: Effect of Anticholinorgio Gonpoundo on Poot~ convulsivo BEG ond Behavior of Psychiatric Potionto. E30 6113. lcurophyoiol. $3: 359-369, 1960 3. Pink, H., Show, 3., Grout, G. and Calcium, 1.8. Corporativo Study of chlorprouojino onc Insulin Geno in the therapy or Poychoéis. J. inor. nod. Aoooc. ;§gs 18h6~18§0, i958. h. rink, H: Electroencephalographic and Behavioral Effects of Torronil. Gonna. Pczch. Assoc. J. g. 166$~1718, 1. rink, K: 1959. Blott, G.A., Ind Lootfcl, 3.6. A new resonator1ntogrotor unit for the antarctic brain wave onolyaor. Clio. Houroghzaiol., g} 113-115, 1953. 6. Viklor, A.: 2&0 Relation of Pazchiotrz to Phornocologz, an. a Wilkins, Boltinoro, 1957. Lohnonn, B.E. and Crank, 3.: Bittorontioi scrocning or Phronotropic Agents in Hon. J. Olin. Razor. Pczchogothol. EEG lg: 222—235, 1957. Klornan, 0.1., Dixaccio, L., firocnblott, K. and Rinkol, H: the Influence of Specific Personality Pottcrnc on the Effects of Phrcnotropio Agents. Biological Pazchiotrz, Gruno & Strottcn, New York, 22h-239, 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 Neuropsychologic response patterns of some psychotropic drugs. In E. Rothlin (ed.), Neuro-psychopharmacology. Elsevier, Amsterdam, 1961, 2:381-4 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-50-016 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 Pollack, Max; Karp, Eric; Krauthamer; Klein, Donald F.; <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 and [preprint]. REPRINTED FROM E.ROTHLIN (Editor) NEURO-PSYCHOPHARMACOLOGY VOL. 2 (1961). Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum Basle 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/aaac38fc36161269f14f4617b6ef620f.pdf 09f64ba46dc2ab1bcb50e506d78ad27a PDF Text Text v._, SOCIAL ASPECTS OF PSYCHIATRIC TREATMENT IN THREE HOSPITALS: METHODOLOGICAL PROBLEMS 1/ «- hoWCV‘ in Max Pollack, Ph. D. , Nathaniel Siegel, Ph. D. Robert L. Kahn, Ph. D. , and Max Fink,_M. D. - inst logic P hospit‘ same } scitiflg The generalization of findings from one population to another is basic to any science. Psychiatry. perhaps more than other medical specialties. is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The organ. ization of multiple hospital studies makes possible the detection and clarification of the" methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study. with reference to the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of. discharge and length of knoWiE tal dis A routin( at MM -ga. would hoapiti hospital stay. pang! Various social psychiatric studies of community and hospital psychiatric populations (1, Z, 6) have established the importance of sociopsychological factors in the type and incidence of mental disorder. the selection and maintenance of treatment and therapeutic evaluations. In these previous studies such selective factors as the patient's financial resources or the extent and type of available treatment facilities may have been more signi. ficant in the observed results than the social variables studied. A more critical test of the role of soda-psychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is met at Hillside Hospital, and in 1957, we embarked out a program of assaying the relation of sociopsychological factors to the treatment of hospi. talized psychiatric patients (3. 4). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Our method of investigation was a census-type survey of all in-patients on a given day (3). In addition a brief modified California F Scale test (2, 5) was administered to all patients. We observed that age, education, sex, foreign-birth. and performance on the California I? Scale were significantly related to choice of treatment, duration of hospitalization, clinical discharge ratings and to clinical diagnosis. order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions. the C. F. Menninger Memorial Hospital and the Massachusetts Mental Health Center (MMHC). These institutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socioeconomic Class I and II patients (Menninger Hosp.) and the other. predominately Class IV and V. L soclat' the let that tr psychc of noti chothe basis' with tl tient c psycht chiatr reside I ciplin' .wn-w gists. view $ In (MMHC). Observations Dia n that tl behav the sa sent 5 charg classi these Hospital Structure ducin; reporting data from ones own institution. the structure of the hospital is taken for granted. and either ignored or briefly mentioned. When approaching a new institution._ .When distox Note the department of Experimental Psychiatry, l/ N.From Y. Hillside Hospital Glen Oaks, 1... I. . Aided. in part, by grant MY-Z715 of the National Institute of Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C. F. ' Menninger Memorial Hospital is gratefully acknowledged. . 202 ‘ and a five-f comp rion ( Disc}: the c: prove �r, 7' attempting to gather comparable data one is made aware of the differences institutions and the nature of the hospital organization is seen as one of the methodoBoth the MMHC and Menninger institutions have day logic problems affecting treatment. physician can care for the hospital units.and Hillside does not. At the MMHC the treating clinic. In such a in the and after-care in the hospital, day in-patient, an ”me patient as the at from an earlier date, hospital ,ctting’ the treating doctor can dischargeforthe‘patient in Hillside Hospiwhereas his patient's care; be he still responsible will that Mowing of the relationship. termination patient-doctor ux discharge means towcvcr- and in . "ru‘ ~1uwv1 different research programs. affecting clinical survey, approximately 20 percent of the patients been had and ill hospitalized for many years. Such a group at MMHC were chronically state would not normally have been in this hospital but they were transferred from another hospital for special study purposes. Designation of Type of Treatment In our assessments of specific variables, we encountered a variety of problems associated with the content of hospital records. For example, it was difficult to determine of time spent in the length of stay prior to referral for a somatic treatment, or the length that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting Which patients were designated by the hospital as having been treated with psy- ‘ chotherapy. At Menninger Hosptial, psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care and were not recorded as psychotherapy. At Hillside Hospital the definition of psypsychotherapy was limited to treatment sessions with the psychiatric resident. Staff the chiatrists did not treat patients directly, but restricted their activity to supervising Another problem was the presence of routincs- For example. at the time of the ..... . a. “syn a -w~a.u.r-- M -.M——-.— 5" t V_ . . ,. v.71 _ .I-uv-n- ‘-.p..o-i.m ‘W, runny-.9. -l residents. ‘4,"V‘OQ‘M'A'fi In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses. medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to inter- view the resident physician in charge of the case. ‘71-'Nuo-nyap ..._...,. ,— —-— -vw“ Diagnosis -\» ,... a... assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic “styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) has shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study. there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we were aware that we were introducing distortions through this maneuver. Table II illustrates the distribution of diagnostic categories within each institution. Note that at the Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses. while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals.- We would emphasize that cross hospital comparisons of populations basedpn diagnosis as the single or the most important criterion does not insure comparability of populations. The .i-u.v.-.‘Mdh& M u--. , ~ ~m.va-»..... P... wv" 4 r .. R." s ~. , . —w . n—‘w—w-vw- \*_sm,~,-.w...—mp-- ' 7 ”avcuuuft Discharge Ratings of Improvement .- Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger Hospital had the most elaborate discharge ratings of improvement and Hillside Hospital. the simplest. . 1 ~ A .w» wo-fi-‘v. - w- 2 203 l ': l . . T 1’ �TYPES OF DISCHARGE DIAGNOSIS Patient Discharge Rating 1. Depression Reaction Narcissistic Personality 2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality 4. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Classification Rating Psychoneurosis Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance ' ‘ Sociopathic Personality Disturbance Schizophrenic Psychosis TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MMHC Schizophrenia 41 52 52 Personalitybisorders 33 6 Psychoneuroses Affective Psychoses Organic Psychoses Transient Personality Disorder 14 18 8 21 16 5 l 5 2 2 6 100 173 N: 13 , 93 ‘ As shown in Table, III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological and syndrome changes. Hillside and MMHC had similar global ratings and it is difficult to state how much weight was given to each of the three factors incorporated in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitalization. Hospitalization Length of hospitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of illness and response to treatment. As such. it is frequently used as an index for interhospital comparison. Table IV compares length of hospitalization by age at the time of the study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet. among these three hospitals there were marked differences. When diagnosis is employed a similar pattern is obtained. At Menninger Hospital the over one percentage of patients with the diagnosis of schizophrenia who were hospitalised ' year was 91%. at Hillside Hospital 35% and at MMHC. 77o. 204 We 11: ' factor not generalizir , methodolog There single diag sociopsych difficulty. 5‘ ‘ Studiii: birth, edui nificantly 1. improvemc: choanalyti<- tures - one the other. ‘ �TABLE III ‘ RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Hillside Menninger Improved Unimproved r. MMHC “'““”i“"‘ ,- «a..——q SOCIAL ADJUSTMENT , "VT'~M-» Recovered Recovered Much Improved Markedly Improved a. waw 9.9. «an::r:r;t?.'fi~'"'fi'f”“ o“ . Improved CHARACTER STRUCTURE Moderately Improved Slightly Improved ' ‘ Unimproved Improved Unimproved . .v-‘n. 1 . Unimproved ’ ~ ~VWT~I Regression SYNDROME .. V ' Complete Remission ””"1" Improved Unchanged (or worse) a'v‘r‘.':'§l':"t'.“"""""""‘ TABLE IV . HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR A~-; _- Inf.) . .,i ~- -‘ .a-.<__. u- .,.I Age Menninger Hillside MMHC Below 20 20-29 30-39 40-49 81 42 14 73 36 6 61 30 6 30 20 0 50+ -_.-..-< vm r , 36 0 , ““*‘".'"‘-'-«rvm-AfiuvnrcM-mvr“ V" ' ' 0 u‘ "rm-J'W- V 12219122192 fl." j J.“ ~.. 4.... We have indicated that the philosophy and organization of institutions is an essential {actor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional methodological stumbling blocks to scientific activity? ‘.r‘a-..—..,._ differences that are the «4“le .-,... a... 5“ -.... 5hérv~naVvu .-- a .-.4 .. “4‘... «a; .v” .. . There is an urgent need for objective techniques to describe populations. The use of diagnostic terms is obviously inadequate. It is likely that detailed behavioral and sociopsychological descriptions of patients may be the best technique for overcoming this single «M-M~—,t...y.-.r, difficulty. Summary Studies of the in-patient population of Hillside Hospital indicated that age, foreignbirth. education and stereotypic attitudes as measured by the California F Scale were significantly related to choice of treatment, duration of hospitalization. discharge ratings of improvement and diagnosis. We have extended this study to other institutions offering psychoanalytically-orientedpsychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center. serving "lower-class" patients and the other, the C. F. Menninger Memorial Hospital. serving "upper-class" patients. . ‘vvw-WOv—u-wm-Mvr- . ws—vt‘v-~.o-‘- .-,. '< ' 205 u r ~-. . .- ”4...”.-. �,rm We have encountered a variety of problems in this comparison. including difference. in l) the type of hospital organization; 2) the definition of the treatment as in the designstion of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and 4) diagnostic "styles” employed. ..... ~. a .w»-._.r ..x a The importance of these methodological problems in current psychiatric research are discussed. References (l) Hollingshead, A. B. , and Redlich, F. C.: Social Class and Mental Illness: A Commun. ity Study. New York, John Wiley & Sons. Inc. . l958. a...» .' (Z) Gallagher, E. B. : Levinson. D. J. , and Erlich, 1.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital. edited by M. Greenblatt, D.J. Levinson, and R. H. Williams, Chicago. Free Press. 1957. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hospital 6: 216-228, 1957. (3) Kahn, R. L. 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. 1959. (5) Kahn, R. L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Neu. Ment. Dis.‘ 130: 189-192, 1960. (4) Kahn, R. (6) Myers, J. K. , and Schaffer. L. : Social Stratification and Psychiatric Practice: AStudy of an Out-Patient Clinic, Am. Sociol. Rev.l 19:307-310. 1954. (7) Pasamanick. B. , Dinitz. S. and Lefton. M. : Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat. . l_l_6_: 127-132. 1959. DISCUSSION DR. KLERMAN: One of the ways to overcome the biasing factors related to length of stay is to calculate the mean stay for each hospital. In this way interhospital comparisons of the effect of such variables as age on length of stay could be compared in terms of quartiles. . r .4 g DR. POLLACK: .9101. .. ;v That's a good suggestion, however it still doesn't overcome the problem of differences in hospital structure. e. g. , the presence or absence of a day hospital facilities. in influencing length of hospital stay. «2' ‘Z uhwfifil'nl DR. OPPENHEIM: The finding that younger patients tended to stay longer at the hospital seemed to be at variance with experience at VA Hospitals. I ask what was it about the therapeutic programs at the three hospitals that led to these findings? What are the theoretical implications of these findings ? “AL. in \:A 9;.- .41: ..., s ——....-.-A..— .-..~u-....v-l-~ .e... “4...-..“ -.‘_......-c DR. POLLACK: The length of time a patient is hospitalized in a psychiatric facility is related to the particular function and philosophy of the institution. In those hospitals that stress psychoanalytically oriented psychotherapy, patients who are most like the therapists with regard to sociopsychological factors are kept in treatment for the longest period. In studies of out-patient clinics with a psychoanalytic orientation, it has been found that persons from higher social levels. as determined by education and income, are treated longer. In contrast. in state hospitals the results are quite different. Thus, it has been shown that state hospital patients with the least education will be institutionalized longer and are more likely to become the chronic patients. Consistent with the concept of state hospitals as largely providing long-term custodial care for lower class patients, the state hospital psychiatrist may be oriented toward a comparatively more'rapid discharge of those patients who come from a background most like his own. 206 v" .va —v : ��Social Aspects of Psychiatric Treatment in Three Hospitals: Methodological Problems Max Pollack, Ph.D., Nathaniel Siegel, Ph.D. Robert L. Kahn, Ph.D., and Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. fios Presented at the Sixth Annual Veterans Administration Research Conference, March 28, 1961, Cincinnati, Ohio. Aided, in part, by grant MY~2715 of the National Institute of From Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. IV: h/17/6l �Social ASpects of Psychiatric Treatment in Three Hospitals: Methodological Problems generalization of findings from one population to another is basic to any science. Psychiatry, perhaps more than other medical specialties, is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The advent The of simultaneous multiple hOSpital studies makes possible the detection and clarification of these methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study, and will consider the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of discharge and length of hospital stay. Various social psychiatric studies of community and heapital psychiatric populations (1, 2, 6) had established the importance of sociopsychological factors in the type and incidence of mental disorder, the selection and mainten— ance of treatment and therapeutic evaluations. previous studies such selective factors as the In these patient's extent and type of available treatment facilities may have been more significant in the observed results than the social variables studied. A more financial resources or the �-2- critical test sociopsychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is not at Hillside Hospital, and in 1957, we embarked on a program of assaying the relation of sociopsychological factors to the treatment of hospitalized psychiatric patients (3, h). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Almost all patients are non-chronic, as their admission to the hospital is associated either with first hospitalization or a recurrence of illness after a long period of remission. The case load is small, with at most ten patients to one resident physician. Our method of all in—patients on modified California all patients. birth, role of the We of investigation was a census«type survey of a given day (3). In addition a brief F Scale observed test (2, 5) was administered to that age, education, sex, foreign- California F Scale were significantly related to choice of treatment, duration of hOSpitalization, clinical discharge ratings and to clinical diagnosis. In order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions, the C.F. Menninger Memorial Hospital and and performance on the �-3the Massachusetts Mental Health Center (MMHC). These insti- tutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socialogical Class I and II patients and the other, predominately Class IV and V. �-hOBSERVATIONS Hospital Structure: When reporting data from ones own institution, the structure of the hOSpital is taken for granted, and either ignored or briefly mentioned. However, when approaching a strange institution and attempting to gather comparable data one is made aware of the differences in institutions and the nature of the hospital organization is seen as one of the methodologic problems affecting treatment. .Both the Menninger does institutions not. At the MMHC MMHC and hospital units, and Hillside the treating physician can care for have day the same patient as an in-patient, in the day hOSpital, and in the after-care clinic. In such a setting, the treating doctor can discharge the patient from the hospital at an earlier date, knowing that he will still be reSponsible for his patient's care; whereas in Hillside Hospital discharge termination of the patient—doctor relationship. Another problem was the presence of different research programs, affecting clinical routines. For example, at the time of the survey, approximately twenty percent of the patients at MMHC were chronically ill and had been hOSpitalized for many years. Such a group would not normally have been in means this hospital but they were transferred hOSpital for Special study purposes. from another state �-5Designation of Type of Treatment: In our assessments of specific variables, we encountered a variety of problems associated with the content of hoSpital records. For example, it was difficult to determine the length of stay prior to referral for a somatic treatment, or the length of time spent in that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting which patients were designated by the hospital as having been treated with psychotherapy. At Menninger Hospital psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care. At Hillside Hospital the definition of psychotherapy was limited to treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients directly, but restricted their activity to supervising the residents. In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses, medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to interview the resident physician in charge of the case. �Diagnosis: The assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) have shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study, there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we are aware that we are introducing distortions through this maneuver. II illustrates the distribution of diagnositic categories within each institution. Note that at the Table Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses, while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals. �We would emphasize tions based that cross hospital comparisons of popula- diagnosis as the single or the most important criterion does not insure comparability of populations. on Discharge Ratings of Improvement: Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger HOSpital had the most elaborate discharge ratings of improvement and Hillside Hospital, the simplest. As shown in Table III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological had and syndrome changes. weight was and MMHC it is difficult to state how given to each of the three factors incorpora- similar global ratings and much Hillside ted in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitaliza- tion. Hospitalization: Length of hosPitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of �-8- illness and response to treatment. As such, it is frequently interhospital comparison. Table IV length of hospitalization by age at the time of the used as an index for compares study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet, among these three hospitals there were marked differences. diagnosis is employed a similar pattern is obtained. At Menninger Hospital the percentage of patients with the diagnosis of schizophrenia who were hospitalized over one When year was 91%, at Hillside Hospital 35% and at MMHC, 7%. DISCUSSION indicated that the philosophy and organization of institutions is a factor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional differences that are the methodological stumbling blocks to We have scientific activity? is for objective techniques to describe populations. The use of single diagnostic terms is obviously inadequate. It is possible that detailed behavioral There an urgent need �-9sociopsychological descriptions of patients best technique for overcoming this difficulty. and may be the �-10SUMMARY Studies of the in~patient population of Hillside Hospital indicated that age, foreign-birth, education and stereotypic attitudes as measured by the California F Scale were signifi- cantly related to choice of treatment, duration of hoSpitalization, discharge ratings of improvement and diagnosis. The same therapeutic facilities were equally available to all patients, predominantly middle-class, and ability to pay was not a factor in treatment. We have extended this study to Other institutions offering psychoanalytically-oriented psychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center, serving "lower-class" patients and the other, the C.F. Menninger Memorial Hospital, serving "upper-class" patients. We have encountered a variety of problems in this comparison, including differences in: l) the type of hospital organization; 2) the definition of the treatment as in the designation of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and h) diagnostic The "styles" employed. importance of these methodological problems in current psychiatric research are discussed. �TABLE I TYPES OF DISCHARGE DIAGNOSIS PATIENT DISCHARGE RATING CLASSIFICATION RATING 1. Depression Reaction Psychoneurosis Narcissistic Personality \2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality h. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance Sociopathic Personality Disturbance Schizophrenic Psychosis �TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MEEE Schizophrenia Personality Disorders hl 52 S2 33 6 13 Psychoneuroses 1h 18 8 Affective Psychoses 5 21 16 Organic Psychoses S l 5 Transient Personality 2 2 6 100 173 93 Disorder N = �TABLE III RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Menninger Hillside MMHC SOCIAL ADJUSTMENT Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved CHARACTER STRUCTURE Improved Unimproved SYNDROME Complete Remission Improved Unchanged (or worse) Improved Unimproved Regression �TABLE IV HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside yfifig Below 20 81 h2 lb 20-29 73 36 6 30-39 61 30 6 ho-h9 3o 20 0 50+ 36 0 0 ggg_ �REFERENCES Hollingshead, A.B., and Redlich, F.C.: Social Class and Mental Illness: A Community Study, New York, Joha Wiley & Sons, Inc., 1958. Gallagher, E.B.: Levinson, D.J., and Erlich, Y.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in Ehe Patient and the Mental Hospital, edited by M. Greenblatt, D.J. Levinson, and R.H. Williams, Chicago, Free Press, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Social Factors in Selection of Therapy in a Voluntary Mental Heepital. J. Hillside Hospital é: 216-228, 1957. 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. l: 565-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Ment. Kahn, 2i§., Egg: 189-192, 1960. J.K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Myers, Sociol. Rev., 19: 307-310, 19Sh. Pasamanick, B., Dinitz, S. and Lofton, M.: Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat., 116: 127-132, 1959. Am. ��Mmunattm of Patton Populations: Catapult-ability of 5mm 2!: Evaluating Thmpiu Mam Mutation! The Mam Fink. M. From A the D. Miami Its-mat. of Ptycmuy at 8:. Loans sum Hospital. 8t. Loni: hand an and“. madman: at tho mum. nuptial. New York in ramwith Du. R. I... Kuhn. N. 310901 and M. Pollack, and tar be puhmhod «Remnant 'smmyohtfloqtal Aspects at madman Truman m m mammary Hospitals“ uin 1863. �Recent community studies have demonstrated a between social factors and psychiatric treatment. relationship In their study psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated of the New Haven illness, types of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, undertaken at Hillside Hospital in 1957. variety of treatment In a survey was this hospital, a including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,5) it was observed that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, modes, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients by psychotherapy and �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aSpects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions ~— Hillside HOSpital, the C.F. Menninger Memorial Hospital of Topeka the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and and education. is a teaching hospital with a full time superactive research departments. They emphasize Each visory staff and psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD A census of institutions all voluntary, adult patients in residence in these undertaken in January, 1959. While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic was schizophrenic state hospital group transferred for a Specific research project. These patients were excluded from the study because of their non-voluntary status. given the California F scale on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2~factor index - a weighted score of education and occupation - was used (2). The study population consisted of 173 patients at Hillside, 100 at Menninger Each patient and 95 was at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrahospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, which is reflected in the varying population sample sizes in the tables. �4,. RESULTS A. Inter-hospital Comparisons l. Methodological Problems reporting studies from a home institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. However, in studying a strange institution and attempting to gather comparable data one is made aware of the many differences between institutions. While we selected these institutions as comparable in teaching, research and treatment programs, we found that they were unlike structurally in ways which influenced the data of the study. Specific problems were noted in the designation of type of treatment, diagnostic classes and the evaluation of treatment outcome. 3) Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making uniformity in classification difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with the psychiatric resident were considered part of routine administrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising the resident physicians. No additional fees were charged. When �-5the Massachusetts Mental Health Center psychotherapy was designated as a function of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American Psychiatric Association while both Hillside and MMHC followed unitary At systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Ratings of improvement at the three hospitals varied in format and detail. The discharge rating at Menninger HoSpital Was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the c) Discharge Ratings of Improvement: Menninger system (Table II). For this study the Menninger syndrome �~6— rating was compared to the global ratings of the other institutions. ----- ------Table II Sociopsychological Variables The distribution of the variables of social class, age, Jacation and California F Scale score among the three institutions 2. is presented in Table III. ------------a) Social Class: There was a marked difference in the social class composition of the three institutions. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, class; lower class. middle b) age: and at Massachusetts Mental Health Center, predominantly There were no differences in age distribution in the institutional populations. c) Education: The populations differed in educational attain~ ment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While bl per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduate. d) F Score: Significant differences in the distribution of scores on the California F Scale were observed. Fifty-one per cent �-7of Menninger patients had F scores below 30, and only eight per cent with scores of 50 or above -- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirtyone per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. Thus, the anticipated differences in the social class of the populations were observed, as well as significant differences in educational attainment and performance on the F Scale. These differences permit testing the hypothesis concerning the relation of sociopsychological factors to the treatment variables among the insti- tutions. 3. Psychiatric Treatment Variables a) Selection of Treatment: Among institutions, significant- ly fewer patients at Menninger Hospital (h3%) received somatic therapy than at Hillside (6h%) or MMHC (68%) as shown in Table IV. b) Duration of Hospitalization: The three institutions differed markedly with respect to patient's length of stay (Table IV). Hospital patients were hospitalized longest, with 65% of patients remaining for twelve months or more, uumynugd to 31 per baht of the Hillside patients and only 5 per cent of those at the Massachusetts Mental Health center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over ho, but lh% of patients under the age of 20 remained longer than a year. Table V ----------- �-10DISCUSSION this comparison of three voluntary psychiatric hospitals we have observed significant interinstitutional differences of patients in the social variables of years of education and social class, but not age: in distribution of California F Scale scores: and in each of the treatment variables -- duration of hoSpitalization, selection of treatments and distributions of diagnoses and discharge evaluations. The expectation that the institution serving upper class patients In the longest duration of stay, higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, lower proportion of patients receiving organic forms of therapy, and poor- would have a est discharge ratings were each confirmed. Similarly, the institution serving lower class patients evinced shorter periods of hospitaliza— tion, low proportions of psychoneurotic diagnoses, and better dis— V charge evaluations. It is our impression that these differences in psychiatric treatment are more related to differences in staff attitudes than to differences in population samples. The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. These .stylistic differences cannot be dismissed as merely idiosyncratic since they follow a pattern related to social differences consistent with previous findings. �-11- population and treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such history which patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or a defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi~ fication. This view was clearly demonstrated by Pasamanick, Dinitz and Lefton (7) in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are largely reflections of the attitudes of the examiners. It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources and favorable factors, it reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher proportion of the population classed asschizophrenia, the reported treatment results are the best. It is probable that this study does not reflect the relative therapeutic efficacy of the institutions. Our data furnishes no independent criteria for determining which heapital provides the better care; nor for assessing the comparability of the population in the degree of institution's own illness. Since the evaluations are based on the ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) it was postulated that different criteria of improvement were utilized for persons of different social background. It was suggested that the higher the person's social background the more complex the criteria employed. This has literally confirmed in the present study, with Menninger's using tripartite rating compared to the global rating of the other two been a institutions. considering the syndrome rating on which our comparative statistical analysis were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persbns the criteria stress such complex Even �~13- intangibles as "developing insight", or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader- ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it difficult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The widespread use of such terms as "schizo— phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. �-111- Increased attention must be paid to the methodological problems of classifying subjects by "objective" criteria rather than the present methods which appear to be so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the thera- pist-patient interaction. �-15.. SUMMARY and CONCLUSION In three psychotherapeutic-oriented teaching hospitals, population characteristics were related to treatment variables. 1. Populations were defined by social class, age, education and F score, and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. Significant interinstitutional differences were observed in characteristics of patient social class, years of education and distribution of California F scores, but not age. 3. The variations in treatment characteristics among institutions were found to be significantly different in the predicted direction. h. These variations in psychiatric practices follow a pattern consistent with social class differences among institutions and are not regarded as being idiosyncratic. S. The differences in institutional style make comparisons of diagnoses, duration of hospitalization, and treatment results between 2. institutions difficult and tenuous, and the need for more objective criteria of classification of populations is emphasized. �REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N.: Authoritarian Personality, The New York, Harper & Brothers, 1950. Hollingshead, A.B.: graphed Two-Factor Index of Social Position, mimeo- publication. Hollingshead, A.B. and Redlich, F.C.: Illness: A Community Study, New Social Class and Mental York, John Wiley & Sons, Inc., 1958. R.L., Pollack, M. and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside £332., 9: 216-228, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Kahn, Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: S65-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. & Ment. Dis., Kahn, 130: 187-192, 1960. Psychiatric Orienta— tion and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer. J. Psychiat., 116: 127-132, 1959. Pasamanick, B., Dinitz, S. and Lefton, M.: �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Passive Aggressive Personality Sociopathic Personality Disturbance Sociopathic Personality Alcoholism Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of At Time of MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Clinical Condition Hospital Discharge HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE 1;; InterhOSpital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Social Class 'v“ N (87) (133) I 31% 7% (72) 3% 20 28 III 17 3h 13 IV 1 3h 28 v o 5 28 x2=121.5; df=8z p<.001 'N (100) (173) (95) 19% 19% 15% 20-39 59 58 52 ho 22 23 33 + x3=3.9; df=h; p=n.s. (100) (173) <12 Education Center ' 51 N Years of Mental Health I II <20 Age Hospital Massachusetts i (91) 23% 32% h1% 12-15 Sh 51 h9 16 23 17 10 + v3=9.7; df=h; p<.os (92) (163) (76) 10~29 51% 33% 20% 30-h9 hl 50 50-70 8 N F Score 17 L i 2 I y3=39.2; df=hi p<.001 38 h2 . �TABLE IV InterhOSpital Differences in Treatment Variables ‘Menninger Hospital (100) N Type of Treatment Hillside Massachusetts Hospital Mental Health (173) Center (89) Psychotherapy 21% 36% 2b% Somatic h3 6h 68 Other 36 ~- 8 1 e a _ _u , xi:82.8: df=h: p<.001 N Duration of Hospitali— zation <7 months 7-11 months :il months (100) (173) (95) 22% 27% 67% 13 h? 27 65 31 S a ’ X2=9o.6; df=h§ p<.001‘ N Recovered, Improved Discharge Evaluation . Much (99) (172) (88) 1% 23% 28% Improved 80 62 61 Unimproved 19 15 10 lvwwy2=29.3; df=h; p<.001 m“ N Schizophrenia Discharge Diagnosis ” Affective Psychosis Psychoneurosis and Personality Disorder (95) (171) (85) h3% 52% 5h% 5 22 17 52 26 29 , X2=23-83 df=h; p<.001 �TABLE V Duration of Hospitalization BX,A§2 PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £53 Menninger Hillside mag Below 20 81 h2 1h 20-29 73 36 30-39 61 30 h0-h9 30 20 50+ 36 �A? 9/7 . THE AMERICAN PSYCHOANALYTIC ASSOCIATION SUMMARY AND FINAL REPORT OF THE CENTRAL FACT-GATHERING COMMITTEE /f" ’4-4-‘"?;"é /L\ W2} The Central Fact—Gathering Committee was established by this Association in 1952 and charged with the responsibility Of setting up a method for pooling :the significant data of psychoanalytic practice. Starting modestly and testing a procedure that ensured professional secrecy, it was hoped that increasingly valid, meaningful data might be accumulated. However, the long-recognized difficulties -- diagnosis, nomenclature and measure of effectiveness -- all have led to increasing resistance and a resultant falling-Off in the number of completed questionnaires. Scarcely any reports are now being received. Therefore, it was recommended at the last meeting of the Association that this Committee be discharged and its materiel stored until such time as further developments warrant confidence in the use of the statistical method in psychoanalytic validation. \7 This summary of the material is being sent to you for your study and files. Although some members of the Committee thought otherwise, the Committee as a whole, the Executive Council and the membership at the last Business Meeting of the Association in December, 1957 approved the opinion that none of this material be published. It is not that the figures can be used to prove analytic therapy to be effective or ineffective, but that the material on which either opinion may be based is inadequately established, and controversial publicity on such material cannot be of benefit in any way. We trust that all will agree and will limit discussion of this ‘ material to those professionally qualified to recognize its serious limitations. is divided into two sections: Part I, the summary of the material from the Initial Questionnaires, and Part II, of the material from the Final Questionnaires. This summary ‘ PART I We received a total Of about 10, 000 Initial Questionnaires and 3, 000 Final Questionnaires, from about 800 participants. Of the 800, about 350 were members of the then total membership of 530, and 450 were senior candidates of the then total 600 senior candidates. SUMMARY OF DATA FROM INITIAL QUESTIONNAIRES 1. Sex: Male: 48%. 2. Race: v“ "114’ or i'TéIIW?“IMI—TNT 315' 51;; g L); (“lgflflIPV iflffl uuunwflkz ”v, jQihfijfiyrf HaAll. n F. F7! :~ , ,LCJHJE: . [2‘3 ,_ rf' 355:3 _ , White: 99%. Female: 52%. (U.S. Census: White: 89%. Colored: 11%.) �3. Age 9; patients: Percentage of total Up to 12 years: 2 2 13-18 14 48 27 19—25 26-35 36-45 ‘ 46 and over: 8 4. Highest educational level: 60% of all patients are at least college graduates. (25% college graduates, 8% attended graduate school, and 27% more completed (U.S.Census: 6% are college graduates.) graduate schooll) . : 5. income: 1—5 . % % ‘ 1 in analysis: in psychotherapy: 22 35 U.S.Census: 71 6-10 25 (In thousands) 11-15 28 16 13 23 6 ' 16-20 21-40 8 9 ' 1 16 13 41.69 4 2 Over 560,303 3 Z (over $10,000) 6. Previous treatment: Regardless of type of diagnosis, about 1/ 6 or 1/7 of all patients had had previous analysis. 1/3 of the cases of neuroses and 1/2 of the cases of psychoses had had previous psychotherapy. Some had had both. About half of the cases of psychoses had had previous psychiatric hospitalization, as did 1/10 of the cases of neurotic reactions and character neuroses. cases being re-analyzed (i.e. , 1/6 of all), only about 1/6 of them are being re.analyzed by the previous analyst. The other 5/6 chose another analyst . Of the group of. 7. Present treatment: 54% Of all cases in treatment are listed as being in analysis, and 46% in psycho. therapy. The percentage runs from 60-65% in analysis in the neuroses, to 40% in analysis in the borderline cases, and 20% in the schiZOphrenias, 8. Place of treatment: Private ofiice: 94%. Out-patient clinics: 9 4%. Psychiatric & general hospital: 1%. . {reguency of treatment: % % in analysis: in psychotherapy: Per week: 1 2 3 4 5 1 6 29 41 20 7 42 33 13 3 6 or more < 2' Q1 10. use of psychological projective tests: The tests are reported as being carried out in approximately 25% of the cases. In 75% of the cases given psychological tests, the clinical diagnosis was in agree. ment with the tests . �II. -3... 213929§§§ Initial diagnoses: The following diagnostic listings are presented with full appreciation of and emphasis on their inadequacy, invalidity, uncertainty and probable insignificance. It reminds one of Freud's remarks when chided about the lack of statistics in psychoanalysis, in 1913: "To compile statistics is at present impossible. To begin with, we work with much smaller numbers than most other doctors who devote so much less time to individuals. Then, the necessary uniformity is lacking which alone can form a basis of any statistics. Should we really count together apples, peas, nuts? What do we call a severe case? Moreover, technique changes and what about the numerous partially analyzed cases and those whose treatment had to be discontinued for external reasons? " ORDER OF FREQUENCY OF GROUPS OF DISORDERS Psychoneuroses Personality trait disturbances (character neuroses) Per sonality pattern di sturba nce s (borderlines) Psychotic reactions Perversions Addictions All others Psychosomatic disorders co-exi stent in: _ Percent of total . 39 33 1 l 9 5 2 1 11 ' ORDER OF FREQUENCY OF SPECIFIC DISORDERS Pas sive-aggres sive personality Compulsive personality, & Anxiety reaction (each) 16 14 Depressive reaction SchiZOphrenias Phobic reaction, Obsessive-compulsive reaction, personality (each) Perversions Conversion reaction, 9 7 & Schizoid Emotionally unstable personality (each) Dissociative reaction, Inadequate personality, Cyclothymic personality, Paranoid personality, & Addictions (each) Paranoia, & Manic—depressive reactions (each) & Psychosomatic disorders co-existent in: Some additional data: Of the neurotic 6 5 3 2 1 11 reactions, dissociative, conversion, de— pressive and phobic reactions were much more frequent to times more) in females than in males . Obsessive-compulsive reactions were somewhat more frequent in males than in females. The diagnosis of anxiety reaction was made equally in males and females. (2 3 diagnosis of borderline disorders, "schizoid", "paranoid", etc. , and of schizophrenia was equally distributed between males and females. Homosexuality was diagnosed two to three times as frequent in males as in females, as were the other reported sexual deviations. The �We have received about 3, 000 Final Reports. These were on cases that had been in treatment at the time the CFC- program began, or that began treatment thereafter. As it became increasingly evident that significant figures could not be obtained because of the previous mentioned lack of uniformity, we confined our study 110 a more intensive investigation of the neurotic reactions that had ”completed" treatment. We cannot say what happened to all of the cases that were in treatment during this program, because only about 1/3 to 1/4 of the cases were terminated during this period. The following information from the Final Reports may be of interest. sis, We found that out of 595 cases of neurotic reactions which undertook analy- 306 were reported as having been "completely analyzed”, that is, approximately years. (W ere this study to be continued, this figure might be higher, as there might be a larger percentage of longer analyses. However, it would not be lower.) Follow—up questionnaires were sent to the participants who had sent in these 308 " completely analyzed" reports. We received a return of 210 replies, that is 70%. Below is a summary of the supplementary information on the above Final Reports of "completely analyzed" cases of neurotic reactions: 50%, and the average duration was 3~4 Is there any doubt in your mind regarding the diagnosis? Did you think there was an underlying psychosis at any time? Had the patient been in analysis previously? Was the patient in standard, or classical, analysis? Of 28% 25% 18% 90% these "cured" cases. 45 Yes: Yes: Yes: Yes: 210 supplementary questionnaires received, 80 were listed as In 35 of these, all of the symptoms were reported as "cured", and in residual symptoms remained. In the 130 questionnaires received on "improved" was moderate in 74 cases, great in 46, and slight in 10. From the above, one might draw the conclusion cases, the improvement that about 97% of patients who undertake analysis for neurotic reactions and "complete" it, are "cured" or "improved" . Of the 50% who do not complete their analyses in this group of disorders, about half discontinue apparently because they were improved. The other half discontinue for "external" reasons primarily, because they did not improve, or were consid— ered untreatable, transferred to other analysts, or required hospitalization. The most frequent reason given for discontinuing, apart from being improved, was " external reasons". �-5RESULTS IN COMPLETE ANALYSIS OF N EUROTIC REACTIONS Final In Analysis Reports Analysis Completed Cured Improved Unimproved Anxiety reaction - ‘ 1,120 cases 335 183 90 35 52 3 70 38 26 11 15 0 cases 85 46 23 11 11 1 Phobic reaction 000-X04 - 500 cases 200 104 61 17 42 2 170 108 43 14 28 1 250 116 63 29 34 0 14110 595 306 117 182 7 50 37 6O 3 OOO-XOl Dissociative reaction OOO-XOZ - 175 cases Conversion reaction GOO-X03 - 250 Obsessive-compulsive reaction OOO-XOS - 500 cases Depressive reaction 000—X06 - 700 cases TOTAL Average Per Cent: REPORTED RESULTS IN Depressive Reactions Total Final Reports: In analysis: Cured Improved Unimproved 000-X06 Compl‘d 29 34 Discont'd 30 7 4 Untreatable Transferred Hospitalized External reasons TOTAL 250 116 Anxiety Reactions OOO-XOl Phobic Reactions 000—X04 335 183 200 104 Compl'd Discont'd Compl'd Discont'd 35 52 43 42 12 3 9 2 4 1 7 5 2 7 1O 29 2 1 2 1 63 53 90 93 12 61 43 �-5REPORTED RESULTS IN Obsessive-Compulsive Total Final Reports In analysis Cured Improved Unimproved Untreatable Transferred Hospitalized External reasons TOTAL Reactions, Compl'd 14 28 OOO-XOS 170 108 Disoont‘d Cured Improved Unimproved 1 441 232 Disoont'd 31 72 0 5 8 2 22 Compulsive PersonalityJ 000-X53 365 237 Compl'd Discont'd 29 77 62 3 l7 4 4 10 10 2 37 135 11 43 65 OOO-XZI Compl'd X29 — 234 42 97 Schizoid Personality 000-X42 Disoont'd 4 3 2 * Compl 'd 5 8 6 3 5 28 Homosexuality 000—X63 82 Disoont'd l3 9 1 7 i 33 1 34 128 101 4 9 35 109 185 HOSpitalized TOTAL Compl'd OOO-XSZ 6O 1 Untreatable Transferred External reasons Personality, 23 Schiz0phrenia Total Final Reports In analysis Passive—Aggressive 65 CompchL Disoont'd 8 13 1 1 6 10 4 3 3 5 2 8 9 48 22 43 Inall these eight reported cures of homosexuality, follow-up communications indicated assumption of full heterosexual roles and functioning. * Thinking it might be of some interest to gather the opinions and general experience of the membership on the expectation of results, the following questionnaire was submitted to the membership about a year ago: "Given a young person, whom one could analyze four years or more, with all conditions favorable, what would be your expectancy of result, in percentage, of cure, improvement and failure" -- for a list of neuroses, char— acter disorders, schiZOphrenia, schizoid personality and homosexuality. were the opinions: We received 120 replies from the membership of about 650. These �-71. 45% expected no cure in any of the conditions. 2. 35% expected a 50-100% cure in the neuroses, less in the character 3. disorders, psychoses and perversions. expected a 5~40% cure in the neuroses, less in the other con- 20% ditions . those that expected no cure or a low percentage of cure, 50% expected moderate improvement, 45% great improvement, and 5% slight improvement. Of those that expected some cures in the various condtions, the average expectancy of cure was: Of . 50% in anxiety, conversion and phobic reactions. in dissociation, obsessional and depressive reactions. in schizophrenia. 4. 20% in homosexuality. 1 2. 3. 33% 10% If these figures are combined with the reports of those expecting the no cures, percentage of cure would be about half, i.e. , 25% in anxiety cases and phobias, 15% in dissociation, obsessional and depressive reactions, 5% in schizo— phrenia, and 10% in homosexuality. Our "findings" suggest a higher percentage of ”cures" than the above opinions. (Please note quotation marks!) All of the foregoing have been presented before closed meetings of the Association and to a number of the societies. Details are available to those members who request them. As Chairman of the Committee, I should like to thank the members of the Committee, the membership, and the participating candidates for their cooperation, advice and criticism. Respectfully submitted, HIW:as 1/5/58 Harry I. Weinstock, M.D. Chairman Central Fact—Gathering Committee different times during the past five years the Committee has included: Drs. Leo H.' Bartemeier, Roy R. Grinker, David Kairys, Lawrence C. Kolb, Lawrence S. Kubie, Alfred O. Ludwig, Milton L. Miller, Milton Rosenbaum, and George W . Wilson, and our consulting Statistician, Jack B. Chassan, Ph.D. At �Janusry 15; 19590 é :9: Br. n. rink art. R.£. Kuhn and H. 51:111 sunancrs fineiul Payehidtrxa study gt manningcr reuadntien, 3.3“,’ 5‘10. 1959‘ yuan: arrived in rapuka rhmrudc ‘evnning, atnuary 7, ;nd ut tn. Paundttian nsrly t a nuxt sarning. Dr. Irving rupcrtud Kurt“: ta. Biractor of tho fi.¥. Xanainqur Munorial Baupital, .1 panel: zraaious and eaoparativa 1n urtry way. Eu bud Ill proyurod the stat: tad patients hatarahand in untiakput1an'at var visit. 8t:f£ coapsrfition at :11 1:101: wt: oxealltnt. rhnrn In: guaninc intsrcst in car :tudy and us had intnrusl Wu dincuaaiana with maths»: of tho stati. Br. Kurtuu Int us ans hi! 05:13: us air handgunrtcra In& and. nrrnnaauunfls tnr um kt lfififirfi :11 nppoin$n¢ntc and obtain ‘11 rouardn ind ropcrtn that I: filiirtdu Przar ta «at again; had tskud a: ta pruvidc him with ma iuiarufition uncut I. indinntin: I11 tun rocord data uttdifi for nut thudy. the nonienl runawaulibrtrinn and he: auatntuat Iptnt fair 6‘}! conp1¢$1ng taut. turn: ta dotnil. siuau sat: a! thin inturuatian was net raudtly avuiltblu in tho ehtrfis, fir. xtrtnu aunt t for: to all t». stat: «twist. in ob$u1n thin inxfirnnticn chart noqdnd. It w¢n1a havc takuu a: pnrh¢pl two nugka ta obtain :11.thu rneard intornfittan aurlclv¢t. ways. Thu a» “ the patiunts It! caninotud in two Iatull tasting of 60 worn aollantaé 1n the tharaday ubaut pttiantt $ha on and t¢utod an aging. :yuanuinn rlnuinlng attifiutu Pridny, tautcd indiviaunlly in thtir reams. baring the Friday tcnting tart a uflgtr nurt¢ nacnuytuiod at 3% all tinnt.ha that as short the various putauuta warn locatad and ta intradusu us ts Glah puticnt. Br. Kartun yartiaipatad in tha udniniutrafiioa at thg test an the dinturhad ward and gran It?! 1% ta a to: pittantn himself. Arrangancntu atrn undo tar tho raeaxflulihwnriun ta sand an tau disahnrxc data can: a manta during fihu next ynnr. an sgtarday neruxng, priar ta war dapnrturq, a: disuuaaod with m. 031‘an Murphy, Br. allay Gardner ”lurch tad Br. Rahart wallontttan. In tddi$1mn, aw dinunnnad garnet: z! ta: «linieal prusrnn with Dru. Rorbnrt auhlguingcr and Philip “that” “lfi‘finn or our Viuit thanks ortry objectiva to tha oxtrauraxntry eaaporttion a: tan manningar atntt, partinnlnrly Br. x;rtns. tun ltr¢et0r at tho huipxtnl and Eva. tauntu, thc modicul ruacrau 13hrnr1an. Ehuy war. ‘11 nuts xraaiaully httpitnblc and and. “a I‘ll-vulcanu and ut hunt. In unitary V0 uehiovod , 3&1143 �7‘, -. nay-u JIRU‘VV 1%: FRQH: Br. a. link art. svnaxata fi¢L. Kuhn and I. 15; 1959; 5103:! antatl Ptrahiuhria study Jlnuury 5‘10; 1959* ufi nhnninsar-rvunégtiqn. a. arrivad in Tapaku Ehnrtdu atoning, January 7, and rqpurttd ut tau runndnttun curly' a ncxt attains. Br. Irving Itrtus ta: Biruetar of fin. 6.3. thningar Hanurinl Balpitnl, was cx%rnmu1y grngiuuu mad weapcrntivn in OVQ?’ may. 30 hafl yrtynrtd sh: stuff gnu pat$nnt¢ butarokund an tnttaipntian ct an? vilit. fiturt aunyaratiaa at I11 Ivvalu in» axaalloat. tag». it: cnnutne inturast in an: Ifiuty lufl a: hlfl tatarnal dinausttvnn with unabcrn o: tha staff. fir. Kurtu: Int an nfio h1¢ oxttac I! an: hundquartorl aha and. arraugnnnnsa In: up %n tantra n11 uppaintncnts and abiain :11 rtearéu and ropnrtn that u: dusivgd.. trig? ta but G§I$fi8 ha had ankud.uu tn pruvidn bin with an iniurnntiun nhutt infiiotting n11 tun rianvd alt: uoaéod tar mar ntndy. 2h: uptufi :01: any: nudietl racirdnlibrnrinu and haw aasiat3nt «unwitting thcua turn: in datnil. $1300 can: 0: this information was nut ra:d£1y artil‘blc in sh. ahsrtc, nr‘ Rattan goat u tar: £9 :11 thc atatt dactarn ta abtuan than internatiun want. aci¢ad. I$~Vflfllfi hava fiakan 1‘ yarhupa tun wash: to obtain all tho roaord information ourscvaaa the aatual tuttinc at thu‘pnticntc wan gnuaucttd an in: nnyu. an fluvial: ukout 60 pntacntn vars eelltutaé in th. gylanpiun tag tpntoa gm amass. .an rrtany, «a; rcxnining'puttaatu thy wridty touting var. tantné ludtvadunlly in that: ragga. flaring saaw $0 no they. in: taunt fit neuonpnaicfi as all I uttti aura. variant patiuutl wart lfiflltid qua to intraduau as to naah patient. Br. tartan partiaipntgd in Eh. téuiniatrution at thp tun! an tbs diatarbod ward and gran ggvc at ta a In: pntiantl hinant. Arringauantt wart ugd¢ tor tho rgeerdtlihrnritn ta 30nd In the dinahlrxa data «an: a lauth fiuring thu nmxt ymar. on antardny-morniux. print ta gar d¢purtnrc nu digcuuand rtactr¢b nativitlna with nr.0%x§mma'nurphy, Br. £11.: euranar aaa 9r. iflhltt waxlumataia. In .dditiau, I. dinuuaaca anptati giltho ulinietl procran with Dru. Earhart achltaiagtr tad fihilip ‘fiflflfla In summary it anhicvnd_tvury ahagat1Vt or an: viast thunk: ta th: axtrtorainury anuparatgan g: tho Hunnincsr utatt, and Era. pnrtioulurly Br. Knrfimt. in: flirtator a! :5. hospital moa£ $3: wart rhuy nodisul-rnaorfis all librartua. xntntu, [racinuuly hatyttgblt and and. In Incl tblafllfi and at boat. ILK:JB ��wwwmgunm fiummfimmmhmmhwbmlw mswm‘mwmmmwwwmnwmw 2mm “WgLoW numm �Jun! 17’ 1959; Dr. Hilton Graanblatt, Haosachusetta Hontal Health Cantor, 72-7h Fonsood Road, Boston, 15, lane. Dear Kilt: I want to take thio opportunity to parsonally thank you and your Staff for the excellont cooperation shown the Billoide workers during their racont visit. They returned laden with considerable data and enthusiastic about the spirit and onthuaiasa manifested by your Staff. I an aoot grateful for your oooporation. / sincerely yours, , ,. éox Fink, H.D. foJB �����Q4: mmmnwm:mun.nm:mmw mamas ' " wMMummuanmmu _gm“, Mm. uuuwufiumnmuumazr- hunt“. " “mama. 7pm.; mm «m, a gm mm m mm: ' V»4,.fi,_,§.,..r* 3. Age" A tu Miamiwnuanhmmummumh‘ ��1/” [W W J7 fké, fax»: .7 .2 =_7 adv/O gala; ,Afuuzs a CH“; ; NV/ g xY/ A A3 / ‘3~*‘~/7::¢4 - ls- 925“ '0’? 4a 9 09% W [W751 13.9140 4 dew/9,567 ) M42 flF/fif. J adeN‘ > .7 Fm”. MM 5% F A?” flu— fink. fut. #mmduiui’ Fay: Q. �APR 5 I!!! HOSPITAL 1. nillnidt 2. nonningar 3. Hnn¢* nautil 2,3,k. PATIENT HUMBER 5. SE: 6,7. AGE Ectlth 1. Kilo a. Funnio --, on. Exact no Ago , intnrn;ti¢n RAGE 1. Whit. Euro 0th.:0. la inrornntien 2. 3. RILIGIGH 1. Pratauttnt 2. c;thalie 3. J¢ n 09. in“ r nu inxorattion 10. szArua‘ KARIYAL 1. Bingld 2. marriud 3. separated h. Divorecd 5. Widow‘d 6. la intaruttioa anueArIol 1. l¢n¢ 2. 1~6 yuarn 3. 7 h, . a s 9’11 ‘ o 6 . 12 7t 13-15 a . 16 9 . 17* e . nu internatiaa uma �«.2... 12. PLACE 1. 2. 0! 31313 USA reroitn tern: lagliah Bpatking ' ' 3. h. 5. 6. 7. 8. o. 13. 21‘38 1. 2. 3c . gammy ‘ ‘ 9‘- F‘ O C‘ U amrunwb 4t O . “”6 o‘ u 90 0. 15,/9 n * ' " I u * * fi : x H I t I 1 countricl Girntnia & Scandiuu tvinn Ittly Prune. & aplin slavie natiaun Latin Ancriet ethnr In internation I! 9.5.A. lativv beta Lap: thua 1*h 1 S~9 10~19 29.29 30+ 30 infatuation 69 at 79»?! 89-69 1... 90~99 16¢~199 110~119 120~12y 1 0‘13? 1 0* Ia intarmation 163 A? FIRE! PSYCHIATRIC 363156! -.. lxaet Ag. inrornltion PATIEIT'S sachL CLASS 1. 61:” 1 2. class 2 00“ He 3o 01". h. 81:” §.v 91:0: 5 9. 5113301“! IBHIIR : OF PRIOR HOfiPITALIfiATIONB «a murmur-i 9. 0. «I 8* Ho intomuntion �.3... TOTAL PERIOD OF PRIOR xxrxnxxxczs Lola than 1 nonth 1-5 not. 6’11 ‘0. t HOfiPITAL 1. 2. 3. h. 5. 6. 7. ‘Ow 0. 12~17 not. 1%-23 “58¢ 2h~35 non. 36-h? mac. h3~59 ”0‘. 5+ No year: internation COHDITION A? DISCHARGE 2. 3. Hueh‘inprovod; rocovarod Inprovod Unchangod or Ilightly wort. o. Ho 1. a. Docctncd informatien 913081861 OR DIAGH0313 l. 2. ESTABLISHED Psyahauis: Schiaephrcnic reaction Paychenia: Afroetiva rotations 3. Payehenifiz Dynamic h. Paychonnurotie Bisordcr 5. Pornonulity Dinardnr 6‘ Transient Situational Peranality ls 0 Ha inlermatian General Paychothornpy 30? TREATMEHT: +3 no internatian TREtTEEfiTT IRELTHEBT: 1. 2. easia#¢—— Psychotherapy Payeheanulyais Paychethnrapy: ”.9. Psychethortpyc 0th.: Gran; Thcrnpy Unlpoaiticd Ho psy¢hethorapy lo infatuatien �“aTREATMENT: 1. 2. Hoprob., dopral, oqunnil h. 1 + 2 1 + 3 2 + 3 1 + 2 + 3 3. S. 6. 7. 8. 29/ ORGANIG Phonothyaninou (OP,P,Tr11 9 C O O Tafranil Gthor organic trcatunnt Ne intermatian Ho LENGTH 6F HOSPITALIZATION BEFORE GRGAHIC TREATMENT Lo:a than t‘ 11- 2 M?“ weeks menths k' 5:6 78 9-10 omwmmru 1 waak u " " 11 + months No 25. infcrmation LE GTE OF CURRENT HOSPITALIZATIE Under 1 menth t v- t o wmwmmrwmwu I 2 3 manths months h-S manths 6 months 7~8 months 9-11 month: 12 month: (1‘. 2?, 2- . .‘ 13+ months No informtticn "F" SCORE —-. a exact 00. ~ Ha scorn information ) �0 \, $550014’o s 0% 'P ~_/”‘ A § PA- N A M H G H ‘1” a f ‘64, . , '_ «a V ’4L Rafi» Psychiatric Group Association for Health Insurance Inc. Mental Health Association PROJECT SPRINO7-6000. Ext. 399 RESEARCH 22' FOURTH AVNUE. NEW VORK3N.V- (Invettigation Into the Insumbility 0f Pch/aiatric Treatments) Helen H. Avnet, Proiect Director November 28, ADVISORY COMMITTEE l 960 Harvey J. Tompkins, M.D. CHAIRMAN lea Perlis VICE-CHAIRMAN A. Oakley Brooks Martin Cherkasky, MD. John M. Cotton, M.D. Jack Elinson, Ph.D. Sylvan s. Furman David Goldstein, MD. Clarkson Hill Paul H_ ”och, M.D. William A. Horwitz, M.D. Lothar B. Kalinowsky, M.D. Mack Lipkin, M.D. Henry B. Makover, M.D. Martin E. Segal Leo Srole, Ph.D. Partic£9ating PSYChiatri-Sts FROM: Harvey P J. Tompkins , M. D. and John M. Cotton, 1...; Participating Psychiatrists, the Project, covering a sample group Of 76’ 000 Persons’ has been operating satiSfaCtorll-y Since July 1,1959 HarrYl.Weinstock,M.D. Bernard Wortis,M.D. Attached msma is a report pating psychiatrists, REPRESENTATIVE COMMITTEE Int erest 1‘18- MANHATTAN: John M. Cotton, M.D. CHAIRMAN An on our survey of particithink you will find Which we address recently made by ArthurHH. Harlow, Jr. PrESident of Group Health Insurance, Inc., on the first, year' 5 experience under the Project, will be summarized in the December issue of the Bulletin of the New York State District Branches of the American Psychiatric KINGS: Morton H. Hand, M.D. BRONX, Jacobo. S-Jaeger,M.D. QUEENS: ArthurW.Schappe|l,M.D. Association. NASSAU: Irving Chipkin, M.D. If SUFFOLK: Robert Wagner, M.D. WESTCHESTER: Miltiades Zaphiropoulos, MD. write us r equ est. you would like additional information please and we will be happy to comply with your NEw JERSEY: David Flicker, M.D. DEPARTMENT EXPERifi'l {filial or ”ii PSYEW HILLSIDE HOSPITAL GLEN OAKS.N NOVZ 31960 M. D. sycuratric Research Pro;. ect Thanks to the cooperation of our S. APA T02 SUBJECT .. . . National American I 1 ulna! Illness (3 Me Financed by National Institute of Mental Health and Group Health Insurance, Inc. �QUESTIONNAIRE SURVEY OF PARTICIPAIING PSYCHIATRISTS possible aid in the eventual evaluation of results of treating Project professional qualifications and customs of participating psychiatrists. As a cases, a survey was conducted on the age, sex, and for participants, returned questionnaires. In addition, data on qualifications were obtained from the latest medical directories of the non-reSpondents. Of 1150 many 1008 In order to encourage the broadest possible response, the questionnaire was limited to one page with a dozen questions in all, mostly check-offs, and with space provided for comments. are: From the Project's point of View, the most important findings of the survey (1) The great majority of participating psychiatrists are well qualified, judging by accepted standards in the field. (2) Over three-quarters of participants regard themselves as primarily analytically and psychologically oriented in their approach to treatment. ‘ é‘EX, AGE;.,L9.CATION - (Tables 1 - 3) More than half the participants are between 35 and 49 years of age. About every tenth participant is a woman. The majority practice in Manhattan, although the suburbs are fairly well represented. TABLE 1 — SEX OFflgAgILQIPATING PSYCHIATR;§1§# Male Female TABLE 2 - AGE 1001 (88 per 138 (12 per cent) cent) Dl§IgIBUTION Age Group‘ Egmbgr 28-34 187 204 144 224 168 99 35-39 40-44 45~49 50-54 55-59 65 60-64 and over Total *excludes those who have resigned or in Group 71 42 1139* who have died ger Cent of Total 16.4 17.9 12.6 19.7 14.8 8.7 6.2 3.7 100.0 �Page 2. - AREA OF PRACTICE TABLE 3 Number Area Manhattan Brooklyn in Area Per Cent of Total 57.0 649 98 8.6 5.2 1.9 59 Queens Bronx 22 Staten Island New Jersey .4 5 6.4 73 7.0 79 Nassau Suffolk 4.3 5.8 49 Westchester 66 16 Rockland Other Total ~23 1.4 2.0 1139 100.0 TYPE OF PRACTICE participants confine their practice to hosPital work. The majority Forty-three per cent treat only in the treat office, referring their hospital cases to colleagues. Seven out of ten answering this question (1000) report that they also do out-patient clinic work. Only 17 both office and hospital patients. QUALIFICATIONS Of 1096 either participants for whom information is available, cent are 85 per Diplomates of the American Board of Psychiatry and Neurology or are ”Board per cent are qualified as psychiatrists, with an ”SI" rating, under the New York State Workmen's Compensation law. 0f the remaining 13 per cent, 6 per cent are accredited as psychiatrists by the New York State Department of Mental Hygiet e, with the "QP" rating, and 7 per cent meet the quali— fications for membership in the American Psychiatric Association. eligible." Another Table 4 shows TABLE two this over-all distribution, and Table 5 breaks it down by age: 4 - QUALIFICATIONS DPN* DPN ‘ . Number Per Cent Cumulative Per Cent 585 53. 4 31. 8 2.1 53.4 85.2 87.3 7.1 100.0 eligibility only* 349 23 SI rating only** 61 QP rating only*** 78 APA membership only Total Known 1096 5.6 9239 100.0 *Diplomate, American Board of Psychiatry and Neurology **Qualified as psychiatrist under New York State Workmen' 3 Compensation Law " " *** by New York State Department of Mental Hygiene - �TABLE 5 - QUALIFICATIONS Page 3. AND AGE Per Cent of Age Group with Boards or Eligibility SI Rating Only Age Group 28-34 90 40-44 45-49 50-54 55-59 89 - 60-64 65 and over 'All Groups (Total Reporting1096) *less than 1 * * 80 35—39 2 87 90 3 86 2 71 68 8 10 85 2 * per cent ORIENTATION invitations to participate in the Project were issued, reasons for nonparticipation were also solicited. Most refusals were based on the practitioner's analytic orientation: The 15 sessions provided by the Project were felt to be far from adequate in terms of the respondent's usual ”A-P” (analytic and psychological) When approach to treatment. Since the "D-0" (directive—organic) and eclectic practitioners were more apt to be optimistic about the effectiveness of short-term therapy, there seemed a possibility that enrollment from these groups might dominate the list of participants. This theory was effectively demolished by the survey. Of over 1000 respondents, 77 per cent checked ”analytical and psychological” as their primary orientation, 10 per cent checked "directive and organic,” and 13 per cent checked "other", usually specifying "both” or a combination of the other two such as "organic and psychological.” Although the majority with the primary A-P orientation exists at every age level, it becomes less of a majority with each age increment, so that what starts out as a 92 per cent A-P orientation, in the youngest group, comes down to a 53 per cent A-P orientation in the over-60 group, as shown in Table 6. TABLE 6 - PRIMARY ORIENTATION AND AGE . Age Group Per Cent of Each Age Group with Specified Primary Orientation Other A-P D-O Combination 28-34 35~39 92 89 2 3 40-44 85 3. 50-54 55-59 60 and over 76 61 10 21 45~49 All Groups(Total Reporting 1002) 6 8 12 53 25 14 18 23 22 77% 10% 13% 59 18 �Page 4. A primary orientation toward one approach does not of course mean that an individual will always use that approach. A psychiatrist who is primarily A—P oriented may use organic approaches on occasion, as shown below. ATTITUDES TOWARD DRUGS,gSHOCK THERAPY, GROUP THERAPY Drugs appear to be almost a universal tool among psychiatrists (98 per cent). 0n shock therapy and group therapy, there were far fewer answers, and it is impossible to evaluate whether a non-response indicates a negative attitude or an oversight. But a comparison of the number responding to each question may in itself be indicative to some extent of the degree of acceptance achieved by each method of treatment. The total responses and the percentage of affirmative answers follow: Total QEEEEEQE Do " H you " drugs? prescribe ” I! Per Cent Affirmative 98 952 693 shock therapy? group therapy? H Number of Answers 75 51 69". A cross-tabulation of the answers to these questions with the primary practice orientation of the respondent shows that the use of drugs and shock treatment is not a distinguishing characteristic of any group, although the non-A-P's are much more apt to recommend shock therapy than their colleagues. - PERCENTAGE OF REPORTING PSYCHIATRISTS TABLE 7 AND GROUP WHO PRESCRIBE SHOCK THERAPY, DRUGS, THERAPY, BY PRACTICE ORIENTATION Per Cent of Each Orientation Who Prescribe - Practice Orientation Shock Therapy 68 A—P D-O 92 90 Combination Drugs Group Therapy 100 100 50 54 34 97 There appears to be no dearth of personnel ready to administer shock therapy this) or to conduct group therapy (208 checked this). (247 checked FEES A question was asked as to differentiation between fees for initial consultatior Of 981 respondents, 45 per cent do differentiate, 55 per cent do not. and treatment. The question as to the respondent's usual fee for a private office session brought 987 responses, of which 789 were explicit, 198 stated a range. In other words, 20 per cent of the respondents do not have a set fee. For most of these, the range indicated was either $15-$20 or $20-$25, but there were instances of a twentydollar spread in the usual fee - e.g.,"$lS-$35" or"$30—$50". For those stating a definite usual fee, the distribution is as follows: Usual Fee $15 $20 $25 $30 or more Per Cent Charging 11 49 36 4 �Addendum: PSYCHIATRISTS AND THE OPERATION OF THE PROJECT Because of the enthusiastic response of psychiatrists to the Project, one of the disappointments of the first year's Operations was the relatively small number who actually saw a Project patient - fewer than a third of the participating psychiatrists. This includes cases treated by more than one psychiatrist, and multiple cases in the same family (usually treated by the same psychiatrist). The number of psychiatrists and patients* seen by each was as follows: Number of Psychiatrists Number of 201 1 Each 1 63 21 15 8 4 Patients 2 3 4 5 6 each 7 ,8,9,10,11 *Excluding cases having hospital care only. Psychiatrists having a in relatively short supply. number of cases are usually child psychiatrists, who are all participating psychiatrists, the psychiatrists who treated on the whole somewhat better qualified (91% vs 87% having Boards eligibility) and somewhat less primarily A~P oriented (67% vs 77%). The Compared with Project cases were or Board treatment. they rendered was mostly individual office psychotherapy. Four per cent of the cases were hospitalized; seven per cent received shock therapy (including hos— pital cases); three per cent received group therapy; seven per cent received psychological testing. Ig_thi£ty-five per cent of the office drugs were prescribed at one time or another during the course of treatment. cases, 0n the basis of the few (36) Project cases treated by two or more doctors, it would appear that psychiatrists are rarely in exact agreement about the diagnosis of a particular case. In 12 cases there was a basic difference as to the severity of the condition, with one doctor calling it a psychosis, the other something less severe. In four additional cases there was a difference as to major category (usually neurosis or personality disorder). In another six, there was a partial difference as to major category, with one doctor calling it a mixed diagnosis; and in another 9, there was agreement as to major category but differences appeared in the sub-categories. cases there were identical diagnoses in 5. 36 Out of Another demonstration of the individuality of psychiatrists emerged during attempts to classify frequency of treatment under the Project. Although six specific classifications were available for coding purposes, 42 per cent of the cases fell into the ”other” or non-classifiable category. Pursuit of this led to a fascinating variety of frequencies of individual office visits, each adding up to exactly 15 visits (the Project limit). There are combinations extending from two months (6 visits one month, 9 the next), to seven months (4,1,2,2,2,3,1; or and in between come all sorts of combinations spreading the visits overl,5,4,2,l,1,1), 3 or 4 or 5 or 6 months. far as is to the Project administration, there has been a negligible unfair advantage of the Certain difficulties inevitably arise with thbse who do not read their mail orplan. and there instructions, are occasional misunderstandings resulting from patients belatedly identifying them— selves as Project-eligible. As far as can be determined, broken appointments are not a serious source of difficulty. In general, the Project has generated the enthusiasm and cooperation which sometimes characterize pioneering ventures. So known amount of abuse, or attempts to take GHI’APA—NAMH RESEARCH PROJECT (for the period 7/1/59~6/30/60) �I: 12/26/60 Social Glaxo, Diognooio, ond Irootnoht In Throo Psychiotrio Hospital: In 1958, Bolliugohood and Rodlioh pahliohod on influontiol voloto, (1); in ohipn botvoon mat it tho: roportOd roiotion- social class) diognooio, tad tho troot- or loan]. dioordon. and Pink (2) which During 1958, Kohn, Pout ok roportod studill tt not lhOfln that who: oduootioh or oooiol slain, Hilllido Hoopitol vhoro woo it It! roiotod to toad who on to iodox on: rotorrod for convulsivo thoropy, one to tho thoropoutic rouponto to this trootnont inotrunont. Tho Bollinglhood ohd Rodlioh study It: oorriod out bororo tho oo-oullod 'tronquili:inz“ drugs oohiovod wido populority. thoropy ooooo oloo demo Tho Kohn, at a facility, woo hood. roportod, for CSflIplflg thot drug tho prinéipol thoropy in only b.31 of tho tho: otudiod.; thoropy won it: It won whoro Pollock o rink study woo ot tho tino, oonvultivo tho major organic thorlpoutio dovioo which �i3Tvvor the heepitele were well The third was the research hospital of a state hospital system etteohed to e its fietiente private facilities. known university medical center. Heat of were voluntary ednieeionl. Each of the heepitele were peyohoenelytieelly oriented and each institution maintained affiliations with local analytic institute. The hospitals were loceted reepectively in the aid-West. Riddle Atlantic, and The queetioee we e New England. wished to answer in relation to social classes for the different hospital settings were: (1) What is the relation of patient social class to (a) diagnosis, (b) treatment, and (o) length of he (2) hospitalisation. For these varieties, are there differences between heepitele vhioh treat different model close groups? Pppuletion a Hethodolegy: During the Winter 1958~1959, e research team each of the three hospitals. population of each hoapitfl. The who visited total adult in~petient were hospitalized on �~11» voluntary cartitieatan day. Each patient word was then at hi: hospitalizatien on studied in a given viaitatioh followed through the course and information regarding his treatmant, langth of hospitalization and discharge status was appended xjfilxiai to tha data ahaata for each patient studiad. All patients discharged tron this hoapital within aightaan months after the study began, were indluded in the sample. This included approximately minty per cent of the originally studied. Eollingahead position and was emphasised which aducational scores. farred to it two factor index of social utilizes Data for each Eollingshead cards to weighted occupational patient I? and V. trans~ on thc p u‘i.05 laval. Class Diatributian within Hogfiitala: In Hospital "A“; 311 or the classes I was facilitata statistical analyaas. Significanccs were computed Results: patiaata and II, 12$ to Class In Haapital Claaaes I and II, 3&5 '3', III, 271 in Class patients warn aaaignad ta and 571 to 615330: at the patients ware in III, and 39% in Clauses IV and I. �-5- '0', In Hospital III, Glass modion 82% and 1‘ in Class IV. class patients have I and II, worn in Classes of Viowod 17% in in turns of the its pationts, Hospital the highest status (Rd: Cleo: A's II), Hospital G's, the lowest (Ed: Close 1!) and Hospital B's petionts fall between tho two, (Nd: Cleo: 1119.10r purpuo of olooo~ ifiontion we visualize Hospital A no treating primarily upper close groups of patients, Hospital close group, and Hospital 0, a lower B, a middle class group. Hospital and Diggnosis: Comparing the proportion of its patients which ouch hospital diagnosed as oithor psychotic or non-psychotic, we found oigniticnnt diagnostic differences between institu- tiono (:2 - 12.73; df- 2; tended to treat p4 .01). In the hospital which predominantly lower close petionto, 75 For cont of-ull the patients were considered psychotic; in-tho hoopitol treating predominantly the middle class group, 7h! per cent were diognoood as psychotic, while in tin hospital trusting predominlily the oppor class grow), par cont wore oollod psychotic. 53 �.5. Social Glace and Dielgceiea It in interesting to note some of the diagnoetic differences in hoepitele, when In Classes I and constant. II the class factor we found patients were called neurotic, in Class neurotic, and in classes IV and V, 20% 36% or the III, 29% wc-e kept was were neurotic. The direction of these statistics tanded to support the observation of Hollinguhcad and Redlich but for the hospitalized patients never theleaa, did not reach significance (12 - 5.99, p on . the 15 level (12 ' 5.77; df - 2; p e 3.8.) .05). Hospitals and Treatment: We found differences in the employment of organic therapies, 1.0., the peychotrcpic coupenndc therepiee p 1n u.; .01). and convulsive the three institutions (12 - 12.12, a: In the clue: patients; hSS facility which tended to at the petiente received tract some - 2, upper torn or organic treatment; in the institution treating middle clues petiente, abs; clean pattente, and in the th hoepitnl treating prinerily lover received crgenic therapy. �.7Social Clan, Dugout: ndtrutnnt: In combined pooulntions or the three hoapitulo, thoro are differences between the major forms of troahncnt that psychotic and neurotic patients experience (12 d: - 2; p ~$.001). compared with 205 of In It! 115$ of the neurotic were administered to tho psychotic cacao. 32% tho go Organic thcaapios of the nourotica and Patients or psychotherapy, constituted 1nd kg of can: the psychotic tacos, psychotherapy the dominant trcatmont modality. wag ' 69-7; the paychotic cocoa. who 23% It I! 76% of received neither organic of tho neurotic cocoa has been shown thot within hospital settings studied, organic forms of therapy worn frequently given to psychotic than nourotic patients. morc In touting tho hypothocoa that a higher proportion of lower class than uppor class patients rocoivo organic forms of trootnont, we round the hyyothosia not to be supported for oithor the neurotic or psychotic groups. Within each oocial clot: group, psychotic patients received organic trootnont more was frequently than uon—poychotic patients but social class not aigniticantly rclntod to whether or not potionta �-3... who were either psychotic or noorotio would receive organic thorooy. Social Class and Length of Hospitalizotion: When no combined hospitals, we for Class I & found the populttions from the three that tho II potionto hospitalization period aoan III 9.2 months, Class was and Class IV and V, 7.2 months. We found no 9.8 months, statistical difference between the lungth of hospitalization or Class I, II III patients (t- 1.66, and div 196, p - H.S.) but found significant differences botvoon Class I, II and patients (t - 7.69, df- 221, ptmm) IV and V . ggopitalo and Length of Treatment: The figures are rotlootod in the different hospitalization periods that hospitals. patients were found in the three In Hospital A, the upper class hospital, were hospitalized for in Hospital 8, the middle class an average of ll institution, for montha, and in Hospital C, the lower S.k months. mean months, 8.9 class facility, for �“9- Rocapitnlation and Conclusion: The primary purooao or this ctudy ha: been to study the rolationahio of social class and psychiatric diagnosis and treatment in hospitals which have available conparablo facilities. troutmont differences, class which have We know members may that baoauso of «coconic gravitate toward institutions available different kind: of therapy, have selected three hospitals which and thus we employ comparable ranges of therapy and which tend to treat nonbors or different socioeconomic groups. “what In affect, what is the hospital experience of oocioocononic groups where all we are thus asking is: members of different forms of thorapy are equally available?" Within the social class was hospital cutting described, we found not related to whothcr a person diagnosed as psychotic or nonvpsyohotio. Ho that was also found aooial class to be unrelated to the employment of ergonio therapy. We believe that the relatively wide use that �-10psychotropic ooopoundo now enjoy nay toad to blur tho sharper diotinotiono whihh oxiotod non. yours ogo than organic treatment was identified with the shook tad con: therapies. We that lower class position found length of time doooribod.Lowo; o was related to tho patient spent in the hospital settings class patients (Glaoaos IV & V) were hospitalized for anorufiormas a: time than Class I, II 0r III patients. Major The difroronoeo were found between the throo hospitals. hospital treating upper class patients tended to diognooo the higher proportion of its patients as non-psychotic, tended to employ a lower comporativo percentage of organic thoropy, and left its patients period oz time. in treatment for the longest In contrast, the hospital which tended to treat patients primarily from the lower portion of tho ocononio ooootrnu had the highest proportion of psychotically diagnosod patients, onyloyod organic treatment more often than the other hoopitalo describod, and tort patients in treatmont for the shortest period of tins. �.11. In an tar us tau thrac hospitals studind arc construed, 300131 61188 woulé appear to ho lass intimataly rclutad to dingnosis and trantuent than scald the naturu at th. hospitzl itatltg and the sacinl gruup tauhieh it tddraascs itself. �1: 1/3/61 . soaihl 61:13, DiIIROIil whrct Paychtatrto und trtaincnt 1; Ht‘pit‘lfi IITRODUCTXOHa Iva hundrtd and ninety patients in $hr¢a uoau cuetadinl aetivu trcntiunt ptyehiatria haupitnln, which ortcrad multipln tharnpicn, primarily ta typur, niddlo a: lawn: clnta ficraoul var. Ifindaud during 1959*60. Questions utudicd were whothnr naninl clans £¢r haspitaltnad paticnta fiypm It: ralntod to (a) dingntsil, a: tr¢ntnen$, aha langfih at trautaunt tnd rahttamhtp at yum: suntan-nu» Cb) a nun “away", ’mifidla', and “tuner” «inns hospitals ta dznauuain, type a: treatment and longth a: traatnaat. W! Volautnurily udaittcd paticnta 1n thrtn kncvn xucxraphtnclly 47W“. u/Cc. f“ V: atpur:tc httntttll w¢11~ which itiflrlé �nan- : rung. if thnrup¢ut1¢ prnxruan. that. putioutu aura prtnnritr rdprutoutattv. at $§fi§upptr, 3:831. at lunar ulnauoa, turn atudiud t! s.aluu d:y in thy wintsr, n! a 311.3 heapittl 19$8~1959 tuilunod thruushaut tacit suntan and if a Putiontl vcro hospitalitutsnu detail: caacorninc that: buneruund, truutuant nud dtusnunin wart rncurdcd* 33831.93: Seats}. 6183! was tau“ ta ha r-alaud to lung“: at notivu truatnnn‘ within tha hotpitnl aettingn. 015': I? and charm Y putt¢nta rtlainad 1n truntnsnt for pox-ands a: an. than. an" x. I: or m paticntu. Signittctnt rolutanuuhipc bctwnun 1031‘; clans, diaguoail ana trtntucut warn mat uhaarvcd. sacniticnut rol‘ticnathn war. found bntwu.n p;t1§nt néubtrthip an upytr,xmiédla and Instr 01‘3t �influx: and dams“, “aunt. and has“ at hupiuluutom the nut» in tutwuomu mum at m "mun, "guitar at Vhflhtr a an: nutwumu m, that mm mm: tho "My“ ma M man.“ u magma-tun; mu rams." wan-am than”, and ”mi '56 Mpiullw tu- t!“ lmut yaw-1M at patio“ m I mum at ‘1‘. a a �1: 1/3/61 anuttl Gitul. nzlgntnia ;nd fruufincat 1a Ebro. Puyuhtatric notpxt;1: 111302301103: tin hundrtd nut ninnfir patlnusc in thran nth. custodial ac‘iis trca‘lnnt'ptrchtafirtu knupttnll, arrdrtd uvlfiiplo thnrnpioa, firtaartlr ta appur, which gladlo or Inuit «1‘3: pirlfifll 2‘3. atudand during ‘ 19$9~60. Quautsnas tindiod war. whithar 300151 31.0: hsnv1%nliutfi pntlcntu it: rnlntad in (I) din¢n¢nts. at trausnunt «:90 a! ircatunat, 3nd 1¢Ig§h raln‘aonshgp a: Fttitn£ llflhirihip a: and Inngth $34 th... ‘ntddlc'. ‘ud ”lower“ cln¢a hmlpttnIu-to flirt or £ruatnant tar (3) 'nppcr'. dianumwzt, a: trnatunnt. 930039332: Valuntslrily adsttttd pgtiunta knuwn geographiaally Iapnrttc 1n thr¢t wail- haipittll which uttarvd �.2. 3 ring. a! thnrtptutis progruun, Vhflri plttfiufii warn prtnlrlly roprcatntafiavu a: ifiiEnppor, ngdéau er lowcr alumnus, aura Uti‘iid an at n ctvuu hmapitui «call: any in tht‘wiufitr. tallauod thmaushtu‘ thttt and 6.13113 unncnrnxug and diltnllil l9$8~1959 BQIrlfi ¢ if Pnttonia var: hampttnlatuttuu that! h$ak¢round, trunfinnu‘ mutt ruocrfiad. Ilflfilg§x Benin: ulna: vat fauna to ht rulatcd to langth at asttro trcntnnnt wt‘han «a; hompttal Ittfiinsl. 015.: IV and V pattan‘u ruuutacd Ln trcntuont {or thurtar 9.3104: at téuo tuna clan! pttlthtl. Signifiauat I, I: at r¢1m§¢nanhapu 01:33, fltlflflfiflil nut tr‘aiuomt lira :11 bitwcun.taotn1 fiat dblorvnd. aacntttcant rolnfiiaalhtpa new: round bntugnn patsaat nadburahip an uyptr, 31441. and luau: «13;: �human and «awn; ”Miami and loan» at h§Ip1£u1tsatioaa 2h. srnttnr it: uaataaiaonuntc Ituiua a: the hanpiQal, rug&raluns a: whither a puticut any n ninbnr gmaup, aha mart a: a aiv¢n aacauuaacnumia 11ktly the pat1.n¢ wanié h: diaznaaed gs nanwpnychofiin, wauln rgaeivv neawurgania therapy, and would be hunpitnliangQr the $130. inngsst patina of �II: 1/10/61 Social Clean, Diegnoeie end Treetnent in Three Psychiatric Hoepitele INTRODUCTIOH: Recent etudiee have indiceted e reletionehip between eociel clean end peychietric diegnoeie end treatment. preeent etudy wee The designed to study whether social cleee for hospitalised patients wee releted to diegnoeie, type of treatment end length of treatment, in three institutions vith differing eociel cleee membership of the patient populetione. PROCEDURE: Two hundred end ninety voluntarily admitted patients to the C.F. Menninger Memorial Hospital, Hilleide Hoepitel end the Heeeechneette Hentel Health Center were etudied ea or e given hoepitel cenene day in the Winter, l958~1959. Petiente were followed by-e reeeerch teen throughout their course of hoepitelieeticn end deteile concerning their beckground, treatment end diegnceie were recorded. �.2RESULTS: Sooisl clsss was found to bs mars significant in coup-risans bstwssn hospitals than in intsr-institutisn analysis. Within institutions socisl class was saluted to lsngth at hospitalisstian snly; class signifiicsntly IV and V patients rsnsinsd in trustmsnt tar shorter psriods thsn III. those in clsssss I, II hespitsls significant rslstienships bstvssn social showsd sud Csnpsrison bstwssn class and disgussis sud trustusnt ss vsll ss lsngth of hospitslisstion. The higher tbs class status of tbs hospitsl, ths morn likely tho pstisnt would be diagnossd as nonpsychotic, vauld not rsssivs samstic thsrspy and would bs hospitslissd for s longsr psriod. hospital was mars Tho class status or ths importsnt than tbs inflividusl patisnt's clsss msnbsrship in dotsrmining thoss rslstionships. liIIIUQ �Junntry 10, 1961. Dr. Gurdnzr Kurphy, Diroctor of Research, Hunningcr Foundition Hoapitnl, Topeka, Kansas. Dear Dr. Murphy: stat: In 1959, Dru. Siogcl, Kuhn and Pollack at thin arranzod with Dr. Ksrtuu, ta undarttkc a canpnrativa population staple study at the in-putiontu Haulaahulitta Hunts! Hunlth Hospitals. Tho dtta colltction ph‘l. at this atudy VII conplotod in Soptunbor, and V. have prone-sad a large part or the atntiaticn and and. Ian. prolininary audguonts. It in our dosiro tn proscnt a comptrativc stnicuont a: the "Social Class. Dingnoui- ind Trontuant in Thruu Paychittric Hanpitalt ta tho incriesn Sociolozianl Sacicty in Augnat. rho dutu bl! bath intlysod according ta hypothcucn undtr otudy in tho in-pationt sorvico at Hillido Hospital in 1957 and 1958. An abutrnct or this initial roport in enclosed for your Honninger Hoapital, It Cbntur and Hilllidu internatian. urn plonuod ta credit the cooparatinu of tho ill thrto institution: in enabling this utndy to bo incomplilhud. I: that. it :ny additional connunicntion W. atattu or noogatngy new as for thc prancntntiou or this data, Du; Robbins and hipyy ycar. Join: us in withing you a Sine-roly yourc, Enel. HFsJB m iInE H05. would you lot anccoasrul �Social Class, Diagnosis and Treatment Jar/a ‘ in Three Psychiatric Heepitals 9s [4 N p as, "Axum If “lips: his 62%;}; s . d/mAM ,/ I INTRODUCTION: as g fag / AL»; 4 Kata, Xvi/5k. we ,4 A . _, Recent studies have .1 / ”wk indicated/a'relationshifi between social class l and psychiatric diagnosis MW“' treatment.I\ and The designed to study whether social class aunt for hOSpitalized patients was related to diagnosis, A type present study was oi—taeotment and length of treatment, in three institutions Withhdiffering social class membership,e£_:h¢_9a;§en¢_. popaiebffifis. PROCEDURE: Two voluntarily admitted patients hundred and ninety to the C.F. Menninger Memorial HoSpital, Hillside Hospital the Massachusetts Mental Health Center were studied as and of a given Patients hospital census day in the Winter, 1958-1959. research team throughout their were followed by a course of hOSpitalization and details concerning their background, treatment and diagnosis were recorded. 71.9.3th )7 5/2, ”mg r [£1 44M” ‘2 I (’- ’3 1,1,4"; at. & “4.4140,,51‘: , 2:3; f.a.Afi/_ 1.14931. 3 , j>gfl(‘""4" I) MM! 14.0741; 5&4: 4‘ I ”my 1:“ 2'33; 4» fall’g’ffrf (4“ {W4 / "w a? “3‘ ” . M was f. a a, ,x. aw Wm, f‘zl/“ié ”*Muwwt‘ .-' 7 “A,“ I ‘5 ’ 1,» . «min ad.“ an» g9 252‘. .6‘ - I J, £354 {V _ an , ' . �-k’ RESULTS: a . Social class was found comparisons between WM if ”54/ to be‘more significantnin hospitals than in inter—institution analysis. Within institutions social class was related to length of hospitalization only; class signifiicantly IV and V patients remained in treatment for shorter periods than 1132.? those in classes I,\II hospitals showed significant relationships between social class diagnosis and treatment as well as length of and hospitalization. The and Comparison between higher the class status of the hospital, the more likely the patient would be diagnosed as non- psychotic, would not receive somatic therapy and would be hospitalized for hospital was more a longer period. The class status of the important than the individual patient's class membership in determining these relationships. M �Mary 16, 1961. Dr. Hilton Greenbhtt, manhunt“ Rental Kuhn Center, 72-76 rammed Road, Bolton, Hen. Dear mm It In good talking to you in Wuhington. I think the meetings went very well and I eapociauy liked Shep Roma's raport location the VA, pnuont-paumt intonation. on also quite an Xurlmd and is little The many nit-moon in studios. more ammo good. bringing out the drug Comm oomtin and for phoebo control! now in and comparative efficacy tasks on saluting be who’s Mom to Encloud in our inltial abstract much to the Andean Sociological Society. we My best. regards. Sincerely you”, an: inn: mfi. Baal. HF: JB new drugs in order. am sending - �1. 3... W .‘ M753 . 2,3,8. z m» 5;. in. 5. 7 8 7. 4/44: m7 IAA/c M, m M4 n n "" If? ’é a , fl. "0 5 . .__n 22...} .JL A ~ MI Ag~nhfi ‘ 13. m. In" M ta man mum at “4.”. I. mmm ms WW!!!” m...“ “,.".“. -WA �at» mamount: ”a“ m I! 1: 'u‘n‘m 5. 19:19 6. 19-” 300 ,_ 15. N»?! 0M! 3. 5.a {@099 Ya 1'0‘1!’ #. ’1 a. 16. u km 6! .. ‘ ”-1” Rod” '9‘. h tumum Q‘tumfl sans. ems :1. 1 ’1 an. 3m. 5 "m m it ms mmum mm ii s g. 11,13. 316/”); I “a M‘. “O “1mm a A6311! as. 1’.”. ruemnn manna“ rm:is! ”I M‘ m. 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Far all vatltnts, psyahqfiharupy no: Ippitid 1n dalyriyoriiunutqu htnh itarnqa ta twp.» «Int. pattua‘a. within «tan dimgnfiat&e granfi, yqyuhatharnpy was apylzcd unfit-affine in npm§r ulna. yaiicmfia tad urinate fihtrtptnn tn lunar ulna: nuha‘ntn‘ fiiaimmr It. ligaxr1canuu at ¢uinanic fantara at traitius paruannal dgtaralaiag thn and availability abnorvgd disrurauman tiuld at! ht uxtludafi in $301: Ifiudiii. to tutu fiho #010 u! �-2. flfiflihl fact!!! in tap $r¢ttuaa£ at hutpttniistd patinuti nadir noadition: axnluaing sh. ruutara a: p¢ti¢nt'n rtuinata Ind availability 0! trcltnuatn, an: «adtriakta it a yaticnt can‘t: try: aurvay 3111114. unnpitul in 1957* yitti. t Viritty at triatntut awn... ind Irzouio thortpiua at. 1st. at thfilr ability $9 pay. In inglndinn pszuhothtrtpy available to «11 pgtiautn r.¢nrd~ an abachtd $hut nan. odnaatsfin and 913:. a:¢n£t1u:utly aaluciutod fiith fibfiifi. Quin hog. #3 at htrth tran‘naut, duratiun a! unflatt:11nnii¢a, altnzaul datahlrgc IvalunQiun daggnunta ( i. 91n¢r, iar'tgnwbara patiantu tarsal uduaattca wurn mart warn with find {a lit‘lu Itkolr tn ruccsv. qu‘tiu thurtpy. var. kupt in tha hnspital for nhurtar pcrioda at tint, aura titan rttaa .0 rancvurgd «r gawk Saerth And an ditchurga. In nanié;at. tho rsuncar, buttot uduoltud and n.ttvc born pafitonta airs at ertsuunt, stimn raeatvud puy¢hothurtpy an wot; haapituiisad it. 001: turn tar tong.» parioas tad rancivud �.3. t3: yearc: cliniuul diauharcu rutinut. Show: obsorvitivna attrautypr :culitarnin 3 rarlactofi final. C v.3. 1n £139 raintud to noniurau or lubjnet': roaponaea to ). Bichar F a nadiriad asorau wart unloointcd with ditgnaicu at 1nv¢1utianal payahnlis, uhartnr parioda or hanpitaliuutiun. and»: tharnpy ( It ). who h$shmr inoiélubc a: roturrul tar nouutia canclndod thtt the atroets patterfia trulfimant at aauiua algal (us dutinud my an ysyahiutria Halliaatho£a tad analluh). tau, advantiaa birthplncn and dogreo at statue» fiypy «tru 33% u result «I aconontc itcigtl or tvuiluhilitr a: uuagilttan an: «luau. trnitpsnt wan tha$ the oblervntionu tafiptutiou. rtrttcfiioa at ditturunt naagl a: 8.2. : tian and uxpruntian. It conuu31¢5w u:a poztnlatai that anhsucta cf 108a: would ROI. 313th :ud uduaattau 1001:: fortian Ioninl ulucunl, in maker nou~varhu1, ar mangory lynptunu ninirunt trcqututly puttnrnas while uyper 015a: subjunts vauld of .xprnulion. utiliip vurhal :¢nnt �.3... A n¢e§nd titaa to flho intirprttatlon, navthr, rc1:tnd th: tratinaat philauophicn tntiauul luadura and It wan anfi paraoanal. lantiiutioau what: ynyuhathhrapr Wfifi absurvuu ;ttitudu¢ at 13:81“ nuggsstod that in ilxhly vstund, uypcr Ginsu iudfividunln wauld rauntvu inordinatu ruprtlcnta$$¢n in ski! fihtrnyy. fianilnrly, dinahara. ovtluntiouu ¢ad duration at hanyattlxaatioa fitnld bu aflostté 195? «tat: at dittcring anciul ain‘t. unpnatntionn for individutln to twat this by nitraronaan in uu¢¢nd aucg¢utiou w. doaiicd Hillaido Iifldy; to naplvy ¢h¢ to rtpcat uh. It». lrotudurnig Ind uon* ¢h§arvati¢na «ataad the to ta ta: oth¢r iantitntiont, currently shn 0.). nannincur Ronarinl Boupttul a: laaaachaaatta Manta: noalth Tupakt tad tho Confiar 0: Boston. In theta thlfit hauptinlu, inlfiitutiaunl ptraonnvl nfxuot similar ttfiitadus in trsatuuut tad education. Eaah I fall tin: Inpurwinory stat: 1a a $¢¢ohins hasxital with uni tutivu rtnnureh dapurtneat. thuy amphaaiaa yaychnnng13t1enXXynarianttd glychntharafiy but �m5.u yrovide ufihor traataantn 1nolud1ng nonttxu fihortpiea «ad aetivp pragrlnt of utiiuu thurnyy. Bach ’trosuos chart- terfi traatmant of voluntary watiuuta, data tedial aura 39% provide gun» ta arav their pafiiont papulntian Ira: and tend: aimilur an; graupa, excluding ehtldrun and thy aunilc ug.d. flfijar inatiuuhznual dxtrcronaun 3:! gain in thoir cantata or iinnnaial anppart, airfarent institutional policies rnnnrd~ Sag lanath at stay find ntfiur¢¢tru. rho Huanuohuanttu Rental Health neuter (Mfific) in a publin Itfifit tundu: Killstdc Hospital institutien suppartud (RR) 1: a nan~pvot£t veluntary hospitui with a ns3ar partinn of its incanc durlvnd and other aonmunity funds; tad Kanningur pr1v¢ta inntitutiun. taliuntifin, «5:1. more Hfi at 33 tic: nit; nanpital (HIE) in a ha; I 90 day limit for haapiw I flotiblo on. yaar retina; kaharal attatuda. At urn $nd @ntpntiunt ulxaia urn while Thu Hana by mafia trail: trailnhla t and HIE, I dty hospital and to all vatznntag thdrela no 43a heapital and I uhopt tutu, limitld �45. tttovenrw proevnu is availabla to 2h: printry ruaaun I tun patinnts. far ouloettng tun tattitutaonu, havov¢r, lay in thy axpnctutiou thnt thuy vauld murvu pattants of differing acuinl alumnus {nae £5) lad that differuneui in this dtutaiicn vauld bu roxlnatad ta. ta trau$nnnt wurinblaa. rho speeifiu purpato cfl tutu stufly wt: ta dotcraina papilla t1en dittnrcnaas betuuan tun fibrin mustttnttant with raaptct to anclnl alman, :39, education and F utorc, na& to rolutn thaaa pttiunt chlraatcrtatica to sho trnntnnnt Ouvtnblun of type at treatmant, durntian or hospi$a111nt1an, diagnonau diuehawg. twilvatinn. Qua �.1. REEBOB A11 : pattoatn in rcaidcnco ia‘th¢un tnafiifiutiana givun dutu in January 1959 aura utuétod. R8 had mane on whiz. urn tan auuhar thoaa a at at duly, stall patients veluntlry Vtrt sultanua by an: uaurt: ta thu institutioa tor puynhiutria ovuluutian, or a chranis aahiuophrqula granp udn1t$¢¢ :nat. fro. in... a ottto hospitll for a Ip‘oific roaanrah pro- putisuta wit: oxuludud tron thy viva: bocauuc at thiir nan~vo1unttry ataxia. ntltnd a: 350h putt-nil fit an, 113 patient wan givun The 100 study popu1¢tloa cou- at urn tad 1h. culitnrnSn P cauln 95 It ( nuns. ) on the agatgnntaa dtxt. Paticntt' roeovdn aura analyutd fitter a ported at 15 nontha. which was the out~o££ vaint far the analyai: a! hut trontm¢nt vnrzuhloa. tor the dntcrninnuiau of toaitl clans, tau nailingthuad 2~ta¢tor inaux wua uncd ( ). �1. nutheaolegle Aaggata it fit: tuna uhlurvod thtfi thc vary tautor: an var: inturcltoa in studying afroatfid thi aollcotiou tad organizt~ tin-u o! tn dun. Via-tutu” in “iguana“: a: tarp: of trantmant and axprausiens auad far dtuguoaia and trottuant awnluatann, mad: aanlyauu attriault, tnfi rcguirad ooastdsrublu sanrtion for unitarnity. I} 1'- at u ut_!r, taint: Among thy tast1§u~ had a tha that the dtslgnataon pattnnt for crituria tionn, rocuivcd 'gnyahothurtpy' aiztavad narkndly. asking autturuity in cluas1rieat1nn difficult. At nrfi‘fiaychatherapy win dot1g¢ nttad ta trautaunt udn1n1;tar04 atnfr paychsatrtst, tar additional i... on a which tha proaariptian basis by a puttont was obtreod tn acasinnu with tbs psyahittric rwsia-nt wart cansifiarud part at routina adninintrative pati-nt earn. At an psywhath¢rtpy Vt! dcfiafid at trcatncnt anatiana with psychifitria rcaiafint. 8‘33: puywhiatraat: do not treat #hn �.9. rationia dircotly, but ruatrlntud that! activitius to uup'ru fitting the reticent th.rnpia$s. At the naac, 1n centrtat, paychotherapy Ina designatcd as a function at many diaciyliuua . payohiutric rustduuta, nurses, lidl¢§1 atudent¢, 3601.1 uorkorn 3nd piyuhalag1atu. Formal rueards at sneh nonstona warn ”Gt ruutfinc inaludgd in tun patannt': rauerd and to accurtttn watch patiynts were ranazving puynhethorapy, v1.3 the r-uadcnt in ohnrgo or each ta intcrw stat. Thor: aura individual b} migfiuouia: we hmd institutional aestza 18:10:, uhzah and. nonpartaans dirtianlt. dinu~ At urn ata¢hnrgo diagnoaaa unployid tn: multiglq clanuificntian rsynhifitrin Asaouantian whila both an tad nyittn.at tho shaving» nanc rallawad unitary indiganoua nywtims. at diagno¢ua tron urn goafiad convuruiona it. savcrul ax‘mplas Itutud in tabla , with *3: angu inté catcgoriaa campartble ta tn. athar tun inatitutiom, providing, how/var, an muvoidnbu sound: or d:stortian.. @iuilnr abaarvufiiona hit» bton rapartad and hit asaacintas ( ) who h&v& by Paanntniak chain thnt diaganac: within �411“ saniax aluau unngupition at thi karma institution: (Enhlt kt urn tho ycyulatioa artdoninantty‘uppar c1;ln with wan par cant of pntiuntn in annaea I at all»: 7. I»: «luau xv, and man. in 5% HR 82 i: uni! can viticut mafia!» «Inna praauuinttcd 31th acct patients in clnauan XII ind xv (éfi par cent}. At-HHHG, 57 It, ). pctianta «are «htafir from tha luwur a1u3;aa with pix eont la olnsans b) 532: Rhurc uué v. XV at: an ailturnaat in tan inutitatianal papnlnfiioan in mg: diatribntxan. a rung: afloat fifih sh» putiuutn an». undur the :3: at twnnty and on: quarter warn :orty yunru at oldgr. a} manuatagg: was populations éitrared 1n adunnfiianal nttainnunt, with patienga at tiau gt fihsn thguc 3x36 it KFH having worn yanra cflucau «use. Whit: k1 gar cunt at tho patiunfiu ruilod ta camylcto high auhacl, only an and 23 ptra¢nt a: at Krfi did sat graduxta. 32 par aunt at aux» Sanding in. cauuxntunt with the anciul clan: diffnraugt, claws the ceaiul �113 8 Intur:uut1tu%1onat countriinu. for aeasnplrahalosiaul Viritb1¢a m 512. 2. 51 an 23 3. h. 17 3h 13 1 3h 29 5. 0 5 28 19% 19 22 1. anti-1 G1!!! 26 Q 315 7% ”we 3% . I 9-.001 ‘ 59 58 333 22 23 33 23 32 bl um m. 2.2.15 51: 51 a9 16 * 23 1? 1o radorn to«29 51 33 20 Sowhfi hi 90 38 Sa~7a & 18 a: Ag. a “121 5 d£~8 39.39 he * 4.12 > 12-3.9 d£*h phn'fl'i ,2, mi .1 n~-0§ $g9.2 ;~.aox �.1a. alas» unnauru 1;, in part, buncfl an t6uani&§n. a) P Squat: 91:2.»¢ue¢¢ in tha diatrihution u: warn ubaurvc&‘ Fixiyuaun put buluw 30. and chi? It In cautraat. I aaala, A: ax tight par «an% at urn pntanutu fifty pi! want of the had accrua watiaatl 9:!" ma an“: a: 50 at mart. hna ? acorns in the hwe in: diaign «I an: study includad within stab r supra. sunk wath snarot mf an ar abuva. tad rurtyutwo par «ant "hum: had aunc tvaufiy gar cunt uura halww 30 on tha 31461: runga bntwaaa 30 «ad tho r Ewart; m nxnuinntion at m myohutric an» 1.: inititntiaa, ta wall as butacun inatiiutioat. tutu uiupuriteaa pruvua difficult, in putt buaauuo a! difrtrw aueid in thy dotinitiun a: fin: paychiatrac variabluu, finfi, in part, huaauau shins variables ranged so widuxy that «gnu parafiln answer: arxtfiria anmlé «at b: autdrniuad. Far umnmpla, ‘o-conpart tautitutican tn relatimn tu Innath a: �«13‘- htlpitnl atty, vuriout eut~¢t£ poriaal any: triod‘but nan: sllnuut tar at 165 At than luau «.11 3150:. urn, cqulvslout putiauta audfir ho yuan: ringinnd 15.0 thin 7 non‘hi. At sane, 70! of All Ind 39$ aura than 12 unathi. runnintd 1.3: than ? ninth». find 63 mar. thtn patilnti 12 manthn. Aauarfliugly, amphuaxa will bu pluaad on 1h; dirtcrunaul btawcan institutiana, with cttatiau wt rolcvnat intruuinuttw tatloatl rolntianthiyn. g) saw pnt1«nta 439 at xru i m: “autumn raw yuanivnd aauutiu thlrnpy than &t tan nthsr tau insfiltutaani. Manning.» ' Gauaurrintly a twnllor parcuntasu of patiautc warn attuned a: rac¢ivla¢ payuhothurnyy, with 3 lawn; aunts: (36 vcr want) r-euivtng niltnu turn. a: trtntaaut. an At KR that. antiautt Hamid hut: bo:a «Inluitiud fitting rgenived payahatyarupyfi x: can cuntruata tun pita owning. or 338 aamatac knurayy, reoniving patient: ahwvu oxanttieuntly lass than wither at tho fithur tun inatztntiano. �.11.. niltvu , (13 Ethics yarsittin: a «catwalk Wfithxu wank it and plyflhflthlvariifl wwrc cauhtuié. a: aunntlu :né taltituiion. trontaant at urn and F ?ut&unta why unto yuan: at pny¢h01¢¢1¢a1 thuruyivn.) nan wan waistla to nu10¢t£ua near: as xru $nd ER (Tablo ). uhnwa F a%oru VI! low rc¢c$v¢d pnyuhothurnyy with srcutnr trflqutaay $han gataouti who Vdra olétr or vha haé high F acoraa. Enua;t1¢nn1 achiavcnoa‘ and innit} eiaxn fiia not nigniticantlr atfcct soltutxan at ’30:: it any hauyéhnix Ana»: fihn yuyohtatrxc Ulrimblmt, within naah aitgnasia twia%* wax inttitut&cn, higfily tun want rulatvd varinhlo ta aaltetxon at itcn%annt. 91l¢hl¥3fi ovuluntiaa honpltuliuutana at 33 find name it urn and aur‘tiaa u: “are :13. rolatcd flu saloation at troatucnfi. than, aanataa truntaint an: :ataatafi for pa‘iiufia clataiiicd nu sanitaphrania and attaativa dincrdlr hart nttna fihnn urn; pafahaaanrntia. Lt that. «littnd an pufilunia rccaivtnc lattiifi arnatntnt (prudnninaatly that: �’15. alaauid an nahisuyhrtntu) rililwflfi dalnhnrsc rating: at minus. pmyuhnfihcruny rn¢a1v1nc p¢i$¢nsa than ngtuprovoé With hyapafinlu acupztuzx:xta¢n, ptticuta dtrtfiififl tn a: rtcnrd finnfi tar langcr ptrlldi b) wtrn that: rtcuivtn: nunutie thcrfigy. eoaniwtrnb1u dittortunau g' vurfi #huwn bfitwnan «a. fibrin inuttfiatfivna with waapaat so paxatufi‘a lungth a! stir 3; (rahlw 31a pasiuafia VI?! han- ta§a¢wt, with 65$ 0: pufi¢¢atfl runniniag pi‘nxasud naathn 0r aura, «savanna tud-unly 5 it 31 9a: aunt that: ut gut auu$ a! H336. 93 it! tar twmlvu the 33 patinafia aqua} ufiny Inuit: at thy while twawthirat EB nxuvun and batuuua savtn fifi! stony a: win within éiflfihflrafifi warn 3836 tan watasnta munQKa a: heapifialiautiong urn uafl fin I! at. wan its luadh 9t haupi§altfitfi$¢n for tha 1nugust veriad. At sauznl tunttr unit alumni: rtlaadd ~~ yauutcr yatxcufin rmmniutns Ovary :50 1Ith, hawavcr, that: �.16.. nt RIB rammiuud lanai: £hnn at an at Indand, an: mane. intnriuntihutiaanl diffuranous voru :9 grant that : putttat in the oldest as. group an: no». ltkniy to ho bospittlisud far trait. nanth: or yuanguat tau stony mart at tt Hana. urn thin war. pntinnta in an. At urn tad an tier. wan tile t aignificnnt relations batwenn durutiau a! honpitnlisutinn and F acara, tho lave: r uaora being atoneit‘od with lanai: in.» pitil atty. a) gigggniggu 1: thaw; t1. 1n rtblo 2h. diutribntion at diaehurgc attsnotnu . tar atatisttecl analysis three diagnaln fiery undue uabtsophranin, n£rautivv ditardfiru 3nd grvnpiugn psyvh¢nouroaaa Iflfl ynrsonultty «Quaraorn. portiona warn similar for the an and tha HFK muse rho é:ngnoci§a prou povulnttons, but pt%1cata warn rngurdoé as having raver urinativa and Iahiaophrania éiuordcrs, but I larger haiku: or paymhanoutotia or ehnrtatar dixardaro. Intrttnetxtationul analyntn chauoa this at as both as. �.1?. and 3 suort ”fir. rwlntnd to difignoaiu: at 3:3 as. clan: of tan sonata tgntart In: volataa to dinauouing whiz: at nuns a: tha senial variablnu war. trig vurinblgs, dingnoaaa can signifia&ntly so rolntcd. haupitnl ta unleatioa or trottmcnt &nd or mafia its rolttcd payouts- 1% «.mn durution at haapittilo nation; Ina val: at an tn aiaahtrgt ovuluutioa (gag: £££E£)~ a) 91353:: 0 Evuiuatiunt In sack heapital, nest patiouta ‘fi urtlnttud It A? the time a! disnharga as ”ingrovodfi (Tabl. ). 338. hatovnr, a higher ptreuatuga (19%) at patisntu warn ratad g. *uninprav¢d* and only I ainala puticnt wt: callud 'rucovnrod* er “hunk impru§ad'. rho highant porcantago at *rccovaro¢* at "Inch impruvod' rutxnga (28%) and thy lu‘nt haunt! at ”unimprovaéfi (165) wort $9334 at ”386. Anulyann within uaoh it an and Mann thqrt vitae haiku: than 1117 institution fine a teuéancy ahavad vuriuhln rlifiltl. for clan: pationta ta ywungcr ones, but thc b0 reunita urn Itntiatiaw significunt only at an. At a!“ that. run nu appositu trand, vita 014.! putxautt'uara liknly ta b. rutcd unimprovti. �__._._.._ u—mmmW__—m ��j w - 49:25 {0‘70 W “i a7 -31 2 5“ ”iii—“T- 7 '5 _ ��f ". ’qg" A comparactu a: Parahantwio truntnuut ta rant: Ybiuntary ntipstull nan-t an. an, Plum", nu mums, rum. lathgaxnl 81‘301. ?h.n. mu m: ’bwu Buapitul. nu, ma. Dmrtnoa‘ a: ta. #103 6th., L.I., znpnrtnnntux Plynhiuiry. laliuido l.!. II~2992 thy Inttunal Inntt‘utu grant a: by u.a. rublxu finnlth survtc.; &ad tho liuuau mfiuilth at Xantul fiuuaiy nuns:1 flutlth 30:96. a$ntt$ at tho lansnahsnntts luatnx I: it. ‘3‘ 0.3. Hummingur fibuuriul flutpifinl 1n In. comptruiatn finalth Busty: an! gratutully ntkuaulodx¢d. Afidraau: rrtltat 3.1. $7. 1.1. * 'VI: 3/5! niviuion a: rayuhautnr. Hau‘utinrc Bouptttl. �tn thoir 331$: at fihw It» fiavuu ptrfihtatrau patilnt flailingahund and anilinh rapovtla Itgntttnaui populnilon, valuisuauhipn baiwaun in xsdaviaumx‘: position in fin. tilill $ti§tad alum: ptruoturc Ina £3. pravuluu¢t at illnaua. twycu of attsuaaud atturamru and kinds and duratica.¢r payahAatrtc truutnuat :anantuiarad ( ). tkgr thattntna. for umaupla. that ; hiahor prupowfiann a: ions: aliin patient. in tvaatncat were alnncixtua Il~pl¥¢hfi§fii whaln‘uignzrinnutlr hithi? ptfi~ .purttons a: uppar ulna: p;t1¢nth var: alanuaxand an nuuraiio and puritanlitr dailrdora. It! all at: inpldrmfi is fliuyrnportaau:sity pnthonfiu. acyuhutharupy high ditrtli with at: ugyuw ¢1§Is pnyuhoni ouch within «inunnutat Iran», gutiyutaa thirty? tduxnzut.r¢d um. its; Otitn fit uppur exist p;t$amtt tad otntatu thnrupmuu in lunar 01a:- uabacatu. who cianiti‘nnst or ifliflfilifl tnc‘uvu at Granting «avid nah pavuunnnl dutaruinluc b. txaludod 1a and uvtilabaltiy it. obntrttd altxaruucau taunt ifiudaua. In tact tau rfilu a: �.1. watts: raster! in tin trontuntt u: hutpitalssd& vutiantc 'udur otndttllai quludtnl tut (natty; at pustanfi‘a £1uauuei and availability at trttfiuautly an! auditinknn t pISai. patlunfi acnaun sip: auvvqy at lillntdu niuptint 1a 1957. in $38: b0!» vnriuty a! firnntucut nudcu, Snalu¢1n¢ ptyfihmshuruyr or;¥nsc aha thnrwpiom irt a: fihutr ability ta §u¢u u wt dbauruud availahiu ka all patauntu rustedn why. that use, Odiatilin and 911a; uf‘birth acre ’atgatritafitmy automiftid with «intau «I trtutuon£. duration at hospitalautttua, arts: ( )a ultu1u¢x ninthnrtu cvnltatiom taa «luau furnaufiubnru nanny. pattcn‘. with littlu Input! giauttiaa war. at». minim: ta rucuavu taunts: taartpy, viva taps in in. hatpattl it» churfiar yariod. fl! $aun, and new. nt‘uu flirt vital in BIDUVIIid aw unit tuprtvcd on.d&nuh¢rtc. In Ionfirnta, tau yuuasur, buttur cfinuutod and natavm burn pasiunsa at»: titan ria¢1th purchaihurupy :3 tan saxo town a! trau*uou§. aura h¢3p£i511tvd 1hr teaser piriodi and tuuuivad �.3. fihc‘poovur ciiniail dinufiuran rfitingg. Ehita uthrvnfittun turn 31:. ruxattd fio'nauturat a: tiawnatrvy a: rurllctnd in nubaoais' vacuum... to a uyda~ {10¢ Gnltforuta I Butt. ( ). Haghnr 2 gotta: war: aasoaann tad v1$h ¢$uau0unl at tuvulutttaul psychouta. thawing purtoau a: htuyitnltl¢tian. and I highnr Lnuidcacu at votnrral 2i! aquatic thtrnpr ( ). 1t nun nanola¢u§ thnt thu uttuuta a: aoat‘z class. :31 Udllltilfl, biuhpinau and dcaroo at clarcaw Sway an purchaatrtc firuuinnat patturuc war. not a rouuit t: ataaautn :Iu‘¢ru or awnainbilitw a: trunungut ilflnic 9a: dbfiurvutiuna war. 3:3:tnttan val thus thg iudtviaunl astrircnnnl in and «uprtslian. X‘ month & ratlcutiou ax a: Iiuytutaon. nununaaaattan uni pcotulatcd that uwh3.¢tu t: taunt cocinl #Ifillflfl, lacinr‘wduuatiaa uaa turuttu birth wtuld aura trtquuutlr nanatalt lympiduu in nanwvorbul. tanner: a» II“? yt‘turuu, nfitn: whtlo upvav alas. If «upruisitnv Itbsattl wall uttiiiu varbnl �“a... t aanaud Lnturpritutiaa, huuuvor. ruluiud in; ubturutw taunt tn tht firnnfiusnfi philaaaphiul tad xsfttada; ct talttm tnsaaunl lucdaml and yawnunnul. tilt: audzv1d3313 nudfl runnivo It Uta aaacafitod that Ipptr inardiautn vupr.uwntahi¢n in psrahnthcrupr in 1a:t&%autoan what. yaymhntharanr vat highly vuluca. ataxitrly. flifilhtrtfi.§VIlfiifiifinfl and durailau a: knapitnlintfixan Imuld ha i33cttud u!pn¢$nt1¢nn tum Sflfl1VSdn§11 20 tons 195? allllléi my ditturaunh: in Ital! a: disrurtn; social «la... that scannd augguutioa an anulaad to ragga: the ntnay unplmrin: uh. u&nc pvuaafluria ind nan» aurr.nslr t0 «stand it» ohnurvut1¢na to tun 6.3. naauaugim armorial Hatpataz at sun ofihur Ebpaku and inatttn‘ltuu. tha untanahucnttl nausnl Hfl‘lfih cuntlr a: vastnn. In that. fihrao haupitnln, initttutianll piraunuol stitch :intlur tttttudai 13 traufinunt and udusntxon. a full llth 13 a itaahta: haupttal with twig auplrvilory nt¢££ find aetiva tumansh dvvarinont. rhuy lflphfitifit purehtanalrtafiallywtrltntnd pnyuhnihurnpr but �«6m H35Iflfi 111 vulnatarr. nanlt pafia-ntn tn rnitdauou in than. inntituianuu an a civun dt£a in Jtuutry flail: urn lad it than. it 1959 vurt ntuditd. an had volum$arr-patxtatn only, a R836 wart tcnigund hr It‘ll unnbur in. ataxia tar yuyuhittrtc avihnitin. or wurt sawhnrt at I otwouiu anhinwyhrunac ntntu haugi‘sl Irafig firtnliurrnd to! I sycatriu riannrth prajutt. that¢.paidnn&a war. umoluand tram thn aiudr hanuvn. a: that: nanwvulnniary abutat. 2h: study pnpuln$1un-etnnlctud at 113 p‘ttnuan ufi an, 190 at K18 titan satin £ha finittaruia F In! C 9E at mafia. ) an tho zach pa‘tau‘ 8t! datttugtta aatg. lithtnon Illihl taint in. knit-utn‘ rauurdn var: nualriad. Jar an. dutarutnataoa at :cetul exams, «an Hullsngahaua floatatar iadax may ntnd ( ). �“a. Autthur tritium of the prtlnnoc it: atrtur'nt ruataruh 1‘ tan itau rcutzaau. alaninit altacttu: grnuraut, sh. ¢£ nuns fix: at pavaunt vutiantn at tucaty upgrauanutaxr aurrny. wart ah:9a1u.lly 111 tad use Eta: hunptiulifiad far ulny Sfitfi a uwtap uuula «at annualir hnwu hunt inst tiny had Esau tranbturrnd tram yturt. in this hecpitu! inothtv skats.1uut1tu~ taou.tuw a Ip¢aiul uindr. rung. it vat anon apparant that £ht Vim: finiflfi war. inturauiod an Isndyiua ntrtcind thy atllua‘aon at nnfi in unite we». prdhlann flat éxtn. spaaarie urgiutswtiaa 9! st. varin‘xouu an finnigan*xnua a: twp: a: troatuuat and exprnualcaa qud tar diuguonin trantn-ut uvnlun‘iau watch aunt .n:1:~ W! at. disfiault 3) and dualguufitn: and viqntrid caaiiéovnblu wxorttau it‘s a puttuat than; sh: institutiouu, tut uni» m "um: for riuutv.d "unrahoth¢rupy* dittlrud making untSQrISty in clu:u$ti¢¢t$nn �.9. ditttailt. as an.par¢hoth¢rupr was davicuuttd nu trus‘uunt atlzulctornd on a yrnaurlyiton basis by tar thigh sh. A aunt: raruhtatrilt, pgfiicut nu: churned an additional (cu. with tho ptyahtgtrle retidant were uonntflursd part at rfiutiuu ti 3! wuywhn‘hornpy ill ulntntntrgttva pntxant oarc¢ to triatuont nunaionn with Station. fiha dart‘ud psychiatric rtnidcut. stuff paywhintritta did not tract pgtiunts diraetly, but raitrtutod thair sativitiom ta aapurviatns tau roaidoufi phywialnnn. Sb. lflfifi parehatharupr Wtfi a.t1gngz¢a g: a function Aluethiuoi-a~ parohtntrzu roatdouta. pmynholagittu. andauui xtudnnta. Formal workura. nuracu and station‘ war: not vau91noly ineiudod and fin unaariaiu which v0 and to ‘b) 1n at uni, «#6131 rieard. a: tank tau paeicut'n roger! patients wart rucotviag puythvthqripy, tutorviov $30 ruttdun‘ in chart. or 'uah oats. < Itylaa his» 5% “atlas Individu31 ialtitutionnl diuunontla mud: uomparioanu atrxicult. At $13 dinuhnrgs dtgtnvuua anplaymd tha mulfiapln awniuufitve data lfihlflfi �.19. ruccnuundol by it. Annrtcnn Payuhtntrzo Attestation uhtlo tellauad unitary syatcun. 5.1.9:: nuanplou bofia an :nd luau at fitnznalun Iron ark 3:. liutad in Tani. I, with our sug- gIatId uouvorniGnn into cathccrie: «caparablt to th. athar tua tuctztntlnna. 1h... canvosataau prcvido, hnwavur. an unuvotdahlt Ififltfi. a: dis#¢rt1¢n. (sinilgr obgorvutian: htva erortud boon ’allntntok by and dioata thus itaananuu within us: anneaiuucd $hn «an; ( ) who in- taut1tut1¢u arc 3130 vulatruhln to individunl dittornuaas nuang nxgntntra.; ‘ “U ”G“ .v."~.-fi fabll I ’ In a) Hunt vnracd :13 an: , tin ' a: I rovunnn I Rating: at zupravon in forum: ;nd actual. in. dischargc 1:113: tripattita with n tapnrgtc urulugtian churicturolocxual and axudrcn: chuncsa. global rbtluca 13 vital txihutlnn of ciah it tacit: HR it tar snaial. and Kane had In! dittiuult to saunas tan anu- 0! ‘ho Runniastr 3:06am (rail: 1!). �.11. tar tux; lwu&y sh: Hiuningar ta ta. slahnl rafiiugt or rating at: ealwnrad syndrome an and 3533. it. “a. .”‘*¢ *‘U’ Tiblt I! mafimflbfidhaou. that. in: 391131 013.0 a narkcd dittcrunoo in tho tanpoci‘ton or an; $hrt¢ tuntatutaoua (tab). :31). it. povnluttdn nun prgdauinuutly*uppar sluts uifih At urn pa! «tut O: pitiunin in dintucs 3 «lat: 1‘ an IV. :36 non. 1a «1‘0; v. rare in «1:539: 11! uavu'iu alannou fi) 53;: and IV nnd XV. whzle a: 9r 1!, only one pafiitnt 1: 3% 68 par onnt of patttat: $330 57 pcr aunt or pltisntt 9‘ rhura nut. no flixxartuot. 1n .3. distribution :3 sh» annt1$uiioual panulgtiaan. an. firth tug pafiiunta at»: this! tan use at tuuuty and one quart.» tor. tort: runrn or oldtr. e) ;:;i fan population: dittowad tn udlaatlaaul �Cwmf Mfl 2%} maxi?" ”an m“ 19$ 54cm 59 may £0 a?“ :- 2: _: ' 19s 53 a: 2‘33 3 13 33 , a:- fi 1:25;; « �.1}. tfifialllmnt, $1». ihnu putttutn at a?! haviag nmri v&§h that. ifi Illa. as Ilia 1.11.! In ca& $0 camplcia a) pat «out at 0inlxutunt while ht par aunt rat! in: a: %&0 a: fifiuflifl pt£1tuta blah iChOOI, tax: 33 par ctn‘ III as: at: u¢oaa1 IUIF£ nfi graauut¢. thin finding :- alga. dittorauua, :lnaa tho aoainl clan: nitsuru in, in putt, husta an education. a) g;§§gggs nirruroueon in the dictrabutiou at hoards «a th‘ salitavngn r Seal: an». ohuurvud. Pittyvonc par a¢a$ at mra patitnts kid with taunt: G! 59 i «mart: htluw J0, uud aux: at short .. an. Eight: r tith‘ pur aaa$ aeorta buing ntmun tinted with hiahav agaruuu a: uturuetypy. In ountraat. $336 flunnty par 91v oonfi fit. h.¢ «iii sworwa putaan$u has t var: hclnu 30 an at 50 or wars. ta. At an 9 it Quilt, and tartrwtua titty pt: aunt at 1009:: in tho mafia}. rung» botuaan 30 nna E9. 3. Wag It: Vggbxq candy inclnfiad .xauiautinn admin: ‘9 fin. a! th¢ rulutioua at 1!. ylythidttifl vfirinhlnn within nauh inatiaufiioa, �~13- I3 v.11 an Butane: inatitufiannu. Thwli noupnrilonn provud dixricult hangar. or dirtortnain in tho attiuitioa rtynhiatriq 1§v1nh1un. tn. *urxahlnu rung.d 01 th* tidal: @ and achw parnhlc wutaoxt ovltarin eeulfi an: by a¢t§r333td. and varying itarcta or ulsaingdntt. .rar'uaaupza, ta canparc tnofiltmfiiani in ralntian an xgugfih at hatp1%‘l stay, variant cutuott p¢rtodi auto triqd but man. allowed 33%. :5: aqutv¢1¢at «.11 11:... At an. gatrtaa of tha patituts ranatnad fawn: tug: 3".» nau‘hs. and sleuthzrfiu “‘3. than twozsa‘aonthu. aeutt$nt, 70$ at .11 aha auly d! any. fih;a #13:. thus: wax pa$iuufio runninad 1... at mass. 13 thin atvun Ioniht, twilia annthu. In fittuvuiutug social informatxan nvailnhlu far 292 a: 371 patioafifi. unalannitiahla at!!! at». flfilt otian flair! thu nduaatsuu at tbs knahnnd at in. {athar at a haaaowtxn «w ntnor wag nwt rnafirde¢¢ aonarainxzy, in the antiwaau cf ysywhzntrfic variable: euphaaaa H111 ha plmoad on the ditfmroueun botv~¢u inattfiutanls. �.15.. with citattun at vii-want tutruutut‘ituttonnl ralntannthipa (!Ih1c IV).' a) figggggggg_gg~gzgg!§gggs tutu: lnltltntianu, tawfir patatnsa it xx: r§a¢1v04 Inuitao fiharnpy fihnn tun institufisvuu (2:31. 1). canenrrantxy 3:: or launsngur plfiilnta instant, 8193 & anallnr parcau‘» act. allllid at rcaaavias paruhau lurta aunts: (as pursuit) raooavtu; allitu turn: at trautaoafi. I: t at $3. uthnr tt a 9:13.17 firuntnon‘ an patiunts r¢ciivanx then: ‘htr:ptua It! claaaltiofi to raaciving psyuhau thavupy utn¢u unuh 1- conventfiauttr again: taint. If on: ann‘rnat fihu aanufiau thgrupy. urn about t rniidals pnyuhtn- paranutlsa a: pt‘ltfltfl vttalvln; atauattuuuttr loan ‘83: 01th.: at tho 038:: in» institutinnu. tibia fltthsu V uncut harn ouuh xnu$1t1t&on, ‘30 I‘i ralntud fia=a¢1aat1uu �.15. a: trautunn‘ ut urn (I: Ihtln 1V, mitt-I and r taut. at both urn «ad I! (tibln If), and plynhnthurtptun aura semiautd, para hittsac a awntrnut u! inattaa Putatuta KFfi who W0?! yuan; it thtftpitfl.) ané puyuhclostnsl urn hr who‘s r nuara was 19: it or 33 ruoetvnd plychothnrxpy 91th sveltar rrnquanay than pattonil who var. altar or ihfi hid task achAQvunan£ and cua$u1 r ttfitti. Eduagtiannl alas: did not axgntxluanflly artist culucticn at tromfiuautlut nay huupit¢1. luau; in: plyuhittriu vurlablau within filah inntitnttuu, iigsnuuta figs fiha unit highly rnlattfl variabzo $e sultatioa a: traafinnkt. aquatic trot‘nnat wt: natcutud tar p‘tiuntn clunoittod t: auhtuoyhrauiu ind nttqctavo diaardur mare than the-y utttoud I! purchonn§r¢tl¢. Bituhtrfia avuiugtton n5 urn and aurgtioa at hanyitgliuat$uu at an rathid s. at trtntuant. ulna titan culmntion At and annc wow. MPH, p:t1natn rceoivtac anun$¢c trnnwn¢nt (pradunlnnntxy that. «lann§é as �“17. hnucvur. than. nt :33 rcnuluua lencur ihnu fit as Iudnnd. ‘3. 1nt¢rtunc1tut1au§1 dalxnruaupt n pataaafi ta ta. «lanai .2: pitalistd tar chIVd 1a the ytuncclt .3. at to :rtafi taut an: airy 112.1: cramp aonthn or new. group worn at at lHRGQ $0 ha ha». £18 than wuru pafiiuutl Hana. fluwtmfinuudafima «tr-bun an '- Emfilc v thwut hath a) Diuggggzgz 3h. d$a%ributtou o: dtnchuraa titanium! 1: shown $u lfiblu VII. Fur ututtutionl uuuiyail three diugv rustic grasping: warn undo: nahtiuphvania, attactlvn attoraara, aaa yirfihfih¢VFIi5§ and ysrioualtty fituordarn. 1k: diuunuutiu pvupovitoaa nur‘ ttntlnr for in. El tat popuxntiona, but H330 sh: urn pa‘imatd warn rncnrfiad at having f$WIr tttnattva and unhatuphrunit diavrdaru and a luvs.» nuuh‘r a: ptrahununrwtla a: pgrnannlity datnrdors. Intriinliitntiiuui and 3 unuiyuts nhnmnd near. cur. allitad ta «13:30.10: that it :t an bath mat urn us. glow: of �.18.. it. aaaaal tuufiuru «at ruiatad to atununoiug non; a: ‘h; I'd!!! VtrtlbIQi have ckintrta vaviabltu. diagnnuil tutu hmnpital ‘0 atlcofitoa pitalahntawn; and duty it. is um, r:%ad It at ham», it. 4; picniltuuntty rtln‘ufl at 711 tr huna (via. In ouch knupttul. rant pttttnts ”mm. um “ingrovnd' (ink). VIII). (195) 9: ”an“ 'tniupruvtd' lad calr a taunt. pltwtus ’rauovawad‘ at ihtut barn tau. at diuahurgi mum-v dwra‘lun £0 «Inuhnruv ovtlunfiaon d) gigggg;§g_§ggggg3§ggs ¢1tluutnfl u. rdlutcdt or ‘ha para a: $rotiuan$ Ian 1% H8 1:51: who that: at lure “math tupanvud'. mu van c.1125 the highest para-ntata a: ”rtcuvurad” at “unit isprovna' rating: (255) and tht luwaut (10;) with sauna at muse. prupawstcu a: "unimpruvwd‘ Antlynau vi‘han Utah anlfitfiuttan giant: varinhlb rulnlil. �.19” At 8! and Inna that: III C sinncuay tgr cldir putluafit if b. rutnd butt.» tan: ytuatar «uni. hut tut renal.» illr lilnitifliai Quty-ut us. At awn trend, with ulnar pttituti intrt an!» lxkuly tr. atatxnttuu vat tn upwtsitu is h. rufiud unimpravnd. �~29» m mum In ibis unvpar‘ntn at ihro¢ vuluutary garuhittric httpitala Vt havu-abttrVad sartoransua q: cannttlun and uninitiuaat tutarxnstituttounl varaubloa 3.61:1 tho in at yuavs a: pt‘itnti tutti: Illfli, but 00$ u¢.; ta diutriiustou a: fiulttuvniu I‘Eaalu trawli; and in unfit of tun triniulnt wart» $51.0 ditivtbxttnn a: aansuauuu sud dinohnrgu tvnlnafitana. In and quxinal atlltlai ‘33 in .. dnrnfiatn a! havpitaltsutzan. tdiauistn or transnaaia it: §1r£oraacou naapxtnl diner tbs «Enutha alyahtairac vtrlannu rut. nuarthnd ta airinruuaul an sunuclfiiud and wins: the nacial ttctarn at causatiun Ina utavio~ iapy n‘ raxlo¢tta in ya. v mourn. In fihn trimhgapttux atair, tntnrtautatattausl-afinyaritanu a: the pirahtttrta Vitib «big: I!!! thaw uiguitiannt sixtaruuogu, and §h§na rulluw nupuatsa «attributiaa thfi its. tars a: fit!&l1_.1flll, aduuntaaa tinnisiodnfi Vast at tat hryathutis 1a: inafiitut&nua1 caapuriaaat, wharc it um: and 1a Oh! r naorng in. iaflvuu tutiaiputgd {ant iocttl �.21” wartu in puythtu§r10 bu valntad ulna ulna: ditturtucau vault cvuravlltng uh: 1n ;ty1an. dxusnaaitu But vuranttdna whiuu. in3$1fiut£¢ua1 varlnttnnt 1n cud hamytiuiiuatxtu duratinu at Affautad anfl «unvaritau: thaiu vatautad diuchsvgu rattan: tho signatscun¢¢ 0% tbs inturhinuittutianil.aunpnrisauu 3! fin ifiliififliiifll'fl¢* aaltcttun at tracing: It? idlflfliid taint fihru: institution: a: bqing aduparuhid in “‘11; Int, acaaamta, rotuntitie nué th¢rap¢utia afi$aa£pattus rigor. printiynt ditttruntui ninth nampaaisAou await} in the thair putaaafia. run: were atrtaruni in whatnl alts! puttivni prfihiana aathafluiuczcal thu bu‘ nest Itriktus sure Vida dinsrdp;ua10u a: mm in: in tha atrialfituus a! tha plvuhtttrla wiriuhloa. can aaa¢1usian qoalé be that t§c dh‘nrvnd difzurauacc in purahiatric Viridhlut uqrfi littln act. 1dianyasr:a1n¢. wt: «untrant ta in hnapihglxsod urn ptttuatt ta; than aéninxntr‘ifion laughs ¢t tam: taut 33% 3nd name in an arm‘s, �n22» havuvir th¢$.1$ in $53 1£k01?‘§h be a raiiccfiiou a: mixturiuaui ta 5h: flip: in it «nah aduluiu§rut1va :avqufitiuu tanturcu an nouplunifiy u: diachiutta hnfi dtuahurnu avalaataon, tinny a: tharipiti lVI11£31l uni thy énfiaitlou and sauna “kink :: fin atttarnncut quuttfiy or uaatnl niiarahr. airiiuiaa at garchothurany are arcat dsxturunaoc £«11nu n gntturn. canttstant vath.9ruvioun randinxn A -. yatturu and hypuuhunal on tan ratafiann.at toaiai :actaxi $9 pxyuhst‘rzu «a»; at hampxifiln tlid fittinntt. It is palsahtu taan, that tau oabfiky a! fin inatitution in aawivnd ta t traufinnnt putt. stuntsiatnt uxtint sociajmyahalmaintl tautuvna fit in» pliiunfi Ivan thn prcdoutnant popnlntxan partly in rolatinn in the proatpticun, uttifiudcu. identificatian rulatian to darivud and asparntsaas {ha nxpcatationa thcir nuainl a: tha ntnrf and pnrtly 0: tbs patient: and that! 1n fililiti buekground. rhino nothfidalagical dittieultiou «nu the ntgnxtiaant arrant or gdmsniptrnfiivc and stat: uttttndua on pnyuhtatrto �.93” vuraiblcn «r. vuluvnni it She cauvunfitaaal was itVt utntavtacg. ugpa¢iu117 thuvapius. The rrtqnaut in: 1a may a: avu1§;fi$nn or aaup¢rn~ at ynynhtstrda 4£I¢hargQ vuiinga, diuwaantic algaanu or I-agth a! heaptttlixntioa us arisiria o: $h¢rtpvutlc valuua ar computability or aubzacts and pfififllltiaui 3.3% ta .xailutvo arrnr unlit: ugtahoé sawing It: fin: at. inatitttaena are olanrly aauini¢trattvc philoncphy uni l9¢1l1 «1:0: a! papulntiua nut variablgt .. ta nfiutznn 9:1: at that study. ruiluvt in naeiuat to: thilt litnral tatirprctution of Thu safiw fine in. paraéexiaal mast 91.13:. altar. at : variablus is in bu Cut abanrvatioa nonpu« noun 1: a at that atuiy. 1h. tub hawk highly trutand reactant! «and!¢t1as tyeaiuaut fi?!‘htn an or iiunx puriod: (unlinitcd) shiah is appliud tar aptiutl pepulntians with in: luau: prapcrtint alaguusnfi in In untuv¢r* uh1¢ pragnautic gravy (cdhisephruuiu) item a: ttvaruhls trvnfiuaut fflltl‘. .- and sat, «a. proparv it iho pomrtct. it Hand, in cantraci, «hat: tug 1¢nst trusuta tharnpiutt 13:1: trnntuaufio �u’hu to: tho attrt¢r periods, to a yapulutita with a higher pam- pnrtann daugucuta nchxsopkvautn (v‘po¢r yrngnosua 1) tau pvuportiou or ttvurt§10 Jiaahlxca rttiaga 1a artuturl ahibualr. thtta obturvutltan an act uizutfitaatlr rail-It thy itarapuuttc hfftcacr a: th¢au tantatntainu. but indiuutun tn. dartbwuat 1&1: critarta a: inprwvcnaat. Inc! or «barity in diagnostic unhona‘a sud incompar~ ability at paychtntrto trantnuat variation Ital: pants to :tttlwtud calpurattvu «$3613: or paywhigtric thavapiun. Iii I!» txanpla, thu vacant failure: by wiricua kaolactcnl natuut1¢ta to confirm ubuartatiana 3:66 in ether laburntlvan: hay'bu an much a raxluotian a! diffuranaiaa in populations, pavufitu atria «attoriu, 233. rha'waéaayraad asa at an £311u¢1oa 1n the numb original hypnthaucu. turn: ‘3 “Inhinophrantufi an '9»:ahou¢na¢sau* to unplaro eh. uhancot 1n payuhologsenl a: bialagiatl roaturca with anntnl illnouu h;n 1.4 ta a scaled. burdcnad by acautivc result: (3.11:3). hast u;rkaa rauuutly �.3... an in. tantztnting railing at tn. rnacc a: «taunts cud paywhulngatul a unrun ruvtav an cfihiiaphrnatn: fit in. whiz: thnripitu or fine transnatarinn if aauaatu inuuqruvakxltty.ot Git phywznzaganaz *~ huhnriuraz corvulattnun an aunt an (Fuuktnat§zn) and tadattan thruahala fiaaks¢ Erna it. uuaholrl «art : vaxtd fibulrvusiua in hi rtvurtad traa tug alxntt, do w: hhva nuthtd! avn$lub1n $9 «uteri»; yepalntfiaus.aduquataiy sauna num£Xraation? .Wu.ha11¢vu not, mad ta gravid: a nunnludo tron fihnfii «bairvatiuuu that incruuugd attuatiua aunt bu ynxd ta tha suathodnluwiani yrnblnud mm“, mm a: alunuzfiyias nubauaia by “ubgnafiavu‘ ma. um mum: mama no hfiahly fiuyaudunt on inatifintianal and and tau zun£ap¢y¢hu1nainal tapuwtx which «was: to to «bauwwir att1$afiula at in. fihurtpiahmyntimufi intirauatmng what aw tha ralmilan at again: fllfiifi t¢»psyeh1x%r1a trantnunfi an t§afla pdyulutiamx? afignzfitant dittiraaaaa it trcutwant anttavn taint betwoun thaau anntatu$aans, nné thqr ‘ �~26» ds-aufldr fig dilrgmnufl moat: Inuiul attuvam, utthfidalauiaal limitliauan umtlinafl wan-no gruufiar a dcfiawninuni hit with!» fihc ilviitv, iafiinl atuti pirkhtnfivia Sh! Vittthiun if «athin any inititutznu than «or: aha «flan» varidblam‘ fin «nuns «may. hauuvur, that m: away” 1» flay ianaiduraiaun «him «a. m we a: vctturna or at in. may, &&:¢nosin and flitting. tharimx unnuafi laniri I! it that-in that! haupxtalu, patiunt twain! tiara grafimhau thn phitnaqphy twcufinua% as an intruahaapisal thutar. 11 Ian: tutanttatr malttnd tn diigniflxl «nu try: bf firuiinuufi than int naturt a: vfiduti hfinpiial uni uh» iflflill canny aaaraaanu tum iaaim it wh£th it‘prtalriir :t-azr. an: paraaunbl a: mazxnaaa lbuyiiil, tantra», likb thmt a: in: sunningar‘fihnaraal awn: mm“ mm unsp1$a1 wad fin. laxtauhuutttu m: WIN: a In institution: with 31f£¢v¢ni fixmmm trt‘tntut iriunfiatifinu. pntaibta taut eitrarint witntiuhu hutw&ua it in theta vurtibtni �wa?fi any ”a ‘h“r“‘i In hntpitnli. gar ixuaplé. whfiwl trnutnant n‘=‘¢£&Iru¢ urn pvfinarilr auutnatuz or «um-tic, or «hurt nut: nuns” mun anagum m infliviauui tacit} alas» it in: in:$itt$&uu may aufi xxx cm Win-mat awn, diiifingfiiah‘firtihfitni grwapte x$ azatt uua afiministwuiivt attitgdat urn a firifiifil Vflrzabla in aufiarnintae tan pa‘iani‘n dinnnnitl; iraufinuut, qua tiawtk at haupiaaligafiica. �culpartnoa a: Suctopuyuhaloglcgl Virtublos nan Psychiatric frnniuunt 1n rite. 'blult‘ry laopltalu A ru.».‘; In: Rdbart L. xnhn. ramnnsk, rn.n. la‘hautcl 311.01. 95.9. and In: Iris 113k, 8.3. tho nontriuont or lxportncltnl Paychtntry, ltllaido loupatnl, Glen Oaks, 3.1., 1.2. £1404 in part, by grant nxuaoyz u: tho lhtlounl Innt1$u60 or lontal fiatl‘h, 8.8. P3511. Health survlco; and the luau.» county floutnl Ioal‘h Basra. tho oooporafitoa at tho stutto «t tho Intiuchuaotta flau$a1 lonlth Gout-r and tho c.r. loaning-r nunartul loapi‘nl 1o stat-fully : acknoulodcod. Division or Hvutcfloro Psychiatry, finnpttnt. ;;U:;ut'tgdruaas ! ’ I C v11: Q 3/62 �I: that: at in. law lav¢u psychiatriu put10n% populutauu, lollinxphcaa and iodlxch r-porfiud Iicn1ttonut utufiy rotatloanhlpc hair‘s: nu individua1’u pantttou in tho tacit! 01:3: struottro :34 tn. provalanoc It treat-d 111-03., £ypcn at diagnouod dalorduru and usual 03¢ duratxan a: puyahttfivtu trcntucut ndntatu‘orod ( ). tiny indicatod that proportionntoly nor. 10rd: 0130. pasxnutu in stout-cut vow. clalilfitd an psych-‘10 whtiu ‘ppar clas- pattcu‘a vow. Iflfllttil ulna-1ttod an noarotto nud parannnltir disordcra. n-unrdloll at digglouiu, plyuhciharupy was Inplcv.d 1a diaproyorttoaa$cly high 4.:rooa with tho uppor at... pntloutu. and annual. thtrnpto: with lcvcr clans subjects. 1h. Stilt-no. or cacnunio Ifint‘u :34 the availability §0I1d or firoa‘iug POIIOIIII not in cauludcd 1n £hou¢ t‘Idlfil. to tout the 901. or noctll_tnctoru 1: tin trcsiacut :1 ho:pitalxnod pufiaon‘a indopusdoat a: plutont's tinnncuu and :vuilubxllty at tro:tnon$u. n yntlca‘ turvoy val undtrtakuu 1951.,x: u:at nan-u. a «rut: :of treatment nod... including ildavsdual paychothnrapy ans orgnuau ‘hnrnpiou ‘90 nvnilnbln ta :11 ptt1ant: rccnrdlcsn mun: ct ‘htir ablli‘r maul, t. guy. In fihnfi tauplo. 33s. tduuutton and plant or birth var. otgnsrinnntlr luuoutntod with chain. ot.‘rautnont, durataoa at hilplfitllll‘illg allutnal discharge ivuluatiou ‘30 �lllfintlii ( ). it. gltatcul factor: war. 11-. ralltod to a non-Ira a: utorootrpy. tho calttorntu 1 Seal. ( ). ltxhcr r acoran tor. turn ur‘on round in pilliatl dauguoaoi a: tuvolntaouul parlhnlzl rctqrrod for sciatic thirty: and hours. taliiod to: a shortcr yuriod ( ). It It. concluded that ti. extant. a: postal altar, uno. ldi'ttiol. htrthplaaa and dagrco a: atarnotrpy on psyohtu‘ric firtatnca‘ pnt‘uvnu VII. uofi a roault at cannanta tno‘orn at availgbtlttr of troutlunt .10... On. tugxon‘iun was that 3001.1 :hcfi'rl tuIquu-od diagnouin :ad tronsncat by atrociing the varbsl and avg-vnrsnl nynptc- pattarnl at pats-It behavior. It was puntnla‘cd tha‘ nubauo£l at lcvor lusts! all-sou. Inna-r oduot‘tua :34 £03.13. Birth vault nartroqnontly'unuttcnt lynptuun non-Vtrbal. IOBIOPI or IOtO! pnttnruq cud «avast phyolonl nofisa or thurapy. Huger ulna. subject. will! utiltic Vtrhal non-n at gunman-10:, and patintputn paycholngioal turn: at troninun‘. A non-ad xn‘crprctataon rilnfiod plynh11$r1¢ trnutnont ‘0 tho philosophinn and uttxfinduu or individutl payuhtatrints and hatptttl ntat! nttttudou. II 1&3‘1‘n‘10ll what. patch.» thartpy Ill hluhlr vulucd. typo: 011-0 pnttunin vculd b. ‘rontod dispruyorttountcly with ptyuhath'rnpr. ataxllrly. dischargc ovuluattonn tad durut1on a: honpttalltntaon U'lld 1n it'll be uttcctcd by itttaroncol :u o‘ttt unpootutioau tor individlu all or distortu; noctal «13.3. �.3. In to“ m. «and menu“ I. «cum: u up.“ $0 lillaldo (ll) :tudy unploytns tin can. proctdurcl :ud tons-trout}: to attend thu diacrquIGnl to in. 0th.: taut:tu‘tonl. ‘hu 0.1. leanings! nuuurtnl inapltll at tarot. (If!) and tho llaunoinncttc lautal lcnlth cantor a: loaton tultt‘ufitann worn loloafiod in tho Impoo‘nttan (ulna). ‘In$ tiny servo putt-at: .8 ditrursux 30.1.1 clunuou and 1951 It... thnt ditfcrOIcoc an ‘hta dinanatuu uculd ho rofinotod in tho trnatucnt vurtdblou. In that. houulnlu $huro 10 a minim lnrlty 1n attitudo £OUIrdI ‘rcntnaut aad oduna‘tou. Inch 1: a ‘oaoltug haapt‘ox with n {:11 $hlo Inpcrvtaorr utntt and out£v0 research dapar€n0a$. tiny 0:93.013. plythae t-nlrttcalxy-orlontod payohttharupr but gravid. 0‘30: trcnt~ lint. inslnlan; taunts. thcrcptou and activ. prosrnss or I111fil £harnpy. Each :troinlt Ihlrtutarl troutnont or valuntnrr puttautl, does an‘ gravid. cuufiodial car. and toads t. d!!! 1‘: pu‘aont pcpnla‘tou trim 01:11:: as. groups. It. Ipouttio till a! £hxl study var. fit duttrntna popu13‘103 airfares-Ia tofivccu th- thrlc lun‘tfiltioan with roupcct to social 01..., a... cantatlol und 1 learn, and to roln$a ‘hunc patient attractorta‘tcn to tho troufiuca‘ variables c: twp. o: ‘rauinout. durut1on or hanpitaltua‘ton, ligament: Ind iililltta uvnlnniitu. �.5. am vuluntnry. adul‘ putiuntn 1n rustic... In ‘htll tuntttuttanl on a 31v.- dn‘c ta Ignutrr 1959 new. studiod. “£11. Ill and as had vnllntary 9a‘1cn‘l only. 3 0:311 nuniar a: ‘Inuc It also not. nultlnad by tho court: tor paychtntrtc ovulittton. or war. numb-r. a: a chronic achtsnphroatc utt‘o holpttul group transforrud for u upocltlo ranoarnh p30500‘. than. pataousn aura «natal-d tram tin Itudy b¢¢uulo of tuna: Ian-vnlunficry status. !Ia I‘I‘V population nountntnd a: 113 patinata at II, 100 a‘ Its sad 9S ut ulna. tutu pattcu‘ III ¢1vcn sh. calitorntn r 00.1: ( ) on tin doatgnntod data. Bastian: mouth: taint the pafitcntl’ rccurda war. anulynod (hr Oh: variant social and payshinfirl: taster. If sh. titty. 1hr tho dafiuruinatton a! social claua. t5. lulltngshaad autuc‘ar luau: was hand ( ). rho utudr thalidod ulnnxan‘aon a: the rolntacua or fihn 0001.1 to it; payahtafirtc vurtublot within tack tau.atu‘lon. .3 3.11 a: tutu-on tnuti‘attonl. otnpurtnonl pravnd dttttcnlt basin-o at littoral... 1: the dutinttton at the paychtnfiric vurinbloa. ‘Io variabloa ranged #11017 lad cnnparnhlo cutout: orttarta 00:16 30‘ to d0$urnanua, and varying dour-on at 31:31:. 41“. lb: uuunplo, to acnpnru tnctatuttonl in rola‘son to length of haupltnl u.ny. Vlrlitl oufioott potion. wore ‘raod but I... IIIIIOG for gilpurnbln dtnttlbuianun. At III, on. Q‘nrtnr or the pattuata tonuilcd raw-r this cart: nouths. tad wwvo‘hlrdo L11 it... �.5“ than twtivu nan‘hn. A: Illa. :3 contract. 701 at :11 61 only Inca ‘htu rauntnad nor. 00"! nath:. I.‘ pitiilil that finalv. mantra. I: inturututug coats: 01:1. ‘haro vac IGIO 08 89! for uVIilabll lltlrlafitul union accurrad what. thy 06‘3ct10n wit. .r in. tn‘hnr at I ulnar Pittoatl. Incluluttinhlo‘ of tho hm:hand of a not... 371 not ruccrdod. Anacrdtus, 1n fiho auolyann or payuhaasrto variation ouphunia will be glucod on tho asst-runaun botvacu sastzfiutlouu. with ostnttuu a! rutnvnnt antrn-tnttstnttaunl roln‘ioashtpa. was �~6- 3mm: I. tn no Whoa riparian; Itndtal 3:1: I hano’inlsatuttou, £30 ltruttlro if it. hanpt‘nl 1| takcu for nrnntod, and ui‘h-r ilflfif04 I? 8.fi*1‘ild brinrly. luvtvur. 1n atnaytuc a cuupnrabia Gut: 13¢ gather nttaupttag Itransn tlntitutian t. 1::51tn-V butt-an tho differ-nae: many 1at tflhrd 3.4: II. $103.. It. hosp1§a1 organisatsun a: a datnruianat a: grantnout in on: nothndolocie prohlcu. Far oxnnplo. bu‘h £h. mane and III havu dny houpttal unttc, while an doc. 39‘. A. name the fieottias phwuxciun can our. tar a patioat an In Qho and an sitar-taro any tbs in hacpt‘ul. tacpattuut, clinic. II Inch a ustttnn, ha 0‘! Ital tree t0 «tachnrgo the pntlont tron tho Ioupital at tn curlxsr «sit. kl¢V1lfl that he v11: still bu ranycnsitil £09 hi: pntxont's c;rn; what-an at In, dischargd lint! tnwuinnfiiou «I shut putiost- 1. I rclttionlhtp. tu-thar probluu an: cu. princnea «I dittoront ruuourch the .2 ‘15. routines. ¢1$i10a1 ti. attoctin: it progra-u. the 91810.1. at a: porcont tunity upprcutnatnly IIIVQI. sane acre chroszaally 111 and had but: haupl‘nlttoa for hnvo ban: in unrn:XIr u such act that! zrc‘p nan: y-arl. thin honpttnl hit tiny and icon trtatturrfid Iran anathur donfier Ittt- Anntttl§£un for That, it. t lytiill silty. vary tactqrn to war. tut-routed in Itn£rin¢ �.7“ situated ‘ho coll-ataoa and arguaisa‘:¢a .: tit dttn. ap.o::1- grails-l var. noted :- do.1¢ua.1¢an 0: try: a: trout-tut, (sag-nattc torn. and actlnntlouwor troutucnt outta... .) naggiggtigg at 3:23 2; rrggfiucntc 2h. crttorit tor looignntlng that I past-It r¢ouivud 'parohothornyy' dirtorod anon; tun tastttntioul, waking unitarnltr in olntlttscatsuu difficult. At Iii p:yohothcrnpy tru;;nant 34.1.II ‘ stat: paychintrtat, was dal13n1§od tttoroa on a pronurtpttoa banxl by lb: uhxch tin patiunt was citrate a ton. sonbaaan with the payohia‘rio rnnidoa‘ v.20 countdnrod part a! rcutxao nintnlutrattvv yafiinnt Giro. At In plythothcrtpy Ill dcttnod at trtntnqnt caution. vith ‘ho plyohto‘rtu raaiduat. Stat! payohattrtn‘o dtc not trgut pl‘ltufil. but rootrlcsad that: cctavt:aos to cupcrva-tag tho téfllflOi‘ phylacxaao. At tho lune pnythc‘hornpy val dalxcnasud an a (tactic; of Ian: diocipltaca ~~ pnyshtu‘rio rusadoatu, psychololiatu. Iactal Iurkorn, strata and nodical students. III-n1 accords at such stations vow. n9$ routtnoxy taclndoa 1n the pntlonfi'u rouurd and to :lcurtain thigh pu‘iontu roociv¢d piytho§lurapy, tn. rouidnn‘ tn charge at oath a... van lu‘trviovtd. h) Diagnaaaus ludividUll 1::‘1tn‘10na1 dtugnoittc atria. fill. and. ocupcrisnnn litticult. At K!B din-barn. �diagnouol nuptqycd tut nultipin cvnlnn‘ivn dn‘n sch-no raculncadod hr thy tntrtouu Paychlu‘rtl 1.00:11‘1uu whilc both in .36 male rolllvod unt‘ury ayutana. anvural 11:191.. at IJI arc iihlo I, vl‘h our in:sootcd convurliona tutu catuturica eunyurthlo to tho 0th.: 11.130000 tru— ltufiod in fags; convvrizoas provtdc, havcvar, tn unavnidabla taste: .3 diutartioa. (31:11:: aboarvntluau havb-nn roperfind by Pas-Inuit: and him tauoetstad ( ) wha indicat. that dilzuntaa Within tho tine tantitutloa Ira db. vulnnrnhlo to individunl titraruacua Ilia: examaacraa five lunfiifiufilouu. u--O-“.““. {thin I ”’W‘.fl u... c) gtlobnrlg Ragggln a: Ingggvcmcut: Rating: 0: invrQVOo aunt wart-é 1n (splat and dotall. It. discharge rating at nil was $r1purt$£o with a inparu§a cvaIunilun tor soatal. ottrac‘urololttal and Irndrona canteen. RI and tune End clubs: ratings in which 1‘ VII difficult ta attain the can. ‘rtbufiton at such tuct¢~ n: tn: 1!! Iyltuu (rnhic 11). Fur than ntuiy gt. 3!! lyndrawc rating van unwanted to it: global rgttuc' a: an and line. C-” t .“G‘”. Q Tibia XI ”“fl“Q‘O” a. Booicgtzphologgggl Virgabloc �‘9. Scotti amp-u; that. at: a ngrkad dixttrcuuu ta ta. .0013} alas! count-$Qton at ‘bn tire. annta$nttonl (tibia 111). g} at. .t as praduninnutly “pvt? 0130!; nxddlc .1333; and at mane, produatnauttr loan! 01‘33. h) figs: Thar. war. no daltcroiaul in 01' itl‘cihltina in tho tus£1sntiounl popula‘aonfi. o) pdn¢ufigggc The nopuln%toas dittarod in oduaataounl attstauant, with pniitu£l at If! havtuu not. glut: a: sinustiou than than: at 3:36. fihlin k1 per aunt of ‘hl pusiunfil 3‘ Hana tutled to aauplotn high cahool. only 32 par canfi at an tud 23 par cant afi urn did not grndutta. d) r Sacra: natturuuaaa 3. tin ata‘rlbnslcn a: metro. an tau calitnruiu ! 3131. war. oblorvcd. Itrth-oao pot ennfi at urn pattaafia had I soar-n hcldv 30, and eat: ctgh‘ not «out wi‘h start. 0! 50 or thaw. ~~ tn. highnr ? neuron 3.1:; .8..egatnd with higher 6.3!... at sgurcoiypy. In coa‘raut, at unnc tumufiy par ccnfi var. halo! 30 at tho 2 30.10, .Id fortytuo par cant hnd intro. 9: 50 or more. At an titty par coat 0! it. patiuatu hnd r an.rua in £hu utddln rgagc botutoa 30 and £9. 3. szph§ggg$g Vutiuhlgt In‘rnainutttuttunnl oonparinoau urn counotidatod 1: tabla 1', while tutaroinlt1£u§10nal unitartitul It. prancu‘od indivifinullr 1n llih not$tcn. In ttbl. IV, ntlbu and payohou thcrnptoo var. cnnbtnad, parntfitana I oontract a: 30-311: uni At 81! the population �pcycholcglaal tharaplnu. 3) 8.1.0.1.: or troatunu‘: ‘80:; inn$1tu.1ona, lunar 6% fOOOSVDd ulna, $hat naught. or thornny I! I?! at yl‘iontu (iuhlo V). OOIOIBIOC‘IV suallcr various... at tho urn pu‘tontl taro 31:35.6 :3 rootivis¢ paynhofihorapy, with u largo tank.» (36 putt-at) ratotvxna 31110: torso at ‘roa‘o tout. 1t an patsonta rocotvtn. nilxou thnrnptou at. Clflliltic¢ an raoniviu: plyluothoragy no i yrs-3:1 Iroatnuut ItIQO sank pattnntil cantonxtanily 3.01:; 3 3.014033 ply-htnsrict. 003331. or rnuctvtnx tho plfituu‘a pcrnonfitnc ion‘ruct on: I: thornpy, urn flhl'. nighttlctntly loo- thlu intact 02 .3. o‘htr tun anlfl1£itaona. . ”U“. d.-.”fi-‘.”.’..~” £311. 1 abuu‘ barn ao¢1a1«paynholoui¢a1 P Old acorn nun Alon; fuotlro, nannisieantly rolatad tn sraawnout nsloc‘ioa (0160» and highsr r Basra patzom‘a at ups; and 9 ant. froqucntlr'vccosvtna somatic therapy) 8.0:. can tainted to troaincnt ooloo‘ton n‘ 33. athar taa‘ora utrc Itgnaticaufi. Ian. of ti. '001n1psychological factor: II. rclntta ta try. at trottaon‘ at nuns (tabla IV). Luau. fin. purchx‘tric vurtabios vi‘hin ouch inntttutiou. diagnosit at: ntgnitso:ntzy‘rolntod 1a '11 tutu. hospital-x discharge ovaluntton ‘t I?! only. had dura$1an or hocyt‘nltunttoa I. �.11.: it an and nano. sonata. troaanan‘ nun aolaotol for pattunta clnnuittud nu ochisnphr-nta titan that $hoa¢ cluaaod tad attactivu diacrdar “or. a; paychgnnlzotio at oath htartt;1. urn. pataanfi: roootvinu acnatxn truafiuont (prudnnilaatly that. tlaa¢ad as Ichanophrontn) raeulvcd ditahnrso rattncu at Iniupruvud nor: artua than pntianta rnnttvini payohoth-rspy At nlonn. b) BI!&I&I! a: BIG 1it11 'zttat 1k. fir-c 11¢t1$ut1¢ul dittorod with roaptot to pnticu“: ltauth at utly (2‘51. 71). ”an“ was mat-nu: 19‘s.", um 65$ at gaunt. taunt-1n. tar traits «oath. .r usrc, compare: ta 31 par cnn£ at ‘ta 1! puttonta and only 5 par aunt 0! than. at nuns“ 2h. an andul afifiy st ‘30 In group it: bctvnoa save: and nl¢vnn noatha I311. tau-thirac at the anus pattun‘n var. diach§r¢od within '1! uoathl a: houpttnlinnfitou. 8.01.1 oinnu and 3 $3020 we». utt rnlutod id aurution at nay tultltutiou. ti. psy¢h1n£rio vurinblua. III! 613330.13 coula ht rtlntod . fig fihnao diuanantd ll achtsorhrouia utro bnlpttalaucd tar inncor puriafli .t each instii‘tscn. at «vary .3. 1.7.1, it... a: at urn ran-incd loagar tuna Qt 38 av Hana. Iadctd. tun lituriantieutiontl dirrcronuon turn a. gruat that a yattcnt in m clan-tn an» m m. lit-11 u be mutant“ “r tulovt manta: or more ut urn thug war. putaautn in fine "II‘II‘ ts. Irv!) at x386. Within initifiatfinns. as. andauducu‘1oa at xxx tad an �a“. war: wizntad ‘0 lsucht a: honpitnlifiatzuu -« runagir tad 1.0: olucutnd pstanntn rinninits for tho linxca‘ porioi tail. 1! dsdnt atrt a) Qgggggggg_gzg;33§;gga In ough hacpitnl. Kilt patient. .32 um um mum“ u. ”wwma" (ran. are cnlutoé u. (19%) 1; a" var. peanut panamWW. Ultli nu ”uninprovaa" and 0&1: ‘ 31331: patient Hus antlua 'rcgovnrod” or .Ififih taprovid‘. tum highcat pareaataec at 'rotovur-d“ a» ”tank inprovud' 31:13:: (20:) :51 an. tenant propurtion a: ”Ininyruvvd’ {101) «0:. Stand at aunc. Lnalyuua within such auntttnaioa uhcutn vurtnbln rouulto. A‘ an and nunc thsrc an: n tandungy IQ! )Iaar putauntn to ho Iltcd hctfior ‘3‘: yolaanr anal, but ‘kc ratnita tr: l‘a.1|$1t~ was m. ma on than n. may aimltisaant awn”. um rm‘cd to 5! with Iatupruvlla oléar likely an». pstinntu trend, tut ‘hia did not aahsava a‘sttltlcni tignittaanno. n m, an. mm a “‘3'“ :9.“‘fll”..”rhbgo VII wa-oonhwficumahha d) btgsnnuila Fur u‘atiattnul analytic $hrnn dinsnontal l¢h38iphliu1¢, arxostavc dsnurdaro. and poyzh¢ncnron15 and tflrlflnllltr ditirdlrt ($351. '11:). nuns and 31-11:: fit: I! disgn¢at1¢ proyorticnn It! It!» It. groupcinsu Ina. 544:: �.13. pcptlnttonn. but it. Ill ’ifiifilfifl «or. rcunrdod an invanu and and a 13:30: Iahtuophrcntc nttacttvo 1130:4023 tart: nn-pur a: purchanourofitc or per-duality dilornora. Intrailltitutlnutl ntalrlta Ibiuid that tt I! tot! l1. tad r loot. wore rolstad to It‘sntuan; 1‘ III an. at... a: £h. nacitl tltttrr was rolntca to dsnxnootng null. as 1386 iii? I! it. 30:13! vuradbla¢ war. no ralatod. at tho p31» Ohllttll var1thlos, it‘snoata val nignitiaantly rtlstnl gt enth hoiyital te tg1:¢tica 01 trnuitcnt llfi durati¢n of sad only at IE to diauh‘wxo artlaatiau. hanpt‘nltuation; .fluflwfi Q. .DI.C“M”O“ flhla V111 dbaut hart U-“OD‘““Om--.fi-“”“~.- �.15. n . 10! In this courtrtaon It fihroa vutun$nrr paychintriu houpa‘alt a. hat. dbuorvud tisaatlonat tn‘orinutitntionnl atttuvuunol I! rattantl 1. ‘ho noctnl vurtlblta a: rtura at oduca‘ioa and 1.01:1 slant, but not ugu; :- distribution at cnlstorutu r acalovan¢rnsy ‘nd 1: oath of tin truntnmat durntaon a: knapst:11uatton. ccluctton o: vurtlbluu trdut-c-tl and atltrtbutton at 1113.0... and danuhnrct ovuluattlua. It. tilt-routs: in ‘rontncnt variable. butt-nu £ho Lia‘stuttuns nay roc‘l‘ Iron man: flitlrl. including £ho 30.1.1 aspoo$o highlightod 13 an! tntfistl ain‘t-t. 2' dttinc tho r01: a: sedan! tho‘oro taro olonvly, vb IIICIiotk tho 1n£r‘~$nlttttt1¢nu1 nulparinOIt. Iron into. afiulyioa. fit» :gok a: cnlutltcnt ralaGloashtpu land: dent: n: in tho v.1. at putlcut nottal tuaiars u‘ priallpil actorntnnnta 1a £routnal£ vtlhln than. tittin... It via an‘tcipatud that wi‘hin ouch tusfiltnttoa. pnfilonin at hichur 00.1.1 clays, turn: r not». ans hat‘ar causation, would to croutud prcrcru tg‘luXXV by pcrthntb¢V£vrg clnsnttiod as nourotio, tuna:tnr shorter partodl and r:¢¢1v. botfi-r danchargo rats-an. wl‘hxn in. :uli1iut10n, an irrtstlnr unsootnfiloa bc‘vtta tn. 1;). (ram. mun-u «I wan. no sauna-n. it. Illa. not. at tin Inuit: $323.51.. var. rotatod tn any cum at: at. tacit! alga: Itliilttc;117 rotataa to 3:: trontnomt vnrlubln at otshcr I! or 313. o: a firoufiuout turtnblus �$3313 3 ___, by nun-qutuuml ”hunch”. Manta“ on Sam. ”I - haunt aolufl“ ' '- mun O: thuufll ' - Duncan 11“ch suit-nun mutton . man or Influuuuu I an" - ”can“ sun“." . Mam” " ii‘lfi 3;: - n. I. “nun-up in- ti mo. m «I» 4» am...» he mu: am0 u r: .05 p< .0). on W .001 �.15. pcccthlc he rclccaccchtpc hchucch ccctcl ccc trcctccnt vhrachlcc, clcvcn crc chctficttcclly nightttocat. fhc dirtcrcnccc 1c tho an cud It! dctc ucy hc a» rctlcchlcc ct thcir pcpclclhdch atttcrcccccu thc rclccicu at 13c cc d1cchcr;c cvclccttcn, ccd r cccrc tc 41c¢nccic at an rctlccticcihc htchcr prcpcrticn c: dcprcccivc illccccccp uhtlc hhc rclcctcc ct cuc cc hrcchucct cclccticn cc urn rctlccttcs choir highcr prcpcwttcc c: {cc-t pcrcccc clccciw tic! pcychcncurcclc cud chcrcchcr itccrdcr. rho ctnilcrthtcc :- I! and Ill much In: rctlcct ctnilcr trcchccut philcccphtcc, which crc littcrcct rrcn thct ct Illa. ccudtttcac c: clcchivc trcchucht ccd clccttvc dcrctxcn ct hccpitclxcchlch catch ct ll cud HIE. and th may hc thin tlcllhtlihy thch pcrcttc tho inhcrccticc ct tho cccicl vcrtchlcc. 1% lane, hcvcvcr. tho lththcd cccy cud cccd tcr rcpid trcctccch rcculhc ta h tctlcrc hc dchchctrchc cc 1ctcrcch1cc ct cccicl vcrichlcc vtch tho trcchhhct prccccccc. Similarly. thc rclchtcc ct cccihl clccc vcrichlcc hc trcchhcht varichlcc 1c hhc lcllxccchccd ccd nclltuh ctndicc Icy rctlcct hhctr dctc cclcchtca, vhtch vac cvcr thc hrccd rccxc ct c11 ccnuhcatw :cctltctcc cud cll trccthcah portcdc. within thcsahcttcnc, hcvcvcr, thccc cccthl thctcrc cppccr lccc «Incl-.111" ct trcchcct ruichlcc. accusing): cvmcvcrcd by tctrcccrcl cdhtctccrcttvc ct {sunsctcl ccccccthtcc. 1c hhc ccrltcr Iillctdc lccpthcl chcdacc ( ) thc rclcttcc ct �~16- vnrtubloc trooinant ‘0 thtad cit-atlas 0: u... r 3019:, 13 u rdlnation of the krona ndnantn‘rativu 1a£1ta¢ua avntlnhlo defined broadly lrtnfinout. var. tans. that a‘ tn pnfilnu‘ car. with cengfitc, nzltou :34 paychofihurnpautto undo. annuity ‘vniznhlo. ”III‘SOQ Ir Incpt‘nlinotton an. broadly duttnod Anni-lion policy 1 raga-atod. 19:31: or to up i: your, at was {113151. and thh taught and purntt‘od tun Ianxslaon or pafituu‘n ‘1‘» a I10. 933;. a: pcylhlatrxa laouraorc. the proacnt an Isudy than: (out: locial-trantnont'rctn‘tono con-fir‘o‘ttn 195? a parka»: ‘ha rollocttuc than s‘uay. nit»! Lu avgilabilifiy a! trcafiuont :hoiooa. ta popu1t£1on 33¢ a uniturn us‘cnnton-cl ditl‘lil at heapttcllulttoa. lit. new ad-tntn‘rnlifih a can‘nlyorcsoouslr thatlsltad pitta... with closer no narkud a Granting axillarity in clonal: $10., the Mt! nodal. Such administruttvo discus-10:. arc iosu no prtutcpal dctorntnlltl or tn. Clorfllllfl or dist-lutton a: social vurinbloa, n. ltl‘lrl ta tho trantncnt prostlu. A lacuna aspect at that. I‘udtoo an: tun Icthodoloctoul problems In 6011.13: tho ‘roatnon‘ Vtrtnbloo. That. last:tltSOan wort toloctod to: that: cantattouni loudnruhtp and be vanld roomrd¢d £ho vurtuono 01¢:rly tha‘ clygctattoa it. uglinod. OI: dirttcultzao in arriving at comparable Asia oouvuattonnl at a: $ht-prdblnn to one! in. tupcrtant tit at. OOIplrfifiiyi it;$ia£ion. 0330015117 1- £3. ovulustton a: psychiatric therapiou. rho trnquun‘ nu. at dilahnrco ratings, �-17- dtncnolttc .11.... or Iongth at houpisaltnatton an ortturta or thorlpputic vnluou at conpnrubtltty or nuts-ct: and poppItttona urn Iibaoct £0 can-031v. array pal... tho inuttfinctono puraduxtn naschnd adulatutrntivo patparuu. tar clourly It. It. cal uupuro at a :atluru ts anounat for this vurinhlo 1- to be 6511 dbucrvnfitoa ‘hc of a in tutprprctataon lttcrnl t: Iii! cindy. an. urn hi! it: most highly train! per-canal oondutttnu troainunt think is applxud for indivicunlly tottaofi,¢ptxan1 portods o: ‘llis it populations with it. 1...‘ propurtion danunouod 1p nu unfavorabls pritlll‘it group (achilophronin) - 1. uncultl (cvorlblo tracing-t a: rot. th. pOOIOIt. At Illa, 1n contranfi, tilt. in: lonat traluod shtruptacfi apply transient. for nu adutntutrativnly llutsnd patina, ‘0 t papnlattou ‘1‘! a tight! prcportlon dtnuuoacd Ichisophrpnia. tho proportten or tnvorablo itscharxt rating: in lixutticnutlr grouper: It 1- prubsblo thnt thun- ohlcrvuu £303: a. sop rutloc£ thy tharapcusac atticppy 0: photo snap:1n infitcatodb ortsorta o: tuprvvo~ attics-loan tu‘ttul, 3" ~- tad tho proportion uonfi. this lack a: alsritv in «tacuautta achcunfi¢ and lacunpnrtbiltfiy or psychiatric trou‘upnt variably. all. landpallc to th. t‘tcnptnd acuparupivc studio: or payohtntria thorpptca. Pb: asunplo. tho rank at rooont failurns or biolcgtcal Ioaonticsu to Courtru ubacrvutioan Ill. 1: «that labor-tartan rip he I: unch a rutloctinn 0: 11:10:03... In �.18. popnlnfisoul. paynhaatrin orssortu,lggg. an tullaniou it tho or131ua1 hip-thus... tin vtdnspmoad no. or tank turns :- ”Ichzscphroaiu' or "plynh'aamtoaiu' to unplarc £hn shuns-n 13 pnyubutagtoal or biological toninraa with noufiaz ilincsc has 106 it a Icioaea burdonod by ungattvu rctaign (Iellak), nont narkod rocuntly 1n tho nontliettng studio: at I tdrll false: in auhaauphroutn, :3d the tact-pur‘btltty or the yhyutologtoul -. hohnvtorcl corrcluttnn: scan in tun u0choly1 (Fulton-toau) and sedatiau thr¢lholfi tnakt. Esta nor. 3 valzd abourvn‘tou to be ropuriod :rcu on. clinic, dc a. havo' nothtdi available ‘0 deliriho poputlilonl manqua‘nzy £0 providc ‘ sound nontlrnatlon? w. haltovu hat, and nonoludc from thugs dbnurvuttcls that incranacd attention unst be paid to she uathodolaaaaal prnblun: o: alttsityina uuhjocta hy 'vb:oot&vo“ cratcriu, rather than fins prosoat untied! whack appear to b: a. hichiy dopoadont a: institutionnl ;ad otuarvar nttittana. In: the oouiopaychological 339.0%. .2 ‘3. thflllptltupl§103‘ tltcrtctiou. �IleI I can? a nu at Bil: WW 1. nnprunaav‘ rouctson Surciaozntlo Puruonnlitr 1: no: WM“ 1 61-1- “mm Payohcncnrostl 2. Auxtuty Roaution larttnntutia Parlounlafir Payohnaonrootl 3. larcttsiutia ?urlcan11my tartan-11:: $ h. lurcatfliutlc Par-annlstr. Alcohcttun chronic Intintilo PartinIISty I acuiuputhic Put-onaltty Btuturhusoo S. Pausivn Augrcuuive P¢rsoun1$fiy Alcoholiun Suctcpcthic Purcoanllty Disturhllco 6. Inthn‘iln rarncnnlzty Schauophrtntu Ronltton StuttOphronlo vaychoail , Suhifil-Afllofi1Vi*2¥pl frtit 31I£I§bnnio �TAELE c 1 5‘ 1 of I: on g; gaggs‘nl aacahnrgo 8a.: tin. Ii u , Illa floats: tgguai-ant Ruusvuroi luouvavud Inpmuvod Bach Inprvv‘d unrkodly InprQV'I Untaprovvd Invrdvnd lodurntolr Improvul alllprcvod 81133‘17 Inprovod Hltnprcvud couplate Ronanaign 2aprov.d v‘ahnugcd (u: wits.) �ans-$3 :33»! . i: on ., w W M . - V. ma w, ,-.M , u. x n Ha ‘ a WE w m V m Vino W4 m .w Vacs. gm H1 II ”Sup-32a a I'_I"II 3.33.. V mfiufififim .63. I; Eu. as PH. no in �EQELE V :2! an kl 173 we v’-82.8; 39 dtwhx p¢.061. ’ 21 h: 36 36 6h 0 ah 68 a ! principalxr lilies thsrtplio �me 95 x'.?0.6; “'1” V5.09! �331.8 quttt‘u I an g! m ‘ ’ Rum“, rum n '1; «huand d 1 c fi Imprond flux-yam! 99 1 an 1.9 17: 23 6: 15 as 61 10 mc- x*-29.3; «rub; p«.oat. �Y Ilstttntaau . V I WM). l achtgophrtnia Puyuhonguronia and E' 7 ml m1 male 171 . 85 t"13.8h1 43-h; pfioanl.‘ far-onalifiy O; !' J££o¢ttvo 33 $2 5 52 26 :92 SL 29 16 �A Couporioon o: sooioplyoholoaiool Voriobloo and Poyohlotrlo trootnout 1o Throo Voluntary Hoopitolo Robort L. Kuhn, Ph.D.', no: Pollock, Ph.D. lothoniol Siogol, Ph.D. oud m flak, um. tron tho noportuont of Suporinootol Poyohiotry, Hilloido Hoopitol, filo: Oaks, L.I., 5.1. Aidod, in port, by grout HI-ZOQI of tho lotionol Inotituto o: Kontol Koolth, 0.8. Publio BooIth Sorvloos ond tho loooou County Kontol Hoolth Hoard. tho cooperation of tho ototto of tho Hooooohuootto Montol Hoolth Contor and tho 0.1. Hoaninlor Houoriol Hoopitol 1o lrototuily ooknovlodcod. o Prooont Addrooo: Divioion o: Poyohiotry, Houtottoro noopttol, I.!. 67, 3.2. VII: 3/62 �In thair atndy a: tha lav lavas payahiatria patiaat populatiaa. lailingahaad and Badliah rapariad aignitiaant raiaiiouahipa batwaan an individuai'a paaitian in tha aohial aliaa airuatura and tha pravaianaa a: traatad iilaaaa, typaa at diaguaaad diaardara ind kinda and duration at payahiatria traatnaat adniaiaiarad ( ). Thay indiaaiad that prapartian~ ataiy aura lava: aiaaa paiiaata in traataant vara aiaaaitiad aa payahatia whiia uppar alaaa patianta vara naraattan alauaitiad aa naaratia and paraaaality diaordara. fiagardiaaa at diagnaaia, payahatharapy waa anplayad in diaprapartianataly high dagraaa with iha uppar alaaa patianta, and urgauia iharapiaa with iavar alaaa aahjaata. W” Tha intiuanaa at aaanaaia atatua tha availability aau‘gviat lfikaualndad in thaaa atudiaa. at traating paraanual fa iaat tha raia at aaeiai taatara in tha traatnant at hoaa finanaagfaui iadapaudani at patiant patiant' pitaliaad M“: JJ’availabilityat iraataauta;a patiant aarvay vaa undertakaa at Biliaida laapiial in 1951. In thia haapitai, a variaty at traatlant nodal, inailding individual payohatharapy and organic tharapiaa at. availabia to .11 patianta ragardlaaa 3”“ at thair ability to pay. In that ....!G. aga, adnaatian and piaca at birth var. aignitiaauiiy aaaaoiatad viih ahaiaa at traatuaai, duratiau at haapiiaiiaatian, aliniaal diaaharga avaiuatian and �.2diecneeie ( ). The elinieel teetere were elee releted to e eeeenre e: etereetypy, the celiternie F snele ( ). Higher r eeeree eere nere etten round in petiente diegneeed en invelntienel peyeheeie referred for eeuetie therepy end heepi~ telieed fer e eherter peried ( ).i 11..., mfiflfl‘iv W” It eee eenelnded thet the elGIItI-et eeeiel eleee, ege, education, birthpleee end degree or etegzgggpy en peyohietrie i:3§::§:7gi eeeienie treeteent petterne were not teetere er eveilebility er treeteent eleee. One eezgeetien wee thet eeeiel teetnre influenced dieueeeie end treeteent by etteetin: the verhel end nen-verhel eynpten petterne e: petient behevier. It wee peeteleted thet eehjeete et lever eoniel eleeeee, lee-er edneetien end tereicn hirth would eere frequently eeniteet eyepteee in nen-verbel, eeneery or enter pettnrne end would expeet phyeieel eedee e: therepy. Upper eleee eehjeete eenld etiliee verhel neene e: expreeeien, end eetieipete peyehelegieel teree er treeteent. A eeeend interpretetien releted peyehietrie treeteeet to the phileeephiee end ettitedee at individnel peyehietriete end heeyitel etet: ettitedee. In inetitntiene where peyehetherepy wee highly velned, upper eleee petiente would he treeted dieprepertienetely with peyehetherepy. Sieilerly, dieeherge eveleetiene end deretiee e: heepitelieetien weeld he etteeted by dittereneee in etet: expeetetiene for individuele of differing eeeiel eleee. ”Sikhs/W! �toot thio ooooad hypothuio no dooidod to "put to Hilloido (an) otody ouployinx tho Iona prooodoroo out l'o 1957 oonoorroatly to oxtoud tho oboorvotiono to two othor institutions, tho 0.}. nounio‘or Honoriol loopitol of fopoko (HIE) ond tho looooohoootto Hootol floolth Cantor of Bolton (ulna). rhooo inotitntiooo not. oolootoo in tho oxpoototioo that they oorvo potionto o! ditroriag oooiol olooooo and that ditrorooooo in thin di-oooiou would ho rotlootod in tho trootnont variation. In thooo hooptolo thoro in o oinia lority in ottitndo souordo trootooot and oduootiou. Each in o tooohinc hoopitol with a toll tin. ooporvioory ototr and ootivo rooooroh doportooot. rho: onphooino poyohoonolytioolly-oriontod porohothoropy but provido othor trottuonto including oonotio thoropioo ond ootivo procro-o o: nilioo thoropy. Book otrooooo chart-torn trootoont o: voluntary potionto, dooo not provido oootodiol ooro and tonde to draw ito potiont populotioo tron oinilor ozo croopo. tho opooitio tin; of this study voro to dotornino population dittoroaooo botwoou tho throo institution: with roopoot to oooiol olooo, ago, oduootion too I oooro, nod to roloto tho-o potioot ohorootoriotioo to tho trootnont voriooloo or typo or trootnoot, duration or hoopitolilotiou, diagnooio and dioohorxo ovoluotioo. �Uh. HEIIOD valaatary, adult pattanaa 1a validaaaa in thaaa taattauttaaa an a titan data in January 1959 wara aaad£ad. whsla 8!! and El had valaatary paataata only, a aaall nuabar a: thaaa at zinc vara aaatsaad by aha eaarta tar payahiatrta avalaaataa, at wara aanbara at a abrania aahtaaphraaio ataaa hospital group tranatarrad for a apaattia raaaarah proJaat. Thaaa patlanaa vara aaa}gaa§mgaan tho atudy baaauaa at that: aaa-valaafiary atataa. fha laud: popu1;‘1.§“;;hai§£;§”;g:§i3 tag-“ice at m and 95 at me. nub van W~_MM' W._~.»M~_~-w gtvan tha calitarnia I aaala ( ) an aha daaigaatad aaaa. is 0!“ ”Univ; MM Eightaaa aoutha later tha-pafitaata' raaar ‘Awara aaaiyaad. to. MMML and tho aha variaua aaatal taatara at payahtatria atady. )far a£3~3:::::2:;tton tar at aaazal alaaa, tho Ballingahaad 2-taatar tad-x was aaad ( ,). Tho atady inaladad aaaatnaaiaa at tha ralatiana of tha aacial ta tha payahiatrta variablaa within aaah inaattatian, as wall aa batwaaa inattantiana. ‘rhaaa aaaparlaana provad difficult baaauaa at airfaranaaa in tha dattataian of tha paychiatrta variahlaa, aha variablaa L11 mung"; pl;;t cut-at: aritaria could not ha dataraiuad, and varying dagraaa at ataatag data. Far axaapla, ta aaapara inatitutiana in ralatiaa to laacth a! haapital raucad widaly and camparahla atay. variaaa nag-or: pariada vara ariad but aana allowad rat aaaparahla diatributtaaa. At Hyfi, ana quartar a: an. pattaata raaaiaad ravar thaa aavan aaatha. aad awa-ahlrda a �.5. Into tuna twclvo acuthu. At ulna, in contract, 701 at .11 pation‘t rcnntnod 1... than IOVOI noaths. tad onzy 61 not. than 3201?. angina. In actor-intng 0.01:1 .1... that. van tarnrnnttou availnbll for 292 of 371 patiouta. Unclaucitxablo Ctlll accurrtd whoro tn. educ‘tion or the unaband or a honouwtto If the tathnr or a liner VII nut rouordod. Loonrdinu, 1n $ho nutty... a: paychiatrio vnrinblot inphllll V111 bu plaacd on tho dittcrcncoo botvoou tuititu‘lonn, with c1t:txon or rolovnnt tnttu-inatltnttonal rolntaonnhtpa. �Katharina“! “no.“ what! "parts.“ tn: hatun I tnutuuou, “at” 11 and “icon for of tho “that hospital crust“, "not”. 1. 4*“ 2y“ 1,: ,7) § )3 § Pg « § 3 studying in briefly. “attend flavour, {LR $ Q 1:”er 77W ', 0”] M and author Guplrlbli d». 44W stunting inflation 3:. fig .W' 3'. M” batvua tho undo 1at q dirt-rue” luuumm. any m\ an 3N M ”1:1” (Md “on. flu hospital. org-nuts.» u a dour-tun at twat-x § Q1: 9. 3* ”3%: both sh. pr-Obltl. 03mph, )W tumultuous hr no“ Q‘s an u ‘ Mflg 3 3g an do“ not. 7“ MM 1mm and am In" in: lupin]. nun, while (ft; Q 3‘ mfg?” At me the trotting phynuua u: can for a pttuu u a ‘E Q“k and tho as 1n é day the utter-nu hospital, W‘fijw Min-pun“, x i to In tool 1% In ;.1. 1,, no): a auburn «a in. “tuna. cunts. w k“ g M"; knowing tho at hoopla! the «run“to, patient in: ”file/:4 , a WV 15%”, 11111 ha hi: tar patint'u to ruponltblo «to; um can % 1;. 'bj’whuufi up») gt an, “sour” nun urination or “at puunA” MW auto:relation“?W M” Jr 1M Vb 5 0: the Authcr $4, III pubic: 51/” “than prune. running m. {Lu u} NM 5”” w” M. use tbs .2 _.., 011““). an. "nun“. ‘y prurun, “tuna: W” w g‘éflm w tho at approximately pan-nu “any para." u «may, W { to:111 had and bun chronically hospitals!“ mo var. “wwizof rb Mara would not normally 1: luv. bun Sun group I yuan. any fig Wu; MW" thin nuptial bit they had bun trmtornd tron author m O | 9' 1,. . |. “0: ax- . in 8 v 8 ”L e , A _ . Mk M ‘ 3 ‘35 ’ 3 \ g , . x ‘ W” ,5 l i ' W" . l at.“ human“ for a ”001.1 ““1. Thu, tho vary not." no In" int-tutu / in studying ,4"ch ‘ �~80 diagnssol unpluynd tho unltipIo avnl‘ativu d.ta Ichuuo rootuaondod by tin Anortcna Psychiatric LIIOOIQ‘itl will. both an and nuns rollovod Iaifiary nyufiunl. 8.7.!!! uxanploo a: dllfllllll tram I)! are liatod 1n Idblo I, with on: on;goutod oonvoruioaa into ottngoricn coaparablo so the cthor two institutiona. {hone aonvorlioul provide, horcvcr, an unavaidnblc neuron of dfstartaon. (31-11nr ebonrvntinln havban rap-rut! by Pun-nut and his uuetntoj ( ) who indicts. th.t diagnoous rifihin the can. tantikutiou arc die valuarnblo to individual ditturoncoc anon; anguinnr-J -“--I‘-----QTtblu I c) Dilahsr 0 anti 3 at In rovcm¢n%: Ratings at inpravc:ont varind in (grant and detail. the dischargo rating It KPH In: triparti‘o with a liptruto cvalustion for social, attractorcloliual and cyndrouo Chlnloto an and Kane had glob-1 ratings in which it was dirtiault to .0303: the con— trtbution or cash factor at th: urn tyntan (rubl- II). For this Itudy the urn urndrono rating VII compared to tho glqbll ratings of an and mane. T‘bla 2. Socioglzeholoitcal Variable. II �-9“ a) Socitl Gina-z that. val I narkod dittoronoc in tho lociil ulna: oonpouition of tho thro- iuttitttions (Table 111). 3% an BEE 01:00; tho produninaltly population uppar In. it niddia olaun; tad at axle. pradcninaatly lava: Ola-u. b) 5.3: Thor. turn as dittaruncun in In. dilirihutiou in the institutional popuiitiano. 0) Education: Tho populitionl dirtorod in cduantioual 1% HIE with having nor. yoirl or adieupaticatt utttinncni, tion than that. it HERO. While kl p02 aunt of tho pttiontl HERO ttilod to cosploto high annual, only 32 par cent at it KPH UK and 23 par cont it did ant ‘raduntc. d) F Sacra: Dittoruncon in the diuiribuiion of scar-I on tho Gilitornia r 80.1. not. obsorvod. ritth~ono par coat or urn paticntl had P score: below 30, cad only eight var cent with IBOrCI or 50 or abuvo -- the higher P acorns being O0..cintod with high-r dugrtul o: sturuotypy. In contrast, at 3336 tittty per cont not. Euler 30 on the F 30.1., and tort Knigz;::;pnr—ttnt $0 two per scat and IBOIII at or nova. it bb¢”»130 chad efinuau~ P&c&¢r véu<_z or the pntiuntl hid F 3002.: ia—ihn—nidd%¢arcntu-hufiwuuu—3O '0'”?ch My Sowua «Jan, 50m 0 3. Pozohiatric Variablu: Intrgoinutitutionnl «satirinonl urn connoiidatod in Tabla IV, wail. iuicr-inutituiional ounparinont are proacntad iadividquly in tack auction. In tibia IV, nirhu uni psychotherapi.a act. conhiuod, parlitting p «cairn-t or countie ind �.11. at an and rune. 3.3.310 two‘s-ant uni uolootna for pattea‘u clan-itlcd an achisaphroain and atfcotivo disorder not. titan than than. Illlflid an paychonuurmszo u$ Illh hoapitll. At HFH, pattou‘a rocolvtll unantio troaiannt (prodcninautly than. 01.8.06 an nthiaoyhrania) rocnlvod dinohsrso ratingot uninprevnd nor. ofton thus putiuata roooivina psychathcrapy alone. b) Duration of Boagitaliuttiona 23. turn. instituticua agitated with roapott t0 ptticnt'o longth of ctny (Tabla VI). MPH patients VII. haupitnliscd leascls, with 65$ of pat1¢atl runtiniag t0: twelvo lanth- or torn. cenpatua ‘0 31 par cont 0: patioutl and 0:1: 5 par coat a: that. it nuns. rho 3.4.1 ttay .1 it. i3 group was hottocn IIVOI and «lurch nonthn Hull. twenthirén of tho XHHC patioata wort diachuracd within six 393th: at hoapttnlisatton. 3031.1 «1::- and F acorn worn 30‘ rnlutod té dira‘ion at any institutian. or tea psyghiatrio variabloa, only diazuoaia 00‘1d b. taint-d - in. HE as tho». diagnonod a. achinaphron1n war. hospttnlaund to: longer porlodn It sunk inutttution. At avury at. 10701, that. at RFE rouninaé $0.30: th¢a It 33 or Mlle. Ind-oi, tho in‘cr- institutionul ditturonotl rat. to grant ‘hat 3 pttiont in th- oldut go pup nu It" 11h): up In lac-punts“ :cr tvlov. tenths cw not. at KPH ‘htl war. pntioats in tho yonncont as. graup at HXKO. Within ill‘iilt10nl..‘IO nudmodnoatton As xv: and an �-12u honpttnltnatiaa ~- youaxnr lid 10!: oducatod putt-at! rinutntng for tho lingolt period worn roln‘od to lunght of Q-.-“-O-QC“-- .O-”--. rabzo V1 abuut her. -U.---'...--’--Q-fi--.~ a) Diuoharlc Evaluation: In cash helpitnl, ants patiouta are ovnluatnd ut th. time o: disaharto :& "taprovcd" (Tabl. VII). 9: pattnntl worn a IIQEI. p¢t1¢nt who call-d At KPH, hoV¢vnr, u high-r porountaun (19$) rntud a: ”unimprovcd” and «317 ”gooovorad" or ”much improvad”. Tho hiahu:£ purncntago or ”roeovorod" or ”such 13336706" r;:1nsa (28$) :ud tha lowcat NHEC. (10%) "unimprvved” {tuna a: ct war. proportian Analya¢a within «ash institution Chalid Ttriiblfl roanltc. At an tad H336 thorn was t tondonay far 9140: puticuta to ho ratcd hatter than youaanr onus, but uh. results arc ut:ttlt1¢33. Afi H33 thorn wan II OppOlt$O anly at aixnirieant all? trund, with older pationta nor. ltkoly to ho rctcd nutupruvod; but this 616 net aahiove ntatiuticaI signiftclnao. -fl‘----‘-fi-“flflfl’.9351: VII -O.--’.-‘-.fi-¢--. d) Diauneais: Fer neltiutiaal annlyulu thrco diltnfii‘lt groupfingc were mudo: achisophrouit, tffottivo aiaordcru. disardora (Tublt VIII). Th. alcgnontie propertians «or. similar for tho an tad Hana und puychoneurcsin anfi pnr¢¢aa11ty �.13. purulntaonu, but it. It! patluuta wort tifllrdol s. h:v1:¢ tow-r atttattvo ate oohasophrcnto 1100:4013 and n.13rxcr author a: plyohcnonrotic or port's-11:; disordatl. Intrainatitutianal nnulylis abound that at RH both as. tad F 000:. not. rclatcd to ditcntats; &% HER use alone at thu nociul factorx uni ralstad to diaguoais; while at EMHG hfififi 0f file social varigbloa were so related. 0f ha payohzattiu variables, diagnoatl wan significantly rulnhad at Ollh hospital to solootion or tdnatnant aha auratian of and(§ging:iélta diucharge ev‘luttien. haspitalinttioag "'----’“-”-fl”. u-~u~q~a25310 VIII about barn u---~-‘n---—-h-~n”ca—umu—Mfln �~1hDISCUSSION In this comparison of throo voluntary psychiatric hospitals as havo obsorvod significant intorinstitntional dirtoroncos of pationts in tho social varioblos of yoars o: oducaticn and social class, but not ago; in distribution or California F Scalo scoros; and in oach of tho troatnont variablos -- duration of hospitalisation, soloction of troatnonts and distribution of diagncsos and dischargo ovaluatinns. pTho littoroncos in troatnont variablos botwoon tho institutions nay rosnlt from many factors, including tho social aspocts highlighted in our initial studios. To ,.__ Ar 7-“, dotino tho rols of social factors noro cloarly, no nndortook tho intra-institttional comparisons. Fron thoso analysos, tho lack of oonsistont rolationships londs doubt as to tho rclo o: pationt social factors as principal dotorninants in troatnont within thsso sottinss. It was anticipatod that within oach institution, pationts or highor social class, lowor F sccro and hottor oducaticn, would ho trootod proton-4 ontially by psychothorapy, classitiod as nourotic, romain for shortor poriods and roscivo bottor disshargo ratings. Within tho institution, an irro ular association botwoon tho (Tablo:;§;). variablos was obsorvod Within ono institution, tho HHHC, ncns of tho social variablos woro rolatod to any ...-- v troatnont variablo; nor was social class statistically ro~ latod to any troatnont variablo at sithor KB or MFR. Of a �-15- ’51, > possible h8 relationships between social and treatment variables, eleven are statistically significant. The differences in the HE and NPR data nay be at reflection of their popnlaltion differences: the relation of age to discharge evaluation, and Fiscore to diagnosis at hH reflectingthe higher proportion of depressive illnesses; while the relation of age to treatment selection at MIR reflecting their higher proportion of young persons classified psychoneurosis and character disorder. The similarities, in HR and HFH uata may reflect similar treatment philosophies, which are different from that at MHHC. Conditions of elective treatment and elective duration of hospitalisation exist at HE and MPH, and it may be this flexibility that pernits the interaction of the social variables. it HHHC, however, the limited stay and need for rapid treatment results in a failure to denonstrate an interaction of social variables with the treatment processes. Similarly, the relation of social class variables to treatnent variables in the Hollingshead and Rellioh studies may reflect their data selection, which was over the broad range of all community facilities and all treatment periods. Within institutions, however, these social factors appear less determining of treatment rariahles, seemingly overpowered by intramural edninistrative or financial necessities. In the earlier Hillside Hospital studies ( ) the relation of �.16. svoru, an: cducataul tn tin ‘routnnu‘ Vtrtttloc in t valuation a: fit. brand adntala‘rufitvo latitudes tvntlnhlo £011.04 broadly ltoutnon‘o not. tans. tn plttcnt 0.20 t‘ that with nonattu, natto‘ cad puythofilnrupuut1n Ind-I aquaixy i'ISXIUIGo Duro§aou at hingt‘ultsattou was tread}: tuttnod gs up ‘u 1 1I¢r, If longs: at rotunl$nd. hints-1's p.131: tun .1 and udnislttu and bath IOIIk$ par-titan (Icntblo II. dtnordorn. at var'hlasrto vtth runs. '1‘. I pattian f01§$$OI~ socxnlutronincn£ (out: In titan In: prtnott I‘l‘! constructxon a 1951 rotlac£1nl parity. Itndr. aha»: its: than tvusluhtlitr a: urinal-at ch¢1¢¢l. in pavulnttun and a intturu cu‘auliou at d§ru610| at hocrtttitlutxol. this with nan :dn:nlttracultauporaacauslr tuttxiutcd : prion-I. itfit clout: marina a Itntlnraty 070.11.: at tics. is nio-zlr adutaautrufiivo daucasaioua as Buck III! Iodci. 8!! It. tn. it. dinuolutltn at or Itficrnxnnnta thoracic. tr yrtnzcvll 0061.1 Vilil‘ltig ca titttri 1: tin trolmnont prcacal. A loalnd tlpoot c: that. Ituiica 3:3 tin nathodcloctonl prdfiloun In dottnln; tun traits-at vurtfibioa. Thai. tact:fiufiaous var. Iclootoa it! ‘hoir causatisngl ltuanrahty and ‘ho capacfia‘ton that tbs rooardul variable! wouId ho altar}: dofiutd. OI: dirttauiticc in Ittlvtts as Odlibrtilirdtil $h¢ cauvcatlosal'uno a: anon at ‘0 sh. gratin: .r. tap-rtaut cuuparntagu o‘ttintlnu. alpuntuIXI 1: fit. ovuluu£1oa a: purch3n%rlc thornpxnu. it: truancnt II. It diachnzao ratings. .3 ago. D �-17ae or criteria hoapiteliaation length diaguoetio cleaner/or of therapeutic valnee or oouparability or aubjeeta and populationa are subject to oxeeeoive error unless the inatitutione The paredoxipa+torna. adninietrativo notched for are clearly '7 be to ie oal nature of a failure to aooouht aeon in a literal interpretation of the observation or this HFH conducting boo personnel The highly the traini loot etudy. treatment which ie applied for individually defined,eptina1 periods or tine; in populatione with the least proportion diagnoeod in an unfavorable prognoa io group (aohiaophronia) ie roenlte treatment and the proportion yet, -o5\£avorabla the poorest. At HMKG, in contrast, where the laaet trained therapioot apply trootnente for an adniniotrativaly limited period, to a population with a higher proportion diagnosed eohioophrenia, the proportion of favorable discharge ratings in eignifioantly greater! It is probable that thoaa observationo do not reflect tho therapeutic ottioaoy or theoo inotitutiona, but indieatafli dittoronoee in criteria of improve- for@ Iont. Thie laok of clarity in diagnostic aohomata and incom- lendo a1ae variables treatnont e: payohiatrio peribility pauae to the attempted comparative etudioa of psychiatric t ranioe. For example, tho raeh of roeont failure: 0! made confirm other in to aoientiate ‘/h(c£jfiau!§iolozioal obaorvettfno laboratories may be as each a reflection of dittoronooa in �-18.. fallooioo in tho on such torus of The use widospzood hypothoaoo. original “oohioophronio” or "poyohononrooio" to oxploro tho chongoo in poyohologiool or biological rooturos with nontol illnooo hos lod to o ooionoo burdonod by negotivo rooulta (Bollok), noat marked roosntly in the conflicting studios of o serum factor in schizophronio, and tho inconporobility of the tho nooholyl in soon oorrolotions hohovioral physiological -(Funkonstoin) and sodation throohold tasks. Even were a havo' do wo from ono be clinic, roportod valid oblorvotion to nothodo available to doooribo populations odoquately to ooncludo Ho and holiovo sound confirmation? not, a provide from thaso obaorvotiona that increased ottontion nuot ho paid to hho nothodologiool problono of olooolfying aubjooto mothodo tho than presont rathor "ohjootlvo" by criteria, which oppoor to bo so highly dopondont on institutional and ohoorvor ottitndoo, and tho oooiopayohologiool oopooto of tho therapist-pationt intoraotion. populations, poyohiotrio oritorio, 323. Ufifi})*l 1" t no �”flu“ Wing mun. nupwum: 1V. Benefit.» Mun“. rmuw AnzacQV mm“ 3. magnum: Puumu‘y rum-nut. running mu h. l'mmuty mus-u: nub-1m em. f 8001me Imus)... Formula” S. 6. I'm“. Farm “mun in tau-nu rwmuw Batu” nun-pm. Baum-ulna" W - 1’me “than” Winn rumba“ Pmbmuw annual-n1. Ply-haul �z§gLs g; W W Ithovod Inst Inprovud Untnvrnvud coupluia nonalciao Ihwruvud Btuhtngad (or aura.) �am 1 M9 m. m “mu on mm ' i ‘ h). sa 5 want“ In".. cm W 33 3: mm“ an m �am um: 0) U) a g a: g . H auton,ann . .m.m So. E? So. 0&5» an a llllll'llglllllllll in CO E3 nonansao>m a“. o H‘ad .m.m Mina-«n can» an m “no no. 3E Hand pm a . an n 8. —:o«a~uwnu¢«.uom and. guaoflanncm .8. we ncvd.lomcuhnaH nodunuvm «uncanny . am «a So.“ ma mo. «nonvooua M. no. mm . nauaeadcm 3. mu . . «6 nuddo “;o«anu«n¢aumuom mouoaufiahm aoaaanuun Queen n«uo:uu«n ouudaunun newcauun “Canon a: h �m1 . u“ m �‘ * M1” .4 m H m . a: It 3? , 67 Innsh OM: $.00), ' 13 $5 a ’1 an s �ms X"2’a3i ‘ as «mush: mum. u a: 10 �Inattfiuttau I schlnophr-ntt rayuhtuanrosiu it}; m n me ‘ 171 - as x'-8)~3h1 firth; p¢.60m. Pursuant: and 8 .1. .. 1* _ 5’ 5’ 53 35 51; V art-1‘11. .99 s > 22 1‘ �ms]: Mutts-ant awn-«um: human on stun m" haunt 01' lap-11.13““!!9mm . ant-cum - " - W1- mum xumm at man mm "finalising " .. ~ 1 8m mud» " . n: - W 5.10.“..- uts-«mug W ti m. n- w m u m E ‘0' M 0" '3' m a a a 00 IWmfi tar man a... a 94. .05 H vs: .01 �IAflLE G0 vnasxox 0! 333313033 BISCRARGfl BIAGEEflES 1- n¢prota1v¢ raaatinn flarciiatatic Portannlity 2. Anxiofiy Rotation 6. I IfiCfiARGE E AflBBSEB GEIIRSL CL‘fifiIFICAT . ?nyohanaaraa15 narcissistic Forv¢aa11ty Plyahounurccfiw Hareienistzc rattannlity Faruuaultty fruit Diufiurbcuc. Strainalutia rtrlantlity Alcahaltsn 0hrnu1¢ Infantile Pattonalihr; Sflflififin$h1¢ Paaaiva Aggrnaaivc Parsonllity Aleeholian flociopnzh1¢ Parawnnlity . Infantila Pernanality schisephrenio finaniion s¢h$ao~1££¢ut1vo typo Parsannlity Disturhiuua Diuturbanca schizophrenia Payabalin �IABLE ‘Gnflraattlvz 8311308 0? OLIRIGAL fiDRBITIfifl oa- Rauniugor 39¢IAL ADJEEIEEYT 7 it QIKB 3 3a Killeida fiflfifi Raaavnrfié atauvartd Inprnvad narxodly Inpravud Improvwfi Rumh fininpravwfi Imyruvnd nodnrntuly Inpruvul flainprovod slightly Inpretnfl ‘~ stancruax Imarnvad Uniaproved agggaena. ¢auwlnfin Rtmianinu :upmuvsa fluthuaaud (yr werua) Uninprovid �Iutnrinatitutiuuul ntfturauea in Solaatiuu at Iggltmnng . - .wt_ _m1e . w. m 21 h: :5 I! 33 6h 6 mm as 53 a x2 «52.3 a: ”guru 9 .1, �taggg Infiorinstatution’l Ditrcrnneil (5 o! 1n itiliilti Duratiuu of not thjuatu) month: in gougital natitutian x? 7*11 1? 0 aka 22 13 65 ”K 27 h? 31 unac 6? 2? 5 :90.6 a: -k n �taggg Intarinatttutional Birrnrcnuau in Dinahargu Ditgnaoin Dingnaatte fiatcgarius (Par agnt) Iantitutlou fl at; me :3 '23.8h a: sh fi { t 001 Payahoncnroaia aha Purtunuiity Disardvr Atrsuttru b3 52 s 952 ‘ an schitophronis 171: 85 V ‘ 52 as 22 Sh 29 16 �fitgfifi Inttrinotifintiennl Ditruranuts X 1n niachar a Evaluattan niacharga Evaluatiau {?ar cunt) Institution W RIB fiflflfi x2 «29.3 df 'h p,§.001 linororeé, Inpravgd Buinpruvod 1 80 19 :3 62 15 nnd Each 1 srgvod �. I. . ,2 ' ‘1‘ ’ , . ' ‘ .. ' ‘ ‘ v I 6) z 'u m 1&1 tum-au< 2" ‘ �WW“ m m, rum. tuna, m my» my. Int-m 1.. mm, mm», “I 3.9. mmwwww maxim, “My m, hM;WMfl~mdfi-meam mammals-nun; m, mmmmmmam. lulu .10 mwammamwmmam ume.r.wmwmumw am.» am Palm mm, W ‘w W T 01’ n.’ : 4‘bv at 1.2. �MWWMuM“WMW¢(Mm mmmfl)mmmnmmmm nmmammmmmmmm, wmaummnmmmmumm umw,mwwmnummm “Mama-mm“). ummmam mnmwxmwm wthatwm‘w Wmmwwmmu ammmum. hmmmmmwortm mummmwwmumwuw. hmmswdmnnmmmmzmmm* «.me mwmm mu �“w- 'ml‘tvflivamu «mtmummmtmwm mawwm‘mmmmm I. “mummumummum. mmwuumummwmmu umumwmummmm,w' ¢J.rwmmmwm.u'mmm mummmnummmmm mmW-umummmammcm nmwmummmmum mm smwummmwmmm. mu. mmmuunwmmmumw mmmwwm m,mmmmmumwn~mm .am‘m. ”mmmammm “.mummm mmummmmuammumm, m,mm3m,mummmwmruuu ’ummmuwaw,mamm mtmmmum-m. mama-rum �mmmmmummmmm (an ummmmmmamm. mamm,mwmmmmm. mm~Wmemmalm,mu ::*:W~*”M1m*~” “WW MWWW:WWW,W3W «mmm‘umwm madam-Worm ,I. W W,um.mmummmm �mam-.nmmmmmumm. wmmmumuwum, t.) W ;_ :' 'm ”A a m “1% M W mmwummt ammmmmmum . . «mumu‘m mum-«mm mafia-Wum‘ mmmumm mm,mmmmmmumm «WWWWMxm-uuwmm Wuamuwmmmm, maummmmumutm mmmummmwmm'mu ‘ E§~ �lvmmm.—v m- n. 5) mm mmmmmmmmmm ummmmwmm mmmmmmmmmmw. meta-am. mmammwmmumuvm ww_mmwmwutnam mmmflm. MWWummm «um. nun-mm mm'mumowmnmum. uwmnmmmmuumuwlmmm. mummuaamw. mamumum mummammlmmmwumammmmt ummmmwamdmmwmmmmm mmmwmrmmmmm «mmmummrmmm. (1mm. WI! mmammamm,m,m �, mwrm—W“ W" mmrsuummmmmumum gammy. W: Mm‘mflflmuthmiu maximammmmm. mwmmm I») Wm'mumam;nmunmm Mgumwummum,mwm. a: mumummummmuw s) m: m,uummnwmmmmmormm mum-m umammmum ummmnmmmwww,maflmm mmmmmuW-mmm a) ' nummammnwmmm.(ma: (1)9393 . ”gm: awdmnmumm mma‘mWIMMW. mini-muse: mmmr'mwnatwmprmuu masoummmmrmcnummmnmm‘ “tn-“aw hm,anpx-mtd wmmmrmwwmnmm-Mmum mm”! m,m>mwmmmmmuenu mmumm,uwnu¢mmmmmum 1 mummmmmrm. WWW“ 'msmmmwummormmm �mwmmwmumm mammal WQMMiWMWM“ wmmmmmmmmum m, ma—mwwmmnmmmmm‘ mummmuu‘mmmmwu mmmm,mwmm. mmmwmm,mmwm“ mummm-Wmm,mmnmmw ummgmmmaomwwm. 'ummumuw, mm,murm mwmuwmm(mwm rmmwwmfimmmxrm «mummnw,uapnwmp WWW hummus.anme Wit:Mwumwmmmamum MM? Mawufiamfi #mée twat HS? MMWWWQ WWQM Wfiflflfl 9W“. �MI ‘ . o‘lo'u mammmmummammm vamwmu-Wnamhuwum WW,‘WM1§WIIW{WUMMW www.mm-ammmmmmwm;m. W? m mummammmm mummmmmmmmmmm mum y‘ ammmmmummmmsm. mm mwmmmmmm,mmwmmuw mmmmewmuw,ummm �WW # mustmwmumunutmormnw. mmnzaurwmuumumummuua, “snowman-Man. mmmumnmutum Wqummxmot-ounmuumuuu o: than 'wmm.m Willi-Ind mam, um mum m toners, It mthmnhtmumutmlmttmm M m,mmmmamxuutmuhrzmmu the of exam mid. new swam M, mm mswhmnmmwmsm'smm,emm, mmm‘m,um,m.,mwwmmu,mm tnmwmmmumumummmo: flu mam mm tom of W new new. th; 13 .mwumanmummmumrmmth-thum‘mmmmmmm “Wummmmnmmmuuutm mew,mmmmmwwmmu unmummmmwmmmtua wuawmumuummmmmmmw If utmmm-mumnmmutwmmmr. mwmmuummmummmm mam,mmmmwmtma mm. WQMtMW,h-mttmmmmmm �gm. anmuquw. Mmumwntmmmwm nm,umm,mnmmmfimmuum. um,uuuu MMWMtwnmmm,dmahusm deMW‘Ifi-Wamum m,mmmmm~mm«m mnmummtm Mmmumu mmmmmnnmmmmmm,n mmnw.m¢mmmmumm. hwmw tin-mmmmmmmmmuwm gamma mmmwmmm mmmumwa mummw mmm,uuwmmtmmummm ma “stumwmmm'wammnmmw ammuuxmmaw'm‘ammmmw WWMH‘WW,‘WWWWK �”V 1 “.17.. —-m_ — mmmmummmmum- -Wamwwmmm gunman -w—rv-v-rvv a. 7—WWVVWWW_W—.__. ummnmmmm ”.mumww,‘ mmwwwwuwmm 7m "— WWW—v N . 0w _ “A .W ..,_,.mw_.—....,.r,.,.- ww-v. ”u'mm*w “Mwumw (M‘m‘ m W‘i ”thawum W mmmnmmwm,mwwmmm mmamnmmmammm mmmmmmummmw «mnwammmm,m~wmm awmmm,m,mmum “at mmm,mmmmmumm J t; " �",wwww w .7"- wry—«W... ..”___,__, » «- .w‘ 3...; Amwmmmnmmwm, umamwmmmmnmm www‘wvwa WW «p—w‘wmmvw—WW mmammm,mmmum WWW-w ”.7“ ~ .— WW. �TABLE I - Redesignation of Discharge Diagnoses r . .m. ._...- in... Menninger Discharge Diagnoses 1. Depressive reaction Narcissistic Personality General Classification Psychoneurosis & reaction Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait 2. Anxiety Narcissistic Personality Alcoholism Chronic Infantile Personality Passive Aggressive Personality Alcoholism Disturbance ' Sociopathic Personality Disturbance Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction Schizo-Affectige Type ~ " Schizophrenic Psychosis *4 . r ., . ' ~ �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL ' Social Ad ustment Recovered ‘1’ MASSACHUSETTS MENTAL HEALTH CENTER Recovered Improved Much Unimproved Improved Moderately Improved Unimproved Slightly Improved Character Structure fiproved Markedly Improved Improved Unimproved Unimproved Szgdrome' Complete Remission Improved Unchanged (or worse) �TABLE III InterhosEital Comparisons for Sociogsychological Variables Hillside Massachusetts Menninger Hospital Mental Health Hospital Center 7% 20 Social ’=121.S df=8 p<. 001 3h Class 3b 5 1970 : . ‘ _ - Age 58 _ _ S2 Y3=3o 9 dfuh p- n.s. 12—15X2'9 <12 Years of Education 16 ” 32% df-h + p<. 51% F 7 OS X"3 2 df-h9 ‘ WWW Score hl SO p<. 001 8 -‘ - --‘” ~ ~ -~ .. x “hm-ave - x-r' row-'t-t'r. «ma-Iv: «cr-r\+:w.-:.wv-'--vvwz- ~‘rwrwg ,..\IQ‘W~("" w my 3‘"5‘WM»WMP �TABLE IV Intel-hospital Differences in Treatment Variables Heminger Hospital Psychotherapy Treatment Duration of Hospitalization Sanatic -(-19— 21% Hillside Hospital -fll)- Husachnsetts Mental Health Center —(-D 36% h3 6h 36 -- 7-11 months 27 11 months Discharge Evaluatim Improved Improved 80 62 Unimproved 19 15 Affective Psychosis Diagnosis 28% Psycheneurosis and Personality Disorder 61 10 �:5” HOSPITAL STAY K ONE YEAR ;P.sTA¥ING,OVER ‘Pfi 8‘1 . 20329 I ~ 6 36' “ ‘ M M - 73 A_ w Hillside Menhinger -‘ . , '61 in I ' BY AGE j :‘35 ~7f 6 I I ‘ 3,0 2.5,; - . 2’0 , 0 . . , 0 0 �7142b, ’- ”‘7‘; aceiopsyuhelogieal 13:11:00 of Pnyuhintric Trontnoat in fire. Voluntary loupttuls Robert L. Iain, P&.D.fi, in: Pollack, Ph.D. lathauxol stag-1, Ph.D. and an: Pink, 3.5. tho Bcpartlont of InpurtHOItal fuybhtntry, lillutdn fro. 61¢: Oaks. L.I., 3.1. loapttnl, Atdud, in parfi. by 29.3% lt-IOOI or the latiounl InItStn‘c’ of labial It‘l‘h. 8.8. ,ublic Inllth aorticag and tho Iguasu County Keats: Bealth Beard. the cacpcrntion of tho stuff. a: the nan-nonalctta mantel Italth Ccntar and the C.?. Hanninacr Nauorial flospital 13 grutctully nokaculodcod. irresant Address: Rivision of Paynhiatry, Haatofioro Hoapital. l.!. 67, l.!. 7!!!! h/62 �In pruvioua coat-payohologionl s‘udioa or leapitcl papulntion a. obncrvcd educatiou,plutu of birth aenlu rut. Iignitiountly 01 galact1on and th‘t scar. fit. 3:11.1do tuck a-pccta an :30, on the calitoruiu I Pointed ‘0 tbs trcntncut variation or trontumut. «11:10.1 disuse-1.. dura‘iou o: hacpitaliuatton gut treatment cytltation. It was ltggoutad at thut tins that tho can. influenco or noelal variation on the treat-cut process Inuit b. observed upon: institutions. to tact this auggontion a: wall as to roylieuto the stud: within inntitutiona, tho prusont study of three hoapitell val undattakta. In a. their study or flu Baron panhin‘ric mutant populsticu. Holliaguhoad and Budlizh rapertud alanifiiaat rtlntlonthlyu button» smut” an individual'a vanities 1n thu 0001.1 pmduu tented 111”". two: at amend uurdcra a: nu- ma «nu-n or pay-untu- duo troatnont cdnintutarod economic status or and tho ( upon tho ). fl. influoaeo o: patton‘ availability or trcnt1ag peruouuol �.-9. van nut fixalndod in this. :tudlua. 1b tact the :01. of coats: factors in tho triatunnt.or hoapttaltaod patients inflaptnddnt or puticnt'l tibiae-a 3nd dvcalnbillty of trnatacnta, I patiout burv.y In: undortakcn It lillolda 1§§7. in Ia thza‘hcapita\. a variaty’ct firockuuut Ibmyifitl ptychoéhnrnpy and organic Ind-n, including individual thorupiua are attllahlo to all pattints rlgardlosu or tags: abilzhy fie pay. In in. tillaido study. Ian. canonfiton and 31-00 at birth cur. utgnttlnuafily nouontatcd ut‘h chain. of trudaaont, duration at honpatglicntaan. alsuxeul diachnrxo aval‘ntiou Ind diagnonlt ( ). It Ill ohncvvod that patiuntn hounltnliuod for th- Ihortnus plrild aura the oldest, had tn. loant cane.» tic: :36 «are taut liktly to bats hut: foreign hnvu. The: wit. prudoulnnntly £rc-find by ouuvulutvo ‘horipy and rocuivnd it. not. fuvauahla diachnrsn ratinga. Ibnngur. unttv. horn and not. sdnaatcd paticnza.uuro hospitalinod fiho lenzuce. puyahofihcrnéy and goaorallr roaotvod trantnd prilntlly fir it: 90020! dischargo rattaga. it. 011310.: (Inter: 0‘3. 51:0 rtluted ta n I.nauru of starcatrpy, tn. culttornia r 80.1. ( ). lxahar I canton Int. tor. o:%ca tound an pu$1onts diagnccod an invalullannl pagthcutn, ruturrua far nonntto shorapy. and hasvttaltaad :91 unartor parted, and nor- Qtttu Uflfi vitae as much Anymovod or roger-rod. it in. 6.01301 to tupont tin 195? .111016. study uuployiug tha nan. procaaursu nnd nongurrtntly ta axteué who obstrvutaona I _ . �.3lnatitnttenu vtth roopact to social alsas. 33o. oduottioa and I to tho scorn. find to relate than. pats-at charactorlttica trtct-ont variahlqs of type if troutsont. duration at hospitalisation, diagnosis A and Ginsburg. evaluation. m enact: a! :11 voluntary. .dult patient. in roatdoaco in than. tuititattona was nadortakou in January 1959. flh$10 lcln1n¢¢r and Hillatdo Hospitals hnd ‘luatary pationta aalr. t 3:311 avatar at tho-e at Danton were anntguod by tho tor psychiatric avalnntton, or war. nc-bcta at aohisophroaxe stat. hounttql group tralalorrod 3 can’t- annual. ter a optoitia ruloarch product. Thane pationta war. cxoludad from the study banana. at tacit non-vuluntcry ntntun. Inch pnttent III :17.» th- cglitoraiu ligation tutti: lctar r 39.1. ( ) on the OOBIII any. the rooordo or dilohnrgod patient- voro untlyucd to dotorninu tho c.0131 and psychiatric factor- ar the otudy. For a mutant. of $03111 glass, the ficlliucahoud �.‘5- 2-tuetor ind-x was 3.06 t of 173 putllatn at ). Thu 81113140. zoo study population consisted at lbaalncor and 95 at ti. rnlationu or Untouchuootta Haltnl flcalth cantor (nuns). Tho study inelndcd «lamination a: in. social to th- paychlutrtu wart-hlcu within each institution, 2h... as wall as butunua inafiltatlons. difficult, hcunvor, boon-no fora-con discunncd below. comparisons were at variouqnnthodologlenl d1:- 9h... difficulttca var. nosQ Infkfld 1n the iatrnhaupitnl anupnrasean, and accordingly, in tin unnlynou a: p-yuhlntpta varinhloc emphasis will be lantttutiana, with citation plannd on tho daft-ronaus §atvoen or lb. intra-tnotltutiannl tronde. Whoa tho otruotnru rcportlnc studs-u fro! a lone institution, at tho houpltul 1- %ahoa tar grunt-d. and 01th:: ignored or Icnttunud briefly. Houwvur, in studying a atranco �a. institutien I“. “at will. I. and author t6 :ttcuptias canaarablo ant: ya. in of tho my allot-«cu but.” “autumn. tclcotod than. tuttituttont an eolpurablo in ‘bnchlag, rtaoarch, and troatunut pryxruuu, we tinc that tho: are unalika atrnct‘rolly in v.11 think influanca tn. data at the study. specific prohlona were notcd 1n dastgnatioul or type a: trnstu-nt, diaguont1a turns and avuluatiau or trontnnnt outcono. a) 90:1 ation a! a at cntlant: Th- critorin for danagatting that a paticut raceiv'd 'pcychotharupy' dirt-90¢ along an natiwtulu, Idling “Remus: «unification aux-nun. At floaningcr Hospital puyuhothurtpy use designated a trogtnaat qdninictcrod an a pro-criytiou ball: by a stat! pcyvhiafiriat, for which th- pattont via chtrgud a too. fienatone with tho ptynhintrta rnnidunt were considered or routine unaiaiutrattva pationt aura. part .0 �.j. it Hillside lsspiisl psyshsthsrspy was astinsd ss viih tho psychistrio rssidsnt. star! trsstasut ssssioas psychiatrisss.¢id not trssii patisuts, but rsstristsd thsir activities to supervising tbs residsnt physicians. it was ths Massachusetts xsntsl fisslth csntsr payohothsrspy assignstsd ss s functiea or many disoiplinss -- psyuhu istris rssidsnts, psychologists. socisi worksrs. nurses sad msdiasi studsats. Portal records a: sash ssssions wars nos routinely insiuded in the patisnfi's rscorfi and to ssesrisin which pstisnts rseoivsd psychotherapy. it was nocsssnrr for this study toss to intorviss tbs reaidsuis in churns washers of o: ssch cssa. b) n ' asis: individual institutionsl disguostic stylus slso Isds soupsrissns difficult. it lbsnisgsr lsspitsl disgussss supisysd ths sultipis svslustss fists caucus asses-sadsd by ths Aussiosn Psychisiric Association hsih Hillsids sad asstsu sun-piss sails toil-Ila usicsry systsss. assorsl st discussss tron lsssiussr sss listsd in 2:51. I, �-3with our ausgaatad aonvarazana into catacortaa nonparabla to that of tha nth-r tan inatttationa. Thaaa convaratona at. an unavoidahla aaaraa of distortion. (statlar abaarva- taona hava baan rapartad by Paaaaaatak and hia aaaocxataa ( ) who indicata that diagnoaaa within tho aaaa inatitatiaa ara alao valnarabla to individual dixtaraacaa anon: ataxiaara). Tabla I fi---“3) ntgoggg‘a gating; of Igggovaaaatn gravalant varied 1n Iattnga a: 1n— foraat and datatl. rho diauharga rating at nanninaar loapxtal aaa tripartite with a aaparata avaluattaa for social aharaatarolaalaal and ayndraaa ahanaaa. I111a1da > Raapttal and flaaaaahnaatta aantal Iaalth cantor had aloha: ntiuga I! in at aaeh which it "a difficult to aaaaaa the ontfibatton taetcr of tha Haaaiaxar ayutaa (Tabla II). for this atudy tho Iaaningar ayudraua rating aaa couparad to tha global ratinaa of tha athar iaatltattana. �.9. fibl. I! 2. aootgzgzggologiog; Vagiablaa Ina diatrtbattan at the variation of aooial 01a... aga, adacattoa and calttornia institution: in praaautad 1n r saala scar: along tha taro. tabla III. a) figg§.;_g;§ggn tiara uaa a Iarkad dittaranaa in tho aaaial clans coup-attic: at tho thraa inatttattona. Nautilus: loapttal tha reputation was At pradantnantly app-r class; at Hillatda laapttal Itddla alas-3 and at laaaaahuaatta lantal Baalth cantar, pvadaainantly 101a: alaaa. h) 553: that. war. as airfaronaaa in ago «attribu- patulattaao. tion in tho institutional a) Eduggtions rho populatzoaa dxttarad 1: tanta- ttaaal attatnlaat, 11th pattaata at naauiagar leapital having not. yaara at educattou than than. at Baa-annuaatta lautal laalth Cantat. 33110 kl ya: want at tho pattanta at also �-19- ha: aat couplutad high ottool, only and 23 per cent 32 par cont at Hillsidt nt loaningur did not graduate. Bittflrcnccs é) {nggggy in ‘3. distributtcu or can on tho annoy-nu I 80.1.. mo obs-nu. titty-cu V 9.: can: or lbnnancor puttautn had only night par cont I In coor¢n below 30, gnu scorn. of 50 or show. ~- thn higher accrue 5.13: associated with highor dcgruos or stereotypy. eaatraat, gt I Inuit, At '1‘! I Boston trout: 9.! coat unto hula: and forty-two par 3.9% had scores Hillside thirtybonc paw at 30 on tho 50 or nor¢. south! the vationta had I uaorol bolaw 30 sad otzhtatn por goat ubOVt 50. In nun-cry, .09131 class ' its a: the ptpllatiun val oblorvcd :3 uncut arr-nun on anticipatod dittorouetu in prudaninalt fit. r 30:10. 2h. 1a ago mutual dtutrlhatioa d1£rtrcnoon thus par-1t tho the institationa. hum-cat «14 not I011 on cigo an: mum“ 11:20:. Then. stair a: troutncut variables along �sum Wm fieduaigflgtion a; D§ge§gggg gag‘noggs M" an mmm nuproncivo reaction I. flnrczsaiatic Foraonality Payehanuaroniu 8. Anxiety reaction larezsalatto Personality 3. lavas-oistto Personality #- latoisoaltac Puruonaltty tlaoholiuu Chronic Infantilo Portolnlity S. Fusttvc Asgruacivc ’oroonality Alaaholxaa 6. Infantila Personality Sohiuophrunsc Ioaotaun antitanltfucttg. typo Psynhalturoais ' Poruouulity fruit niatnrhanco sociopathic Paraanality niufilrbunoo Seatapnthio Pirwnxrllfiy fiiaturbanao achisnphrauic Flywheels �aggzggattvo figttugg gt glgngog; geudition IIIIIHGII BOSPIZIL 33218132 HOSPITAL fillfllfiflflalfifl gg‘bffi CENTRE locovurnd loaovorod Each lproved Eark¢d1y Improved Ingrovod Hadnratoly Inprovod Unznprevod slightly Inprovcd Enimproved 60I§10to admission Ilprlvud Fuehnnged {or were.) HEHYIL �ammonia). muggy»souguzcholofiut 1'3; Yuan“ Hanna. ’nuluhmutn Ear-pun luau). Rum: liming" 30-pin). Gum 31$ 75 3% ' Saul c1». . Au 51 20 as 1? 35 13 1 3h 28 0 S 28 19$ 19! se 59 22 , p-n.l. 23 at Ian “mutton 33-9.? - ' 5.0!. W005 X..3909 did: 9‘ a 001 �m m. _ . i typo of '1'th Psychotherapy W mum t £10,111th manhunt:- mmani 215 Sal-nu 1:3 mm» 36 H1111“. Baum. ’ ; my. mm 36% 21a: 63; 68 - . B �.113. 7:23;;gt510 frogtysnt Vagiuhlog a) Soloetton or front-onto than: tultltucionn, taunt yattoutn 3‘ Ian-13:0: uoapttal rucctvcd sciatic thornpr than n$ flail-14. or "Ric, (fable 2'). caucnrron£1y a cnnllur parenting. or the nuaatuucr patttnia vita 013.004 to rocctvlng payche‘horupyp with a 132:. author (36 Iilica tor-- of treats-at. was an £111.14. lotpttnl - that. spacial doutcuataon tor Itliou therapies sud pationtn are 01:13:21.6 :- rocolvtuc payoho‘hcrapy Iont also. Iafih pattbnt psychiatrist for at nook. 1% pit cant) rteotving :- 10.1% II n priusry trout- tohcdnlod to so. u valid-mt tar... ouoohalt hour session: per 2h; pcrooafiacc 0: pa‘tou‘o rocotvtnu lunatic thorupy, at louatuscr natpltnl (3h!) 1. Isgntttcan‘ly 1-3: than n‘ ot‘hor at tho 0th.! in. houpttalu. lfibflt patient. ulnacad II cahtxophrcntn. thnr. was no atrrurunoo along houpltalo. for 10.30; a: such pationt' at each hospital recoivod notatio for.» of troatnont during �-13. It. hpnplltllsnfilon. 1: hated on $ho thé altroroaogu anon: laltlfiutloua dittorlng attitude. lounrdo gallant; oloacltlod a. puyohonourotlo, bahavlor diaordor sad dcprocnlvn payohoaln. its turn. llotltutlonl b)‘a3glgggg_g‘_lglg;§.;§g§§§ggs «11:09.4 with racy-ct lo pullout'n lcnuth 0: its: (2331. IV). loaning-r Hospital patlualo v.9. hocpltalluod least-t. with 653 a! pntlnnta rounlnlln for witlvu mouth. or loan. cou- ‘1 93304 to 31 par cant lb. 8111.140 pattcntl and only 5 91-: cast or £30.. Qt the lhcauohnnottn lontal loalth Ooutnr. fli- Iodd any of tho clovgn tenth: lull-id. group II but»: urea will. two-thirds of the diachgrsod within Boston and valiant: cor. .1: tenth: of hoayllalllatlaa. In cash hospital. tout pntlanta arc ovqltatod ufi tho tan. or discharuu ca 'lnprovcd* (tnblo 11). ll lounlugar loopttal. havuvur. a blunt: poroautnco (l9!) 0: pttluutn turn rated II 'Inluprovud* and only a tingle psfiluat �.13. woo oollod 'sosovosod' or 'sooh ispsovod'. rho hishost possontoso or “rooovosod' or “soon iopsovod' sstinas (881) sod tho ioooot provostioo st at ‘osiopsovod' (10$) ooso (bond Boston. d) ggg‘ggggg; For otstistissl ossiysis throo diogaostis groupings soso nods: sohioophrouis, ottostivo disosdoss, sad poyohonoorosis sud porosasiity disssdoss (roblo IV). tho diocoostio proportions of pstiosts within thoso groups loss sinilss tor lilisido sad lostoo in that slightly ovor holt discussod as sshisophssnio sad oppsouiootoiy oso-qoostor os psychooonrosio or ottootivo disordos. In sootssst ot Housings: loopitoi, poyoholsosooio sad possouslity dioosdor to: oooooatod . ovos n 1. lo titty pot O 0 o i coat of tho popslstion. 1 Probl Vsriols nothodoiosieol problsss vitistod intro-hospital ototi'otisol sou-potions. lost pro-issue. on tho has of loosinxtul out-or! ssitorio for subdivision or populstions. �-m- ft: oxaaplc. in ecuparo instituiioau in rpiniiou to Inacth or hospital Iiay, vuriouu eat-ct: varied: var. iriod uni n03. it lanaiacar lonvisui. Clio-04 for coupIr-blo distributioao. oat-quarto: at tho pationto runaiaod turn: Ina SII~thrdl taro than tunivo Inathu. its: auto: suntan, it Insoashtlottn ncnini laaiih easier, in couttuot. 70! at :11 paiioatu ro- ttinod 103! ill: ncvca months, and only 6’ :99. than tapivc Ionian. Anothtr aspect III tho oouatriotica of tutoroconoity or the population sulpic. In in. Boston group, tho crucial rooturoh patient. and th- uonrt roturrais sure hath dnlotod. in contra-tins tho_1957 and 1959 xiii-id. papuiutioa, II ob-orvad n uicaitieant accr.ano in it. an. o: oomvuinivo ihorapy its and an at pniiulia under tho :3. o: to. II. number a: cit-r patiouta, inure... in the coupurnhiiiiy a: as. group: in tho turn. halpitulo in this I‘Id’ lakes ihat similar pron-cunt lay lattes rumba! have oocarrod in it 113.17 in. fire-cat and lonuiacor populatioan. than ducrcioina tn. rang. �.13., e: file diecueetie, treatment In verieblee. end ecneetieuel elnttleu, Iteeiug tutorletlea eeelel oleee an lefierntuetaeqlee e teeter in vitietlng £ntre-heep1te1 eelperteeae with sate variable. In deteretetux eeetel eleee enere wee tater-eeiee W eveileble for 29! e! petieute. thleeetrteble eeeee 371 occurred where the edncetlen o: the huebend e! e heueea site Or the tether e: e miner wee ne‘ reeorded. alibi: these letheeelegteel ltnttettene. e number 0: the latte-heepltel eelperleele rare of eizatfleenee. With recerd to selection or treetleut. age end I eeere were significantly releted et Healteger Ieepltel (elder higher r aom pan-nu therapy) end 1 Score wee were frequently end unsung eon“. releted te zreetnen‘ eeleetion et I111e14e. In “eaten-u evaluation. t. ere an e teatime: tor older petten‘e te be re‘ed better then younger euee et lilletde' end Benton; but at leantncer there wee en eppeette trend. �-15... with oldcr ptttoato nor. likely $0 be rated tninprovud; finial: 0: .3. Loasth n: haupttalllnzttn and tho causation III. loup¢tols . rolutod st .ai Itll-tdo tho youugur IB“XCOI oduoatod putts-ta riulntu; tar tin luacont parted. that. dunonatrntod In in Danica (13b1pa$1sa$s Ind-r rilntionahipn 1% bo‘h tho Honnlatcr un‘ V) Whiz- such ruluttoanhtpn two hoart‘nla, riot. a. vnttcatl I 01:11:: it. trail 070: be. but 13 noted 1&1 a: as. to taunt: loucor than/n 70.2. 31.11:: It. for education, and for diacuousl. 30%04 abusinzor noupttcl the poroautaco at pationtn with fiho dinxnoain at ouhtaophrausu.uho wore hoapttalinod ova: an. yin: II. 911. at ltlllld. [capital laltal luulth cantor 7!. C...”rablo V 35‘ and at luaucshlcotto �# .W IGRPI‘I‘IL ”fill“a; 0: 53! an. Mon to 3H! 3'! £63 21! £32 6501!? 8131136 0785 W . ‘0 .35...“ M 81. ha 73 36 6 30*” 61 30 6 ho-M so to o 50 o 36 o o tan-29 11: �.17In thin nonpartgon of this. vquatary payhhtntria hocpt‘alc we have obs-trad significant tu$ar1act1tutzoanl diff-roast. or pufitcu:a tn ‘hc social vurxabznt or want. a: oduaa$1on tad .00131' .1305, But not .50: a: itafiribufiinu o: calitoruta r anal. sacral; Ind ta ouch a! fiho irnuIn-n$ variation ~~ duration at haupl‘oltunitaa, noloo‘ton at invaalsl§a and dia‘rtbutaona a: (taunt... uni dischargu Isuzunttnnt. in. oxpoctn‘ion fihat the institutton carving «99¢! G1.il pattnuts vault but. the long-at durattou o: otur: I uschu! pvoporttan a: payuholourotao Gianna... and nor: ooupluu diagnosfific nah-nuts; lunar preporttoa a! patients requiring organs. turn. or thavnpwa and peasant ditchuruu 1:31:30 use. each contarlnd. 81-41331!) tho tuctttution serving lav-r clan- putioata lvtnoad Ibortar purtoda at hocpttnllnutita, 10w proportaaua at pay-honaurotio cinema-us. and bot‘ar 41:03.13. uvnllafiaonl. In addition, tho diatrihitt-II at r 30.1. scorn. anon; tho that. hn0p1%aln tollaund tic arising: atllaidc it‘d: in that low accruuurc lost uhnrtn%¢rtnt1u at tho upper :1... group, and high score: at the lava! 0130-. 1951 mam. n: mu»by ropltoafiaon 3% Islamic; $fl 1959. a: null no tntvn—tua‘ttuttonal ‘ a. “mg a «m:- m am analysts 5‘ tbs ofih'r fin. holpttalo. '0 VII. intuucooutul. It. ‘33. tuttod to anhlcv: a‘a‘tn‘ionl Itgnittonacu. in part huaunuo at variomy or no‘hodologtcal prohluun. bnfi th- trcudu of tho lafia I?! 01-11:: to the ortxtaal study. . �.18. wall- theee etedlee have egeln eupheeleed the rele et eeeiel tedbre 1n peyehletrle tees-eat, we neat. have been lepreeeed by eke letheeelezleel preble-e e: etedleepereee laeeltetlene. theee leetltelleee were eeleeted tee their edeeetlenel leederehlp end eke expeetetlea thee the recorded vertehlee would be eleerly defined. our dirtteelelee 1a errlvtec et eoapereble dete ere invertent euee to the preblee o: the eeeventlenel eee e: eeeperettve eeetletloe. eepeelelly treqeene in the evelietlel e: peyehleerie thereplee. ihe eee e: dleeherze retinal, alecueeele eleeeee or length or heepltelleetlen ee craterle in therapeutic eveluetleue er ldeatltleetlen the e: eeepereblle populetloae ere enhaece te exceeelve error enleee eke tee stainletrettve peteerne. lnetlteeleee ere eleerly eetehed The peredexleel neenre e: e fellere te eeeeent for tneeltelleeel idleeyaereelee be eeea 1: e llterel :nterpretetlee e: the 1e to observation or sale etedy. fhe Refinance! neepllel bee the leet highly trelued �.19. par-onuol conducting trontuant thick to applied fur iudtvtda Optimal port-dd utlly Outta-a. ti. 10:33 propnrticn at tinny in population. with diagnaaud 1: an unfavorahlo prognostic grasp (nahtnophron1n1 . - and rut. tn. proportion of ruportod (ivornblc traatlont rouulta 1. tin recruit. It lintll lanlth 10.3% cantor, 1a contra-t, that. th-rnpiltn apply trout-nuts tor its atlluahunuttu an administruttvaly t'utnod lilatod potted, to a populntlou with a hithcr pruportton diagnouud an tahtuophrunta. the propor$1ou or Ihorco rafianaa :- than. dhnIrVn$£ann tarornhlc III-It: 41-- otgnatto-ntly grants!) 1‘ to yrobnhlo do not garlogs %hu% the thirapoutlo efficacy a! «a... tnltatuttann. but ludioutnn differ-aces 1n oritnrtn or ilprflvnncat. this luck of clarity in dilanos%1c Ichcuatn and 130.!- pnrthtlity or pnyuhiatrac truinant 1:31.310: :10. load. panic tn tn. attc-ptcd comparative stanzas 0: psychiatric tbcrapioa. for tun-win. tho rlIh or roounfirntlurcn o: �.26- hioleslatl caloutlltl to contlrn obnorvatloaa and. 1: othor laboratorlou In: bu as such a rotlcntlau o: dittoruaec. in popnlttloau. payehlnlrlo orltarln,'g§g, an fallout.- 1: the original hapothcuon. the widcaprhad “cohltophr'uln' or ‘puyahououroslu' II. £0 at Utah turn. as caplet. tho ohnngoa in payuhdbatonl or blclogluol tosGIrOI with mental 111:... ha. 1.! to a totals. burdcnod by nasatSVI result: (lullnk). coat Ijrkad ruouutly in lb. atatlletlng stadium at taste: in anhinophruals. physiological ~~ and tho lneonparnblllty bohuvlornl corrolntlona Icon 1. (runkuuulnln) and meantiou threshold tutti. Sven I It'll at the t3. Incholyl turn I 1.111 ohnurvntloa to b. roportod from on. allnlo. in v. is!- II‘hOdl twillablo to doccrlba povulctluno adoquntol: lo provido 1 00.34 ountlrun‘lon? 270: than. obocrvntiaal at icllavu ao‘, and concludn tint lucrtnuoa attention list to p.16 to the nothodlocloal problana of clnaaltylix substatby 'objoativo' criteria. rcthor thus ta. pro-oat lathe!- uhlnh,uppo-r to ho so highly dcponloat an inatttutlonnl �-g1. :ad ohatrvur nttiiudul, and tho nociepoyuhoiegieul nspuctc or it. thorupintapnsiont intcraction. studio: :13. highlight the situate of changing !hnuu populatidns on Iinilnr mind: than italics. lillnido lbnpitsl rho peasant that: rich! soaiopayuholocicai~troatlcat rclntioachipu it. 1957. rufloo‘inc. I. btliovu, a constriction in tho typo. fit trout-out. and th- .30 runs. at tho patiuntu. flora in; a nicnitiegnt rnduoiiou in the inure... in Icflocting anon oduontionai iovdi an 13010... in noun use, and as o: its population, it. nunbar of aJQIOlotnt and 33.33 aduli patients. baring in. in. yaw! purine, that. can 31.0 a untied voduoiion in tho incruasc in czalndnd was iii. it. nan u:- o: couvuluivv ihar:py chain. in the 1957 Itudy, wail. tho aoliacnt lunatic truatloat or thin study. at in. pvt-ant study, and a z: at poyuhatropic 4213!. art; ihorupy In. :- s irontlaat ‘OOOp‘QEQO and dittttcat ii had both a crcntcr it it the stuff psychological mooning than can. vulaivu incrlpr. Ind hearing, parhapc a diff-punt mulbioachip to attic! variablnn. its availability at an ottoctivcihorupy �9.2;. (or viauruua tout tor sinusitiaation) nay liaidbo in. intin-uco or uoeial «in-I vurinhlcu lliiin‘ahnad Ina lodiich (bund clans aad typo a: truttnayt did for tho oehiuophroaiaa. 317.3 dial-cu, than in n rolatittly ottaoiivu, n0 on iruatnnut. Etna. rulntion intros: loci-1 tar attentivt 'fhil payohoni: but tho: aficcontc that trail-at mils“. it, which inaxp-nnivu and tachaically for a i. lilplo. 01.0: ditfnruueun nay ho Podtcld, but not niiuiaafiod‘. 2:11. that. inter-hospital dittoroncoo 8‘! he loak¢d initial liliallc inirn-houpitai ‘ um. um peanuts.» and It. iatcrauiin DIOOOIIOI and expectation! of tho atndy. Xt_io our i-pr03Ii0I. tron-out mm “bun-hip. 1.9301: Invited iron tint: and authoriticu it. .ttiiudoo uiilil 0.83 institution.‘ thug. duration or patient tiny. Ginsburg. rating, type or transient anniniotcrod ind diagnosis are In �-52.. dutcrltuod an Inch by ‘30 attitude 6! the phyuiotnn and thy hanpttal niltcn 1a which tho‘pcsinlt rind: hilonlt. a: In: acuitollntion o: uyupttu or history which in In: pros¢nt. snob ralntionshapa ooaditlna tiara will he host lurkod in than. psychiatric that. diagnostic critnrin at. lunn‘ 39.01119. 5‘3‘, tho obaaoQavu «9:53:13 aloostntod with 4300.... hats: arcs-10 inpuirI-nt arc ahacnt, at an an achisuphrcuin. plynhancurolsn, and pcraouazt‘y and bohavior disordcrc. Vain: conditacnn or anbtcnitr tbs obcurvor'l internal can. (ntttwudal. alpoctttionl) hood-o and by clansiticatton hamlet, ( tic ball. for pyrotptton ). this via: 31.1%: and 1.1!“! 1!: was clonrly douonu$rutcd flair study of vandal in dingao¢1u within a £13315 institution. Th0: dbuurvod that 1: pnttnuts rials-1: assign-d to ditturoaf lords inns powulattonl d1! not 6111.: in sang it Idlllltin, Inrttal otntnn. vasecttla. as. or contain... stxusftoaa$ 41:211-300. 41¢ occur, hcvcvnr. 1- 13014030. of diagnoses anon; tItIO �5""? mg “m ammuuun- in on an. u that unman- mo notably at “he.“ in the mmu». I. an.“ they at largely "nuan- of tho “«Nu. and uts“: at the Ian-1:0". �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary HoSpitals Robert L. Kahn, Ph.D.*, Max Pollack, Ph.D. Nathaniel Siegel, Ph.D. and Max From M.D. the Department of EXperimental Psychiatry, Hillside Hospital, N.Y. L.I., Aided, in part, Mental U.S. ‘Glen Oaks, Fink, Health, Mental Health Board. by grant MY-2092 of the National Institute of Public Health Service; and the Nassau County cosperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully The acknowledged. NOYI * Present Address: Division of Psychiatry, Montefiore HOSpital, NOYO 67, �Recent community studies have demonstrated relationship between social factors and psychiatric treatment. In their study of the New Haven psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated illness, types a of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, a survey was undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,S) it that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily by psychotherapy and generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients was observed �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aspects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions -Hillside Hospital, the C.F. Menninger Memorial Hospital of Topeka and the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and education. Each is a teaching hospital with a full time supervisory staff and active research departments. They emphasize psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD these in residence in adult patients census of all voluntary, and Menninger While 1959. institutions was undertaken in January, of number small a only, Hillside Hospitals had voluntary patients (MMHC) assigned were Center Health Mental those at the Massachusetts chronic a of members Or were by the courts for psychiatric evaluation a for specific transferred group schizophrenic state hospital from the study excluded These were research project. patients A the patient because of their non-voluntary status. the months later F Eighteen California scale on the census day. social the determine to examined were records of discharged patients and psychiatric factors of the study. For a measure of social class, Each was given and education of score the Hollingshead 2-factor index - weighted 173 of consisted The study population occupation - was used (2). 95 Massachusetts the and at 100 Menninger at patients at Hillside, a Mental Health Center. social the of of the relations examination included study to the psychiatric variables within each institution as well as The between institutions. These comparisons were difficult however, These below. discussed differences because of various methodological and comparisons, marked the most in intrahospital difficulties were will emphasis variables of the in analyses psychiatric accordingly, be placed on the differences between institutions with citation of to missing led also These difficulties trends. intrainstitutiOnal information for some data, which is reflected in the varying population sample sizes in the tables. �RESULTS A. Inter-hosEital Comparisons l. Methodological Problems institution, the reporting studies ignored and either granted for taken is of the hospital structure institution a strange studying in or mentioned briefly. However, the of made aware is one data comparable and attempting to gather these selected we While institutions. between differences many pro— treatment and research teaching, in comparable as institutions wh ways in structurally unlike were they found that we grams, in noted were problems Sp‘cific the of study. influenced the data the and classes diagnostic of treatment, of type the designation outcome. treatment of evaluation desigfor The criteria 8) Designation of 212s of Treatment: the among differed "psychotherapy" received a nating that patient When from a home difficult. classification in uniformity institutions, making treatment as designated was At Menninger Heepital psychotherapy for a psychiatrist staff by basis a on prescription administered the psychiatric with Sessions a fee. which the¢patient was charged care. patient administrative of routine considered part were resident treatment as defined was At Hillside Hospital psychotherapy did Staff psychiatrists resident. sessions with the psychiatric to supervising activities their not treat patients, but restricted charged. were fees No additional the resident physicians. �-5At the Massachusetts Mental Health Center psychotherapy was designated as a function of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American PsychiaMMHC and both while followed unitary Association Hillside tric systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. c) Discharge Ratings of Improvement: Ratings of improvement at the three hospitals varied in format and detail. rating at Menninger Hospital was tripartite with discharge separate evalua- The a tion for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study-tho Meaninger syndrome �rating was c Sociopsychological Variables age, of social class, variables the of The distribution institutions three the among F Scale score and California education 2. is presented in Table III. M social the in difference a) Social Class: Hospital Menninger At institutions. three the of class composition Hospital, Hillside at class; upper predominantly was the population There was a marked predominantly Center, Health Mental Massachusetts and at middle class; lower class. b) Age: There were no differences in age institutional populations. distribution in the attaineducational in differed 0) Education: The populations Menninger at education of more years having with patients ment, hl While per Center. Health Mental Massachusetts than at Hospital 32 only school, high MMHC completed not had Cent of the patients at not Menninger graduate. did cent at 23 and per Hillside at cent per of distribution the in differences F Score: Significant d) cent per Fifty-one observed. F were Scale California the scores on �-7cent and eight per only below 30, scores of Menninger patients had associated F being scores with scores of 50 or above -- the higher thirtyHillside at In contrast, with higher degrees of stereotypy. MMHC while at 30 below F had scores one per cent of the patients F 30. below were cent only twenty per the of class social the in differences Thus, the anticipated These differScale. educational attainment and performance of relation the concerning the hypothesis testing permit ences insti— the among variables treatment the to factors sociopsychological on the F tutions. 3. Variables Treatment Psychiatric Among Treatment: of a) Selection institutions, significant- therapy somatic received Hospital Menninger at fewer patients ly IV. Table shown in MMHC (68%) as than at Hillside (6h%) or differed The institutions three b) Duration of Hospitalization: IV). (Table of stay markedly with respect to patient's length longest, hospitalized were Menninger Hospital patients cent 31 to compared per months or more, twelve for remaining patients the of those at 5 cent of the Hillside patients and only per Hillside the of modal The stay Massachusetts Mental Health Center. the of two-thirds while months was between seven and eleven (h3%) group of months hospitalization. six within MMHC patients were discharged were most patients each In hospital, c) Discharge Evaluation: At IV). (Table “improved“ evaluated at the time of discharge as �-3(19%) of patients percentage a higher Menninger Hospital, however, called was patient a single and only were rated as "unimproved" "recovered" of The percentage highest "recovered" or "much improved". of lowest proportion and the (28%) "much ratings improved" or Health Mental Massachusetts the "unimproved" (10%) were found at Center. groupdiagnostic three analysis d) Diagnosis: For statistical and psychodisorders, affective ings were made: schizophrenia, The diagnostic IV). (Table disorders neurosis and personality Hillside for similar were these groups within of patients proportions schizophrenia as diagnosed were and MMHC in that slightly over half disorder. affective or psychoneurosis as one-quarter and approximately and personality psychoneurosis Hospital In contrast, at Menninger the of population. cent than per fifty disorder accounted for more B. Intra-Hospital Comparisons Problems Methodological l. by limited were comparisons The intra—hospital statistical lack the was Most prominent problems. methodological of a variety of subdivision the for criteria cut-off statistical of meaningful within the of population due to the homogeneity populations, in part analyses the In statistical size. each institution and to the sample had which obtained were cells several within a single institution �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were trend two a in these was noted at the significant hospitals, similar MMHC (Table V) where no patients over ho, but lb% of patients under the age of 20 remained longer than a year. -—-_------- �-10.. DISCUSSION we hospitals psychiatric of voluntary three In this comparison of differences patients interinstitutional have observed significant but and social of education class, of in the social variables years of each and F in Scale scores; not age: in distribution of California hospitalization, selection of the treatment variables treatments and distributions of diagnoses and discharge evaluatimfih The expectation that the institution serving upper class patient! would have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata,10W6r proportion of patients receiving organic forms of therapy, aM'poorest discharge ratings were each confirmed. Similarly, the flfititution serving lower class patients evinced shorter periods of howitaliza— disand betwr low of diagnoses, psychoneurotic proportions tion, charge evaluations. It is our impression that these differences in psycuatric treatment are more related to differences in staff attitfles than to differences in population samples. The contrasts betweeninstituthccomplexity. tions in duration of hospitalization are great, as are of diagnostic formulations, discharge evaluations, definifions of details and amount of recorded data These and the psychotherapy, stylistic differences cannot be dismissed as merely idiosywratic since they follow a pattern related to social differences mnsistent with previous findings. —- duration of �-11- treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such population and history which a patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi- fication. This clearly demonstrated by Pasamanick, Dinitz and Lefton (7} in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did view was occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are reflections of the attitudes of the examiners. largely It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources At treatment results. the poorest and favorable factors, it reports MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher the reported classed asschizophrenia, of the population proportion treatment results are the best. the does relative not reflect study this that probable is It Our no furnishes data of the institutions. therapeutic efficacy the which provides hospital for determining independent criteria better care; nor for assessing the comparability of the population the based on evaluations the Since are of the in degree illness. institution‘s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) it Was postulated that different criteria of improvement were utilized for persons of different social background. It was suggested that the higher the person's has This employed. the complex the criteria more social background Manninger‘s using with the confirmed study, in been literally present two other of the the global rating a tripartite rating compared to which our on Even syndrome the rating considering institutions. contention our is were based, it analysis comparative statistical in improvement to we assess lower apt class are that for persons work, resume to capacity the symptom patient's relief or relation to while for upper class persons the criteria stress such complex �-13- intangibles as "developing insight", or "working through one's problems." investigations have again demonstrated the role of social factors in psychiatric treatment, we have been considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it diffi— cult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The wideSpread use of such terms as "schizoWhile these phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. reported from one �~1h- Increased attention classifying subjects must be paid to the methodological problems of criteria rather than the present and on institutional dependent highly by "objective" methods which appear to be so of the and aspects the sociopsychological observer attitudes pist-patient interaction. thera- �-15.. SUMMARY and CONCLUSION hospitals, variables. treatment to related were characteristics population F and education score, social by defined age, class, were Populations and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. in observed were differences 2. Significant interinstitutional and education of characteristics of patient social class, years F of California scores, but not age. distribution 3. The variations in treatment characteristics among instituthe in predicted different be found to significantly tions were direction. a follow pattern practices in psychiatric h. These variations and are institutions among differences class with social consistent not regarded as being idiosyncratic. of make comparisons S. The differences in institutional style between results and treatment diagnoses, duration of hospitalization, need more objective for and the and tenuous, institutions difficult emphasized. is of populations of classification criteria 1. In three psychotherapantic-oriented teaching �REFERENCES l. Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New York, Harper Brotherg R.N.: The Authoritarian Personality, 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo- graphed publication. 3. Mental and Class Social F.C.: Redlich, & Sons, Inc., New John Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: 2., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Ho 5. Arch. Gen. Psychiat., 6. l: 565-57h, 1959. (CaliM.: M. Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, Scale) fornia Kahn, 130: 187-192, 1960. 7. OrientaM.: and Psychiatric S. Lefton, Pasamanick, B., Dinitz, Mental a in and Treatment to Diagnosis tion and Its Relation Heapital, Amer. J. Psychiat., 116: 127-132, 1959. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Impr oved Markedly Improved Improved Moderately Improved Unimproved Slightly WW- Unimproved Syndrome Complete Remission Improved Unchanged (or worse) ~———-————-—-——— Improved Unimproved �TABLE III Comparisons for Sociopsychological Variables Interhosgital Menninger Hospital ' Hillside Hospital t I Massachusetts Mental Health ! i t t Social Class EIII % 17 3h 13 i g § IV v 1 E t 28 �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health {Hospital Psychotherapy Somatic of Treatment Type 68 Other 8 1 . as”ii.ii.ii_wmm.mi“iiiiiiiiii.i,__ Duration of Hospitalization i:QfiiéimfiifAL_R$;991MW_WWWW“a. _-._~ _-_rmi...._i__.mwt 7-11 months 1 months “—W.W - came-u «rr Recovered, Improved Discharge Evaluation Much 61 Improved 10 'Unimproved I .. , m Discharge Diagnosis ..—W_-»lnw w-‘W a . df=h§ B<.OOl.~W___ y3é29.3; ..... Schizophrenia Affective Psychosis _ “p M 1? Psychoneurosis and Personality Disorde x2=23-83 df‘h? P<-001 29 *__,m_.__". �TABLE V Duration of Hosgitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR i» mm Below 20 Menninger Hillside 81 73 61 3O 30 20 2422219. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance ‘Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality AlcoholiSm Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �.0". m an.» "mm ”turn M m «trauma in a Want a mu “am“. m. to m: Imitation mums It“ ”'01:“! 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Rejec’t' “1 ram 13 0 ~ 1 o 7 11 3 ° ° 9 11 O1 1 ll] o 57 - 70 7 8 001.23/3 35 > li $7, 2312 Col. 1 ‘1 IJ" | 1 7/01.} TALLY SHEEP 601.26/1 ‘7 ,..,2 Deckf - D11 1 0 1 1 ‘ 0 . / 9 4 . 75" 0011.29/8,9. {Mama 1%‘5‘5 I! I 2 391 3 5 1h 0 o Reject O 5‘3 20111.11 X 11601.26/1 // 2 3 _ — 0. Asa .0 as: 1 111: 1 1 1 35‘ 115 a - r 16 - _ o 1 W—‘i— 01.1 Re I .9.— 1. 9‘ 11 .3- " M-w—«efim 0 H ect 1mm. 01 77 1 55 “_~_ 53 f �Dock: I , “BALL! Qilvcéév 31‘ comes/1 . , 2 a?” sum sol-23k ,Gol.23/1 ” _ 001-23/3 17 3 O l 20 6 . O , O mutt» ‘00“ 6 3 o 3 3 O 33 3 o Reject ICE“. 7 O 3-- o �f x 7“ ,/;.!,/, fl _ TALLY SHEEP g/ 001.2611 ‘7 57‘7“.”— ' 001,237.! 7‘1"" 1" a ! 'i , /’ , 16 h ’* J 5 u fl 7 ,. . ”J--. ., x . . o. V- o . o 2 ~_ - V 0 . 7.1.07 , 0 _-. J ‘1‘ 36 7 , 0 a “I, 74.,47445 Co1.23/3 ‘ 7 ,. Q- . V I 5 7 35"“! 7,001.23/2' 1...,_ 27 . J fiYlI ‘, 2 " bro" Decks" I 16 , i t. .. . . - 57 . . 0 0 , - 13. O I [4' 7 7 II 8 9. 7-07 ll l V 0 I. iii Owfil" Reject H warm. ” “I": afia’ .. ‘ , , . I V. O 0. II. 3 0 O ~ A - D _ .. ~ - , . O , , . - H 4 ’9. {IV/J '11.: farm/1:22.— , , , , .16. , 9 69.19.2311... - . 2 .39.-. 3 S - -h- .0 o Reject MAL X 5‘3 // 2 not“ - .3 - .0 V J.» V. 5 . .35‘ - 0 8' 7 ‘ C? .o . m____9__ 0 f _. - Reflect - __ . . 43 ,a .0 _._V ., 3 , O A -601026/1 - limo), 001.29/8,9. Duh“ - ,, 55 .9— .V 9‘ - .. ,3- «wag—m... 53 / �-3Menninger Hospital, however, a higher percentage (19%) of patients called rated as "unimproved" and only a single patient was "recovered" or "much improved". The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health were Center. d) Diagnosis: For statistical analysis three diagnostic groupings were made: schizophrenia, affective disorders, and psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside in that slightly over half were diagnosed as schizophrenia and approximately one-quarter as psychoneurosis or affective disorder. In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. and MMHC -‘---------’ Table B. Intra-Hospital Comparisons l. Methodological Problems The a IV intra-hospital statistical comparisons variety of methodological problems. of meaningful statistical cut—off were limited by Most prominent was the lack criteria for the subdivision of populations, in part due to the homogeneity of the population within each institution and to the sample size. In the statistical analyses within a single institution several cells were obtained which had �Page 5. COMMENTS BY PSYCHIATRISTS Most of the unfavorable (1) (2) more insufficient " criticism can number of " " be divided into two complaints: sessions per patient paid for by Project patients point, many apparently feel the Project should advertise itself to its eligible subscribers, reminding them of the availability of coverage. 0n the second Favorable criticism was in general directed at expressing approval of the idea of testing psychiatric insurance. There were in addition a surprising number of complimentary remarks about the planning or administration of the Project. SUMMARY typical participating psychiatrist is a man between 35 and 50, practicing in Manhattan. He treats patients in the hospital as well as in his private office, and he also does some clinic work. He has his "Boards" in psychiatry. His usual office fee is $20 or $25. His primary orientation in his practice is analytical and psychological. This does not preclude his prescribing drugs or shock therapy. The interest in the Project is demonstrated by the fact of his participation. If he has some adverse criticism, it is apt to be directed at the number of sessions allowed, which he regards as insufficient, or at the small number of patients who have sought care, which he regards as a reflection of an inadequate educational program. In short, his criticism is generated by his tendency to view the Project as a social rather than an insurance experiment. He feels the Project, Operating in an area where the supply of private psychiatric time apparently exceeds the demand, is in a unique position to promote more psychiatry for more people, which is what he really wants - insurance or no. His APA-NAMH-GHI RESEARCH PROJECT August 30, 1960 �MWQQIPWZMMMWMS. mmuummmumuaumm umm-mmmyutnwmuum mmmummmammw «mummy-"um. mmumtmmmuwm mmnm.mumn nun-1 mm m "WW nu» M m mnflMmMWmuumu-m ml; Wax. m- 1: m», W‘s: ”.mtunmwmmtm.mm Mnmw‘um. mam. uanwmmum.nm ��~19. tut Oil. innfiltution urn vniulruhla ‘u individual dittorunaai among uxaainera.) uwdflflflh‘b an“ “it Tabla fittings at infirOth neat variad in tornat uad antltl. MIR #3: triptrtit¢ Yb: diaahtrmc with a toynrtta cvtlnntion aburnctaralugi¢nl and buhnvtoral changnt. it wan dattianlt tar rating at toc&31, 3R and name had cltbnl ratings in which tribution at taator a: th‘ fldngiaaar first.» (tabla II). 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Uta: (Tibia VI). urn pattnaia houyltulinud tonguut. with éfifi tuttvt unathn aw aura, casparnd pniaautn and «n1: 5 pi! aunt tiny at an. a: pattoutl t; ramuiuing (or 3: par can‘ at th¢ an at ihiifi at Inna. 2k: unfit! an group an: autumn» Ii?in whit. twanthirdl of thc vane pattcntn '18 ninth! wuru and GllVIh ninth: worn «inahavcud within I! httpttfllifiitfilnw &i K?! :nd an lli «at tho inuial‘r:otor utus elatily vtlntta ‘0 luacth or haunt‘nltuatiol rtuuiainc tar sh. toauaut purine; It .. fia‘iouiu yuingar ovary use lcvut, �I. Winn ttruaiurc at thu hmnpt‘nl isnuvud a... is flak.» It! uranfitd. rcpar‘tu; itudtin Iran a ii nautxuaua in¢titutiau 1h» autumn brlitxv. finntvnr, and I3QOHfiflifii and: aunrt a: find inntitutaun. “ad tam titan! 3n studying a atwtnun ta cutuar nanpnrahia data an. an nun: dirzurananu butwafin instituhtaaa. a! an. gutpxtnl argumiustzan twanmnn «no a: sh: naihudoiiuin prdhlqua firtuoiana trnaiucntfi tar nuanpln, bath tit auaa and urn mat. At suns tun at hiVO day an «at: it: hacpital, and 1a ‘hc nttar~¢uru Iu.nauh a ti‘filfifi. ht as; tau! Iran in diflflhlrsi sh: Fattunt {run 8%. hllflhfll fit an chatter unfit, Running £hat to «111 with; be ramrauathiu wharcat unlit, flfiill ttu.i£nc phyciatmu a‘n «at. far I yutxdat an innpattcut, an 933 n11»&a. haugfi‘al at an. dtflahnrca dun‘nr r01&t10n;&19. manna tar hi; putaont‘n,nnr¢; turuaunstan_¢£ shat pn‘iuntn �dc» cu hon, a'mu wanted an my mm. min» pun-sonata on ohm“ u «a. �£03" £in 2:? artootod the colltction and organisttton 0: ‘ho dutn.\fifiQfigfi~ Spacitic problcnn were uotnd 1n dociguntiano a: typo or 1 L}! 7p”; 011/” 'rflt “’ Wm Mt qfl’ U 9/ fl:;;pg{§‘ W 54?” Vlfl” // ‘ \ Q ”uncut, (lunatic tom antenna and «autumn: train.“ a) Dootgnntion or 322. o: rrcttntut: rho criterig tor dalignntin; that n patioat rocutvad 'puyohathtrtpy' dartorod Ilbfifl tho instituttoal, fishing unttornity in claalttienttun difficult. At HIE payohothorupy can designated as ilturod trc;;noat ndm1n~ procertpttan btllu by a otntt paychiutrict, for which tun pationt wan chargcd t I... Stadium. wi‘h in. puychtatrie rolid¢at wort Ionatdorod part of routtuo Idninistrntivu patina: cure. xx it paythothorapy val defined at transient nautical with thu psychiatric recidont. Stat: paychintrista did not trutt paticnta, but rtatriétcd thotr no£1v1ttul to auporvtstac tht ruaidcat physicianl. At the lane psychathornpy was donixnttod u. 1 function 0! many disciplinol .. pljchlltrie runtdontl, pnyoholoututo. loclnl nurture, nurses and :ndtc;1 studonta. Furnnl record: or Inch caution. var. not routincly includnd 1n the pt‘tcnt'c rcoord and to ‘lccrtuin which pationtc rcccivcd psychotherapy, the resident 1n «Egret or ouch ctno van intervicwed. b) an noun Individual Institution}. Guano-tn Itylou Illa and. saupnriaona difficult. 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E fl m” he 4, ~ ' :'*13I:§ ‘ «a 9".”‘ 1“ 31-3 9 ”‘03:: at" .1 it'We” it”$001 “it" 90. � 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 Social aspects of psychiatric treatment in three hospitals: methodological problems. VA Cooperative Studies in Psychiatry, 6:202-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59-001 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 Pollack, Max; Siegel, Nathaniel; Kahn, Robert L.; <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 9 items. 1: Photocopy of publication with Q & A. 2: [preprint]. 3: Draft. 4: The Identification of Patient Populations: Comparability of Subjects in Evaluating Therapies Among Institutions by Max Fink, M.D. 5: The American Psychoanalytic Association Summary and FInal Report of Central Fact-Gathering Committee. 6: Correspondence. 7: Handwritten notes. 8: Social Class. Diagnosis, and treatment In Three Psychiatric Hospitals. 9: Research, drafts, and letters. 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/159923c8867e9781f49e8300e7f3e2d3.pdf 560d0723c8cbc5298ad5e04e592ff291 PDF Text Text 0 Reprinted from the A. M. A. Archives of Neurology and Psychiatry October 1952, Vol. 68, pp. 481-490 Copyright, 1952, by American Medical Association EXOSOMESTHESIA OR DISPLACEMENT OF CUTANEOUS SENSATION INTO EXTRAPERSONAL SPACE MORTIMER F. SHAPIRO, M.D. MAX FINK, MD. AND MORRIS B. BENDER, M.D. NEW YORK MONG phenomena that may be apparent during examination of patients with disease of the sensory pathways is mislocalization of a sensory stimulus. It has long been known that a person with a sensory defect, as seen in the common varieties of cerebral hemiplegia, may inaccurately localize stimuli applied on the paretic side. Such point mislocalizations are apparent in examinations using a single stimulus and have been described in detail by Head} These mislocalizations can be accentu— ated by the use of double simultaneous stimulation techniques.2 In addition, when these techniques of examination are employed, other varieties of mislocalization, such as displacement,3 become apparent. Displacement is the patterned mislocali— zation of one of two stimuli simultaneously applied to different body areas. The direction of displacement is in a definite pattern, which is dependent upon the parts of the body stimulated. Characteristic of mislocalization so far reported has been the fact that their extent was within the limits of the patient’s body. In the course of studies of cutaneous perception, we observed a new form of displacement in which the patient consistently and in a predictable fashion mislocalized stimuli into extrapersonal space. This type of displacement we have termed “exosomesthesia.” 4 Exosomesthesia is not a commonly observed phenomenon. More than 400 patients with brain disease were examined at Psychiatric Pavilion of Bellevue Aided by a Fellowship from the National Foundation for Infantile Paralysis (Dr. Fink). This investigation was supported in part by research grant #MH-139 from the United States Public Health Service, National Institutes of Health. From the Department of Neurology and Psychiatry, New York University College of Medicine, and the Neurological Service of the Mount Sinai Hospital and Bellevue Hospital Center. 1. Head, H.: Studies in Neurology, London, Oxford University Press, 1920, Vol. 2. 2. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724 (Dec) 1949. Bender, M. B.; The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination, M. Clin. North America 32:755-758 (May) 1948. 3. Bender, M. B.; The Phenomenon of Sensory Displacement, A. M. A. Arch. Neurol. & Psychiat. 65:607-621 (May) 1951. 4. The term was derived by Dr. Judah A. Joffe (Hinsie, L. E., and Shatzky, J.: Psychiatric Dictionary, New York, Oxford University Press, 1940) from the Greek 55w, out of; will“, body, and 41709710”, perception by the senses. �2 7 Hospital Center by routine and specialized sensory tests. Exosomesthesia was observed in only 15 cases, an incidence of about 3%.5 The following case reports illustrate the phenomenon and demonstrate some of the conditions under which it was observed. CASE REPORTS CASE 1.—H. M., a man aged 64, was admitted to the Psychiatric Pavilion of Bellevue Hospital with a history of progressive mental changes of six years’ duration. The first four years of illness were marked by slowly progressive impairment of memory, concentration, and other intellectual functions and by increasing apathy to his' environment. In the last two years there was rapid exacerbation of this condition, resulting in the loss of his job as a store manager. During this period his speech became increasingly garbled and stammering. He vacillated between irritability and complete apathy. He was occasionally incontinent, ceased bathing, had difficulty in dressing, and was sometimes so forgetful and confused as to wander into the street without his trousers. Routine Neurologic Examination—In walking, the trunk was tilted to the right, and there was a tendency to drag the right lower extremity. However, there was no significant motor weakness, reflex change, or tonus abnormality. Coordination tests were well performed. The cranial nerve functions were intact. Vibration sense was correctly perceived only in the clavicles and the head, while position sense was lost in the fingers, wrists, toes, and ankles bilaterally. Temperature differences were poorly perceived except in the face area. His responses to touch and pinprick stimulation will be described later. A mild degree of “mixed aphasia” was present. This speech difficulty was evident only by special testing or when the patient was fatigued by prolonged examination. There was a fluctuating dyspraxia of moderate severity. Occasionally he had difficulty in dressing, being unable to handle buttons and sleeves. However, he could perform such functions as feeding himself, combing his hair, and other routine daily tasks. He was usually unable to mimic the more complicated patterns of the hand-praxis tests. An electroencephalogram showed bilateral diffuse abnormality, with decrease in amplitude and intermittent suppression of activity over the parietal regions. A pneumoencephalogram disclosed bilaterally dilated ventricles and moderate “cortical atrophy,” particularly in the left temporal lobe. Psychiatric Status—Although the patient was oriented for place and situation, he made errors as to date and time of day. There were defects in recent memory, concentration, calculation, and ability to assume the abstract attitude. He usually sat placidly staring into space or wandered aimlessly about the ward. He did not mix with other patients. When approached by members of the staff, he was friendly and passively cooperative. Testing procedures were approached with cheerful indifference. When, however, he was pushed into test situations greater than his capacity, he reacted with increasing irritability and tension, eventually culminating in a “catastrophic reaction.” At such times he would become red in the face, shout that he knew the answers but did not want to continue, and suddenly begin to weep. Body Schema—He was able to distinguish the right side of his body from the left, but was unable to make this distinction on the examiner’s body. He had no difficulty either in locating midline structures of his body, such as the nose, mouth, chin, umbilicus, and penis, or in pointing to his eyes. With eyes open he readily found both ears; but when his eyes were closed he groped about his face for several seconds before locating them. He could point to his thighs, knees, ankles, and toes but could not point to any specific toe other than the big toe. He frequently had difliculty in locating portions of his upper extremities. If asked to point to his shoulders, he correctly located one shoulder but then groped behind his neck looking for the other. This defect was even more noticeable in trying to find the “other” elbow and wrist, and greatest in trying to find the “other” hand. His search for the “other” hand or wrist was bizarre. He would look under the pillow or rummage under the mattress, becoming tense and Fink, M.; Green, M., and Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology 2:46-58 (Jan-Feb.) 1952. 5. �3 insisting it was lost. It should be emphasized that, despite the great difficulty in locating parts of his body, the patient was able to name the body parts, except the fingers and toes. This was true whether the part pointed to was on the patient’s or on the examiner’s body. Sensory Status—(w) Single Stimulation: He had difficulty in differentiating between the sharp and the dull end of a pin. This defect was present throughout the body, although he made significantly fewer errors in the face and hands. Touch stimulation was poorly perceived. Usually he could not state whether or not he had been t0uched. Again, there seemed to be relatively better preservation of this modality in the hands and face. Except under special conditions of examination of the hands, to be described later, the patient was able to locate the site of a pinprick by pointing. However, if the pin was repetitively and rapidly applied to one region, or if the prick was steadily maintained at that one place, he could not locate the point of stimulation. He would make frantic, random searching movements over his body, and not infrequently around the bedclothes, grimacing as though in pain and exclaiming that he was trying to remove the pin. If asked where he was being pricked, he dis— regarded the question and continued to try to remove the stimulus. This phenomenon occurred on stimulation of any portion of the body but was most apparent when the hand was tested. (b) Double Simultaneous Stimulation: The phenomena of extinction and displacement were frequently observed in tests of different body areas by simultaneous tactile stimulation. On stimulation of the face and hand, stimuli to the hand were not perceived or were mislocalized to the cheek. In tests of homologous body areas (as hand-hand) extinction of one percept was common. The side on which the stimulus was not perceived fluctuated, so that at one moment only a. right—sided stimulus was perceived and a few moments later only a left-sided stimulus was perceived. Exosomesthesia—Whenever his palm was in contact with a portion of his body or any other object, and the dorsum of that hand was pricked with a pin, the patient consistently mislocalized the stimulus. This mislocalization was to whatever object the palmar surface of the hand was touching. For example, if the patient’s hand was resting on his thigh and the dorsum of the hand was pricked, he insisted that the thigh had been touched, and not the hand. This mislocalization —exosomesthesia—occurred to the thigh, abdomen, leg, or face and was present with stimuli to either hand. It was observed even when the patient was urged to look at the hand during the application of the pin. Exosomesthesia could not be elicited, however, by stimulation of the palm or palmar surface of the fingers when the dorsum of the hand was resting on a portion of the body. Furthermore, localization of stimuli to the dorsum of the hand was correct if the hand was held in space. Mislocalization also occurred to objects external to his body. If his palm was resting on a table or on his bed, and the dorsum of the hand was pricked with a pin, he would point to these objects and state that the pin had been applied “there.” When questioned, he stated that the hand had been touched but continued to point to the bed or table. Frequently, however, he insisted that it was the bed or table that had been touched, and not his hand. If asked how he could feel the bed being pricked with a pin, he would become tense, avoid the question, and insist, “You touched the bed, not me.” Displacement into extrapersonal space was not eliminated by simultaneous stimulation, even when extinction of one of the percepts occurred. For example, if pins were simultaneously applied to the dorsa of the hands while the palms were resting on a table, he would report feeling only one pinprick, that on the left (or right, as dominance fluctuated) and point to the place where the left hand had been resting, saying. “You touched the bed there.” This phenomenon of displacement into extrapersonal space occurred daily during a period of more than two months. C 0mment.——~In this patient a requisite to displacement into space was that the palm of the hand be in contact with an external object. In other words, there were two cutaneous stimuli simultaneously in operation, namely, the pinprick on the dorsum of the hand and the pressure of the object in contact with the palm or fingers. A single stimulus, such as pricking the dorsum of a hand held in space, did not elicit the displacement. �4 Exosomesthesia was elicited only on stimulating the hands. This occurred even though single pinprick was perceived more sharply in the hands than in any other area except the face. Although this patient showed inability to locate correctly parts of his own and the examiner’s body, it does not necessarily mean that exosomesthesia is determined by this particular type of disorder in body scheme. The following case illustrates the phenomenon of exosomesthesia in the presence of the patient’s ability to locate body parts. 2.—E. K., a woman aged 52, was admitted to the neurologic service of the Mount Sinai Hospital in August, 1950, with a history of grand mal seizures. She had been in good health until 1947, when there appeared sporadic, momentary sensations of “blacking out.” About two years before admission she began to suffer monthly grand mal seizures. There was no aura. Routine examination on admission showed that her status was within normal limits except for anosmia in the right nostril. There was no organic mental syndrome. X-ray studies revealed evidence of a subfrontal neoplasm. On August 12 a craniotomy was done, and after amputation of a portion of the right frontal lobe, a large bilateral subfrontal meningioma was excised. Her postoperative course was stormy. For two weeks she was semistuporous. She responded only to massive, painful stimulation, and these responses were limited to vague, ineffective attempts to push away the stimulus. In this period she lapsed several times into coma and showed Cheyne-Stokes respiration. The Babinski response was obtained bilaterally. Her pupils did not react to light. From about Aug. 23, 1950, the patient improved slowly and steadily. She began to respond verbally, and contact could be maintained for short periods. Vision, which had apparently been absent, began to return, although right homonymous hemianopsia remained for some time. A marked organic mental syndrome characterized by confusion, disorientation, and anosognosia, was present. Routine Neurologic Examination.——Neurologic examination in September, 1950, disclosed right homonymous hemianopsia, severe impairment of visual acuity with bilateral secondary optic nerve atrophy, nystagmus in all directions of gaze, a bilateral Babinski sign, and a mild degree of aphasia. Position sense, vibration sense, and temperature perception were unimpaired. There were difficulties in perception of touch and pinprick stimuli, as described below. Psychiatric S'tattusr—The patient was usually friendly and cooperative. However, she was frequently irritable and would not permit examination. She was disoriented as to time and occasionally to situation, but not to place. There were defects in retention and recall, covered by confabulation. She was euphoric and displayed little self-restraint or concern in social situations. Usually she would lie with her body fully exposed. Not infrequently she soiled herself or wet the bed. Anosovgnosia was prominent. Body Schema—On command, the patient was able to identify and locate correctly parts of her own and the examiner’s body, such as the ears, eyes, feet, and parts of the upper extremities. She exhibited some confusion about the right and the left side of the body. Sensory Status.—(a) Single Stimulation: The patient perceived single pinprick stimuli well, although she made occasional nonpatterned errors in localization. These errors were more frequent on the left side. (b) Double Simultaneous Stimulation: On simultaneous application of pinprick to the two sides of the body, except the hands, extinction on the left or displacement on the left toward the level of the right—sided stimulus was the usual response. Homolateral simultaneous stimulation on the right side of the body showed no extinction, but stimulation on the left side elicited frequent extinction and displacement. CASE Exosomesthesia.—Displacement into extrapersonal space occurred when the left hand was pricked at the same time that either the right hand or the right cheek was stimulated. The phenomenon could also be elicited when the left hand and any other area of the left side of the body were simultaneously stimulated. Under these conditions the patient mislocalized the stimulus to the left hand into space near that hand, or to the object on which the hand was lying. For example, if pinpricks were �5 . simultaneously applied to the right cheek and the left hand, the patient indicated she had been pricked on the right cheek and the arm of the chair on which her left hand had been resting. As a rule she answered by pointing. If asked to verbalize, she would say, “The right cheek and about here,” (pointing to the chair arm or into space near her left hand). If asked directly. “Was your hand touched?” she would avoid the question, responding only, “Here,” pointing at the same time to the left chair arm or into space. It is to be noted that, except under the special condition of simultaneous stimulation, the patient was always able to point to or to name her left hand on demand. If pricked simultaneously on the dorsa of the left and right hands, she correctly localized only the stimulus on the right, both by pointing and by stating, “My right hand.” The stimulus on the left, however, was localized only by pointing to the chair arm and saying, “Here.” If asked whether the chair arm and not her left hand, had been touched, she answered, “No, here,” pointing to the chair arm. When pinpricks were applied to the left hand and, at the same time, to another area on the left side of the body, a similar displacement into space was evident. Usually the stimulus to the left hand was mislocalized onto whatever structure the hand was resting or else 'into contiguous space. The other stimulus on the left side was usually correctly localized, though this stimulus, too, was occasionally displaced into space. When this double displacement occurred, the patient would state that she felt two stimuli and would point into space to the left of the arm, stating, “Here and here.” These mislocalizations were repeatedly observed during a period of a month and were not always limited to the left side. They were occasionally observed to occur on the right side. At these times localization on the left was always correct, as indicated by pointing and by verbalization. C omment.—Exosomesthesia was elicited in this patient only under the condition of multiple simultaneous stimulation. It could not be elicited by single—stimulation methods. Also significant is the fact that exosomesthesia was apparent even though there was no gross disorder in body scheme on routine testing. Furthermore, it is evident that her errors in localization were not simply inability to point to or identify parts of her body by name, as ordinarily she experienced no difficulty in doing this. on command. Both patients mislocalized percepts to parts of the body, to objects, or into space contiguous with the area stimulated. Occasionally, we have also observed displacement of a stimulus to the person of the examiner. Usually such percepts are mislocalized to a homologous portion of the examiner’s body; e. g., a stimulus applied to the patient’s hand is reported by him as though it had been applied to the examiner’s hand. Rarely, the mislocalization is to any part of the examiner’s body. This type of displacement is illustrated in the following case. man aged 52, was admitted to the Psychiatric Pavilion of Bellevue Hospital with the complaint that he had become confused and depressed. For about a year he had been disoriented and confused as to date and his relationship to people and had wandered about the city aimlessly. He had been admitted to the Farm Colony about a half-year before and had worked as a barber until the week before his admission to the hospital. Routine N emologic Examimtion.—Neurologic examination showed normal gait and station. Coordination tests were well performed. The reflexes were active bilaterally, with normal plantar and abdominal responses. Cranial nerve functions were normal. The sensory status showed changes, but only with special methods of testing. A pneumoencephalogram demonstrated moderately dilated ventricles, without shift or deformity, and some dilated cerebral sulci. Psychiatric Status—A severe organic mental syndrome was evident. In the ward he sat quietly for hours by his bedside, taking little interest in his surroundings. When approached by members of the staff, he appeared perplexed but was affable. During the testing procedures he was cooperative unless confronted by a test situation in which the examiner demanded tasks CASE 3.—-R. M., a ‘ �6 ‘ beyond his ability. At such times he showed a “catastrophic” reaction, became excited, and discontinued his efforts in the examination. He was disoriented for time, place, and situation. However, he was able to find his way about the ward, locating his bed, the nurses’ desk, the doctor’s office, and the lavatory. Severe difliculties in intellectual function were observed. He was unable to give an adequate history. He could not recall the examiner’s name or the events of several hours before but did not confabulate. Calculation and symbol—identification tests were poorly performed. Severe aphasic difficulties Were evident. He was unable to name common objects, clothing, or most parts of the body. He could not comprehend written commands, nor could he write, but he was able to follow simple verbal commands. Mild dyspraxia was demonstrated in his attempts to imitate finger and mouth movements. However, he was able to dress, feed, and otherwise care for himself. Body Image.—He had difficulty both in naming body parts and in locating them by pointing. The defects were severest in the fingers, wrists, and elbows, and occasionally the feet. There was difficulty in right-left orientation. Sensory Status—(a) Single Stimulation: Routine sensory studies of touch, pinprick, and vibration stimuli showed no consistent impairment. These stimuli were usually correctly localized and described. Occasionally a single stimulus to the hand or forearm was displaced to a contiguous object or to space about the upper extremity. (b) Double Simultaneous Stimulation: On double simultaneous [touch] stimulation the patient displayed extinction and displacement of tactile stimuli. This was most evident in trials of the face—hand test 6 but was seen in tests of other body parts as well. For example, on simultaneous stimulation of the cheek and the opposite hand, he would either report only the stimulus to the cheek (extinction of the hand stimulus) or report a stimulus to each cheek (displacement of the hand stimulus). The pattern of sensory dominance was that usually seen in diffuse cerebral disease, the face being most dominant, the hand least.5 There was no lateral dominance. Exosolm-esthesriav.—Displacement into extrapersonal space was occasionally observed on single stimulation. This displacement was from the hand, forearm, or elbow to space contiguous to the part touched. Exosomesthesia was, however, markedly exaggerated when double simul— taneous stimulation was employed. Again, the areas from which the phenomenon was most frequently observed were the hands, forearms, and elbows. For example, when stimuli were applied to the dorsa of the hands as they were lying on the patient’s lap, he pointed to space in front of his knees. If asked to state where he had been touched, he would say, “The hands,” but would continue to point to the space in front of his knees. Exosomesthesia was rarely noted when other body parts, such as the cheeks or shoulders, were simultaneously stimulated. Occasionally it was found that on tests with double simultaneous stimulation the patient mislocalized a stimulus from his body to the homologous region of the examiner’s body. For instance, when the hands were simultaneously touched, he would grasp the examiner’s hands and affirm he had been touched “there.” Despite the examiner’s insistence that the stimulus had been to the patient’s hands, the patient would persist in pointing to the examiner’s hands. When asked to name the parts touched, he would say “There, there.” The same phenomenon was occasionally observed on simultaneous stimulation of the two elbOWS or cheeks. It was significant that this mislocalization to the examiner’s body occurred even when the patient was urged to look at the stimulations. It was observed that emotional tension, increase in the rate of testing or undue prolongation of the examination increased the incidence of exosomesthesia. For example, to initial application of pinprick to the right hand and the left cheek, the patient reported only the face percept, omitting the hand stimulus. Later, he localized the two stimuli to the cheeks. As the examination progressed and the physician speeded up the testing, the patient became tenser. He then localized the face percept correctly but insisted that the hand stimulation was into space in front of the hand. Finally, both stimuli were displaced into space or to the examiner’s body. These phenomena were observed daily over a period of 2% months. . Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of Face and Hand, Tr. Am. Neurol. A. 75:250-252 (June) 1950; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:35‘5-262 6. (Sept) 1951. �7 Comment—While single stimulation occasionally produced exosomesthesia in this patient, the phenomenon was more pronounced under conditions of double simultaneous stimulation. This patient also mislocalized stimuli to the examiner’s body. Emotional tension, prolonged examination, or increase in the rate of testing exaggerated the phenomenon of exosomesthesia. GENERAL COMMENT On consideration of these cases, it is immediately apparent that exosomesthesia is associated with a severe organic mental syndrome. Therefore, it might be argued that exosomesthesia is merely a manifestation of the patient’s mental confusion; that the patient simply points into space because he is confused. However, we have examined many severely confused patients and found exosomesthesia only rarely. Moreover, exosomesthesia is a patterned phenomenon, demonstrable in each patient under defined conditions, predictable as to the area from which it will occur and the extrapersonal spatial region to which the sensation will be projected. For example, in Case 1 exosomesthesia could be elicited only from the hand, and only when the dorsum was stimulated at the same time that the palm or fingers were in contact with another object. Displacement under these circumstances was usually not haphazard. As a rule it occurred to the object touching the palm or fingers. In Case 2 exosomesthesia could be elicited only by double simultaneous stimulation. It was seen most clearly in the hand and could be elicited only unilaterally at any one examination. Again, the displacement was not haphazard; the stimulus as a rule was localized to extrapersonal space contiguous to the area actually stimulated. In Case 3 the phenomenon was observed again under conditions of double simultaneous stimulation, and the displacements were either to space contiguous to the stimulated area or to homologous areas of the examiner’s body. It is significant that these displacements could be elicited even when the patient was urged to look at the application of the stimuli. Moreover, even when the examiner pointed out the error in localization and emphasized the implausibility of the response, the patient characteristically insisted on the correctness of the mislocalization. Factors Inflnencing Exosoimesthesiax—Many factors influence the appearance of exosomesthesia. Except in children under special conditions, it has been observed exclusively in patients with severe mental changes resulting from disease of the brain. It is influenced by the type of stimulus used and the rate of stimulation, as well as by the element of simultaneity of stimuli. Moreover, the emotional state of the patient has a significant effect on the phenomenon, as does the part of the body stimulated. In some cases exosomesthesia has been made apparent by administration of small doses of amobarbital sodium. These factors will be discussed. (a) Bilateral Cerebral Disease: The symptom background in every case of exosomesthesia is an organic mental syndrome secondary to bilateral cerebral disease. We have not been able to demonstrate exosomesthesia in an adult unless there were severe mental changes. But, as previously noted, it is a rare phenomenon, and only a few patients with severe organic mental syndrome show it. In 400 patients with organic cerebral disease, of varying severity, exosomesthesia was observed in approximately 3%.5 Even in these patients it was not manifest in every examination, and its frequency was readily altered by changes in the conditions of testing. It is therefore evident that severe bilateral cerebral disease in itself is not sufficient to produce exosomesthesia. �8 That simultaneous stimulation may elicit sensory phenomena not apparent on single stimulation has previously been demonstrated.2 For example, a hemisensory syndrome in a hemiplegic patient may not be discernible except under conditions of double simultaneous stimulation. Thus, single stimulation may be well perceived and localized by the patient, but the addition of a second stimulus simultaneously applied may so affect integration that the phenomena of extinction, obscuration, and displacement become apparent. Similarly, simultaneous stimulation elicited exosomesthesia when it was absent on single-stimulus examination, or exaggerated it when it was occasionally manifest on routine stimulation. In Cases 1 and 2 simultaneous stimulation was a necessary condition for eliciting the phenomenon. It could not be demonstrated by single stimulation. In Case 3 exosomesthesia could occasionally be elicited on single stimulation, but with simultaneous stimulation the phenomenon was demonstrated with much greater frequency. (c) Type of Stimulus Most Effective: Of the various stimuli used in these examinations, such as single touch, single pinprick, repetitive touch, and repetitive pinprick, it was noted that repetitive touch stimuli were most effective in eliciting exosomesthesia. This was especially true on double simultaneous stimulation. (d) Effect of the Patient’s Emotional State: Exosomesthesia was exaggerated by alterations in the test situation which made performances more difficult. Increasing the rate of stimulation or unduly prolonging the examination increased the displacements to extrapersonal space. If the examiner was deliberately critical of the patient’s errors, the phenomenon also appeared with greater frequency. These factors increased the emotional tension of the patient and if carried further produced a “catastrophic” reaction. (e) Effect of Drugs: It has previously been demonstrated that difficulties in perception may be exaggerated by barbiturate intoxicants.5 Amobarbital sodium was administered intravenously in doses of 3 to 7 grains (0.2 to 0.45 gm.) to patients with diffuse cerebral disease. Prior to administration of the drug, these patients manifested the phenomena of extinction and displacement of percepts on simultaneous tests, but not exosomesthesia. While under the influence of the barbiturate, three patients showed exosomesthesia, in addition to extinction and displacement. In two other patients, in whom exosomesthesia had been elicited only after a protracted testing period, the administration of amobarbital sodium elicited exosomesthesia at the onset of testing and exaggerated the phenomena of extinction (2)) Effect of Simultaneous Stimuli: and displacement. Relation of Exo'somest‘hesia to: Extinction, Obscumtioln, and Displacement—In our experience, whenever exosomesthesia has been observed, the phenomena of extinction, obscuration, and displacement are also present. Exosomesthesia, how— ever, is a rare phenomenon, whereas extinction, obscuration, and displacement are commonly observed. Moreover, whereas extinction, obscuration, and displacement are frequently seen in adult patients with mild cerebral dysfunction,5 displacement into extrapersonal space is present only in cases of severe mental changes due to disease of the brain. It may therefore be concluded that exosomesthesia in adults represents a severer type of cerebral dysfunction than other simultaneous stimulation phenomena. �9 Relation of Exosomes'th‘esia; to Body I mage.——It might be said that exosomesthesia is a pathologic extension of the body image. The normal person is continually extending the boundaries of this image. For example, Head cites the examples of the woman with a feather in her hat who “feels” when the feather is touched, and the surgeon who handles his probe as though it were an extension. of his fingers.1 In the normal person, however, these extensions of the body image are fluid, immediately reversible, and clearly recognized by the subject as artificial. The surgeon, for example, is able at any moment to redefine correctly his body image. He “knows” that the probe is not his finger. In the group of patients described above, however, the extension of the body image seems to operate in a pathologic, rigid form. Under certain conditions these patients lose the ability to maintain a realistic definition of the limits of their body. They behave as though portions of the contiguous external world are concretely incorporated into the inner image of their body’s extent. Although we may consider exosomestheisa as a specialized body-image disturbance, it should be noted that patients who do not show difficulties in identification and location of body parts still may show mislocalization into extrapersonal space. On the other hand, patients with an inability to identify or locate their body parts on command do not necessarily manifest exosomesthesia. In similar fashion, there is no necessary relationship between exosomesthesia and position-sense difficulties. A patient (Case 3) who manifested displacement of sensation into extrapersonal space did not make errors in routine tests of position sense in the extremities. This is consistent with observations previously made by Head1 that localization of single stimuli is not functionally related to sense of position of the extremities. Role of the Hand—Although displacement into extrapersonal space has been elicited from various areas of the body, it has been observed to occur most frequently from the hand. Moreover, in no case has it been elicited from another area and been absent from the hand. This predilection for the hand is consistent with the manner in which other dysfunctions of the nervous system are reflected. As a rule, when the functioning of one side of the body is impaired through cerebral disease, the disorder is most manifest in the hand. Thus, in the usual hemiplegia resulting from a capsular lesion the paresis, body-image disturbance, and sensory loss are most prominent in the hand and fingers. In these patients, and in others with diffuse cerebral disease, the phenomena of extinction, obscuration, and displacement are also best elicited when the hand is tested. Furthermore, studies of the order of sensory dominance of various areas of the body demonstrate that the hand is in the lowest rank. This is true of the dominance order of patients with cerebral disease,5 and also of normal subjects, both adults and children.6 Similarly, when allesthesia is observed, it is seen most clearly in the hand. Bender and Nathanson 7 described a case in which the clinical course was reflected in a Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, Arch. Neurol. & Psychiat. 64:501-515 7. (Oct) 1950. ‘ �10 waxing and waning allesthesia. As this patient improved, the areas from which the phenomenon could be elicited diminished, until finally allesthesia was demonstrable only in the hand. In autotopagnosia the hands are more profoundly affected than other regions. Finger agnosia, possibly the earliest sign of body-image disturbance, is frequently seen in the absence of other gross disturbances of the body schema. Furthermore, phantom limb, anosognosia, causalgia, and synesthesia are phenomena in which the role of the hand is especially prominent. Just as these pathologic phenomena are manifest in tests of other body parts, but are most clearly demonstrable in the hand, so, too, exosomesthesia, though occasionally demonstrable elsewhere, is most apparent in examination of the functions of the hand. Exosomesthesia in the N ormal C hild.—It has been observed that sensory phenomena which occur in patients with cerebral dysfunction may be found in the nor— mal young child.6 Similarly, exosomesthesia, which we have never found in adults except when there is severe cerebral disease, can be readily observed in children up to the age of 4 years. In examination of a large series of normal children it was noted that the initial responses of children to double simultaneous stimulation fre— quently included exosomesthesia, although the commoner responses were extinction and displacement. Exosomesthesia was rare, however, after the initial few trials. The frequency with which exosomesthesia may be seen in children up to the age of 4 years suggests that it may represent, in the child, a “normal” developmental stage in the organization of perception. Its appearance in adults with severe brain disease may possibly be, as with other pathologic phenomena, a regression in function to a previous level of sensory integration. SUMMARY , The patterned mislocalization of tactile stimuli into extrapersonal space is described and termed exosomesthesia. Exosomesthesia is observed in patients with severe organic mental syndromes. It is apparent only rarely on single tactile stimulation and is more readily elicited by the technique of double simultaneous stimulation. It is exaggerated by fatigue, rapid testing, and increased emotional tension. Barbiturate intoxication also may elicit or exaggerate the phenomenon. Exosomesthesia is most apparent in stimulation of the hand but has been observed in tests of other body parts. While it may be considered a pathologic extension of the body image, it is not dependent upon concomitant body-image disturbances. Although exosomesthesia has been observed chiefly in patients with severe mental changes, it is not a manifestation of confusion, but is a patterned, predictable phenomenon. It may be a regression, in patients with cerebral dysfunction, to a previously “normal” stage in sensory development, as suggested by the fact that it is readily observed in simultaneous tactile tests of young children. Printed and Published in the United States of America �EXOBOMIBTHIBIA OR DIEPLkGIIIIT 0P OBTlfllflfls 83N3£TIOIIINQO EantuflRSOIAL BPACE‘ EV Martino:- F. Shapiro. am. an: Fink, K.D.'* and Kerri: B. Bender, H.D. ., " "i 3”“ a"? ,y. Univcruity College or’ncdieiuc and tn. 3 enrol 651331 Service of thc Haunt flinfii ficlpital Ind lollcvuo fibflpitfll, I0! Yer! 0131. 'Dntdod by a flullaulhip tram thy lationnl roundntion for Infantile QJ‘ V‘W‘ , g j , ‘9ar111510. ibis investigltion in. lupportod, in partin:by a rouonroh grant stutt- Public not ammo. mum or fianlth. aun-139 tram tho unit.d Inltitutel fl �Among phenomena bbeb new be epperenb during exe-inebion or petienbe eith dieeeee or the eeneory pebbueye is nielooelisebion It individual with e eeneory defeat, on eeen in the cannon vuriebiee or cerebrel beniplegie, any looeiioe ineoonrebely ebiuuli applied on the of e eeneory etienioo. bee long been known that on ‘ perebio bide. point nielooelieebiono ere epperenb in exelinetionl ueing e eingie ebiunlue, end have been deeoribedbin detail by Hood (1). These nationalisation: can be eooentuobed/b‘e uee or double Snob einnlbeneoue obi-ulebion techniques (2).- In eddidon, when theee technique. of exeninetion Ire enployed, other veriebiee or nielooeiieetion,-euob ee diepieoenent (3). become apparent. niepleoe-nnb ie the petberned nielooelieebion or one or two ebinnli eiunlbeneouely applied to different body areas. The direction or diepleoeuent ie in e definite pattern, which is dependent upon the parts or the body Ibilnleted. choreoterietio of nieiooelieetion on for reported bee been ‘ tho fact bhet their lxtent VII uibbin the lilibl of the patient’l body. In the oouree or obodiee or outeneoue peroeption we obeerved I new torn or diepleoenent in which the patient oonoietenbiy end in e prediobeble reebion nielooelieel obi-n11 into extra-pereonei epeoe. Thin type of diepieoenont on have teamed “exoeo-oebheeie'.¢ of the derived by Dr. Judeh A. Jotte, Editor 19%0, the tron Press. Oxford Boivereity reyobietrio biotic: none", , by ”eiotheeie”, perception body; the Greek "one", out or; 139 FI?’!53'€5§E eeneee. wee ll; Exoeoleebbeeie ie not e commonly oboerved phenomenon. more than #00 patient: with brain dieeeee were examined at Bellevue Peyobietrio Hoopibel by routine end epeoielieed eeneory beete. �2. Shoeoneetheeie wee obeerved in only 15 oeeee ~ en incidence of ebout 3! (5). who following oeee reporte illustrete the phehoaenon end deoonetrete eoee o: the oonditione finder which it wee obeerved. Case 15 H.I., e 6% year old male, wee admitted to Bellevoe Peyohietrio noepitel with e hietory or progreeeive sentel cheeses or eix years doretion. The firet tour yeere or illneee were lurked by eloely progreeeive ilpeirnent of memory, oonoentretion end other intellectual funotione. end inoreeeing epeth: to hie environnent la the leet teo ii yeere thie oondition exacerbated rapidly, reeulting the lone of hie Job ee e etore neneser. During thie period hie epeeoh bean-e inoreeeingly serbled end Ito-nerihg, Be veeoilleted oolplete epethy.i. 1*: f”;irTWT€nL. he wee oooeeionelly incontinent. mm bathing; nee dittioulty in dreeeing, end wee eoneti-ee eo forgetful end oonrueed ee to wander into the etteet eithout hie troueere. Routine georologio Ian-ioetion; In welkins the trunk wee tilted to the right end there wee e tendency to drag the right, lower extreaity. However, there wee no eignitioent motor weekneee. reflex change or tonne ebnor-elity. Coordination teete were well perromned. The oreniel nerve function: were intact. Vibretion eenee wee correctly perceived only in the oleviolee end the heed, while poeition eenee wee lost in the tinsere, eriete, toee end enklee bilaterally. Temperature difference: were poorly peroeived exoept in the teoe.eree. hie reeponeee to touch end pin prick between irritebility end nild degree or “mixed epheeie" was present. This epeeoh difficulty we: evident only epeoiel testing or then the petient wee retigued by prolonged eti-uletion will exeeinetion. be deeoribed leter. A by there one e fluctuating dyeprexie of noderete eeverity. �3. Occuionally n. ma difficulty in drawing, being unable to handle button: and alaavca. however, he could partonn Inch tunaticna aa reading hinaalr, ccwbing hia hair and cthar routine daily taaka. Ha waa naually unabla to wiwic tha aura ccwplicatad pattarna of the hand~praxia tanta. licetrcancaphalcgrwa ahcwad_bilatcral dittuao abncmnality. with dacraaaa in awplituda and interwittant auppraaaion or activity ova: tha pariatal regiona. Pnauacancaphalcgranldiaclcaod bilaterally dilated vanericlna and wodarato “cortical atrophy". particularly in an ion moral lobe. szphiatric Statua; Although tha patiant waa ariantcd for place and situation, he wada crrora an to data and than or day. Thar. war. datacta in vacant unwary, concentration, calculation and ability to aaauln the abatract attituda. no uwually aat placidly ataring intc apaca or wandered aialaaaly about tha ward. Ia did hat win with cthar pationta. whcn approachad by tag atarf he waa friendly and paaaivoly cccparativa.' Tasting proceduraa ware approachad with a chaarful indittcranca. Hhan, hcwavcr, ha was panhad into Boat aituaticna :raatar than hia capacity, ha reactad with incrwaainx itvitability and tanaicn, avantually calainating in a “cataatrcphic reaction.” it such tiwna ha would baccwa rod in tho taco, about that ha know tha ahawara but didn't want to continua and mcccniy basin to map. a. waa can. to distinguish tho right aid. or his: body tro- the 1321:; but waa unable to wake can distinction on tha miner's body. 11. had no difficulty either in locating nidlinc atruccuraa or hia body, auch aa tha uoaa, heath, chin. nabilicua and pania, or in pointing to hia cyan. With oyoa cpan ha readily fauna W ' �e. hath eere, but when hie eyee were cloned he seeped ebeut hie teee for eeverel eeeende betere leeetlns then. he eeuld'belne to hie thighs, kneee, ankles end tees but could not point to any epeclrlo toe ether thin the his teen. frequently had Alrtlculty 1n locetlns port1ene or hie upper extrenltlee. It eeked to point to hle ehouldere. be correctly located one ehoulder, but then grayed behind his neck locking for the other. This defect was even more noticeable in trying tn find the ”other" elbow and wriet, and creeteet in trying to find the "other" hind. file eeereh for the ”other" hand or wrist Be bizarre. He would parts of hie body, the look under the pillow, or rummage under the nettreee becnnlng tenee and ineietius it we. lost. It should be eupheeieed that despite the great difficulty in lecetlns was petlent was able to name the body parts. except the tinseve end toee. This was true whether the pert pointed to nee on the petient'e or on the examiner'e body. 33939;; Stetueg (e) ééfifil? Btlnhletlon: He had difficulty in differentleeins between the sheep end dull end of e pin. This defeat wee preach: throughout the body, elthoush he made eignitieently fewer erreee 1n the reee end hende. Touch atlauletian was poorly perceived. Heuelly he coulé not state whether or not he had been tauched. Again, there �5. «m to be relatively better preoorvotion or this modality in ' the hand: and face. Except under opooiol oonditiono or examinotion of tho hands, to he described liter, the patient who ohle to locate the eite of it the pin on. repetitively and or it the priok woo steadily maintained a pin prick by pointing. however, rapidly applied to one rosion, at that one place, he could not looeto the point of otinmlotion. tendon scorching lav-neat: over hio body and not infrequently around the bed olotheo. srinaoing on thouah in pain and exoloinins that he one trying to renove the pin. If ookod He would make frantic, where he one being priokod, ho diorozorded the question and con» mm on tinued to try to move the stimulus. "m. phmmnon stimulation or any portion or the body, but who most apparent when the hand no tested. (h) Double SiuultOneouo ethnolotigg; Tho phone-en: or oxtinotion end dioplooo-ont were frequently ohoerved in tests or different body area- by oilultoneouo tactile otiuuli. 0n etinnletins tho race and hand. otinuli to the hand we». not perceived, or nioloooliaod to the cheek. In touting honolosoue bod: stone (on hondvhond) extinction of one poroept III col-on. The side on which the stimulus III not pcrooivod fluctuated, no that at one uooont only a right-sided stimulus one perceived and o for momentleter, only a lott~oided etinnloo not perceived. Exooonootheoio; Whenever his pal: who in oontoot with a portion or his body or any other ohJeot, and the dorouh of that hand In: prioked with o pin, the patient oonoiotently nioloohliaod the �6. ottuulun. this nialooaiisation who to whatever object the phi-tr tartan! of the hand was touching. For txlhplc, 1f the pntioht'l hand was routing on his thigh and the doroun of tho hand VII priokod, he insisted that tho thigh had boon touched, and not the hand. Th1: ninlootlisntion ~ oxooonoothooio - occurrod to the thigh, obdonnn, 105 or (too, had who present with stimuli to oithor hind. It Ill observed even when the patient who urged to look 1t tho hlhdt durtng the application or the pin. nah-anesthesia could not be elicited, however, by otinulhtion of tho pnln or polmar curtuoes of tho ringer! uhnn the aorta: of tho hhné ill rooting on a portion or the My, runner-more. ionization or dorul hand amnion um correct 1! the hind III hold in space. Iloloooltsntion also ooourrod to abduct: external to hit body. It h1o pal: ill rooting on I tabla or on his bad. and the doroun of tho hand It; prioknd with I pin, ho would point to those ohjooto and 091th thlt tho pin had been $991106 "thmru." Whoa quantionod. ho hinted thlt tho hand had huen touched, but continued to point to tho bid or table. Proquontly. however. ho'inntotod thht it on. tho bod or tohlo that hon boon touohnd thdhnntphhohhnnd. Ir alkod how he could too;_tho bod being priokod with a pin he would booonn ton... avoid the queut1on and inliot ”you touohod the bed, not In". III not ell-inatod by Itlhltanooun stimulution, oven whnn extinction of one of tho parocpto occurred. for 03:391., 1! pins hero oinulthnoouoly applied to the aorta of both hands Ihllo tho pal-n wore resting on o table, he would report fetish; only on. p1n prick, that on tho loft (or right, a: dominance fluctuhtod) and point to thn plloo whore the loft hind huh boon rooting. saying ”you touohod the bed thoro.” Displheonont into outrouporoonnl than. �this phone-enon or dilplucancnt into cxtra~peroonal tpnoe occurrcd daily during e period or over two nonthn. Commont: In this paticnt a rccuicitc to dimplecenmnt into space was that the pmlm or the hand be in contact with an external object. In other words. then. were two cutaneooo stimuli limnltcnecully in operation, nemoly the pin prick on the doreun or the hand and tho pro-lure or the object in contact with the palm or ringcro. A single nti-nluc. eooh II pricking the dornun or e hand held in upeoe. did not elicit the dicplnccmnnt. luoeomeutholih III elicited only on otimullting the hands. mu oocumd am though Ilmle pin print as: perceived me cum: in the hand: than in any other areo. excepting the thee. Although thin potient showed In lnability to oorroctly locate phrte or his own and tho esnminor's body, it doc: not necoecnrily amen that exolcnelthscic in dutenmined by thie particular type of disorder in body ache-n. the following case illustrate. the phenomenon or exoocmeetheaiu in the preeonce or to. patient'n some: to locate body pam. can. 23 l.l., a 52 your old woman, III edmitted to the. Neurolosio Service of the flaunt Sinai hoeoitdl in August 1950 with I history of grand hnl eelxuroo. She had been in good honlth until 1937 uhcn there appeared sporadio, noncntnry ecnuutione of "blacking out." About two year: before hdniehion she began to suffer Ionthly ' Ill leisurel. There was no euro. Routino exeminntion on admiulion III within normal limits, oxoept for dnolmia in tho right nontril. there one no organio honthl cyndromo. apocinl x~rcy studiel reveoled evidonoo or a oohfronthl grand necplcen. an August 19th a oreniotoly mm: done and following amputation of e portion or the right frontal lobe, a large bilateral �8. ‘tub-troattl III umniaginnn was axcitcd. nor pout~opcrutive courts an; stormy. For tut lacks an. saui~stup¢rann.r 3h. raupondod anly ta lassive, painful stimu— than: renpanuaa flirt limited to vague ineffective nttenpta ta.punh Quay tat stimulun. In this pcriod the lnpuod uovcral tin»: latian, irate and om um: "sputum um chem-Magma did not Bar rttpannoa rare pruatnt. pupil: mutem ublmkl retot to light. tn. pltiint inproved slowly and steadily. an. hogan to rtlpond vcrbtlly and contact could be maintained far short poriodn. Vinita, union and apparently been absent, begin Frau about Augunt 23, 1950 to rcturn, tlthough a right unnonyloul halinntpuia tiltinofi for Dunn tino. A Iarkod orgtnic nanttl syndrtlo characterised by confusion. disorientation and nuouognusin was prcnant. Routine laurolggic xxnlinntion: laurtlosit exnuination in aoptonbor 1950 diteltuoa a right honcnynnun honiunopnil, asthma impairment of vilual Inuit: with bilatorul nocondnry Optic atraphy, urttaslnl in all directions or ante, bilaterally patitiv. nabintki night. and a nild dogree or uphatin. Position nan... vibration and tonporntur. porcuptian wire unimpairtd. Thor. were difficulties in perceptien or touch Ind pin prick stimuli at anacribod belwu. Puzehiutric Status: The patient was usually friendly and cooperative. Bouvver, the III frequtntly irritable 1nd unuld not pomnit culmination. an: an. dilaritnt-d II to tins and notational: to situation, but not to placa. Thar: var. defeat: in retention Ind maul covered by contabulatian. am am euphoric and 41:91:,“ littlc self restraint er aoneern in social oituatiana. Usatlly uh: would lie with her body fully oxpoaod. not intrtqunntly she toiled �bereelt or wet the bed. Anaeognoein In: prominent. Bod: Scheme: 0n contend the petient we: able to identity lbette correctly parts of her can and the examiner's body, such In ears, eyee, feet and parts of the upper extremities. She exhibited name oenfueion about the right and left eidee a! the bady. end Season; statues] (a) siggie atiuulntian: The patient perceived single pin prick cumin mi, eitheugh m undo 0003:1011“ nompntterned em» in localisation. Theta errors were more frequent on the left side. (b) Double ginniteheaue stimuletion: 0n sinulteneouu epplicetion of pin prick: ta both tides or the body (excluding the hands) extinction on the left, or dieplaceaent on the left toward the level at the right-aided stimulus were the usual reepaneee. amneleterll linulteneaus etimuletion on the right side or the body shaved no extinction, but ntinuiatian on the left side elicited frequent extinetian and displacement. Runneleetheeieg Dieplaeenent lute extra—portend! space either occur-m than the lettihahdawn pridked at the me time the right hand or right cheek were stimulated. The phenamenon could u ' ulna be elieited then the left hand and day other are: or the left side or the body were simultAneeualy etimnleted. Under theee conditions the patient nislocelixed the stimulus to the left bend.inte evade near that hand, or to the object on whieh the mind was lying. For example. it pin pricku were e’imltehemu applied to m right cheek and the 1m; tune, the patient indicated she had been pricked on the right cheek and the are or the chair on Ihich her left bend had been renting; As 1 rule ehe answered by pointing. I: neked to verbelise the ebuld any, “the right cheek end about here,“ (painting to the their emu er into space near be: lett �10. hand). 1! ssksd dirsotiy, “was year hsnd touched,” sh. sauld avoid the gunmen mymzug can; "use," pointing st m um em to tbs 10ft oasis sun at ta spans. It is to be netsd that oxespt undsr the spssisl condition at sinultsnsaus stimulation tbs patient was always sbls to point tu as to ash. hsr‘istt hand on dsssnd. 1r prieksd silnltsnsuusiy an tho dorss or was isrt sud right hands. shs carrots}: localissd only tbs stimulus an tbs right, been by painting sad ststins. “I: right hand.” 2h! stilnlus an the new-y». m 190311104me by painting to m chair s:- and saying, “asrs.* 'It ssksd lasthsr the «hair sun. sud not but 10!: hand use issn toushsd, shs snsssrsd. ”as. hs:s’ pointing to tbs chair an, sun. Inna pin prints ssrs spplisd to tho lsrt hand. sad It the suns «ins, to snethsr sass on the 1st: sids or any baay,s 51-11.: dispisosssus into spsos III status. Ususlly tbs stisulus to tbs lift hand was sislosslissd onto Instsvsr structurs the hsnd sss rusting at else t9 contiguous spsos. tbs uthsr‘stflsuius an tbs 10ft sids was ususiiy oarssotly locslissd, though this stimulus too It: onessionsiiy displaced into spans. when this doubis displsosssnt oocurrsd, tho psiisnt.soula stats sh. rsit eve stimuli and staid paint inte space to tbs lots sf tbs ans. stating "bars and have”. !hsss saslosslisstiens ssrs rspsstsdiy ohssrvsa during s period or s.smnth, sad wars not sissys limited to tbs 1st: lids. tbs: ssrs ecossionslly obssrssd to scan: on sh. right sins. At an... c1... localisation on tho lots its slings aorrsot ss indiestsd by pointing and vsrbslisstion. . siioitsd in this pstisnu only the oenditian or Imitiplo smsuitsnsaus sci-ulstian. It scald can-snsz Ixososssthssis was ' under not be sliaitsd by .1331. summon isthmus. mo signifiosnt :- �11. that oxooonoothooid Ill appoxont ovoa though thoro In. no gross diuordor in body ooh... on routine touting. rurthonuoro, it is evident that bar errors in localisation not» not oi-ply on inabiiiiy to point to or identity park: or her body by nine. ll ordinarily the exporidaood no difficulty in doing this on oonldad. In hoth onto. paranoia word nioiooolinod to part. or the body, to abstain. or into npnoe contiguous with tho tron stinulotod. ooouoiondliy. we have nine observed dilpldodnant or a stimulus to the pardon or the can-inor; Usually ouch percent: art nioloodlilcd to o homologous portion of tho cal-inor'o body, 0.3., a otilniud appliod to tho potiont'u hand in reportod by hin.oo if it had been oppiiod to tho tau-inor'o hand. 'narolr, tho nioioodlizntion ll to any part? of the oxaniner'o body.‘ this §ypo or dioplaoonont is illuotmttod in the following on... also 3; 1.1., o 52 your old male, to: aduittod to Boliovuo Payohiltrio Hoopitll with the oonplnint that ha pad hood-o oontuoed and doprooood. for about a yetr ho had boon disoriented, oootnsod on to date dud rolutionohipo of pooyIi, and had uialdred ubout the 01¢: dill-nix. a. and been to um um colony about a mu “ you: beforo, and had uorkod no d harbor until tho rook before his mum“ to the hupiui. mum ' Slowing shouod non-o1 tomnod. lm;gio fixation! leurologiool examination gait and Itation. coordination Scots our. '01: per- lagrrotioxoo wore doiive bilaterally with normal plantar and undo-inol.rolponnoo. Cranial norvo runoiiono ward now-n1. otltuo thouud Ohtnxil, but only by opooidi nothodo or testing. A pnou-oonoophalogrnu dononotrutod nodordtoly dilated ventrioloo "ith°“t '31" 0’ def°flitia Ind ton. dilated cerebral ouloi. 098.1110 mu} Indra. Status I donoory Militia 3 m “. �12. evident. 0n the word he eet quietly for boure by hie bedside taking little interest in hie surroundinge. 'Ihen opproeched by the eterr he eppeered perplexed but one erreble. During the teeting procedures be one cooperative unleee confronted by e teet eitoetion in which the emeniner demanded teeke beyond hie ebility. At theee ti-ee he showed e ”ceteetrophic' reeotion, bece-e excited end diecontinued the exeeinetion. Re wee dieoriented for time. place, end eituetion. However, he nee eble to find hie Hey about the nerd, looeting hie bed, the nnreee deek, the dootore office end the lavatory. severe ditticultiee in intellectual function were obeerved. He nee oneble to give en edeqnete bietcry. fie could not recell the examiner's none nor the evente or several houre before, but did not contehulete. Celculetion end eyebol identification teete were poorly performed. severe epheeic difficultiee were evident. Re nee uneble to none cannon objecte, clothing or moat body perte. He could not colorehend written collende nor could he write, but he wee able to einple verbal cannon. lilo dreorexie nee demonstreted in hie ettenpte to imitate ringer end mouth novenente. nouever, he lee able to drone, feed, end otherwise cere for hinoelt. Bod: gaggeg He bed difficulty both in neling body perte, end in locating the: by pointing. the defect: were Imet eevere in the fingers, wriete end elbows, and ooceeionlly feet. There nee difficulty mm ‘ ' in right-10ft orientetlan. age-or: Statue; (e) giggle Stinuletionx Routine eon-cry etudiee or touch, pin prick and vibration eboeed no ooneietent inpeinlent. Theee �13. correctly looalieed and deaoribed. Oooaaiohally a eihgle stimulue to the hand or toreahn wee dieplaoed to a contiguous object, or to apaee about the upper extremity. (h) Double Simultaneoae stimulation: 0n double aiaultaneoua touch atinolation the patient dieplayed extinction and dieplaoaleht atianli or were ueually tactile etinali. lhie he would trials or the teoemhand teete or other body parte as well. to: on ai-nltaneouely etindlating the cheek end the oppoeite hand either report only the etioulue to the cheek (extinction of text (6), hot example, nae moat evident on nae eeen in the hand etianlua) or would report e etmlulue to eeoh oheek (displacement or the hand stimulus). The pattern or seneory doainanoe wee that oeoally eeen in ditruae cerebral dieeaee, the race being aoet dominant. the hand leaet (5). There nae no lateral doaihanoe. Rho-oaeetheeia; Dieplaoeeent into extra-pereonal apece eaa oceaaionelly ohaerved on single etiaulation. This displaoeaent vae fro- the hand, forearm. or the elbow to apaoe oontiguoue to the part touched. lxoaoaeetheeia was however aarkedly exaggerated when double einultaneoua atuuuuon was employed. Again the am. from which the phenomenon was noet frequently dheerved were the hands. toreeraa and elbovl. tor ext-pie, when etieuli were applied to the dorae or both hande ae they were lying on the patieht'e lap he pointed to epeoe in front of his kneea. It aaked to etate where he had been touched he uould say. "the hande" but would continue to point to the epaoe in front or hie knees. laoeo-eetheeie nae rarely noted when other body parta. euoh ae oheeke or ehouldere were simultaneoualy stimulated. Occasionally it one found that on teete with double allula taneoue atinulation the patient nielooeliued a etihnlue tron hie body to the hoaologoue region or the exeeiner'e body. For inetanoe, when both hand: were oinultaheoualy touched he would grasp the exauiner'e �1%. binds and strin- ho had boon touched “there.” Dsopito tho sxosinor's insiotsnoo thst tho stinnlu: hsd boon to tho outiont'o hoods, tho pstiont would persist in pointing to tho oxouinsr's hands. When asked to noon the ports touched, he would on: 'thsro. thorc." The fill. phonononon Isl occasionally observed on liltltsnoons sti-nlotions or both elbows or ohooko. It was signirioont that this nislooslisotion to tho oxosinor's body occurred oven thou tho potiont urgod to look ot tho otinnlotiono. It III observed that onotionsl tension, inoresoing tho rot. or touting or unduly prolonging the oxasinotion, inorossod tho inoidonoo of oxosolosthosis. ror ext-910, to initisl sppliostion was of pin priok to the right hand and loft chock, tho pstiont reportsd only tho the. psrospt, quitting tho hsnd stimulus. Lstor, ho localised the two othnulino tho ohooks. As tho sxoninotion pro« groslod sad the phyoioion opsodod up the testing. tho patient boot-o sore tohss. no thin looslisod tho toos pore-pt correctly, but innistsd thst the hand otimlntion as into upon. in front at the hand. tinslly both stimuli our. displaced into spooo or to tho oxaninor's body. those phononons wort obsorvod dsily over s period of two and a half unhthl. Coulent: Hhilo single stimulation occasionally produced oxooolnlthosio in this individual, tho phenomenon Ill note pronounced under conditions of double oi-ultonoouo Iti-nlstion. this ntiont sloo lioloooliood stilnli to tho oxsninor's body. lhotionol tonoion, prolonged canninstion, or inorossing tho onto or touting exaggerated the phone-anon or ozosonosthosin. Bisousoion; In oonoidoring thou. ossoo it is illodistoly opporont thst oxooolosthosis is osoooiotod with o savor. orgsnio �sentsl syhdrose. therefore, it night he ersued thst exoscseethesis ‘is sorely e ssniteststiou of the petient's sentsl contusion; thst 15. the petient sisply points into spsce becsuse he is confused. However, we hsve eyesined sssy severely confused pstieuts end found exososesthesis only rarely. moreover, exososestheeie is e petterned phenomenon. desonetrstle in eschvpstieat under defined conditions, predicteble ss to the eree tron which it will occur end the extra» personel spetisl region to which the sensation will be projected. For exemple, in Case I, exoscsssthesie could be elicited only from the head end only when the dorsus use etisuleted st the sese tine es the psls or fingers were in contsct with smother object. Displscesent under these circusstsuoes use ususlly not hephsssrd. sis s rule it occurred to the object touchins.the palm or fingers. In exososesthesis could be elicited only by double silulteneous stteulstion. It see seen most clearly in the head end could be elicited only unileterslly st say one exesinetion. Again the Case 2, displace-eat use not hspheesrd; the stimulus es s rule use locslised to extre-pereonsl speoe contiguous to the eree sctuelly stilulsted. In Cece 3 the phenosenon use observed sgsin under conditions or double sinnltsneous stimulation. end the displsceseuts were either to spece contiguous to the stisnlsted eree, or to honologous srees of the exsliner'e body. It is signifiosnt thst these displscesente could be elicited even when the or the stimuli. pstients to look st the epplicstion the ensuiner pointed out the error were urged noreover, even when in looelisstion end esphssised the i-plsusebility or their response. the pstiente chsrecteristioelly insisted on the correctness of the nislooslistion. rectors Influencing lxososesthesisa There ere esny rectors which influence the sppesrsnce of exoeosesthesis. Except under specisl conditions in children, it �16. has been obeerved exclueively in patiente uith severe mental chensee reeulting true dieeeee or the brein. It ie influenaed by the type of etianlue need. the rate or etiluletion. ee veil an by the elelent of einnlteneity or eti-mli. loreover, the e-otianel etete at the petient nee e eignificent effect the phenuuenon ee doee the pert or the body etinnleted. In ease oeeee exoeaneetheeie nee been nude epperent by edeinietretion at eeell doeee or enoberbitei eodiun. :heee feature will be diecueeed. (e) Bilateral Cerebrel Dieeeee; the emlptae beekground in every eeee or exoealnetheeie ie en arsenic uentel eyndraee eeoondery to bilateral ceretrel dieeeee. we have not been eble to denonetrute exeealeetheeie in en adult unleee there «ere eevere neutel thengee. But,ee previouely noted,it ie e rare phenonenou end only few or the individuele vith eevere arseniereentel eyndruee show it. In boo patiente with arsenic brain dieeeee at verging eeverity, exoeaneetheeie ee- obeerved in ephroxintely as or the one: (5 ). Even in then patiente, it wee not leniteet in every exeeinetion. end it: frequency vee reedily eltered by «bungee in the oonditione of teeting. It ie therefore evident that eevere bileterel oerebrel dieeeee, in iteelr, ie not sufficient to produce exoeoleetheeie. (b) Irrect or Binnlteneaue atiunli: whet einnlteneoue eti-uletion nay elicit eeneory phenaleue not epperent on eingle eti-nletion nee been previouely denonetreted (2). tor exllple, e henieeneorw eyndrtne in e heeiplegia petient he: not be diecernihle except under eonditione or double ei-nlteneuue etinuletion. Tune. single etilnietion may be well perceived end latelieed by the petient. but the eddition at e eecond etinulue einulteneouely applied .1: no effect integration thet the phenomene of extination, obecuretion end diepleaeeent become epperent. on �17. ‘ m ‘sullarly, “alumnus “mutton elicited “comma 1: an aunt an angle annulus umlnulon. or magnum 11: when 'oun 1 n In Manama: mun: and 2. man. stimulation. In ulmltmem «mung» am a menu»: “mum on for aligning the phonon-anon. It could not be amount-um by tingle uttunlatlan. In am 3, ant-tumult could “nationally onum on .112ng stimulation. but annulment “mutton dmmtum flu. inhuman run much water frequency. b0 (a) :12! a! gtggglu! Inst lrtbotgvug or tub vurioua Uzi-”11 and in that Manama. mix as final. when. :5.le pin prick, ripotltlvc tauch and rlpctltlvc pin prick. it It: noted that mutt" tmh "man mm was: «1'00th 1!: allowing cucum- thuu. m. m «mull: two on double almlum Itimlltion. (a) gram o: t! "time's an»! momentum-la anal um amt-mud hr 31%.!!qu in th- m: “mum which and» mum“. not. difficult. lama tbs n“ of “hunting, artho unduly prolonging mn~m~ml Imo. tantalum 1mm“ Alta, 11‘ the the Multan-nt- to twin" was deliberately critical or the mtlmt'o 0mm, tho phonmmm appomd with 5mm futon mam-d an. action“ switch at tho Imam”. patient, and 1t amt-d mun-r. prom.“ I "ututmphlo" mctlan. m man of m: It In» boon pmlmly dmtnm that arugula» in pomcpucm my be magnum by mum-ac. (0) nous-mu: team an administered lutnvmmly la 400.30! or 3 to 7 srllnl tn pltlonta Ilth altrus. ctrohwll distant. Prior to am “nutrition. thou patent! mnltum the phone-on. at «amulet: and dllplumt at pump” on ““1”me tutu, but lntuloanta not. (5) . alumnus“. m1 lo under the lntlmmc or the Whitman �18. three pationta ahovad oxoaoneatheaia. in addition to extinction and displacement. In two other patienta. in whoa axoooaootheaia has boon alioited only after a protraoted taating period. the administration or anoharbital aodiua elicited exoaoaeatheaia at the onset or teating and exaggerated the phone-one of extinction and displace-ant. Relation of lxoaoleotheaie to Extinction, Ottonretion and Diaplaoalent: In our experience. whenever exoooaeatheaia haa been observed. phonon-nu of extinction, obeouration and displacement are alao preaent. lxoaoaoathaeia, hou‘var. ia a rare phone-anon, whereae extinction, ohaouration and diaplaoolent are eon-only ohaerved. loreover. ahareaa extinction, otaouration end diaplaoaaont ere treouontly aeon in coult patient: with lilo cerebral dyoronotion (5). diapleoelent into extranperooael opeoe 1a only preaont in oaaaa or severe aental ohangea due to diaeaae ot-the brain. It may therefore he oonoluded that exoeolootheaia in adult: repreaenta a aora severe type or oarebrel dratunotion than other oiaultenaoua m otiaulation phone-one. nalation of Ixoaoleatheaia to gag: logger It night he aeid that exoaoaaatheaia ia a pathologio extenaion or the body image. The normal individual is continually extending the boundariea or thia image. For example, need oitae the eta-plea of tho lolan with a teeter in her hat who “real!" when the feather ie tonohod, and the aurgeon who handlea hia probe as though it were an axtanaion or hia tingera (1). In the normal individual, holever, theae extension. of the body 1-130 art fluid, illediately raveruibla and clearly recognised by the individual aa artificial. the surgeon for example, ia able at any'nolent to redefine correctly hia body Liege. no “known" that the prob. it not his finger. In the group or petionta ’ �19. described above. hosover. the extension of tho body isage scans to operate in a pathologio, rigid tons. under certain conditions these patients lose the ability to ssintain a realistic definition of tho lisits of their body. The: behave as though portions or the contiguous external world are concrsteix incorporated into tho inner image of their body's extent. Although say oonsider exosoaesthesis- a spooiaiiaed body ilage disturbance it should ho noted that patients who do not show we diftionlties in identifioation location of body parts still us: show aisiocaiisstion into estrsapersonsl space. Convorsely, patients with so atolhility to identity or locate their body parts on oosssnd. do not neoessariiy sanirest eaosoassthesis. In similar fashion, thers is no necessary relationship between ascsoaoothsais and position sense difficulties. A patient (Case 3) who manifested displacessnt of sensation into extrs~personai space, did not asks errors in routine tests a: position sense in” tho extresitiee. this it oonsistent sith observations previously ssdc by Head that localiation of single stilnli is not functionally roleted to senss of position or the extrusities (1). non or the land: Although displsoelont into extrs~persona1 space has been elioited tron various areas or the body, it has been observed to ooouh lost frocoentiy tron the hand. loreover. in no ossc hoe it been elicited from another area and been absent tron and 1 the hand. this oredileotion tor the hand is consistent with the ssnncr in shioh other dysfunctions of the nervous system are reflected. As a role when tho functioning of one side of tho body is impaired through cerebral disease the pathology is soot saniast in the hand. �20. lhne 1n the annex heuiplegit reeultina tram e capeulur leeion the pereeie, body image diuturhenoe end eeneory late ere use: pruexnene 1n the hind Ind (insert. In the-e petaente end in other. eleh dzrruee cerebral dieelee the phennlenl a: extinction. eheourltion end diepleoenent Ire elee beet e11¢18ed when the head in teeeed. lurthenlore. etufliee at eh. order at eeneory dullnenee or verioau ereee or the had: Genoa-trite the hand in the lowest hunk. thie in true in the eminence order or petunia with cox-em), dieeue (5). and mm nor-e1 eubjeete, both edulte and children (6). stallerly, then elleetheaie 1: oheerved, 1% 1e eeen she: olenrlr 1n khe head. Bender tad lethnneon (it) deeovihed e «nee 1n ehioh'the clinical courae III reflected in e waxing end unnans alleetheexe. Ae than petient inpraved, the trees from ehseh the phenunmaen oould be elicited amniniehed. ale delohetreble only in the hand. until finally alleethneie In entotopegneeie the hands hre ante proraundly effected thin other regiane. ringer Isnneie. paneibly the enrlieet etsn or body image dieturbenee, 1- trequentlr eeen 1n the eheenae or other groee dieeurbanaee or the bed: eehnne. Furthemeore, phantom 11gb, tnoeosnoeia. cluellsxn and eyneetheeie Ire phenalnne in which the role a: the hand 1e eepectclly praninent. Just an en». ”811010310 puma-em uniteet in tests or other body parte. but 3:. that aleerly delonetrehle 1n the hand. so the. exoealeetheete, though nonunionnlly delanetrnhle eleevhere, layman: apparent in exnlihntion of the function! at an. hand. 14: It hne been observed that luaealeytheele 1n the ham-e1 eeneory pheno-mne which aoeur 1n pettente with cerebral dylrunction m �.1 {{{{{ 21. h any bu fauna in tho annual young child (6). Similarly. have unvor fauna in adult: nxecpt than QSOOGIOIthlltl, thick I. that. in lirkod cornbrnl Ginsu... nun b0 roadily obnorvod in childrcu up to in. ago or tour. In urn-ining a 13:30 302103 of norm. chiidm it u. now that the initial mpm or ohildron to iambic ninnitunooal Itinuiation fruqunatly incinnnd' axoianucthnuia. nithough tho nor. can-an rosponnos In». «xtinctian and dispinou-ont. lionenusthonia was IIrO. havuvor. utter tho initili til trinis. In» truqunaa: with union uaonalusthnain.nnw he noon in children up to tho as. or tour insanity that it an: roprouont. in thy child, 3 ”annual" dovelopnuntai Itsse in on: ergnnisation of perception. It: uppourunan in uduits with novor. brain €110.30 any possibly ha. I. with aunt: pathologio phauulcnu, a rungIIion in function to a pruvioul iovvi at ntnnory integration. aBIIiII; lillooIIilation of tnotil. Itflluli into axtrn~poruuna1 space is dcnarihad tad tar-pd alone-cathonii. Bantu-nathnlil 1' aha-trod in pationta with saver. organic unntal lynarunon. It in apnaront only very rural: on tingle tactilu Itilnintion and in not. readily elicitdd by tho t'ahnituo of Gambia lilnltnnsoul atiunlntian. It is exaggcrntod by fatigue, rigid touting find incrOIlld unotional tonlian. lurhitnrttc intaxiention also may elicit or uxnggorlto the phauuncnon. Eh. pattoraod linsannathnuin in swat apparnnt in Itinniutian of the hand, but his bOCn obsorVCd in tiatl of othnr body part0. flail. it an: be canaidorod t pathologio axttntian of an. bad: image, it is act dopondcnt upan othcr ¢on¢anitunt body inns. disturbanotl. �nelmthOllt Mu bola observed chltfly 1n gamma nth nun natal chanson, u 1: not a manna» or contusion, but a patterned pnucun- phonmnm. It may be a "mum,“ patient: win: Mum}, animation. to I 93110th “new” was. in smear «alumna, u mated by the rut Although that 1t 1. «mum. "Ian: abut-"d in cinnamon- men. tut: 91‘ mg �1. 2. 1mm, 3.: Studies London, 1920. (a) £3. &1mm in lourolcgy, Vol. II, Oxford Univ. Prom, ammo, Id. lad wanna, Mm: Extinction mu, inILL, humans“. mu.xm1.unzuhut., g2; 717-725 phenomenon member, 19%. m, m. as: Itnuutien (b) r advantage. or the method at unannounthe neurological omimtion. monument: Anal-1c... 11.3.: 12.; 755-458. 1n V was. mm: he pheamnm or union unplacuo‘nt. mm, Awhmmelwr .. u. 9 607-621, lay, 1951. (I) MIR, LB... SWIM), IJ‘. lad gutuiugggo: the body team. W Arcth m fl.gm1.uq¢nug., a 1 m 3.1“: - ind anaemia §£L tea-am. Jeannine” ‘ (b) LB. and “We! 11.: Pattern: in alumni: their unfit»: to disorder of find: when and other unto” phone-m. 5. vm, I... film, I. Ind g5; 501615, October, m and 1950. tun-mm tut mm, Maximum sign or untrue heatnmiymejnmlm, 3!. £6.58, 1952. 6. (I) and mm, In Datum 1n perception I... rm,atII.no. on IMltlmm 0! Ind land. I I 250-»252, June, 1950. aura“) LBJ m, (2:) an , 809mb“, 1951. 0. . . 111.8. mm, I. and 11.: mm, mm, {out or and hand. “autumn no. §§: 355-362. £8 Patterns 11: . ”nation mammobgguglg8%.. � 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 Exosomesthesia; the displacement of cutaneous sensation into extra-personal space. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 260-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-6a-008 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 Shapiro, Mortimer F.; <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 [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry, October 1952, Vol. 68, pp. 481-490 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/7defb938ce2262c49752d69a21de6f6d.pdf 5a753824ca2576c05cbbf0c478051e0c PDF Text Text Spinal Fluid 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. Forty— eight 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, bi— lateral punctures were done in four, and combined bilateral carotid and ver— tebral 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 an— giomatous 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 an— From the department of neurology and psychiatry, New York University College of Medicine and the neurologic service (third division) and psychiatric division, Bellevue Hospital, New York City. Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, No. 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. CONCLUfiONS 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 1. OLSSON, 0.: Cerebral angiography: Toler- ance for contrast media of diodrast type, J. Neurol., Neurosurg., 1949. 6c Psych, 12:312, � 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 Spinal fluid findings following cerebral angiography. Neurology. 1953 Feb; 3(2): 137-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-10-014 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 Stein, Joseph M.; <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 Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol.3, No.2 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/7e92065b94f7b6d5425d61aa477e6ec4.pdf e45a9c50dfd09b37a641b179b46ee31a PDF Text Text ABSENCE OF A PARENT AS A SPECIFIC FACTOR DETERMINING CHOICE OF NEUROSIS Preliminary Study SIDNEY TARACHOW, MD.1 and MAXIMILIAN FINK, MD.2 New York, N. 'Y. Psychoanalytic experience has made important contributions to the problem of the differential etiology of various neuroses, psychoses, and character disturbances. This has been accomplished chiefly by the identification of the decisive areas of conflict in the patient. Among the factors involved are the nature of the instincts in the conflict, the time of the decisive conflict, the intensity of the frustrations or traumata, the availability of substitute gratifications, and the characteristics of the historical situation (Fenichel, 1). It is difficult to evaluate the specificity of any one of these factors in the choice of a particular neurosis. Recent investigations tend to show that while a particular neurosis may apparently be an expression of conflict at a certain level of development, nevertheless experiences at some earlier or previous level may produce tendencies which provoke, potentiate or distort conflicts of a subsequent period of development. With increasing psychoanalytic knowledge, the task of isolating concrete factors influencing specific choice of neurosis becomes ever more difficult. It becomes even more difficult if one attempts to assess the intangible factor of ego strength of an individual in his struggle to control and express his various instincts or his attempts to fashion defenses or character traits. Nevertheless, it 1Attending Psychiatrist, Hillside Hospital, Glen Oaks, N. 2 Fellow in Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 67 Y. �68 TARACHOW—FINK should be possible to find a way of approaching mental operations in a systematic way which would lead in the direction of solving the problem of specificity of choice of neurosis. In seeking a systematic way to solve this problem, it occurred to us that perhaps certain elements in the external historical situation might lend themselves more easily to the preliminary steps of such a search. If a certain external historical situation were isolated and studied, perhaps it could be correlated with certain invariable psychic consequences. Freud (2) made such an observation when he noted that men who have weak or absent fathers tend to develop homosexual trends. The external historical factor we selected was the presence or absence of both parents during the important developmental years of the child. We decided to investigate the relation of this external factor to the success or failure of the resolution of ambivalent feelings, the ability to fuse the instincts of love and hate. For reasons to be noted we selected hysteria and obsessive-compulsive neurosis as the clinical expressions of the success or failure of the fusion. We then set up the following hypothetical basis for this study and made a tentative prediction of the data to be discovered. A child brought up by both parents will solve the problem of resolu— tion of ambivalent feelings more satisfactorily than a child who has lost one parent for any significant period of time. A child facing only one parent does not have both his love and his hatred equally and freely available to be directed to the parent. If he loves the single parent the hate will tend to be repressed, and vice versa. A child with both parents, on the other hand, has two objects against whom both sides of the ambivalence can be directed in turn. He can hate one and love the other, or the opposite. Two objects give the child much more liberty than one. This freedom would not hinder resolution of ambivalence, but rather facilitate it. He would have all his feelings relatively more available to him in comparison to the child with one parent. When the time arrives for the necessary fusion of feelings for more mature relationships the child who had had both parents is in a better position. Both sides of the ambivalence having been available, the fusion is more complete and normal. The other child, having relatively only one side of the ambivalence available, never succeeds �CHOICE OF NEUROSIS 69 in fusing his ambivalent feelings and remains with a burden of one-sidedly more repressed and defused instinctual feeling. According to our hypothesis the child who had two parents and had succeeded in fusing his feelings would tend to develop hysteria, if he developed a neurosis. The other child would tend to develop obsessive compulsive neurosis. This follows from the familiar psychoanalytic formulations of defused ambivalence in the compulsive neurosis and the fused genital level of feeling in hysteria. This hypothesis was tested by consulting the case material from Hillside Hospital. We searched for clearly defined cases of each category and studied the incidence of absence, death or loss of one parent for any reason whatever. Only clear-cut cases were used. All mixed and intermediate syndromes were eliminated, as were phobias and anxiety states. Sixty-one records have so far been found suitable: of these, twenty-seven were patients with conversion hysteria and thirty-four with compulsive-obsessive neurosis. Separation from a parent was defined as the absence of a parent for periods exceeding one year before the child’s fifteenth year of age. Note was made of the time of the separation, the reason, the duration, and the age of onset of the neurotic symptoms. Of the twenty-seven patients with conversion hysteria, three (11%) were subjected to periods of separation. In each the separation occurred between the ages of five and nine; in two by death and in one by emigration. In the latter the period of separation was of six years’ duration. Of the thirty-four patients with obsessive-compulsive neurosis, fifteen (44%) suffered extended periods of separation. Nine occurred between the ages of five and nine, four before the age of five, and one each at thirteen and fifteen. Separation was caused by death in nine subjects, hospitalization in three, and emigration in three. In the latter the separation lasted from one to three years, during the child’s age of three to seven years. In four subjects there were double separations. In one subject there was hospitalization of a parent for a year, return home as an invalid for two years and then death. In three other subjects there was death of one parent and illness of the other at another time in the child’s life. In all instances the parental loss occurred before the clinical onset of neurotic symptoms. �70 TARACHOW—FINK These data point in the same direction as the hypothesis suggested, namely, that loss of a parent tends to increase the difficulties of solving the problem of ambivalence.3 So many other factors enter into the situation that we would limit ourselves to the conclusion that these findings warrant further study of the suggested correlation. Other studies of parental deprivation have taken a somewhat different direction. Oltman et al. (5) studied the difference in rate of parental deprivation, comparing various psychoses with neuroses. They found that the incidence of loss of a parent did not vary in schizophrenia and manic-depressive psychosis from their control group, while psychoneuroses were higher. Their control group was State Hospital personnel, with 32 per cent deprivation. Psychoses showed 34 per cent and the neurotic subjects 49 per cent. The psychoneurotic group was not diagnostically further differentiated. Madow and Hardy (4), in a study of clinic population in the Army, found parental deprivation by death in 36 per cent of the neurotics. They used as a control, life insurance statistical tables which indicated an 11 to 15 per cent incidence of parent loss before the age of sixteen. A third study (3) of a student health clinic population in a State University indicated that 31 loss of neurotic the cent through subjects reported parent per death, while only 131/2 per cent of the controls (normal students) did. None of these workers were searching for the factors we are, and there is no breakdown into the various neurotic categories. These observations cannot be used comparatively with our specific point in mind. In general the data from the literature indicate that the incidence of parent loss is greater in neurotic subjects than in psychotic and control groups, although the various control groups show a lack of uniformity. Our own subjects taken as a group (this excludes many mixed neuroses, phobics and anxiety states) show an average incidence of parent loss of 30 per cent. The incidence in the obsessional neurotic is higher than in the cited controls, while in hysteria it coincides with the lower percentages of the controls. Apart from the subtleties of the psychodynamic processes which this study overlooks there are also gross difficulties in evaluating 3Chi square was calculated as 6.32 which is significant at the .01-.02 level. The chi square was corrected for continuity by Yates’ method. �CHOICE OF NEUROSIS 71 the statistics. First of all, the sampling is small. This will be remedied as the study continues. No other study differentiated among the neuroses, and diagnostic criteria probably vary from one institution to another. This study can be refined and develoPed in a number of directions. The dynamics with reference to the separation could be explored. The presence or absence of parental surrogates should be looked into. Other factors of separation such as deafness or blindness or parent’s going out to work must all be considered. SUMMARY A hypothesis was formulated stating that unresolved ambivalence (instinct defusion) may be related to the absence of one parent during the critical formative years. It was tentatively predicted that obsessive-compulsive neurosis (illustrative of instinct defusion) would therefore show a high rate of parental deprivation and that hysteria (illustrative of instinct fusion) would show a low rate. The actual data were: thirty-four cases of obsessive-compulsive neurosis showed 44 per cent of parental loss: twenty-seven cases of hysteria showed 11 per cent parental loss. We consider this at least a provocative difference. Even though many intrapsychic factors enter into the problem of unresolved ambivalence, these data warrant further study along these and related lines. REFERENCES (l) Fenichel, 0.: The Psychoanalytic Theory of Neurosis. New York: W. W. Norton 8: Co., 1945. :2(2) Freud, S.: Three Contributions to the Theory of Sex. In The Basic Writings of Sigmund Freud. New York: Modern Library, 1938. (3) Ingham, H. V.: A Statistical Study of Family Relationships in Psychoneurosis. Am. J. Psychiat., 106:91-98, 1949. (4) Madow, L. and Hardy, S. E.: Incidence and Analysis of the Broken Family in the Background of Neurosis. Am. J. 0rthopsychiat., 17:521-528. 1947. (5) Oltman, J. E., McGarry, J. J., and Friedman, 8.: Parental Deprivation and the “Broken Home” in Dementia Praecox and Other Mental Disorders, Am. J. Psychiat., 1082685-694, 1952. �Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 1953 � 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 statistical study of a psychoanalytic hypothesis: absence of a parent as a specific factor determining choice of neurosis. Journal of the Hillside Hospital, 2: 67-71, 1953. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-11-015 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 Tarachow, Sidney; <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 Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 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/e7dc2fcb5fc19380588fec1c1d7b8cf6.pdf e4bf0125cc9cc7fe7c750dbacfa00dd7 PDF Text Text �SOME EFFECTS OF A NEW PSYCHQTOQEN IN BEFRESSIVE STATES J. Mednna Univereity of Illinoie College of L. G. Ahood A and L. Hedioine group of 3~R~snhetitnted piperidyl beneiletee have been recently denonetreted to poseees peychotceieetic propertiee(l.2). The N-nethyl-snpiperidyl beneilete, in doeegee of 5-10 mg orally, produced distinct auditory and visual hellucinatione in every nor-e1 individual teeted. The hallucinations lasted for many bears, and were accompanied by green distortion of visual perand by e confosionel etete corresponding to delirium. ception A nnnber of subjects exhibited paranoid ideotion and ideee of grandeur, while others suffered a conplete loee of contact with the environ-eat, end frequently reacted to their hallocinetione. When the toxic symptoee disappeared, the experienced ethecte e earked physical eeekneee for 10—24 honre, after which period they regained their pro-experimental statue. It see noticed, however, that some of the normal volunteer subJects developed a change in their heeic mood and drive. This change usually appeared 24 to 48 hours after the phyeicel weakness disappeared. The newly energies modulation of need can be characterized es slightly hypenenic end of increeeed drive. This leet observation indicated that the drug night he naefnl in the treatment of peychietric states in which the ontetending eyepton ie a depressed need. In the course of exonining the structureoaotivity relationships of various congenere of the piperidyl beneiletee (3), it wee found that substitution or e cyclopentyl for one of the phenyl groups in beneilic acid considerably enhanced peychotogenie potency end greatly prolonged the duration of action. The colu pound, deeigneted JB-329', has the following structure: Q *- {’ I “2‘5 0 Ell/Q - g 361 ‘0 N-ethyl-B-piperidyl cyclopentylphenyl glycolate hydrochloride This derivative also eeened to produce considerably more hyperend central etieeletion than did its beneilate congener. ectivity The present comnunicotion concerns the nee of J8~339 on psychi- etric patients. DB, one a 60-year-old eon, e first patient, §5g3_figt_*: ormer r cklayer, who had been hospitalized for the last ten years. Exeeinetion revealed his caee to be one of eevere depres» eion iith suicidal tendencies, ceoeed apparently by the necrotic The �. 7 .., . t V... ".7“ .........4. ,g-vvwmh . ”a...“ . man. w.- ...,..r.....,....... r.” ..u._,..,,.,.—Y “any,” p,..r.._....~.w.....F—, .»... wwv.-.» an...“ ...~.,v»,., . "fin y”... wr—u-nrl’nu _,., V... ..W;.,..I.:.v...._.._..r*‘ 7.. reaction of his burned~out body to the insoluble probles of his wife’s gsychotio illness. The patient eas given 12 as of 33-329, and sit in an hour showed signs of confusion, drowsiness, ataxia, and hypereflexia. A few hours later he began hallucina~ having tions, saa disoriented, extreaely restless, and beg nning to lose contact with the environaent. Autonosic syaptoas were present throughout, such as aydriasis, tachycardia, dryness of the south, and muscular weakness. At the end of 24 hours, he seeaed con~_ siderahly less depressed, sailed, laughed, and was such sore talkative, although he professed to be Just as depressed as he was before the treat-ant. Psychological re-exaaination with the Eduardo and Rorschach tests indicated a definite iaproveaent in seed and general outlook, and although the depression still existed, it seessd realistically based, and was considerably less overehelding. The patient, hosever,.rofased to go back to his psychotic wife, and was returned to a state hospital. EP, a an 33~year-eld unaarried shite aan, coaplained he, 0%.. o extreee apathy, and a chronic spastic colitis. spression, He had quit his job over a year ago because of an increasing depression, accompanied by feelings of inadequacy and lack of desire to work. Psychological tests revealed his to be iasature, with little or no effect, no signs of anxiety, and no insight into his condition. He reacted to 10 ag of JB~329 in such the seas manner as the previous patient, covering a tine-span of 18 hours. At the and of this period, he appeared very cheerful, and of the depressed, haunted features of his face had disappeared. all He gave the iapression of a nan sell on the way to after recovery a long illness. That ease day he indulged in a rather vigorous gene of baseball, nixed, and talked freely with the other patients. He adsitted feeling sore aggressive and exuberant, and expressed a desire to go back to sort as soon as he was discharged. Psychological re~exaaination showed his to be sore responsive, less inhibited, and his outlook less liaited. The patient was discharged two days after receiving the drug, and two days later be procured a position, which he still retains after three aonths. c a had lea, 47-yearweld'aarried.aan, a history §%;f_§g‘_%l 0 ntera ttent depressions since 1953. He had been unable to work during the past year because of the depression. at the ties of his admission, he showed syaptoas of restlessness and extreae agitation; he ens harassed by self-accusations and feelin of guilt. Pro-therapy tests revealed an inadequate personal ty with en extreaely passive dependence.on other people. The existent anxiety and depressive features sore overlaid upon a longostanding character disorder. The patient's response to 12 ng of JB~329 differed fro: the previous patients only insofar as the halluci» natory episodes sere far aore vivid and of longer duration. After 36 hours, the patient exhibited aarked increase in actor activity and a draaatic iaproveaent in need. Psychological reexasination revealed that he was now able to express hopeful and resolute attitudes toward the future, although he still had little confidence in his ability to achieve the goals he envisioned. �after being discharged, which he spontaneously erote a letter were taken the following statements: free For your infor~ nation, ay progress has been good. I as working about [all tine have gained-about ten pounds. fly appetite is very good not. as extremely grateful to you for what you have done.‘ Two weeks ...I ...I who a 54*yearuold earried sea shite eoaan ap» gagg_§g‘_3z each older, and had been in a very severe depree~ pears very sion for the last ten years. She had phobic paranoid reactions, suicidal ideas, and hysterical attacks accoepenied by screening. excessive crying, and other indications of desire {or attention. Psychological exaninetion indicated an unsound personality strse~ tnre which scene to have been infantile even before the onset of the present illness. The effects produced by 12 a; of JB~329 were to those in the other patients. and lasted for 24 hours. eiailer The following day, she appeared more vivacious and nest of the outward signs of her illness had disappeared. 0n the succeeding day, she socialised for the first time with other patients, and participated in occupational therapy activities. She seeaed‘sur~ prisingly cheerful, enjoyed her food, and appeared outgoing. After three days, when her husband case to take her hose, she reacted violently and relapsed into her previous condition. Her' condition was apparently developing into a full—bloen psychosis. Electroshock therapy was adninistered during the next week, and although the patient showed improvement at first, she again relapsed into the previousaagiteted depressive condition. No 5: KB, a 46—year-old shite-nnaerried resale with Ca paranoia delusions. was depressed and apathetic. She was extra-sly tense and anxious. and her grasp on reality was tenuous. Her reaction to 10 a; of JB~329 see similar to that of the other except that the hallucinations and disorientation lasted patients, up to 36 hours. Two days later, she appeared definitely anieated. cheerful. and coegosed. When questioned about her past condition, she replied, "I feel such more alert and don’t toel.depressed. Strangely enough, this was one of the first things I noticed. I feel new as it before the treat-ant I had been living in a [let tee-dimensional eorld and I had sort of retreated into ayseli. and nee, after this treatment, I feel I as out in the noraal three-dioensional world. I feel such sore alive...I have lore energy and enthusiasm.“ The patient resneed her work on the day following.her discharge. She continued to shoe improve-ant during B the next few weeks, although after one south-she appears to be relapstng into her former state. She reported. however, that a symptoms, which she referred to as a ”catatonic nightnere." a condition during which sheeeeeaed to be conscious but was unable to sore and which had existed for eany years before the treat— aent, had coapletely disappeared and had not yet returned. LCCT ' DISCUSSION Five cases have been presented which serve as pilot experiaents in the application of the piperidyl bensilatee to patients manifesting psychopathology. Of the five cases, the first and �“-vv—l‘vrr‘vr‘n-I—vw—v'wvwbvu' .V ‘1"N"x'-w-*,—- meg-w,v—u—m- . mun—aw wr— . Wmuw‘aw—r _.. wenhvvrv-"v' Wham-1 rap. >mvr-.-.—_—,WVgrnww.-m.n WK‘J'W‘ wm ~ wane—v - .w u-‘nnw -4the fourth can be considered eo experieentel ouccooeee but therepeutic failures. These two particular ceeee have never reepondod‘eell to any other for: of therapy, including electron check and drugs. In three case: (Noe. 2, 3, end 3) the single application of the oxperiaentol dru; proved to he of therepeutic value. Cece: No. 2 and 3, who were unable to work for over e before the oxyear porieent, were able to do oo. Case No. 5, which is the neat interesting of our small oxporieental group, wee working prior to the experiment; but that petiont'e state-onto end our objective observation are both indicative of the therapeutic effectivonoee of the drug. Cece No. 4 proved to be a therapeutic failure with reepect to the drug. but the patient aloe failed to recover after electric convulsive trootnonte., All five canoe treated hed only one synptoa in cannon-~ooee degree of doproeeion. The other most remarkable con-on feature of cases No. 3, 3, 4, and 5 one an extreme infantile personality which could not be expected to change after a eingle treatment of whatever eort. If it were not for the fifth coco, where the loot remarkable ohengee were produced, this drug, 38-329 and ite con¢enere could be earmarked for the treatment of depreoeive otateo only. In the fifth case, however, beneath the light dopreeeion were deeper disturbances of thinking end perception eluding superficial observation. In effect, ehe eee psychotic. lhethor her perticular paranoid state ehoold be diegnoeod ae latent eohieophrenie, effeltivo paychooie, or achieophroniforio beside the point. The ieportance of this case io that it indicates some usefulness of the piperidyl benziletee in e patient eith lurked perceptual and cognitive dieturbenooo. There are a great nu-ber of questions uneneeered by thie proliainary experiment. Both the extent and duration of leproveaent have not been fully aeeoeeod. It reneino to be detereinod 1) whether repelted adainietretion of the drug in hallucinogenic doeeo would have produced a greater degree of improvement in the eueceeefei canoe and total or partial leproveaont in the unseen ooeeful fourth cone; or 2) whether the production of the poychotogonic etete ie necoeeery et oil to produce ieprovenent; or 3) if deily repeated small doses of the drug for an extended time would have produced the care but clover iiproveoent. Both the effect end proper doeege ochedule of e aeintonenco ascent of JB-329 have yet to be determined. Finally, the proper field of application of this drug in peychiatry ie in doubt. do for co the cxporieentol results on nornel and pathologic etheoto permit any conclueion, the drug would be epglicable to depree~ eive etetee. Our fifth case. however, reieee some slight hope that JB-329 or related derivetivee night be useful in treating the grove personality dieordere cocoonly diagnosed an albino. , - a phrenil. L of enticholinergic egonte in the treetaont of eohieophroeie ie not nee. Forror and eo~eorkere (4) odainieterod very large The nee '10.!"me �W “u—wmumw—HWM‘ w , y:- m ;«m« mu, 7-" v mlm“ wflwnm—u‘u—w“ Imam. m... .. -. . .r t i . a r n . - _ _ i n. --'—-'-v>-vv_uru'v » 'I‘uflv-"vWO4‘m‘ <‘AmevN’--ww z-ew11IUI'm—rl—I- .5doses (up to 200 mg) of atropine intramuscnlerly to schizophrenics seniteetinc eose degree of anxiety. [Such doses of atropine produced core; but nest of tho psychotogonic and stisuleting notions achieved with JB—329 were absent. It remains to be seen whether the besic eeoheniss ot-thooe tvo nodes of therapy is sisiler, although our findings suggest that atropine is devoid of the exceesive stimulating properties of JB~329. LSD—38,_enother hellnoinogen, has been used therapeutically in treating psychotics, lsrsely es en edJunct to psychotherapy or electroshock convul— sions (5, 6). With regard to the code of sction hardly more can be said than that the substance has definite enticholinorgic properties, but evidence thet the central ettect itself involved cholisergic blocksde is locking (1, 3). The piperidyl bensiletes in smaller doses produce facilitation of sotor neurons (Renshee cells) in the lesbsr region of the cat‘s spinal cord, while larger doses produced couplete inhibition (7). Acetylcholine is presumed to be a mediator in Renshew cells which are believed to exercise a generalized sup reesion in motor neurons innervating okeletel soocle.v Kiseich ‘8) hes demonstrated en inhibition of electricel activity in the reticular bulber forention of the rabbit with 2.5 eg/kg of JB~329. in contradictincticn to LSD, which in exci~ tetory. Such neurophysiologicel studies are merely prelisinsry end. although they say oxplsin certain effects of the drug, such es hyporrcrlexie. considerably more work of this sort releins to be done. clinical results with the drug are even more obscure, perticnlerly since the therepentic effects become apparent long after the hellucinatione and autonomic sysgtoss have disappeared. Furthersoro, otudieo on animals indicate that the drug is rcedilg hydrolyzed in the body, and is completely elisineted in 24-48 ours.. One can only conclude, therefore, that therapeutic effects are related to the drug in a secondary manner. The piperidyl beneilntos probably serve es a trigger necheniss for e long series of neuroohysiologicol effects resulting in the inprevelent in the pstient s psychopathslogicel etstns. Sub~ sequent clinioel work ie oiled at working out proper dosage schedules, on well no the indications for the use of this and other related drugs. The SUMMARY entioholinergic psychotonimetic agent, Noethyl-3~piperidyl cyclopentylphenyl glycolote (JR-329), has been used in the treat~ sent of e snail author of depreeeed patients. The drug induces e drive of eotivity eccosponied by sons sood elevation. This sceningly desirable effect tron s therapist's viewpoint occurs after e period in which there are psychopathologicel effects or s definitely psychotic nature. The post~psychotic effects which sees desirable are of a prolonged duretion (days to reeks possibly). There is st least all ht evidence in two casee or e continuing stete of isprovenent n inte3retion of the mental functioning and A new behavior. ' �. ,w... E. n‘vw-“m-w~'mwwm‘w‘m‘—Iw — ,., -—- --——- q"r.xr)r.«,"l‘w wine—uw.w m_m , .v . w-..-....w w. m—u—wnm .c up... (“mu—r . .- "le- REFERENCES l. 6., Oetfeld, N., and Biol, J. A new group of peychotceieetic egente. Proc. Soc. Exp. Biol. end fled., Ahead, L. A. 97: 433, 1958. 2. Oetteld. A. l., Ahead, L. 6., end Hercne, D. A. Studies with cerulopleeein end e nee hellucinogea. A.M.A. Arch. Neurol. and Peychiet.. 79: 317, 1958. Abuod. L. 6., 03:5.1a. A. u., and 31.1, a. Structure~ activity roletionehipe of Supiperidyl heneiletee with peychotcgenic propertiee. Arch. Int. Phereecody. ct Thor. (in prose, 1958). Forrer, G. R. AtrOplne toxicity there_y in the treatment of aental dieeese. AI. J. Paychiet., 08: 107, 1951. Just, F., and Penal, fl. Proepective peychietry. Inch. Mod. fiche-chr.. 99: 889, 1957. Sandlson, R. A., end Whitelae, J. D. A. Further etudiee in the therapeutic velue of LSD in eentel(illnees. J. » 3. 4. 5. 6. 7. 8. Heat. Sci., 103: 332, 1957. Ueki, 8., hiehi, 8., end chcteu, K. Hieeich. K. Persoael coneunicetion. Personal communication. Foorxowas ‘ Syntheeieed bf Dr. John Biel, Lekeeide Leboretoriee, Hilveukee, Wieceeein. authors ere deeply lndebtefl to Dr. F. J. Gerty for hie eeny invaluable suggeetione, end to Dr. Alec K. Roeeneeld for the plydhalogicel teete. Aiéed by greute free the Mental Health Fund, Stete at Illincie. end the Teegle Foundation. The �Institute of Human Nutrition, Praha, (J. Mast-k) A PSYCHOSIS CAUSED BY BENACTYZIN INTOXICATION Minis VoJ'i‘cmuovsm" The dimethylaminoethyl ester of benzylic acid is known in the literature by the following names: Benaetyzin, Suavitil, Parasan. It was synthesized in 1936 in the CIBA Laboratories in Switzerland as a spasmolytic agent, but it was not until 1955 that it first came to be used in psychiatry by Munkuad & Jacobsen, where it proved to be a useful tool for decreasing anxiety and psychic tension, without having any hypnotic side effect. During the following two years it was roughly investigated for both its clinical and pharmacological qualities and was applied to many patients in various institutions. The specific action of this drug upon the central nervous system placed it, together with the tranquilizers, on the level of the leading modern psychopharmacological agents. For its composition and central nervous action it was called an “antiphobic” agent, while its chemical structure ranged it among the diphcnylmethanes having a central nervous effect (together with e.g. Meratran. Frenquel, or Atarax). 'I‘herapeutically it is used more commonly in cases of neurosis than in psychotic cases. Its pharmacological and clinical attributes have been described thoroughly in other publications. This substance was also synthesized in Czechoslovakia, in the Laboratories of the Institute for Research in Pharmacology and Biochemistry and has been tested since May 1956 in several clinical institutions (Dr. Hanzlic‘ek, Dr. Vina‘r’, Dr. Vojté’chovsk‘y). The results of these tests have been published elsewhere. At the clinical department of the Institute of Human Nutrition we administer Benactyzin in the therapy of some gastrointestinal diseases. Thus we had an opportunity to observe the course of an acute intoxication, which we refer to in the following case history. It was the enormous size of the dose used, fifteen times greater than described in the literature (Jacobsen (1955)— 90 mg). as well as the fact that to our knowledge it is the only case where psychotic symptoms appeared, which stimulated the communication. .43, . i �A PSYCHOSIS CAUSED BY BENACTYZIN INTOXICATION MILos \’o.1'r1'«:1;11ovs1\'\" The dimethylaminocthyl ester of benzylic acid is known in the literature by the following names: Benactyzin, Suavitil, Parasan. It was synthesized in 1936 in the CIBA Laboratories in Switzerland as a spasmolytic agent, but it was not until 1955 that it first came to be used in psychiatry by Munkvad & Jacobsen, where it proved to be a useful tool for decreasing anxiety and psychic tension, without having any hypnotic side effect. During the following two years it was roughly investigated for both its clinical and pharmacological qualities and was applied to many patients in various institutions. The specific action of this drug upon the central nervous system placed it, together with the tranquilizers, on the level of the leading modern psychopharmacological agents. For its composition and central nervous action it was called an “antiphobic” agent, while its chemical structure ranged it among the diphenylmcthanes having a central nervous effect (together with e.g. Meratran, Frenquel, or Atarax). Therapeutically it is used more commonlyin cases of neurosis than1n psychotic cases. Its pharmacological and clinical attributes have been described thoroughly in other publications. This substance was also synthesized in Czechoslovakia, in the Laboratories of the Institute for Research in Pharmacology and Biochemistry and has been tested since May 1956 in several clinical institutions (Dr. Hanzlié’ek, Dr. Vina‘r’, Dr. Vojféchovsk'y). The results of these tests have been published elsewhere. At the clinical department of the Institute of Human Nutrition we administer Benactyzin in the therapy of some gastrointestinal diseases. Thus we had an opportunity to observe the course of an acute intoxication, which we refer to in the following case history. It was the enormous size of the dose used. fifteen times greater than described in the literature (Jacobsen (1955)— 90 mg), as well as the fact that to our knowledge it is the only case where psychotic symptoms appeared, which stimulated the communication. �515 CASE HISTORY L.B., a 29 year old married female, a physician by profession, with a sensitivepersonality, but without previous psychiatric symptoms, during a short period of emotional excitement following some misunderstanding with her husband, consumed almost a teaspoonful of pure Benactyzin. (During the reconstruction of the case it was ascertained by weighing approximately the same amount of the drug, that the patient had consumed about 1300—1400 mg of Benactyzin). It was used solely for its soothing effect without any intention of committing suicide. The course taken by the intoxication, as described by the patient herself and corroborated by her husband and the physician summoned to the case, was as follows: About ten to fifteen minutes after taking the drug the patient became confused, she felt as if she were looking at herself and her surroundings from a distance is; as if everything was running away from her. She expected to faint, but remained seated quietly on the sofa. After about twenty minutes she became agitated and leaving her seat walked in a very unstable manner to the bathroom to take a shower. There she noticed in the semi-darkness a pile of laundry lying on the floor, and on top of it she suddenly saw her six months old son. Let us continue in the patient’s own words. “I was unable to realize at the time that this could not be true since the baby was actually at home with his grandmother. As I kept looking the baby suddenly turned pale, then yellow, his eye-balls deviated to one side and he appeared to be on the verge of dying. Finally, before my very eyes, he started fading away and disappeared. In a wild attempt to find him I searched among the laundry and then, feeling completely desperate, I ran out to seek an injection for him. My husband prevented me from going out. I accused him of being the cause of our baby's possible death.” According to the husband there followed a short struggle and the patient was compelled to remain in the room. What occurred in the next period is covered by amnesia (that is between the twentieth and the fiftieth minute), and it is the husband alone who continues the description of the case as follows. “She showed signs of anxiety and her face held a terrified expression. Her orientation in space was altered, when she tried to seize an object she would miss it by about 20 cm, she would also miss the chair when trying to sit down. She became more.and more agitated and repeatedly tried to run into the corridor, even though she was only partly dressed, with the persistent idea of obtaining the injection for saving her child. A short time later, having managed to escape, she was found on another floor, in vain seeking an opening into a wardrobe and talking confusedly about the death of her baby. She was brought back into the room, where she became slightly calmer." The patient is able to continue the description of the events which followed (that is about an hour after the consumption of the drug), as the amnesia was lifted for this period. “I tried to understand that I could not really have seen the baby, since he was not there, but whenever I thought about him the whole situation appeared again very clearly before my eyes and I felt a terrible anxiety. At this time I partly realized that I had only suffered from a hallucination. I tried to focus my mind on my surroundings and the conversation, but my thinking was disrupted and l was unable to integrate individual notions into a logical whole, even though I did partly realize the inadequacy and incoordination of the words I used. I believe I even repeated certain phrases stereotypically.” At this time, that is between the first and second hour of 'the intoxication, the physician, who had been summoned, noted considerable psychomotor excitation, agitation, inadequate behaviour and inadequate answers to questions and diagnosed 33 ac-ra rarcu. rr NIUIOL. scan, 33, 4 �516 psychotic state. The patient confessed having taken a large dose of Benactyzin, but resolutely denied any suicidal intention. Her face was flushed and showed signs of crying, her pupils were dilated and she looked terrified, her pulse was 921 min., her blood pressure was not recorded. Caffeine and coramine Were applied hypodermically. The patient violently protested against taking the injection saying, “Do not give it to me, but to my son, who is dying.” Two hours later, when the physician saw the patient once more, there were still slight signs of psychomotor agitation and emotional instability, but the patient had just experienced a critical attitude towards the hallucination and psychotic state. In her story the patient describes her feelings during the period between the second and fourth hour after consumption as follows: “After the injection I felt roughly normal. I realized the impossibility of what I had seen, but I still remembered it with a feeling of terror.” Her husband observed that she became calmer after the injection, but her speech was still inadequate. Four hours after taking the drug she became normal, but was very tired and sleeply. An hour later, that is five hours after taking Benactyzin, she was able to ride home on the bus. Then she spent a quiet night, and the following day she was without symptoms. a EPICRISIS Ten to twenty minutes after consumption of 1300—1400 mg of pure Benactyzin a 29 year old married and mentally healthy female, a physician by profession, showed signs of indisposition, ataxia and derealisation, later there appeared psychomotor excitation and a temporary true optical hallucination showing the horrible image of the death of the patient’s baby. This experience led to great anxiety and psychomotor excitation and the whole behaviour was centered on saving the baby. In the period between the twentieth and fiftieth minute of the intoxication the patient passed into a delirious state, wih confused consciousness and followed by amnesia. This stage was characterized by the appearance of a secondary delusion about the death of the child and accompanied by aggressive behaviour motivated by the wish to save him. Thinking was incoherent, there was a feeling of blocking of the thoughts with a strong accentuation on anxiety, agitation and ataxia. The physician who examined the patient some time between the first and second hour after the intoxication, noted a psychotic state with signs of agitation, inadequate answers to questions, and the delusion about the death of her baby. Upon physical examination a flushed face, dilated pupils, and tachycardia were observed. The psychomotor agitation decreased after the application of coramine and coffeine and there arose a critical attitude towards the hallucination and delusion experienced, but the emotional bond to their memory remained. Disorders in thinking stood out foremost (blocking of the thoughts). These were apparent in the form of incoherence and perseveration. Three or four hours later the psychotic state had definitely ceased and was re9 �517 placed by tiredness and sleepiness. After this phase there were no further complications. DISCUSSION The toxic dose of Benactyzin has not been ascertained for man. Experiments on the human subject were made impossible by the marked effect of even small doses of the drug upon the central nervous system, as may be observed both clinically and on the electroencephalogram (Coady & Jewesbury 1956). After a dose of four to six mg of Benactyzin, the following unfavourable side effects were described: dizziness, apathy, relaxation of the muscles, a dull feeling of the extremities, as if they were not connected with the body, sluggish thinking and lowered attention, decreased reactivity to external stimuli, blocking of the thoughts, derealisation, ataxia. Among the symptoms of disturbance of the vegetative nervous system, it was especially dryness of the mouth and palpations which stood out. The side effects described above occur in about 40 per cent. of the patients treated, causing a marked decrease in the therapeutic value of Benactyzin. The dose used to date never surpassed 90 mg (per single dose) and were never accompanied by qualitative disturbances in thinking or hallucinations or. confusion (Jacobsen 1955). The Benactyzin intoxication described above (about 1300 mg) was characterized by a delirious psychotic episode with a brief optical hallucination, followed by a secondary delusion, confusion, and psychotic behaviour. Before and after the delirious state in our case, there were the other side effects commonly described in the literature, namely ataxia, derealisation, and blocking of the thoughts. The atropine-like visceral effects which could be expected after such a large dose of the drug were not felt by the patient herself even though they could be observed to a small extent (tachycardia, flushed face, dilated pupils). The psychotic course of the intoxication could be explained by the specific and quantitative action of Benactyzin upon the central nervous system. While the theme of the psychotic episode might well be understood psychodynamically: a sensitive mother whose main problem of life is the health of her six months old child, the optical hallucination may be the realisation of her fears. The relatively benign course and short duration of this intoxication and the negligible visceral symptoms which accompanied it, even though the dose taken surpassed therapeutic dosages more than a thousandfold, denote a relatively low toxicity of Benactyzin. On the other hand this case only accentuates the predominative action of this drug on the central nervous system. 33‘ �518 SUMMARY The clinical course of an intoxication by about 1300 mg of Benactyzin characterized by a short benign delirious psychotic state is described. REFERENCES GeseIIscha/l f. chem. Iniluslrie, Basel, Schw. Pat. No. 183065, 187825, 1936. (.‘oady, A., & E. C. 0.1ewesbury (1956): A clinical trial of benactyzine hydrochloride (“Suavitil”) as a physical relaxant. Brit. med. J. 1, 485—87. Davies, If. B. (1956): A new drug to relieve anxiety. Brit. Med. J. 1, 480—84. Jaeobsen, E. (1955): A new drug efective on the central nervous system. Dan. Med. Bull. 2, 159-160. Jacobsen, E., A. Kehler, V. Larsen, I. Munkvad & K. Skinhaj (1955): Investigations into autonomic responses during emotion. Acta psychiat. (Kbh.) 30, 607—25. Jensen, 0. ”slergaard (1955): Suavitil in the treatment of psychoneuroses. Dan. Med. Bull. 2, 14043. Munkvad, I. (1955): Treatment of psychoses and psychoneuroses with a new sedative (Suavitil). Acta psychiat. (Kbh.) 30, 729—39. Vinar, D., M. Vojté'chovskfi & Vinarova’ (1958) : Cas. lik. Ees. (Prague), in press. , Received April 4, 1958. Milo} Vojtéchovsk)", M.D., Praha XIV, Budéjovika 800, Czechoslovakia. �Reprinted from Psychotropic Drugs THE COMPARISON OF THE PSYCHOTIC EFFECT OF TRYPTAMINE DERIVATIVES WITH THE EFFECTS OF MESCALINE AND LSD-25 IN SELF—EXPERIMENTS S. SZARA Central State Institute for Nervous and Mental Diseases, Budapest (Hungary); Forsehungsabteilung, Psychiatrisehe und Nervenklinik der Freien Universitat, Berlin (Germany) INTRODUCTION \ Indolealkylamines have been considered for a long time as a group of active substances of rather slight pharmacological and almost no psychiatric interest. Renewed attention has been focused on them since the discovery of the presence of 5-hydroxytryptamine in blood, in the enterochromaffin cell system, spleen, kidney, and the central and peripheral nervous tissue. An excellent review on the pharmacology of indolealkylamines by ERSPAMER appeared in 1954, and many other reviews have appeared on 5-hydroxytryptamine or serotonin (AMIN et al.1; FREYBERGER et al.11; GADDUM et al.12; HIMWICH13; LANGEMANN17 ; PAGE2"; ROTHLIN). The tryptamine derivatives have been of interest only in connection with their effect on blood pressure. Data on their effect on the central nervous system can be found only sporadically (NIEUWENHUIZENlS; SPEETER AND ANTHONY“). Our attention towards their possible psychotic action was attracted by the works of FISH, JOHNSON, AND HORNING9 on Ptptaa’enta alkaloids among which they found bufotenine, N,N-dimethyltryptamine, and their N -oxides. In experiments on animal they found these drugs to have psychotic effects, but experiments on humans were made only with bufotenin by FABING. We therefore decided to make self-experiments and experiments on normal volunteers with N,Ndimethyltryptamine and with the N,N-diethyl compound also (Fig. I). Bufotenine HG I /\ANH/ l I l CH2CH2 N(CH3)2 C (WCHZCHz-N(CH3)2 DMT “ T—g l \ANH /\j—j— \NH CH 2 CH 2 -NCH (2 5)2 Fig. I. The chemical constitution of bufotenine. DMT and T—9. References 1). 466. �PSYCHOTIC EFFECTS or DMT, r-g, 461 MESCALINE, AND LSD-25 METHODS AND MATERIALS The N,N—dimethyltryptamine (DMT) and the N,N-diethyltryptamine (T-g) were obtained synthetically by the method of SPEETER AND ANTHONY. For the purpose of purification the amines were distilled in high vacuum. For the experiments, sterile aqueous solutions of the hydrochloric salts were prepared and used in a concentration of 30 mg per ml. The lethal doses estimated in white mice by the usual method were 135 mg/kg in the case of DMT, and I20 mg/kg in the case of T-9. ' Although the substances have been not very toxic in mice, we were very cautious in the self-experiments. In the peroral experiments, starting from 14 mg and increasing the dose up to 150 mg no observable psychic or vegetative effects were found. After the unsuccessful peroral experiments, intramuscular experiments were made. In this titration series other physicians of the Institute of Budapest took part. The doses administered were IO mg, increasing to 150 mg (zle. 2 mg/kg body weight). Psychotic effects were observed from 30 mg, Le. 0.2 mg/kg body weight; they reached their optimum in doses about 0.7—1.0 mg/kg body weight. On further increasing the doses the psychotic symptoms were suppressed by the vegetative and organic symptoms. Therefore the further experiments on normal volunteers were made with the above-mentioned optimal dose. A detailed paper on the results obtained with normal volunteers, is to appear in Psychiatria at N eurologica (SAI—HALASZ et al.22). THE SELF-EXPERIMENTS The purpose of this report is to compare the psychotic effect of tryptamine derivatives with the well-known effect of mescaline and lysergic acid diethylamide in self— experiments. I believe that this method of experimentation is one of the best ways of obtaining direct information on subtle psychopathological phenomena, which are of great importance in understanding the schizophrenic syndrome. TABLE I THE DATA OF SELF-EXPERIMENTS Dose Substance I. Mescaline II. LSD-25 III. DMT DMT DMT DMT IV. T-9 0.35 g IOO lug 0.25 mg—I 50 mg 75 mg 75 mg 60 .mg 60 mg A dmin. Date per 05 per 05 per os i.m. Dec. 1955 Dec. 1956 i.m. i.m. i.m. March—April 19 56 April 1956 June 1956 March 1957 Nov. 1956 Place Budapest Vienna Budapest Budapest Debrecen Berlin Budapest The experiments were carried out over a period of 16 months. I took mescaline at Christmas—time 1955, and the LSD—25 was tested in Vienna at the Psychiatric Clinic of the University, by courtesy of Prof. Dr. HOFF and Docent Dr. ARNOLD, in De— cember 1956. The first intramuscular administration of DMT occurred at the end of April 1956, and was followed by the experiments on normal volunteers. We reported References 1). 466. ' �s. szARA 462 the results at the Annual Meeting of the Hungarian Physiological Society in Debrecen. During this meeting I made the second intramuscular experiment in order to get an electroencephalographic recording. A third DMT—experiment and some biochemical investigations were made in Berlin at the Research Department of the Psychiatric and Neurologic Clinic of the Free University, by the courtesy of Prof. Dr. SELBACH. The T—g—experiment was made intramuscularly in November 1956 in Budapest. I shall not go into details about the effects of mescaline and LSD-25 becauseI am not able to add any new aspects to that well—known picture. Nevertheless, the chief features of these experiments will be mentioned later. At present I shall only describe in more detail the symptoms of DMT and T—g model psychoses, in View of the lack of such reports in the literature up to now. (a) The BAIT—experiments As mentioned above, DMT ingested per as has no observable effect. But an intramuscular injection of 30 mg could already produce some mydriasis and subjectively some perceptiOn disturbances. The larger the dose, the more striking are the symptoms. About the self—experiment made with 1.0 mg/kg, Le. 75 mg DMT in total, I can report the following: In the third or fourth minute after the injection vegetative symptoms appeared, such as tingling sensation, trembling, slight nausea, mydriasis, elevation of the blood pressure and increase of the pulse rate. At the same time eidetic phenomena, optical illusions, pseudo—hallucinations, and later real hallucinations, appeared. The halluci— nations consisted of moving, brilliantly coloured oriental motifs, and later I saw wonderful scenes altering very rapidly. The faces of the people seemed to be masks. My emotional state was elevated sometimes up to euphoria. At the highest point I had compulsive athetoid movements in my left hand. My consciousness was completely filled by hallucinations, and my attention was firmly bound to them; therefore I could not give an account of the events happening around me. After %—I hour the symptoms disappeared, and I was able to describe What had happened. In the second intramuscular DMT-experiment, the duration in time and the symptoms were mamiy the same. At the third DMT-experiment, the dose was somewhat smaller (60 mg); the symptoms were thus milder, but qualitatively the same. (b) The T—g—exyberimem The symptoms of the T-g—experiment are briefly as follows. About 15 minutes after the injection of 60 mg of T-g came the same vegetative symptoms as described for DMT. The illusions, hallucinations, and the athetoid compulsive movements in the left hand were the same as for DMT. But the alteration of the surrounding world and the emotional reaction to them were strong and impressive. The mask-like faces of the' persons, the dream-like mysteriousness of the objects and the room gave me the feelnig that I had arrived in another world, entirely different and queer and full of secrecy and mystery. This wonderful but strange world attracted me at one moment, but the next moment I did not want to accept it. I became perplexed; I did not know what I ought to do. I began to walk anxiously up and down, and said: ”I ought to do something, I must!” There was a peculiar double orientation in space References p. 466. �463 PSYCHOTIC EFFECTS OF DMT, T-9, MESCALINE, AND LSD-25 and time: I knew where I was, but I was inclined to accept this strange world as a reality, too. The dusk of the room was lightened for some minutes, and again the light was switched off, and that seemed to me as if this period might be an entire epoch, filled with events and happenings, but at same time I knew that only several minutes had passed. (6) The comparison of the results I should like to compare the effects of the two tryptamine derivatives outlined above with the effect of mescaline and LSD-25. The most outstanding differences can be established in their time of duration. Intensity of symptoms T-9 DMT LSD-25 Mescalin Flg. 2. Schematic course of the self-experiments. _ In Fig. 2 it can be seen that the duration of the DMT-induced model psychosis is about one hour, that of T—g is about three hours, while the LSD— and mescaline symptoms lasted for 8—10 hours. The onset of the symptoms in the case of tryptamine derivatives is wsentially quicker than the onset of the others. The elevation of the dose of DMT did not produce a longer state of intoxication, but the symptoms were more organic. It is remarkable that in all the four model psychoses the symptoms developed and passed away in wave form. The specialsymptoms are demonstrated in Table II. TABLE II THE MAIN SYMPTOMS OBSERVED IN SELF-EXPERIMENTS Symptoms I. Vegetative symptoms 2. Athetoid movements 3- IIIUSiODS 4. Hallucinations 5. Disturbances of a. spatial perception b. time perception 6. Bodily sensations 7. Depersonalisation Emotional reaction a. euphory b. anxiety 9. Autism 10. Language changes 8. References 1). 466. Mescaline DM T LSD-2 5 T- 9 Preceded the other symptoms Coincided with the other symptoms — + + ++ ++ — _ I +++ + + ++ +++ + ++ + ++ + —_ — -— ~—— +++ ++ —|— ++ _+ ' , +++ + +++ + + + +++ ++ + + +++ ++ +++ + +++ ___ +++ _+ �464 s. SZA'RA As can be seen, the different symptoms were not equally apparent in every case. (I) The vegetative symptoms in mescaline and LSD-25 preceded the other symptoms, while in the case of the tryptamine derivatives the disturbances sensory appeared as early as the vegetative symptoms began. (2) An interesting phenomenon observed only in the tryptamine derivatives was the appearance Of athetoid, choreiform compulsive movements. As far as I know, these symptoms have not yet been described in the case of other hallucinogenic substancesf (3) The perceptional disturbances are qualitatively the same for all the substances; only quantitative differences could be observed. (4) The emotional reactions, however, were qualitatively different, viz. my reaction to mescaline and DMT was euphoric, to the LSD—25 anxious, but in the case of T-9 euphoria and anxiety alternated. These phenomena, together with the severe autism and the above-mentioned ambivalency were observed only in T-g. However, it is well—known from the literature that it can occur in the case of mescalnie and ‘ LSD-25 also (HUXLEY14, SOLM523). The comparison shows that the structure of a model psychosis, which can be considered as a form of the acute exogen reaction type (BONHOEFFER), depends on the chemical structure of the causative agent, apart from the fact that absorption, metabolic and excretion processes may determine the course in time. BIOCHEMICAL INVESTIGATIONS v ‘ The rapid onset and the short duration of the symptoms in the DMT—induced state is very interesting from a biochemical point of View, and it is probably connected with the rapid metabolism of DMT (FISH ct LIL). We know from the investigation of ERSPAMER6 that in rats the main breakdown product of DMT is 3—indolylacetic acid (3-IAA) which is excreted in the urine partly in free form, but largely bound to glycocol as indolaceturic acid. We investigated the excreted indole derivatives in the human volunteers chromatographically and photo— metrically, and obtained the same results as ERSPAMER (SZARA25). In addition, an interesting phenomenon was observed (Table III). We found in the urine after a larger dose of DMT more 5-hydroxyindolylacetic acid (5-HIAA) excreted than was normally present. Unchanged DMT was not estimated in the urine extracts. These data suggested TABLE III TOTAL 5-HIAA EXCRETED THE APPROXIMATE AMOUNT OF AND AFTER THE N 0. I 2M 3‘” 4 * Dose of DM T 150 mg I50 mg 75 mg 60 mg IN A 6 DMT EXPERIMENT h PERIOD BEFORE Amount of 5-HIAA* alter expt. 1.0 mg 1.2 mg 1.5 mg 2.0 mg before expt. 3.0 mg 3.0 mg 1.2 mg L5 mg Estimated by two-dimensional chromatography, developed with p-dimethylaminO-benzalde‘and the hyde, eluted spots measured colorimetrically. ** Self-experiments. References p. 466. �PSYCHOTIC EFFECTS OF DMT, T-g, MESCALINE, AND LSD-25 465 that the DMT is very rapidly metabolized, and perhaps displays its effects by means of serotonin. In order to obtain more information about the relationship in the blood, I made an experiment with 60 mg DMT. The extracts of I5 ml blood taken before, and IO, 30 and 90 minutes after the experiment, were chromatographically investigated, and I found qualitatively only two indol derivatives, namely tryptophan and 3—IAA, but no serotonin 5—HIAA or unchanged DMT could be demonstrated. The 3—IAA level of the blood was elevated in the 10th and 30th minute (Fig. 3). 3- 1AA lug p.c. 100 50 10 _ 30 ._+.> 90 minutes Time in after injection of DMT _ . Fig. 3. The 3-IAA level of blood during the DMT experiment. This finding did not support the presumption that serotonin plays a role in the psychotic effect of tryptamine derivatives. The evidence, however, is not sufficient to allow one to draw definite conclusions in this respect. DISCUSSION In discussing the mechanism of action of tryptamine derivatives, it must be admitted that at present there is no definite knowledge about the biochemical mechanism of action. The clinical picture, however, taking the other experiments on normal volunteers also into consideration, enables us to give some information concerning this mechanism. The rapid onset of the psychotic symptoms makes it seem probable that DMT affects directly those brain structures that are affected indirectly by LSD and mescaline (BLOCKZ). The appearance of choreiform athetoid movements is possibly due to an effect on structures other than those affected by LSD or mescaline. The tryp— tamine derivatives seem to be the first hallucinogenic substances to cause athetoid movements, and should therefore provide a new tool for investigating experimentally the exact mechanism of this phenomenon. Unfortunately, I have not enough time to develop in detail the very interesting psychopathological symptoms of T—g, which reminded me of the conception of the “schizophrene Grundstimmung”, described by WYRSCH27. It is, however, very remarkable that tryptamine derivatives without the OHgroup in the 5-position are able to produce mental phenomena. As UDENFRIEND at al. demonstrated in animal tissues, there is no enzyme that could decarboxylate trypto— phan to produce tryptamine; it is assumed therefore that only the enteral bacteria can produce this substance. ‘ References p. 466. �s. szARA 466 There is a possibility that from this tryptamine the schizophrenic organism may is It noteworthy in the enzymically. substances way hallucinogenic wrong produce in of disturbance evidence team4 a his BUSCAINO presented and recently Prof. that be desirable. would field in this work Further in schizophrenia. metabolism indole the SUMMARY The psychotic effects of N,N-dimethyltryptamine (DMT) and N,N-diethy1tryptamine (T—9) have been compared with the effects of mescaline and LSD-2 5. The most outstanding features of DMT model psychosis are the rapid onset and the short duration Of the symptoms. This may indicate a different mechanism of action from that of LSD and mescaline. New symptoms appearing with both tryptamine derivatives are the choreiform athetoid movements. This phenomon could be a new tool for investigating experimentally the mechanism of the extrapyramidal compulsive movements. of indole and aminotoxic the theory Of derivatives supports effects tryptamine The psychotic schizophrenia. REFERENCES ]. Physiol. (London), 126, (1954) 596. A. H. AMIN, T. B. B. CRAWFORD AND I. H. GADDUM, 2 W. BLOCK, Z. physiol. Chem., 294 (1953) 1; lbid., 294 (1953) 49; ibid., 296 (1954) 1; ibid., 296 (I954) 1083 V. M. BUSCAINO, Quaderni aeta neural, (1953). 4 V. M. BUSCAINO, D. KEMALI, R. BAGNULO, Aeta Neural. (Naples), 10 (1955) 547. 5 V. ERSPAMER, Pharmacol. Rev., 6 (1954) 425. 6 V. ERSPAMER, 118. (1955) (London), 127 Physiol. ]. 7 H. D. FABING, Am. ]. Psychiat, 113 (1956) 409. 8 H. D. FABING AND J. R. HAWKINS, Science, 123 (1956) 886. 9 M. S. FISH, N. M. JOHNSON AND E. C. HORNING, ]. Am. Chem. 500., 77 (1955) 5892. 10 M. S. FISH, N. M. JOHNSON, E. P. LAWRENCE, E. C. HORNING, Blaehim. Biophys. Aeta., 18 (1955) 56411 W. A. FREYBURGER, B. E. GRAHAM, M. M. RAPPORT, P. H. SEAY, W. M. GOVIER,O. F. SWOAP AND M. J. VANDER BROOK, ]. Pharmacol. Exptl. Therap., 105 (1952) 80. 12 I. H. GADDUM AND A. HAMEED KHAN, Brit. ]. Pharmacol., 9 (1954) 240. 13 H. E. HIMWICH, Nervous Mental Disease, 127 (1955) 413. ]. 14 A. HUXLEY, The Doors of Perception, London, 1954. 15 D. KEMALI, V. M. BUSCAINO AND R. BALBI, Aeta Neural. (Naples), 11 (1956) 209. 16 D. KEMALI AND G. ROMANO, Aeta Neural. (Naples), 11 (1956) 959. 17 H. LANGEMANN, Sehwelz. med. Waehsehr., 85 (1957) 957. (9). (1936) 18 F. Amsterdam, Akad. Koninkl. Wetensehap, 39 Proc. NIEUWENHUYZEN, J. 19 I. H. PAGE, Pharmaeal. Exptl. Therap., 105 (1952) 58. ]. 20 I. H. PAGE, Physlal. Revs, 34 (1954) 563. 21 E. ROTHLIN, A. CERLETTI, A. KONZETT, W. R. SCHALCH AND M. TAESCHLER, Experientia, 12 (1956) 15422 A. SAI-HALASZ, GY. BRUNECKER AND S. SzARA, Psychiat. et Neurol., (in press). 23 H. SOLMs, Praxis, 45 (1956) 746. 24 M. E. SPEETER AND W. C. ANTHONY, Am. Chem. 500., 76 (1954) 6208. 25 S. SzARA, Experientia, 12 (1956) 441. 23 S. UDENFRIEND, C. T. CLARK AND E. TITUS, ]. Am. Chem. 500., 75 (1953) 501. Daseinwer’se. Paul 27 Psychologie. Klinlk, Studlen des zur Die Person Sehlzophrenen. WYRSCH, J. Haupt, Bern, 1949. 1 j. ' DISCUSSION A. SAI—HALAsz, I stltuto Centrale per le malattie Nervose e M entali, Budapest (Ungheria) Il collega SzARA ha avutO occasione stamane di parlare in dettaglio sugli esperimenti fatti con me Or—a vorrei richiamare l’attenzione soltanto su un normali. in soggetti la dimetiltriptamina con fenomeno, che mi sembra assai interessante dal punto di vista clinico. Su 30 persone esaminate 22, schema dello i disturbi 1e le allucinazioni, illusioni e semilateralizzati: i1 sintomi cioé 73% avevano i segni di lesioni piramidali prevalevano a anche ed atetosici i movimenti dello spaziO, e corporeo �PSYCHOTIC EFFECTS OF DMT, T-9, MESCALINE, AND LSD-25 467 sinistra. Questa differenza era netta. Per esempio un soggetto sperimentale guardando la mano sinistra diceva che essa non gli apparteneva pil‘l, aveva cambiato forma ed era divenuta luminosa e bellissima; guardando invece la mano destra, diceva. che non presentava nulla di straordinario. Abbiamo sperimentato su tre persone mancine, e in questa i fenorneni prevalevano alla parte destra. Si dovrebbe concludere che 1a dimetiltriptamina produce una Iesione semilateralizzata dell’emisfero non dominante del cervello. Questo fenomeno finora. non segnalato dalla letteratura. per gli altri farmaci psicotropi ci propone due questioni: (1) La prima sarebbe la seguente: come si pub immaginare, che una sostanza chimica abbia un effetto nocivo molto pi1‘1 forte sull'emisfero cerebrale non dominante? Sappiamo a1 contrario, che é appunto l’emisfero dominante i1 ph‘l sensibile, specialmente se danneggiato nel sistema vascolare. (2) La. seconda domanda é di carattere psicopat'ologico. Si tratta cioé di sapere se questa semilateralizzazione ci pub dire qualcosa sugli aspetti delle psicosi sperimentali. HOFF e PéTZL hanno gia‘L/dimostrato collo “Zeitrafferphéinomen”, che lesioni organiche dell'emisfero non dominante possono produrre fenomeni psicopatologici molto strani. Lo “Zeitrafferphéinomen” é stato descritto gié da BERINGER nel corso di psicosi sperimentali mescaliniche. Secondo 1a nostra. opi— nione sarebbe di grande interesse studiare ancora. 1e psicosi sperimentali gié conosciute, a1 fine di evidenziare se ci sono diflerenze fra. 1e due parti del corpo. Ci pare probabile, che questo fenomeno non sia un efletto solo della dimetiltriptamina. Ad ogni modo, conoscendo i fatti suddetti, noi possediamo ora una. nuova. sostanza per aiutarci a conoscere meglio i problemi dell’emisfero cerebrale non dominante. ‘ �Reprinted from Psychotropic Drugs SHORT COMMUNICATIONS 283 Effects of psychomimetic drugs on cerebral synapses The psychomimetic drugs allow us to elicit at will a limited, reversible, mental derangement in man and a related distorted behavioral pattern in animals. They can therefore be highly potent tools equally for the physiologist, the behaviorist, and the experimental psychiatrist. The tremendous versatility of the brain is nonetheless the manifestation of activity in a finite number of structures and of mechanisms relating them. It follows, therefore, that the multiple patterns that add up to biological behavior must share in part the available mechanisms. It is by virtue of this probability, rather than because of any exact or fancied resemblance to the clinical conditions, that the study of chemical or so-called model psychoses and the agents producing them can be expected to be fruitful. To the physiologist this suggests the need for identification of the underlying unitary processes involved; to the behaviorist, the identification of the combinations constituting known behavior patterns; and to the experimental psychiatrist, the comparison of natural and induced psychoses. All can profitably use drugs as tools for analysis. The clinician, furthermore, can convert these findings into tools for diagnosis and the means for therapy. The high vulnerability of synapses to chemical influences makes them a natural focus of inquiry. We have utilized the synapses of the optic cortex of the cat (lightly anesthetized with sodium pentobarbital) activated by transcallosal impulses initiated in one cortex and evoking post-synaptic impulses recorded at the symmetrical point in the opposite cortex. This has proved a very convenient preparation and the data are representative of a variety of cerebral synapses, including cortical, subcortical and medullary synapsesl. By intracarotid injection we achieve an active concentration of the drug or chemical in the ipsilateral hemisphere with sufficient dilution on entry into the systemic blood stream to obviate peripheral effects. The ipsilateral recording elec— trode simultaneously monitors the input and output of the terminal synapses in the system, which is submaximally activated every two seconds. In this way we have established that synaptic transmission is under the control of a delicate chemical equilibrium between cholinergic excitation reciprocating with adrenergic inhibition. It is then evident that a disturbance of this equilibrium would lead to abnormal synaptic transmission, resulting in disturbed cerebral and mental function. Among the synaptic inhibitors naturally found in the mammalian brain are adrenaline, nor— adrenaline, and serotonin. The last is by far the most powerfu13. Substances with a chemical similarity to these become candidates for the role of psychomimetic drugs. Such is indeed the case with mescaline, adrenochrome, adrenolutin, lysergic acid diethylamide (LSD-2 5) and bufotenine. Mescaline is closely related chemically to adrenaline, which on oxidation is converted initially to the indole, adrenochrome. Adrenolutin is a minor modification of adrenochrome. Serotonin and dimethyl-serotonin, or bufotenine, are indoles, and LSD-2 5 can be regarded as built on an indole nucleus. It strengthens the argument, therefore, that we find all of these to be synaptic inhibitors3 4. Furthermore, their ranking as synaptic inhibitors parallels the ranking as to psychomimetic potency in man. The agreement between data from the anesthetized cat and the human encouraged us to believe and test that tranquilizers, reported to be clinically effective in partially offsetting mental disturbance, would have a predictable action on synaptic inhibition by psychomimetic agents. If the synaptic inhibition so produced were truly instrumental in bringing about psychotic behavior, then the improvement of such behavior that is observed clinically might be due to antagonizing of an endogenous chemical corresponding to the exogenous psychomimetic drugs. This, indeed, turns out to be the case. The prophylactic administration of chlorpromazine, promazine, reserpine, and azacyclonol, in doses having no effect per 33 on synaptic transmission, prevents or reduces the synaptic inhibitory action of the psychomimetic drugsz. Overdoses of tranquilizers clinically produce toxic phenomena, some of them taking the form of depression, and even psychosis. Likewise, large doses of the tranquilizers produce a depression of synaptic transmission indistinguishable from synaptic inhibition. Characteristically, the tranquilizers exercise their clinical effect without a corresponding degree of depression. This is reflected in the ratio of depressant to prophylactic dose, or “synaptic safety margin”. This safety margin is nonexistent for phenobarbital, equals 2 for reserpine, IO for promazine and 20 for chlorpromazine and DEPARTMENT OF EXPERIMENTAL PSYCH'IIRY ‘ s “ APR wetHyTAL 30 40.59 �284 SHORT COMMUNICATIONS azacyclonol. The above data suggest the hypothesis that synaptic inhibition is one of the mechanisms responsible for some forms of mental disturbance. A perversion of metabolism resulting either in an excess of endogenous inhibitory substance or an excess susceptibility of the neurons upon which it acts, would result in abnormal patterns of activity whose variety would be determin— ed by varying thresholds and, in particular, by abnormal inhibition interrupting normal control, and thereby releasing more primitive and less adaptive —perhaps subcortical—t—patterns of activity. Such conceptions emphasize the role of naturally occurring inhibitory indoles in mammalian brain. Of these, serotonin is highly active, dimethyl—serotonin or bufotenine is twice as active as serotonin, while adrenaline and adrenolutin are relatively weak inhibitors. Psychotic manifestations have been clearly described for all but serotonin, whose powerful peripheral disturbing actions seriously obscure the picture when it is introduced by the usual routes. For this reason we are testing the effects of intracarotid serotonin injections in man. The importance of serotonin has caused us to extend our original observations of its cerebral synaptic inhibitory action with experiments designed to record the action of “in situ serotonin”. This is accomplished by the use of iproniazid, the inhibitor of monoamine oxidase (MAO), the enzyme responsible for the destruction of serotonin. With intracarotid injections of iproniazid we can reproduce the cortical action of serotonin and show that, at the height of the synaptic inhibi— tion, the MAO titer on the inhibited side is, in fact, lower than on the control side; as would be expected if iproniazid is exercising its action by inhibiting MAO and, consequently, accumulating natural serotonin at the synapses. Following the reasoning already outlined, we again assessed the pertinence of the data to possible clinical significance by testing the action of tranquilizers against serotonin. We find that the tranquilizers exercise a prophylactic or preventive action against the inhibitory effects of serotonin in the same way that they antagonize psychomimetic drugs. A comparison of the cerebral synaptic action of psychomimetic drugs with that of naturally occurring cerebral synaptic inhibitors and their modification by tranquilizers produces data consistent with the hypothesis that a disturbance of synaptic equilibrium—in this case, by a preponderance of inhibitory effectiveness—is a potential mechanism for some kinds of mental disturbance, and that therapeutic results could be anticipated by various means of preventing or annulling this eflect. The opposite kind of disturbance or a preponderance of excitatory effectiveness seems also plausible. The prevention or annulling of this deviation in synaptic equilibrium would require different measures. The effectiveness of different tranquilizers and varying therapeutic measures might be expected to become diagnostic criteria. Veterans Administration Research Laboratories in Neuropsychiatry, V. A. Hospital, Pittsburgh, Pa. U SA. 1 2 3 4 A. A. A. A. AMEDEO S. MARRAZZI S. MARRAZZI, Science, 118 (1953) 367. S. MARRAZZI, Ann. N. Y. Acad. Sci, 66 (1957) 496. S. MARRAZZI AND E. R. HART, Science, 12I (1955) 365. S. MARRAZZI AND E. R. HART, ]. Nervous Mental Diseases, 122 (1955) 354. APR ,7 3 ‘0"!!! DEPARTMENT OF EXPERIMENTAL PEVOH‘AIRY HILLSIDE HOSPITAL GLEN OAKS, N. Y. �a hemical aspects of Psilocgpin p39 0......” “-4 cum -c£—¢h—-g-M- by A;Hofmannj Eagle psychotropic act1ve principle of Psilocybe mexic! Helm has been isolated in crystalline form. This fungus 6ne is of the so- called magic or s.a¢red Mexican mushrooms used since orecolumbian times by the indians of Mexico- dur1ng religeous ceremonies and also by soothsayers to acquire clairvoyence. The inawater, but practically unsoluble organicmost in solvents._r Analysis, Spectra and colour react10ns indicated that 1t 13 a \\ tryptamine. The spec1al structural features of psilocybin are dis~. . �to central autonomic stimulation, the study of Psilocybin on 1solated variety of organsshows Only on peripheral structures ¢ littleactivity ofshe ‘ adrug 5 ‘ ��8 MARCH 1958 . ‘ PSYCHOSIS AND TREMDR DUE TO ' \L MECAMYLAMINE . _ M. HARINGTON M.B. Cantab., M.R.C.P. SENIOR REGISTRAR AND MEDICAL TUTOR PRISCILLA KINCAID—SMITH M.B. W’srand, M.R.C.P., D.C.P. REGISTRAR DEPARTMENT OF MEDICINE, POSTGRADUATE MEDICAL SCHOOL OF LONDON ganglion-blocking agent for treat— ing hypertension was introduced two years ago (Freis 1955, Ford et a1. 1955), and since then it has been widely used in clinical practice, its chief advantage being that it is fully and regularly absorbed when given by mouth. It produces the same side-effects, due to blockade of the parasympathetic system, as do other ganglion-blocking drugs, but in addition reports have been published in America indicating that mecamylamine may also have a toxic action on the central nervous system (Schneckloth et al, 1956, Deming et al. 1957). We describe here four patients in whom tremor and mental disturbance, with confusion and hallucinations, developed while they were receiving mecamylamine, and we suggest that this may be a not uncommon complica— tion of treatment with mecamylamine given in large dosage. MECAMYLAMINE as a \ Case-reports Case l.—A man, aged 55, was first seen in July, 1955, com— plaining of headaches. He had two years’ history of high blood-pressure and fifteen years’ history of gout. Although intelligent, he was unstable and did not follow any regular occupation. On examination his blood~pressure was 230/140 mm. Hg; he had numerous retinal haemorrhages and exudates; his urine contained a trace of albumin and could be concentrated to 1.020; and his blood-urea level was 30 mg. per 100 ml. Treatment.—-—Benign essential hypertension having been diagnosed, he was treated with subcutaneous pentolinium, to which reserpine 0-1 mg. thrice daily was later added. This regime reduced his blood—pressure, and his fundi considerably improved. Mecamylamine therapy—In July, 1956, mecamylamine was substituted for the pentolinium, 20 mg. thrice daily being necessary to keep the blood—pressure down to 140/80 mm. Hg, with the patient in the erect position, for the greater part of the day. This dosage, however, caused troublesome side-effects, at first principally constipation, but later difficulty in micturition associated with frequency. DR . HOBSLEY BaraEtlaésCZIS 499 ORIGINAL ARTICLES REFERENCES M. (1952) Rev. Sanid. Polie., Lima, 12, 198, cited by Ferris et al. 2 Bernstein, C., Klotz, S. D. (1952) Ann. Allergy, 10, 479. Dameshek, W., Neber, J. (1950) Blood, 5, 129. Dobson, A. M., Ikin, E. W7. (1946) 3'. Path. Bact. 58, 221. Ferris, H. B., Alpert, S., Coakley, C. S. (1952) Amer. Praetit. 3, 177. Frankel, D. B., Weidner, N. (1953) Ann. Allergy, 11, 204. Hoffmann, C. R. (1957) Surgery, 41, 491. Loew, E. R. (1950) Med. Clin. N. Amer. 34, 351. Maunsell, K. (1944) Brit. med. _7. ii, 236. Mollison, P. L. (1951) Blood Transfusion in Clinical .Medieine, p. 317. Oxford. F. M., Margolin, S., Jackson, D. (1953) 3‘. med. Soc. N. i. 50, Offegkgantz, 3 . Simon, S. W., Eckman, W. G., Jr. (1954) Ann. Allergy, 12, 182. Stephen, C. R., Martin, R. C., Bourgeois—Gavardin, M. (1955) 7. Amer. med. Ass. 158, 525. Wilhelm, R. B., Nutting, H. M., Devlin, H. B., Jennings, E. R., 0. A. (1955) ibi‘d. p.’ 529. W’inter, C. C., Taplin, G. V. (1954) Ann. Allergy, 12, 717. Wright, W. A. (1950) .Med. Times, N.Y. 78, 466. Brines, Readmission.—In February, 1957, retention of urine developed and the patient was readmitted to hospital. His bloodurea level was now 60 mg. per 100 ml., rising after ten days to 72 mg. per 100 ml., he had a urinary infection, which was treated with tetracycline. Soon after admission his requirement for mecamylamine fell: the dosage was reduced from 60 to 30 mg. daily, and his blood-pressure was maintained at 110/70 mm. Hg with the patient in the upright position. Mental and nervous symptoms.——On Feb. 19, 1957, he had a tremor of the hands. All hypotensive treatment was stopped, but next day the .tremor had increased and he became mentally confused. Two days later his condition had deteriorated further: he had a coarse generalised shaking affecting his whole body, present at rest, and accentuated on attempting any voluntary movement. His speech was slurred and jerky. There was a general increase in muscular tone and in the deep reflexes; the plantar responses remained flexor. He was completely disoriented in both space and time and had vivid frightening hallucinations. His extreme restlessness and picking at the bedclothes suggested alcoholic delirium tremens. From time to time he had lucid intervals during which he had considerable insight into his condition. Repeated large oral doses (10-15 m1.) of paraldehyde subdued the tremor and relieved the hallucinatibns for three to four hours at a time. This striking clinical picture persisted for a week and then gradually subsided. By March, twelve days after the mecamylamine treatment had been stopped, the hallucinations had disappeared and the patient’s mental state had returned to normal. He could now remember in detail what had happened during his delirium. Slight tremor persisted for a further two days before finally clearing. During this period he had been treated with subcutaneous pentolinium because his blood— pressure had risen after the cessation of hypotensive therapy; but it was difficult to keep his blood-pressure down, because he was confined to bed. He was discharged from hospital on March 14, 1957, taking two injections of pentolinium daily; his blood-urea level had fallen to 38 mg. per 100 ml. Readmission.——Four months later he was readmitted with uraamia and left ventricular failure and died in five days. Necropsy There was atheroma of the blood-vessels at the base of the brain, the gyri were flattened, but no localised abnormality was found on section of the brain. The kidneys showed lesions of malignant nephrosclerosis. Case 2.—A woman, aged 65, was admitted to hospital in July, 1956, with left ventricular failure. She had eight weeks’ history of exertional dyspnoea. Her blood-pressure was 300/160 mm. Hg, and she had hmmorrhages and soft exudates in her fundi. Her blood-urea level was 30 mg. per 100 ml. She was treated with digitalis, mersalyl, and hypotensives— at first subcutaneous pentolinium and later oral mecamylamine. When first seen at Hammersmith Hospital in September, 1956, she was very much improved symptomatically, but her bloodpressure was 200/130 mm. Hg, and the dosage of mecamyla— mine was increased from 12-5 to 20 mg. twice daily. In October the dosage was further increased to 45 mg. daily; but, although this dosage did not control the hypertension, urinary retention developed and she was admitted to hospital on Oct. 29, 1956. On admission she was cooperative and well oriented but somewhat apprehensive and overexcitable. Her blood-pressure was 290/140 mm. Hg, and soft exudates but no papilloedema were noted in her fundi. There was no sign of heart-failure. Her urine contained albumin, and her blood—urea level was 66 mg. per 100 ml. Mecamylamine therapy was continued, the dosage being slowly increased until on Nov. 6, 1956, she was having 65 mg. daily. Her systolic blood-pressure remained about 200 mm. Hg. .Mental and nervous symptoms.—ln the early hours of NOV. 11, 1956, she became agitated and confused, having hallucinations of voices and complaining of noises in the head. Her bloodpressure was 170/90 mm. Hg. She had general hyperreflexia. K2 �M 500 ORIGINAL ARTICLES During the succeeding days her confusion increased, and she was disoriented for most of the time but had intervals of insight and cooperation. Mecamylamine therapy was stopped on Nov. 13. On Nov. 17 she was grossly confused and hallucinated, with paranoid delusions. She also had a coarse tremor of arms and legs. Her blood-urea level had risen to 97 mg. per 100 m1. on Nov. 17 and to 140 mg. per 100 ml. on Nov. 20. She became more agitated and violent and was completely inaccessible. On Nov. 21 her condition made it necessary to transfer her to a mental observation ward. She went progressively downhill, her blood-urea level rose to 296 mg. per 100 ml., and she died on Nov. 30, 1956, without any improvement in her mental state. mid-poms. The kidneys were typical of malignant nephrosclerosis. Case 4.—An electrician’s mate, aged 46, presented in January, 1956, with four months’ history of blurring of vision and dyspnoea. His blood-pressure was 250/150 mm. Hg and he had bilateral papilltedema with scattered retinal haemorrhages. His urine contained albumin, granular casts, and occasional leuco— cytes; his blood—urea level was 155 mg. per 100 ml. There was no history to suggest previous renal disease. In view of his visual symptoms hypotensive therapy was considered advisable, in spite of the severe renal failure, and treatment was started with subcutaneous pentolinium. At the end of February his blood-urea level was 222 mg. per 100 m1. Mecamylamine therapy—At this stage he was given oral mecamylamine. He was not very sensitive to it, 60 mg. in divided doses daily being needed to keep his blood—pressure down to 160/100 mm. Hg. On April 14, 1956, six weeks after mecamylamine therapy had been started, he was readmitted to hospital with increasing trembling of his arms and legs for the previous three days. On admission his blood—pressure was 160/90 mm. Hg. He still had bilateral papilloedema. He was dyspnmic, and his jugular venous pressure was raised. Mental and nervous symptoms.—He was drowsy and mentally! confused. He had occasional spontaneous quivering of his lips and a coarse irregular tremor of his limbs. His muscular tone was increased; his lower limbs showed almost cogwheel Necropsy The left kidney was small (55 g.) with generalised ischazmic atrophy suggesting occlusion of the renal artery. The right kidney weighed 110 g., and its histology was that of florid malignant nephrosclerosis. The brain showed a small area of softening in the right internal capsule, and the cerebral arteries were considerably affected by atheroma. Case 3.—An electrical engineer, aged 53, was found in January, 1956, to have a blood—pressure of 240/140 mm. Hg, bilateral papilltedema, heavy albuminuria, and a blood—urea level of 40 mg. per 100 ml. Malignant essential hypertension was diagnosed, and he was treated with subcutaneous pentolinium and with rauwolfia alkaloids; but his“ blood—pressure was difficult to control, and during the next six months further deterioration in the fundi and increasing cardiac enlargement were noted. On admission to Hammersmith Hospital in July, 1956, he had heart-failure, blood—pressure 260/140 mm. Hg, bilateral papilloedema, haemorrhages and exudates in his fundi, and albuminuria. His blood-urea level was 139 mg. per 100 m1. Treatment with subcutaneous pentolinium was continued, a dosage of 30—40 mg. twice daily being necessary to control his blood-pressure. Rauwolfia was not given. Chlorpromazine 50 mg. thrice daily was given because of vomiting. After a month the heart-failure had cleared and the blood-urea level fallen to 60 mg. per 100 ml. Mecamylamine therapy—On Sept. 10, 1956, mecamylamine therapy was started, and pentolinium was withdrawn gradually during the next few days. The blood—pressure was not satisfactorily controlled during the period of transfer, but by Sept. 17 it was down to 140/80 mm. Hg, with the patient in the erect position, for most of the day. This was achieved with a dosage of 20 mg. mecamylamine thrice daily. By now the blood-urea level had risen again to 100 mg. per 100 ml. The fundi still showed papilloedema, but there were no fresh exudates or haemorrhages. Mental and nervous symptoms.—On Sept. 24, 1956, shaking of the limbs and trunk was first noted. This tremor also affected the face and tongue; it was coarse and present at rest but exaggerated on voluntary movement. The speech was jerky and difficult to understand. There was a general increase in muscular tone; the tendon—reflexes were exaggerated, and knee and ankle clonus could be elicited; the plantar responses were flexor. Mecamylamine was withheld after it had been taken for fourteen days, and pentolinium therapy was restarted; but the tremor increased, and four days later the patient became drowsy and confused. He was now disoriented and hallucinated, speaking to imaginary people and seeing snakes and insects crawling across his bedclothes. His body shook so violently as to rock the whole bed. Paraldehyde reduced the tremor somewhat, but he remained confused and steadily deteriorated. His blood-urea level rose to 170 mg. per 100 ml. , his urinary output fell, and he died, after repeated attacks of left ventricular failure, on Oct. 7, 1956. Necropsy The brain was overweight (1490 g.) and oedematous, with a small area of recent softening at the posterior end of the putamen on each side and a recent small haemorrhage in the THE LANCET rigidity. His tendon-reflexes were uniformly increased, and he had bilateral ankle clonus. His plantar responses were flexor. Hypotensive therapy was stopped, and he was treated only with digoxin, but the confusion and tremor persisted, and he died on April 16, 1956. Necropsy ' The kidneys showed the changes of malignant nephrosclerosis. The brain showed cerebral oedema, but no localised lesion or other abnormality. Discussion The clinical picture was similar in each of these four patients. In three the first neurological abnormality to be noted was a coarse tremor which affected the trunk and head as well as the limbs and caused difficulty with speech. It was variable in the early stages, perhaps hardly noticeable when a limb was at rest, but brought out when voluntary movement was attempted. The shaking of the trunk made it look as if the patient was shivering. The tremor was equally present on both sides of the body. At its height it was so violent in two patients as to shake the whole bed. Mental symptoms were observed before the tremor in one patient, but in the others a few days after the tremor. They consisted of a clouding of consciousness with confusion and disorientation, together, in three cases, with hallucinations which were usually visual but sometimes also of hearing or of touch. The mental state fluctuated, and there were lucid intervals, with some insight, between periods of extreme delirium. Both tremor and mental symptoms were alleviated temporarily by administration of paraldehyde, in case 1 strikingly so. In this patient, who recovered from the episode, the mental abnormalities disappeared first, the tremor persisting for a few days before finally clearing. Examination of the nervous system in these patients revealed a general increase in muscle tone, symmetrically exaggerated tendon-reflexes with clonus, and flexor plantar responses. In no case were any lateralising signs found. Electroencephalography in three cases gave records which were difficult to interpret because of arte— fact due to muscle tremor; there was complete absence of alpha rhythm, but in no case was positive evidence found �8 MARCH 1958 501 ORIGINAL ARTICLES either of a general metabolic disturbance or of a localised lesion. The patients all had severe hypertension. In two this was frankly malignant, with papillaedema; in the other two the presence of active retinitis and progressive renal failure indicated that the hypertension was in a premal— ignant phase, and at necropsy lesions of malignant nephro— sclerosis were found in the kidneys. Renal function was impaired in all. In three there was gross renal failure with a raised blood-urea level which continued to rise until death in case 1, who already had some renal impairment, shown by a failure of concentrating power, but who had a normal blood-urea level, there was a further deterioration in renal function and a temporary rise in the bloodurea level coincident with a urinary infection. This patient’s blood-urea level had returned to normal by the time that his neurological symptoms had cleared, but it rose again later, and uraemia was present at his death four months afterwards. All four patients were receiving large dosages of meca5 mylamine (60—65 mg. daily) because smaller amounts had not reduced the blood—pressure. The duration of admin— istration of mecamylamine before neurological symptoms developed varied from seven months in case 1 to fourteen days in case 3. Case 1 had the least impairment of renal function. Since cerebral arterial disease is common in hypertensive patients, the question arises whether organic brain damage due to haemorrhage or to infarction could have caused the symptoms observed. Evidence of local cerebral lesions was found at necropsy in two cases: in the right internal capsule in one case; and in both basal ganglia and the pons in the other. The whole clinical picture, however, was more like a toxic confusional reaction, bearing in its fully developed state a striking resemblance to alcoholic delirium tremens. The symmetry of the tremor, the absence of any lateralising signs in the central nervous system, and particularly the complete disappearance of symptoms in case 1 after mecamylamine had been withheld suggest strongly that this drug was to blame. In the patients who did not recover, uraemia and death supervened probably before sufficient time had elapsed to allow the mecamylamine to be cleared from the body. Mecamylamine is a secondary amine and freely diffusible across cell membranes. There is evidence that this drug is concentrated within the cell (Milne et al. 1957). It is therefore likely that its mode of action differs from that of ganglion-blocking agents such as hexamethonium and pentolinium, which are quaternary ammonium compounds and are distributed only in the extracellu— lar fluid. That mecamylamine has a different, and previously unrecognised, mode of action at the neuromuscular junction has been shown by Bennett et al. (1957). From this it might also be expected that mecamylamine, apart from producing the same side—effects due to parasympathetic blockade as other ganglion—blocking drugs, might also have toxic actions from which methon— ium compounds are strikingly free. There is some experimental evidence of a direct toxic action on the central nervous system. Rats given mecamylamine in large doses develop a tremor and have generalised convulsions before death (Milne et al. 1957). The frequency of this complication of treatment is not certain. Doyle et al. (1956), Smirk and McQueen (1957) and Kitchin et al. (1957), in their accounts of clinical experience with mecamylamine, do not mention any neurological symptoms related to its administration. The four cases described here occurred among ninety patients treated with mecamylamine at this hospital (twenty of them with malignant hypertension). The average daily dosage of mecamylamine in the whole series, however, was only 35 mg. , and only sixteen patients received more than 50 mg. daily. Moreover, this is a selected group of patients, including some with severe hypertension who were speciallyreferred. In addition to the cases described in detail above, three other patients treated with mecamylamine developed a tremor without mental symptoms: a woman, aged 31, with malignant hypertension and systemic lupus erythematosus and a woman, aged 51, with malignant hypertension and renal-vein thrombosis, both with moderate impairment of renal function (blood-urea level 40—70 mg. per 100 ml); and a man, aged 51, with malignant essen— tial hypertension and urxmia (blood-urea level 114 mg. per 100 ml.). The daily dosage of mecamylamine in these patients was 25, 50, and 30 mg. respectively. In the two women the tremor disappeared when the dosage of mecamylamine was reduced and pentolinium was partly or wholly substituted. It certainly seems that patients with severely impaired renal function are much more likely to develop symptoms of neurotoxicity while taking mecamylamine: of five patients in whom the blood—urea level was 100 mg. per 100 ml. or higher at the start of treatment four developed tremor and three of these mental symptoms. This complication is presumably related to the retention of mecamylamine in the body, its urinary excretion being reduced in renal failure (Milne et al. 1957). Summary Four cases are described in which a syndrome of tremor, mental confusion, and delirium developed under treatment with mecamylamine. Tremor developed in three other patients. This complication of mecamylamine treatment occurred in patients receiving large dosages thereof (60—65 mg. daily); all these patients had or subsequently developed malignant hypertension and in all renal func— tion was impaired. We thank Prof. J. McMichael and Dr. M. D. Milne for their help and advice; and Dr. I. F. Goodwin for permission to report a patient under his care. REFERENCES Bennett, G., Tyler, C., Zaimis, E. (1957) Lancet, ii, 218. Deming, . B., Hodes,M . E., Edreira, J. G., Baltazar, A. (1957) New Eng]. E.Med. 256, 739. Doyle,A ,y,Murph E A. Neilson, G. H. (1956) Brit. med. ff. ii, 1209. Mo yer,]. H. (1955)]. Lab. clm. Med. 46, 815 Ford, R. Dennis,E., Freis, E. D. (1955) Lancet, ii, 977. Kitchin, A. Lowther, C. P. Turner, R. W D. (1957) 1'b1'd. p. 605. Milne,M. D., Rowe, G. G., Somers,K., Muehrcke,R. C., Crawford,M. A. (1957) Clin. SE1. 16, 599. Schneckloth, R.E ,Corcoran, A. C. Dustan, H. P., Page, I. 3'. Amer. med. Ass. 162, 868. Smirk, F. H., McQueen,E G. (1957) Brit. med. 3‘.1, 422. H (1956) “ How then does a good physician help a patient to face death and, accepting the ways of nature, to meet it? It is not done by all the busy paraphernalia of scientific medicine, keeping a vague shadow of life flickering when all hope is gone. . . . If man lives as a stranger in a lonely crowd, he dies utterly alone. Whereas his entry into the world is the first stage of the dissolution of an intimate partnership with his mother, his final departure is the ultimate in solitary procedures.”——WILLIAM B. BEAN, Arch. intern. Med. 1958, 101, 201. �W 502 ORIGINAL ARTICLES ESSENTIAL FATTY ACIDS AND IDIOPATHIC HYPERCALCIEMIA OF INFANCY A. T. JAMES J. WEBB Ph.D. Lond. and then after roller drying of this concentrated milk. No loss of these two acids was found, although the same experiment was repeated several times. Table I also shows the linoleic-acid + linolenic-acid contents of the same sample of milk after storage under various conditions. After three months at room temperature or at 37°C the “ essential ” fatty-acid content had fallen to two-thirds of the original value 5 after six months’ storage under similar conditions the “ essential” fatty acids had dropped to less than half their previous B.Sc. Lond. THE NATIONAL INSTITUTE FOR MEDICAL RESEARCH, MILL HILL, LONDON T. STAPLETON W. B. MACDONALD D.M. Oxon., M.R.C.P. M.D. Melb., M.R.A.C.P. ASSISTANT DIRECTOR LECTURER PEDIATRIC UNIT, ST. MARY’S HOSPITAL MEDICAL SCHOOL, LONDON ATTENTION has been‘drawn deficiency Of “ essential ” fatty to the possible role of a acids (linoleic and arachi— donic acids) in the genesis of idiopathic hypercalcaemia Of infancy (Lancet 1957). It has been suggested (Sinclair 1956a) that in the preparation of evaporated milks there is some loss of essential fatty acids and an even greater loss in the production of National Dried Milk made by passage over hot rollers; thus infants fed on dried milk preparations might receive a diet deficient in essential fatty acids. This suggestion could have provided an additional explanation of the frequency with' which hypercalcaemia of infancy has been recognised in the United Kingdom, where dried milks are widely used, although one established factor to explain this frequency has been the extent of fortification of infant foods with vitamin D (British Medical journal 1956). We have studied the fatty-acid composition of samples of human milk, cows’ milk before and after drying by a variety of commercial techniques, stored dried milk, and evaporated milk. Similar analytical studies of whole blood from three healthy infants have been made, as well as from three infants with idiopathic hypercalcaemia; the latter were studied both before and after treatment with cotton-seed oil (a rich source of linoleic acid). The fattyacid analyses were made with the gas-liquid Chromatogram (James and Martin 1956). value. Comparative Analyses of Various Milk Preparations used in ' Infant Feeding Table II shows comparisons of the fatty-acid composition (major components only) of two samples of human milk, fresh cows’ milk, roller-dried milk, National Dried Nlilk, and ‘ Carnation ’ evaporated cows’-milk. The difference in the levels of linoleic + linolenic acids in TABLE I—LINOLEIC-ACID CONTENT OF cows’ MILK DURING PROCESSING AND STORAGE (As PERCENTAGE OF ACIDS IN THE RANGE C3-C20) Milk Under the conditions used for the fatty-acid analyses the gas chromatogram does not differentiate between the cis-cis, cis-trans, and trans—trans forms of linoleic acid. In addition linoleic and linolenic acids (the C18 di- and tri-unsaturated acids) are not separated; so‘ the figures reported refer to the sum of these two acids. However, the linolenic-acid content of all the fats studied is likely to be low. Studies in collaboration with other laboratories have shown excellent agreement between the gas chromatographic and spectrophotometric techniques for determining (1) a combined value for linoleic and linolenic acids and (2) arachidonic acid. The linoleic acid isolated from cows’ milk by the gas chromato— gram has been shown to be 9 : lZ-octadecadienoic acid by the micro degradation procedure described by James and Webb (1957). Results Changes in Fat-composition of Milk on Processing to Dried Milk and on Storage In Table I are listed the linoleic-acid + linolenic-acid contents of fresh milk, the same milk after concentration, Powder Powder stored stored Powder 3 mos. 6 mos. stored at room at room 3 mos. 8 temp- temp- at 37° erature erature Fresh concen-. milk trated After before roller 120/ t ota(l drym dryin _ solids (21% Kincaid) so Linoleic acid + linolenic acid 3-2 s 1 3-0 3-4 2-3 1-4 2-4 Powder stored 6 mos. at 37° 1-1 human milk and cows’ milk was less than has sometimes been supposed; but the effect of diet on these levels has yet to be determined. “ Essential Fatty-acid ” Levels in Blood of Infants with Methods Each sample Of milk was extracted exhaustively with ether-ethanol overnight to remove the lipids. Samples of whole blood were similarly extracted. The lipid extracts were saponified with methanolic potassium hydroxide, and the non-saponifiable material was extracted with petroleum ether. The alkaline solution was acidified with 5N sulphuric acid, and the fatty acids were extracted with petroleum ether. The extract was dried over anhydrous sodium sulphate, and the acids were converted to methyl esters by refluxing with anhydrous methanolic hydrochloric acid. Samples were stored in high dilution in petroleum-ether solution at +2°C, and the solvent was removed by evaporation before applying the sample to the gas-liquid chromatogram. THE LANCET . Hypercalcaemia Case 1.—A male infant, born on Feb. 21, 1956, who had well-established hypercalcaemia, was studied at the age of 9 months. He was fed cotton-seed oil containing 500/0 w/w of linoleic acid for twenty days. During the first five days he received about 5 ml. of cotton-seed Oil a day; during the next twelve days about 8 ml. a day; and during the last three days about 20 ml. a day. The serum—calcium (table III and fig. 1) had been high for so long that it seemed improbable that the fall from 15-8 mg. per 100 ml. to 9-9 mg. per 100 ml. in ten days was due to a chance variation in its level, although such variations are known to occur. Analyses were made of the fatty acids of whole blood taken from this child before, while, and after he was given cotton-seed Oil. NO significant change TABLE II—MAJOR COMPONENTS OF MILK FATS FROM VARIOUS SOURCES EXPRESSED AS PERCENTAGE OF FATTY ACIDS IN RANGE C3-C20 Human milk Sample 1, ten days after start of lactation Acid Myristic . . Branched C15. . nC15 .. Palmitoleic .. Palmitic Branched unsat. C17 nC17 . . . Linoleic Oleic . . . . Isomers of oleig acx Stearic . . Poly-unsat. C20 (not arachidonic) Cows’ milk Sample 2, three mos. Fresh after start of lactation 5-7 0-5 0-8 3-9 26-5 1-5 9-0 0-2 0-4 2-6 20-0 0-7 5-1 38-6 Trace 4-4 46-0 0-7 3-2 23-3 12-1 1-8 7-7 10-6 1-6 1-2 2-0 16-6 2-0 1-1 36 3-5 26-1 3-1 0-6 4-1 30-4 10-0 0-8 4-4 26-0 5-1 10-3 12-0 10-5 1-0 13-8 2-0 . 0-8 1-0 2-2 26-4 1-5 Not measured Not measured National ‘ Cama— OsterDried ’ milk Milk tion ’ roller- bought tinned dried from a milk clinic 10-7 1-3 1-3 2-2 29-7 1-5 . 0- ‘ Dill"; . . . i . . . EXPERIMEI‘EIAI. r. .5 .....;-.‘a' {II HILLSIDE HOSPITAL “24.53 GLEN OAKS, N. Y. 9-4 1-8 1-4 2-4 21-8 1-5 �Effects of Pitressin Hydration on the Electroencephalogram Paroxysmal Slow Activity in Nonepileptic Patients with Previous Drug Addiction ABRAHAM WIKLER, M.D. Surgeon (R), United States Public Health Service LEXINGTON, KY. 0. s. MPMTWHT or HEALTH, tenement... MD rustic mum: sum! fiEPRiN‘lED WITH PERMISSION FROM “in"!!! A. M. A. ARCHIVES OF NEUROLOGY ANi} P‘S‘IQHIATRY VOL. 57-JAN. 194')" HEV-J-L’EI" KV'. �EFFECTS PITRESSIN HYDRATION ELECTROENCEPHALOGRAM OF ON THE Paroxysmal Slow Activity in Nonepileptic Patients with Previous Drug Addiction ABRAHAM WIKLER, M.D. Surgeon (R), United States Public Health Service LEXINGTON, KY. LTHOUGH hydration by forcing of fluids and the use of pitressin has long been employed to precipitate epileptic seizures for diagnostic purposes in persons suspected of having idiopathic epilepsy,1 no study has been made of the electroencephalographic changes produced by this procedure, either in normal or in epileptic subjects. 'A single injection of pitressin has been reported to have no effect on the electroencephalogram,” but no data have been found on the effects of water intoxication except for the statement by Allen 3 that some experiments of this type on dogs had been attempted. The present study was undertaken in an attempt to solve a clinical problem. A patient at the United States Public Health Service Hospital was referred for electroencephalographic study because he exhibited periodic episodes of antisocial behavior. A diagnosis of psychopathic personality had been made, but it was desired to rule out epilepsy. A routine electroencephalogram was essentially normal. A pitressin hydration test was then made with a view to provoking a fit, antisocial behavior or “epileptiform” changes in the electroencephalogram. Neither a fit nor antisocial behavior occurred during this procedure, but paroxysmal slow activity did appear in the electroencephalogram. This was difficult to interpret because of the lack of control data in the literature, and therefore further investigations were made. MATERIALS AND METHODS The subjects for these experiments were 14 male patients at the United States Public Health Service Hospital who were undergoing trearment for addiction From the United States Public Health Service Hospital. 1. McQuarrie, I., and Peeler, D. B.: The Effects of Sustained Pituitary antidiuresis and Forced Water Drinking in Epileptic Children: A Diagnostic and Etiologic Study, J. Clin. Investigation 10:915. 1931. Hilger, D. W.; Mueller, A. R., and Freed, A. E.: The Pitressin Hydration Test in the Diagnosis of Idiopathic Epilepsy, Mil. Surgeon 91:309, 1942. 2. Gibbs, F. A.; Gibbs, E. L., and Lennox, W. G.: Effect on the Electroencephalogram of Certain Drugs Which Influence Nervous .Xctivity, Arch. Int. Med. 60:154 (July) 1937. 3. Allen, F. F.: Spontaneous and induced Epilegtifo: 1n Attacks in Dogs, in "tr-rel iat. 102:67, 1945. Relation to Fluid Balance and Kidney Function, f= m. 5 �to opiates while serving sentences for violation of the Harrison Narcotic Act and who volunteered for this test. All these subjects had been in the institution six months or more and had not used opiates habitually for at least that length of time. Their ages varied from 32 to 46, with an average of 37.1. None gave a history of epilepsy, and in no case had a seizure been recorded since the patient’s admission to the institution. All were in good health. For 7 patients a diagnosis of psychopathic personality was made on admission. Electroencephalograms were made before and after pitressin hydration. Silversilver chloride cup electrodes were applied to the scalp, and bipolar recordings were made from the frontal, precentral, parietal and occipital regions. The electroencephalograph was a four channel, capacity—coupled, amplifier and oscillographic apparatus with photographic recording on bromide paper. During the recording the patient lay quietly on a comfortable bed in an electrically shielded, sound— proofed, air-cooled room. An observer was always present to note movement and to make sure the patient was not asleep. Records were taken before, during and after hyperventilation. Each record was analyzed as follows: A representative thirty second sample was selected, and all waves over 5 microvolts in amplitude were measured and counted. Paroxysmal activity was not included in the strip. The mean alpha frequency was calculated by averaging all frequencies from 8 to 13 per second, and the percentage of alpha activity was determined by calculating the time occupied by such frequencies during a thirty second recording. A frequency spectrum was then plotted. The limits of individual variation from day to day were determined on several records, and, with this method of analysis, the variation in alpha frequency was found to be not more than 0.5 cycle per second, and that in percentage of alpha activity, 12 per cent. The method of hydration varied to a considerable extent because of differences in the ability of the. subjects to tolerate this procedure. In the first few experiments, pitressin was injected hypodermically every hour for seven hours (in doses of 0.3, 0.4, 0.5, 0.5, 0.5, 0.5, 0.5 cc.), and the patient drank 500 cc. of water every hour for eleven hours. Some patients were able to tolerate this, but others suffered from vomiting and abdominal cramps. The procedure was then altered by giving smaller doses of pitressin hourly for eight hours (0.2, 0.3, 0.3, 0.3, 0.3, 0.3, 0.3, 0.3 cc.) and administering 1,000 cc. of 5 per cent dextrose in distilled water intravenously every two hours until a total of 5,000 cc. had been given during the eight hour test period. Some minor modifications were made in the dosage in individual cases. The patients were admitted to the research ward in the morning, and preliminary physical examinations and records of pulse, temperature, blood pressure, respiration and weight were made. An electroencephalogram was made in the afternoon. Pitressin hydration was begun early the next morning, and the patient was weighed at frequent intervals. Another electroencephalogram was; made the same afternoon, after maximum ’hydration had been achieved. The patients were closely observed, and records of blood pressure, pulse, respiration and temperature were made every four hours during the period of hydration. A regular' diet was prescribed, but coffee, tea and soup were excluded. RESULTS Clinical Observations—Some of the patients were fairly comfortable during these procedures, but most of them had some degree of discomfort, chiefly nausea, abdominal cramps and occasional vomiting. �Considerable pufliness of the face appeared in a few patients. In none did alarming reactions of circulatory nature appear, and there were no significant changes in pulse rate 'or blood pressure. No epileptic seizures of any kind were precipitated. It was found that the smaller doses of pitressin (0.3 cc.) were just as effective in inhibiting diuresis as larger amounts and produced less discomfort. On the morning fol— lowing pitressin hydration voluminous diuresis took place, and the patient’s weight returned rapidly to or slightly below the control level. Electroencephalographic Observatiom.—The data are summarized in the table. The average gain in weight at the end of hydration was Eflects of Pitressin Hydration on the; Electroencephalogram r—A—‘M—q Total Per Cent Alpha Frequency Alpha Percentage Snb- Pitres- Gain in ject sin. Body Differ No. Cc. Weight Before After ence Before After Difference 1 3.4 5.3 9.9 10.1 +0.2 71.0 73.7 + 2 3.4 3.2 3.2 5.0 4.5 2.7 10.2 11.1 10.7 9.8 10.6 —0.4 10.5 ——0.2 83.5 47.3 42.3 82.1 40.0 63.3 — 1.4 — 7.3 2.6 5.1 11.5 11.6 10.9 11.4 ~0.6 42.7 57.4 42.2 67.8 — 0.5 3 4 5 6 3.0 3.0 4 —-0.5 —0.2 8 3.2 2.6 1.8 3.2 9.9 10.3 10.0 10.0 +0.1 —-0.3 87.1 76.2 90.8 67.7 9 2.5 7.3 10.3 9.7 —0.6 74.3 58.9 10 1.3 4.3 11.5 11.5 0.0 22.6 22.9 11 1.3 5.3 11.1 10.5 —0.6 42.9 63.9 12 1.3 4.4 10.9 10.7 —o.2 63.3 41.2 13 14 1.7 1.0 5.3 3.9 10.4 11.1 10.4 10.6 0.0 67.0 60.8 61.2 46.9 7 ——0.5 2.7 Comment Shift to slow side and paroxysmal delta activity after hydration 721.0 Shift to slow side after hydration +10.4 Shift to slow side and parox~ ysmal delta activity after + 3.7 — 8.5 hydration " Shift to slow lid-e after hydration —15.4 Shift to slow side and paroxysmal delta activity after hydration + 0.3 Paroxysmal delta activity after hydration +21.0 Shift to slow side and paroxysmal delta activity after hydration -—-92.1 Paroxysmal delta activity after hydration 5.8 —13.9 —- Shift to slow side and paroxysmal delta activity after hydration ’_—“__——-—-——————— 3 4.1 or per cent of body weight. In 3 of the subjects the mean alpha frequency was lowered 0.6 cycle per second, but in the remainder the changes in alpha frequency, although mostly in the direction of slowing, were within the range of daily variation. In half the patients the frequency spectrum showed a definite shift toward the slow side (fig. 1). In the remainder no definite shift could be observed. In no case was there an unequivocal shift toward the fast side of the spectrum. The most striking change, however, was the appearance of bursts of slow activity (6 cycles per second) of moderately high amplitude in 7 of the 14 records after hydration (fig. 2). All but 1 of the control recoyds were essentially normal and contained no paroxysmal slow activity, either before or after hyperventilation. In the one record Kg.,. �a scant amount; of paroxysmal 6 per second rhythm was present, and this activity was greatly increased after hydration. In those records which showed paroxysmal :3 per second rhythms, such activity appeared in short bursts of 8 to 15 waves two to six times during the entire run, which was usually about three or four minutes. The incidence of paroxysmal slow activity was not entirely the same as that of shift in the frequency spectrum to the slow side. In 2 records there was a shift but no paroxysmal slow activity. and in 2 the latter was present but there was no shift in the spectrum. There was no correlation between the incidence of paroxysmal slow activity and the degree of hydration or the total amount of pitressin injected. Nor was there a correlation between the admission diagnosis of psychopathic personality and shift in frequency spectrum or incidence of slow activity. Such changes in the electroencephalogram after pitressin hydration were present in 50 per cent of patients with diagnoses of psychopathic personality and in 50 per cent of the others. Consciousness was not grossly disturbed 5 6-7 89 IOII l2!) l4 '5'l6 I? 2| M27 30 Fig. 1 (case 1).-——Efl'ects of pitressin hydration on the frequency spectrum of the electroencephalogram. The solid bars indicate values before, and the outline bars values after, pitressin hydration. On the abscissa are plotted frequencies in terms of cycles per second; on the Ordinate, the number of such frequencies in a thirty second record. Note the shift to the slow side after hydration. IS during the electroencephalographic recording so far as could be determined by the observer in. the electroencephalographic chamber. COMMENT Although none of the patients gave a history or showed clinical evidence of epilepsy, the electroencephalograms obtained on‘ half the subjects after pitressin hydration could be termed “epileptoid” because of the presence of paroxysmal slow activity. Furthermore, it is noted that this change occurred in only half the subjects and was independent of’the degree of hydration. This suggests that the appearance of “epileptoid” changes in the electroencephalogram depends on individual susceptibility. It should be emphasized here that the persons subjected to this test were not truly representative of a “normal” group, since all �had previously been drug addicts and recent studies at this institution have shown that the great majority of the drug addicts fall into either the psychopathic or the psychoneurotic group.‘ The findings provide a partial answer to the clinical problem which gave rise to this study. It is evident that the appearance of paroxysmal slow activity in the electroencephalogram after pitressin hydration cannot be considered indicative of epilepsy in the clinical sense of the W. wwmwww.WWwwmwwwwMaW A l 2 3 4 . ”NM.“.V“Mm”,rwyfl-MMMW‘MWfi«MV"V’AM'W‘W(VM/MVW‘v’w..”’V"'V’”‘tM/“fi'“MP“v . WW WW",MM:A 2 3 A' fl ,1 , 35‘3“” 'W ”Ki—mfimmwmwwm IVWWWWWM mm . A “A I .5. 1 v n________r_______,____ vwmsxwlMMWWmswwm . 4 .— . g. .l W.NWMNWJWW¢MW{MINWMMMWW N‘MMWEMWMWMMMWWwmwwwvwflwawwWW - 2 3 ii “WW MW M;WWWMWIW{V\I‘JNWW ”Wm-WWW h___________n_________n B I ' ‘JWMWN MMWWi‘Wlw 5‘ WWW“V““M/“V’WMWMWWW-wWWW" t 5- H 2 3 4 “W . hW‘Wmm» ‘ , n n ,- [-1 4 M'._M"‘wfw”.“f{‘wflgfl/fiffiAewMflWWNVI‘fiM'JWI/l {\VWK‘WAWMV l W“ W.’x{AMA}.A!W‘My/WWJfNUWWWW'WIl/V”NWAAfv’KVM/MM'y‘M‘fMfiWV’V/‘N‘ F“ ' WVNVWMmtwAvW‘fPMdWWM . , M B - - '1 2-. a a I r‘v‘wAMN/WwwwwwwwMMNMWx/vvwvvwv .WW“.[it~ww’hwtwmwmmwniM”"¢"MWWWW‘MW n P Wfi__u—rh———nn-_ of pitressin hydration the “W- Fig. 2 (case 6_‘i.«—~-Effects on electroencephalograg: (bipolar recording from the frontal (1), pretentral (2), parietal (3) and occipital (4) leads; calibration 50 microvnlts; time in seconds). A and B are control records made before and after hyperventilation, respectively; A' and 8’, records obtained before and after hyperventilation after pitresszin hydration. Note the paroxysmal 6 per second activity gr hydration. 4. Aldrich, C. K., and Ruble, D. Addicts, to be publishsd. x." : Studizs w“ the Pe sonalities of Drug �term. However, it does suggest the possibility that the physiologic mechanism which underlies the production of clinical seizures by this method is also operant in certain susceptible nonepileptic persons and that, essentially, quantitative threshold differences determine whether or not, in any given case, clinical seizures will be precipitated. It would be illuminating, in this connection, to compare the group observed in this investigation with “normal” subjects and with persons known to have epilepsy with special reference to the incidence of paroxysmal slow activity. in the electroencephalogram after pitressin hydration. However, such studies have not yet been made. SUMMARY AND CONCLUSIONS The electroencephalograms of 14 nonepileptic men with previous drug addiction were studied before and after pitressin hydration. No clinical seizures were induced by this procedure. The alpha frequency showed a tendency to slowing after hydration, but in only 3 instances was the degree of change greater than that which could be expected from day to day variation. There was no significant change in the percentage of alpha activity. In half the records there was shift to the slow side of the frequency spectrum. In half the records paroxysmal slow activity of moderately high amplitude appeared after hydration. There was some correlation between the appearance of paroxysmal slow activity and the shift of the frequency spectrum to the slow side, but no correlation with the degree of hydration or the amount of pitressin ' administered. The possible significance of these observations in their relation to idiopathic epilepsy is discussed. United States Public Health Service Hospital. �Reprinted from THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS Vol. 98, No. 4, April, 1950 EFFECTS OF METHADONE AND MORPHINE ON THE ELECTROENCEPHALOGRAM OF THE DOG ABRAHAM WIKLER AND SOL ALTSCHUL‘ U. S. Public Health Service Hospital, Lexington, Kentucky Received for publication January 26, 1950 | J-. .4. ‘v... The present study was made as part of a comprehensive investigation of the comparative actions of methadone and morphine on the central nervous system (1, 2). The dog has been utilized in these studies because the effects of small doses of methadone and morphine on this species are analogous to those in man (3—5). In particular, however, we wished to compare the effects of large doses of methadone and morphine on the electroencephalogram since such studies cannot be made with safety in man. Some of the observations made in the course of these investigations are also of interest with reference to the pharmaco—physiologic aspects of convulsive seizures. Electroencephalographic studies were made on eleven dogs. In eight of these animals the effects of methadone and morphine were observed without previous anaesthesia or curare. This was accomplished by the insertion of wire or “mercury cup” electrodes which made contact with the dura over the desired cortical area. The mercury cup electrode (figure 1) was inserted under aseptic conditions and permitted the recording of electroencephalograms without muscle artifacts in the same dog as often as desired over a period of several months. In one experiment a bipolar wire electrode insulated except for the tip (interelectrode distance about 1.0 mm.) waslinserted into the left anterior lateral hypothalamic area and fixed in place by cementing its upper end to a metal cylinder which was screwed into the calvarium along with other screw leads which served as cortical electrodes. In these eight dogs the electrodes were inserted under sodium pentobarbital (Nembutal) anaesthesia but experiments were not made until one or more days later after full recovery from the anaesthetic. In the three remaining dogs screw electrodes were inserted into the calvarium and in the midline plane of the sphenoid bone (Via the oropharynx to a depth of 1.0 to 2.0 mm. below the floor of the sella turcica). This was done under ether anaesthesia and the animal was then curarized (“Intocostrin” 1.5 cc. I.V. initially and 0.5 cc. I.V. at about 40-minute intervals thereafter) and artificial respiration was maintained through a tracheal cannula. Experiments were not begun until the ether effects had worn off as indicated by a return of the electroencephalogram to a normal pattern. In all dogs, silver disc electrodes were also fixed on the ears to serve as reference leads. In most experi— ments, a 3-channel Grass resistance-capacity coupled inkwriting electroencephalograph was used; in some, a four channel resistance-capacity coupled amplifier-oscillograph was used with photographic recording. Shielding of the animal was accomplished by a wire screen grounded cage. The motor patterns of convulsive seizures produced by large doses of methadone or morphine were studied in six other dogs. After one or more seizures they were terminated by intravenous injection of Nembutal. Moving picture records were made for subsequent analysis of the convulsive patterns. The dose range for methadone was 2.0 to 75.0 mgm./kgm. and that for morphine, 5.0 to METHODS. 1 Now Resident Psychiatrist, Illinois Neuropsychiatric Institute, Chicago, 437 9 (as. is ‘ it 111. �438 ABRAHAM WIKLER AND son ALTSCHUL initial doses were given subcutaneously while subsequent doses were given subcutaneously or intravenously. 350.0 mgm./kgm. In all experiments The pre-medication resting electroencephalograms of the dogs varied considerably from dog to dog and on different days in the same dog (figure 2, control records). However, the changes produced by methadone or morphine were quite different from spontaneous variations in electroencephalographic pattern. After small doses of methadone (2.0 mgm./kgm.) or morphine (5.0 to 10.0 mgm./kgm.) irregular high voltage random slow waves appeared in cortical tracings although fast activity present in the control records persisted (figure 2). After larger doses of methadone (about 75.0 mgm./kgm.) or morphine (about RESULTS. LUGITE CUP RUBBER DAM MERCURY ,4 SILVER m: _%/ WIRE \ mLT‘T" \ ,//fl\\\\\\\m&\‘ //// Hm ' . . ,l y } 2 -' ,, , J ‘ ._ _— SCALP ———MUSCLE SKULL DURA —r---CORTEX FIG. 1. Mercury cup electrode for recording E.E.G. from dura in unanesthetized and uncurarized animals. Under Nembutal anesthesia, the scalp and muscles are incised and a threaded trephine opening is made in the skull. The mercury cup is screwed in place and the scalp sutured over it. After recovery from anesthesia and healing of scalp wound, recording of EEG. is made by inserting a sharp-pointed, fine but rigid needle, insulated exis The latter conthe into dam rubber and the mercury. scalp for cap the through tip, cept nected by the stout silver wire to the underlying dura. After completion of record, the needle is removed. Mercury is rescaled in cup by rubber darn. Procedure may be repeated indefinitely over a period of several months. 200.0 mgm./kgm.) the earliest change (about one to three minutes after sub— cutaneous injection) was the appearance of bursts of high voltage moderately fast activity (figures 3B and 4B) in the cortical tracings. Later, high voltage slow waves appeared in the cortical tracings (figures 30 and 4C). In several exof of bursts high voltage the another change was striking appearance periments less and (figure 4D) after dome morphine mal”—like and spike sequences “petit frequently and less typically after methadone (figure 3D). These complexes apassociated not but both were from hemispheres in cortical or one tracings peared with any significant change in tracings from sphenoid leads (figures 3D, 4D, and 4F). In some experiments bilaterally synchronous spike and dome activity in the cortical tracings could be induced by sudden loud noises (clapping hands—figure 4D). Relatively early (twenty to thirty minutes) after methadone seizure discharges spike voltage after high four morphine to hours) later (two or appeared synchronously in the cortical tracings (figures 3E and 4G). In one of .-. f? n r �438 ABRAHAM WIKLER AND SOL ALTSCHUL In all experiments initial doses were given subcutaneously while subsequent doses were given subcutaneously or intravenously. 350.0 mgm./kgm. The pre-medication resting electroencephalograms of the dogs varied considerably from dog to dog and on different days in the same dog (figure 2, control records). However, the changes produced by methadone or morphine were quite difierent from spontaneous variations in electroencephalographic pattern. After small doses of methadone (2.0 mgm./kgm.) or morphine (5.0 to 10.0 mgm./kgm.) irregular high voltage random slow waves appeared in cortical tracings although fast activity present in the control records persisted (figure 2). After larger doses of methadone (about 75.0 mgm./kgm.) or morphine (about RESULTS. W /// ' LUCITE CUP RUBBER DAM / MERCURY SILVER wnRE \m+.—' \ //fl\\\\\\\\\\\‘ 3W ,1 . ..,\//l 0/” V x//// W, , .. 5 ‘.,- '_' 23932,, "ww/ , .. y i . ' “‘8-//////////%m,m . J \N 1 1 2 _ SKULL DURA -————coarsx FIG. 1. Mercury cup electrode for recording E.E.G. from dura in unanesthetized and uncurarized animals. Under Nembutal anesthesia, the scalp and muscles are incised and a threaded trephine opening is made in the skull. The mercury cup is screwed in place and the scalp sutured over it. After recovery from anesthesia and healing of scalp wound, recording of EEG. is made by inserting a sharp-pointed, fine but rigid needle, insulated exis con— The latter the into dam rubber and the mercury. scalp for the cap through tip, cept nected by the stout silver wire to the underlying dura. After completion of record, the needle is removed. Mercury is rescaled in cup by rubber dam. Procedure may be repeated indefinitely over a period of several months. 200.0 mgm./kgm.) the earliest change (about one to three minutes after sub— cutaneous injection) was the appearance of bursts of high voltage moderately fast activity (figures 3B and 4B) in the cortical tracings. Later, high voltage slow waves appeared in the cortical tracings (figures 30 and 4C). In several exof of bursts high voltage the another change was striking appearance periments “petit mal”-like spike and dome sequences after morphine (figure 4D) and less frequently and less typically after methadone (figure 3D). These complexes apassociated not but both were from hemispheres cortical in or one tracings peared with any Significant change in tracings from sphenoid leads (figures 3D, 4D, and 4F). In some experiments bilaterally synchronous spike and dome activity in the cortical tracings could be induced by sudden loud noises (clapping hands— methadone after minutes) to thirty (twenty early Relatively 4D). figure seizure discharges spike voltage after four high morphine hours) later to (two or appeared synchronously in the cortical tracings (figures 3E and 4G).-Irr gnepf W-." : "em 4" , ‘ .1] — *Since the publication of“ 95. paper we -nvo substitutged fdi'fii's an the since Wire latter for *"z’rplatinum Silva. a Fer-i 0d of time and permits amalgam with mercury a mercury to leak throughw rel ~. _ ‘ .4 , . ‘ ‘ ‘5: 3.: �439 METHADONE AND MORPHINE ON EEG three experiments with sphenoid leads, such spike seizure discharges appeared in the basal lead as well (figure 3E) and were followed by a steady 25 per second rhythm in the latter while the cortical tracings were isoelectric or showed only l N~VAVE K..~u,,V‘.~ -. v I". fl ,' .w.”w“: ‘w‘flxfifll‘fi,'\" I} c V ——.—-—_—.~. .’ 1 \ .-*.*' - 9' N\W’WW§;""MJ a? u :~' .I. $15” A ,5 '—- _ FIG. 2. Dog #70. Mercury cup electrodes in left fronto-parietal and right parieto-occipital regions. No anesthesia or curare. All tracings bipolar transcortical. Time in seconds. Gain same throughout. A—control. Note predominantly fast activity. B—two and onehalf hours after methadone 2.0 mgm./kgm. subcutaneously. Note general increase in voltage and admixture of irregular slow waves. C—control, two days later. Note irregular rhythms, varying from 10—30 per second (large “spikes” are probably EKG artifacts). D—two and one-half hours after morphine 10 mgm./kgm. subcutaneously. Note changes similar to those in B. slow activity (figures 3G and 3H). In another experiment the spike seizure discharge from the cortex followed immediately after a typical spike and dome paroxysm (figure 3G). In the single experiment with hypothalamic bipolar leads, typical spike and dome discharges after morphine 20.0 mgm./kgm. (subcutane- �440 ABRAHAM WIKLER AND SOL ALTSCHUL WWW WWWW WWW/«WAN EFFECTS OF METHADON 75 MG/KG. ON E.E.G. OF DOG ”AI—um... axe SMMA’“ A ”“1 smVI WWW WWWMMW WWW . .. l \ FIG. 3. Dog #102. Curarized. Artificial respiration. Screw electrodes in left anterior- parietal, right posterior-occipital and basi-sphenoid regions. In all records, upper tracing is right occipital to right ear, middle tracing is left parietal to left ear and lower tracing is sphenoid to left ear. Calibrations on “A” apply to all records except “F” where gain was reduced as indicated. A—control. Note mixture of fast and slow frequencies of moderate voltage in cortical tracings and periodic 4 per sec. waves of moderate voltage on a back‘ ground of low voltage fast activity in basal tracing. EKG is shown to point out slow activity in basal tracing is of approximately the same frequency as heart rate. B—three minutes after methadone 75 mgm./kgm. subcutaneously. Note bursts of high voltage spikes in cortical tracings and little change in basal tracing. C—fifteen minutes after methadone. Note admixture of high voltage slow waves in cortical tracing; occasional random spike in basal tracing. D—nineteen minutes after methadone. Note burst of 2 per sec. dome ously) appeared in the cortical tracing from one hemisphere; later the spike components increased progressively in voltage and the pattern assumed �441 METHADONE AND MORPHINE ON EEG EFFECTS OF METHADON 75 MG/KG. ON E.E.G. OF (CONTINUED) 006 WMWMMWWWWh MUM/MtllttfltttttttttttltWWW MNWWWMMWMWWW WWWMWWMWMWWWWWWWMWWW WWWWWWWWWWWMIWW [WV wwwwmwwmwwtwwmwwwwmwm I “0}N FIG. 3 (Continued) and spike discharges from left- parietal region alone. E—twenty-two minutes after metha-I done. Note very high voltage seizure discharges synchronous1n all tracings, consisting of repetitive spikes of about 8 pe1 sec. frequency, gradually becoming faster. F—twenty-eight minutes after methadone during a second seizure discharge, shown at 1educed gain. Frequency 15 per sec. G—end of seizure Note steady low voltage 25 per sec. terminal discharge in basal tracing while cortical tracings are practically isoelectric at first, then show only irregular slow activity. H~thirty- seven minutes after methadone. EKG and basal tracings showing cardiac slowing and abrupt end of another seizure discharge followed by steady 25 per sec. low voltage activity. that of a sustained high voltage spike discharge. The tracings from the contra- lateral cortex and from the hypothalamus showed no significant changes during this period. In all instances, after subsidence of the seizure discharges the cor- �442 ABRAHAM WIKLER AND SOL ALTSCHUL EFFECTS OF MORPHINE 238 MG/KG. ON EEG. OF 006 M'L’NMWNWNWWW WWWWW 7 lhll I fl wwMMJ‘tWJlsl .«qulllllll 'uln kW] \liiWW”"AMMWMAN'"MW,“AA . : :4 ii D respiration. Screw leads in right parieto-occipital, left fronto-parietal and basi-sphenoid regions. In all records, upper tracing is right parietois lower and tracing left to is fronto—parietal left ear middle tracing to right occipital ear, record middle Note records. all on gain refer “A” to Calibrations left on to ear. sphenoid is almost twice that on the others. A—control. Note mixture of moderately high voltage slow and low voltage fast activity. B—one minute after morphine 200 mgm./kgm. subcutaneously. Note increase in moderately high voltage fast activity in cortical tracings; there is little change in basal tracing. C—twenty-seven minutes after morphine. Note admixture of high voltage slow waves in all tracings. D—one-half hour after total of 238 mgm./kgm. FIG. 4. Dog 7% 93. Curarized. Artificial tical tracings were isoelectric for a few seconds and then high voltage slow activity appeared. In most experiments this sequence of events was repeated several times after the last injection of either methadone or morphine. The motor patterns of the seizures were similar after either drug except that �443 METHADONE AND MORPHINE ON EEG EFFECTS OF MORPHINE 238 MG/KG. ON E.E.G. OF (CONTINUED) 006 mll‘léllllijlW-“meww WSMI , FIG. 4 (Continued) of morphine (24 mgm./kgm. I.V. 3% hours, and 14 mgm./kgrn. I.V. 4 hours after first dose). Note burst of high voltage spike and dome complexes from right parieto—occipital region alone; irregular high voltage slow activity in basal tracing. E—seven minutes after D. Burst of spike and dome complexes from right parieto-occipital region with synchronous activity in left fronto-parietal tracing, elicited by clapping hands loudly. F—eight minutes after E. Similar synchronous cortical discharges occurring spontaneously. G—continued from F. Note burst of spike and dome complexes from cortical leads followed immediately by seizure discharge of very high voltage spikes. No change in basal tracing. H—end of seizure. No change in basal tracing. they appeared sooner after large doses of methadone (ten to thirty minutes) than after large doses of morphine (two to four hours). Clonic movements were more prominent in the seizures produced by methadone. The morphine seizures were predominantly tonic. �444 ABRAHAM WIKLER AND SOL ALTSCHUL between the effects of methadone and morphine on the electroencephalogram have been reported in the cat (6). In this species small doses of methadone produced diphasic spikes with admixture of slow waves while larger doses produced seizure—like sustained spike activity. Small doses of morphine caused an increase in frequency while larger doses produced slow waves and subsequent disappearance of electrical activity. These differences appear to be peculiar to the cat for in our experiments with dogs, small doses of either drug produced admixtures of slow waves while larger doses produced seizure-like discharges. The bursts of moderately high voltage spike discharges seen early after methadone or morphine were very similar to the changes produced ab~ in of this the species cortical in the electroencephalogram rat; morphine by olition of cortical electrical activity seemed to be due to anoxia since brain waves reappeared after tracheal insufliation of oxygen (7). In man also, the effects of single and repeated doses of methadone and morphine on the electroencephalogram are comparable (5, 8). Likewise in chronic spinal and in chronic decorticated dogs single and repeated doses of methadone and mor— phine produce similar effects (1, 2). However, in our present studies, some quantitative differences between the effects of these drugs were noted. Convulsions appeared much sooner after subcutaneous injection of methadone than after morphine. Also “petit mal”-like spike and dome activity in the electroencephalogram were much more prominent after large doses of morphine than after methadone. Electrical seizure discharges from subcortical basal structures of the in of in but dose methadone none experiment one after large a were seen experiments with morphine. However, this difference may not be a consistent one since a sphenoid lead was used in only three experiments. Nevertheless, some differences in the actions of methadone and morphine may be expected since these drugs appear to exert different actions on enzyme systems concerned in brain metabolism (9). Our observations are also of interest with reference to the origin of the electrical signs of convulsive activity, particularly the spike and dome pattern. Hursch (10) found that section of the corpus callosum did not alter the pattern of bilaterally synchronous “petit-mal” discharges in the cortex. Jasper and Drooglever-Fortuyn (11) and Hunter and Jasper (12) were able to produce spike and dome and sustained spike activity in both cortex and thalamus by electrical stimulation of medial thalamic structures. These observations suggest a subcor— tical origin of “petit-ma ” complexes. On the other hand, Hayne, Belinson and Gibbs (13) as a result of studies in man, concluded that “. . . The present findings do not suggest a subcortical but a cortical origin for the three per second wave and spike of petit mal, because (a) the spike registers on the cortex as neg— ative when referred to a relatively inactive area, (b) it can appear as an isolated and purely focal discharge in one cortical area and (0) no evidence was found that it is causatively related to thalamic or other subcortical activity.” Our findings are strikingly analogous to those of the latter group since after large doses of morphine electrical seizure patterns could, and most often did appear in cortical tracings without concomitant significant changes in tracDISCUSSION. Differences �METHADONE AND MORPHINE 0N EEG 445 ings from sphenoid or hypothalamic leads, and spike and dome discharges were frequently observed in cortical tracings from one hemisphere only. However, while suggestive, our evidence is not conclusive with regard to the origin of spike and dome activity since in our experiments the two cortical electrodes were not in strictly homologous areas and our basal electrodes (sphenoid lead and bipolar hypothalamic leads) could not be relied on to pick up electrical activity in the dorsal thalamus. Our records also indicate that the spike and dome discharge and sustained spike activity are closely related since in several instances after large doses of morphine a spike and dome pattern was followed by prolonged sustained spike activity without interruption. Except for the question of the thalamic origin of these seizure discharges, these observations are analagous to those of Hunter and Jasper (12). It is also of interest to note that when a seizure discharge was recorded from the sphenoid lead, this was followed by a sustained low amplitude 25 per second discharge apparently originating in subcortical basal structures. This resembled strongly the “after seizure” discharge seen in chronic decorticated cats following electroshock (14). In the latter study, morphine appeared to alter the electroshock seizure pattern so that fast and slow sequences resembling “petit mal” discharges were seen in some records. In our present investigation, this 25 per second discharge appeared in the sphenoid lead tracings while cortical activity was absent or of a different character. Such independent activity of subcortical structures and cerebral cortex has also been noted after fluoroacetate (15). SUMMARY The effects of small and large doses of methadone and morphine on the electroencephalogram were studied in unanesthetized and uncurarized dogs and in curarized dogs. The motor pattern of the convulsive seizures induced by large doses of these drugs was also observed in different dogs. 2. A “mercury cup” electrode is described which facilitates the repeated recording of electroencephalograms from the dura over the cerebral cortex in unanesthetized and uncurarized animals, without interference due to artifacts from the scalp and temporal muscles. 3. Small doses of methadone or morphine produce an admixture of fast and high voltage slow activity in cortical tracings. Large doses of either drug produce seizure discharges which may appear synchronously in cortical and basal tracings or in cortical tracings alone. The seizure discharges from cortical tracings were both of the spike and dome and sustained spike patterns. At times the former passed over into the latter Without interruption. An “after-seizure” 25 per second low voltage discharge in the tracings from the sphenoid lead was not associated with activity in the cortical leads. 4. The motor pattern of seizures induced in dogs by large doses of methadone or morphine were essentially the same, although clonic movements were more prominent in the methadone convulsions. These seizures appeared much sooner after subcutaneous injection of methadone than after morphine. 1. �446 ' ABRAHAM WIKLER AND SOL ALTSCHUL REFERENCES 99°F!" S" WIKLER, A.: Am. J. Psychiat., 105: 329, 1948. WIKLER, A., AND FRANK, K.: THIS JOURNAL, 94: 382, 1948. SCOTT, C. C., AND CHEN, K. K.: THIS JOURNAL, 87: 63, 1946. SCOTT, C. C., CHEN, K. K., KOHLSTAEDT, K. G., ROBBINS, E. B., AND ISRAEL, F. W.: THIS JOURNAL, 91: 147, 1947. ISBELL, H., WIKLER, A., EISENMAN, A. J ., DAINGERFIELD, M. A., AND FRANK, K.: Arch. Int. Med., 82: 362, 1948. LEIMDORFER, A.: Arch. Internat. Pharmacodyn. et de Therap., 76: 153, 1948. CAHEN, R. L., AND WIKLER, A.: Yale J. Biol. Med., 16: 239, 1944. ANDREWS, H. L.: Psychosom. Med., 6: 143, 1943. GREIG, M. E., AND HOWELL, R. 8.: Arch. Biochem., 19: 441, 1948. HURSH, J. B.: Arch. Neurol. Psychiat., 63: 272, 1945. JASPER, H. H., AND DROOGLEVER-FORTUYN, J .: Res. Publ. Assn. Nerv. Ment. Dis., 26: 272, 1947. HUNTER, M. B., AND JASPER, H. H.: J. Electroencephalog. Clin. Neurophysiol., 1: 305, 1949. HAYNE, R. A., BELINSON, L., AND GIBBS, F. A.: J. Electroencephalog. Clin. Neurophysiol., 1: 437, 1949. WIKLER, A., AND FRANK, K.: Proc. Soc. Exper. Biol. and Med., 67: 464, 1948. WARD, A. A.: J. Neurophysiol., 10: 105, 1947. » E‘PSDSDF'?’ Hg... 12. ~ 13. 14. 15. �EXPERIMENTAL SCHIZOPHRENIA—LIKE SYMPTOMS MAX RINKEL, M. D., H. JACKSON DESHON, M. D., ROBERT W. HYDE, M. D., AND HARRY C. SOLOMON, M. D. Boston, Mass. Reprinted from AMERICAN JOURNAL OF PSYCHIATRY Vol. 108, No. 8, February, 1952 Printed in U. S. A. �[Reprinted from THE AMERICAN JOURNAL OF PSYCHIATRY, Vol. 108, No. 8, February, 1952] EXPERIMENTAL SCHIZOPHRENIA—LIKE SYMPTOMS MAX RINKEL, M. D., H. JACKSON DESHON, M.D., ROBERT W. HYDE, M.D., AND HARRY C. SOLOMON, M. D. Boston, Mass. Printed in U. S. A. �EXPERIMENTAL SCHIZOPHRENIA-LIKE SYMPTOMS ‘ MAX RINKEL, M. D., H. JACKSON DESHON, M.D., ROBERT W. HYDE, M. D., AND HARRY C. SOLOMON, M. D. Boston, Mass. - The nature and cause of the major psychoses are still unknown. Repeated attempts have been made to reproduce experimentally psychotic symptoms in the hope to uncover their psycho—physiological relationship. In 1886, Schmiedeberg succeeded in producing cataleptic phenomena in rabbits by the use of ethyl-urethan. In 1904, Peters(II) discovered the cataleptic action of bulbocapnine; Baruk and de Jong(1, 9, Io) investi— gated this, as well as many related chemicals, more extensively and demonstrated the catatonic elfect upon man and animals. With the discovery of new chemicals and chemical compounds, new tools are made available to the psychiatrist to investigate psychoses experimentally, and a new branch, experimental psychiatry, is emerging. The experimental psychiatrist has the advantage of knowing the one factor, in the causation of psychotic symptoms, the chemical that was administered to the patient and started the chain of reactions. The psychopathological genesis, however, of the psychotic phenomena will best be investigated by methods of the inter— Read at the 107th annual meeting of The Ameri— can Psychiatric Association, Cincinnati, Ohio, May 1 7-11, 1951. From the Department of Psychiatry, Harvard Medical School, and the Boston Psychopathic Hos— pital; Dr. Harry C. Solomon, Director. Aided by a grant from the McCurdy Company, Rochester, New York. H C /8 HC \‘/ CH. \C/ /\{twin/ \/ \/ C‘ CH 572 H / */\ C _, CH. 8 > CH. \f”? /\if”?!/ \/ \/ HC N~CH;; CH_ NH \r/ HOOC .. GET—CE 5 HC Chemistry and Plu'zrmacology L.S.D., which stands for the German Ly— .vergsdure Didthylamid, is the abbreviation used for the diethylamid tartrate of lysergic acid which, according to A. Stoll, A. Hofmann, and F. Troxler(I7), is diastereomer but not structurally isomeric with isolysergic acid as seen in the accompanying formula. coon \*/ Hi pretative analytical branch of psychiatry. Of the chemicals used experimentally at present 2 are outstanding: mescaline, an alkaloid known in its crude form as peyote for hundreds of years, though only in the past few years chemically synthetized, and d—lysergic acid diethylamide tartrate (L.S.D.), a member of the ergot group. Although these chem— icals are quite different in their chemical structure, in their effect upon normal subjects and psychotic patients they show great simi— larities with regard to the production of psychotic symptoms. The schizogenic effect of mescaline has been reported in a number of articles, most recently in a brilliant experimental and psychopathological publication by Paul H. Hoch(8). Our paper is concerned essentially with the description of the effect of d-lysergic acid diethylamide tartrate (L.S.D.) upon male and female individuals who, subsequent to the administration of this chemical, responded with the production of psychotic-schizophrenic-like phenomena. +— C Hi HC CH C CH NH N—CH. CH. �- I952] M. RINKEL, H. J. DESHON, R. W. HYDE AND H. C. SOLOMON It is water soluble and administered orally. Pharmacologically L.S.D. belongs in the group of the ergonovine substances. It has a definite“ effect upon the in situ uterus of the rabbit, and causes peculiar states of motor rigidity similar to the catatonic phenomena in the dog and cat as' seen with bulbocapnine (19). In our own experiments we noted an especially strong physiological reaction in a 29-year-old very sensitive white girl who was menstruating at the time. She complained of most violent abdominal constrictions, which may have been caused by vehement uterine contractions. The peculiar psychological effect, seen as excitation in experimental ani— mals, was first observed and described by the chemist, A. Hofmann. In his laboratory notes of April 4, 1943, he remarked that, while working with L.S.D., he noticed in himself a peculiar restlessness associated with slight dizziness. He had to interrupt his work and went home to rest. While at home, he felt as if intoxicated, a condition characterized by an extremely stimulated phantasy. After darkening his room, for the daylight bothered him very much, he had a most wonderful experience. Phantastic images of most extraordinary plasticity and intensive kaleidoscopic coloring passed before him. This state of intoxication lasted about 2 hours. Literature Following this discovery a number of au— thors investigated the effect of L.S.D. in self-experiments, on normal subjects, and on psychotics. W. A. Stoll(18), who first systematically investigated the psychological phenomena of LSD, confirmed Hofmann’s experiences and reported as the most striking psychological findings disturbances in perception that led to hallucinations, acceleration of thinking, slight dimming of consciousness, but maintenance of judgment. He regarded the psychotic condition as an acute exogenous reaction type and pathologically as diencephalosis. Condreau(4) confirmed most of Stoll’s findings, but reported that in his experiments the subjects’ consciousness was not disturbed aside from the feeling of intoxication. He added that the subjects maintained their capacity of self-criticism, but showed increased distractibility andiwere less able 573 to concentrate. The basic theme of thought remained unchanged, and the changes in feeling tone he felt to be merely an intensifica— tion of the previous underlying mood. He added as a new observation forced laughing and one instance of athetoid movements as suggestive of involvement of the diencepha— lon, thus contributing to W. A. Stoll’s origi— nal conception. A. M. Becker(2) essentially confirmed the observations of Stoll and Hofmann and emphasized the astounding production of psychosis—like syndromes following the administration of mere “traces” of a chemical substance. He believes the psycho— logical manifestations are the result of two different basic disturbances: affectivity and impulsivity on the one hand, and intention— ality on the other. The most striking contrasts among his observations were manic— hyperkinetic and inhibited depersonalized manifestations. In contrast to Stoll, who termed L.S.D. a “Phantasticum,” Becker suggested the designation of “Psychoticum” for L.S.D. Umberto de Giacomo(6, 7), of Italy, in his experiments with rather large amounts of LSD. (300 to 500 gamma) ob— served in his patients catatonic-like phenomena, which were similar to those produced by bulbocapnine. M. Rinkel(12) and Victor H. Vogel(18) reported their experiences with diethylamide of lysergic acid, adding as new observations paranoic trends and, in contrast to previous publications, slowing of thinking and poverty of thought. Bush and Johnson( 3) used L.S.D. as an aid in psy— chotherapy, and reported that their psychotic patients responded with an increase in activity and greater verbalization of psychopathology. They noted occasional short periods of confusion and disorientation, and occasional transitory visual hallucinations. Most of their patients showed some degree of eu- phoria. Method and Procedure In our own experiments, L.S.D. was given I 7 times to 15 normal adult volunteers, students, nurses, and doctors, in the 19—48 age range, and, as freshly prepared solution, to some psychotics: dementia praecox and manic-depressive, depressive type. The observations on the psychotic patients are still in progress and will be published later. The �574 EXPERIMENTAL SCHIZOPHRENIA-LIKE SYMPTOMS normal subjects, who were kept without breakfast, received LSD. in doses ranging from 20 to 90 gamma p. 0., in most cases one gamma per kilogram body weight, while the psychotics were given 3 gamma per kilogram body weight. This increased dosage for psychotics was chosen on the basis of the unanimous reports in the literature that psychotic patients were particularly resistant to the effect of LSD. The subjects were kept under continuous observation by at least one of the authors for the first 5 hours and, on occasions, tape recordings of the subject’s productions were made. The subjects remained under observation the same day at the hospital, and were seen again the following day. The main emphasis in our observations was on the clinical psychiatric picture. Routine neurological and circulatory system examinations were not done, but signs occurring in these areas were noted, if observed. In 9 of the experiments, electroencephalograms at or near 2 hours after L.S.D. were taken, and Rorschach tests were given to 5 normal subjects and concrete-abstract thinking tests to 2 subjects during the height of the L.S.D. reaction. Controls of EEGS and psychological tests were done while the subjects were in their normal mental state. Results I. Disturbances of Thought and Speech.— The most prominent psychological changes observed were those in thinking and speech. They were present in all our experiments. There was no cloudiness of consciousness, no intellectual weakness, but most frequently we observed difficulty in the power of expression. The subjects became more and more slowed down, poverty of thought became apparent, and the flow of speech became increasingly diminished and blocked. One subject, a middle-aged depressed pa— tient, went into a complete stupor. In another instance occurred unwillingness to speak, a symptom similar to the negativism of the schizophrenic. Hesitancy, indecision, and impairment of abstract thinking were frequently present; also looseness of thought and actual disconnection with increased dis— tractibility were common observations. As in schizophrenic patients, some of the sub— [Feb jects exhibited such phenomena as lack of spontaneity, irrelevance, pedantic imitation, and subjectively automatic speech. In one instance, we had the impression of the formation of a neologism. Acceleration of thought with flight of ideas associated with rhyming and punning; garrulity and loquacity of the hypomanic type were seen in a cyclothymic medical student within 45 minutes after the administration of LSD. In general, the effects appeared within 30-45 minutes after the oral administration of L.S.D., and disappeared gradually after 3-4 hours. II. Affect and M ood.—-Clear-cut blunting of affect and suspiciousness, as often seen in schizophrenic patients, were outstanding. These symptoms frequently led to feelings of indifference and unreality with disturb— ances in body image. The subjects experienced hostility and resentment, and on rare occasions ambivalence. The phenomena occurred about 15' minutes after the administration of LSD; feelings of indifference and blunting tended to be protracted; suspiciousness, hostility, and resentment were always more transient. Changes in mood were twofold: euphoria and depression, which occurred in about equal number. Euphoria was either of the shallow elation type with silliness, as seen in the hebephrenic, or, in a cyclothymic subject, of the jovial and infectious type, as found in hypomanic and manic states. Depression was combined with dependency, indecision, insecurity, passivity, and feelings of being “lost.” In no instance did we observe the happy and dreamy feeling of ecstasy as it has been described by other authors who experimented with L.S.D., mescaline, and other similar chemicals. III. Perceptiou.—Usually within 40 minutes after the intake of LSD. disturbances of perception were observed. Those of visual perception were most common and mainly of the illusional type. The subjects would see rippling or wavy lines on the wall that might evolve into geometrical pattern, or be associated with color such as yellow, orange, or pink. In some instances, subjects saw a thermostat on the wall as a crucifix but fully realized that the experience was an illusion. None of the subjects, however, had the feeling of seeing something of extraor— dinary beauty, as it was stated in early re- �I952] M. RINKEL, H. J. DESHON, R. W. HYDE AND H. C. SOLOMON ports on L.S.D., or as it may occur under the influence of mescaline. Gustatory disturbances occurred frequently; the subjects experiencing a metallic or “funny” taste or heavy tongue. Auditory perception was changed only in a few instances. The subject would hear a sound that was either near or distant, and in one instance of a depressed patient, the noise of a typewriter in an adjoining room was perceived as music, seemingly beautiful music. The sense of time was disturbed in II out of 17 experiments. It was characterized by the feeling of time accelerated or retarded. IV. Hallucinations and Delusions—Disturbances in perception, in a complex way, often lead to hallucinations and delusions. A vivid phantasy, a pseudohallucination or illusion, in the process of mental dissociation, may ultimately appear as a real object outside the subject and thus constitute a real hallucination. By a similar process, changes in auditory perception, combined with exist— ing suspiciousness, may lead to ideas of reference and delusions of persecution. It may be stated that hallucinations, predominant under the influence of most phantastica, sub— sequent to the injection of LSD. were rather meager and never showed the quality of an extraordinarily beautiful or threatening experience. The occasional visual hallucinations consisted mainly of formed images, which occasionally were preceded by crude flashes of light. Perhaps the above—men— tioned disturbances of taste perception should be mentioned here as gustatory hallucina— tions. In only one instance we noticed an auditory hallucination, which consisted in hearing bells, although there were none anywhere around. Haptic hallucinations were experienced by two subjects. One male sub~ ject had the rather vivid feeling of his trousers being wet from urine, and one female schizoid patient was convinced that she lost urine and wet her slacks and the bed. She actually, later on, did wet the bed, and it may be possible that her hallucination was stimulated by autonomic excitation of the bladder mechanism. Morbid ideas were common; they included ideas of reference and ideas of influence. One female volunteer became quite paranoic and was Still disturbed the following day. Major delusions, ideas of gran— 575 deur or persecution, as seen in the delusional states of the paranoic or paraphrenic, were not observed. That may be due, perhaps, to the fact that in our experiments on normal volunteers we used only relatively small amounts of L.S.D. V. Depersonalization.—Alteration of personality occurred rather frequently. Those changes consisted mainly in the subject’s feeling that his legs were either extraordinarily long or heavy; in one psychotic patient the feeling was that the leg between ankle and hip had disappeared entirely. Most common was the feeling of unreality as regard to the subject, himself, and the outer world. Though these phenomena were of minor magnitude, they, too, indicate symptoms particularly ob— served in the schizophrenic patient. In no instance were we able to elicit experiences, of synaesthesias, as frequently seen in mescaline intoxications. VI. Behavior.—The most and striking change consisted in underactivity, associated with lack of spontaneity and initiative. One schizoid-depressed patient went into a state of catatonia; another one became stuporous. A female schizophrenic patient, who had received 3 gamma/kg. body weight of L.S.D., became agitated; after an initial state of inertia, she suddenly stood up and went through many and various motions. She knelt down, kissing the wall, the floor, the examining table, and progressively became more and more excited. She tore off her clothes and became noisy to such an extent that the ex— periment had to be terminated by the intravenous injection of 0.5 g. of sodium amytal. In our normal subjects, overactivity or in— appropriate behavior was rarely noted, but psychomotor manifestations, such as smiling, giggling, and laughing, more often appropriate than inappropriate, were frequently observed. This was particularly so in a student of cyclothymic personality make-up. VII. Intellect—In our normal subjects, intellectual functions were never disturbed. The subjects were aware of what they were doing at every moment of the experiment. Their memory also never became disturbed; each one was able to give, in a written report, a description of all the experiences he went through. Also, the psychotic patients did not show any particular memory defect. . �576 EXPERIMENTAL SCHIZOPHRENIA-LIKE SYMPTOM S Patients Whose verbal expression became slowed down and finally completely ceased, as in the case of stupor or catatonia, were able the following morning, under sodium amytal or d—desoxy-ephedrine, to recall their thoughts or personal experiences of the day before under the influence of L.S.D. VIII. Autonomic Nervous System.—All normal subjects and also the psychotic patients had numerous subjective complaints and symptoms. Since they mostly belong in the group of disturbances of the autonomic nervous system, they are best described here. The most common symptom was change in appetite, which more often was decreased, and associated with nausea, than increased. Complaints of headiness, giddiness, faintfre— and tremulousness, shaking were ness, The subjects complained , quently expressed. of chilliness and coolness of whole or part of the body, lump and “funny” feelings in ab— domen, constriction with oppression in chest and precordial discomfort, violent cramps and constriction in the abdomen in a pa— tient who just happened to menstruate. Objectively observed were flushing, sweating, shivering, and shivering with goosepimples. Tachypnoea, salivation, pallor, sighing, and obscattered micturation of were urgency servations. Changes in pulse rate and blood pressure were of minor magnitude and observed only occasiOnally. Involuntary smiling, giggling, or laughing were considered in the nature of “risus sardonicus” where the subject described these phenomena as occurring Without or against his will. One subject stated that in a smile he felt as if his facial muscles were like plastic wax being moved by some inexorable force. Pupils were often maximally dilated. Gross disturbances of the cerebrospinal nervous system were not observed, except in some instances “dysarthria,” which consisted of a transient stumbling over words and was never marked. IX. Electroencephalogram.—EEGS were taken in 9 experiments at about the height of L.S.D. reaction, and compared with the EEG of the same subject in his normal state. In general, the EEG changes were only slight. Principal changes occurred in the alpha rhythm, which was characteristically increased in rate from 1-3 cycles per second. [Feb. In one case, an individual who was very relaxed, a slowing of about 2 cycles per second was observed. Hyperventilation showed a diminished responsiveness and may be due to the subject’s reduced cooperation. X. Psychological Tests. A. Rorschach—Controlled Rorschach tests were given to 5' subjects at the height ofL.S.D. reaction. All tests given during L.S.D. reaction showed abnormalities principally of the schizophrenic or paranoic type. There was noticed autistic thinking with decreased organization, contamination responses, and lack of logical thinking, also negativism and diminished emotional inhibition indicating anxiety, depression, and aggression. One Rorschach test revealed a moderately schizophrenic picture with autistic thinking and withdrawal. B. C oncrete-Abstract Thinking—The tests consisted in employing proverbs and aphorisms and recording the subject’s reaction. On the whole, the results, especially the wide range of responses in abstraction and overgeneralized and tangential thinking, were similar to those obtained in schizophrenic patients. DISCUSSION The common denominator in all our experiments with L.S.D. on normal subjects is a profound transformation and alteration of the psychic state of the individual, as it is a common factor in all psychotic states. The various mental phenomena that we have reported were brought about by mere traces (I:I,000,000g/kg. weight) of a chemical, d—lysergic acid diethylamide tartrate. The mental phenomena show similarities to symptoms that occur in actual psychoses. We noticed, predominantly, changes similar to those seen in schizophrenic patients. The subjects exhibited preeminently difficulties in thinking, which became retarded, blocked, autistic, and disconnected. The affect was shallow or there was clear-cut blunting. Feelings of indifference and unreality with suspiciousness, hostility, and resentment also approximated schizophrenic phenomena. Hallucinations and delusional disturbances though present were much less prominent or striking, but together with the manifestation ' �‘ 3952] M. RINKEL, H. J. DESI-ION, R. W. HYDE AND H. C. SOLOMON of depersonalization were most reminiscent of schizophrenic dissociation. To a much lesser degree were there similarities to the confusional states. Gross clouding of consciousness was absent in our experiments, but illusional misinterpretations were not infrequently observed. A few cases showed similarities to the manic-depressive states, with changes in mood of euphoria or depression. However, only in one cyclothymic-pyknic subject the intensity was of a hypomanic or manic state. Delusions of grandiose or persecutory nature, familiar in the paranoic psychoses, were not seen. We mention the similarities of the experimental phenomena to actual psychotic states in order to caution against fallacies that may occur in the interpretation of experimental psychotic disturbances. The same caution that is warranted in the application of an animal experiment to a pathological condition in man is needed in the application of the psychiatric experiment to natural psychosis. Our experiments have brought to light the fact that, in a short space of time, under the influence of a mere trace of a chemical agent in normal subjects, a variety of mental symptoms occur that are similar to natural psychoses, and that in psychotic patients an accentuation of existing, or elicitation of latent, schizophrenic phenomena takes place. It may be possible to assume that fundamentally the mechanism of origin of natural and experimental psychotic phenomena is a similar one: a chemical agent that pathologically stimulates selectively various higher, especially perceptive, brain centers with the result of hallucinatory and delusional experiences. H. J. DeShon, M. Rinkel, and H. C. Solomon( 5) have already pointed out that the clinical effects of LSD. imply such an involvement of the higher and highest centers of the central nervous system, and perhaps of lower levels of the nervous system as well. Many authors assume that chemical endogenous substances are the cause of schizophrenic psychosis. We must bear in mind that, in addition to d—lysergic acid, a great variety of seemingly unrelated chemical substances are capable of producing transi- 577 tory psychotic-like symptoms. Although observations are still too few to allow the for— mulation of a well-founded scientific theory as to the chemical origination of psychotic symptoms, we strongly believe that this branch of experimental psychiatry is progressing in the right direction, and may some day provide an answer to the most perplexing problems in psychiatry. SUMMARY The effects of minute amounts of dlysergic acid diethylamide tartrate (L.S.D.) on normal subjects, with an age range of 19—48 years, and some psychotic patients of the schizophrenic, depressive, and paranoic type are reported. 2. Psychotic phenomena and alterations of the autonomic nervous system were observed. The psychotic phenomena were pre— dominantly schizophrenia-like symptoms that were manifested in disturbances of thought and speech; changes in affect and mood; perception; production of hallucinations and delusions; depersonalization and changes in behavior. The basic intelligence was not reduced. 3. Electroencephalographic examinations at the height of the L.S.D. reaction revealed only slight changes, principally increased alpha rhythm, except in one case where there occurred a slowing of about 2 cycles per ' second. 4. Rorschach tests showed abnormalities principally of the schizophrenic or paranoic type. Concrete—abstract thinking tests also, on the whole, showed responses similar to those obtained in schizophrenic patients. 5. N 0 scientific theory for the origination of the natural psychotic phenomena or psychoses is being advanced, but the belief is expressed that experimental psychiatry progresses in the right direction. 1. Credits Our preparation of LSD. was supplied, in ampules containing I mg. substance, by courtesy of Professor E. Rothlin, Director of the Pharmacological Laboratories of Sandoz Chemical Company, Inc., Basel, Switzerland. �EXPERIMENTAL SCHIZOPHRENIA-LIKE SYMPTOMS 578 BIBLIOGRAPHY I. Baruk, H. Psychiatric. Medicale, Physiologique et Experimental. Masson et Cie. Paris (VI), 1938. 2. Becker, A. M. Zfir Psychopathologie der Lysergsaure-Diathylamid-wirkung (On the psychopathology of the effect of lysergic acid diethyla— mide). Wien. Ztschr. Nervenh. 2:402, 1949. 3. Bush, Anthony K., and Johnson, Warren C. L.S.D. 25 as an aid in psychotherapy. Dis. Nerv. Syst. 11 : 241, Aug. 1950. 4. Condrau, Gion. Klinishche Erfahrungen an Geisteskranken mit Lysergsaure-Diiithylamid (Clinical experiences in mental patients with lysergic acid-diethylamide). Ejnar Munksgaard, Copenhagen, 24: 9, 1949. 5. DeShon, H. J., et 31. Mental changes experimentally produced by L.S.D. Unpublished article. 6. Giacomo de, U. Données biologiques sur l’ac— tion psychopharmacologique de la diéthylamide de l’acide lysergique (Biological data on the psycho— pathological action of Lysergic acid diethylamide). Paper read at the Symposium on “Chimie cerebrale” of the International Congress of Psychiatry, Paris, Sept. 18-27, 1950. 7. Giacomo de, U. La catatonia sperimentale. Schizofrenie, 4: 195, 1934-1935. 8. Hoch, Paul H. Experimentally produced psy— choses. Am. J. Psychiat., 107:607, Feb. 1951. 9. Jong de, H. Die experimentelle Katatonie als vielfach vorkommende Reaktionsform des Zentralnervensystems (Experimental catatonia, as a frequent reaction type of the central nervous system). Ztschr, ges, Neur. Psychiat., 139 : 468, 1932. 10. Jong dc, H., et Baruk, H. La catonie experimentale par la Bulbocapnine. Paris: Masson et Cie, 1930. Pharmacologische Untersuchungen iiber Corydalisalkaloide (Pharmacological in- II. Peters, F. [Feb. vestigation of Corydalisalkaloids). Arch f. Experi— ment, PathoLogie, 51:130, May 1904. 12. Rinkel, M. (I) Discussional remark on L.S.D.—Clinic of the American Psychiatric Asso— ciation, held at the Annual Meeting of the A.P.A. May 1, 1950, in Detroit. J. Clin. Experiment. Psy— chopathol., Jan. 1951 (Van Ophuijsen Memorial Issue). (2) Discussion at symposium on “Chimie cere— brale” of Ist World Congress of Psychiatry, Paris, Sept. 18-27, 1950. Printed in “Les comptes-rendus du Congrés.” 13. Schmiedeberg, O. Uber die pharmacologischen Wirkungen und die therapeutische Anwendung einiger Carbamin Séiure-Ester. (On the pharmacological effect and therapeutic application of some of the esters of the Carbamin acid). Arch. f. Experiment. Pathologie und Pharmakologie, 20: 203, 1886. J. E. Psychopathologie der 14. Staehelin, Zwischen-und Mittelhirnerkrankungen (Psychopathology of the diseases of the diencephalon). Schweiz. Arch. Neurol. und Psychiat. 53 : 374, 1944. 15. Stoll, A. Les Alcaloidés de L’Ergot (The alkaloids of ergot). Experientia 1:250, 1945. I6. Stoll, A., and Hofmann, A. Partialsynthese von Alkaloiden vom Typus des Ergobasins (Partial synthesis of alkaloids of the type of the ergo— basins). Helv. Chim. Acta, 26:944, 1943. 17. Stoll, A., et a1. Ueber die Isomerie von Ly— sergsaure und Isolysergsaure (On the isomery of lysergic acid and isolysergic acid). Helv. Chim. Acta, 32 (No. 2) : 506, 1949. I8. Stoll, W. A. Lysergsaure-diithylamid, ein Phantasticum aus der Mutter-korngruppe. (Lysergic acid diethylamide, a phantasticon of the ergot group). Schweizer Arch. Neurol. und Psychiat., 60: I, 1947. 19. Vogel, H. Victor. Discussional remark to Hoch’s paper (ref. 8). ‘ ��ILQMH ‘_ .1”. '_ ., z::y1;,;m.ynom 32/ [7 _ kHLLQJ-» '2 2rd, GLEN QAKS N. L CLINICAL EFFECTS OF A “STIMULANT” BARBITURATE (Sodium I :3—dimethylbutyl ethyl barbiturate) in Schizophrenics BY HARRY [Reprinted from H. PENNES, MD. T8: JounNAL or Nnnvous AND MENTAL DISEASE, Vol. 119, No. 3, Mar. 1954] �[Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 119, No. 3, Mar. 1954] CLINICAL EFFECTS OF A “STIMULANT” BARBITURATE (Sodium 1:3-dimethylbutyl ethyl barbiturate) in Schizophrenics HARRY H. PENNES, M.D.‘x‘ central the nervous than rather depress stimulate barbiturates Many of these drugs evaluation clinical but animals in experimental system barbitu— of central—depressant Administration a limited been has (15). of amelioration transient often sodium produces such amytal as rate different symptoms' in schizophrenics (6, Io, 3). These symptom changes are usually attended by a variable degree of hynotic (sleep— producing) eflect which may proceed to actual sleep as the dosage is increased. In the drug therapy of schizophrenics the excessive narcosis produced by the central-depressant action of the barbiturates in common administered. be which conveniently total the limits dosage may usage It was considered possible that a central—stimulant barbiturate might of the desirable ordinary depressant the activity therapeutic possess barbiturates without the disadvantage of excessive narcosis. The stimulant barbiturate utilized to test this hypothesis was 1,3— dimethylbutyl ethyl barbiturate, sodium salt (15), (hereafter designated as DMBEB) which is similar structurally to sodium amytal (14). A small number of observations has also been included on another stimu— lant barbiturate, namely, 3,3—dimethyl allyl ethyl barbiturate, sodium salt, (supplied for research purposes by Eli Lilly and Company, Indianapolis) (16). According to reports, DMBEB produces a period of increased alertness and restlessnes in unanesthetized dogs, followed by convulsions; the seizures, which occur only in warm-blooded animals, are Violently tonic in type and the locus is probably the spinal cord; no hypnotic or anesthetic effects are noted in sublethal doses (13, 14,). The reflex contraction of m. tibialis anticus is augmented in spinal and barbital—anesthetized dogs; in this regard it is I/250th as active as strychnine, one—fourth as active as picrotoxin, and more active than caf— feine, cocaine, or ephedrine (9). The crossed—extension reflex in m. gas— trocnemicus and respiration are also augmented (8). The convulsant activity of DMBEB may be antagonized by administration of sodium amytal (14). The sodium salt of 3,3—dimethyl allyl ethyl barbiturate produces a restless, frightened, or boldly vicious animal in which con— ‘From the Department of Experimental Psychiatry (Paul H. Hoch, M.D.), New York State Psychiatric Institute. [25I] �252 Harry H. Penna: vulsions finally ensue; blood pressure and body temperature rise while respiration is stimulated (I6). Gottlieb has previously observed that DMBEB produces a euphoric effect in depressed patients after oral administration in subconvulsant doses (4). The drug was likewise maintained at a subconvulsant level in the present study in order to rule out the possible therapeutic effect of a generalized seizure. PROCEDURE schizo— administered hospitalized 20 to Patient5.—DMBEB was duraMean mean females. 8 males and was 32.5 12 years; age phrenics, tion of illness, 13.4 years; mean duration of hospitalization, 2.2 years. The diagnostic categories were as follows: pseudoneurotic, 6; catatonic, The pseudo— unclassified schizophrenic, mixed 1 II. ; or hebephrenic, 2; neurotics presented diffusely neurotic symptomatology in a basically of criteria the and to according diagnosed were schizophrenic setting schizo— unclassified and mixed of The Polatin Hoch and (7). group phrenics presented admixtures of catatonic, hebephrenic, and paranoid cata— Gross disease. of the features the well as primary as components tonic stupors or excitements and diagnostic categories other than schizo— phrenia were not included. Most of the patients were quite well pre— served. Sixteen of the 20 cases had either no or slight deterioration (6 pseudoneurotics, 2 catatonics, I hebephrenic, and 7 mixed or un— classified schizophrenics); these patients were chiefly short-term, volun— tary hospital admissions. The remaining 4 subjects displayed an advanced degree of schizophrenic deterioration and were long—term, state hospital patients. All but 2 patients had received at least one course of electric convulsive and/ or insulin coma therapy at some time during the course of the illness. Dru gun—DMBEB was dry—sterilized in an electric oven at I50—I60° C. for one to two hours. Immediately prior to intravenous injection the drug was dissolved in 20.0 cc. of sterile distilled water at a concentration of 5.0 mg. per cc. A colorless solution was quickly formed. The the in administered 20 of that dose 63.5 DMBEB was was mg. average subjects. An injection rate of about 5.0 mg. per minute was used in all subjects. The same procedure was followed in the administration of 3,3—dimethyl allyl ethyl barbiturate, sodium salt, to 2 patients both of whom also received DMBEB on another occasion. Each patient also independently received intravenous injection of sodium amytal (Amobarbital sodium, Eli Lilly and Company, Indianapolis), 250-500 mg. dis— solved in 10.0 cc. of sterile distilled water at a rate of about 50 mg. per minute, as well as 20.0 or 40.0 mg. of pervitin hydrochloride (Smith, �Efiect: of a "Stimulant” Barbiturate 253 Kline and French Company, Philadelphia) in 2.0—4.0 cc. of solution in one minute. Six patients also received intravenous sodium amytal in the same dosage and rate of administration as that of DMBEB. The drugs were administered in random orders to the various subjects. Injections were performed between 8:00 A.M. and 4:00 P.M. without limitation of food or the subject’s usual ward activities. Changes in the patient’s baseline clinical status were recorded in protocol form for a period of at least 48 hours following injection. RESULTS I. Mental Reactions.——DMBEB reduced clinical symptoms in II (55.0 per cent) of the series. Three patients (15.0 per cent) showed only increase of symptomatology and 6 (30.0 per cent) had no reactions except for side-effects to be described in section II. A. Symptom-reducing reflect—The therapeutic action was most pro— nounced in the pseudoneurotic group. Four out of 6 patients in this group experienced complete or almost complete relief of anxiety and tension, phobic concerns, irritability and hostility, and depressive manifestations. All 3 obsessive—compulsive patients in this group experi— enced amelioration of the disabling symptomatology, slight in I and quite complete in 2. The usual duration of relief was two to eight hours, but in 2 subjects the improvement lasted 16 to 24 hours. The symptomatic improvement began during the injection, usually concurrently with cephalic sensations described variously as “light—headed” or a “subtle feeling of relaxation.” In the 14 overt schizophrenics (hebephrenics, catatonic, mixed, and unclassified), 7 patients showed slight to mod— erate therapeutic responses which were in general less complete than those of the pseudoneurotics. The effects in the overt schoziphrenic group consisted principally of signs of personality reintegration with more normal emotional feeling and display, less self—concern and self— preoccupation, an increased tendency to contact the environment, and a somewhat higher verbal productivity. The most deteriorated cases responded least to the drug in a therapeutic sense; these patients also responded least to sodium amytal and pervitin. These therapeutic responses to DMBEB were qualitatively identical with those often produced by central—depressant barbiturates. How— ever, the therapeutic response to DMBEB was more complete than to sodium amytal administered in the same low dosage to 6 patients (30, 50, 65, 89, 100, and 100 mg.); this was particularly true in the pseudoneurotic group. Moreover, clinical signs of hypnosis with DMBEB occurred in only 4 patients in the series and consisted of transient drowsi- �254 Harry H. Pennes excessive slurred speech, and nystagmus, a sleepy expression; ness euphoria, and other signs of acute barbiturate intoxication were not feel— relieved reported no subjects present. Some of the most completely after such of signs and objective of drowsiness displayed no ings DMBEB. In addition, DMBEB produced none of the signs of psychic “stimulation” that usually occurred after pervitin, a cephalotropic sym— pathomimetic amine. Administration of pervitin was almost invariably attended by a positive “stimulation” aspect consisting of increased alert— ness and energy, feelings of optimism, and heightened psychomotor acaction the DMBEB, to therapeutically In responding patients tivity. elimina— neutralization or summarized be therefore a as symptom may tion without concomitant “stimulation” and, as described above, with occasionally a minor degree of sedation. B. Symptom—increasing eflects.—Symptom intensification occurred in him— for felt copiously, follows: sorry one subject wept 3 patients as self, and complained bitterly of mistreatment by doctors; a second identi— of seizure origin hysterical subject had a brief, opisthotonic cal with the type occurring in the drug—free state; the third subject felt more perplexed, confused, and depressed. These reactions were all exacerbations of pre—existent manifestations which had also previously increased spontaneously or in response to amytal and/or pervitin. These excessive reactions appeared to be precipitated “psychologically” as a secondary reaction to the unusual side effects produced by DMBEB barbituof showed acute of these signs None subjects Section 11). (see resemble did the reactions entirely not In subnarcosis. addition, rate the exaggerated emotional discharges so often produced after pervitin, since none of the primary “stimulation” effects of pervitin on psycho— motor processes was present. C. Absent mental reactions.—Six patients (30.0 per cent) had no reac— tions to the drug in terms of pre—existent symptomatology. In 3 of these, the side-reactions to the drug were so intense that the patients were preoccupied with little else. In the 3 other subjects, there were no mental side-effects. considerable of absence the of despite significance changes II. Side Reactions.—Practically all (18 out of 20) patients experi— enced side—reactions. The toxic effects appeared during the injection and the sequence of events was approximately the same in the majority of subjects. Tingling sensations or other paresthesias began in any part of the body, and rapidly became pruritic in nature; this was followed by or associated with hot and cold sensations and a mottled erythema in face, chest, and trunk. Pilomotor reactions often appeared on arms �Efiect: of a "Stimulant” Barbiturate 255 and back; less frequently there were feelings of vague abdominal dis— comfort or slight nausea; repeated, forceful sneezing; and occasionally burning of the eyes. Cephalic sensations previously referred to (Section IA) usually began early in the injection in a small minority of sub— jects; on assuming the erect position some patients complained of a vague vertigo of nonspecific nature and minimal degrees of ataxia were observed. The maximum dosage of DMBEB that could be comfortably tol— erated by the subjects was limited by the pruritis, which was the most frequent side-reaction (18 out of 20 patients). The itching usually began in scalp, face, eyes, soles of feet, or genital areas. Spread was rapid and in some cases the pruritis became generalized; some subjects rubbed and scratched vigorously and became extremely distressed, tending to disregard the other actions. All the side-reactions enumerated above were of relatively short duration, usually subsiding in IO to 30 minutes. In some cases, the pruritis persisted for several hours, although distress was always minimal after the first 10 to 30 minutes. In 17 cases, the injection was discontinued when the above reaction definitely appeared, particularly the pruritis. The average dosage administered to these subjects was 64.4 mg. total or 1.01 mg. per Kg. of body weight. The threshold dosage for the appearance of any effect, mental or toxic, was in the neighborhood of 30.0 mg. The range of effective therapeutic dosage without toxicity was therefore quite narrow. Two patients received full dosage of 97.0 and 101.0 mg. total without side— effects and a marked symptomatic improvement in one. Two subjects displayed seizures at dosages of 59.0 mg. (0.65 mg. per Kg.) and 68.0 mg. (1.04 mg. per Kg.), although other subjects receiv— ing equal or larger dosages did not display seizures. The involuntary movements were of a jerky, nonrhythmic myoclonic type; in one subject the movements were more or less generalized and in the other limited to the right arm. The movements occurred in cycles of about 15-20 seconds duration for a period of about 10 minutes. Consciousness was not impaired during the seizures; deep reflexes were normal in the inter— seizure phases; there were no facial weakness, pupillary changes, nys— tagmus, Hoffman or Babinski reflexes. The seizures appeared in these two subjects after the itching had become severe and generalized. Continued experience with the drug showed that no patient developed a seizure if the injection was discontinued at or shortly after the appear— ance of the pruritis. None of the side—effects of DMBEB occurred after sodium amytal with the exception of its quite minor hypnotic action. Pervitin sideeffects were totally distinct, consisting usually of mouth and throat �256 Harry H. Penna: dryness, peripheral numbness and lightness, chest pressure, and cephalic tightness or aching. Sodium 1,3-Dimet/zyl Allyl Ethyl Barbituratc.—This stimulant bar— biturate was administered in doses of 1.26 and 1.37 mg. per Kg. to 2 subjects. The same side-effects were produced as with DMBEB and with the same apparent intensity. One subject experienced generalized myoclonic—like twitchings. No therapeutic effect on mental symptoma— tology was observed. DISCUSSION DMBEB has been classified as a “stimulant” barbiturate in animals in the experimental pharmacologic literature because of its convulsion— producing property and augmentation of spinal reflexes (13, I4, 8). The epileptogenic action was confirmed in this clinical assay of the drug inasmuch as 2 subjects had seizures under the drug, the dosage being maintained at the subconvulsant level in the other patients. The seizures occurring in these 2 subjects were of myoclonic type, whereas Swanson and Chen reported that the drug produced severe convulsions of tonic convul— of difference This animals to as in (14). type laboratory type sion may be a species difference or reflect the limitation of dosage in man. The median convulsant dosage after intravenous administration to guinea pigs, rabbits, cats, dogs, and monkeys ranged from 2.0—3.0 mg. with brief the whereas episodes myoclonic (14), weight body Kg. per DMBEB in this series occurred with dosages of 0.65 and 1.04 mg. per Kg. The numerous side—reactions observed in man have not been reported in animals; some of these side—reactions are purely subjective and there— fore not observable in animals. Knoefel found that DMBEB produced a stage of increased alertness and restlessness prior to the seizures (8); dogs under sodium 1,3—dimethyl allyl ethyl barbiturate became restless and also appeared frightened or boldly vicious prior to the onset of convulsions (16). These apparent changes in emotion and behavior in animals could have been secondary to a highly distressing action such as occurred in man, mainly the severe paresthetic and pruritic response. Either a peripheral or central locus of action might underlie the typical constellation of tingling, burning or cold, pruritis, pilomotor contrac— tions, erythema and sneezing. The sneezing in man may be analogous to the respiratory augmentation observed in animals (16). Gottlieb noted that the toxic reactions to DMBEB in man were not significantly affected by administration of antihistaminic drugs (4). Despite the motor Stimulation caused by DMBEB in man and reported in animals, there was little or no evidence that the drug acted �Efiects of a “Stimulant" Barbiturate 257 in stimulation” The “psychic in stimulant” term patients. as a “psychic behavioral and emotional the is exaggerated to applied generally man the to sodium amytal, or with intravenous of subnarcosis as phenomena with as mood of psychomotor processes, or “primary” heightening of these of Neither amines. types the cephalotropic sympathomimetic be the this drug In may DMBEB. after respect reactions occurred which and are potent metrazol strychnine such with as grouped agents of absence The stimulants.” weak “psychic convulsants but relatively be in DMBEB with man stimulation” may of obvious signs “psychic associated with the fact that the seizure locus in animals is apparently the spinal cord (14). have been no hypnotic or has to reported DMBEB Although observed effect weak was hypnotic animals effects a in (14), anesthetic difference This series. of the may of the present in the minority patients reflect species variation or technical limitations in animal experimenta— tion inasmuch as a slight degree of narcosis is often purely subjective. From the therapeutic point of view, DMBEB produced symptom effects the of the series; of cent 20 or 55.0 per amelioration in II out ob— Gottlieb were most complete in pseudoneurotic schizophrenics. 60.0 i.e., material, different in results patient the tained almost same of series IO in administration a oral after per cent improvement, schizo— of a whom as diagnosed was only one severely depressed patients, establish advisable deemed therapeutic been to has It not (4). phrenic value on more than the present preliminary tentative basis because of the high toxicity of the drug which would preclude therapeutic appli— cation. The same conclusion was reached by Gottlieb (4). The observed therapeutic activity of DMBEB cannot be explained allevia— because action weak symptom hypnotic—narcotic in terms of its tion (particularly in pseudoneurotic schizophrenics) occurred without obvious of absence and the fact this of view In action. such appreciable the of action the that is therapeutic it stimulation,” apparent “psychic drug requires another explanation. Two hypothetical explanations are the following: and stimulation” properties does “psychic DMBEB really possess I. in addition the hypnotic action of the ordinary barbiturates; the balance between these two actions is such that a net weak hypnosis is occasionally the resultant in man. In this case it would have to be assumed that the complete almost the theoretically retained is despite action therapeutic of level far effects in stimulant as and so narcotic of cancelling-out consciousness is concerned. In support of such a possibility is the clinical observation that in simultaneous administration of amytal and benzedrine to mental patients, considerable therapeutic activity may ensue �258 . Harry H. Penna: despite a fairly complete mutual neutralization of the narcotic and stimulant actions of the two drugs (11). In this connection it may be observed that Gottlieb interpreted the euphorizing action of DMBEB in mental depression as a consequence of its “stimulant” properties and from this concluded that amytal may exert its euphorizing action in the same condition by a stimulant rather than a narcotic action (4). Gottlieb did not report any hypnotic action of DMBEB in his series such as was observed in the present study; the difference may possibly be a function of the oral route of administration in his study as compared with the intravenous route in this report. His data could also be inter— preted in terms of a narcotic rather than a stimulant action of DMBEB and the beneficial effect of amytal in depression still explained in terms of a narcotic action rather than a stimulant one. 2. The second hypothetical mechanism for the therapeutic action of DMBEB would be that the drug exerts this effect by a mechanism other than central depression or stimulation. Direct evidence for this interpretation is lacking. However, there are several sets of data which suggest that the ordinary central-depressant barbiturates exert their therapeutic action on mental symptomatology independently of their hypnotic-narcotic actions. These data are the following: (a) a few subjects display almost complete relief of symptomatology after intra— venous injection of small amounts of sodium amytal before any or much intoxication is apparent in the form of drowsiness, slurred speech, or nystagmus. Conversely, a few subjects show little change in the mental status even though the central-depressant action may be carried to the point of sleep (10, 5). (b) The first effect of the barbiturates on the human electroencephalogram is the appearance of relatively rapid (20-25 sec.), medium—high voltage activity, particularly in the frontal leads (II, I, 12). The appearance of this activity coincides temporally with reduction of anxiety and tension in some patients and the appearance of a more or less euphoric state (11, 12). The physiologic significance of this rapid activity has not been fully determined as yet but in any event it is distinct from the EEG charges which are usually accepted as manifestations of depressed consciousness, i.e., high voltage, slow activity (2). In view of these considerations, it is possible that both DMBEB and the ordinary barbiturates owe their therapeutic effect on mental symptomatology to some hitherto undisclosed feature of their action. The pharmacologic literature contains reference to a large number of motor stimulant barbiturates which have never received clinical assay. These compounds show no underlying uniformity of chemical structure and many are in the thiobarbiturate series. The possibility exists that �Efi‘ects of a “Stimulant” Barbiturate 259 without these of drugs with obtainable some therapeutic action may be the excessive toxicity of DMBEB. SUMMARY bar— ethyl The “stimulant” barbiturate, sodium 1,3—dimethylbutyl various with 20 patients biturate, was administered intravenously to value. of its therapeutic forms of schizophrenia in a preliminary assay effect therapeutic occurring I. The drug exerted an irregularly in pseudoneurotic degree of complete which most was (55.0 per cent) further establish advisable to deemed been schizophrenics. It has not which toxicity the high of relatively because the therapeutic efficacy would preclude therapeutic application. in convulsant is the a that drug literature the 2. In accord with remainthe in seizures; had series myoclonic this animals, 2 patients in level. A subconvulsant maintained a at ing subjects the dosage was small minority of subjects showed weak signs of central nervous system central—depressant the drowsiness; of form the slight in depression action has not been reported in animals. occurred independently the of usually effect drug The therapeutic 3. evidence was No action. central—depressant and of its weak infrequent of the in sense stimulant” acted “psychic as a obtained that the drug heightening of mood and psycho-motor processes. action the of therapeutic mechanism the of 4. Several explanations of the stimufurther of investigation the desirability and offered were lant barbiturate series indicated. BIBLIOGRAPHY the Cerebral CorBarbiturates of Action on E.: and I. Finesinger, A. M. B., (1) Brazier, tex. Arch. Neural. 6r Frye/liar” 53: 51-58, 1945. Brain. the of Activity Electrical the Underlying Mechanisms : Physiological (2) I. Neural, Neurosurg, 6* Psych, 11: 118-133, 1948. Sodium Amytal of Intravenous Value M.: Prognostic and I. Hope, S., (3) Gottlieb, I. in Cases of Schizophrenia. Arc/z. Neural. 6' Prychiat., 46: 86-100, 1941. Acid. Arch. Barbituric 5-(1,3-Dirnethylbuty1)-5—Ethyl of Action Antidepressive (4) Neurol. 6r P5yc/ziat., 66: 318—328, 1951. and Sodium Amytal of Administration of Effect S. B: (5) Harris, M. H., and Katz, Sodium Rhodonate on Mental Patients. Am. I. P:yc/ziwt., 12: 1065-1083, 1933. NERVOUS & JOURNAL and Therapy. of Narcodiagnosis Status Present (6) Hoch, P. H.: MENTAL DISEASE, 103: 248-259, 1946. Psychiat. of Schizophrenia. Form Pseudoneurotic P.: Polatin, and (7) Hoch, P. H., Quart., 23: 248—276, 1949. by Nervous Central System the of and Depression Stimulation K.: (8) Knoefel, P. Therap., 6' Pharm. Exper. Acids. I. Thiobarbituric and Barbituric of Derivatives 84: 26-33. I945<9 Exper. Therap., 57: Pharm. Barbiturate. I. Convulsant of Action a : The (9) 130, 1936 (Proc.). Sodium Amytal, Pervitin to of Schizophrenics Reactions Clinical H.: H. (10) Pennes, ' —: �260 (11) (12) (I3) (I4) (15) (16) Harry H. Penna: Hydrochloride, Mescaline Sulfate and D-lysergic Acid Diethylamide (LSD25). (To be published.) : Personal Observation. Rubin, M. A., Malamud, W., and Hope, 1.: EEG and Psychopathological Manirestations in Schizophrenia as Influenced by Drugs. Psychosom. Med., 4: 355-361, 1942. Shonle, H. A., et 31.: Relation of the Structure of Dialkyl Barbituric Acids to the Length of Their Action. I. Am. Chem. Soc., 58: 585—587, 1936. Swanson, E. E., and Chen, K. K.: The Aberrant Action of Sodium I :3—dimethylbutyl Ethyl Barbiturate. Quart. I. Pharm. é‘r Pharmacol., 12: 657-660, 1939. Tatum, A. L.: Present Status of the Barbituratc Problem. Physiol. Rem, 19: 472502, 1939Taylor, N. B. G., and Noble, R. L.: Some Pharmacological Properties of Sodium Ethyl, 3:3 Dimethylallyl Barbiturate. Nature, 163: 447, 1949. ��W Ruth. t , mm mm.bail. Ion-r “I!“ i mammcsmmcm mmmnufl.‘ iv P.hmulJ.I.lIOou ,_ «2:! "WWW“ 'thfi-WMW-lmw mun-nuns; MM,” mug-v.4 pawn 1...,” .»,t Proof. to: Dr.J.D.lcCou it. nonu- Ltd. but lo: 959 “on“, “a m �gnu-gotta or flu «unnoand at up nun-um at»), mum». Ann; tho mm, (mm, mauuorummwgpu'wubom attache-amid. ”haul-Watt!” muunuu,nwu,mumwwu1uu vlllult. m,ud¢mlduquuonoffiom¢nub Mr uticomamnleutboc-W mummwu,muuaoomump mm,1umovd1h-u(cmsuand,19533 Inn-r, M1955, mam, 1955. 1957; 1956; -.‘-a.-1-- ran 195‘). mmmuxtuwmtmsmtzu “mummmwmumm Min-lull. Itmmuthttumotm «rutnammuummwwmd Wan-«An m .u-.. Hum.» a.‘ “.“.".‘m' .- ‘ �4-1-1- We CN nice weighing between 1.8 and 20 gram were used; all 0.2 of :1. value a m in intraparitoneany inJected were 8201'. 80 of .experilenta were carried out at a root tcperatnre The clonio convuleion (produced ”I nicotine, pentylenetet— was taken ae tho end point and the resale, etrychnino or picrotoxinfl obeerved date. the frocalculated van 613,. in tern of “Jim. (LIICEI’IIID I HMO! The 1949). Imaof phenobarbital duration nor-a1 the increase in noeie (neaeured by the ion of rightinc reflex) produced by the” of the of potutiation intensity couponnde we investigated. eeriee by a the Iowa in ooapared van phenobarbital by these agents the dose the in presence obtained by varying of doeo-ruponee aux-roe The (30 of phenobarbital don constant of a Prolininary ”en-eats were I‘m/in.) carried out to eetahlieh the latentperiodof thepbonobarbitalandtoeneurothattbedoeoeot 15 The iajooted were latter the ataractioe need were euboonvnlaant. atar— neefnl were those clinically nopnoba-ato were teeted. Five of of etmtaral their became selected were othere while aotice (Table I). to bemtynine relationlhip 0 obtained were and pierotoxin Pentylenetetrasole nicotine 95$ Laboratoriee; ellfate fro. 1'. l H. filth, fro- laatnen Ltd. fret in Organic Chemical-g Meat“ etryebnine �w. ‘TSE' rm-Nr‘mn '.5w-7- ‘,-v T: .viq m fouroonnlmtlbytho mutmumottbocnnoftho Mucupmatutdmm-nnndinhhlon. mow q»: u; 1“v " Input-uhthouinqunu-hcflihtmottbflgg �9i was.“ 43-3: :2 .'.w -.....< . entegonised the convulsions ea did ediphenine. end 80 525A eholished the tonic The “upload, piprsdol phase. effect of ease of the etereotios of phenoherhitel is shun in rehle III. The on the ties of fieently shortened with eech eta-pound used while the motion ves signifieestly prolonged . Further iflicetioe of the menus station onset use sini— antics of W ' of intuitw of this phenobdbdtslestienoenheseenieml. Thesedese-reqeeu “1;" de-oeetrete the relstive effectiveness Iillitrsl for sillin. oftheseeaepeueds. 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Marmara-sin, murmur“. 0!.thqu and mute]. on Wuumlmmwwmmmmm. u«.mmmmuuatunmmmflfio Pavia”mmmuamwunuuu. nub-WWmenth-pnmottm I: Wd‘O/UO. mnummwwwmummfim innaundtmmutthMp-éflyw ,. "a I. (Wingw, WW (1957) In many Mdmtuuuu u cm. do.) an udulM-(uquu-mwaaumaw mum-g mmummwormm.“ mmamumumutuwmd Wu.utuqaumutbunuuwuunua of'utomdow. .; mmmamwwwmwmm «www.m-mwwmwmum mthmuopotuqupcumuthuuuuu. Wanna uh mm‘mrmmumuugmcm mm... nulmmmmu-mmzu- MM mumumm(m,uumm19fl). �”IL-*- 1 :1. u“- 1‘ a A . . :\ 1 : 1 ~=‘-<‘Wlfl-me~4 a“ airfiai’iw" .. MmmtnottmoIWNLWn-(I) (l)uluuy¢loao1(l)ondlnuuctw m1“), mu umcwwaomphmmul. .1 �m Wu,morp1nn,uprobmto,uuqmm1, nova-.1 «Ml-cum. any-um proau. utma; of Ion clouo to thMM.” tumult” nth c unpai1. Wm mun-mu, 1311.00. manual, am or 3100“...th- w ‘ 2. mule-91d um, Mnmnu,m1u, wuwmulot,hnuonndifi~ityofm awmumnmtmdammuw. ummammuaummm 3. “Wham-WMuRMtme-Mdm umumd,n-¢om,mw,wmorm “ulna-mm ammotu-Wtyuw-n munu1ummnmmmwm.m1m ' A. W muamudmpoumu. to «mm. 3M0 )uuu n V « , ~ ;, s. z . 1,, .. (.9; A a.» you. man mm I Mm¢ha3a11vaé2r$imH lMMfiAxtfi-m¥*-"‘m&héw«gu \ �.74).?— W in with to flunk thou orpniutiom for tonal-3 tolu- "11111310 tho wm": ~WW»II"M ~ ..--M- .....,... n... .. 9.. . Ml!....; that cart“! in nun. , “I‘M“ Ia Met, IJ. m1.“ E11100 0000. 8" 525A 0000. W Pipndol m. m mm man ad to mu,m. 0.0.. “10mm 3x ,:;"'-. 55.1.6 at“ -. .ifimi-fliafi.“ .0 ‘ “a .3... W. “an,” oo;oo '5 1 W, m M .1“. n1” ‘Pun. .' 4.52. - �Box-pr, r.n.. J. m1. Borg-r, LIL. Ann. M, mu, 0., 0., 1.x. And. 11m”. Int. India, 3.,Sloro, 1954. m. “1. 301. J. nan-«1. m... mm, 413 1957, 91, 685 1955.19,?” 1956. 0.1.. n. an an Pllvu, 1.. “maxim, am, ’0, ”3‘" 8.. m. Win,nun-t.W, 1956.13.14: IO, ‘0' 3.. M m1. 1953, 23: 305 Arch. ad mun. mm, 0.11., 1:19.. 0.11., and 5m 1., Apt: Pint-001. ct renal. 1955. tended. at not: “J,‘., git ? m. 1133 m MOD», '0' 1956, run-«1. a. r..,:. at my... mama, 320 1957, tron. MI. 1. and lb :.n. sun, Wall, In 1957, and pro“. 3001.1, 1.3., aura, 9., ll», IJ. 3.3. 1955. 1949, 99 n. we n. 3&6 ��‘ .........,., 4 8n» AU 8. _ Ian-av. 8m. o8 08 so an» 8. on. a... 8. a. a. : an»? u n ,5 9.5. .3.an . “at. LED- ..,..y �CV A3 ot'oflg gwgong p.» aw.a.p.uv pro Acto.9.wv . a.» Au.~.w..v u.w or» Aarqnarov a o ~u...u.nv �� 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 and reprints: hallucinogens and EEG, 1958 (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-03-01-002-13-014 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 Various authors 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/c577bc7f069484c31c474ab088079b96.pdf ecc528f0eb233cc9aa9e8503f0092d28 PDF Text Text OF' THE EFFECTS CERTAIN DRUGS ON CEREBRAL SYNAPSES By Amedeo S. Marrazzi Reprinted from ANNALS OF THE NEW YORK ACADEMY OF SCIENCES APR 3 0 1qt§9 ‘ ‘ Volume 66, Article 3, Pages 496—507 March 14, 1957 DEPARTMENTOF . EXPERIMENT” PSYBH‘HRY SIDE HOSPlTN- Hug-LEN OAKS. N- Y- �THE EFFECTS OF CERTAIN DRUGS ON CEREBRAL SYNAPSES By Amedeo S. Marrazzi Velerans Administration Research Laboratories in Neuropsye/ziatry, Veterans Administration II ospital, Pittsburgh, Pa. As Edward Evarts has so clearly indicated in his contribution to this volume, we are all interested in determining the neurophysiological correlates of mental disturbance in the hope of thereby gaining an inkling of its underlying mech— anisms and developing a rational therapy for it. Humphry Osmond has drawn a dramatic picture of the opportunity presented by the situation made possible by the psychotomimetic drugs, which afford us the means of inducing at will a reversible model psychosis. This model psychosis, even though it bears only a fragmentary resemblance to schizophrenia, nevertheless simulates certain aspects of mental disturbance by perhaps similar mechanisms. Furthermore, the so-called model psychosis also can be shortened and terminated is in effectiveness clinical which for schizophrenia will the tranquilizers at by claimed. The use of drugs as tools thus creates favorable conditions for studies of mental illness. Our efforts, as investigators, are directed more toward an intelligent applica— tion of the hypotheses of mechanism rather than toward simple clinical evaluation. The conditions that we wish to interpret are fully and truly exhibited in man but, before we can take full advantage of controlled conditions induced in humans, it is necessary to perform some prototype experiments in animals since, in such experiments, more procedures are permissible and in them those experiments intended for man can be constructed and rehearsed. This pur— is be humans with work before done, needed can the my groundwork pose, justification for presenting some data on animals and making comparisons with clinical conditions and experimentally induced conditions in man. FIGURE 1 summarizes the data that led my co—workers and me to a hypothesis that served as the point of departure for studies in this field.1 It shows that in our survey of a variety of sites in the nervous system we find, as far as we have gone, that a consistent reciprocal relationship exists between excitation or enhancement by acetylcholine and acetylcholinelike substances, including anticholinesterases, on synaptic-transmission phenomena and inhibition by epinephrine, norepinephrine, all sympathomimetic amines in varying degrees, and related substances.2 It seemed plausible that any perversion of metabolism that would distort the balance of endogenous chemical or neurohumoral control of synaptic-transmission processes could lead to abnormal cerebral performance or mental disturbance, and that chemicals or drugs could alter the equilibrium of transmission and thereby alter cerebral and mental function in the direction of health or disease. The limitations of communication with animals make it exceedingly difficult, though not impossible, to relate the behavioral disturbances that can be produced in them with mental disturbance in man. Since our basic premise, however, is that all cerebral function, including both behavior and mental proc— in series and in accumulated parallel of units is functional made esses, up 496 �Marrazzi: Effects of Certain Drugs on (‘erebrztl Synapses 497 SIMILARITY OF CHOLINERGIC EXCITATION AND ADRENERGIC INHIBITION AT VARIOUS SYNAPSES ACETYLCHOLINE ATROPINE 0R CURAFIE ANTICHOLINESTERASE TEA EPINEPHRIQJE mnzpmepuamz AMPNETAMINE Epnsonms (-) CORTEX ‘MIDBRAIN (—) ~n£spmnoav (_) CENTER PARASYMPATNETIC GANGLIA (-) svunmznc GANGLIA (_) ”c/ (-I 6.23536: * ----------- 553%? ( - 4 ENHANCEMENT 3' BLOCK ‘I HONOLOGUE OF SVMPATHETIC mcounzn OF ** GANGLION FIGURE an. , _______ (-) INHIBITION CNOLINERGIC EXPERIMENTS 2‘ DEPRESSION EFFECTS IN PROGRESS 1 combinations to form patterns, I believe it of value to study such units, that is, the synapses. The transparent model of the brain of the cat (FIGURE 2) illustrates a relatively simple synaptic* preparation that we have found convenient for study. I must emphasize, at the outset, that we consider the experiment pertinent to the extent that it deals with visual pathways, since the powerful psychotomi— metic drugs exhibit an important Visual component in the hallucinations, dramatically so with mescaline. More important than that, our findings im— press us with the similarities rather than the differences between synaptic per— formance and susceptibility to chemicals, either endogenous or exogenous (drugs). Therefore, we are really using the transcallosally activated cerebral synapses in the visual area of the cat merely as representative of cerebral synapses in general, all of these synapses having qualitative similarities and varying principally by differences of threshold. We do not intend to suggest that an alteration in this specific pathway is necessarily responsible for mental disturbanceT A little later I shall outline a general working hypothesis based ‘ “Synapse” is used throughout in the sense of designating the total complex involved the functional arat ticulation of 2 neurons, that is, presynaptic nerve ends, transmission process, postsynaptic dendrites, and soma. ’r Chronic interruption in a system such as the transcallosal. as mentioned by Edward Evarts, should not necessarily be expected to produce the same changes as an acute interruption by drugs unaccompanied by surgical trauma and subsequent degenerative processes. �498 Annals New York Academy of Sciences 93 .5“ .Qafida 05 mm 399% @003 .3235 029533 33. Saginaw Qumozaumqnbv 18:38.35 gobs—Tm wagon? £35 2: we 1:58 “223359 .12.— . .N 35c 5:... ~ A 688.: . �Marrazzi: Effects of Certain Drugs on Cerebral Synapses 499 patterns that results from alteration in amounts of synaptic regulators or in the thresholds of the neurons upon which they act. Since Edward Evarts has already outlined our technique I can be very brief in pointing out certain features. Because the brain is a communication system it seems most appropriate to measure function by recording the handling of a test message. The test message is supplied in the form of a submaximal elec— trical stimulus applied to 1 optic cortex in a cat that has received a. light dosage of pentobarbital sodium. This stimulus initiates a conducted response in the association or transcallosal tract that connects the stimulated point to a sym— metrical point in the contralateral cortex where, after synaptic. transmission, the stimulation evokes a cortical potential, as first described by Curtis and Bard.3 To help distinguish between peripheral effects that would contribute to the afferent drive constituting the background against which the impulses are elicited and the strictly central effects, we take advantage of the fact. that an intracarotid injection will achieve a transient, higher concentration of drug on the ipsilateral or recording side but, when diluted by the blood in the general circulation, the concentration of the drug is brought down to levels that are below the threshold for the peripheral effects. Under the conditions of our experiment, the amounts of the drug passing through the circle of Willis to the other cortex are unimportant. In this way it becomes possible to demonstrate (FIGURE 3) that epinephrine, a chemical natural to the body, one known to produce anxiety when accumu— lated in sufficient amounts, either endogenously or exogenously, also produces cerebral synaptic inhibition, as indicated by the reduction in the signal (surface on a disruption of normal negative wave) corresponding to outflow, while the inflow (surface positive wave) is essentially unaltered. The same type of synaptic inhibition is shown for another cerebral neurohumor, norepinephrine, in the next line of the same IOO LIV. IOO ”\4 The cerebral synaptic action of epinephrine and norepinephrine in a 2-neuron intercortical (transcallosal) system. Potentials are evoked in the optic cortex by the electrical stimulation of a symmetrical point m the contralateral cortex. Epinephrine (10 lag/kg.) was injected into the i silateral carotid artery after A. and norepmephrine (150 lug/kg.) was injected after D. A and D are centre 5, B and E represent inhibition, and C and F show recovery. FIGURE 3. �500 Annals New York Academy of Sciences 0-9-? H I HO H0 H I OH H I H -N\ CH3 EPINEPHRINE (dihydroxy-phenyl—ethonol methyl amine) h‘h‘,“ ”'9?" HCH3H AMPHETAMINE (phmyl-isopropyl amine) _*.+ H __'.+ H CHSO MESCALINE (trimethoxy-phenyl-ethyl om'ne) FIGURE 4. Types of phenyLethyl amines producing mental effects. figure, but this action is evidently weaker than the other, requiring a larger dose to produce approximately the same degree of inhibition. In FIGURES 4 and 5 are shown some structural chemical similarities of compounds with which other contributors to this volume have already dealt. Attention is called to the close structural similarity (FIGURE 4) of epinephrine to amphetamine, which is also capable of producing anxiety, and mescaline, which does so regularly and with dramatic intensity, producing a full-blown “model psychosis.” These drugs in turn are related to the group shown in FIGURE 5, in which epinephrine15 once more presented alongside a first— oxida— tion product, adrenochrome, which is an indole. Below these are pictured d- lysergic acid diethylamide (LSD- 25), the very highly potent psychotogen which can be considered to be built on an indole nucleus, and 5- hydroxy— tryptamine, or serotonin The epinephrinelike psychotogens thus can be chemically related to the indolelike ones, including established drugs such as LSD— 25, reputed drugs such as adrenochrome, described at the beginning of this monograph by Humphry Osmond, and by myself elsewhere,2 and the b which is 4“ in the postulated by Woolbrain, naturally occurring indole found ley and Shaw5 to be sufficiently related to LSD- 25 possibly either to compete with or to add to its action. We now looked to see whether there was any functional parallelism or neurophysiological correlate of this relationship by using the objective test of cerebral performance afforded by the evoked- potential ac— IS FIGUR126 the that data there an showing the c.at presents in technique tual correspondence111 structure, and that all the compounds produce synaptic �Marrazzi: Effects of ("ertain Drugs on Cerebral Synapses - EH-c-("6"3 no no on 0 ——> 0 501 N has EPINEPHRINE H CON ADRENOCHROME /\ Cat's C2H5 N-CH3 -c-c-NH2 HO N N SEROTONIN D-LYSERGIC ACID DIETHYLAMIDE (LSD-25) FIGURE. 5. inhibition identical in kind to that produced by epinephrine, but vary in degree of effectiveness, so that for the approximately equivalent effects shown it re— quired milligram amounts of mescaline, but only microgram quantities of LSD-25, which duplicates the relative potency of these compounds as found in clinical experience. The dosages used throughout our experiments are inten— tionally of a size selected to produce incomplete actions, so that recovery back‘ to the control level can be secured more readily. Very interesting is the finding with serotonin, which turns out to be the most effective cerebral synaptic inhibitor of all, being effective in as little as l—ug. doses. Accordingly, rather than being an antagonist, this indole, or something like it, may represent the type of endogenous substance that is instrumental in bringing about some forms of spontaneously occurring mental disturbance. b and is brain48h is in the serotonin since so naturally present Furthermore, highly potent (about 20 to 25 times as potent as epinephrine in the same experiment), serotonin becomes, as we pointed out over a year ago,2 an even better candidate than either epinephrine or norepinephrine, which are also found 6 1" for the role of inhibitory neurohumor.* This finding would in the brainfi‘“ must penetrate the blood-brain barrier at least in the small amounts required to exercise the cerebral action described. ’ Serotonin �Annals New York Academy of Sciences 502 IOO MESCALlNE IOO UV. IOO ’D 100‘: UV. / 4" A A A A '°°” A A SEROTONIN CONTROL MAXIMUM EFFECT RECOVERY FIGURE 6. point even more closely to a derangement of neurohumoral balance at synapses as a potential mechanism of cerebral or mental derangement. Unfortunately, except for the intraventricular injections described by Sherwood,7 there have been, thus far, no documented reports of serotonin—induced mental disturbance* in man that are clearly separable from the natural anxiety initiated by the profound peripheral effects such as circulatory disturbance, other autonomic effects, and emesis. There are, however, such reports for a close analogue of serotonin, dimethyl-serotonin, or bufotenin, which is used for its mental efiects by some primitive peoples and has been observed by Fabing8 to produce such disturbances in man experimentally. These 2 subof metabolite epinephrine that well presumed adrenochrome, a as as stances, ‘ The fact that patients with carcinoid have large amounts of circulating serotonin without showing marked has develsym toms of mental derangement could represent an adaptation to very high levels of serotoninofthat such patients ope and accumulated gradually. This suggestion would account for the relative immunity to the possible central effects of high doses of serotonin injected intravenously. �Marrazzi: Effects of Certain Drugs on Cerebral Synapses 503 CONTROL MAXIMUM EFFECT SEROTONIN IO pg RECOVERY nomcwcnmn, N H0 /hCH- /kg. CH 3 CHEN'CH’ ./\N H BUFOTENIN 0= 0: 5 pg /kg MON / N H ADRENOCHROME 2000 pg/kg. FIGURE 7. (‘erebral synaptic inhibition by indoles in a _2-neuron intercortical (transcallosal) system. The potentials evoked in‘the cerebral cortex of the cat by electrical stimulation of the contralateral cortex every 2 seconds. The injections were given in the 1psxlateral common carotid artery. Hoffer, Osmond, and Smythies9 report as reproducing some aspects of the clini— cal syndrome of schizophrenia when injected intravenously in man, are com— pared in the cat in FIGURE 7. Again, all these compounds have the identical qualitative effect, namely, synaptic inhibition, but bufotenin, tested in the same animal, exhibits twice as much effectiveness as does serotonin, which required 10 pg. for its effect on this occasion. Adrenochrome, though it does induce synaptic inhibition, requires so large a dose, 2 mg, that it seems an unlikely candidate for the role of endogenous psychotogen responsible for a form of mental illness, although a substance somewhat like it might be responsible. The great effectiveness of serotonin not only suggests that this is the type of chemical structure implicated, with the reservations already noted, but that it constitutes 1 link, another being its natural occurrence in the brain, in the chain of evidence identifying it as a cerebral neurohumor. A required piece of information to round out this evidence would be the measurement of the actual liberation of serotonin during, or prior to, the recorded synaptic activity. This is a tedious and difficult type of experiment, and it is attended by special handicaps in work on the brain. Another approach leading to a similar conclusion, however, is quite readily followed. This approach is the accumulation of what must be naturally occurring serotonin, strategically located at the synapses, by the poisoning of the enzymes that normally lead to the destruction of serotonin and account for the ready reversibility and short duration of the action of serotonin. This is the technique that has been used so successfully in the study of the function of acetylcholine in the brain, and it is in this manner, by the use of a powerful anticholinesterase, that we demonstrated the presence and operation of acetylcholine at cerebral synapses.1 Serotonin is known to be very susceptible to destruction by monoamine oxidase, which is abundantly �504 Annals New York Academy of Sciences CONTROL EFFECT RECOVERY FIQURE 8. The cerebralsynaptic action of iproniazidin a 2-ncuron intercortical ttranscallosal) system. potentials evoked in the optic cortex of the cat by electrical stimulation of the contralatcral cortex every onds. The iproniazid (S mg./lu;.) was injected into the ipsilateral carotid artery. MAXIMUM The 2 sec- present in the brain.10 We therefore attempted to inhibit. this enzyme by iproniazid (Marsilid). FIGURE 8 shows the result of a preliminary experiment in which we injected iproniazid into the common carotid artery of the cat. in the same way that we had done previously with serotonin. The effect produced duplicated the serotonin effect as if, indeed, the serotonin at the synapse had been preserved by the inhibition of monoamine oxidase by the iproniazid. I believe this finding offers another piece of important evidence that serotonin is present naturally, not only in the brain, but at strategic sites where it is capable of influencing synaptic transmission. We have not as yet measured, as we need to do, how much this dose of iproniazid, given in this way, inhibits cerebral monoamine oxidase in the cat. We believe that the somewhat discouraging attitude of some investigators toward basing clinical prediction on animal experimentation is not, entirely justified, since this procedure is a natural result of the comparison of objective criteria such as we have just described with clinical evaluation based upon questionnaires and much undoubtedly shrewd clinical observation, both of these types of data being very difficult, indeed impossible, to quantitate. Ac— cordingly, we are more impressed by the degree of correspondence obtainable rather than by the discrepancies that are to be found. Thus our evoked-potential experiments in the cat rank the psychotogens and psychotomimetic substances studied so far, in general, in the order of clinical effectiveness, and they suggest that at least part of the mechanism responsible for mental disturbance is to be found in an imbalance in the regulation of synaptic transmission. One such imbalance we have already described. If this hypothesis is truly useful, and if the animal preparation used bears other than a merely empirical relation to the clinical data, we should expect that. the various tranquilizers for which varying degrees of clinical success have been claimed would have some action here also. “'e proceeded to test this extension of our thinking, and we found that all of the several types of tranquilizers are capable, when administered prophylactically to cats, of partially preventing, in the doses used, the cerebral synaptic inhibition of a test dose of mescaline. this reaction, using chlorpromazine ('l‘horazine). 'l‘he figures now read from top to bottom instead of from left to right, as in the previous FIGURE 9 shows �Marrazzi: Effects of Certain Drugs on Cerebral Synapses 505 MESCALNE 2.5mg/kg MESCALINE AFTER CHLORPROMAZINE CHLORPROMAZNE 0.05mg./kq. CONTROL MAflMUM EFFECT RECOVERY 60’\. 200 UV. The_prevention of the mescaline effect by chlorpromazine in a 2-neuron_intercortical (transcallosal) system. The potentials evoked in the cerebral cortex ofthe cat by electrlcal stimulation of the contralateral cortex every 2 seconds. The injections were made in the 1psrlateral common carotid artery. FIGURE 9. The first column shows the control, the mescaline inhibition at B, and the recovery at C. After this, chlorpromazine is given in doses which, per se, have no apparent effect on synaptic transmission, as shown by the new control D in the second column, but now when mescaline is given again, the synaptic inhibition E is much reduced when compared to B. Without the tranquilizers, the same degree of inhibition of mescaline can be repeated several times in succession, provided that complete recovery is allowed between in— jections. Records G and II show again that this dose of chlorpromazine did not impede synaptic transmission despite the ability of the drug to protect against mescaline. If the dose is increased twentyfold it does have a depressant figures. MESCALINE A 2.5 mg./kq. MESCALINE AFTER RESERPINE D CONTROL B MAXIMUM EFFECT C RECOVERY n E RESERPINE 0.lmg./kg. G m I The prevention of the mescaline effect by reserpine in a 2-neuron intercortical (transcallosal) system. The potentials evoked in.tlie cerebral cortex of the cat by electrical stimulation of the contralateral cortex every 2 seconds. The anCCtlonS were given in the ipsilateral common carotid artery. FIGURE 10. �506 Annals New York .‘Xcademy of Sciences MESCALINE CONTROL MAXIMUM 2.5m/llq. MESCALINE AFTER FRENOUEL FRENOUEL tqu/kq. m The prevention-of the mescaline effect by It‘renquel in a Z-rieuron intercortical (transcallosal) system. The potentials evoked In the cerebral cortex of the cat by the electrical stimulation of the contralateral cortex every 2 seconds. The unections were given in the ipsilateral common carotid artery. FIGURE 11. action on synaptic transmission. The same prophylactic action is obtained with reserpine (Serpasil), as shown in FIGURE 10, and with azacyclonol (\lt‘renquel), as shown in FIGURE 11. Another point of correspondence with clinical findings is that the margin of safety, in this case the range between the prophy— lactic and the synaptic-depressant, dose, is large, the depressant dose being 15 to 20 times the prophylactic. dose with both chlorpromazine and azacyclonol, but the factor is only 2 with reserpine. The latter drug approximates the action of the barbiturates, which can reduce the degree of demonstrable inhibition from mescaline by reducing synaptic transmission in the first place. I feel justified in saying, then, that the preparation described is pertinent to the clinical situation in that it ranks the psychotomimetic substances in the order of their clinical eli'ectiveness, and that the action of mescaline, the only drug that we have tried so far, is prevented by the tranquilizers. By use of the evoked—potential technique, we have demonstrated that: (1) There exists an equilibrium of neurohumoral control of transmission at cerebral synapses and throughout the nervous system, as far as I have surveyed it, that is susceptible to distortion and imbalance by disturbance in the amounts of chemical regulator or the susceptibility of neurons. (2*) The psychotogens and psychotomimetic substances discussed. structurally and functionally resemble the actions of the fairly well-established inhibitory synaptic neurohumors, epinephrine and norepinephrine, and of sero— tonin, the new one that we have described. (.3) Serotonin or its dimethyl derivative, bufotenin, comes close, even closer than does LSD-25, to representing the type of endogenous psychotogen that might be a natural cause of some forms of mental disturbance. We speculate that such disturbance can be produced by direct perversion of normal patterns of neuronal activity by the undue influence of synaptic inhibitors or, indirectly, by such inhibitors impeding the flow of impulses from higher controlling centers and releasing the more 1,)rimitive, simpler, and less well—adapted patterns of activity that we call abnormal. �Marrazzi: Effects of Certain Drugs on Cerebral Synapses 507 References 1. MARRAzzr, 118: 367. A. S. 1953. Some indications of cerebral humoral mechanisms. Science. E. R. HART. 1955. Relationship of hallucinogens to adrenergic cerebral neurohumors. Science. 121: 365. 3. CURTIS, H. J. & P. HARD. 1939. lntercortical connection of the corpus callosum. 126: 2. MARRAZZI, A. S. & 473. B. B. CRA\\'F()RD & J. H. GADDUM. 1954. The distribution of substance P and 5—hydroxytryptamine in the central nervous system of the dog. J. Physiol. 126: 596. 4}). PAGE, I. H. 1954. Serotonin (5—hydroxytryptamine). Physiol. Revs. 34: 563. 5. WOOLLEY, D. W. & E. SHAW. 1954. A biochemical and pharmacological suggestion about certain mental disorders. Science. 119: 587. 6. VOGT, M. 1954. The concentration of sympathin in different parts of the central nervous system under normal conditions and after the administration of drugs. J. Physiol. 123: 451. 7. SHERWOOD, S. L. 1955. The responses of psychotic patients to intraventricular injections. Proc. Roy. Soc. Med. 48: 855. FABING, H. D. 1955. Personal communication. 99° HOFFER, A., H. OSMOND & J. SMYTHIES. 1954. Schizophrenia: a new approach. II. Result of a year’s research. J. Mental Sci. 100: 29. 10. KOELLE, G. B. & A. DE T. VALK, JR. 1954. Physiological implications of the histochemical localization of monoamine oxidase. J. Physiol. 126: 434. 4a. AMIN, A. H. T., '1‘. �APR 23 ‘959 DEPARTMENT OF EXPERIMENTAL PSYBHMIRY HILLSIDE HOSPITAL GLEN OAKS, N. Y. �PSYCHOTOMIMETICS, CLINICAL AND THEORETICAL CONSIDERATIONS: HARMINE, WIN-2299 AND NALLINE 17%;»4” M :9 HARRY H. PENNES, M. D., PHILADELPHIA, PA., AND PAUL H. HOCH, M. D., NEW Reprinted from AMERICAN JOURNAL OF PSYCHIATRY Vol. 113, No. 10, April, 1957 YORK CITY �PSYCHOTOMIMETICS, CLINICAL AND THEORETICAL 1 WIN-2299 AND CONSIDERATIONS: HARMINE, NALLINE HARRY H. PENNES, M.D.,2 PHILADELPHIA, PA., AND This report describes the clinical effects of 3 psychotomimetics in mental patients. The results will be related to nosological and certain biological aspects of the “model psychoses” in general. The agents are (I) harmine, an alkaloid present in plant prepara— tions ingested by some South American tribes(1) ; (2) Win-2299, a synthetic cholinolytic(2) and (3) N-allylnormorphine (Nalline), a synthetic morphine antagonist (3, 4, 5). MATERIAL AND METHODS Single dosages of the drugs were given to 32 voluntary, physically normal mental patients, at the New York State Psychiatric Institute; 29 were in the 18-35 year age range; 19 were males and I 3 females. Twenty-two were schizophrenics of the pseudoneurotic and other nondeteriorated types, with only the primary symptoms of the disorder. Five additional schizophrenics had auditory hallucinations or delusions be— fore the drugs. The remaining 5 subjects had severe psychoneuroses or recurrent depressions. No patient had clouding of consciousness. Each drug was given about 9: 00 and breakfast after a 48-hour light a am, medication-free period. Examination by the authors and nurses were made for the remainder of the day in a shaded private room and also in the succeeding 72 hours. No patients were informed of the probable effects of the procedures. Most subjects showed excellent cooperation in reporting drug effects. In most cases, each patient received one drug of the 3 tested, but some received different doses of harmine on differRead at the 112th annual meeting of The American Psychiatric Association, Chicago, Ill., April 30May 4, 1956. 2 Director of Clinical Research, Eastern Pennsylvania Psychiatric Institute, Philadelphia, Pa. 3 Commissioner of Mental Hygiene, New York State. The actual study was performed at the New York Psychiatric Institute, New York, Department of Experimental Psychiatry. 1 PAUL H. HOCH, M. D.,3 NEW YORK CITY ent days. Each drug was given in salt form but for brevity will be referred to as the base. RESULTS GENERAL Since the new manifestations under the drugs were not present in the pre-administration period, they were clearly distinguishable from the patients’ baseline symptoms. At low dosage, each drug produced slight drowsiness, either with or without other symptoms. With medium or high dosage, the reactions qualitatively resembled those in a former series of similar subjects who received mescaline or LSD(6, 7, 8). Thus, diffuse alterations usually occurred in many realms—autonomic, motor, perceptual, emotional, intellectual, and be— havioral. Unlike mescaline or LSD (cf. Discussion for dosages), the present drugs regularly elicited some degree of clouding of consciousness in addition to the preceding changes. The characteristic reaction at medium or high dosage was a semidelirioid or confusional state with intermittent drowsiness or sleep. The confusional periods were cyclic. Their intensity and time of occurrence correlated only partly with drowsiness or sleep. Major symptoms were impairment of contact, attention, grasp, responsiveness, and concentration, with general “dreamy” or twilight quality. Full delirioid reactions occurred in 2 subjects at the highest dosages of 2 drugs (Win-2299, Nalline). Most subjects had intermittent amnesia during the reaction itself but were able to provide adequate descriptions of the major events. A spotty defect in recall was usually present in the 72-hour follow-up period. Visual hallucinations (cf. Discussion for alternative terminology) occurred at medium or high dosage with all 3 drugs. Subjects were easily roused after the onset of drowsiness or sleep and reported some of the hallucinations that had occurred in the “dream887 �888 CONSIDERATIONS OF PSYCHOTOMIMETICS ing” state. In all cases, the hallucinations occurred only with eyes closed and disappeared promptly when the eyes were opened. Hallucinations other than visual were infre— quent. Perceptual distortions of body and environment were moderately frequent. Neurological changes included varying degrees of subjective vertigo, light—headedness, subjective and objective ataxia, and sluggish speech. Like mescaline and LSD, these drugs produce a variable degree of intensification of different types of baseline symptoms. Harmine also occasionally produced a shallow euphoria. Nalline often produced relaxation of rather marked degree. After a few initial hours of peak intensity, reac— tions usually subsided gradually between the fourth to eighth hours, often with fluctuations in degree before complete remission. No subject reported effects after 24 hours except for minor, nonspecific “hangover” feelings. INDIVIDUAL DRUGS Harmine.——Turner, Merlis, and Carl have recently pointed out that the alleged hallucinogenic activity of pure harmine is a complicated issue on the basis of the previous literature on crude plant extracts(9). The threshold hallucinogenic dose of the pure drug in the present study ranged from I 50.0— 200.0 mgm. intravenously. With this route, 5 of 11 subjects reported visual hallucinations of varying degrees of complexity and organization. Bradycardia and hypotension occurred with all doses of intravenous harmine despite a 20- to 30-minute injection time, thereby limiting maximum dosage to 300.0 mgm. Average maximum changes were a pulse rate of 18 beats per minute and systolic blood pressure fall of 16 mm. mertermi— in was one subject Injection cury. nated at 210.0 mgm. because pulse rate dropped from 82 to 48 per minute and blood pressure from 118/78 to 88/60. Recovery occurred in about 30 minutes. The drug was not hallucinogenic by the oral or subcuta— neous routes. However, ingestion of crude plant extracts by natives does produce visual hallucinations according to field observations(10, 11, 12). In an experimental study by Cardenas(13), normal subjects also reported visual hallucinations and other effects [Apr. noted here, after ingestion of an aqueous solution of yahé (Banisteria caapi, a source of harmine). Visual hallucinations might have occurred in the present study with higher oral (loses, the maximum oral amount (960.0 mgm.) being 4.8-6.4 times greater than the intravenous threshold hallucinogenic amount (150.0-200.o mgm.). The amounts of harmine taken orally under field conditions and in Cardenas’ study are unknown, precluding comparison with the present study. Further analysis of the hallucinogenic activity of harmine is complicated by nu— merous botanical and chemical considerations(1, 10, 11, 14). Additional reactions to harmine which occurred frequently were: nausea and vomit— ing; slow, coarse, spontaneous tremor of the extremities of an “extrapyramidal” appear— ance; humming and buzzing noises (no voices); “waviness” of the environment; “sinking” sensations of the body; subjective sense of body vibration; and subject numb— ness, accompanied by objective evidence of reduced sensitivity to light touch and pinprick. These reactions, plus all the preceding, occurred in almost every patient with the intravenous route; and (except for hallucinations) some occurred with oral dosages higher than the threshold of 3000-4000 mgm. The reactions were generally more intense by the former route. Win-2299.—The mental effects of Win2299 in man have apparently not been described previously. The 2 subjects receiving 2.0 mgm. had the sedative effect. One of these subjects in addition became “hypersensitive” to light and sound, and spots on the wall moved and changed form. At the 6.0 mgm. level, all 4 subjects had severe mescaline- or LSD-like reactions plus a confusional state of moderate degree. These mescaline-like effects included bizarre perceptual distortions of soma and environment, unreality feelings, and synesthesias in one case. The single subject at 10.0 mgm. had a full delirioid episode with complete loss of contact, disorientation for time, place, and person, and responses to complex, organized visual and auditory hallucinations. This reaction occurred in brief but cyclic episodes; partial contact and lucidity were restored after persistent comments and questions. �I957] HARRY H. PENNES AND PAUL H. HOCH Most subjects had a moderate degree of mydriasis; blood pressure and pulse rate changes were insignificant. Nall-ine.—The results with Nalline in the main confirmed previous observations of others in different types of subjects, includ— ing normals( 3, 4, 5). Past and present findings included varying degrees of relaxation or euphoria, anxiety and dysphoria, miosis, nausea, drowsiness and sleep, thought disturbances, feelings of heaviness or lightness of limbs, and visual hallucinations. In the present series, visual hallucinations occurred in the single subject receiving 10.0 mgm., in 7 of 8 at 20.0 mgm., and in 2 of 3 at 30.0 mgm. In 4 cases (and in 2 with harmine) the hallucinations were Lilliputian in type, a not infrequent feature of acute toxic psychoses in general. So far as can be judged from the literature, a possible major difference from previous observations consisted in the occurrence of frank mescaline-like or delirioid reactions. At 20.0 mgm, 3 subjects had typical diffuse, bizarre per— ceptual disturbances, severe unreality feelings, and other signs of psychic disorganization. At 30.0 mgm., a similar reaction occurred including auditory hallucinations and synesthesias. In another subject at this dose the effect was overtly delirioid, with a strong resemblance to the Win—2299 toxic psychosis previously described. The intravenous route probably accounts in part for the appearance of these reactions, since previous reporters of the mental effects of Nalline have used the subcutaneous route, usually at dosages of 10.0-15.0 mgm. and sometimes higher( 3, 4, 5). DISCUSSION Relatively high doses of harmine by the intravenous route were required to produce the full psychotomimetic effect with visual hallucinations. The same was probably true of Nalline. It is conventionally stated that acute toxic psychoses occur in apparently normal individuals after high dosages of various other drugs, for example, atropine and cocaine(I5). There is a dearth of precise data on the number of such drugs, dosages required, and regularity of effects. However, not all drugs in relatively high dosage produce the diffusely abnormal men- 889 tal changes which are the criteria of psychotomimetic action. For example, clinical differentiation may be made between a confusional-hallucinatory state and a simple, progressive depression of level of consciousness elicited by narcotics and other agents. High dosage alone would therefore not preclude the classification of the present or other drugs as psychotomimetic in a selective or specific sense. Transient cerebral anoxia could have resulted from the hypo— tension and bradycardia with intravenous harmine or a respiratory depressant action of Nalline, which has been reported at dosages used in this study(3, 5). The florid and diffuse reactions elicited by these 2 drugs would certainly not appear to be characteristic of those in cerebral anoxia. In addition, the circulatory effects of harmine usually disappeared about 20 minutes after termination of injection, whereas the mental re— actions lasted at least several hours at peak intensity. Harmine, Win—2299, and Nalline fundamentally produced an acute organic reaction type, because of the basic mental clouding and confusional effects. Harmine and Nal— line each produced mental clouding together with systemic toxicity (cf. above) ; on the other hand LSD and mescaline elicit neither clouding or toxicity in major form within a certain dosage range. However, Win-2299 did not display this association of the 2 effects, since severe mental clouding occurred without obvious systemic toxicity. It is possible that confusional aspects may be more prominent for a given agent whose threshold psychotomimetic dosage is high relative to threshold dosage for any effect. Quantitative data relevant to this proposition are lacking for any psychotomimetic but are obtainable in principle. It is very probable, however, that absolute dosage thresholds for psychotomimetic activity correlate poorly with mental clouding. In ascending order, these dosages are very approximately: LSD (oral or intravenous) under 100 micrograms; Win—2299 (oral) and Nalline (subcutaneous or intravenous) 55.0-20.0 mgm.; harmine (intravenous) and mescaline (oral or intravenous) over 100.0 mgm. LSD and mescaline are at opposite extremes of an enormous absolute dosage range, and produce �89o CONSIDERATIONS OF PSYCHOTOMIMETICS practcially no clouding whereas the 3 intermediate agents elicit frank clouding at near threshold. There is evidence, however, that LSD and mescaline may produce clouding of consciousness at dosages well above threshold. Pennes has previously reported a sedative effect of LSD in 26.0% of a series of schizophrenics(8). The drug less occasionally (about 10.0% of cases) produced a confusional state(7). MacDonald and Galvin more recently reported a 58.0% incidence of mental clouding and confusion after LSD in 50 subjects. The psychotic subjects in their series apparently received the drug in dosages (per kilogram of body weight) up to 6.0 micrograms as compared with 1.0-2.0 micrograms orally in Pennes’ series(16). Mescaline sulfate (4oo.o—6oo.o mgm., intravenously) often produces slight drowsiness throughout the entire reaction and occasional confusional states(7). There may be an underlying similarity for all the drugs under discussion in the relationship of the visual hallucinogenic response to visual restriction and hypnagogic mechanisms. First, it will be recalled that visual hallucinations with the present drugs always disappeared when the eyes were opened. Wikler noted the same in post-addicts under mescaline(4). The authors have not noted this effect in frank form with either mescaline or LSD but have occasionally observed that hallucinations are reported as less distinct and vivid when the eyes are opened. Darkening of the room does initiate or intensify visual hallucinations with eyes open under mescaline or LSD. If eye closure and reduction of intensity of external light affect drug-induced hallucinations by the same mechanism, then the difference with respect to this mechanism may therefore be negligible between the present drugs and LSD. Such a mechanism may be related to that presumably operative in hallucinations and other mental disturbances recently reported as occurring with generalized restriction of sensory input(17). Secondly, the abnormal visual phenomena with the present drugs are probably best categorized as hypnagogic hallucinations or even more broadly as hypnagogic imagery or visions. This term is used because of the [Apr. invariable drowsiness (cf. Results, General) ; disappearance on eye opening is also consistent with the hypnagogic quality of the response. According to Ardis and McKellar, spontaneous visual hypnagogic images in normals are usually experienced in the drowsy state and with eyes closed. These authors also found strong resemblances in detail between mescaline visual hallucinations and normal visual hypnagogic imagery (18). Previous workers with Nalline have variously used the terms visual hallucinations, day-dreaming, vivid visual fantasies in a dreamy state, or nightmares. The apparent differences between the present drugs and mescaline or LSD may therefore be quantitative rather than qualitative. The conclusion would be that mescaline and LSD may also basically produce an organic reaction type. It is a familiar ob— servation that the visual hallucinations which are so characteristic of the drugs under consideration are relatively infrequent in chronic schizophrenia. These considerations obviously do not preclude various possible relationships between psychotomimetics and a possible endogeneous “toxic factor” or metabolic disturbance in the “functional” psychoses. Hoch and Wikler have recently and independently summarized the other implications of the drugs and the “model” psychoses for experimental psychiatry(19, 20). The indole nucleus, alleged to be specific for psychotomimetic activity(2I), is absent in mescaline, Win-2299, and Nalline. How— ever, with the exception of mescaline, the remaining 4 psychotomimetics contain a tertiary nitrogen grouping (2 in LSD). Since these compounds are otherwise grossly dissimilar in molecular configuration (fig. I), the entire structure undoubtedly has to be taken into account. Despite this well-known factor and the very small series of drugs, there are certain indications that the tertiary nitrogen grouping may contribute to psychotomimetic activity. In brief, some of the evidence relates to effects of apparently minor changes in the LSD molecule, effects of quaternization of VVin-2299 on its CNS potency(2), and comparison of the actions of serotonin with those of its tertiary amine derivative, bufotenine(22). However, in ad— dition to mescaline, the literature reports �HARRY H. PENNES AND PAUL H. HOCH I957] 891 other psychotomimetics without the tertiary nitrogen groupings: marijhuana, which is n0n-nitr0geneous(9) and 3,4,5-trimethoxy— amphetamine, a mescaline derivative(23). 9 W: "5 Some types of centrally acting drugs other OCH3 \ c2 “5 than psychotomimetics also possess the terFuther of OCH: analysis grouping. tiary nitrogen IE SCALINE on, these relationships will be presented elsewhere(24). There is no apparent common neurophar— macological basis for the psychotomimetic action in general and for harmine, Win—2299, and Nalline in particular(2, 5, 25). Win2299 is qualitatively similar to atropine in animals by virtue of its peripheral cholinolytic and central actions(2). The mechanism of production of abnormal mental effects ‘HCL HO- 0" C- 0' CH2. CH2- / similar be both for N\ drugs, Win—2299 apmay \°2"5 parently having a lower threshold dosage. 2299 (2 2 to recent speculations, some psy— According —-— chotomimetics may produce their effects as antagonists of cerebral serotonin(26, 27'). N-CH20H=CM2 The mental effects of oral LSD and intravenous harmine (both indoles and peripheral antiserotonins) differ in many respects (Results, General and Harmine) . The difference in route of administration is not a factor in 0n View of the finding of Hoch that oral and 0 "CL ' intravenous LSD have the same qualitative effects(28). However, differences in relative Structures of Some Psychotomimetics. levels contribute the to dosage apparent may FIG. I.—Harmine was supplied in 2 forms: as the base isolated from Banisteria caapi(I) and as the dissimilarities between the 2 drugs. c—N CH35 \ \ HARMINE NH LYSERGIC ACID DIETHVLAMDE C2 H5 6- D5 WIN- DIETHYLAMINOETHYL GLYCOLATE CH N CYCLOPENTYL THI‘ENVL) HYDROCHLORIDE G“ CH2 H ALLYLNOHMCRPHINE synthetically-prepared HCl-zHaO. The following dosages refer to hydrochloride form in each case. Harmine: oral, II patients, zoo-960.0 mgm.; subcutaneous, 6 subjects, 40.0-70.0 mgm.; and intravenous, II patients, 100.0-3oo.0 mgm. Win-2299 tablets: 7 patients, 2.0-I0.0 mgm. Nalline: intravenous, 12 subjects, 10.0-30.0 mgm. Intravenous harmine and Nalline were injected over a 20-30 minute period. Mescaline and lysergic acid diethylamide (LSD) were not given in this study. LSD and harmine contain the indole nucleus whereas the remainder do not. The tertiary nitrogen grouping is present in LSD (both in aliphatic chain and cyclic constituent), harmine (non-indole member), Win-2299 (aliphatic side chain), and Nalline (linking allyl side chain with ring member). Cf. Discussion. Both forms of harmine were supplied as the dry compound by Dr. K. K. Chen, Eli Lilly Laboratories, Indianapolis, Indiana. For parenteral administration, solutions in pyrogen-free distilled water, 20 cms.,3 were used several hours after autoclaving. Win-2299 was supplied by Sterling-Winthrop Research Institute, Rensselaer, N. Y., as the racemic mixture of the hydrochloride salt. Nalline was supplied by Merck and Co., Rahway, New Jersey, N- SUMMARY Harmine, Win-2299, and Nalline in single dosage produce many new mental effects in schizophrenics grossly similar to those elicited by mescaline and LSD. Many of the same effects are reported in normals after harmine and Nalline (other workers). Unlike mescaline and LSD at usual dosage levels, the present psychotomimetics regularly produce drowsiness and sleep along with the aberrant mental effects. The resultant state is partly that of “hypnagogic” visual hallucinations or imagery. The results with increased dosage suggest that the basic Allylnormorphine HC1= Nalline HCI; ampoules of distilled, pyrogen-free water containing sodium bisulfate, 0.2% and sodium citrate, dihydrate 1.5%. For intravenous administration, ampoule contents were diluted up to 20.0 cms.3 with pyrogen-free distilled water. �892 CONSIDERATIONS OF PSYCHOTOMIMETICS effect of these agents is to produce an acute toxic reaction type. The difference between them and mescaline or LSD with respect to clouding of consciousness and certain aspects of the hallucinogenic response may be quantitative rather than qualitative. The indole nucleus is not necessary in the structure of psychotomimetics since Win-2299 and Nalline are non-indoles. The tertiary nitrogen grouping may contribute to certain aspects of psychotomimetic action. BIBLIOGRAPHY 1. Chen, A. L., and Chen, K. K. Quart. J. Pharm. Pharmacol., 12:30, 1939. 2. Luduena, F. P., and Lands, A. M. J. Pharm. Exper. Therap., 110:282, 1954. 3. Wikler, A., Fraser, H. F., and Isbell, H. J. Pharm. Exper. Therap., 109: 8, 1953. 4. Wikler, A. J. Nerv. Ment. Dis., 120: 157-175, I954. Lasagna, L., and Beecher, H. K. The Analgesic Effectiveness of Nalorphine and NalorphineMorphine Combinations in Man. J. Pharm. Exper. Therap., 112: 3 56-363, 1954. 6. Hoch, P. H., Cattell, J. P., and Pennes, H. H. Am. J. Psychiat., 108: 579, 1952. 7. Hoch, P. H., Pennes, H., and Cattell, J. P. Proc. Assn. Res. Nerv. Ment. Dis., 32: 287, 1952. 8. Pennes, H. H. J. Nerv. Ment. Dis., 119:95, 5. 1954- 9. Turner, W. J., Merlis, S., and Carl A. Am. J. Psychiat., 112:466, 1955. Perrot, Em, Raymond-Hammett. Bull. Sci. Pharmacol., 34: 337; 417; 500, 1927. 10. 11. 1941. 12. 195513. [Apr. Iberico, C. C. 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A. Arch. Internat. de Pharmacodynam.. 50 : 379, 1935. 26. Gaddum, J. H. Drugs Antagonistic to 5- Hydroxytryptamine. Ciba Foundation Symposium: Hypertension. pp. 75-77, London, 1953. 27. Wooley, D. W., and Shaw, E. Proc. Natl. Acad. Sci., U. 5., 40: 228, 1954. 28. Hoch, P. H. Studies in Routes of Adminis— tration and Counteracting Drugs. Lysergic Acid Diethylamide and Mescaline in Experimental Psy— chiatry. New York: Grune & Stratton, 1956. ��Psychiatria et Neurologia Internationale Monatssehrltt tiir Psychiatrie und Neurologie Revue Internationale Mensuelle de Psychiatrie et de Neurologie International Monthly Review at Psychiatry and Neurology Editor: J. KLAESI, SchloB Knonau Redactor: E. GRUNTHAL, Bern S. KARGER Basel (Schweiz) New York Printed in Switzerland Vol. 135. No. 4/5, 1958 Separatum Sal-Hulda, 11.; Brunecker, G. 11nd Szdra, SL: Psychiat. Neurol., Basel 135: 285—301 (1958) Aus dem Staatl. Zentralen Neurologisch-Psychiatrischen Institut in Budapest (Frau Dr. M. Gimes) Dimethyltryptamin: ein neues Psychotieum Von A. SAI-HALASZ, G. BRUNECKER und ST. SZARA Einleitung Die ohere Stufe des Entwicklungsprozesses der Fachwissenschaften, die sogenannte experimentelle Stufe, beginnt die Psychiatrie fast als letzte der medizinjschen Féicher nur neuerdings zu erreichen. Den wirklichen Anfang bedeutet Beringers Monographie fiber Meskalin [1927], mit welcher zu gleicher Zeit die HaschischBeobachtungen von Frdnkel und Joel erschienen. Den zweiten groBen Fortschritt auf diesem Gebiet bildete die Entdeckung der Lysergséiurediéithylamid (LSD 25) durch Stall und Hofimann [1943]. Der erste ausfiihrh'che Bericht Stalls [1947] bedeutete den Anfang einer groBen Anzahl von Publikationen. Das Ziel dieses Artikels ist die Bekanntgabe eines neuen Psychotikums bzw. dessen Wirkung auf normale Personen. Die Bewohner Haitis benutzten schon seit J ahrhunderten bei religifisen Festen ein narkotisch wirkendes Schnupfpulver, das «Cohoba» genannt wurde. Mit Hilfe dieses Mittels konnten sie angeblich mit ihren «helfenden Geistern» in Verbindung treten, sogar auch von diesen Ratschlfigen erhalten. Das «Cohoba» wurde aus der Frucht der Piptadenia Peregrina gewonnen und enthjelt unter anderen Alkaloiden auch verhéiltnisméifiig groBe Mengen Bufotenin und N-N-Dimethyltryptamin (DMT), wie dies auch von Stromberg und Fish et al. bewiesen wurde. Bufotenin und DMT sind beide Indolamine und in naher Verwandtschaft mit dem biologisch hfichst aktiven Serotonin: �Sai-Halész, Brunecker und Széra 286 {\/\NH) /\——-—-—CH2—CH2—NH2 0H II |' OH A— 1 n —CH2—CH2—N/CH3 :1 \/\NH/ \cm. Bufotenin Serotonin /CH3 /\————CH2—CH2—N \CH3 b“ J \ \NH N-N-Dimethyltryptamin Bufotenin ist daher ein N-Dimethyl-Derivat des Serotonins, beim DMT fehlt jedoch vorigem gegenfiber eine 5-OH-Wurzel. Das Bufotenin isolierte Handovski aus der Haut von Kroten [1920], Wieland hat es synthetisch hergestellt. Raymond Hamet gab Hunden intravenos Bufotenin und stellte voriibergehende BlutdrucksteigeAfl'en intravenos fest. gréBere Evarts, Tachypnoe Apnoe, spiter rung, Dosen Bufotenin und LSD-25 verabreichend, stellte bei jenen eine beinahe identische Wirkung der zwei Chemikalien fest: voriibergehende Erblindung, Ataxie und ein Zahmwerden. Er erklfirte dies alles durch eine Hemmung der sensiblen Reiziibertragung. Evarts nahm die Wirkung des Bufotenins und LSD-25 als Analog des Serotonins an. Nach Fabing ist Bufotenin ein in der Natur weitverbreitet vorkommendes halluzinogenes Indolderivat, dessen eine Hauptquelle die sogenannten Amanita-Pilzarten bilden. Fabing experimentierte an jungen, intelligenten Verurteilten: er injizierte intravent‘is wéihrend 3 Minuten Bufotenin. Es traten Erroten, Gesichtsperspiration und Kribbelgefiihl im ganzen Korper sowie Oppression in der Brust auf. Die Versuchspersonen sahen einige Minuten lang purpurne Flecke, die Storung der Raumwahrnehmung und Konzentration, daneben Depersonalisationsgefiihl und psychomotorische Unruhe dauerten fort. Bei grofieren Dosen war Erbrechen, Nystagmus und Mydriasis zu beobachten, deshalb hielt Fabing das Mittelhirn zum Teil als Angrifl'spunkt des Bufotenins. Die kardiovaskulfire Wirkung des Mittels war verhiiltnisméiBig gering. Die Versuchspersonen berichteten wéihrend 6 Stunden nach der Injektion iiber angenehmes Relaxationsgefiihl. �Dimethyltryptamin: ein neues Psychoticum 287 Material und Methode Unseres Wissens nach wurde die Wirkung des DMT am Menschen zuerst durch uns gepriift. Das DMT wurde von uns selbst synthetisiert nach der von Speeter und Anthony angegebenen Methode. Die salzsfiurige Losung wurde als Injektion angewandt: die wirksame Dose war 0,7—1,0 mg/kg intramuskuléir, meistens gebrauchten Wir 0,8 mg/kg. DMT wurde an 30 normalen Personen, meistens Arzten, gepriift (I7 Manner, 13 Frauen; Alter zwischen 20 und 42 J ahren). Jede Versuchsperson wurde vorerst somatisch untersucht, und nur jene erhielten DMT, die vollkommen gesund waren und keine starkere vegetative Labilitéit zeigten. Auf den Blutdruck wurde sehr geachtet, da das DMT leicht starke Hypertonie erzeugen kann. I6 Versuchspersonen wurden vor und wéihrend des Versuches mit Rorschach untersucht. (Auf dessen Ergebnisse gehen wir hier nicht ein, da einer von uns1 auf dem III. Internationalen RorschachkongreB in Rom 1956 iiber diese berichtete.) Wfihrend dem Versuch wurden parallel zwei Protokolle aufgenommen und die Versuchs2—3 Tagen die subjektiven Erlebnisse nach aufgefordert, personen aufzuzeichnen; die Protokolle wurden dann durch diese Aufzeich5 Fallen wurde wiihrend des Experimentes EEG In ergéinzt. nungen durchgefiihrt. (Bisher noch nicht verofl'entlicht.) Ergebnisse Schon nach 3—5 Minuten nach der Injizierung ffingt das DMT zu wirken an, und innerhalb einer Stunde léiuft die ganze experimentelle Psychose ab. Die Wirkung ist plotzlich und intensiv, mehrere Versuchspersonen berichten anfangs V011 einem weltuntergangsé‘thnlichen Erlebnis mit Starker Todesangst. In einigen Fillen war jedoch die Angst nicht so ausgepréigt, und die éiuBerst intensiven Illusionen und Halluzinationen fesselten die Aufmerksamkeit. Die Angstperioden wechselten mit solchen Starker Euphoric ab. Wéihrend des ganzen Versuches war das wellenartige Auftreten bzw. die Intensitfitsschwankung der gesamten pathologischen Phéinomene sehr charakteristisch. Wahrnehmungsstfirungen bzw. solche des Korperschemas, Depersonalisationserscheinungen, extrapyramidale Hyperkynesien, objektive Reflex- und Sensibilitfitsstfirungen ffirbten oft das Bild. Natiirlich waren bei den Versuchen auch die kultu1 A. S.-H. �288 Sai-Halész, Brunecker und Széra rellen und Pers6nlichkeitsunterschiede bemerkbar. Bevor wir die einzelnen Symptome naher betrachten, geben wir hier einige typische Protokolle wfirtlich wieder: Dr. J.N., Arzt, 28 Jahre. 10. 5. 1956. 50 mg DMT i.m. P.: 78/Min., RR 130/100 Hgmm. 3! Starker Schwindel und Kribbeln im ganzen Kiirper; hauptsiichlich sind die Lippen geffihllos-eingeschlafen. 4/ «Alles ist glfinzender, die ganze Welt ist bedeutend heller.» 5/ «Als ob meine Stimme aus einer tieferen Kehle kfime. Das Zimmer ist gespensterhaft. Mir schwindelt. Ich amfisiere mich darfiber, wie Ihr mich belauert.» «Ach, wie herrlich sind die Far-hen!» Er lacht und spricht andauernd. (Zwangslachen, Logorrhoea.) Maximal erweiterte Pupillen. RR: 160/120 Hgmm, P: 88/Min. Rhythmische Bewegung des linken FuBes. «Ach, neue Welle! Die Bilder kommen in solchen Mengen, daB ich gar nicht weiB, was ich mit ihnen anfangen soll! Zuvor waren sie noch angenehm, doch jetzt ist es schon zu viel!» Er lacht wiederum auf. «Alles ist so komisch. Die Farben leuchten ganz fantastisch. Die Gesichter sind auch ganz anders. Warum beobachtet Ihr mich so verdachtig ? » 10' «Ich sehe eine Farbenorgie, doch in mehreren Schichten nacheinander. Die Welt bewegt sich immer mehr.» 11' Er schmunzelt, spricht inkohéirent, bewegt sich viel und gestikuliert lebhaft. RR: 165/120 Hgmm. P: 88/Min. Er klagt fiber Dyspnoe. 12' «Ich fiihle in meinem Bauch Leere und trotzdem Ffille, dorthin hat sich alles Schlechte verzogen.» «Hofl'entlich kommt es nicht wieder.» «Man sieht seltsame Sachen, und trotzdem ist alles schnell vorfiber, so wie auf der Wellenbahn.» «Die Wand bewegt sich auch, marchenfilmhaft. Ich ffihle mich ganz so, als ob ich geflogen ware.» RR: 155/120 Hgmm. P: 88/Min. Assoziationen aufgelockert, sucht nach Ausdriicken. Keine Dyspnoe. «Das Zimmer beginnt seine normale Form wieder zurfickzugewinnen! Nein, doch nicht . . . » Er setzt sich auf und sieht zum Fenster hinaus. «Nur wenn ich hinausschaue, ffihle ich, daB ich auf der Erde bin. Mir ist, als oh wir bis jetzt geflogen wfiren! » «Ich habe das Geffihl, daB dies fiber allem ist, fiber der Erde. Es ist beruhigend, zu wissen, daB ich wieder auf der Erde bin.» Pupillen noch maximal erweitert. RR: 145/110 Hgmm, P: 84/Min. Bewegt sich andauernd, gestikuliert viel. Sprache ist fifters inkoh'arent, kaum verfolgbar. «Ich habe inneres Zittern, meine Geffihle kann ich nicht gut ausdrficken. Ich ffihle mich so, als ob ich hetrunken ware.» Er zittert. «Dieses Zittern ist gar nicht so unangenehm, es bedeutet, daB die Reise zu Ende ist, aber alles ist noch nicht vorfiber.» Rhythmische Zuckungen des linken FuBes. «Jeder Anwesende hat gleichmiiBig gelbe Zfihne.» �Dimethyltryptamin: ein neues Psychoticum 289 28' «Alles hat einen fiberirdischen Stich und ist doch so real. Schade, daB alles in einem geschlossenen Zimmer geschieht. Mir scheint, daB ich zusammen mit dem Zimmer fliege. Erlebnis der Reise. . .» Pupillen miiBig erweitert. RR: 140/100 Hgmm, P: 80/Min. «J etzt habe ich schon das Gefiihl, daB alles vorbei ist.» Ziindet sich eine Zigarette an. Die ZigaIette sieht er grfiBer und umfangreicher. «Ich habe das Gefiihl, als oh ich lande. Die gehobene Stimmung léiBt nach.» Assoziationen noch immer gelockert. Hort in der Mitte angefangener Séitze auf, vergiBt was er sagen wollte, spricht iiber anderes. «Alles scheint gelb zu sein, hauptsfichlich die Schatten. Ich weiB, daB dieser Zustand aufhéirt, und doch. fiirchte ich mich, daB er weiterbesteht.» «Ich bin so nervos, als ob ich fiebrig wire. Es ist beruhigend, daB ich dauernd bei BewuBtsein war.» Klagt fiber Miidigkeit. «Alles ist voriiber, nur meine Gedanken schwirren durcheinander.» «Alles ist grau und farblos. Die Welt ist jetzt ganz ode.» AuBer leichter Miidigkeit beschwerdenfrei. Assoziation schon normal. «Ich hatte stets das Gefiihl, daB sich nur die AuBenwelt und nicht ich selhst mich verwandelte.» Dr. Z.J., Arzt, 30 Jahre. 1. 6. 1956. 60 mg DMT i.m. P: 72/Min., RR: 110/70 Hgmm (linkshfindig). 5' Er fiihlt sich ein wenig schwach. «Kollapsartiges Gefiihl.» 6' Ausgesprochenes Schwindelgefiihl. 7' RR: 130/90 Hgmm, P: 84/Min. Pupillen etwas erweitert. 8' Schwache Dyspnoe. «Das ganze ist eher angenehm.» 9' «Die Farben sind unveréindert. Mir schwindelt sehr. Leider geht es mir auch so mit dem Alkohol: mir schwindelt, ohne daB ich mich wohl fiihle.» 10' «Ich habe einen beklemmenden Druck auf der Brust, aber es kommt mir vor, daB ich auch ohne Luft existieren konne.» 11’ «Das silherne Muster der rechten Wand des Zimmers ist ganz reliefartig. Das Beklemmungsgefiihl nimmt ab.» 12' RR: 135/80, P: 88/Min. Rechter Patellarreflex verstfirkt, rechtsseitig Babinski13' 14’ 15’ 16' 17' 18' 19' Tendenz. «Die Gesichter haben sich veréindert, sind ganz mephistoéihnlich geworden.» «Uberall dominiert die silberne Farbe! Die Gesichter sind auch aus Silber und teuflisch. Die silberne Farbe ist schon, nur ein wenig furchterregend.» «Der eine Gummischlauch des Blutdruck-MeBapparates ist violett, der andere silbern.» (In Wirklichkeit schwarz.) «Die Gesichter sind asymmetrisch wie im Kino. Alles verandert sich im Raum, auch die Gesichter und Gegenstéinde.» RR 130/85 Hgmm, P: 88/Min. Reflexdifierem der unteren Extremitiiten ist auch weiterhin vorhanden. «1111' schwebt alle im Raum. Bis J'etzt habe ich noch nicht die Rfiumlichkeit der Dinge bemerkt. Die Anschauung des Menschen veréindert sich vollkommen.» «V01: ungefiihr einer halben Stunde konnte ich die Injektion bekommen haben. Mir kommt es vor, als ob diese Minuten viel reicher wfiren, deshalb erscheinen sie mir linger.» �Sai-Halész,Brunecker und Széra 290 20' «Mein Uhelsein verstfirkt sich wieder, ich fiihle mich sehr schwach. Mir ist, als ob ich keinen Atemreflex hfitte; wenn ich nicht daran denke, wiirde ich zu atmen vergessen. » 21’ «Alles ist statuenhaft. Die Gesichter sind teuflisch.» 22' RR: 130/80 Hgmm, P: 84/Min. Pupillen mfiBig erweitert. 23' «Mir fallen solche Details auf, die ich bis jetzt noch nicht bemerkt babe.» 24' «Ich fiihle mich vollkommen gewichtslos, gar nicht, als ob ich 75 kg wiege.» 25' «Es ist merkwiirdig, daB mir meine Hinde vollkommen fremd sind, als ob sie gar nicht mir gehorten.» 26' «Ich kann die Réiumlichkeit der Dinge besser beobachten; ich glaube, die Kiinstler sehen sie immer so. Wenn es so bliebe, wfirde ich Maler werden.» 27' RR: 130/85 Hgmm, P: 80/Min. Rechtsseitge Babinski-Tendenz besteht weiter. 28' «Die Gegenstéinde haben gar kein Gewicht. Ich glaube, ich konnte viel grijBere Gewichte heben als zuvor.» 29' «Die Gesichter sind noch immer statuenhaft.» 30' Er verlangt schwere Gegenstéinde und versucht, sie aufzuheben. «Die haben alle kein Gewicht.» 331' Er hort Musik mit geschlossenen Augen und lichelt. 32' RR 125/85 Hgmm, P: 80/Min. Keine Reflexdifl‘erenz. Pupillen mfiBig erweitert. 33’ «Die Musik ist schon und fesselnd. Als ich diese (Abendsternarie aus Tannhéiuser) letztes Mal horte, schwebte die Musik fiber mir, ich war jedoch auf der Erde. J etzt schwebe ich zusammen mit der Musik.» 34’ «Die Nebengerfiusche storen mich sehr, schade, daB es Grammophonmusik ist.» 35' «Alles wird schon natiirlicher. Das ganze ist sehr angenehm.» 37' RR: 125/75 Hgmm, P: 76/Min. Pupillen méiBig erweitert. 40' «Ich fiihle mich schon halbwegs in Ordnung. Meine Hand gehort wieder mir.» 45' RR: 120/70 Hgmm, P: 80/Min. 50' «Ich bin ein wenig miide, sonst ist alles voriiber. Das Gewicht der Gegenstéinde kam auch zurfick. Es war merkwiirdig, daB sich am Anfang Angenehmes und Unangenehmes vermischte, in der zweiten Halfte jedoch war alles schon und I gut.» Von den retrospektiven Erinnerungen ist folgende ihres lyrischen und subjektiven Charakters halber von Interesse: Dr. E.Ch., Arztin, 27 Jahre. 50 mg DMT i.m., 27. 8. 1956. Teils fiirchte ich mich, teils bin ich sehr gespannt, was eigentlich auf mich wartet. Mein SelbstbewuBtsein mochte ich gem durchwegs behalten. Was werde ich wohl erfahren? Mit 16 Jahren hitte ich gerne Gott gesichtet — wird das jetzt kommen? Oder wird sich eine andere Zeit meiner Vergangenheit verlebendigen? «Guten Tag, Ihr Versuchskaninchen ist angekommen», begrfiBte ich die zwei jungen Minner. «Ich messe IhIen Blutdruck, dann gehen wir ins andere Zimmer hiniiber. Der Blutdruck 120/90. Sie ffirchtet sich gar nicht», sagt der eine. Ich fiihle einen Stich, jetzt gibt es schon kein Zurfick mehr. «Sehen Sie sich gut im Zimmer um», hore ich, «sehen Sie auch aus dem Fenster.» Fliichtig schaue ich auf den Schreibtisch, die Stiihle und die monotone Wand. Alles ist kahl. Ich schaue durch das eisenvergitterte Fenster und sehe die groBen alten Baume. Ich sehe den déimmerigen Himmel, und auf einmal fing es an... �Dimethyltryptamin: ein neues Psychoticum 291 Mir schwindelt entsetzlich, es trommelt in meinen Obren, mit meiner rechten Hand greife ich zum Hals, da ich dort einen ziehenden Schmerz fiihle. Mir schwindelt. — In diesem Augenblick bedauere ich, mich in dieses Experiment eingelassen zu haben. Ich sehe auf meine Uhr, es sind noch kaum einige Minuten vergangen. GroBer Gott, wann wird dieser Versuch ein Ende nehmen? Der Kopf des einen Kollegen zieht sich in die Lange, er bekommt Schlitzaugen. Das Gesicht des anderen wird flacher und vierkantiger. Dieses eigenartige Licht, als ob der Schein einer Quarzlampe dammere. Meine Hand ist ganz zyanotisch. Ist sie wirklich so ? Ich ho're Sausen. Ich bin irgendwohin unterwegs, aber wohin? «Blutdruck 160», hfire ich, «Puls 100.» Das ist jetzt der Tod. Wie einfach alles ist. Das Sausen hat aufgehort, ich bin angekommen. Vor mir zwei stille, sonnenbeschienene Gfitzen. Freundlich nickend beobachten sie mich. Ich glaube, sie begriiBen mich in dieser neuen Welt. Es herrscht dumpfe Stille, wie in der Wfiste. Ich wage nicht, sie anzusprechen. Das ist doch Agypten, diese die Siihne der Sonne, und ich bin endlich zu Hause. Zu Hause in jener wirklichen und schonen Welt, wo binter den zwei Gotzen sich heitere Menschen zwischen den hohen, gelben Sfiulen und Statuen bewegen. Wie vornehm und einfach sie sind. Ihre sonnengebraunten Gesichter sind verklart, ihre Bewegungen frei und grazios. Weiter drinnen singen die Priester mit brausenden Stimmen. Der eine Gotze — nur seine Augen leben spricht mich an: «Geht es Ihnen besser?» «Es wird mir sehr gefallen, wenn das Ubelsein, welches der hohe Blutdruck verursacht, aufhiirt», antworte ich. Ich sehe mir meine Hand an, ein von mir ganz unabhéingiges, selbstandiges Wesen und dazu sehr schon. Die Form ist so wie zuvor, doch als ob sie mit einem goldbraunen Staub gepudert ware. Und die N age] sind rosa Muscheln. «SchlieBen Sie die Augen. Was sehen Sie ?» Ich gehorche. Aus der Dunkelheit sehe ich durch schwarze Eisengitter in den hellen Tempe]. Griiner Ranch qualmt darin und der Gong tont. China! Ich kann meine Augen nicht geschlossen halten, da mir schwindelt. J etzt zeigt man mir die RorschachTafeln. Ich kann mich so schwer darauf konzentrieren, es ist so langweilig. Jetzt erheben sich die hellen, metallschimmernden Wande, dann sinken sie wieder nieder. Es ist, als 0b das Zimmer atme. Auf der ganzen Flache kreisen vielfarbige — gelbe, hellgriine, rosa und blaue — Fischschuppen. Die glanzende Kugel der Lampe beugt sich kreisend naher. Ich sehe wiederum das Gitter, doch ist jetzt dahinter kein Ranch, sondern nur glatte runde grfine Steine. Auf meinem linken FuB kriecht etwas, doch sehe ich dort gar nichts. Alles bewegt sich und wogt. Im F ensterglas kreisen farbige Kranze und Fackeln mit ungeheurer Schnelligkeit. Ich mochte gerne erklaren, was ich sehe, doch .. . An den Wanden sehe ich das zischende, weiBgekronte, wogende Meer. Einige Wellen erreichen mit gedfimpftem Brausen den Strand. — «Debussy» — sage ich. Ich bin ein ganz kleiner Punkt, wie eine Bliite auf dem Wasser von den Wellen geschaukelt. Doch ich weiB, daB mir kein Leid geschehen kann. «Pupillen sind verengt, Blutdruck sinkt», bore ich. J etzt ist es schon still, die Schuppen kreisen immer langsamer, endlich bleiben sie stehen und verschwinden. Nur die seltsame Beleuchtung wéihrt fort. Das WeiB �292 Sai-Halasz, Brunecker und Szara ist noch auffallend weiB, alle Linien scharfe schwarze Konturen. Die Dimensionen sind sonderbar. Die ganze Welt ist furchterregend realistisch. Das ist die wahre Farbe und Form der Dinge. Geféihrliches Spiel, es ware so leicht, nicht zurfickzukehren. Ich bin mir dunkel bewuBt, daB ich Arzt bin, das ist aber gar nicht wichtig; Familienbeziehungen, Studien, Plane und Erinnerungen sind von mir sehr weit entfernt. Nur diese wirkliche Welt ist wichtig, ich bin frei und ganz allein. Zuriick, zuriick, drange ich mich. Ich muB den Weg zur realen Welt zuriickfinden. Auf dem Weg nach Hause trefl'e ich einen Bekannten im Bus. Ich beginne mjt ihm zu plaudern, damit ich die Realitéit der Beziehungen zu spiiren bekomme. Die am Wege stehenden Baume erscheinen grau und verblichen. Das Leben ist stumpf, unfreundlich und gleichgfiltig. Ich bin ein anderer Mensch geworden, erfahrener und freier. J etzt verstehe ich schon viel mehr. Wenn wir die einzelnen Symptome der DMT-Psychose betrefl's Haufigkeit untersuchen, finden Wir folgendes: 1. Vegetative Symptome wurden in allen 30 Fallen beobachtet. Das bestandigste Symptom war die Steigerung des Blutdruckes, die im allgemeinen 20—40 Quecksilber-mm erreichte, manohmal sogar noch mehr. Die hochste von uns beobacbtete Blutdruckerhohung betrug 70 mm, in einem Falle, wo der systolische Druck vor dem Versuch 140 mm zeigte und sich wéihrend des Experimentes bis auf 210 mm steigerte. Der diastolische Druck erhohte sich regelméiBig, doch in kleinerem MaBe als der systolische (meistens 10—20 mm, in einem Falle sogar 40 mm). Fast regelmaBig war die Pupillenerweiterung. Die Mydriase schien parallel mit den farbigen Halluzinationen zu erscheinen. Ob jedoch zwischen diesen ein kausaler Zusammenhang bestand, ist kaum wahrscheinlich. Eine Pulsbeschleunigung geringeren MaBes war auch in fast allen Fallen festzustellen. Objektive Atmungsstorungen fanden wir nicht, doch wurden von 23 Versuchspersonen (76 0/0) fiber Atemnot berichtet; diese wurde von einem Oppressionsgefiihl des Herzens begleitet. Dieses klinische Bild erinnert stark an das durch Serotonin hervorgerufene; es konnte vermutet werden, daB die molekuliire Ahnlichkeit der zwei Substanzen diese Erscheinung erkléirt: DMT verursacht auch wie Serotonin einen Krampf der pulmonalen Arteriolen. Die sympathicomjmetische Wirkung des DMT unterstiitzt diese Vermutung. Zur volligen Klarung dieses Mechanismus miiBten natiirlioh weitere Tierexperimente durchgefiihrt werden. Die sympathicomimetische Wirkung des DMT konnte nicht an allen Organen nachgewiesen werden. So fanden wir z.B. keine be- �Dimethyltryptamin: ein neues Psychoticum 293 deutende Hyperglykéimie und Tachypnoe. Die ganze vegetative Wirkung des DMT iihnelt mehr derjenigen des Serotonins als der des Adrenalins. 2. Sinnestiiuschungen wurden in 27 F fillen (90%) beobaohtet. Diese waren in der Mehrheit optischen Charakters: helleuchtende, farbige Illusionen und Halluzinationen, die sich stets im schnellen Wechsel befanden. Bei geschlossenen Augen vermehrten sich die Halluzinationen und nahmen szenenhaften Charakter an. Eine unserer Versuchspersonen erzéihlte mit geschlossenen Augen: «Ich sehe F elsen, Téiler, méirchenhafte Gegenden, mit kaum einem Schein von Rot als belebende Farbe. Watteau-artige Bilder, dort sind jedoch die Gestalten griiBer. Diejenigen, die ich sehe, sind ganz winzig und verlieren sich in den Felsenrissen, kleine Anhiinger der furchterregenden Umgebung.» Oder spéiter: «Orthodox-griechische Einsiedler, die in F elsen gehauenen dunklen Hfihlen leben. An den Wéinden leuchten Ikone. Man spiirt, daB ihr ganzes Leben auf diese Heiligenbilder zentriert ist.» AuBer den optischen fanden wir auch — wenn auch seltener — akustische und haptische Halluzinationen fliichtigen Charakters, die ebenso plfitzlich verschwanden, wie sie erschienen. 3. Stb'rungen der Raumwahrnehmung wurden in 22 Féillen (73 %) beobachtet. Die Dimensionen des Zimmers finderten sich am auffallendsten. Nahes und F ernes verschmolz ineinander. Die Form des Zimmers wurde ganz neu: oval oder vielkantig. Es konnte festgestellt werden, daB sich eben jene Dimensionen finderten, auf welche die Aufmerksamkeit gerichtet wurde. Wie auch in Meskalinund LSD-25-Psychose veréinderte stets jene Mauer die Lage, die eben angeschaut wurde. In einigen Fallen, in denen die Versuchspsychose Starker ausgeprfigt war, gingen die Raumdimensionen vallig verloren. Es stellte sich dann immer ein subjektives Erleichterungsgefiihl ein, sobald die richtige Riumlichkeit der Dinge wieder wahrnehmbar wurde. 4. Stb‘rungen des Kb'rperschemas erschienen fast immer gleichzeitig mit denen des Raumes. Es handelte sich um Symptome, die an den parietalen Symptomenkomplex erinnerten: die Versuchsperson bemerkte z.B., daB ihre Hand schon nicht ihr gehiire; oder wenn auch die GewiBheit bestand, daB es doch ihre eigene Hand sei, hatte diese doch etwas Selbstéindiges und Seltsames an sich. 0ft waren die St6rungen des Kérperschemas halbseitig; in 4 F fillen dehnte sich die St6rung auf die ganze linke Kiirperhfilfte aus. �294 Sai-Halész, Brunecker und Széra 5. Zeitstc'irung war in geringerem MaBe in allen Fallen vorhan- den, erreichte aber nie eine grijflere Intensitéit. Solche Erscheinun— wie beim Meskalin-Versuch berichtet — daB Zeitsinn der ganz gen, verlorengegangen ware, haben wir nicht bemerkt. Die Dauer des Versuches wurde immer etwas fiberschfitzt. Eine Versuchsperson fiihrte das «auf die reichere Fiille der Minuten» zuriick. 6. Denkstb'rung. In 21 Fallen (70 0/0) fanden Wir eine ausgesprochene Auflockerung der Assoziationen. Die Sprache wurde inkohéirent, angefangene Siitze konnten nicht beendigt werden, da schon der néichste Gedanke im Vordergrund stand. Diese Inkohéirenz verursachte auch beim Protokollfiihren Schwierigkeiten. 0ft schwiegen die Versuchspersonen fiir einige Minuten, antworteten auch nicht auf Fragen; sie erkléirten spéiter, daB sie ihre Gedanken nicht genug beherrschen konnten, um etWas Verstéindiges zu antworten. In 5 Fallen hatten wir es mit paranoiden bzw. wahnéihnlichen Gedanken zu tun. Diese Versuchspersonen berichteten erst 1—2 Tage spater, daB sie wéihrend des Versuches fiberzeugt waren, man wolle sie tfiten bzw. vergiften. DMT war das Gift, die Versuchsleiter die Mfirder. Eine Versuchsperson wurde Wéihrend des Experimentes sehr unruhig und muBte mit Gewalt niedergehalten werden. Sie erkléirte am néichsten Tage folgendes: «Ich fiihlte, daB ich vergiftet wurde und sterben werde und schon nichts dagegen tun konnte. Trotzdem kéimpfte ich einen seelischen Kampf, ob ich bis zum letzten Moment am Leben hé’mgen Oder ruhig sterben soll; das letztere war sehr verlockend, da ich mich sehr wohl fiihlte. Dieser seelische Kampf éiuBerte sich in meinem Motorium als Unruhe; ich spiirte und wuBte alles.» In anderen Fillen waren die Beziehungsideen nicht so ausgeprfigt, doch berichteten die Versuchspersonen nach einigen Tagen, daB sie betrefi's der Aufrichtigkeit und Zuverléissigkeit der Versuchsleiter ein wenig unsicher waren. Am nichsten Tage war dieses Gefiihl mit den eventuellen aggressiven Einstellungen zusammen verschwunden. 7. Afi'ektive Verdnderungen. Euphorie ist eine verhfiltnismfifiig 0ft zu beobachtende Erscheinung der DMT-Psychose. In 8 Féillen (27 0/0) war sie stark ausgeprfigt, in 12 Fallen (40%) milderen Grades Oder nur auf kiirzere Zeit bemerkbar. 0ft trat sie zusammen mit Zwangslachen auf, in anderen Féiflen war sie mit Introversion verbunden; letztere wurde durch ein «verkléirtes» Lficheln begleitet, das manchmal fast wéihrend dem ganzen Versuche dauerte. Die �Dimethyltryptamin: ein neues Psychoticum 295 Versuchsperson lag mehrere Minuten lang wortlos mit geschlossenen Augen und léichelte; manchmal jedoch weinte sie vor Seligkeit und seufzte: «Oh, wie wunderbar ist doch alles!» Wie schon bemerkt, ist die Angst eine der héiufigsten Erscheinungen der DMT-Psychose. Am stéirksten ist sie einige Minuten nach Verabreichung der Injektion bemerkbar, wenn sich die Umwelt so plfitzlich und intensiv veréindert, daB die Versuchsperson die feste Umgebung verliert. Nur 4 Personen berichteten, keine Angst gehabt zu haben. In der zweiten Héilfte der Psychose tritt Angst Viel seltener auf. Nur eine Versuchsperson klagte wfihrend des ganzen Versuches iiber Angst und sagte: «DaB es nur nicht zuriickkomme ! » Was nicht zurfickkommen sol], konnte sie nicht erkléiren; sie antwortete: «Na ja, das Ganze!» 8. Bewufitseinstb’rungen. Nur in 7 Fallen (23 0/0) haben wir eine BewuBtseinstriibung beobachtet. Sie war stets am Anfang des Experimentes bemerkhar, d.h. 8—15 Minuten nach Verabreichung der Injektion und dauerte nicht léinger als 2—5 Minuten. Wéihrend dieser Periode sprechen die Versuchspersonen nichts, und auch spéiter bestand eine Amnesie der Ereignisse, die inzwischen geschahen. Es blieb ihnen nur das Gefiihl, daB etwas Schreckliches vorging. 9. Neurologische Verc‘inderungen. Die Reflexe waren wéihrend des Versuches 0ft (63 %) erhtiht oder lebhaft. Voriibergehende pathologische Reflexe (Babinski usw.) fanden wir nur in 3 Fallen (10%). Im Motorium zeigten sich ausgepréigte Veréinderungen. Fast alle Versuchspersonen hatten eine hyperkynetische Zeitspanne, in der sich unwillkiirlich-extrapyramidale und Willkiirliche Bewegungen mischten. Nur einmal war die Hyperkynesie so stark, daB Gewalt angewandt werden muBte, um einen Unfall zu verhiiten. Sensibilitéitsstfirungen gesellten sich oft zur Stfirung des K6rperschemas. Meistens waren die Fehlleistungen seitens der Tiefensensibilitéit, Gewichtsschfitzung, Kfirperlage usw. zu beobachten. Die Oberflfichensensibilitéit war relativ viel besser erhalten. Sensibilitéitsstfirungen fanden wir in 18 Féillen (6000). 10. Halbseitigkeit der Symptome. Eine der interessantesten Beobachtungen beziiglich der DMT-Psychosen war, daB in Mehrzahl der F fille die Symptome halbseitig ausgepréigter waren. Dies war ebenso bei den neurologischen Symptomen wie bei den Halluzinationen und Kfirperschemastfirungen bemerkbar. Die linke Seite war stets die stéirker betroflene. Wir hatten Gelegenheit, 3 Linkshéindige unserem Experiment zu unterziehen; bei diesen dominierten �Sai-Halész, Brunecker und Széra ___—____—_——_—————————————-—-———~ 296 Abb. 100 % 1 80% 40% 20% s-aaa°a°-Eaa°a:a°§-Eé°-EE g be :1 :5 a; s: >., a "-4 0 '8 A: H m "‘ {-11 o I: cu 3'3 E,” H o9-1 >5 no 3:: g: .H .0 gcu 8 0 .=: :2 53 Q '8 au :5 uo .5.” 0 aa o 0 m C121 :o ‘53 a:3 (I) 1 :1 '-' :5 an .... f:O m flw m a a)” ‘ M o CIT-I o a: ‘9 '8 w "" ho” s 2": cc 94 aH :o 2; 4.: '-' fl tan 5:: 5 4:: 0 m F ‘3 w Q 5 E75 b; <‘. :1 H :o E E :1 «a p: '5cs o :1 g 3 g .... < g v-c an E o A4 v “-1 = 4 Q. m :1 I- :o gm 4-» ' 53 rd a a E :3 .ao _. g m o "=1 ° [—1 an g g c: "" ‘9 *8 6) u m g cc a 5.0 c: .2 s m die Symptome rechtsseitig. (Auf diese Erscheinung kommen wir in der Besprechung noch zuriick.) 11. Nachwirkungen. Alle Versuchspersonen klagten am Experiment folgenden Tage iiber Miidigkeit. Diese dauerte manchma] nur einige Stunden, bei einigen jedoch 1—2 Tage. Wéihrend dieser Periode 2 Nach ein 7 Tagen depressiv. %) (23 wenig Versuchspersonen waren Die in betrefl's alle 30 Ordnung. Personen vfillig Stimmung waren 1 der in wir Abbildung einzelnen der gehen Symptome Hfiufigkeit wieder. Besprechung Durch die DMT-Versuche ergeben sich 3 Tatsachen, die fiir das weitere Verstéindnis der sogenannten Modell-Psychosen éiuBerst interessant sind: und kurze Dauer der DMT-Psychose. 2. Halbseitigkeit gewisser Symptome. 3. Nahe chemische Verwandtschaft zwischen DMT und Serotonin. 1. Pliitzlicher Anfang �297 Dimethyltryptamin: ein neues Psychoticum Wirkung des DMT ist etwas ganz Neues unter der Psychotica. Meskalin fingt nach fast einer Stunde zu wirken an, Haschisch und LSD-25 wirkt noch langsamer. Aber auch die Dauer der Psychose ist beim DMT auffallend kurz, und zwar 40~60 Minuten. Um diesem Problem nfiherzukommen, haben wir — wie schon berichtet - die Ausscheidung von DMT und 3-Indolessigséiure wéihrend und nach dem Versuch untersucht. Wir fanden, daB nach Verabreichung von DMT die Quantitéit der 3-Indolessigséiure im Harn stark zunjmmt und in den ersten 6 Stunden schon ungeféihr das Zehnfache der normalen Ausscheidung erreicht; ebenso erhfiht sich — jedoch nur in geringerem MaBe — die Ausscheidung der 5-hydroxy-3-Indolessigséiure, was auf einen Zusammenhang mit dem Serotonin-Stoffwechsel hinweist. Im Harn fanden wir jedoch kein unveréindertes DMT, was bezeugt, daB das DMT im Korper sehr schnell und vollig abgebaut wird. Dies kann uns erkléiren, warum die Wirkung so schnell abléiuft und auch das DMT peroral unwirksam ist: wahrscheinlich wird es in der Leber abgebaut, bevor es die psychische Wirkung ausiiben konnte. Es bleibt aber noch immer die Frage ofl'en, warum das DMT so schnell wirken kann. Nach der Theorie von Rothlin und Patzig veréindert sich das Meskalin und LSD-25 im Organismus, bevor es eine Wirkung ausiiben konnte; es wéire eigentlich ein Umbauprodukt dieser Substanzen, das die psychotische Wirkung habe. Beim DMT kann kaum von so einer Transformation die Bede sein; das plotzliche Auftreten der Symptome unterstiitzt die Vermutung, daB das DMT selbst die psychotische Wirkung ausiibt. DMT wéire demgemfiB das erste Psychotikum auBer Bufotenin — das selbst ohne Abbau oder Umbau die experimentelle Psychose verursacht. 2. Die Halbseitigkeit einiger Symptome ist eine der interessantesten Erscheinungen der DMT-Psychose. Es treten gleich zwei Fragen auf: a) wie ist es moglich, daB eine chemische Substanz auf eine Hemisphfire stéirkere Wirkung ausiibt als auf die andere, und warum stets auf die nichtdominante Hemisphéire ? b) hat die nichtdominante Hemisphéire eine wichtige Rolle im Auftreten der experimentellen Psychose oder wenigstens einiger Symptome ? Diese Fragen kann man heute noch kaum beantworten. Es wfire zu oberfléichlich, sich auf die erste Frage mit der Antwort zu begniigen, daB die nichtdominante Hemisphéire chemischen Intoxi1. Die rasche -— Psychiat. New-0]., Basel. Vol. 135, No. 4—5 (1958) 20 �298 Sai-Halész, Brunecker und Széra kationen gegeniiber mehr «verwundbar» wire; dies sollte sich doch dann auch bei anderen Vergiftungen zeigen. Oder aber ist der Kreislauf der dominanten Hemisphéire im Notfall zu besserer Regulation ffihig ? Die zweite Frage, 0b néimlich die rechte Hemisphfire im Auf— treten psychopathologischer Syndrome eine wichtige Rolle habe, wurde schon in anderen Zusammenhéingen beriicksichtigt. Hofi und Pfitzl fanden, daB das Zeitrafi'er-Phéinomen nur bei rechtsseitiger Lfision zu beobachten war and meistens bei parieto-okzipitalen Schfidigungen. In der DMT-Psychose zeigt sich ein groBer Tei] der Erscheinungen eben als parieto-okzipitale F unktionsstfirungen (visuale Halluzinationen, Kfirperschemastfirungen, Raumwahrnehmungs-Stfirungen usw.). Es scheint, daB die Halbseitigkeit bei der DMT-Psychose uns einen weiteren Beweis bietet, die Theorie von Hofl und Pb’tzl zu unterstiitzen: eine rechtsseitige Gehjrnschéidigung iibt eine «bahnende» Wirkung beim Auftreten gewisser psychopathologischer Phfinomene ans. 3. In den letzten J ahren héiufen sich die Publikationen, die eine zentrale Rolle des Serotonins in der Funktion des zentralen Nervensystems annehmen (Brodie et al.). Es wurde auch angenommen (Woolley), daB der Serotonin-Stoffwechsel in der Genese der Psychosen, hauptséichlich der Schizophrenic, einen wichtigen Anteil habe. Wie schon erwéihnt, fanden wir im Harn der Versuchspersonne ungeféihr 4—5mal mehr 5-hydroxy-3-Indolessigséiure als bei Normalen; diese Substanz ist, wie bekannt, das Hauptabbauprodukt des Serotonins. Es gibt wiederum zwei Mfiglichkeiten: entweder wird die 3-Indolessigséiure, also das Abbauprodukt des DMT, sekundfir oxydiert, oder aber mobilisiert das verabreichte DMT eine bedeutende Menge des gebundenen Serotonins. Im letzteren Falle ware die experimentelle DMT-Psychose im strengsten Zusammenhang mit dem Serotonin-Stofl'wechsel verbunden. Hier k6nnte man nach gewissen Analogien einen in den zentralen Synapsen abspielenden kompetitiven Antagonismus der zwei Aminen vorstellen. Es miissen noch weitere mit radioaktiven Isotopen gezeichnete DMT-Experimente vorgenommen werden, um diese Fragen zu lfisen und auch damit einen Wichtigen Schritt zum biochemischen Verstéindnis der psychotischen Zustéinde im allgemeinen zu tun. Durch unsere ohigen Beobachtungen kfinnen wir auch feststellen, daB auBer dem Bufotenin das DMT auch eine bedeutende R0116 in der Gesamtwirkung der Piptadenia-Extrakte zu spielen habe. �M“— Dimenthyltryptamin: ein neues Psychoticum 299 Insofern unsere Ergebnisse mit den spfirlichen an Menschen gewonnenen Bufotenin-Beobachtungen zu vergleichen sind (diese sind wegen der intravenosen Anwendung des Bufotenins kaum moglich), ist es auffallend, daB das DMT eine periphere-vaskulfire, serotoninartige Wirkung in geringerem MaBe als das Bufotenin ausiibt. Dies kann vielleicht der strukturelle Unterschied, d. h. die beim Bufotenin vorhandene 5-OH-Wurzel erkléiren. Diese und die iibrigen Detailfragen konnten bloB weitere, an denselben Personen und unter gleicher Anwendung der 2 Indolamine durchgefiihrte Versuche kliiren. Z usammenfassung Dimethyltryptamin wurde synthetisiert, und dessen psychotische Wirkung untersucht. Nach intramuskuléirer Verabreichung von 0,7—1mg/kg Dimethyltryptamin tritt schon nach 3~5 Minuten ein psychotischer Zustand auf, der in vielen Erscheinungen denen ahnelt, die durch Meskalin und LSD-25 verursacht wurden. Die Dimethyltryptamjn-Psychose lauft innerhalb einer Stunde ab. AuBer der Beschreibung der Symptome werden 3 Probleme nfiher untersucht: 1. Was kann die Ursache des plotzlichen Auftretens und schnellen Ablaufes der Dimethyltryptamin-Psychose sein. 2. Welche Rolle spielt die Halbseitigkeit der Symptome, also die stiirkere Schiidigung der rechten nichtdominanten Hemisphéire beim Auftreten der psychopathologischen Erscheinungen. 3. Welche F olgerungen konnen beziiglich der Bedeutung des Serotonin-Stofl'wechsels im zentralen Nervensystem betrefl's der nahen cliemischen Verwandtschaft zwischen Dimethyltryptamin und Serotonin gezogen werden. Die Ahnlichkeiten und Unterschiede zwischen den Bufoteninund Dimethyltryptamin-Psychosen sollen weitere Experimente klarstellen. Re’sumé On a synthétisé la diméthyltryptamine et étudié son action psychotique. Aprés une administration intra-musculaire de 0,7—1 mg/kg de djméthyltryptamine, un état psychotique est apparu aprés 3 a 5 minutes déja. Il ressemhlait par beaucoup d’aspects a ceux qui sont �300 Sai-Halasz, Brunecker und Széra provoqués par la mescaline et le LSD 25. La psychose a la diméthyltryptamine dure une heure. A part la description des symptfimes on a étudié de plus pres 3 problémes: 1. Quelle peut étre la raison du début brusque et de la fin rapide de la psychose a la diméthyltryptamine. 2. Quel role joue la latéralisation des symptémes ainsi que l’atteinte prépondérante de l’hémisphére droit, non dominant, lors de l’apparition des symptomes psychopathologiques. 3. Quelles conclusions on peut tirer de la proche parenté chimique entre la diméthyltryptamine et la sérotonine pour la signification du métabolisme de la sérotonine dans le systeme nerveux central. D’autres expériences montreront les ressemblances et difl'érences entre les psychoses a la Bufotenine et a la diméthyltryptamine. Summary Dimethyltryptamin was synthesized and its efi'ect on psychosis investigated. An intramuscular injection of 0.7—1 mg/kg Dimethyl3—5 minutes a psychotic condition after and was given tryptamin was induced which in many respects resembled those phenomena induced by mescalin and LSD 25. This Dimethyltryptamin psychosis lasted less than an hour. Besides a description of the symptoms we have investigated three problems: 1. The reason for the swift start and rapid departure of the psychosis. 2. What is the significance of the one-sided nature of the in of the disturbance the right degree is, that greater symptoms, non-dominant hemisphere when the psychopathological phenomena begin to show. 3. Having regard to the close chemical affinity between Dimethyltryptamin and Serotonin, what conclusions could be drawn as to the import of serotonin metabolism in the C.N.S. Further experiments should clarify the similarities and differences between psychoses induced by Bufotenin and those by Dimethyltryptamin. LITERATUR Beringer, K.: Der Meskalim'ausch, Springer, Berlin 1927. — Brodie, B. B. et al.: Science 122, 968, 1955. — Erspamer, V.: Pharmacol. Rev. 6, 425, 1954. — Evarts, E. V.: Arch. Neurol. Psychiat. 75., 49, 1956. — Fabing, H.D.: Amer. J. Psychiat. 113, 409, 1956. — Fabing, H.D. and Hawkins: Science 123, 886, 1956. — Fish, M. S., �m Dimethyltryptamin: ein neues Psychoticum 301. N. M. Johnson and D. C. Homing: J. amer. chem. Soc. p. 77, 1955. — Fraenkel, F. und E. Joel: Z. ges. Neurol. Psychiat. 111, 84, 1927. — Hofi, H. und 0. Po'tzl: Z. Neurol. 151, 599, 1934. — Page, I.H.: Physiol. Rev. 34, 563, 1954. — RaymondHamet: Compt. rend. Soc. biol. 135, 1414, 1941. — Rothlin, E.: Experientia 12, 154, 1956. — Speeter, M.E. and W. C. Anthony: J. amer. chem. Soc. 76, 6208, 1954. — Stall, A. und A. Hoflmann: Helv. chim. Acta 26, 944, 1943. - Stromberg, V.L.: J. amer. chem. Soc. 76, 1707, 1954. — Stoll, A.: Schweiz. Arch. Neurol. Psychiat. 60, 1, 1947. — Szdra, SL: Experientia 12, 441, 1956. — Wieland, H. und H. Mittasch: Ann. Chem. 513, 1, 1934. — Woolley, D. W.: Brit. med. J. 1954, 122. Adresse der Autoren: Dr. A. Sai-Halész, Dr. G. anecker, Zentrales Neurologisch-Psychiatrisches Institut, Budapest-Lipétmezb‘ (Ungarn). Dr. St. Széra, 113 Hesketh Street, Chavy Chase 15, Md. (USA). �, u '1‘ �Copyright, 1958, by the Society 'for'Experimental Biology and Medicine. Reprinted from PROCEEDINGS OF THE SOCIETY FOR EXPERIMENTAL BIOLOGY AND MEDICINE, 1958, v97, 4837486 A New Group of Psychotomimetic L. G. ABOOD, A. M. OSTFELD Agents.ale AND (23782) JOHN BIEL Divisions of Psychiatry and Preventive Medicine, University of Illinois College of Medicine and Lakeside Laboratories, Milwaukee During the past few years, much interest has developed in psychotomimetic agents, particularly with regard to LSD 25 and mescaline. At the same time, considerable emphasis has been placed on the possible role of adrenalin and serotonin in psychoses, particularly because they are structurally related to the psychotomimetic agents and are pharThe, role Of macologically antagonistic. acetylcholine and acetylcholine- like sub'stances, on the other hand, has received relatively little attention. Knowledge of the hallucinogenic properties Of cholinergic blocking agents,,such. as atroh pine and hyoscine, dates back to thetime of the ancient Hindus. Recently, a group of piperidyl benzilates possessing anticholinergic properties were synthesized by Biel and associates(l) as possible antispasmodics in the treatment Of duodenal ulcer(2). In the course of therapeutic trials, it was found that the tertiary amine hydrochlorides of the benzilate esters, although active anticholinergics, produced undesirable side effects, particu- larly hallucinations. The quaternary ammonium salts, on the other hand, were entirely devoid of such effects. We have recently, Obtained a series of such substances and examined their psychotomimetic effects on animals and human subjects(3). Methods. The psychotogenic effects of the N—methyl-3-piperidyl benzilate and related congeners were tested on over 40 human volunteers who were either normal or patients complaining of minor disorders. Although some of the patients had limited knowledge of the psychotogenic action of the drugs, the majority of subjects were completely unaware Of their nature. Ceruloplasmin determinations were made on many subjects, employing a method described previously(4). All of the agents were tested for their behavioral effects in animals, including some 30 Siamese fighting fish, 50 rodents, and 5 cats. The action of these agents on the Siamese fighting fish is comparable to those described 'for LSD by Abramson(5). In rodents there were marked behavioral changes, such as initial excitement and marked' hyperactivity, spon* Supported by grants from Mental Health Fund, taneous squealing, lack Of ”responsiveness to State Of Illinois, and Teagle Fn. stimuli, muscular weakness, (and lethargy. , _ 4 _ �NEW PSYCHOTOMIMETIC AGENTS The anticholinergic effect of the agents was determined on isolated smooth muscle preparations and the rectus abdominus according to the method of Chang and Gaddum(6). Results. Experimental findings have indicated that the compounds are extremely powerful hallucinogens, in many respects more interesting than LSD and mescaline. When administered in 5-15 mg doses, orally, to human volunteers, distinct auditory and visual hallucinations occurred within one hour in for recurred and periodically individual every periods up to 10 hours after administration of the drug. Hallucinations were accompanied by gross distortions of visual images and severe alterations in feeling state. A number of subjects exhibited paranoid and megalomanic delusions, while the affective states ranged from a feeling of unpleasantness to extreme terror. Some of the subjects actually carried on conversations with imaginary individuals involving situations dating back 10-20 years. The following are almost exact quotations from different subjects: “People from India are standing outside a tent. They have turbans and those are camels.” “I see six people sitting around a table playing cards . a monkey is over the table hanging by his tail.” “I am walking down a narrow corridor and suddenly stop and cannot move is beating . . . a band is playing . . . a drum 3/4 rhythm.” The subjects receiving 10 mg (orally) of N-methyl-3-piperidyl benzilate were in complete loss of contact with the environment for vis— dramatic While hours experiencing many ual and auditory hallucinations. In many respects these anticholinergic agents come closer to simulating clinical psychoses than do mescaline and LSD. Thus far, a number of congeners have been tested for both hallucinogenic properties and anticholinergic effect on the isolated colon (Table I). Of all the compounds tested for hallucinogenic properties, N-methyl-3-piperidyl benzilate is the most potent, with the Nethyl derivative being somewhat less effective. The tetramethyl derivative is considerably less effective than the N—ethyl derivative. The quaternary derivative is devoid of , psychotogenic effects. As for the antispasmodic potency, although the 3 substances possessing psychotogenic properties are perhaps the most potent, the remaining compounds are still quite effective. Ceruloplasmin determinations were made on all subjects, since this enzyme was shown to be increased in the serum of acute schizophrenics(4,7). The method used has been described previously(4). Preliminary observations have indicated that as much as a 50-75% elevation in the blood ceruloplasmin accompanies the hallucinatory episode produced by these agents. The enzyme increased only when marked psychogenic disturbances were apparent, returning to normal shortly after the psychogenic effects disappeared and while peripheral autonomic effects, such as mydriasis, muscular weakness, and dryness of the mouth, still persisted. A rise in ceruloplasmin has been shown to accompany changes in affective or feeling states, regardless of the mechanism by which the effects are produced (3 ) . Discussion. A discussion of the relative antispasmodic properties of this group of compounds appears elsewhere(1). It is apparent from the present study that in this series of compounds there is no direct relationship between the anticholinergic effect on smooth muscle and psychotogenic potency. The presence of the hydroxyl group in the acid moiety to yield the diphenylacetate ester is undoubtedly essential for hallucinogenic effect, while only slightly enhancing the anticholinergic effect. Since both the diphenylacetate and the benzilate derivatives penetrate the blood brain barrier, it would appear that the hydroxyl group is an absolute require— ment. The presence of a quaternary nitrogen in the piperidine ring only slightly influences the anticholinergic effect, but apparently pre— vents the compound from penetrating the blood—brain barrier. As a rule, quaternary ammonium compounds are not able to enter the central nervous system through the blood stream. Preliminary observations have shown that intrathecal injections of the quaternary compound into rats produce much the same kind of neurological and behavioral disturb- �_,,' _ a \ 4 l NEW PSYCHOTOMIMETIC AGENTS TABLE I. Structure-Activity Relationships of. Some Piperidyl Benzilate Congeners. Anticholinergic effect was determined on isolated rat colon with concentrations of about 10“ M. \ / Ill/Q ox R—O—C—C \ \/\O — Relative Relative halantilucinogenic cholinergic potency potency Name R X N—methyl-3-piperidy1-benzilate m 0H ++++ ++++ OH +++ +++ OH — + +++ I \N/ CHs N -ethyl-3-piperidyl—benzilate \/ N 02115 1,2,2,6 tetramethyl-4-piperidyl benzilate CH3 \N/(CHS) 2 CH3 N-ethyl-3-piperidyl-diphenylacetate \/ H 0 +++ OH 0 +++ N 02H5 m \/ /\ N-dimethyl—3-piperidyl benzilate N+ CH3 ances observed with the tertiary benzilates. At present, numerous other congeners are being examined for their hallucinogenic properties. Future synthetic work is contemplated in an effort to explore other structureactivity relationships from the point of view of hallucinogenic effect. In view of the work of others on anticholinergic substances, it may be predicted that the distance between the hydroxyl group and the piperidyl nitrogen is critical( 8,9). Introduction of alkyl groups into the molecule would, therefore, presumably diminish the anticholinergic potency, and it will be of interest to determine the relationship of such a change to hallucinogenic effectiveness. Summary. A series of synthetic anticholin- C'H3 ergic agents have been shown to possess potent psychotomimetic properties. Chemically, the agents are esters of piperidine and benzilic acid. Among the effects produced are megalomanic and paranoid delusions, visual and auditory hallucinations, and a partial loss of contact with the environment. A number of congeners of the compounds have been examined with regard to structure-activity relationships. J. H., Sprengler, E. P., Leiser, H. A., Horner, 1., Drukker, A., Friedman, H. L., J. Am. Chem. 1. Biel, Soc., 1955, v77, 2250. 2. Ewing, P. L., Seager, L. D., Keller, G., Dodson, D., J. Pharmacol. Exp. Therap., 1954, v110, l7. 3. Ostfeld, A. M., Abood, L. G., Marcus, D. A., �NEW PSYCHOIOMIME’TIC AGENTS Arch. Neurol. Psych. in press. 4. Abood, L. G, Gibbs, F. A, Gibbs,E ., ibid., 1957, v77, 643. 5. Abramson, H. A., Evans, L. T., Science. 1954. V120: 9906. Chang, v79, 255. H. C., Gaddum, J. H., J. Physiol., 1933, . t ' ' 7‘Akerfeldt, M., J. Pharmacol. Exp. Therap., Lands, 8. S., Science, 1957, v125, 117. A. 1951, v102, 219. 9. Goodman, L., Gilman, A., The Pharmacological Basis of Therapeutics, ed. Macmillan Co., N. Y., 1955. Received December 23, 1957. P.S.E.B.M., 1958, v97. DEPARTMENT OF EXPERIMENTAL rsvcumm HlLLSlDE HOSPITAL GLEN OAKS. N. v. MAY1 4'53 '- �Reprinted from the A. M. A. Archives of Neurology (5“ Psychiatry March 1958, Vol. 79, pp. 317-322 Copyright 1958, by American Medical Association Studies with Ceruloplasmin and a New Hallucinogen ADRIAN M. OS'I'FELD, M.D.; LEO G. ABOOD, Ph.D., and Knowledge of the hallucinogenic prop—erties of atropine—like compounds is cer— tainly as old as that concerning the effects of mescal and marihuana. It has been pos— tulated that the oracle at Delphi induced her prophetic vision with belladonna. Hughes and Clark1 quote a lively description of a 17th century American epidemic of atro— pine poisoning. Readers of English detec— tive novels or American Western stories are familiar with the deadly nightshade and Jimson weed, respectively. The recent synthesis of N-ethyl-3-piper— idyl benzilate hydrochloride, JB 318*,2 an agent chemically related to atropine (Figure), led to the present studies. Originally intended as an autonomic—blocking agent in the treatment of peptic ulcer, the drug exhibited hallucinogenic properties, so prominent as to merit further investigation.3 At the close of the conference of the Brain Research Foundation on blood tests in mental illness in 1957,4 several unan— swered or partly answered questions were raised or implied. What are the serum ceruloplasmin levels in disturbed behavior not of psychotic proportion? Does the con— centration of this protein vary with the severity of the mental disorder? Is its concentration in the blood increased during Submitted for publication Sept. 16, 1957. Department of Preventive Medicine and Division of Psychiatry, University of Illinois College of Medicine. Now at the Institute for Psychosomatic and Psychiatric Research and Training, Michael Reese Hospital (Dr. Marcus). This research was supported in part by the Mental Health Fund, State of Illinois; the Brain Research Foundation, and the Dan Crego Fund. *The material was supplied by Drs. John Biel and H. L. Daiell, of Lakeside Laboratories. Dr. John Biel cooperated in the study and made helpful suggestions. DAVID A. MARCUS, M.D., Chicago N—ETHYL—B-PIPERIDYLBENZILATE (JB 3l8) CHz—7CH—CH2\ N—CH: \ CHz——- CH——-CH2 / CHzOH l CH—O-C H ATROPINE drug—induced psychoses? And, finally, since ceruloplasmin attacks certain pyrocatechol (catechol) amines in vitro, what effect does an increase in these pyrocatechol amines in the blood have on ceruloplasmin? The present study, then, had the dual purpose of examining the psychotomimetic properties of ]B 318 and assaying the effects on serum ceruloplasmin of (1) JB 318—induced “psychoses,” (2) intravenous infusion of some pyrocatechol amines, and '(3) naturally occurring behavior disturb— ances of moderate severity. Experimental Methods and Results Studies with J B 318.—In all, 45 volunteer nonpsychotic subjects were studied. JD 318 was administered orally to nine subjects in doses of 10 or 15 mg. Three who took the agent were professional persons employed in the hospital; six were medical ward patients, selected only because their general state of health was satisfactory. The three 317 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY professional persons had prior knowledge of anxious to repeat the experience. Seven the effects of the drug, whereas none of experienced visual hallucinations, and four the patients were told what to expect. Blood of these also described auditory hallucina— was drawn for serum ceruloplasmin deter— tions, which were especially prominent in mination before and at the peak of the three. The visual hallucinations usually consisted hallucinatory phase. Ceruloplasmin was measured by the method of Abood5 in of amorphous colored forms, whereas eight of the nine subjects. brightly colored, elaborate images were inThe determination was done as follows: frequent. In the five cases in which animal One-tenth milliliter of fresh serum was and human forms were reported the images incubated with 0.1 ml. of 0.1% p-phenylene— were usually related to specific events in the diamine and 1.0 ml. of 0.2 M tris(hydroxy— recent past experience of the subject. Most methyl)ethanolamine buffer (pH 6.8) for hallucinations lasted only a few seconds, al— a period of one hour at 37 C. After the though one subject reported images persist— addition of 2 ml. of distilled water the mix- ing for many minutes. Generally, but not ture was read at 490m“ on the spectro- always, the maximum hallucinatory effect photometer. An optical density reading of was attained when subject was kept alone 0.100 corresponds to an activity of IOMM in a darkened, quiet room. The auditory hallucinations consisted of substrate (p—phenylenediamine) oxidized of musical such mainly sounds, stand— 0.1 as whistling, hour ml. The of one serum. per ard curve was determined by oxidizing the singing, and band playing. A few reported substrate with purified human cerulo~ noises, such as sirens and hammering or banging radiators. Emotional disturbances, plasminrt such fear and as bewilderment, seem to acReactions related to the autonomic activ— visual whereas hallucinations, the company the 30 of about minutes ity drug began after oral administration and consisted of auditory experiences were not usually disthe following: dry mouth, blurred vision in turbing. Two be subjects to appeared paranoid all cases, usually tachycardia, facial flushing, hallu— the during or immediately following and disappearance of the carotid sinus re— ef— While the cinatory central responses. flex. There was no appreciable effect on fects ofthe drug persisted, the subjects blood pressure. Nausea occurred in two pa— showed reduction of intellectual a capacity, tients, vomiting in one. The autonomic recharacterized rela— short attention by span, actions began 15 to 60 minutes before the tive and anomia, inaccurate time grossly hallu— and outlasted the psychic phenomena All remained in judgment. contact with cinations by l to 24 hours. The peak auto— the actual environment, but the presence of nomic effects preceded the peak psychic familiar a person or object was required to effects in every case. enhance orientation and allay apprehen— Perceptual responses were characterized sions. by distortion of Visual images, visual and The following are taken essentially verauditory hallucinations, and alterations in batim from the comments of dur— a patient feeling state. All nine subjects reported dis— ing the period of hallucinogenic effect: tortion of visual images and an initial change “My arms are heavy and everything feels far in mood, characterized by apprehension and away. My head feels light. I’m very weak. . . .” “Lots of people are talking incoherently. I think lethargy. The general feeling tone was re— it’s Spanish.” ported as unpleasant by eight of the nine “The room feels distant. I wish I could lift my subjects, and none of the subjects were left is arm but I can’t. The and Dr. G. D. Cummings, of the Michigan Department of Health, supplied the purified human cerulo— plasmin. 1' 318 room a narrow, band is playing. The rhythm is M. . . .” “The room is a long corridor, and I’m in it and I’m 8 or 9 years old. I wonder how I’ll get out. I Vol. 79, March, 1958 �I CERULOPLASMIN AND NEW HALLUCINOGEN of .18 318 on Serum Ceruloplasmin’l‘ of Normal Volunteers TABLE l.——Eflect Before JB Ceruloplasmln Approximately Two Hours After J B 318 Subjects Who Hallucinated 318 230 242 304 224 188 230 241 2l 1 115 120 155 315 * 160 170 Subjects Who Did Not Hallucinate _ «——~ - _ _ -_ . __ -_ 143 296 The values are expressed as optical density X10 8. know I’m in bed and also in that other place. There must be more than one of me, and one is a little girl.” “People from India are standing outside a tent. They have turbans, and those are camels.” An electroencephalogram taken on one subject revealed no abnormality, even dur— ing a series of vivid hallucinations. Ceruloplasmin levels uniformly increased in the six subjects who experienced hallucinations and decreased slightly in the two who did not (Table 1). The parallelism of ceruloplasmin levels in schizophrenic psy— choses and those induced by JB 318 is evident. There was, however, no propor— tionality between the per cent increase in ceruloplasmin and the severity of the psy— choses. Nor were the ceruloplasmin levels during the drug psychoses as high as commonly occurs in acute schizophrenics?6 Studies with Pyrocatechol Amines and Human Subjects.—Pyrocatechol amines and their breakdown products have been increas— ingly implicated in schizophrenic psychoses. Since ceruloplasmin has been shown to at— tack epinephrine and serotonin in vitro,7 it was deemed worth while to infuse certain pyrocatechol amines intravenously and to gauge their effects on behavior and serum ceruloplasmin. There was a uniform slight decrease in serum ceruloplasmin with each agent, as well as with control dextrose in— fusion. The subjects were general medical patients who were either convalescing or not seriously ill. None had rheumatoid arthri— tis, liver disease, acute infections, or known carcinoma, conditions sometimes associated Oxtfeld at (11. with high cerulopla51nin.4'6 The infusions were all administered by an unfamiliar physician in a new setting. Apprehension was initially evident in the behavior and Speech of each subject. Common were such comments as “We’re on the same side, aren’t we, Doc. . .you won’t hurt me”; or “lf the test comes out bad, will I have to stay here [in the hospital] longer?” With a single exception, the subjects were relaxed, beginning about 15 minutes after perfusion was started. About half slept, and nearly all commented on how comfortable and tranquil they felt. None of the subjects on levarterenol, serotonin, or dex— trose reported any unusual sensation. The subject on isoproterenol U. S. P. and the two who received epinephrine experienced a rapid heart rate but no emotional disturb— ances. One subject who received epinephrine grimaced, tossed about, and was agitated during the infusion. Since the effects of the infusion on ceruloplasmin were identical regardless of the agent administered, the parallel decline in anxiety and in ceruloplasmin attracted our attention. It was postulated that if there were a parallelism between feeling state and ceruloplasmin, then both would be ex— pected to undergo an increase during peri— ods of disturbed behavior. 2.—E[fect of Various Agents“ onSerum Creruloplasmin of Normal Human Subjects TABLE Agent Levarterenol Epinephrine Dosage 10 jug/min. 10 jig/min. 20 jig/min. 5 pg/min. 10 ug/min. 10 ug/min. 15 Isoproterenol Serotonin Iproniazid 5% dextrose with water jig/min. pg/min. ng/min. 15 15 5 ug/m‘m. mg/min. mg/ min. 100 mg. orally 0.25 0.50 Ceruloplasmin Control 186 213 292 228 350 144 235 220 188 211 222 196 During Drug Eflect 140 232 225 191 347 102 205 200 214 189 224 1' 177 230 225 240 278 182 228 236 160 187 170 __- 141 150 TThis subject alone was markedly agitated during the infusion. N onpsychotic at present, he had been previously hospitalized six times for acute schizophrenic episodes. 319 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY Ccruloplasmin* of Disturbed and Tranquil Subjects Who Were Not Psychotic TABLE 3.——Serum Disturbed Tranquil 262 250 220 222 136 157 154 272 240 lVlean * S. l). 348 230 282 410 263 202 170 181 118 186 156 230 170 120 166 The values are expressed in terms of optical density X10 5. This thesis was tested in 26 consecutively referred clinic patients. Previously, one pa— tient who could not speak English and three whose psychological states were not clearly discernible to the observer were not included, leaving a group of 22 patients. Each subject was interviewed in order to determine his general psychological state. Eleven exhibited disturbed behavior, such as weeping, pacing the floor, sweating, and tachycardia and/0r admitted to prominent feelings of anxiety and depression. An equal number whose illnesses were not viewed by them as unduly threatening were calm in the clinic setting. Ceruloplasmin levels for the two groups are shown in Table 3. No attempt was made to determine a pre— cise psychiatric diagnosis, but the behavior disturbances in the one group were of neurotic proportions. Increased ceruloplasmin levels in the disturbed group are evident and are significant at the 0.001 level of probabil— ity. Comment The correlation of elevated ceruloplasmin with particular types of behavioral disturb~ ances apparently involving an alteration in “feeling state” raises the problem of the mechanism of ceruloplasmin production. In- asmuch as hallucinogenic agents, such as the present one (see also Alkerfeldtfi Abood“) seem to stimulate ceruloplasmin production only during the hallucinatory or psychogen— ically disturbed phase, a central mechanism would appear to be involved. It is of par— 320 ticular significance that the onset of the enzyme elevation is within minutes after the occurrence of hallucinations or anxiety, suggesting a rather unique mechanism for enzyme production. Contrary to our origi— nal expectations, an elevation in blood pyrocatechol amines, which are apparently endogenous substrates for ceruloplasmin, was not, in itself, a stimulus for increased production of ceruloplasmin, but, rather, caused a decrease in many instances. What increases were noted in the infusion studies were apparently related to anxiety reactions to the manipulative procedures involved’in handling the subjects. Since, in the present studies, no noticeable alterations in feeling state resulted directly from the pyrocatechol amines, it remains to be seen whether in those instances in which such reactions have been attributable to infused epineph— rine8 an elevation in ceruloplasmin does occur. Future studies are aimed at the clarification of many of these points. The suggestion that changes in cerulo— plasmin may reflect alterations in emotional state has been proposed by others. Leach and associates9 have postulated that many environmental factors, including stress, can alter the enzyme level. Meduna4 described a patient who exhibited a high serum cerulo— plasmin >during an acute schizophrenic psychosis and a normal value during a lucid interval. Hoffer10 has noted an increase in a serum pyrocatechol oxidase (presum— ably not ceruloplasmin) during the acute phase of a schizophrenic attack. Schizophrenia is a genetic limitation involving par— ticular enzymes within the brain or elsewhere in the organism. In the face of environmental stress, such limitations be— come prominent, and metabolic products with psychotomimetic properties accumu— late." The psychosis itself is ushered in by the sensory distortions, altered feeling state, and hallucinations so induced. Sub— sequently, when the patient attempts to reconcile his present state with his past ex— perience, the disorganization of cortical function begins. Vol. 79,‘ March, 1958 �CERULOPLASMIN AND NEW HALLUCINOGEN Numerous reports”12 are available on the psychogenic properties of the bella— donna alkaloids, but the effects were quite variable and difficult to interpret because of the many peripheral side-effects, particularly with atropine. JR 318 possessed about one—third of the cholineric—blocking effect of atropine on smooth muscle,‘3 and at the doses used in the present study produced a slight, if any, effect on blood pressure, heart rate, or gastrointestinal tract. Even the more superficial peripheral effects ob— servable with atropine, such as mydriasis and dryness of the mouth, were occasion— ally absent with the doses of JB 318 used. With regard to the possible mechanism of JR 318 and other cholinergic—blocking agents on the central nervous system, very little'can be said. Although the evidence in support of the role of acetylcholine as a chemical transmitter in the central nervous system is not convincing“:15 disturbances in its concentration or action within the central nervous system result in a wide variety of psychic and neurological symp— toms. Many cholinergic agents, such as isofluro— phatef“,17 produce central nervous system disturbances which are apparently associated with the accumulation of acetylcholine in the brain. The observations of Pfeiffer et al.18 that the “muscarinic” component of acetylcholine—like agents, such as arecoline and physostigmine, are of value in the treat— ment of catatonic schizophrenia, suggest a role of acetylcholine in mental disease. There would appear to be a conflict between the argument that a cholinergic agent is beneficial in schizophrenia, while a choliner— gic—blocking agent is psychotomimetic; but the neural mechanisms involved in psycho— genic phenomena are much too obscure to justify the comment on this apparent dis— crepancy. What is significant is the fact that acetylcholine does seem to influence psychogenic phenomena and may be of im— portance in the study of mental disease. Ostfeld at al. Summary A recently synthesized atropine—like compound, N-ethyl—3—piperidyl benzilate, induced altered feeling states, visual and auditory hallucinations, and increased se— rum ceruloplasmin in seven of nine patients. Infusion of four pyrocatechol amines— epinephrine, levarterenol, isoproterenol, and serotonin—appeared to have no effect per se on serum ceruloplasmin. Iproniazid, an amine—oxidase inhibitor, was likewise inef— fective. Serum ceruloplasmin undergoes small, but significant, increases during psychiatric disturbances of neurotic type and proportions, and decreases by a similar amount during periods of tranquility. Department of Preventive Medicine, University of Illinois College of Medicine (Dr. Ostfeld). REFERENCES Hughes, J. D., and Clark, J. H., Jr. Strontium Poisoning: A Report of 2 Cases, J. A. M. A. 112: 1. : 2500, 1939. J. H.; Sprengeler, E. P.; Leiser, H. A.; Homer, J.; Drukker, A., and Friedman, H. L.: Antispasmodics: II. Derivatives of N—Substituted— 3-Piperidols, J. Am. Chem. Soc. 77:2250, 1955. 3. Biel, J. H.: Personal communication to the authors. 4. Brain Research Foundation, papers read at Medical Conference, Chicago, Jan. 12—13, 1957, by Akerfeldt,5 Abood,8 and Meduna. 5. Akerfeldt, S.: Oxidation of N,N-Dimethyl—p' plienylenediamine by Serum from Patients with Mental Disease, Science 1252117, 1957. 6. Abood, L. G.; Gibbs, F. A., and Gibbs, E.: Comparative Study of Blood Ceruloplasmin in Schizophrenia and Other Disorders, A. M. A. Arch. Neurol. & Psychiat. 772643, 1957. 7. Holmberg, C. G., and Laurell, C. B.: Investigations in Serum Copper: IlI. Ceruloplasmin as an Enzyme, 'Acta chem. scandinav. 5:476, 1951. 8. Hoffer, A.: Epinephrine Derivatives as Potential Schizophrenic Factors, Quart. Rev. Psychiat. & Neurol. 18:27, 1957. 9. Leach, B. E.; Cohen, M.; Heath, R. G., and Martens, 8.: Studies of the Role of Ceruloplasmin and Albumin in Adrenaline Metabolism, A. M.A. Arch. Neurol. & Psychiat. 762635, 1956. 10. Hoffer, A.: Conference on Biochemistry and Mental Disease, University of British Columbia, Vancouver, B. C., Canada, June, 1957. 2. Biel, 321 �A. M. A. ARCHIVES OF NEUROLOGY AND 11. Quigley, J. P.: Mental Disturbances from Atropine or Novatropine to Subjects Under the Influence of Insulin, J. A. M. A. 10921363, 1937. 12. Wangeman, C. P., and Hawk, M. H.: The Effects of Morphine, Atropine and Scopolamine on Human Subjects, Anesthesiology 3:24, 1942. 13. Ewing, P. L.; Seager, L. D.; Keller, G., and Dodson, D.: Cardiovascular Effects of Some Derivatives, J. Diphenylacetate 3-Piperdy1 Pharmacol. & Exper. Therap. 110217, 1954. 14. Eccles, J. C.: The Physiology of Nerve Cells, Baltimore, Johns Hopkins Press, 1956. 15. Feldberg, W. S.: Central and Sensory Trans— mission, Pharmacol. Rev. 6285, 1954. 322 PSYCHIATRY Koelle, G. B., and Gilman, A.: The Chronic Toxicity of Di—Isopropylfluorophosphate (DFP) in Dogs, Monkeys and Rats, J. Pharmacol. & 16. , Exper. Therap. 872435, 1946. 17. Rowntree, D. W.; Nevin, S., and Wilson, A.: The Effects of Diisopropylfluorophosphonate in Schizophrenia and Manic Depressive Psychosis, J. Neurol. Neurosurg. & Psychiat. 13:47, 1950. 18. Pfeiffer, C. C., and Jenney, E. H.: The 111- hibition of the Conditioned Response and the Counteraction of Schizophrenia by Muscarinic Stimulation of the Brain, Ann. Nevv York Acad. Sc. 662753, 1957. '- Printed and Published in the United States of America �DEPARTMENT OF PSYCHIATTY EXPERIMENTAL HILLSIDE HOSPITAL GLE. CAKS. MAY-1 4's; N Y. �Vol. 167, No. l MEDICAL LITERATURE ABSTRACTS neuralgic pain from herpes zoster, and in patients with tabetic crisis. R 875 was then given to 8 patients with psychalgia in whom a diagnosis of cenesthopathia associated with depression had been made. In these patients the drug proved to be ineffective; it was tolerated badly and the cenesthopathia frequently was increased. Thus, the effectiveness of the drug in patients with organic syndromes contrasted with its complete ineffectiveness in those with psychalgia. R 875 may be administered orally or subcutaneously; the intravenous route of administration is contraindicated because of the risk of respiratory accidents. Certain undesirable side-effects of the drug, such as malaise, nausea, vomiting, and oc— casionally drowsiness, require care in administering it; rest in bed is advisable, at least for the initial phase of the treatment. the Hearing Level Following Severe Poliomyelitis. R. Batson and F. McConnell. A. M. A. J. Dis. Child. 95:139-145 (Feb.) 1958 [Chicago]. A Study of The authors report on 87 selected, extensively paralyzed patients, between the ages of 5 and 37 years, with poliomyelitis who underwent detailed audiological assessment in order to determine the precise status of auditory acuity. The audiograms obtained from these patients were compared with those obtained during the same period from 2 groups of young adults without poliomyelitis. Near— ly all the pure-tone thresholds in the patients with poliomyelitis departed from the zero decibel reference level by more than 10 db., indicating some depression of hearing acuity as compared with the levels in the control subjects, which adhered ex— tremely closely to the zero decibel reference level, denoting normal threshold of audibility. Inspection of the pure-tone and speech thresholds in the patients with poliomyelitis revealed that more than 75% (28 patients) showed at least a slight depression of acuity which would be considered deviant from the norm. Numerous factors were considered in an effort to clarify the causative significance of the reduction in sensitivity to auditory stimuli in the patients with poliomyelitis. Factors such as age, sex, and possible drug therapy were not thought to influence these results. It was believed that depressed hearing responses could not be attributed to emotional disturbances or lethargy accompanying serious illness, since the patients gave oral responses to speech-hearing tests which required more physical energy than the effort required for signaling in response to pure-tone stimuli. It was found that the duration of disability did not correlate well with the extent of hearing loss. Several patients who were ambulatory and others who were in a wheelchair throughout the day demonstrated the same defect. A significant correlation, however, was observed between loss in hearing and loss in 117 vital capacity, in that patients with marked decrease in vital capacity were apt to show significantly greater hearing loss. The significance of this is not clear, and it may be only a reflection of the severity of the disease in a particular patient. Because there are many other clinical symptoms more distressing to the patient and the physician, and since communication with such patients is usually at close range, reduction in sensitivity to auditory stimuli can be easily overlooked even when it reaches moderate proportions of severity. The causative significance of this finding is not clear. New Group of Psychotomimetic Agents. L. C. Abood, A. M. Ostfeld and J. Biel. Proc. Soc. Exper. Biol. 8: Med. 97:483-486 (Feb.) 1958 [Utica, N. Y.]. A group of piperidyl benzilates possessing anticholinergic properties were recently synthesized as possible antispasmodics in the treatment of duodenal ulcer. In the course of therapeutic trials, it was found that the tertiary amine hydrochlorides of the benzilate esters, although active anticholinergics, produced undesirable side-effects, particulary hallucinations. The quaternary ammonium salts, on the other hand, were entirely devoid of such effects. The authors recently obtained a series of such substances and examined their psychotomimetic effects on animals and human subjects. The psychotogenic effects of the N-methyl-S-piperidyl benzilate and related congeners were tested on more than 40 human volunteers. Although some of the patients had limited knowledge of the psychotogenic action of the drugs, the majority of the subjects were completely unaware of their nature. All the agents were tested for their behavioral effects on animals, including some 30 Siamese fighting fish, 50 rodents, and 5 cats. The action of these agents on the Siamese fighting fish is comparable to the action described for lysergic acid diethyl amide (LSD) by Abramson. In rodents there were marked behavioral changes, such as initial excitement and marked hyperactivity, spontaneous squealing, lack of responsiveness to stimuli, muscular weakness, and lethargy. The compounds proved to be extremely powerful hallucinogens, in many respects more interesting than LSD and mescaline. When administered in oral doses of 5 to 15 mg. to human volunteers, distinct auditory and visual hallucinations occurred within 1 hour in every individual and recurred periodically for periods up to 10 hours after administration of the drug. Hallucinations were accompanied by gross distortions of visual images and severe alterations in feeling state. A number of subjects exhibited paranoid and megalomanic delusions, while the affective states ranged from a feeling of unpleasantness to extreme terror. Some of the subjects actually carried on conversations with imaginary individuals involving situations datA _ �118 MEDICAL LITERATURE ABSTRACTS ing back 10 to 20 years. The subjects receiving 10 mg. (orally) of N-methyl-S—piperidyl benzilate were in complete loss of contact with the environment for many hours while experiencing dramatic visual and auditory hallucinations. In many respects these anticholinergic agents come closer to simulating clinical psychoses than do mescaline and LSD. Of all the compounds tested for hallucinogenic properties, N-Methyl-S-piperidyl benzilate is the most potent, with the N-ethyl derivative being somewhat less effective. The tetramethyl derivative is considerably less effective than the N-ethyl derivative. The quaternary derivative is devoid of psychotogenic effects. As for the antispasmodic potency, although the 3 substances possessing psychotogenic properties are perhaps the most potent, the remaining compounds are still quite effective. Recurrence of Glioma of Cerebral Hemispheres: Histological Features and Therapeutic Possibilities. I. Papo and R. Tritapepe. Minerva chir. 12:144-31446 (Nov. 30) 1957 (In Italian) [Turin, Italy]. A second surgical procedure was performed on 34 patients with a recurrent supratentorial glioma. At the first operation this tumor appeared to be an astrocytoma in 7 patients, an oligodendroglioma in 7, a glioblastoma in 16, and a changing type of tumor in 4. Histopathological changes from astrocytoma to glioblastoma were observed in 1 patient 11 months after the first operation. It is possible, however, that areas of glioblastoma were originally present. Atypical areas were found in sections of the oligodendroglioma in 4 patients, who were operated on, from 35 to 103 months after the first operation. This phenomenon could justify the differentiation of the oligodendroglioma. The immature and atypical features of glioblastoma became more evident at the second operation. A type of glioma, which originally appeared to be oligodendroglioma with atypical areas, changed into glioblastoma in 1 patient 25 months after the first operation. The longest postoperative survival period in patients with astrocytoma was 19 months, in those with oligodendroglioma 21 month, in those with glioblastoma 26 months, and in those with a changing type of glioma 6 months. The authors point out that in most instances there is reappearance of the symptoms of glioma rather than its recurrence. Astrocytoma and oligodendroglioma often change into glioblastoma. There is no evidence to show whether this is due to the intrinsic character— istics of the tumor, to the surgical intervention, or to the x-ray therapy. A gradual higher degree of malignancy seems to develop even in those gliomas which did not originally present a neoplastic structure. Surgical therapy, with rare exceptions, affords no benefit to patients with recurrent glioblastoma but may be considered in patients with recurrent astrocytoma and oligodendroglioma. ].A.M.A., May 3, 1958 GYNECOLOGY & OBSTETRICS Induction of Ovulation in the Human: Therapeutic and Diagnostic Importance. H. S. Kupperman, J. A. Epstein, M. H. G. Blatt and A. Stone. Am. ]. Obst. 8: Gynec. 75:801-309 (Feb.) 1958 [St. Louis]. The authors explain on the basis of a diagram the current status of knowledge of the normal cyclic functioning of the pituitary-ovarian axis. A defect or alteration in any one of this normally sequential series of interactions can result in menstrual irregularities, ovulatory failure, and/0r amenorrhea. It was felt that specific hormone therapy in properly selected cases of failure of ovulation might artificially trigger the defective ovulatory mechanism. Since the proposed therapy theoreti— cally was to be specific for an isolated defect in ovulation, patients with other hormonal imbalances that secondarily influence the pituitary-ovarian axis were not included in the series. The patients who were euthyroid with normal adrenal function and who menstruated fairly regularly or who menstruated after therapy with progesterone and showed an absence of pregnanediol with a flat basal body temperature were judged as having ovulatory failure and fulfilled the criteria established for the “potentially responsive” cases. Those whose only endocrinopathy was failure of ovulation received 20 mg. of conjugated estrogens (equine), administered intravenously as a single dose, not sooner than the 18th day of the menstrual cycle. Of the 40 patients treated, 31 were barren, and 9 were either single women with menstrual irregularities or married women practicing contraception. Nine pregnancies resulted among the 17 infertile patients in whom ovulation was induced after no more than 2 injections of estrogens given intrave— nously at intervals determined by the patients’ own basal body temperature charts. The history of infertility in the 9 women in whom treatment resulted in pregnancy ranged from 2 to 7 years. One of the nonpregnant patients had her first spontaneous ovulatory menses in 3 years in the cycle subsequent to the menses induced by estrogens given intra— venously. Three other patients with a history of only infrequently occurring spontaneous ovulatory menses also had normal 28-day cycles for 1 period after that induced by estrogen. Moreover, 4 of the 9 pregnancies occurred during the cycle subsequent to the estrogen-induced ovulatory response. The negative responses were due to mechanical inability of the ovaries to respond to pituitary stimulation, i. e., polycystic ovaries of the Stein-Leventhallike syndrome, where the thickened fibrous tuniCa presents a mechanical barrier to ovulation. Surgical exploration with bilateral ovarian wedge resection was advised in 8 of 12 infertile patients who were negative responders. In each of the 8 patients op- �COUNCIL ON DRUGS 1634 Orphenadrine Hydrochloride.—N,N-Dimethyl-2(o-methyl-a-phenylbenzyloxy) ethylamine hydrochloride—The structural formula of orphenadrine hydrochloride may be represented as follows: [CH3 CH Cy 0 CH2CH2N\ CH3 ' HCI CH3 ~ Actions and Uses.—Orphenadrine hydrochloride, the o-methyl analogue of the antihistamine, diphenhydramine hydrochloride, produces a reduction of voluntary muscle spasm. The effect is central, presumably by an inhibitory action on cerebral motor areas, and resembles the central effects of atropine. Orphenadrine exerts only weak antihistaminic and sedative eHects. It is not primarily a peripherally acting anticholinergic agent since, in therapeutic doses, it produces few of the typical effects on smooth muscle, the eye, or secretory glands which characterize atropine and other peripheral para— sympathetic blocking agents. The skeletal muscle relaxation is not of the type produced by mephenesin or zoxazolamine, since there is no evidence that it interrupts transmission through peripheral neuromuscular pathways. Nor is there any indication that it acts at the myoneural junction in the manner of the curariform drugs; it does not cause ganglionic blockade. Orphenadrine has been used for the symptomatic management of paralysis agitans (Parkinson’s disease). Subjective observations seem to indicate that the drug may bring about beneficial effects in approximately half of the patients so treated. Rigidity is apparently relieved much more readily than is tremor; in occasional patients with severe spasticity, tremor may even be accentuated as the spasticity is relieved. Other salutary effects ascribed to the action of the drug include relief of oculogyria, sialorrhea, diaphoresis, blepharospasm, and disturbances in gait and balance. The drug also exerts a euphoriant effect which is useful in combating the depression and fatigue that frequently accompany this syndrome. In common with other antiparkinsonian drugs, the therapeutic effectiveness of orphenadrine diminishes with prolonged use. For this reason, and because it is considered somewhat less active than other antiparkinsonian drugs, orphenadrine is probably best employed as an adjunct to such other agents as procyclidine, trihexyphenidyl, cycrimine, or benztropine for the treatment of paralysis agitans. It may, however, be tried alone for patients who have become refractory to the other antiparkinsonian drugs. Because of its antispastic effect on voluntary muscle, orphenadrine has been proposed for use in a variety of clinical conditions which may be unrelated in etiology but in which pain due to J.A.M.A., July 26, 1958 skeletal muscle spasm is present. These have been described as sprains, strains, fibrositis, whiplash injuries, noninflammatory rheumatic and arthritic states, and torticollis. Although such use might be considered a logical clinical application of the drug’s pharmacological action, the evidence available to date is not adequate to permit a sound conclusion as to the ultimate effectiveness of such therapy. Further studies are also needed to confirm the possible usefulness of orphenadrine in the treatment of the extrapyramidal involvement associated with high doses of reserpine or phenothiazine-type tranquilizing agents. The clinical toxicity of orphenadrine hydrochloride appears to be low, at least with therapeutic doses. Thus far, side-effects have been limited to nausea, dryness of the mouth, dizziness, mild excitation, and occasional hallucinations. Most of these effects tend to subside or disappear with a reduction in dosage. Because of its anticholinergic classification, orphenadrine should be administered cautiously to patients with glaucoma, tachycardia, or urinary retention. Dosage—Orphenadrine hydrochloride is administered orally. The usual initial dose is 50 mg. given three times a day. This dosage should then be ad— justed according to the clinical response of the individual patient and the appearance of sideeffects. Preparations: tablets 50 mg. Applicable commercial name: Disipal. Biker Laboratories, Inc., cooperated by furnishing scientific data to aid in the evaluation of orphenadrine hydrochloride. Pancreatic Dornase.—A stabilized preparation of the enzyme, deoxyribonuclease, prepared by fractional precipitation of aqueous acid extracts of beef pancreas followed by dialysis, sterilization by filtration, and lyophilization. The activity of pancreatic dornase is determined by measuring the rate at which it reduces the viscosity of thymus deoxyribonucleic acid, potency being expressed in terms of units. One unit is an amount of enzyme which causes a drop of one viscosity unit in 10 minutes at 30 C, where the flow-time of water is taken as one viscosity unit. Actions and Uses—Pancreatic dornase is derived from beef pancreas, and, in contrast to the deoxyribonucleases produced by hemolytic streptococci (streptodornase), it is a single nuclease. Like streptodornase, it acts directly upon a substrate of deoxyribonucleoprotein (and deoxyribonucleic acid). The action of pancreatic dornase has been characterized as one of rapid depolymerization, with a resulting decrease in viscosity of purulent material. Pancreatic dornase degrades deoxyribonucleoprotein to relatively large-sized fragments, thus differing from streptodornase, which continues �Vol. 167, No. 13 COUNCIL ON DRUGS Mepazine Hydrochloride. — 10—[(1-Methyl-3—piperidyl ) methyl] phenothiazine hydrochloride—The structural formula of mepazine hydrochloride may be represented as follows: N-CH; < CH2 (II) .3 - HCI Actions and Uses—Mepazine hydrochloride is a phenothiazine derivative with actions and uses similar to, but not identical with, those of chlorpromazine. Although less potent, mepazine is not merely a weak chlorpromazine. Pharmacological studies indicate that it differs from chlorpromazine in that it does not lower the body temperature in rats as does chlorpromazine; it does not antagonize the waltzing syndrome in mice as does chlorpromazine; and it augments carotid sinus reflexes in cats whereas chlorpromazine inhibits them. The significance of these differences with respect to its clinical usefulness is, at present, unclear. The drug is used principally for its calming or tranquilizing action in the management of neuroses and psychoses in which anxiety, tension, agitation, and increased psychomotor activity are predominant; it is said to exert a selective action to normalize the thinking process of mentally or emotionally disturbed patients. Because mepazine is less potent than chlorpromazine, it does not produce the excessive sedation, drowsiness, and depression which frequently accompany therapy with the latter drug. On the other hand, the diminished potency of mepazine makes it less effective than chlorpromazine for the long—term control of the most severe forms of agitation and tension; it has little or no immediate effect on acute psychotic disturbances. In terms of over-all psychotherapeutic effectiveness, mepazine might be considered to be intermediate between the most potent agents such as chlorpromazine and the milder agents such as meprobamate. Like chlorpromazine and other phenothiazine derivatives, mepazine hydrochloride exerts an antiemetic effect and may be used for the control of nausea and vomiting from a variety of causes. The drug has also been used for its calming effects in surgery, in obstetrics, and in anesthesia. Other reported clinical applications include use in narcotic withdrawal to control restlessness and agitation, in chronic alcoholism to lessen anxiety and tensions, and in advanced neoplastic states to reduce the 1633 quantity of narcotics needed for control of pain. However, sufficient evidence is not available to establish its usefulness for the latter purposes. The acute toxicity of mepazine hydrochloride in experimental animals is less than that of chlorpromazine hydrochloride, and, in general, its clinical use is followed by a somewhat lower incidence of side-effects and untoward reactions. As already indicated, the usual doses produce a calming effect, with little sedation and drowsiness. Although jaundice has not as yet been observed with administration of mepazine, physicians should be alert to its possible occurrence. The drug should not be given to patients with a history of jaundice or liver damage. The most frequent side-effects of mepazine are atropine-like in nature and include blurring of vision, dryness of the mouth, and constipation. Since constipation can lead to more serious forms of intestinal obstruction, it should not be neglected; if necessary, laxatives should be prescribed. Less frequent side-effects include occasional dizziness, tremor, urinary retention, and transient hypoten— sion. The most serious toxic reaction to mepazine is referable to hematopoietic depression. As with chlorpromazine, the drug can produce leukopenia and granulocytopenia. It should, therefore, be used with discretion; peripheral blood cell counts are indicated at frequent intervals during therapy, and patients should be advised to report to the physician immediately upon the onset of fever, sore throat, or marked weakness. Because it potentiates the action of other central nervous system depressants, mepazine is contraindicated in patients under the influence of large doses of narcotics, barbiturates, or unknown large quantities of alcohol. Dosage.—Mepazine hydrochloride is administered orally. For the treatment of ambulatory neurotic patients, the usual initial dose is 25 mg. three or four times daily. This dosage can be increased every week by increments of 25 mg. per day until the desired effect has been attained. For those psychiatric conditions which are severe enough to require hospitalization of the patient, the initial dose is 100 mg. per day; this may be increased by 50 mg. every five to seven days. Maintenance dosage for such patients is usually 400 mg. per day or more. For the treatment of nausea and vomiting, the dosage ranges from 50 to 100 mg. per day. Dosage for use in surgical and obstetric patients has not been firmly established; single doses ranging from 50 to 200 mg. or more have been employed. Preparations: tablets 25, 50, and 100 mg. Applicable commercial name: Pacatal Hydrochloride. ’ �COUNCIL ON DRUGS 1632 the bacteria, as such, responded to the antibiotics, i. e., a transformation of the original bacterial arthritis into a chemical arthritis occurred. If the nodules were originally situated only in the skin (as clinically described) and only later appeared in the subcutaneous fat tissue (as described in the biopsy specimen and at autopsy), one could postulate that originally circulating trypsin caused vascular alterations in the deeper layer of the corium, with resultant skin nodules, and later the circulating lipase resulted in subcutaneous fat necrosis and subcutaneous nodules. Summary A chronic alcoholic patient had episodes of abdominal pain for two years, on the basis of a relapsing pancreatitis. Four weeks prior to his death, he developed swelling and tenderness of the various joints, with chills and fever. This could have been due to a bacterial polyarthritis associated with an acute pulmonary lesion such as pneumonia. The bacterial infection could have precipitated an acute pancreatic fat necrosis, on the basis of a Schwartzman phenomenon. Excessive amounts of circulating enzymes (trypsin and lipase) caused a striking involvement of the extrapancreatic fat tissue, cutaneous and subcutaneous nodules of fat necrosis, and necrosis of the periarticular fat tissue, initiating a chemical polyarthritis. The abdominal symptoms that appeared later were due to extensive J.A.M.A., July 26, 1958 mesenteric fat necrosis. The terminal jaundice was due to hepatocellular damage (toxic hepatitis) secondary to the pancreatic and extrapancreatic fat necrosis. The depression of blood calcium level was characteristic for extensive pancreatic fat necrosis and was due to saponification of the fatty acids liberated from neutral fat by the enzymatic action of pancreatic lipase. References 1. Roberts, N. J.; Baggenstoss, A. H.; and Comfort, M. W.: Acute Pancreatic Necrosis: Clinicopathologic Study, Am. J. Clin. Path. 20:742-764 (Aug) 1950. 2. Balser, W.: Ueber Fettnekrose, eine zuweilen todtliche Krankheit des Menschen, Virchows Arch. f. path. Anat., 90:520-535, 1882. 3. Hansemann, D.: Discussion in Verhandlungen arzt- licher Gesellschaften, Berl. klin. Wchnschr. 26:1115, 1889. Blauvelt, H.: Case of Acute Pancreatitis with Subcutaneous Fat Necrosis, Brit. J. Surg. 34:207-208 (Oct.) 1946. 4. Ponfick, E.: Ueber die sympathischen Erkrankungen des Knochenmarkes bei inneren Krankheiten, Virchows Arch. f. path. Anat. 56:534-556, 1872. Scarpelli, D. 0.: Fat Necrosis of Bone Marrow in Acute Pancreatitis, Am. J. Path. 32: 1077-1087 (Sept-Oct.) 1956. 5. Vogel, F. S.: Cerebral Demyelination and Focal Visceral Lesions in Case of Acute Hemorrhagic Pancreatitis, with Consideration of Possible Role of Circulating Enzymes in Causations of Lesions, A. M. A. Arch. Path. 52:355-362 (Oct) 1951. and Brakney, E. L.: Acute Hemorrhagic Pancreatic Necrosis Produced by Local Schwartzman Reaction: Experimental Study on Pancreatitis, J. A. M. A. 1553569574 (June 5) 1954. 7. Richman, A.: Acute Pancreatitis, Am. J. Med. 21:2466. Thal, A., 274 (Aug) 1956. COUNCIL ON DRUGS NEW AND NONOFFICIAL DRUGS Monographs and supplemental statements on drugs described here and in subsequent editions of New and Nonofficial Drugs are based on the evaluation of available scientific data and reports of investigations. H. D. KAUTZ, M.D., Secretary. Mepazine Acetate.—10-[ ( l-Methyl-S-piperidyl) methyl]phenothiazine acetate—The structural formula of mepazine acetate may be represented as follows : N " CH3 < 0 CH2 ‘ u CH3C OH Actions and Uses.—Mepazine acetate has the same actions and uses as mepazine hydrochloride, except that it is administered parenterally. (See the monograph on mepazine hydrochloride.) Dosage—Mepazine acetate is administered by intramuscular or intravenous injection. For severely agitated psychotic patients, the dose by either route is 50 mg. three or four times daily. For the treatment of severe nausea and vomiting, daily doses of 25 to 75 mg. are injected intramuscularly. Dosage for use in surgical and obstetric patients has not been firmly established, but single intramuscular or intravenous doses ranging from 50 to 200 mg. or more have been employed. Mepazine acetate may be injected parenterally either as the full-strength solution or as a diluted solution. Chloride or alkaline solutions should not be used as diluents since they cause precipitation of mepazine acetate. Oral therapy with the hydrochloride salt should be substituted for parenteral injection as soon as possible. Preparations: solution (injection) 50 mg. in 2 cc. Applicable commercial name: Pacatal Acetate. �1631 DIAGNOSTIC PROBLEMS Vol. 167, No. 13 with antigenic properties may cause a Schwartzman reaction, and antigenic specificity is not involved, i. e., the provocative antigen need not be identical with the sensitizing antigen. It may be recalled that, in the case under discussion, the joint involvement was conspicuous early in the course of the disease. There was no definite evidence of rheumatoid arthritis, either clinically or pathologically. Bacterial polyarthritis, specifically of gonorrheal origin, should be considered, although a most careful search failed to reveal any evidence for a gonorrheal infection of the genital organs. Gonorrhea] polyarthritis in the early stages shows a serous type of synovitis, and cultures of synovial fluid may be negative. The association of polyarthritis with periarticular fat necrosis and pancreatic fat necrosis raises the following possibilities: 1. There may have been a rheumatoid of coincidence polyarthritis a pure with pancreatic fat necrosis, whereby the peri- The interesting feature of this case was the onset, with polyarthritis followed by the appearance of disseminated subcutaneous nodules, while the abdominal symptoms appeared later. The involvement of the pancreas proper, revealed at autopsy, TABLE 3.—Etiology of Acute Pancreatitis“ I. The common channel theory: reflux of bile into pancreatic duct secondary to obstruction of ampulla of Vater a. Calculus at ampulla of Vater b. Spasrn of the sphincter of Oddi c. Edema II. Obstruction of pancreatic ducts by 1. Stone 2. Spasrn of sphincter of ampulla of Vater 3. 4. 5. 6. Fig. 5.—Relatively well-preserved body and tail of pancreas. Large hemorrhagic, chalky, mesenteric mass extends downward from pancreas. III. Alcohol A. Acute B. Nutritional IV. Metabolic disturbances 1. Malnutrition (as it has been produced experimentally by ethionine) was not too extensive; it is possible that extrapancreatic involvement occurred early and was limited to the retroperitoneal space, enabling the escape of pancreatic lipase into the circulation by way of the lymphatics, circumventing the enterohepatic circulation. The resultant high lipase levels may account for the extensive involvement of the joints and skin. The various theories about the etiology and 2. Site Trauma VI. Vascular changes (Necrotizing arteriolitis; periarteritis nodosa) VII. Infection (e. g. mumps, scpticemic, acute cholecystitis?) VIII. Allergic a. Schwart7m3.n phenomenon * Extrapancreatic Fat Necrosis In Literature In Our Case + + ....................... Retroperitoneal fat tissue .................. + + Mediastinal tat tissue ...................... + — Subepicardial fat tissue .................... + Subcutaneous fat tissue ................... + + — Bone marrow ............................... + Central nervous system + (perivascular demyelinization) ........... + — Periarticular fat tissue ..................... + necrosis at the site of the original intradermal Mesenteric fat tissue Hyperlipemia V. pathogenesis of acute pancreatitis are summarized in table 3. An interesting recent theory6 relates acute pancreatitis to the Schwartzman phenomenon, whereby intradermal injection of a cell-free filtrate of Salmonella, followed by intravenous injection of the same filtrate, results in hemorrhagic TABLE 2.—-Sites of Edema of papilla of Vater Tumor of pancreas Squamous metaplasia of the epithelium in the ducts Surgical ligature —— V injection. Using this principle, injection of a bacterial endotoxin in sublethal doses into a pancreatic duct, with a subsequent provocative intravenous injection of the same endotoxin, has produced a fulminating pancreatitis in rabbits. Any substance Richman" (modified). articular fat necrosis occurred in a site of decreased resistance; but, despite the high incidence of rheumatoid arthritis and the relative frequency of pancreatitis, such a coincidence of these with periarticular fat necrosis has never been reported. 2. The pancreatic fat necrosis in the early clinically latent phase of the disease, with liberation of lipase into the circulating blood, may have led to a chemical polyarthritis due to extensive periarticular fat necrosis. 3. A bacterial (gonorrheal?) polyarthritis preceding pancreatitis cannot be excluded, despite the negative bacteriologic findings. One might speculate, on the basis of morphologic evidence of a chronic pancreatitis, that the pancreas was already sensitized. A bacterial polyarthritis could then have provided an antigenic provocation for a Schwartzman phenomenon, which led to an acute pancreatic fat necrosis, in the course of which large amounts of circulating trypsin and lipase were liberated. The circulating lipase caused a peri— articular fat necrosis, which in turn caused a proression of the polyarthritis, despite the fact that DEPAR MENT OF EXPERIMENIAL PSYCHIATRY HILLSIDE HOSPITAL GLEN OAKS, N. Y. JUL3 1 ‘5. �elements. 3. The rhythm of 4 -6 cycle/sec in the sub- cortical area disappears completely following administration of chlorpromazine in the dosage of 7.5—10 mg per kg, and does not appear even in response to painful stimulation with electric current; which undoubtedly indicates an inhibitory effect of chlorpromazine on adrenergic elements of these structures. 4. Administration of epinephrine against a background of a pronounced chlorpromazine effect produces a temporary decrease in symptoms of the chlorpromaaine effect on the organism. Accompanying this, there is a tendency to activation of electrical activity in all parts of the brain. 5. Comparison of our data with those in the literature leads us to the conclusion that the adrenergic substrate of the reticular formation exerts a complex influence on individual structures within the reticular formation as well as on the cerebral cortex. This action is apparently associated with metabolism of adrenergic substances, and for this reason it changes in a reciprocal manner as a result of the action of epinephrine and chlorpromazine. RE FERENCES 1. 2. AGAFONOV, V.G., Zhurn. nevropatolog. ipsikhiatr., 56, ANOKHIN, P.K., No. 2, 94, 1956. XX Mezhdunarodnyi kon— v Briussele (Collected gress fiziologov papers, 20th International Congress of Physiologists in Brussels), 151, M. , 3. 4. 5. 6. ’ 7. 8. 1956; Fiziolog. zhurn. USSR, 43, No. 11, 1072, 1957; Zhurn. vyssh. nervn. deiat.. 9, No. 4, 489, 1959. ANOKHINA, I.P., Zhurn. nevropatologi psikhiatr., 56, No. 6, 478, 1956. BAN'I‘SEKINA, M.M., Biull. eksper. biolog. i med., No. 8, 3, 1959. VERSHININ, N.V., Farmakologiiamchobnik) 137, M., 1952. GAVLICHEK, V., Fiziolog. Zhurn. USSR, 44, No. 4, 305, 1958. DOBRZHANSKAIA, A.K., Zhurn. vyld. nervn. deiat.. 9, No. 1, 22, 1959. POPOV, E.A. and T.A. NEVZOROVA, Zhurn. nevropatolog. No. 7, 559, 1956. 9. SHUMILLNA, 11. 12. 13. 14. 15. 56. A.I., Zhurn. nevropatolog. ipsikhiatr, 56, 10. ipsikhiatr.. No. 2, 118, 1956; Kinf. po vopr. elektrofiziolog. ts. n. s.. Tez. dokl. (Abstracts of Confsnnes on Problems of Electrophysiology of the C.N.S.), 144, M., 1958. BRADLEY, P.B. and A.I. HAUCE, EIG clin. Neurophysiol., 9, 2, 191, 1957. DELL, P., M. BONVALLET and A. HUGELIN, Journ. Physiol., 48, 403, 1956. GANGLOF‘F, H. and M. MONNIER, Physiol. et Pharmacol., acta, 15, l, 83, 1957. RINALDI, F. and H. HIMWICH, Dis. Nerv. System, 16, 5, 1955. ROTHBALLER, A.B., EEG clin. Neurophysiol., 8, 603, 1956. VOGT, M., Journ. Physiol.. 123, 451, 1954. THE ANTAGONISTIC ACTION OF CHOLINOMIMECTIC AND CENTRAL CHOLINOLYTIC AGENTS ON THE EEG OF THE RABBIT P.P. DENISENKO, Division of Pharmacology, Institute of Experimental Medicine, Um}! Academy of Medical Sciences, Leningrad (Received January 21, 1959) Today the presence of cholinerglc synapses in the central nervous system, particularly in the cerebral cortex, is considered an estab— lished fact. The cerebral cortex can be stimulated with acetylcholine (Markosian, 1937; Feldberg, 1950) and various "cholinopositive" substances — cholinomimetics (nicotine, arecoline) and anticholinesterases (physostigmine and diethyl p-nitrophenyl phosphate, or phos- phacol) — which, like acetylcholine, are capable of causing excitation of choline-roactive systems (Rizzolo, 1929; Miller, 1037; Stewart, 1952; Michaells, Finesinger, Ver— ster, Erickson, 1954). The rate of profile- tion of acetylcholine in the cortex depends on the functional state of the cortex (Macintosh and Oborin, 1953). The establishment of the role and significance �of aeetylcholine in the activity of the cortex and other parts of the brain has aided in the under— standing and the correct evaluation and interpretation of the influence of cholinolytic drugs such as atropine, scopolamine, etc. upon psychic activity. ()1 the other hand, it has given rise to the synthesis and investigation of new sub- stances with cholinolytic action, inasmuch as this opens up an opportunity for entirely new methods in drug therapy of psychic and nervous diseases and increases the armamentarium of sedative and anticonvulsive drugs, as well as antidotes for poisoning with anticholinesterases. Among the cholinolytics known today there are a considerable number of substances capable of exerting a blocking influence chiefly on cholinergic structures in the central nervous system. Owing to the obvious predominance of central cholinolytic action over peripheral, substances of this type have, at the suggestion of S.V. Anichkov, been classed in a separate group — central cholinolytic agents.1 In chemical structure, central cholinolytic agents in most cases are complex esters of amino alcohols and aromatic acids, such 'as diethylaminoethanol and diphenylacetic acid. Pharmacologic studies of central cholinolytic agents are conducted by various methods, especially the methods of conditioned reflexes and electroencephalography; among others are experiments with convulsions produced by nicotine, arecoline, pentylenetetrazol, and other ' drugs. As research, electroencephalography is being increasingly widely used. However, out of the large group of cen— tral cholinolytic agents, this method has been used only for partial investigation of caramiphen (Pentaphen, Parpanit), benactyzine (IEMa method of 22, Diazil), and Z—diethylaminoethyl diphenylacetate (Diphacil, Trasentine) (Schallek and Smith, 1952; Paskov, 1958). In the current study an electrophysiological investigation was made of five new substances synthetized by S. F. Torf in the chemical lab— oratory of the Division of Pharmacology, In— stitute Fxperimental Medicine, USSR Acad— emy of Medical Sciences: Preparation IBM263 (benzene sulfonate 0f l—diethylaniinoisopropyl methoxyd l pheny lacetate . Preparation IEM-265, or Methyldiphacil (racemic l—diethylaminoisop ropyl diphenylacetate hydrochloride), Preparation [EM—268 (racemic 1-dimethyl aminoisopropyl diphenylacetate hydrochloride), Preparation [EM—273 (benzene— sulfonate of 2-methylcholine diphenylacetate), Preparation IBM—275, or Methyldiazil (racemic l «timethylaminoisopropyl benzilate hydrochloride». We also made a comparative study of the influence of certain other central cholino1 ‘The term "central cholinolytic agent" was approved and accepted at the 9th All-Union Conference of Physiologists, Biochemists, and Pharmacologists in 1959. 125 olytic agents, namely Diphacil, Diazil, Pentaphen, Aprophen (fl-diethylaminoethyl diphenylpropionate hydrochloride), Diprophen w—di-Npropyl thiodiphenylacetate hydrochloride), and Tropacin (tropine diphenylacetate hydrochloride) upon the bioelectrical activity of the brain. METHOD Experiments were conducted on rabbits weighing 3 —4 kg with implanted nichrome or platinum electrodes. Potentials from the cortex (temporal and occipital areas), thalamus, and hypothalamus were recorded unipolarly. Experimental equipment consisted of a differential amplifier from the Moscow experimental shop and either an ink-writing or a type MPO—2 oscillograph. The amplitude—frequency characteristic of the ink-writing apparatus in the O — 70 cycle/sec range was flat to within 20%. The influence of the central cholinolytics, as well as of acetylcholine and cholinomimetics (nicotine and arecoline), on the spontaneous electrical activity of various parts of the brain was investigated. In addition, electroencephalography was used to show the existence of antagonism between these two groups of substances. No substance was administered to the same animal more than once a week. EXPERIME NT A l. RESULTS Before proceeding with the study of the in— fluence of central cholinolytic agents on the electrical activity of various parts of the brain, we considered it necessary to determine how it changes under the influence of acetylvholine and cholinomimetics (nicotine and arecoline). This was essential because one of the tests in the study of substances of central cholinolytic action involves a determination of their anticonvulsive activity in nicotine and arecoline convulsions (Bovet and Longo, 1951; Kharauzov. 1954; Artem'ev, 1955. 1957; Zeimal', 1955, 1957; Golikov, 1956; Liberman, 1956; Sokolova, 1957; Smirnov, 1957; Fedorchuk, 1958; Jacobson, 1958). Intravenous injection of nicotine and arecoline (0.4 mg/kg) produces tremor and convulsions in the animal due to the stimulating effect of these substances on the choline—reactive systems of the brain. For further evaluation and analysis of the influence of central cholinolytic agents on the bioelectrical activity of the brain it was important to compare the picture of general excitation of the animal with the changes in the electrical potentials of the brain. Normally, the electrocorticogram of the rabbit was made up chiefly of waves of medium amplitude (30 -60 uv) and a rate of 4 —9 per second. Superimposed on these we re fast small waves with an amplitude of up to 15 av. Occasionally single high-amplitude waves appeared (5 —8 per min). As a rule, potentials �large doses (0.4 -0.5 mg/kugi. 1.9. .dosos which usually cause a convulsive seizure is animal. In the last case we recorded simultaneously the champs in brain potentials and of the thalamus and hypothalamus, were faster than those of the cortex but of considerably smaller amplitude (Fig. 1. 1-3; Fig. 2, 1-3; l-‘ig. 3). .l FIG. 1. Influence of nicotine and Diphacil on the RH; - - - somatosensory cortex; B hypothalamus. l normal EEG; 2 — 3 min after intravenous administration of nicotine in a dose of 0.43 mg/kg; 3 — prior to administration of Diphacil (6 days after the initial application of nicotine); 4 — 5 min after intravenous administration of Diphacil in a dose of 5 rug/kg; 5 — absence of stimulating action of nicotine (0.43 mg/kg) administered after Diphacil; 6 — 4 hours after administration of the preparations. A Cholinomimetics (nicotine and arecoline) were used in small doses (0.25 mg/kg) and the contractions in the hind limb. After the administration of choiinomimstios 126 �no FIG. 2. Antagonism of cholinomimetic arecoline and choline— lytic Methyldiazil displayed in the rabbit EEG. A — - somatosensory cortex, B thalamus. 1 — normal EEG; 2 — 3 min after administration of arecoline in a dose of 0.45 mg/kg; 3 restoration of original state; 4 — 5 min after intravenous- administration of Methyldiazil (0.5 mg/kg); 5 — absence of stimulating influence of are coline in the same dose after Methyldiazil; 6 — 8 hours after administration of the preparations. - the animal's behavior changed abruptly, espe— cially if administration occurred against a background of general depression which was usually observed after the rabbit had temporarily been in a darkened room. Whereas prior to the ad— ministration of the preparations the rabbit lay quietly in its stand with its head between its paws and at times even semi-asleep, following administration of nicotine or arecoline it exhibited unrest, turned its head, jerked, pricked up its ears and reacted keenly to any external stimulation. Mter epinephrine was given intravenously in the dose of 0.4 mg/kg, severe convulsive movements were observed lasting, with interruptions, for several min— utes. Along with the changes in the behavior of the animals already mentioned, there were also marked changes in the spontaneous elec— trical activity of the brain (Figs. 1 and 2). These changes took the form of an increase in amplitude and number of the high—frequency potentials and quantitative diminution, to and including complete disappearance, of high- �FIG. 3. EEGs in various parts of the rabbit brain before (upper oscillograms) and 5 min after (lower oscillograms) intravenous administration of central cholinolytic agents in the following doses: Diazil 0.5 mg/kg (A), Diphacil 5 mg/kg (B), Aprophen 2 mg/kg (C). Left, cortex; right, subcortical structures. amplitude slow waves. Changes in the EEG appearing after administration of nicotine evidently are not the result of induction of muscle currents but reflect changes in the electrical activity of the brain. inasmuch as they precede motor excitation of the animal. Such a supposition appears to be even more probable because 10 — 15 min after the strongest general excitation produced by administration of nicotine, the rabbit calms down (muscle tone becomes normal, movements decrease or disappear, and the animal reposes quietly in its stand) . Simultaneously with this, lowering of general EEG activity is observed, with an increase in the number of abrupt high waves and a diminution of the high-— frequency discharges. Comparison of changes in the EEGs of different parts of the brain discloses that follow— ing administration of nicotine cortical potentials show the first and strongest changes. Changes in the EEGs of the hypothalamus, thalamus, and other subcortical structures are less pronounced and appear later than the cortical changes. The other cholinomimetic, arecoline, in doses of 0.4-0.5 mg/kg also had a stimulating action: it caused unrest. convulsions, and tremor, which, as is generally recognized, are the result of the stimulating action of are— coline on the choline-reactive systems of the brain. The stimulating action of arecoline on ~ 128 the brain is reflected in the EEG to the same extent as is that of nicotine. As shown in Fig. 2, the amplitude of the fast oscillations, especially in the subcortex, rises sharply and the number of oscillations increases appreciably. Typical changes characteristic of excitation appeared in the EEG following intravenous injection of acetylcholine in doses of 0. l - 0. 8 ‘y/kg. In doses of 1 ~50 'y/kg acetylchouno produced such changes only du ring the first, very brief timevinterval after the injection; this was followed by a pronounced depression of electrical activity. Thus, in experiments with cholinomimetics (nicotine and arecoline) and acetylcholine. a characteristic picture of EEG changes a» crease in amplitude and number of fut rhythms and a decrease in slow waves) was produced which in combination with changes in the general condition and behavior of the rabbits (excitation, tremor, convulsions) permits us to regard, with a high degree of probability, the observed picture of EEG changes as a roll..tion of cerebral excitation. In addition, a clear—cut distinction was observed between the action of nicotine and arecoline on the cholinergic systems of the brain: the first and most marked changes uder the influence of nicotine are in the cortical EEG, but under the influence of arecoline, in the subcortical structures. The changes produced by �arecoline and nicotine are not identical in duration. The intensification of activity prochiced by administration of nicotine lasts a maximum of 10—15 min and is often succeeded by a general dqreesion of electrical activity. Potentials of normal magnitude and rhythm appear in l - 1 1/2 hours, but the sensitivity of the cholinsrgie systems to nicotine and mani— festation of the corresponding reaction to nicotine are not restored for 4 -—5 days. Arecoline a more lasting excitation which is succeeded by the normal EEG picture. 0n repeated one hour after the first injection, one may observe complete restoration of sensitivity b arecoline. Ahinistration of central cholinolytic agents gave opposite results. General calming of the animal was observed following administration of cholinolytic agents. This was manifested especially prominently when central cholinolytic agents were administered to animals which had not yet become accustomed to the stand and the experimental conditions, or when the prepara— tions were administered at the very beginning of the experiment when the rabbit remained somewhat excited. In such instances the ad— ministration of a cholinolytic agent caused jerking of the paw, attempts to escape the stand, head movement, and reactions to external stimuli (noise, light, and sound) to disappear immediately. Two to five minutes following admin— istration of Diphacil, Diasil, Pentaphen, Aprophen, and other substances in the group under investigation, the state of unrest was succeeded by general depression. of an intensity which depended on the dose of the cholinolytic agent. The rabbit lay quietly in the stand and reacted feebly to external stimulation. Simultaneously with the change in the state and behavior of the animal, characteristic changes were also observed in the electrical activity of the brain: slow waves (1 - 2 per sec) lg) to ”0 v predominated in the EEG. High— a potentials disappeared entirely or marke‘y decreased in number (Figs. 1, 2, 3). These cheapo in electrical activity following the injection of central cholinolytic agents could be registered in all portions of the brain which were under study. The intensity and duration of theee depended on the dosage of the agents admhistened as well as on their properties. This. similar changes could be observed following intravenous administration pm Motion frwy We of Diphacil. 5 mar/ks. Wen, Mammal-oil. 2 mar/ks; mg/kg; Diaail, 0.6 mg/kg; Methyl— easu. 0.1 mg/kg; and Diprophen, 15 mg/kg. other hand, intravenous administration cholinolytic agents in identical heee redted in dissimilar changes in the thalamus. and hypothalad cortex, such as Diazil and Methylmus. Motions dis-ll greater changes in the potentials of the structures than of the cortex. whereas administration of Methyldiphacil and Difllacil renlted in greater changes in the cortex. Under the influence of Pentaphen. 1 it.eeet ~ ‘ I” h a“ Meal 129 131’ Aprophen, and to some extent Methyldiphacil, changes in the EEGs cf the cortex and subcortex were approximately identical (Fig. 3). Duration of the action of the preparations under study varied between 2 and 30 hours depending, apparently, on the dosage and their physico-chemical properties. The strongest and most lasting effect was observed after the administration of Diazil and Methyldiazil, and the weakest and shortest after administration of [EM-268 and Diprophen. Thus, experiments with central cholinolytic agents showed that they cause general depres— sion of the animal, a decrease in reflex activity and characteristic changes in the EEG (predominance of slow, high-amplitude potentials). Comparison of changes, following administra— tion of central cholinolytic agents, in behavior, general condition, and EEG, which were oppo— site to those seen after administration of cholinomimetics (nicotine and arecoline), per— mits the conclusion that the EEG changes produced by central cholinolytic agents reflect a state of cerebral depression due to blocking of the cholinergic systems of the brain. From our own and published data we knew of the antagonistic relationships between cholino— lytic and cholinomimetic agents that have been demonstrated on peripheral structures as well as in experiments with conditioned reflexes and with nicotine and arecoline convulsions. It was of interest to find out whether these antagonistic relationships are exhibited in the EEG. A special series of experiments were therefore carried out for the purpose of investigating the influences of central cholinolytic agents on the EEG already altered by the administration of cholinomimetics, and vice versa. It was found that central cholinolytic agents in definite doses prevent and cancel the action of cholinomimetics. As shown in Fig. 1, Di— phacil prevented the action of nicotine administered in a dose which usually produced a pro— nounced rise in electrical activity. Convulsions were the external manifestation of the stimulating influence of nicotine on the brain. Nicotine administered after Diphacil, Methyldiphacil, Pentaphen. and other preparations never pro— duced convulsions. Similar results were obtained wifli arecoline: preliminary administra— tion of Methyldiazil prevented the effect of a convulsive dose of arecoline (Fig. 2). Figs. 1 and 2 show that normally both of these cholinomimetics exerted a pronounced influence on the EEG. Their administration in the same doses against a background of action by central cholinolytic agents was without effect; the EEG remained the same as after administration of central cholinolytic agents Diphacil and Methyldianil. In these experiments there were also data indicating a certain preferential antagonism batman arecoline and Diazil or Methyldiazil and between nicotine and Diphacil or Methyldiphsoil. Preparations such as Pentaphen and Aprophen prevent and cancel the action of - �arecoline and nicotine equally effectively. as application clinical for agents tion of these cholinolytics and tranquilizers. DISC U$ION REFERENCES experi— the of the course in clear It became experito an administration following ments that (Diphacil, preparations older of animal mental as and others) Aprophen. Pentaphen, Diazil, S.V.. In the book: Novye i eksperimente v sredstva lekarstvennye 1. ANICHKOV. and in experiments klinike (New drugs clinic), 5. L.. 1958. protivosudo— Izyskanie V.S., ARTEM'EV, 2. rozhnykh sredstv metodom eksperimental'anticonvulsive for search (A noi terapii agents by the method of experimental 1955; L. Dissertation. , therapy). i atsetilkholina rol' Fiziologicheskaia izyskanie novykh lekarstvennykh of role physiological (The veshchestv new for search the and acetylcholine drugs), 1. L.. 1.957. soveshch. dokl. Tez. GOLIKOV, S.N., 3. i claim. strukt. mezhdu sviazi p0 probl. the of (Abstracts veshchestv lekarstv. between Connection the on Conference 13, of Drugs), Action and Structure Tarw, 1956. dokl. Tez. iref. 4. DENISENKO, P.P., deiat. nervn. vyssh. probl. soveshch. p0 Problems on Conference the of (Abstracts of Higher Nervous Activity). No. 1, ‘6, 1... 1958. 1 mom. 5. ZEIMAL‘, E.V., Biuli. eksper.book: the in 1955. 42, 1, 39, med., Fiziologicheskaia roi' atsetilkholinai izyskanie novykh 106m rstvennykh of veshchestv (The physiological role new for search the and acetylcholine drugs), 79, 1... 1957. itoksiFarmakolog. LIBERMAN, 5.8., 6. kolog.. 6, 10, 1956. bioBiull. eksper. A.A., MARHEIAN, 7. 1937. 4 119, (2), med., log. Farmakoiogicholtm D.S., PASKOV', 8. GEM-275), Methyldiazil — agents well as newer — sigIBM-268 and (IBM-265), Methyldiphacil slow EEG: large the in develop nificant changes be— waves medium and waves appear and small be may changes These come less numerous. of cere— state of a manifestations regarded as confirmed interpretation an bral depression, the of experibehavior and condition the by mental animals. The depressant effect of central cholinolytic nature, cholinolytic of a is brain the agents on action the cancel and prevent inasmuch as they (nicotine, cholinomimetics and of acetylcholine stimu— a exert themselves which by arecoline), some is There brain. the on influence lating already which was antagonism, preferential discussed earlier. more one as serve hand, one on These data, synapses cholinergic of existence the of proof other the on system; nervous in the central the that proof convincing hand, they provide not characteristic is central cholinolytic effect of an but agents, cholinolytic individual only of of esters (complex entire class of compounds acids) which have amino alcohols and aromatic been called "central cholinolytic agents." and new that hope to Our data permit us found be posmay agents cholinolytic powerful Two action. central sessing a predominantly —- [EM-265 (Methyl— of the preparations studied — are (Methyldiazil) IBM-275 and diphacil) and tranquilizers as trials undergoing clinical cholinolytic drugs. 1 CONC LU SION'S to used was Electroencephalography 1. of properties cholinolytic establish the central complex representing of substances a number and aromatic diethylaminoethanol of esters acids. in manifested 2. A pronounced antagonism, central between exists EEG, their action on the agents. cholinomimetic and cholinolytic be— interdependence 3. There is a definite of action the and tween the chemical structure to the degree cholinolytic agents. According study under the preparations of vigor of action, of diminorder following the in may be arranged ishing strength: Methyldiphacil, and Aprophen phen, Diprophen. and IBM—268, Preparation chocentral the 4. The EEG data regarding esters complex of series of this ytic action recommenda— the which permits investigations u kharakteristika alkaloids Mann antikholinesteraznogv sredstva (Pharma— alkaloid of the characterizatmn cological Disantichoiinesterase), an nivaline as sertation, L.. 1958. rol' Fiziologicheskaia 9. SOKOLOVA, LA. . atsetilkholina i izyskanie novyldl vennykh veshchestv (The phydol“ role of acetylcholine and the 1957. 122, L., drugs), new 1 Parmakolog. 10. FEDORCHUK, IU. G.. 130 imh m ' toksil<olog., 4, 52, 1953. 11. KHARAUZOV, giperkine zov N.A., Farmakoterapfll tsentral'nogo proiskhoal- hyper“ deniia (Pharmacotherapy of of central origin). Dissertation. L.. 1954; Izbiratel'noe vliianie lekar not.” tsentral'nuiu na veshchestv nykh of influence (Selective nuiu sistemy -_., L.. system). nervous central the on ' ‘ �13. FELDBERG, W., Brit. Med. Bull., 6, 11, 312, 1950. 14. JACOEON, E... Antibiot. Med. a. Clin. Therapy, 5, 2, 89, 1958. 15. MACINTOSH, F. and P. OBORIN, Abstr. Comm. XIX Intern. Physiol. Congr. 580, Montreal, 1953. 16. MICHAELIS, M., J.E. FINESINGER, F. VERSTER and R.W. ERICKSON, Journ. Pharmacol., III, 2, 169, THE EFFECTS OF 17. 18. 19. ' 20. 1954. MILLER, F.R.. Journ. Physiol., 91, 2, 212, 1937. RIZZOLO, A., Arch. Farmacol., sper.,50, 16, 1929. Tsit. p0: Chem. Abstr., 24, 1158, 1930. SCHALLEK, W. and 1LT. SMITH, Journ. Pharmacol., 104, 3, 291, 1952. STEWART, W., Brit. Journ. Pharmacol., 7, 2, 270, 1952. HYPOCAPNIA ON THE FUNCTIONAL STATE OF THE RESPIRATORY CENTER G.L. FEL’DMAN, Department of Human and Animal Physiology, State University, Rostov-on-Don (Received January 8, 1960) METHODS The question of the physiological mechanism and biological function of sleep has long interested investigators (Legendre and Pierron, 1913; von Eoonomo, 1925; Hess, 1949; and others) and has also been the subject of syste— matic study in experiments conducted at the Pavlov Laboratory (Pavlov, 1911, 1923, 1935; Krasnogorskii, 1911; Rozhanskji, 1913; Petrova, 1941; Asratian, 1953; Anokhin, 1958). Ole method adopted for exploring the nature of sleep inhibition and its effect on normal behav— ior of the brain is that of artificial sleep depri— vation. Thus, as early as 1891, M.I. Manasseina demonstrated that keeping puppies awake for a period of 4 to 5 days will lead to death by degeneration of the nervous tissue of the brain Legendre and Pierron (1913) described histo— logical changes of the neurons in the region of the motor analyzer in the cerebral cortex of adult dogs deprived of sleep for 7 days. Prolonged sleep deprivation produces severe derangement of brain function, manifested in a derangement of the processes regulating biochemical activity (Fedorov and Sikolskaia, 1M1), nervous breakdown (Ukolova, 1959), and so on. Reports by N. Kleitman (1923), N. Kleitman and M. Li (1923), Tyler (1955), Bredlend (1955), and others, describe changes during experiments in sleep deprivation in The present study was conducted on 34 ani— mals (10 kittens between 18 and 30 days old, 13 kittens between 35 and 55 days old, 6 adult cats, and 5 puppies between 25 and 40 days old), with electrodes chronically implanted according to the method described by A. B. Kogan (1952). The electrodes were implanted in the region of the motor and visual analyzers of the cortex and in the subcortical sections of the brain. Potentials were recorded bipolarly with an interval between the electrodes of 3 mm for the surface electrodes, 1.5 mm for the depth electrodes. Recording was done with a two—channel electroencephalograph with optical recording or a four—channel ink-writing electro— encephalograph. Physiological tests were made of the effects of a sound stimulus (intermittent siren twice per second) and a tactile stimulus (an air current). Parallel with this, and with the same chronically implanted electrodes, determinations were made of the thresholds for direct electrical stimulation of the correspond— ing points in the brain. For purposes of comparison, we studied the intensity relationships for the motor components of the natural conditioned food reflex (Varukha, 1954) and coordination tests in which we analyzed the placement of the footprints made by the animals in walking. Throughout the period of wakefulness the animals were permitted to move about without restraint and were constantly observed under natural light by day and bright elect‘ric illumination at night. We kept the humans. Thus a study of the effects extended wake— fulness has upon brain function as revealed in the EEG and other indicators of. the functional state of the brain is a matter of definite interest. 131 �may be somewhat wider than the actual distribution, due to analytical errors and biological variation in the ratio of single bone to whole skeleton. It is predicted that in 1966 the average young child in the world will have a skeletal concentration of strontium-90 of about 4 MIC of strontium-90 per gram of calcium; that 10 percent may have a concentration of 8 one; that 1 percent may have a level of 20 uuc; and that none will have a level exceeding 80 one of strontium-90 per gram of calcium. References and Notes 1. Lamont Geological Observatory Contribution No. 347. This research is being supported by the Division of Biology and Medicine of the U.S. Atomic Energy Commission. Many individuals have contributed valuable suggestions and criticism. These include E. C. Anderson, C. L. Dunham, M. Eisenbud, H. Hollister. W. H. Langham, W. F. Libby, J. F. Loutit, L. Machta, W. G. Marley, N. G. Stewart, H. L. Volchok, and H. Q. Woodard. We also express our gratitude to the many medical doctors around the world who have assisted in essential sample procurement. Rieta Slakter is in charge of the Lamont analytical laboratory. R. Alley, W. Blake, T. Bott, J. Brokaw, D. IO :55» 5. 6. 7. 8. 9. 10. 11. 12. Harlin, M. Mandel,.._G. Markle, J. Rippey, J. Sonderburg, and R. lWoehr assisted in various aspects of the techniCal and secretarial work. J. L. Kulp, W. R. Eckelmann, A. R. Schulert, Science 125, 219 (1957). W. R. Eckelmann, J. L. Kulp, A. R. Schulert, ibid. 127, 266 (1958). The two commercial laboratories were Isotopes, Inc., Westwotid, N.J., and Nuclear Sci— ence and Engineering Corp., Pittsburgh, Pa. H. L. Volchok, J. L. Kulp, W. R. Eckelmann, J. Gaetjen, Ann. N;.Y. Acad. Sci. 71, l, 293 (1957); H. L. Volchok and J. L. Kulp, Nucleonicr 13, 49 (1955). D. L. Thurber, J. L. Kulp, E. J. Hodges, P. W. Gast, M. Warhpler, Science 128, 256 ' (1958). A. R. Schulert, E. A. Peets, D. Laszlo, H. Spencer, M. Charles, J. Samachson, Intern. ]. Appl. Radiation and Isotopes 4, 144 (1959). A. R. Schulert, E. J. Hodges, E. S. Lenhoff, J. L. Kulp, Health Phys., in press. J. L. Kulp and R. Slakter, in preparation. F. J. Bryant, A. C. Chamberlain, G. S. Spicer, M. S. W. Webb, Brit. Med. ]. l, 1371 (1958). Health and Safety Lab. U.S. Atomic Energy Comm. Publ. No. HASL—42 (16 June 1958). J. L. Kulp and R. Slakter, Science 128, 86 (1958). D. V. Booker, F. J. Bryant, A. C. Chamberlain, A. Morgan, G. S. Spicer, Atomic Energy Research Establ. (G. Brit.) Publ. No. HP/R 2182 (1957); F. J. Bryant, A. C. Chamberlain, A. Morgan, G. S. Spicer, Atomic Energy Research Establ. (G. Brit.) Publ. No. HP/R 2056 (1957). H. H. Mitchell, T. S. Hamilton, F. R. Steg~ 13. 14. Isosterism and Competitive Phenomena in Drugs q_ A study of structure-activity relationships in agents acting upon autonomic effector cells Daniel Bovet Making use of the considerable means offered by organic synthesis, many investigators have directed their efforts to the field of therapeutics and have sought to lay the groundwork for a pharmaceutical chemistry or, better, for a chemical pharmacology. If such an ambitious program has not yet been fully realized, nevertheless, during the last five decades, one can notice the emergence of a few basic concepts whose usefulness continues to be confirmed. This is particularly true of the concepts of isosterism and of competition. Numerous drugs were first derived from products of biological origin, par- ticularly the alkaloids. The elucidation of their structure helped chemists to embark on syntheses of analogous compounds. In this respect cocaine, atropine, 8 MAY 1959 and morphine are good illustrative examples. The molecules synthesized according to their models exhibited clinically useful anesthetic properties, spasmolytic activity, or pronounced analgesic effects. In each case, chemical similarity produces in-some-way-related physiological properties. Analogous observations have subsequently been gathered in many other fields, but it has also become evident that sometimes very different, even antagonistic, pharmacological properties may be found in chemically similar molecules. Despite the fact that the concept of “antimetabolite” is based on rather old experiments, it was defined essentially in the field of “antivitamins”; the work of Woods (1940) and Fildes (1940) on 15. 16. 17. 18. gerda, H. W. Bean, J. Biol. Chem. 158, 625 (1945). H. Spencer, D. Laszlo, M. Brothers, ]. Clin. Invest. 36, 680 (1957); “Deposition and Retention of Ingested Strontium-90 in the Skeleton" (Washington, D.C., 23 Apr. 1957), committee report (official use only). C. L. Comar, R. H. Wasserman, M. M. Nold, Proc. Soc. Exptl. Biol. Med. 92, 859 (1956). C. L. Comar, I. B. Whitney, F. W. Lengeman, ibid. 88, 232 (1955). Consumer: Repts. 24, No. 3, 102 (March 1959). 19. J. L. Kulp, A. N. Kaufman, R. S. Slakter, W. R. Eckelmann, in preparation. 20. Health and Safety Lab. U.S. Atomic Energy Comm. Publ. No. HASL-5I (10 Nov. 1958). 21. L. Machta and R. J. List, “Stratospheric data and meteorological interpretations,” paper presented at a meeting on “ABC—sponsored Research and Development Related to the Collection and Classification of Atmospheric Particulates,” held in Minneapolis, Minn., Oct. 1958. 22. W. F. Libby, Proceedings symposium on Noxious Eflects of Low Level Radiation, Schweizerischen Akadcmie der Medizinischen Witsenschaften 27-29 Mar. 1958, p. 309. 23. R. S. Russell, Nature 182, 834 (1958). 24. Unpublished data from the Lamont Geologi8—9 25. 26. 27. 28. cal Observatory, Palisades, N.Y. A. M. Brues, Science 128, 693 (1958). M. P. Finkel, ibid. 128, 637 (1958). E. B. Lewis, ibid. 125, 969 (1597). F. J. Bryant, E. H. Henderson, G. S. Spicer, M. S. W. Webb, Atomic Energy Research Establ. (G. Brit.) Rept. No. C/R 2583 (May 1958). the antisulfonamide component of yeast and its identification as p-aminobenzoic acid found a large acceptance. The idea that a compound structurally similar to one normally present in the organism is able to interfere with the function of this metabolite could be applied in many ways. Its success, especially in enzymology [where, for the first time, it was clearly formulated by Quastel (1925— 1928)], in chemotherapy, in vitaminology, and in endocrinology, obviates a detailed discussion of the underlying physi-L cochemical and biological principles. Instead, I would like to draw your attention to the importance of studies of competitive phenomena in pharmacodynamics, especially in the pharmacology of drugs of the autonomic nervous system. I would like to show how a very large part of therapeutical chemistry depends on the relations between many alkaloids or synthetic compounds and a few hormones, chemical transmitters, and products of tissue metabolism of rather simple chemical structure: epinephrine and norepinephrine, acetylcholine and propionylcholine, histamine, and 5-hydroxytryptamine (Table 1). Dr. Bovet is head of the department of therapeutic chemistry at the Istituto Superiore di Sanita, Rome, Italy. This article is a translation of his Nobel lecture, presented 11 December 1957, when he was awarded the Nobel prize for medicine and physiology for 1957. It is reproduced here with the permission of the Nobel Foundation. We are indebted to Dr. Ernest Schoffeniels of the department of neurology. College of Physicians and Surgeons, Columbia University, for the translation. 1255 �Drugs of the Autonomic Nervous System The history of the research in this field is one of the most spectacular and successful chapters in the chemistry and physiology of the alkaloids and hormones. As far as transmitters of the sympathetic system are concerned, one may recall that the isolation of epineph— rine by Takamine (1901) was preceded both by empiric application of ephedrine-rich mahuang by the Chinese, and by the fortuitous discovery of the properties of tetrahydronaphthylamine by Bamberger (1888). The exact significance of norepinephrine has been established only recently, by von Euler (1946). In the field of parasympathomimetic agents, the observation of the properties of muscarine (1811) and the synthesis of acetylcholine (1866) preceded, by a century and a half century, respectively, the discovery of acetylcholine of Loewi (1921) and its isolation from tissues (1931). Histamine was synthesized (1907) shortly before its identification in the products of animal and plant origin and before Dale and Dudley (1910) began their well-known studies of its pharmacological properties. The recent discovery of 5-hydroxytryptamine (Rapport, 1949) is the culmination of the work of Erspamer on enteramine isolated from enterochromaflin cells (1937—1952) and the work of Rapport, Green, and Page (1947— 1948) on the vasoconstrictor factor of serum, serotonin. The relationship between epinephrine, (CH2) /COO.CH2.CH2.N(CH3)31 “\COO.CH2CH2N(CH3)3 1 £5 E I34 8 0- 3 7 a% 2 w .=‘ - 3 g . 0 Fig. n=12345 Curarizing effect of choline esters 8 1. and dicarboxylic aliphate acids with normal chains. Curarizing activity was established in rabbits by measuring the “head dro P ” dose of the various compounds given intravenously. Curarizing activity reaches a maximum with succinylcholine and decreases with higher homologues of the series. [Bovet, Bovet-Nitti, Guarino, Longo, and Marotta, 1939] 1256 Table 1. Drugs with a competitive action with respect to epinephrine, acetylcholine, histamine, and 5-hydroxytryptamine. Adrenaline (noradrenaline) H \ CH0H.CH2rN/ , CH 0H Hydroxytrypt amine . . Histamine Acetylcholine CH 3 K CH3.COO.CH2.GH2.N\ 6213 CH/ H H \\N—c CH3 ’H NH-CH . OH CH 2. CH 2. H- cHz.CHz.N\H N/ \H H Sympatholytic Antihistaminics : Parasympatholytic Antihydroxytryptaagents : agents : .mines ” Ergotamine 929 F Atropine (spasmolytic Yohimbine 2339 R.P. (Antergen) agents ) Benzodioxane Curares: Pyrilamine d-Tubocurarine (933 F) Diphenhydramine Dibenamine Gallamine Antazoline Phentolamine Decamethonium Promethazine Succinylcholine Ganglioplegic agent: Hexamethonium Central ganglioplegic agents: Antiparkinson agents Antiphobic agents _ , tissue acetylcholine, and the nervous system was recognized early. In 1904, Elliot, struck by the similarity existing between the pharmacological action of epinephrine and the effect of stimulating the sympathetic system, proposed the hypothesis according to which epineph- rine is released from sympathetic nerve endings and transmits the impulse from nerve cell to smooth muscle fiber. Wieland in 1912 and Le Heux in 1919 tried to demonstrate that choline and acetylcholine were local hormones. Their hypothesis, we know, was successfully developed by Loewi, Dale, Cannon, and Bacq, whose experiments established the concept of chemical transmitters. The hypothesis of chemical transmission by acetylcholine first proposed for viscera innervated by the parasympathetic system was later extended by Dale, Feldberg, and Vogt (1936) to the neuromuscular junction. Recent investigations on the physiology of the end plate have, in sum, confirmed this mechanism. The reaction between acetylcholine and its receptor located at the postsynaptic mem— brane can now be integrated within the framework of electrophysiological findings, particularly those demonstrating electrical nonexcitability of this membrane and its great sensitivity to the transmitter (Kufller, 1948; Castillo and Katz, 1956). To turn now to substances antagonizing these various hormones and transmitters, models for the synthesis of adrenergic and cholinergic blocking agents were furnished by compounds of biological origin, such as ergotoxine, atropine, and curare. The antihistaminics were studied later and represent syn- ' thetic products of completely original design. In practice, these drugs have been widely used in the symptomatic treatment of dysfunction of organs which are dependent on the activity of the autonomic nervous system: heart, blood vessels, bronchi, gastrointestinal tract, and uterus. The antagonists of epinephrine found their major application in the treatment of vascular disorders and hypertension. The antagonists of acetylcholine are used primarily as spasmolytic, mydriatic, and muscle-relaxing Table 2. Structural relations between and sympathomimetic Sympatholytic agents. [Raymond-Hamet, 1937; Bovet and Simon, 1936; Druey, 1936; Bovet, de Lestrange, and Fourneau, 1942; de Beer and Fassett, 1938; Hartmann and Isler, 1939; Gross, Tripod, and Meier, 1951] SYMPA'HOMIMEIIC AGEN’S /’ H0 \0H SYMPAYNOlVYIC AGENYS CHOHCHZNHCHg ACHECHENHE CH2CH2N(C2H5)2 V AC CH2CH2NHCH3 \v OCHZCH2N(C2H5)2 OH ANHCHECHzNH: N< V CH 2 mm L c (2115).? 93*” HUM HOMNH CH3 NCH3 o/\I~1chzc{r\m-<':H2 CHJDV OCH3 \N—CH; N CH2 C<NH—(IIH2 \N—CHg CH3 0H SCIENCE, VOL. 129 �agents. The antihistaminics are most useful in the treatment of urticaria, rhinitis, asthma, and other allergic diseases. For specific illustrations, I shall use examples from three different pharmacological groups. For the epinephrine group, I will consider ergotamine; for the antiacetylcholine group, curare; and for histamine, I will consider the syn— thetic antihistaminics. “ifssfim " , '" CH? C3 Synthetic Sympatholytic and Ergotamine-Like Compounds Sympatholytic drugs form a group characterized by common pharmacological properties. They act as competitors—or blocking agents, in AngloSaxon terminology—by opposing the effects of epinephrine and norepinephrine. Most characteristically, they block the hypertension and vasoconstriction produced by epinephrine. As is often the case, various drugs of this class were introduced empirically into therapeutics long before their pharmacological actions were established. As long ago as 1909, Froelich noticed that animals pretreated with small doses of the dextrorotatory isomer of epinephrine became resistant to the effects of the natural isomer. Today we explain this observation as resulting from a partial block of the receptors by a pharmacologically much less active enantiomorph of the compound. Later Loewe (1927), Kiilz (1936), and Raymond-Hamet (1937) described N-alkyl derivatives of phenylethylamine with sympatholytic properties; analogous properties were described in the phenoxyethylamine series (Anan, 1930; Levy and Ditz, 1933; Bovet and Maderni, 1933; Bovet, Simon and Druey, 1937), the phenylethylenediamine series (Bovet, de Lestrange, and J. P. Fourneau, 1942), the isoquinoline series (Hjort, de Beer and Fassett, 1938), and the phenylaminoethylimidazoline series (Meier and M'Liller, 1939; Hartmann and Isler, 1939). In each of these groups the structural similarities between the antagonistic molecules with either sympathomimetic or sympatholytic properties are evident (Table 2); the degree of substitution on the amine, the suppression or displacement of the phenolic function, the closing of a ring, are sufficient to reverse the pharmacological action. It is very important to notice that while the distance betWeen the amine function and the aromatic ring remains constant in both sympathomimetic and sympatholytic agents, the inhibitory 'molecule has always, in con: 8 MAY 1959 {gags seems i} {We casing mag, Fig. 2. Pachycurares. (Left) d-Tubocura- rine; (above) gallamine. Table 3. Classification of the main groups of sympathomimetic and sympatholytic agents. ©-c-c—N ©—o-c—c—N ©mc-c-n Phenylethylamines Phenoxyethylamines Phenylethylene diamines Tiiii r i Sympathomimetic agents Phenolic derivatives of Phenylethylenediamine and Epinephrine its phenolic derivatives Phenylethylamines and their phenoxyethylamine phenolic derivatives Sympatholytic agents (aromatic series) N-Diethyl-N’-propyl-N’N-Diethylphenylethylamine N-Diethylphenoxyethylamine phenylethylenediamine Dibenamine Dibenzyline Tetrahydronaphthylamines, N-substituted Sympat/tolytic agents (heterocyclic series) N -MethyltetrahydroBenzodioxane: Phenylpiperazine Phentolamine isoquinoline Prosympal Benzylimidazoline Piperoxan Sympatholytic alkaloids Yohimbine Ergot alkaloids Table 4. Structural relations between sympathomimetic and sympatholytic agents: from epinephrine to ergotamine. [Marini-Bettolo, Chiavarelli and Landi, Vittory, 1950—1953; Bovet, Bovet-Nitti, Virno, Longo, Marotta, and Sollero, 1953] [NH _ CH3 CHOH-CHZ NH 2 ,NH2 / (31+2<:H2 NH2 GHz'ct' 0H3 OH OH Adrenaline Phenylethylamine Amphetamine Tetrahydronaphtylamine CH30H‘I3H2 IcorchH5 CH3 _ 843 LS alibi-c co C H2 -0H \Nz—CH 2 H 5-» 3 9| 6 1.5. _ CIH2 CH\ N/CHZ c,o\lI NH— N\ COG N‘ X30 ERGOTAMINE 1257 �The most active natural and synthetic tradistinction to the excitatory one, an amino group substituted by more, and heavier, radicals. Generally the inhibitory molecules also have a more stable structure and a higher molecular weight. sympatholytic compounds, whose effectiveness is sufficient to permit their use in the clinic, are generally polycyclic or heterocyclic, with structures analogous Table 5. Investigations of synthetic oxytocic agents, derived from phenylglycinamide. [Bovet-Nitti, 1952, 1954] CH CH 3 3 NH- CH- CHZOH co- CONH-CIZHCHZOH CH2' CH2 N— CH3 CZ H5 NHCOCH2N< c2*‘5 8331.8. Ergometrine 62' " s CZ H5 NHCOCH2 N 1048 I €sz 1.3. ,6sz NHCOCHZN. H 0sz‘N- co- CHz-N c ’2 5 |062 |058I.S. 1.5. Table 6. Natural and synthetic curares: d-tubocurarine (King, 1935; Wintersteiner and Dutcher, 1943); 3381 RF. (Bovet, Courvoisier, Duclos, and Horclois, 1946) ; gallamine (Bovet, Depierre, and de Lestrange, 1947) ; succinylcholine (Bovet, Bovet-Nitti, Longo, and Marotta, 1949; Fusco, Palazzo, Chiavarelli, and Kniisli, 1949). “3‘0 <300 H 3 ‘ E"? 06H; on / ;.. C2H5 \ /"x I 1‘ ————©—o O—(CH2)5-—-0 I °2H5 3381 R.P. d-Tubocurarine ' O‘CHZ-CHZ'N(CZH5)3I ' on 2coocnzc H2N(CH3)BC! - , . o-cwcwmcm-I' 2 2. 253 or 0 Hz- CH2*N(CZH5)3'I ] _ . CHz-COOCHZCH2N(CH3)3C!‘ Succinylcholine Gallamine Table Subject Mammals Birds Amphibians (rectus abdominis) 1258 7. Pharmacodynamic properties of synthetic curares. Pachycurares (competing agents) : tubocurarine, gallamine Curarization Curarization Antagonism to acetylcholine Leptocurares (depolarizing agents) : succinylcholine, decamethonium Curarization (muscular fibrillation) Contracture followed by curarization Acetylcholinic contracture to the above-mentioned compounds despite their complexity. Benzylimidazoline (Meier and Miiller, 1939) and dibenamine (Nickerson and Goodman, 1947) are related to the phenylethylamines; the aminomethyl-benzodioxanes (Fourneau and Bovet, 1933), to the phenoxyethylamines; and phentolamine (Gross, Tripod, and Meier, 1951) to phenylethylenediamine derivatives (Table 3). Studies conducted at the Istituto Superiore di Sanita by Marini-Bettolo and Chiavarelli, on the chemical aspects, and by F. Bovet-Nitti, Longo, Marotta, and Guarino on the pharmacological aspects, illustrate the usefulness of the concepts of isosterism and of competition in this kind of investigation. When the isolation and structural determination of the ergot alkaloids was achievedwresearches for which we are largely indebted to Stoll and Jacobs—— much work was done to prepare derivatives by partial or total synthesis; thus, dehydrogenated derivatives (Rothlin, 1947) and oxytocic derivatives closely related to ergometrine (Rothlin, 1947) were prepared, and the diethylamide of lysergic acid with hallucinogenic properties was discovered (Stoll). Since we proposed to investigate the structureactivity relationships of ergotamine, we used as our working hypothesis the con— cept relating structure to antagonistic action. At first sight, the structure of the ergot alkaloids seems to be very different from that of epinephrine or of sympathomimetic derivatives of the phenylethylamine series. Nevertheless, since the skeleton of B-tetrahydronaphthylamine (2-aminotetralin) can be recognized in'the structure of lysergic acid, we decided to study compounds of this group (Table 4). Pharmacological tests with derivatives of relatively simple structure demonstrated the sympatholytic activity of 2-diethylaminotetralin (843 1.5.). Studies with more complex molecules, in particular the amide and amine derivatives of 2-tetralin, are a new step in the attempt to reproduce the essential portion of the lysergic acid skeleton. Using molecules of increasing complexity, one may go by successive stages from phenylethylamine to tetrahydronaphthylamine or to N-(2-tetra1yl) -N-methyl-N’-ethylB-alaninamide (916 LS.) and the ergot alkaloids, with a resulting progressive diminution at each stage of sympathomimetic properties and the appearance of sympatholytic properties. Oxytocic activity was observed in a large number of synthetic derivatives, SCIENCE, VOL. 129 �and this class of compounds seems very broad compared to that of adrenolytic substances (Table 5). In the course of experiments performed on rabbit uterus, isolated or in situ, several derivatives of aminotetralin and of aniline and even some aliphatic compounds showed strong activity. We may single out such examples as N,N-diethyl-N’- ( 2-tetralyl ) glycinamide (621 I.S.); N,N-diethyl-N’-3( 1048 4-dimethylphenylglycinamide LS.) ; and N,N,N’,N’tetraethylglycinamide (1062 LS.) (Bovet-Nitti, 1953). The main difficulty, apparently encountered also by other investigators, was the lack of parallelism between effects observed in laboratory animals and in man. Generally speaking, a satisfactory solution to the problem of syn— thetic oxytocies has not yet been reached, and the question is still under study. Antagonists of Acetylcholine: Synthetic Curares The problem of competitive agents that antagonize acetylcholine activity is rather complex, due to the multiple functions of this transmitter. Acetylcholine is the chemical transmitter in viscera innervated by the parasympathetic system; it has a role at the neuromuscu— lar junction, and it is liberated in ganglia during the passage of a nerve impulse. A surprising fact, which has been profitably exploited in pharmacological investigations of competitive agents, is that compounds antagonizing acetylcholine differ according to the site of action of the local hormone. Thus, atropine and benzoylcholine neutralize the muscarinic effects of acetylcholine on cardiac receptors, on the intestine, or on secretions; tetraethylammonium iodide or hexamethonium block the nicotinic action of acetylcholine on sympathetic and parasympathetic ganglia. Finally, curares are specific antagonists of acetylcholine in striated muscle. With respect to the structure of antagonists, synthetic curares furnish us with a succession of examples comparable to those we have reviewed in the sympatholyticgroup. These investigations were begun in 1946, after King’s elucidation, in 1935, of the structure of one of the physiologically active constituents of Amazonian curares, and after the introduction by Griffith and Cullen in 1942 of the chemically pure alkaloid as an adjuvant in anethesia. d-Tubocurarine, which is extracted from a menispermum, Chondodendron tomentosum, is found in curares prepared by the natives of the Upper Ama8 MAY 1959 , emcageugcagcagefcam Mammengmécm {1:39} CHQCG B Ci‘iéci‘ig ‘ ’ R;C8313 (CH333NCHgCRgu C0 CHg Fig. 3. Leptocurares. (Left) Decamethonium; (right) succinylcholine. zon. It is an alkaloid of the group bis ( benzyltetrahydroisoquinoline) , whose molecule has two quaternary ammonium ity, and this was also true for polyphenol ethers and aromatic esters. The latest investigations on the path to ultimate simplification are concerned’ with the activity of aliphatic derivatives. In England, Barlow and Ing and Paton and Zaimis (1948) reported extremely interesting observations on the curare-like effect of decamethylene—w- functions. In research done with our colleagues, Viaud, Horclois, and de Lestrange, we first looked for molecules structurally close to the selected model. By successive transformations, we were able to synthesize relatively simple derivatives with analogous properties (Table 6). From a series of new compounds with two quinolinic rings bearing quaternary ammonium functions, we first selected the diiodoethylate of 8’ ,8’ ’ -diquinolyloxy1,5-pentane (3381 R.P.). This was the first synthetic compound with curarelike action in mammals showing a specificity comparable to that of natural alkaloids isolated from curare (1946). It was then found that aminophenol derivatives which have neither quinoline nor isoquinoline rings had similar activ- bis-trimethylammonium hydrate (decamethonium). In our Laboratory of Therapeutical Chemistry at the Istituto Superiore di Sanita, the curare-like action of succinylcholine was first recognized. This compound was synthesized by Hunt in 1911. The number and variety of compounds with curare-like action, the relative simplicity of their mode of action, and the possibility of precise pharmacological assay permitted a careful study of structure-activity relationships of synthetic curares. Solveni front D Iodine Carboxylic reagent Bromothymol blue 0 000 @%s + 60 O Enzymic hydrolysis (5%) 01 cm.{ R; 1 o O o @ @s....,...ho.... @ @ @ ® + a 2 § § Choline Succinylmonocholine Succinate 3 20 Control Non-enzymic hydrolysis (96) Fig. 4. Chromatograms of (a to e) succinlycholine at various stages of enzymic hydrolysis; (f) a mixture of succinylcholine and its products of hydrolysis; (g) 0.1 mg of succinylcholine after nonenzymic hydrolysis. [Whittaker and Wijesundera, 1952] 1259 �Fig. 5. Comparison between curarizing effects of d-tubocurarine (left) and of succinylcholine (right) given intravenously as a single fol— muscle of the Contraction anesthesia. gastrocnemius chloralose under (First line) the dog, continuous perfusion on injection or by lowing the.rhythmic stimulation of the sciatic nerve; (second line) control of the speed of injection; (third line) blood pressure. The record shows clearly the difference between the duration of neuromuscular paralysis following a single injection of succinylcholine (370 1.8., 0.05 mg/kg) and of d-tubocurarine (0.1 mg/kg). Also, on comparing the effect of a single injection of d—tubocurarine with continuous perfusion of succinylcholine (initial injection of 0.05 mg followed by repeated injection of 0.0062 mg at each signal), one sees that, for the duration of subtotal and reasonably uniform eurarization (about 80 percent, for 20 minutes), the reversibility of the effect is quick (about 10 minutes) after infusion of succinylcholine while it is slowly progressive (about 50 minutes) after injection of d-tubocurarine. [Reuse, 1953] I will mention only two important factors which influence the activity of bis-quaternary derivatives: the distance between the quaternary ammonium groups and the massiveness of the molecule. The first factor is illustrated by comparison of polymethylene-bis-trimethylammonium derivatives (Barlow and Ing; Paton and Zaimis, 1948) as well as of aliphatic diesters of choline (Bovet, Bovet-Nitti, Guarino, Longo and Marotta, 1949) (Fig. 1). Careful pharmacological study showed that the action of new synthetic derivatives was sometimes quite different from that of the natural alkaloids. The differences between the action of decamethonium iodide and succinylcholine iodide on the one hand and the action of d-tubocurarine and of the tri— iodethylate of gallamine on the other were carefully studied by Paton and Zaimis, Brown and Dias and in our own laboratory. The British authors have proposed calling these two groups depolarizing agents and competitive curares. We proposed designating decamethonium and succinylcholine as leptocurares, and tubocurarine and gallamine as pachycurares (Figs. 2 and 3; Table 7). The advantage of our nomenclature lies in the fact that it does not presume the mechanism of action. The main differ— ence between the pharmacodynamic effects produced by the two types of curares is determined by the responses of amphibian and bird muscles. In birds, the pachycurares are typical curarizing agents, while leptoeurares induce con- ESHWEH H . CH, C“Cf~iLCHNH }; fag; \g‘fsfmwx ‘ as? N 1260 y 2‘ ecu, '2 CHECHEMCHM Fig. 6. (Left, top) Histamine; (left, bottom) pyridylethylamine; (above) pyrilamine. tracture that is followed by eurarization. In mammals the differences between the two groups are less sharp. The responses of muscle from different species or of different muscles from a single species are not always comparable. Also, intermediary steps seem to exist between depolarization and curare competition. The distinction between the groups, though relative with respect to the mechanism of action and the type of preparation used, are, nevertheless, useful if we want to compare relations between chemical structure and pharmacological activity. Clinically, the most important factor in classification of curares is duration of effect. In this respect, the introduction of a short-acting curare, particularly succinylcholine, is an important step forward. The relative ease with which suc— cinylcholine is hydrolyzed by pseudocholinesterase and the very low toxicity of the products choline and succinic acid account for the brevity of action and the remarkable tolerance of the organism for this curare (Fig. 4; Table 8). The first clinical observations concerning short-acting curares were published by Valdoni (1949) and Scurr (1951) and deal with suxethonium. The introduction of succinylcholine into anesthesiology was first proposed in Sweden, by Thesleff (1951), Holmberg and Thesleff ( 1951), Tammelin and Low (1951 ) , and von Dardel (1951), and in Austria, by Briicke et al. (1951), Mayrhofer and Hassfurther (1951), and Holzer (1951). In the light of these various investigations, one may today recognize two methods of using succinylcholine: single injection when very short action is required (as for endoscopy or electroSCIENCE, VOL. 129 �Table 8. Hydrolytic products of succinylcholine. (CHgaN‘CiECi-izococ Hacib c OOCHZC HZN ’(c 1493.1’ -Succiny|choline 1'. (CH3)? CHZCHZOCOCHZCI‘ECOOH + OHCHZCHZN (cl-1‘3)3 I Choline Succinylmonoct‘oline l lrl(.7H3)3N CH2 CH 2OH+ HOOCCHZCHZCOOH Succinic acid Choline shock) or continuous infusion in surgical procedures of long duration. Two recordings from a study in our laboratory demonstrate results obtained with the two types of application. They show the superiority of continuous infusion of short-acting curares over the classical technique (Fig. 5). Antihistamines The last example I will use to illus— trate the concept of competition is concerned with compounds that antagonize the third local hormone, histamine. This particularly rich field since the usefulness of these compounds has stimulated a great many investigations within a very few years. In 1937, in Fourneau’s laboratory, we began—A. M. Staub and I—to look for compounds antagonistic to histamine. Considering the number of features that histamine, acetylcholine, and epinephrine have in common, we looked for antagonism comparable to that exhibited by sympatholytic compounds toward epinephrine and by parasympatholytic compounds toward acetylcholine. We obtained the first positive results in 1939 with thymoxyethyldiethylamine (929 F). Our experimental work was then directed toward defining criteria for antihistaminic activity. Staub (1939) extended her observations to phenylethylenediamine derivatives. In 1942, the syntheses by Mosnier, the pharmacodynamic studies of Halpern, and the first therapeutic results of Cuilleret, Thiers, Gaté, Celice, Perrault, Decourt, and Durel with dimethylaminoethylbenzylaniline, or Antergan, definitively established interest in compounds of this group. The role played by histamine in many allergic affections assures a broad area of clinical application of these compounds. After the pio— neers (Maderni, de Lestrange, and Benoit in Fourneau’s laboratory in Paris; is a Table 9. Principal groups of synthetic antihistaminics: 929 F (Bovet and Staub, 1937) ; Antergan (Halpern, 1942); antazoline (Meier and Bucher, 1946); diphenhydramine (Loew, Kaiser, and Moore, 1945); promethazine (Halpern and Ducrot, 1946); chlorphenamine (Tislow, La Belle, et al., 1949) ; pyrilamine (Bovet, Horclois, Walther, and Fournel, 1944); tripelennamine (Mayer, Huttrer, and Scholz, 1945) ; thonzylamine (Reinhard and Scudi, 1947). Antihistaminics related to: Sympatholytic agents onQ [OHS CH ocnac H2N(62H5)2 CH3 929F ”Q CH ‘0H 2 0H 2 Maria) 2 Antergon Q Spasmolytic agents 0 \ZCH CH Diphanhydramine O cuzcnmcusiz N \ N-CH2 _ Antozoiine 8 MAY 1959 :EH GHZCH2N(CH3)2 Chlorphenamino 2N(CH3) Pyrilamine N‘cnacnzmchu 3 CH— @001 ECHocH ZCHZNKSH 3’2 Promethazine \C Histamine Tripulennominc flZOOCHS N/ \ZCHZCHZNCHa) Thonzylamino Table 10. Structural relations between histamine and antihistamines. [Walter, Hunt, and F osbinder, 1941; Nieman and Hays, 1942; Bovet and Walthert, 1943] NH /\ / / ’I CH2 CH2 NHZ , I, HISTAMINE Histamine action 2. N I Antihistamine action HQ": CH2 CHZN: (/\n-CH2.GH2.NHZO KEV) /J Nona \ ,/<CH 2 .0H 2 .NH 2 \ "[0142 A" (7N1ii KN 6H2 ii; N’0 2 ‘01:: CH 0 o \N ~ /-CH2CH2. NH2 “3 + K I R N: N [CH3 CH2.CH .N\ * CH% Viaud, Horclois, Mosnier, and Charpentier in French industry; Hartman and Hofman in Switzerland; Rieveschl, Scholz, Huttrer, and Roblin in the United States; Cavallini in Italy), about 500 chemists synthesized, in less than ten years, more than 5000 compounds in the antihistaminic group. Pharmacologists were easily able to recognize the competitive nature of the antagonism exerted by these antihistaminics toward histamine. Chemists, however, could not perceive any relation between the structure of antihistaminics and histamine which logically might explain such activity, nor could they find a relationship among the various active compounds. It was therefore impossible to escape the conclusion that most of the results were rather empirical. From the pharmacological viewpoint, it was possible to distinguish three groups of substances (see Table 9) with antihistaminic action and relate them to (i) the sympatholytic group; (ii) the parasympatholytic-sympatholytic group; and (iii) histamine itself. To the first group belong the phenolic esters (929 F) and the phenylethylene— diamine derivatives (1571 F) studied at the Pasteur Institute, Halpern’s Antergan, and the antazoline of Meier and Bucher. The compounds of the second group, from a chemical point of view, have more homogeneous structures, in 1261 �common with atropine-like drugs and other spasmolytics; some of these are, in fact, spasmolytic as well as antihistaminic (diphenhydramine). In derivatives of a-aminopyridine, which form the third group, the antihistaminic action is more specific and almost free of secondary effects. It is interesting to note in this group the isosteric reactions which account for the pharmacological activity. Walter et al. (1941) and Niemann and Hays (1942) have shown that a-pyridylethylamine derivatives have histamine-like activity, and that a fundamental difference exists between a-, [3-, and y-substituted pyridines in this respect. In this case, the analogy of structure which is not evident between histamine and pyrilamine (Neo-Antergan) may be seen between the groups a-pyridylethylamine and (it-pyridine ethylenediamine (Table 10, Fig. 6). A typical compound from this group is pyrilamine (see Fig. 7), but many other synthetic compounds of similar design have also proved to be active. Central Action of Transmitters The compounds considered so far do not exhaust the ranks of competitive agents. Pharmacologists are to some extent les enfants terrible: of physiology. They did not wait for the battle of the neuromuscular junction to be won before engaging in a more difficult encounter. They proposed that the available evidence suggested the action of a chemical transmitter in the central nervous system, exactly as in the autonomic nervous system. Analyzing the collective results from various laboratories, Feldberg (1950) concluded that the theory ascribing a transmitter role to acetylcholine in the central nervous system was the only one able to offer convincing and satisfactory interpretations. Even if intervention of noncholinergic chemical transmitters in the central nervous system is not excluded, we must admit that our knowledge about the probable roles of norepinephrine, epinephrine, histamine, and 5-hydroxytryptamine is still quite incomplete. The physiological role of the reticular formation in the brain stem has been clearly defined by Moruzzi and Magoun (1949). In the last few years, a considerable number of investigations have shown that compounds affecting the autonomic nervous system also affected this formation. Paradoxically enough, cholinergic as 1262 HISTAMINE 0.001 cm/H 0 20 .mm/Hg 200 100 0 15 PYRILAMINE HISTAMINE 1.0 0.001 “ j 1 V. 10 5 0 0 ‘_3lOsec Fig. 7. Antagonistic action of pyrilamine with respect to the vasodilating effects of histamine in cerebral circulation. The subject was a dog under chloralose anesthesia. (A) Blood pressure, femoral artery (mm-Hg); (V1) pressure recorded through a catheter introduced in a centrifugal direction into the external maxillary vein (mm-H20) ; (V2) pressure in the internal maxillary vein (mm-H20). Injection was made into the saphenous vein; dosages are given in milligrams per kilogram. [Virno, Gertner and Bovet, 1956] well as adrenergic substances affect the electrical activity of the cortex in the same way that direct electrical stimulation of the reticular formation does. Under well-defined experimental conditions, acetylcholine (Bonnet and Bremcr, 1937) and epinephrine itself (Bonvallet, Dell, and Hietzel, 1954) provoke a transient activation in the electroencephalogram. The administration of either an anticholinesterase (eserine, diisopropyl fluorophosphate) or of amphetamine (Bradley and Elkcs, 1953) produces an intense and prolonged desynchronization. From a strictly pharmacological viewpoint, the major interest in this type of investigation stems from the similarity in observed antagonisms between various groups of drugs in the central nervous system and in viscera innervated by the autonomic nervous system. As early as 1947 we suggested that in extrapyramidal syndromes some relation might exist between the central, “antiparkinson,” effect of certain tertiary amines and their ganglioplegic properties in peripheral ganglia (Sigwald and Bovet; Dumont; 1947). “Antiparkinson” drugs form a relatively homogeneous group comprising diethazine (Diparcol), isothazine (Parsidol), caramiphen (Parpanit), and trihexyphenidyl (Artane), as well as some antihistaminics (diphenliydramine and promethazine). Electroencephalographic studies (Fig. 8) have shown that three groups of compounds produce an electroencephalogram similar to that recorded during sleep: the parasympatholytics (scopolamine and atropine), the central ganglio— plegic or “antiparkinson” drugs (Table 11), and the neuroleptics (chlorproma- w; mwgwmmwww W MWMvM 51mm ‘ . -..,: p‘, 51%; g‘fi‘kfifig‘fi’?‘ “if“?'9““(high ‘) K $3.)wa ai’zfiig'f$6,133?3.25% “ if: (3:1‘331“ ii 4, ,. “‘ ;.§l(¢t {brave-112m}? Fig. 8. Antagonistic action of diethazine against convulsive patterns caused by nicotine on the electroencephalogram of curarized rabbit. (A) Blocking reaction after acoustic stimulation (black line). (B) Convulsive seizure by nicotine (2 mg/kg) in normal animal. (C) After injection of diethazine (5 mg/kg) a second injection of nicotine no longer produced the electrical changes observed previously. and the acoustic stimulus fails to produce the blocking reaction. [Longo and Bovet, 1952] SCIENCE, VOL. 129 �zine, reserpine). These also antagonize the cortical reaction elicited by external stimuli (stress) or by desynchronizing agents (eserine and amphetamine) (Bovet and Longo, 1956). The effect of such synchronizing agents may, as a first approximation, be localized in the reticular formation and thus be comparable to the importance of chemical transmitters at this level. Many observations suggest that specific receptors fOr epinephrine, acetyl- choline, and histamine are specific proteins with a structural configuration complementary to that of the transmitter. This concept was first proposed by Fischer, who illustrated it with the now famous model of key and lock. his mechanism has been invoked to explain observations in physiological and chemical studies of taste and smell. Recently, Landsteiner and Pauling applied this idea of “complementary configuration” in the field of immunological reactions. At this point it would not be possible to consider the various aspects of reactions between chemical transmitters, inhibitors, and receptor proteins without taking more space than is available. The particularly simple case of binding acetylcholine with cholinesterase has been studied by Nachmansohn (1953— 1954) and Wilson (1954). They consider acetylcholine to be attached at two points, one electronegative and the other elcctropositive, and have drawn valid conclusions with respect not only to various anticholinesterases but also to a new group of drugs that reactivate the phosphorylated enzyme. If I cared to develop the extensive areas covered in this article I could include other topics and point out that different groups of compounds affect the metabolism of mediators because they are precursors or because they inhibit synthesis, slow down or accelerate liberation, or interfere with destruction. In every phase, investigations have been successful and the results appear to be very promising. Conclusion The composite picture I have tried to present, at the risk of relating many al— ready well-known facts, appears, despite inevitable gaps, very certain. If, in concluding, we rapidly retrace our path, we will see that in covering the vast field of pharmacology, the structures of a small group of remarkably simple biogenic amines have led us, like the thread 8 MAY 1959 Table 11. Central ganglioplegic agents: diphenhydramine (Loew, Kaiser, and Moore, 1945) ; diethazine (Sigwald, Bovet, and Dumont, 1946; Bovet, Fournel, and Charpentier, 1947); caramiphen (Domenjoz, 1946; Griinthal, 1946); trihexyphenidyl (Doshay and Constable, 1949). / \ / \ CH-O-CHz-CH2~N(GH3)2 Diphenhydramine (Benadryl) -GO'O‘ OHZ'GHZ'N(02H5)2 Caramiphen <// \\> S N'CH2'CH2N(02H5)2 :COH'CHZCHZN > Diethazine Trihexyphenidyl of Ariadne, through the labyrinth of very a name always well-known and sometimes very close to us. The future of pharmacodynamics is, nevertheless, so rich and promising, and diverse physiological actions and chemical structures. It has been said that the art of the orator is to speak about what he knows and to hide his ignorance. I do not feel any need to resort to such an artifice in presenting the current picture of the chemical pharmacology, because it is, in final analysis, only a kind of “natural history” and classification of organic molecules. I would say that the results obtained so far give rise to optimism because they let us catch a glimpse of the pharmacology to come as a well-ordered and well-defined science in which foods, drugs, and poisons will be integrated in the metabolism of the simplest constituents of living matter. Finally, in recalling the great names associated with studies of the pharmacological agents that made it possible for us to reach our present level, I can only speak with emotion of all those who preceded me, particularly of my teacher, Ernest Fourneau, who wrote such a great and glorious chapter of therapeutic chemistry and whose name will forever be written in the history of this science. My feelings are sincerely divided between the immense pleasure I feel at the honor which is bestowed on me and my sense of inadequacy at being unable to repay my teachers and colleagues all that I owe them. This feeling is the more vivid because therapeutic chemistry is a very young science that has developed amazingly during the past half century; perhaps in no other domain does the part played by each individual appear so clearly and with such continuity as in our studies, where every formula bears it bears so many theoretical and prac— tical possibilities, that I cherish the hope that my future work will justify not only the marvellous distinction I have received today but also the confidence and the friendship of my teachers and colleagues, whose works cannot be separated from those I pursue with confidence, enthusiasm, and love. Bibliography The following bibliography includes mainly general reviews; concerning studies published prior to 1948, the reader is referred to the work published in collaboration with Mme. F. Bovet-Nitti. Z. M. Bacq, “La pharmacologie du systeme nerveux autonome, et particuliérement du sympathique, d’apres la théorie neurohumorale,” Arm. physio]. physicochim. biol. 10, 467 (1934). D. Bovet, “Introduzione allo studio fisiologico e farmacologico del curaro,” Boll. soc. ital. bio]. sper. 25, 539 (1949). , “Introduction to antihistamine agents and Antergan derivatives,” Arm. N.Y. Acad. Sci. 50, 1089 (1950). , “Some aspects of the relationship between chemical constitution and curare-like activity,” ibid. 54, 407 (1951). and F. Bovet-Nitti, Structure et Activite’ pharmacodynamique des Médicaments du syrtéme nerveux vége’tatif (Basle, 1948). “Curare,” Experientia 4, 325 (1949). , “Rapports de structure entre sympathomimétiques et sympatholytiques. De l’adrénaline a l’ergotamine,” Actualités pharmacol. N0. 6 (1953), p. 21. , “Le chlorure de succinylcholine, agent curarisant a breve durée d’action,” Sci. Med. Ital. 3, 509 (1955). , S. Guarino, V. G. Longo, R. Fusco, “Recherches sur les curarisants de synthése. III, Succinylcholine et dérivés aliphatiques,” Arch. intern. pharmacodynamie 88, 1 (1951). D. Bovet and V. G. Longo, “Pharmacologie de la formation réticulée du tronc cerebral,” Oomph-rend. 20éme Congr. intern. physiol. Bruxeller (1956), pp. 306—329. D. Bovet and P. Viaud, “Curares synthése: Chimie et pharmacologie,” Aneslhésie et analgésie 8, 328 (1951). F. Bovet-Nitti and D. Bovet, “Recherches sur les ocytociques de synthése: dérivés de la phenylglycinamide,” Arch. intern. pharmacodynamic 6, 327 (1954). F. Briicke, “Dicholinesters of -dicarboxylic acids ‘ 1263 �and related substances,” Pharmacol. Revs. 8, 265 (1956). W. B. Cannon and A. Rosenblueth, Autonomic Neuroeflector System (New York, 1937). J. Castilljo and B. Katz, “Biophysical aspects of neuro—muscular transmission,” Progr. in Biophys. and Biophys. Chem. 6, 122 (1956). H. H. Dale, “Transmission of nervous effects by acetylcholine,” Harvey Lecture Ser. 32, 229 (1937). L. Donatelli and U. Serafini, Gli antistaminici di sintesi (Naples, 1951). J. C. Eccles, “The electrophysiological properties of the motoneurone,” Cold Spring Harbor Symposia Quant. Biol. 17, 175 (1952). V. Erspamer, “Pharmacology of indolealkylam~ mines,” Pharmacol. Revs. 6, 425 (1954). U. S. von Euler, “The nature of adrenergic nerve mediators,” ibid. 3, 247 (1951). S. M. Feinberg, S. Malkiel, A. R. Feinberg, The Antihistamines (Chicago, 111., 1950). W. Feldberg, “The role of acetylcholine in the central nervous system, Brit. Med. Bull. 6, 312 (1950). R. Fusco, G. Palazzo, S. Chiavarelli, D. Bovet, “Ricerche sui curari di sintesi, IV,” Gazz. chim. ital. 79, 836 (1949). L. S. Goodman and M. Nickerson, “Clinical ap- plication of adrenergic blockade,” Med. Clin. N. Am. 34, 379 (1950). H. R. Griffith and G. E. Johnson, “The use of curare in general anesthesia,” Anesthesiology 3, 418 (1942). B. N. Halpern, “Les antihistaminiques de synthese, essais de chimiothérapie des états allergiques,” Arch. intern. pharmacodynamie 68, 339 (1942). , “Sur le mécanisme d’action des antihistaminiques de synthése,” Presse Med. 57, 949 (1949). H. R. Ing, “The curariform action of onium salts,” Physiol. Revs. 16, 527 (1936). S. W. Kufller, “Physiology of neuro-muscular junctions: electrical aspects,” Federation Proc. 7, 437 (1948). O. Loewi, “Problems connected with the principle of humoral transmission of nerve impulses,” Proc. Roy. Soc. (London) 1188, 299 (1936). G. B. Marini~Bettolo, “Contribution a l’étude des alcaloides des Strychnos du Brésil,” Festschr. Arthur Stoll (Basel, 1957), pp. 257—280. , S. Chiavarelli, D. Bovet, “Ricerche sui simpatolitici di sintesi della serie dell’ergotammina,” Gazz. chim. ital. 80, 281 (1950). A. R. McIntyre, Curare. Its history and clinical use (Chicago, 111., 1947). D. Nachmansohn, “Metabolism and function of Manuel Luz Roxas, Agricultural Chemist Manuel Luz Roxas was one of the foremost scientists in the Philippines. His valuable services to the University of the Philippines as a teacher of chemistry in the College of Agriculture and the important role he played in the creation and organization of the National Research Council of the Philippines will be long remembered. Almost immediately after Dr. Roxas’ graduation from the University of the Philippines in 1911, with a BS. degree Hg? ‘ \ ._ Manogmmm OF in Agriculture, his first research work appeared in the Philippine Agriculturist and Forester under the title “The pandan industry in Majayjay.” This was soon followed by three other articles in the same journal: “The cultivation of coconut,” “The effect of some stimulant upon rice,” and “The coffee industry in the island of Luzon.” Dr. Roxas pursued further studies in his chosen field and in 1913 obtained his MS. degree at the University of the Philippines, where he then served as instructor in chemistry until he was appointed a university fellow to the United States. Evidently this appointment was in recognition of his unusual endowment with the “divine spark” to perform research. He enrolled in the University of Wisconsin and received his Ph.D. there in 1916. On his return to the Philippines, Dr. Roxas resumed his position in the Col-' lege of Agriculture in the University of the Philippines, where he was later appointed assistant professor, then professor of chemistry, and ultimately, professor emeritus of agricultural organic chemistry. He was also named Distinguished Alumnus of the University of the Philippines in 1932 for achievement in scientific research. All these deserved 11111111111111 131111111111 HILLSIDE HOSPITAL QLEN omsm. v. ' recognitions were due to his active labor in the field of research, especially in agricultural chemistry and food technology; his 95 scientific papers were published in various journals, including the Philippine Agriculturist and Forester, the [ournal of Biological Chemis— try, Sugar News, and the Journal of the Philippine Islands Medical Association. The National Research Council of the Philippines owes its origin to the leadership of Dr. Roxas. He headed a committee that worked continuously in preparing the draft of the bill for its creation which was introduced in the House of Representatives. With the support of Manuel L. Quezon as Senate President and other leaders of the Philippine Legislature, and the cooperation of the then Governor General Frank Murphy, Act 4120 creating a National Research Council for the promotion of research along scientific lines was approved on 8 December 1933. Elected as first chairman of the National Research Council, Dr. Roxas did a great deal in the organization of the different divisions integrating the Executive Committee of the council. For his distinguished and outstanding contributions in scientific research in the Philippines, Dr. Roxas may well be considered the “father of the National Research Council of the Philippines.” Manuel Luz Roxas was a man of sterling character, a good Filipino and patriot, simple and humble; all these qualities enhanced his merit as a true man of science. Our country can never repay what it owes him for his scientific labor and devotion to research. ANTONIO G. SISON National Research Council of the Philippines, Quezon City SCIENCE, VOL. 129 _ 3.1u1111959 the nerve cell,” Harvey Lecture Ser. 49, 57 (1956). W. D. M. Paton and E. J. Zaimis, “The methonium compounds,” Pharmacol. Revs. 4, 219 (1952). M. Protiva. “Chemie antihistaminovych latek a histaminové skupiny,” Nakladatelstvi L'eskolovenske’ Akademie véd (Prague, 1955). M. M. Rapport, “Serum vasoconstrictor (serotonin) : IV,” ]. Biol. Chem. 180, 961 (1949). Raymond-Hamet, “Sur un nouveau cas d’inversion des eflets adrénaliniques,” Compt. rend. acad. sci. 180, 2074 (1925). Rend. ist. super. sanita‘ 12, 1-264 (1949) (numero speciale sui curari di sintesi). Ibid. 15, 723—1040 (1952) (numero speciale sugli ergotamminici di sintesi). E. R. Rothlin, “The pharmacology of the natural and dihydrogenated alkaloids of ergot,” Bull. schweiz. Akad. med. Wiss. 2, 249 (1947). A. M. Staub, “Recherches sur quelques bases synthétiques antagonistes de l’histamine,” Ann. inst. Pasteur 63, 400 (1939). S. Theslefl', “Succinylcholine iodide. Studies on its pharmacological properties and chemical use,” Acta Physiol. Scand. Suppl. 99, 1 (1952). D. W. Woolley, A Study of Antimetabolites (New York, 1952). �Cultural Determinants of Response to Hallucinatory Experience ANTHONY F. C. WALLACE. Ph.D. PHILADELPHIA �Reprinted from the A. M. A. Archives of General Psychiatry July 1959, Vol. 1, pp. 58-69 Copyright 1959, by American Medical Association Cultural Determinants of Response to Hallucinatory Experience ANTHONY F. C. WALLACE, Ph.D., Philadelphia Hallucination attracts the attention of the anthropologist for several reasons: First, because, as one of the most ancient and most widely distributed of the modes of human experience, most, if not all, human cultures provide definitions of and responses to it which are of interest to the descriptive ethnographer; second, because a vast quan— tity of content has been introduced into the cultural repertoire of mankind by halluci— natory ideation in dreams, visions, and hypnogogic imagery, and hallucination must therefore be considered in relation to culture change; and, third, because hallucination is often defined in Western societies as a symptom of mental and/or physical disease, and anthropologists play a role in medical research in these societies. It is in the last context, particularly in the area of mental health research, that the present inquiry is undertaken. Cross—cultural materials on hallucination may be of interest in a mental health re— search context in at least two ways. First, and rather obviously, both psychiatrist and anthropologist will expect the manifest con— tent of hallucination to vary, as does the content of other behavior, to some degree with cultural setting, and they may be interested in the range, frequencies, and associations of various types of manifest content. Differences of opinion exist in Submitted for publication Sept. 3, 1958. This study was in part supported by Grant M-1106 from the National Institute of Mental Health, U. S. Public Health Service. Research assistants were Fred Adelman, Josephine Dixon, Joan K055, and Robert J. Smith. The writer has benefited from discussion of methodological problems in psychopharmacology with Dr. Harry Pennes and Dr. Harold Rashkis, of the Eastern Pennsylvania Psychiatric Institute. 74/58 regard to the supposed variability of latent content: Lincoln, in his study of dreams in primitive cultures, and other psychoanalyti— cally oriented scholars have emphasized the universal presence in dreams of Oedipal themes and the classic “Freudian” sym— bols 13; less strictly psychoanalytic ethnolo— gists have not emphasized the presence of these themes so much as culturally and personally idiographic onesfi2'3 In any case, however, we shall not be primarily concerned with the content per se of hallucina— tions. Rather, we shall deal with the problem of the definition of and response to the experience, by the society, by the scientific observer, and by the hallucinator himself. The rationale for such an approach, in a mental health context, is twofold: First, knowledge of the range of definitions and response, and their cultural associations, may help in diagnosis and in communication with patients; and, second, it is likely that in some cultural subgroups in our society the nature of definition and response to hallucination entertained by hallucinator and his associates may aggra— vate or precipitate other mental disabilities in the hallucinating person. Indeed, the mental patient may suffer from added anx— iety precisely because of the nature of the definition of hallucinatory experience which he entertained prior to experiencing it him— self. Certainly among hospitalized patients in our society, the attempt to conceal halluci— natory experiences from the staff is both chronic and, in one sense, realistic: Staff members frequently take a negative View of hallucinations, and hallucinating patients are subject to measures which, from the pa— tient’s standpoint, may be punishments (de- �RESPONSE TO HALLUCINATORY EXPERIENCE lay in discharge, restriction of privileges, questioning on sensitive issues, subtle contempt, and even ridicule, from both staff and other patients) .23 Problems of Definition Uncertainties of definition impede re— search in the area of hallucinatory experi— ence. Although hallucination is commonly treated by psychiatrists as a symptom of mental disorder, its occurrence is neither a necessary nor a sufficient condition for such a diagnosis. Most psychiatrists, furtherword the restrictions two on impose more, “hallucination,” excluding from its exten— sion those ideational experiences which oc— cur during sleep and assigning to it a generally negative valence. These restric— tions are useful in psychiatry in our own cultural setting, but they are not helpful in establishing a cross—culturally applicable definition (nor need they be, for a Western psychiatrist’s definition is to be regarded as only one cultural variant), since in some societies dreams and waking visions may be for many purposes treated as equivalent. For the purposes of this study, “hallucina— tion” will be defined, very broadly, as pseu— doperception, without relevant stimulation of external or internal sensory receptors, but with subjective vividness equal to that aroused by such stimulation. Included in its extension, therefore, are dreams, the ter— of “hallucinations” psychiatric waking minology, and hypnogogic imagery; excluded is the fainter audiovisual imagery of reflective thought. There remains a some— what dubious category, occasionally referred to as hallucinations in the psychiatric lite-ra— ture, of perceptions whose subject matter is unambiguously provided by external stim— ulation but whose form displays subtle or gross distortion. The most familiar exam— ples are the undulating floors, stretched perspectives, echoing sounds, and other dis— tortions experienced by some subjects on administration of the so—called hallucino— genic or psychotomimetic drugs, and by normal subjects who have consumed nar— Wallace or alcohol, have been breathing anesthetics, or are in process of losing consciousness (fainting). We shall leave these phenomena out of the range of our definition, on the ground that a “hallucina— tory” dimension already exists, of vividness of subjective imagery in the absence of sensory stimulation, at all points of which the pseudoperception may be equally undis— torted, and relate these dubious cases, rather, to a logically independent dimension of perceptual distortion. The relationship between the two dimensions may, of course. be investigated empirically. A second major problem, in addition to the concept of hallucination itself, is that perennial flower of confusion, the word “possession.” Casual observers and many anthropologists alike use this word in two very different senses: as a label for some person’s overtly observable behavior, and as a label for a native theory to explain this be— havior. These two uses are, unhappily, often confused. It may be best to state flatly, at the outset, that I shall use the word “possession” to denote any native theory which explains some event of human behavior as being the result of the physical presence, in a human body, of an alien spirit which takes over certain or all of the host’s executive functions, most frequently speech and control of the skeletal musculature. A phe— nomenon of possession does not, therefore, for me exist; the word merely labels a theory. Now the possession theory happens to be frequently applied, in folk beliefs, to three very different classes of phenomena, for each of which other terms exist. One of these is hallucination; the second is hysteri— cal dissociation (including multiple personality, fugues, somnambulism, conversion hysterias, and hypnotic states); the third is obsessive ideation and compulsive action. Clinically, these are distinguishable phenom— ena. But any one, or group, of them can be, in folk theory, explained by the mecha— nism of possession. Unfortunately, some observers have, in their eagerness to empa— thize with their subjects, used the word cotics, 75/59 �A. M. A. possession to denote not only a type of folk theory but also whatever phenomenon their folk happen to use the theory to explain. In other words, if a people use the concept of “possession” to explain certain hysterical dissociations (such as the stereotyped fugues which are so commonly induced in many religious rituals), the anthropologist tends to say that the dancers in the ritual are “possessed”; similarly, if a people use the theory to explain hallucination (which is, incidentally, a less common use of the concept), the anthropologist may refer to hallucinators as “possessed” persons. Even more confusingly, the ethnographer may use the word to denote any person who is thought to be persistently influenced by a supernatural being, whether located inside or outside the person’s body. A third problem of conceptual ambiguity is the notion of trance. There would seem to be at least two major uses of this term: (1) to denote physiological collapse with coma or the occasionally concomitant delirious hallucinations; and (2) to denote (again) states of dissociation. The possi— bilities of semantic confusion are manifest. Problems of Methodology At first, it was hoped that the Human Relations Area Files (HRAF), including the old Cross—Cultural Survey Files at New Haven and the completed portions of HRAF at New Haven and Philadelphia, would provide a sample of societies various of whose cultural features could be sta— tistically related to the phenomena of hallucination. The data contained in HRAF, however, even when supplemented by mate— rial from sources not tapped by HRAF, and by data on societies not included in HRAF, proved to be not amenable to statistical treatment, for three reasons: A sample which included representative cul— tures from all major culture areas was not available; the data were not comparable from society to society, because of the extreme unevenness of the reporting (rang— ing from no report at all to careful, exten— 76/60 ARCHIVES OF GENERAL PSYCHIATRY sive, and psychiatrically informed study), and the data provided were usually too crude to permit the discriminations which I regarded as significant for statistical cate- gories. N0 quantity of time or money spent in HRAF and other library compilations can remedy all of these defects of the eth— nographic literature, and only a vast expenditure of funds in field work could amass new and adequate data on a sufficient num— ber of societies. The inference to be made is, rather, that the ethnographic literature available for areal or world samples, of the sort envisioned by Murdock 14 and others in connection with HRAF, is not suitable for statistical analysis with respect to all dimensions of anthropological interest, but is suitable only with respect to certain highly formalized and conventionally re— ported dimensions, such as kinship and subsistence activities. The cultures on which data were collected from HRAF in the abortive statistical phase of the study are the following: Abipone Achewa Ainu Andamanese Apiaca Apinage Aranda Arikara Assiniboin Balinese Bena Blackfoot Buka Bushman—Hottentot Canella Chuckchee Creek Crow Cuna Dahoman Easter Island Gros Ventres Hopi Ifugao Indian Yoga Kamilaroi Kwakiutl Lamba Maori Marshallese Plateau area (North America) Sherente Since nontrivial and significant statistics appeared to be unachievable, the obvious next step was to consider what prestatistical manipulations of the data were possible and whether any of these might yield formulations of interest. Experimentation along these lines brought me to construct a rather tedious list of “existence theorems,” which I shall not reproduce here, but which proved later to be valuable in setting up the matrix of concepts. Existence theorems are Vol. 1, July, 1959 �RESPONSE TO HALLUCINATORY EXPERIENCE eminently prestatistical, but they are neces— statistical of description, sort to any sary since they define the relevant and nontrivial categories. An existence theorem is merely a statement that of the class A: there is at least one member concerning which the statement [9 in true; thus, for instance, the theorem where “there exists at least one (x) such that . . .” (3x)=df and (x):df “society” and A ber of the society as meaningless concatenations of visual and/or a u d i to r y pseudo-perceptions.” The whole of the theorem would read: “There exists at least one society such that hallucinations are defined by some members of the society as meaningless concatenations of visual and/or auditory pseudopercep— tions.” From the existence theorems, derived from the HRAF cross—cultural ma— terials and from my ethnographic knowledge, the dimensions of hallucinatory experience shown in Table l were con— structed. These dimensions are offered as a formal frame of reference within which to observe cultural definitions of hallucina— tory experience, and as a rough statement of the range of cultural variability evident in the ethnographic record. With the foregoing semantic and methodological considerations in mind, we may proceed to discuss, informally and nonstatistically, certain implications of the ethno— graphic data. Conditions of Hallucination If one were to design an electronic brain which behaved in all respects like a normal human brain, one would have to include in its specifications both a capacity for hallucina— tion and a capacity to distinguish halluci— nation from sensory perception. Most human beings hallucinate (in the broad sense of the term which is employed in Wallace Communication Contains no information but is a meaningless pattern of auditory or visual images (:2 Contains information in the form of observation of phenomena that really exist somewhere (but are not messages) (1. Contains message from a supernatural being (ghost, soul, demon, divinity, etc.) located outside Ego’s body a . Contains message from, or is the experience of, a supernatural being (ghost, soul, demon, divinity, etc.) located inside Ego’s body ((5 Contains message from one part of self (e. g., own soul, conscience, memory, Id, subconscious, etc.) to another (6. g., consciousness, ego, etc.) or to other person as Contains message from a natural being communicating by means of radio, telepathy, or other means of telecommunication (1 1 B p12“hallucinations are defined by some mem- 1.—Dimensiom of Hallucinatory Experience TABLE Mechanism of control Can be controlled by hallucinator and/or hallucinator’s fellows by manipulating physical condition and/or foreign biochemical factors ()2 Can be controlled by hallucinator and/or hallucinator's fellows by nonphysical means (such as will, prayer, ritual, worry, suggestion, autosuggestion, psychotherapy, etc.) I). Can be controlled by will of alien supernatural or natum being b I) 1 t b5 b. b1 b3 b 1A0 2 0 [Ab 3 b 2N) a I) 1A0 2A1) . Other (fill) [Vb sz 3]) 0 Induction c. Hallucinator seeks to induce or repeat experience C 2 /—"C 1 D Concealment d1 Hallucinator conceals experience from group or denies oc- currence d 2 ,—/d 1 Punishment E e. Group institutes punishment and/or social extrusion e 2 He 1 Therapy 1“ Group or individual institutes therapeutic and/or prophy— lactic measures f1 fz Hf! G Role assignment g1 Experience qualifies individual for valued social role (adult hood, shaman, healer, diviner, priest, etc.) g2 My 1 H Behavior guidance hi Content of experience may be taken as guide for individual and/or group action (other than therapeutic) irrespective of social role of hallucinator h: Content of experience taken as guide for individual and/or group action (other than therapeutic) only when hallucinator already fills certain social roles (e. g. shaman, prophet) h , Content of experience not taken as guide for individual and/ or group action (other than therapeutic) 77/61 �A. M. A. this paper), in one way or another, quite frequently; and there is no society, to my knowledge, in which hallucinatory experience is unknown. Hallucination is, in fact, one of the most widely distributed of the modes of human experience. Explicit re— ports of dreams, visions, and the hearing of voices are found in the sacred literature of the pre—Christian Near East; if mythology, ritual, and other religious behavior be re— garded as in part the legacy of such experi— ences passed on by oral or written tradition, we may suspect an antiquity measured in tens or hundreds of millenia. Under the general rubric of hallucination, however, there can be assembled a wide range of types of experience, from the Vivid and realistic supplanting of reality in ec— static visions and auditory revelations, to a relatively pallid verbal or visual imagery which blends imperceptibly into ordinary “thought.” These experiences are known from Western clinical observations to be prompted by the most various circum— stances: sleep, anoxia, pharmacologic agents, brain tumors, psychological stress, fatigue, sensory restriction, and others. Relatively little seems to have been done to relate the conditions precipitating and surrounding an event of hallucination to the content of the experience; ethnographic investigation may offer a few clues here. The specific conditions under which hal— lucinations have been reported in the ethno— graphic literature may be divided into the following categories : Sleep Fatigue Hunger and thirst Prolonged physical pain Extreme physical illness Social isolation Special exercises (breath control, posture, sensory restriction) Drugs Emotional stress in normal persons Mental illness It should be noted that these conditions are not logically independent, and that frequent— ly (and especially in voluntarily induced hallucination) two or more of the conditions are realized at the same time. Three observations are pertinent. First, in many societies relatively little significance 78/62 ARCHIVES OF GENERAL PSYCHIATRY is attached to differences in the conditions under which hallucination occurs. In par— ticular, dreams during sleep, spontaneous waking visions, and induced hallucinations under drugs or stress may be given equal status and comparable evaluation. Western society is remarkable for the importance it assigns to differences in the precipitating conditions of hallucination; the most strik— ing example, of course, is afforded by the profound distinctions we draw among dreams (in sleep), delirium (in illness or intoxication), and “hallucination” in the restricted sense (in the waking state). Second, we must take note that, although not all hallucinatory experiences are regarded as desirable in any society, in primitive socie— ties it is very common for hallucinations with desirable content to be not only ac— cepted with pleasure but deliberately sought with the aid of such devices as hallucino— genic substances (e. g., some American Indians ingest parts of the cactus peyote and Paleo—Siberians, the mushroom fly agaric) and various sorts of personal disciplines, ranging from breathing and posture exercises, through hunger, thirst, and isola— tion, to prolonged physical self—torture. The tendency to minimize discrimination among hallucinations on a criterion of precipitating condition of course does not imply any inability to discriminate between hallucina— tion and sensory perception; the preferential status of hallucinatory experiences is possible only when it is clearly differentiable from normal experience. Third, it appears that both the subjective feeling tone and the specific content of the hallucination are heavily influenced by a still more pervasive condition: the cultural milieu in which the hallucination, and particularly the voluntary hallucination, takes place. The latter point is worth elaborating here, although it anticipates some of the material to follow, because it is relevant to the methodology and evaluation of clinical research with hallucinogenic compounds under varying experimental conditions. Typically in such research the clinician administers Vol. 1, July, 1959 �RESPONSE TO HALLUCINATORY EXPERIENCE to a group of healthy urban adults, often medi— the with identified themselves persons cal or an auxiliary—medical profession, a substance which induces various instrumentally measurable physiological changes and observable alterations in behavior. The subjects are asked also to report verbally on their subjective experience. These verbal reports reveal a considerable variety of experience: Some subjects are euphoric; some are entranced by the intensity of esthetic pleasure they achieve in the contemplation of color, form, and movement divorced from meaning; many complain of anxiety, physical discomfort, various un— welcome perceptual distortions, and attitu— dinal changes; some hallucinate and some do not. These various reports and observa— tions are taken to indicate the psychological actions of the drug. Similarly variable re— sults, but usually with transient intensification of chronic symptomatology, are given by mental patients from roughly comparable cultural backgrounds (but, of course, by virtue of illness occupying a very different social status). But no cultural controls are employed; and it is possible that to an unknown degree the subjective experience, and hence even the physiological measures, is influenced by the negative attitude toward any distortion of normal sensory and cognitive experience which many members of our society share, at least those people who do not customarily seek such special experi— ences as are afforded by narcotics and alcohol or by mystical or esthetic preoccu— pations. Some indication of the quality and mag— nitude of the possible effect of differing cultural attitudes toward hallucinatory ex— perience under differing conditions of drug administration is given by the differences in the experiences reported by normal white subjects after administration of mescaline and by American Indians after consumption 0d of introduction, and of intragroup per— sonality differences: first, the influence of tains mescaline). The literature on the mescaline experi— ences of normal subjects is rather scattered, Wallace and some of it, particularly if it has an early date of publication, is unsatisfying because of the inadequacy of sample description and the disjointed and anecdotal style of presen— tation conventional at the time. Neverthe— less, the consultation of several prime sources “'25 reveals a reasonably consistent pattern of described phenomena, which con— trasts with the pattern described (also, unfortunately, sometimes in undefined sam— ples) by anthropologists’ American Indian informants.”12'1“"!24 The fact of major contrast has been briefly remarked in print by one of the—foremost anthropological stu— dents of peyotism, Slotkin,21 who observed in the course of discussion of attempts of white persons to suppress peyotism that “the responses described in clinical experi— ments on Whites are so different from the responses described by Indian Peyotists . as to fall into completely different catego— 2.—Contrasts in Prevailing Character of the Responses 0f_Climcally “Normal” White and Indian Subjects of M escaline Intoxication TABLE White Indian Variable and extreme mood shifts (agitated depression, anxiety, euphoria, depend— ing on stage of intoxication and personal characteristics) Initial relative stability of mood, followed by religious anxiety and enthusiasm, with tendency toward feel— Frequent breakdown of social inhibitions and display of Maintenance of orderly and “proper” behavior (“revivalistic" enthusiasm is socially proper in context) No report of suspiciousness “shameless” sexual, aggressive, etc., behavior Suspiciousness of others present in environment (reported to be uniformly present by Guttmann and noted in self by Kliiver) Unwelcome feelings of loss of contact with reality, depersonalization, meaningless“split-personality," ness, etc. Hallucinations largely idiosyncratic in content No therapeutic benefits or permanent behavioral changes ings of religious reverence and personal satisfaction when vision achieved, and often, also, expectation of “cure” of physical illness Welcome feelings of contact with a new, more meaningful, higher order of reality, but a reality prefigured in doctrinal knowledge and implying more, rather than less social participation Hallucinations often strongly patterned after doctrinal model Marked therapeutic benefits and behavioral changes (reduction of chronic anxiety level, increased sense of personal worth, more satisfac» tion in community life) 79/63 �A. M. A. ries; they do not seem to be talking about the same thing.” The salient differences in the reports are displayed in Table 2; the reader should note that a meaningful statis— tical presentation of frequencies of response types, while desirable, is precluded by the nature of the data available. These marked differences would seem to be plausibly explained by two related fac— tors which are independent of possible differences in racial physiology, of chemical action of the drug owing to variations in dosage, mixture with other agents, of meth— od of introduction, and 0f intragroup person— ality differences: first, the influence of the setting in which the drug is taken (the white subject’s experiences occur usually in a hospital or university research setting; the Indian experiences, in a ceremonial lodge during a solemn religious ritual); and, second, differences in the psychological meaning of the primary drug effects when experienced. Certainly, gross enough situ— ational and semantic differences exist: White normal subjects generally take mes— caline once or twice, in a clinical research setting, with definite knowledge of an ex— perimental or a clinical purpose in the investigation, and without any commitment to or interest in peyote, or to mescaline in any form, as a personal religion; Indian peyote users take mescaline repeatedly, in a solemn religious setting to the accompaniment of serious ritual, with definite knowledge of a religious purpose in the usage and, often, with hope for per— sonal salvation, of which the vision is the evidence. The former factor—the setting— 5 been has reported by Fernberger to yield differences in content, which can to some degree be affected both by suggestion by the experimenter and by autosuggestion. The latter, the semantic, factor would seem to be significant at the present stage of theory concerning the action of the hallucinogens, since it is recognized that both personal character and, perhaps, personally or cul— turally determined values concerning the “homeostasis of subjective—experience” may 80/64 ARCHIVES OF GENERAL PSYCHIATRY affect response to experimentally induced changes in sensation and perception.19 We quote the work of Hoch, Cattell, and Pennes 8 in this connection. We have pointed out that the alterations in the vegetative nervous system appear first under the influence of mescaline, lysergic acid, pervitin, etc. This is usually followed by alterations of per— ception, bodily sensations, and changes in body image. In many patients it would appear that the perceptual alterations are conducive in producing anxiety, uncertainty, and, at times, rage. Seemingly, the perceptual alterations lead to a lowering of reality control, thence to tension and anxiety, which in turn lead to depressive, aggressive, and paranoid manifestations. Schizophrenic patients whose reality contact is already impaired are seemingly more vulnerable to drugs that have a disorganizing effect on reality perception. As yet it is unclear whether the emotional alterations seen in these patients are due to a physiological action of the drug per se or due to the experiencing of an alteration of reality and other changes on a psy— chic level. Interpretation of Content In most primitive societies, even if (on other grounds) the hallucinator is regarded as being ill, or the hallucination itself is unpleasurable, the content will not be re— garded as a meaningless concatenation of pseudoperceptions. The content of hallucination is sometimes interpreted as a message introduced directly into the subject’s consciousness by a supernatural being, directed either to the hallucinator himself or to the community through him as an intermediary. More frequently, hallucination will be in— terpreted as a real perceptual experience by the soul, which has wandered from the body and is seeing and hearing events involving real or supernatural persons which are occurring in another place, or which is able to see and hear events and supernatural beings present but imperceptible to others. The message—intrusion theory tends to blend into primitive theories of possession; in our society, it is expressed in the conventional telepathy, radio, radar, brain—washing, and electrical—current delusions and is classed as a paranoid mechanism, while the spiritual— perception theory is associated with extreme Vol. 1, July, 1959 �RESPONSE TO HALLUCINATORY EXPERIENCE religious enthusiasm. But in both theories, the content of hallucination is interpreted as significant information. In at least two culture areas, that of the 17th—century Iroquois Indians of what is now New York State,26 and of Western society after the advent of psychoanalysis, a third theory also has existed as an alterna— tive explanation for hallucination. In this theory, the hallucination conveys an emo— tion—laden message from the soul, or some unconscious part of the mind, to the conscious self, and thus is a process of thought. This view, like the others, regards the content of hallucination as a message containing information. It appears to be a rare idea that the content of hallucination is mean— ingless, and one may hazard the guess that this notion is largely confined to psychiatri— cally unsophisticated, nonparanoid, and tepidly religious, or nonreligious, members of Western society. If a hallucination is regarded as a mes— sage, there are evidently two approaches to its interpretation: to take the manifest con— tent literally, and to regard the manifest con— tent as a symbolic expression of significant underlying ideas. The latter approach may entail various techniques, such as guessing and devices of free association, the consul— tation of a formal list of symbols and their meanings, and the more or less standardized derivation of meaning from the context of circumstances (such as ritual, illness, situ— ational stresses, and the like) in which the hallucination occurred. It is not important here whether or not there are, in truth, universal themes and symbols expressed in dreams and other hallucinatory experiences, as psychoanalytic theory and data suggest. The important point is that most human beings, in most societies, outside Western civilization, regard hallucinatory content as communication bearing significant informa— tion which can be understood either directly or by the use of special methods of interpretation. Now this belief in hallucinatory content as communication, particularly when it is Wallace coupled with the conviction that the com— munication is not merely intrapsychic, seems to have an effect both on the content of hallucination and on the hallucinator’s, and his community’s, response to it. Halluci— nation in itself is not frightening, either to hallucinator or to his community, al— though the content may be; but even if the content is frightening, it is valuable knowl— edge. Hence the overt response to halluci— nation will very likely be markedly affected by its classification as communication. It is to the topic of response to hallucina— tion that we now turn. Response to Hallucination The difference in response between Eng— lish white and Australian black to a course of hallucinations in a mourning woman is vividly illustrated in the following anecdote, reported by Parker,15 the author of a study of the Euahlayi tribe of Australia. Our witch woman was rather a remarkable 01d person. When she was, I suppose considerably over sixty, her favourite granddaughter (lied. Old Bootha was in a terrible state of grief, and chopped herself in a most merciless manner at the burial, especially about the head. She would speak to no one, used to spend her time about the grave, round which she fixed upright posts which she painted white, red, and black. All round the grave she used to sweep continually. More and more she isolated herself, and at last discarded all her clothes and roamed the bush 5. la Eve . . . as she had probably done as a young girl. She dug herself an underground camp, roofed it over, and painted enormous posts which she erected in front of her “Muddy wine,” as she called her camp. She never came near the house, though we had been great friends before. She used to prowl around the outhouses and pick up all sorts of things, rubbish for the most part, but often good utensils too; all used to be secreted in the underground camp. She never talked to anyone, but used to mutter continually to herself and her dogs in an unknown tongue which only her dogs seemed to understand. We thought she was quite mad. One day, while we were playing tennis, she sud— denly, muttering her strange language and dancing new corroboree steps, clad only in her black skin, came up. Matah told her to go away, but she only corroboreed round him and said she wanted to see 81/65 �A. M. A. She danced round me for a little time, then sidled up to me and said: “\Nahl [negative or “no”] you frightened, wahl me hurt you. I only womba—mad—all yowee— spirits—in me tell me gubbah— good—I lib ‘long a youee: bimeby I come back big feller wirreenun [as a medicine woman] wahl you frightened? I not hurt you.” And after crooning an accompaniment to her steps, off she went, a strange enough figure, dancing and crooning as she went towards her camp; and not until the spirits gave up possession of her did she come near the house again. I used to tell the other blacks to see that Bootha had plenty of food. They said she was all right, the spirits were looking after her. Lunatics, from their point of view, are only persons spirit-possessed. Gradually old Bootha, clothed as usual, came back about the place. Strange stories came through the house back to me of old Bootha. She was very ill for a long time, then suddenly she recovered, not only recovered but seemed rejuvenated. We heard of wonderful cures she made; how she always consulted the spirits about any illness; how there were said to be spirits in some of her dogs; how she was now a rainmaker, and, in fact, a fully fledged witch. me. . . . The reader will note a typical Western attitude toward the “lunatic,” a blend of amused contempt, pity, and anxiety, and also the native woman’s awareness of the attitude, and her effort to clarify the white man’s misunderstanding by explaining that her hallucinatory experiences were “good.” Noteworthy also is the satisfactory (both to the woman and to her associates) social remission, which was achieved in the course of becoming a shaman: a remission which, I suggest, was facilitated by her anxiety— free acceptance of hallucinatory experience. This anxiety—free acceptance of, and willing— ness to describe, hallucinatory experience contrasts vividly with the common shamed, fearful, self—doubting attitude of Western patients, who frequently try to conceal the fact that they “see things” or “hear voices,” and sometimes “confess” (as the psychi— atrist puts it) to hallucinations only under very careful questioning. Response to hallucination may be considered both as a matter of the hallucinator’s response to the experience and as a matter of the response of his group (and the two, 82/66 ARCHIVES OF GENERAL PSYCHIATRY of course, may be equivalent). As I have indicated, in primitive societies the fact of hallucination per se is seldom disturbing; but the content itself may be disturbing or not, depending on the nature of the socially appropriate response. Dreamers or vision— aries may resist strenuously the hallucinated suggestion that they undergo an arduous process of becoming a shaman, or that they accept the role of berdache (an institutional— ized inversion of sexual role among the Plains Indians), or that they commit some act, like murder or incest, which violates social norms; they may be stricken with panic at learning of approaching community disaster, or that they have been bewitched, or that they will be captured, tortured, and killed in a future war. Similarly, the hallu— cinator’s associates may respond with dismay, or with enthusiasm, to the wishes of his soul, and may institute protective meas— ures to avert harm from him or from them— selves, may induct him into the special social relationships indicated by his vision, may conduct the indicated medical treatment, or may take his revelation as a code for social reform. The significant point is that it is the content of the communication which is the focus of interest and the fulcrum of action rather than the fact of hallucination itself. Let us now consider, by contrast, the responses to hallucination typical in Western societies. In some social groups, particularly religious sects, hallucinatory experience with supernatural figures ap— parent in the manifest content is interpreted as divine, 0r Satanic, revelation, and is responded to either by acceptance of in— junctions discovered in the content or by repression, or even punishment designed to drive out “possessing” devils. In psycho— analytically influenced groups (which prob— ably include a considerable proportion of the urban population of Western countries), dreams are interpreted and used as a basis for psychotherapeutic action, but waking hallucinations are regarded as symptoms of serious psychic illness. And in the rest of Vol. 1, July, 1959 �RESPONSE TO HALLUCINATORY EXPERIENCE the population at large, waking hallucina— tions are probably regarded primarily as indications of “nervous breakdown,” or even “insanity.’ The latter unfavorable social diagnosis is very commonly followed by the social extrusion of the hallucinator, with or without prior medical advice, into a mental hospital or some other socially restricted environment, or at the very least into a quasiostracism at home or in lodgings. Police force is available and not uncom— monly used to sanction and to effect this extrusion. In medical circles, despite recog— nition that hallucination in many conditions is a secondary symptom, and despite the insistence of workers like Boisen that “what the voices say is the important thing, not 1 hallucina— the mere fact of hearing voices,” tion is commonly taken to be a grave sign. In some of the research literature, indeed, hallucination is treated as if it were the essential feature of psychosis. Now it is reasonable to suppose that most persons, when they hallucinate for the first time (certainly when the first waking hallu— cination occurs), are aware of the culturally standard interpretation of and response to hallucination in their society. Even if they do not accept this interpretation and re— sponse as wise or proper, they will be aware of its probable evocation in others. If this is the case, then it is likely that the person’s interpretation of, and response to, the fact of his own hallucination in a given context (as well as its content) will be a function of the way in which the fact (and content) of hallucination is defined by his culture. The function should determine in part his ’ emotional experience both during and after the event, and possibly (by cultural suggestion) its perceived content as well. 'We may ask, at this point, how much anxiety, self—depreciation, and cognitive dis— tortion are added to the miseries of mental patients by the circumstance that they have learned to fear waking hallucination in the course of living in a society in which waking hallucinatory experience is almost uni— formly negatively valued? (The scientific validity of the valuation is irrelevant.) Furthermore, we must question the completeness of any research into the psychophysiological action of the so—called psychomimetic drugs, of sensory restriction, and of other hallucinogenic procedures which fails to weigh not only the magnitude but also the direction of the probably mas— sive contaminating effect of cultural sug— gestion upon the subjects. For what is measured is not just the action of a drug or other procedure, but the action of the procedure plus the subject’s interpretation of and response to this action, plus the feedback effect on the continuing action itself (Figure); and all of these actions, inter— pretations, responses, and effects are factors with direction, as well as magnitude. There may be much that the therapist can do to alter the internalized cultural defini— tions of hallucinatory experience in his patients, if he wishes. But it is research problems that chiefly concern us here. It would be possible in clinical research to con— trol for the direction of cultural effects by employing as control subjects persons whose subculture differs sharply from that of the Hallucinatory pseudo— perception SPECIFIC HALLUCINOGENIC STIMULUS CONDITION cognition of Situation -””'“°'°‘ , . -39. “—3). _____ Musculofure 1’ Vaugned'gme" "em”s ' . WWW / ‘ . personal-3y . 2‘ .. dynamics , Internalized cultural 15" definition of situation 9 MOTOR vEggAL *{ RESPONSE Mediation of response , , to hallucmOgenic stimulus by facets 0m; subjectlve experience. _ - - 9 NERV° Wallace 83/67 �A. M. A. experimental subjects in its definition of the expected experience, and by ensuring that the experimental conditions for the controls were sufficiently close to culturally normal conditions for them to permit generalization from past learning. Furthermore, it would be possible to select subjects systematically on criteria of personality, of past experi— ence, and of attitude toward the expected events; and it would be possible to vary deliberately the general situational structure with other variables held constant, both by physical manipulation and by deliberate in— struction and suggestion to the subjects. Such procedures, incidentally, should also be considered in relation to other than halluci— nogenic compounds; they evidently would apply to such drugs as tranquilizers, sedatives, and energizers, which on other evidence also depend in part for their effects on relatively unexplored interactions with personal dynamics and sociocultural milieu.18 Methodologically, such manipulations are the reverse images of the controls imposed by the placebo—and—blind (or double—blind) techniques and of analysis—of—variance tech— niques involving multiple pharmacologic agents; whereas the placebo-plus—blind, or variance—analysis, design varies the chemical agent and holds situation constant either by randomization or by laboratory control, the method of cultural and situational controls would hold the drug constant and vary such aspects of situation as the physical experi— mental conditions, instructions to personnel, and character and background of subjects. Drug and cultural controls should ideally be combined in one design. Summary The paper briefly examines the range of cultural variation in conditions inducing, interpretations of, and responses to, hallu— cinatory experience. The published data suggest strongly that internalized cultural definitions of hallucinatory experience have a profound effect on the responses both of mentally ill and of normal persons. Meth— odological controls for cultural differences 84/68 ARCHIVES OF GENERAL PSYCHIATRY are indicated in research with hallucinogenic substances. Eastern Pennsylvania Psychiatric Institute. REFERENCES Boisen, A. T.: The Exploration of the Inner World, New York, Harper & Brothers, 1936. 1. Eggan, D.: The Manifest Content of Dreams: A Challenge to Social Science, Am. Anthropologist 2. 54 :469, 1952. Eggan, D.: The Personal Use of Myth in Dreams, J. Am. Folklore 68 :445, 1955. 4. Fernberger, S. W.: Observations on Taking Peyote (Anhalonium lewinii), Am. J. Psychol. 3. 34 :267, 1923. Fernberger, S. W.: Further Observations on Peyote Intoxication, J. Abnorm. & Social Psychol. 5. 26:367, 1932. Guttmann, E.: Artificial Psychoses Produced by Mescaline, J. Ment. Sc. 82 2203, 1936. 6. Hoch, P. H.: Experimental Induction of Psychoses, in The Biology of Mental Health and Disease, 27th Annual Conference of Milbank Memorial Fund, New York, Paul B. Hoeber, Inc. (Medical Book Department of Harper & 7. Brothers), 1952. Hoch, P. H.; Cattell, J. P., and Pennes, H. H.; Effect of Drugs: Theoretical Considera— tions from a Psychological Viewpoint, Am. J. Psychiat. 1082585, 1952. 8. Huxley, A.: The Doors of Perception, New York, Harper & Brothers, 1954. 10. Klfiver, H.; Mescal Visions and Eidetic Visions, Am. J. Psychol. 371502, 1926. 11. La Barre, W.: The Peyote Cult, in Native American Culture, Yale University Publications in Anthropology, No. 19, New Haven, Conn, Yale University Press, 1938. 12. La Barre, W.: Primitive Psychotherapy: Peyotism and Confession, J. Abnorm. & Social Psychol. 42:294, 1947. 13. Lincoln, J. S.: The Dream in Primitive Cul— tures, Baltimore, Williams & Wilkins Company, 9. 1935. Murdock, G. R: World Ethnographic Sample, Am. Anthropologist 592664, 1957. 14. 15. Parker, K. L.: The Euahlayi Tribe, London, Archibald Constable & C0., 1905. Petrullo, V.: The Diabolic Root: A Study of Peyotism, the New Indian Religion, Among the Delawares, Philadelphia, University of Pennsyl— vania Press, 1934. 16. Vol. 1, July, 1959 �RESPONSE TO HALLUCINATORY EXPERIENCE Radin, P.: The Winnebago Tribe, Washington, D. C., Bureau of American Ethnology, 37th Annual Report to Secretary of Smithsonian In— stitute, 1915-1916, 1923. 17. Rashkis, H. A., and Smarr, E. R.: A Method for the Control and Evaluation of Sociopsychological Factors in Pharmacological Research, Psychiat. Res. Rep. 9:121, 1958. 18. Rubin, L. S.: The Psychopharmacology of Lysergic Acid Diethylamide (LSD—25), Psychol. 19. Bull. 54:479, 1957. 20. Slotkin, J. S.: Menomini Philos. Soc., n. 5. 42:4, 1952. Peyotism, Tr. Am. J. S.: The Peyote Religion: A Study in Indian—White Relations, Glencoe, 111., Free Press, 1956. 21. Slotkin, Wallace 22. Smythies, J. R.: The Mescaline Phenomena, Brit. J. Philos. Sc. 3:339, 1953. 23. Smythies, J. R.: A Logical and Cultural Analysis of Hallucinatory Sense—Experience, J. Ment. Sc. 102:336, 1956. D.: Personality and Peyotism in Menomini Indian Acculturation, Psychiatry 15: 24. Spindler, G. 151, 1952. 25. Stockings, G. T.: A Clinical Study of the Mescaline Psychosis, with Special Reference to the Mechanism of the Genesis of Schizophrenia and Other Psychotic States, J. Ment. Sc. 86:29, 1946. 26. Wallace, A. F. C.: Dreams and the Wishes of the Soul: A Type of Psychoanalytic Theory Among the 17th Century Iroquois, Am. Anthropologist 602234, 1958. Printed and Published in the United States of America 85/69 �� 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 and reprints: hallucinogens and EEG, 1959 (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-03-01-002-15-015 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 Various authors 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/ac5e73da19470d46979be1d3e57b7963.pdf 289f176e87e6c22e9a18830dea076106 PDF Text Text Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume V April, 1956 Number 2 �EVALUATION OF HIGH-DOSE RESERPINE THERAPY FOR RELIEF OF ANXIETY1 MORTON WACHSPRESS, M.D.,2 ARNOLD G. BLUMBERG, M.D.,3 MAX FINK, M.D.,4 and JOSEPH S. A. MILLER, M.D.5 ‘ During the past few years increasing interest has been shown in the role of drugs in psychiatric practice. Previous studies on the usefulness of extracts of Rauwolfia Serpentina at this hospital demonstrated minimal value for this drug in alleviating anxiety symptoms (4). In the light of these studies which contrasted with more recent enthusiastic reports, an investigation of the effectiveness of large doses of reserpine in relieving anxiety symptoms and altering behavior was undertaken. Numerous reports have appeared in the past two years describing the effectiveness of reserpine in reducing aggressive and assaultive behavior (2, 5); alleviating manic states (14); and reducing the need for electroshock therapy (10). The reports of its potency in reducing anxiety, affecting neurotic symptoms or altering depressive symptoms (6, 12) have been less laudatory. In addition, reserpine-induced depressions have been noted in the course of treatment for hypertension (9, 11). No evidence has been forthcoming that reserpine has altered the course of a psychiatric illness, although many reports emphasize the quieting effects of the drug or its usefulness as an “adjuvant to psychotherapy” (7). This investigation was undertaken to determine the usefulness of reserpine in a voluntary psychiatric hospital population treated in an open ward setting. A double-blind placebo controlled study with 1 From the Research Service and Medical Department of the Hillside Hospital, Glen Oaks, N. Y. ZSenior Resident Psychiatrist, Hillside Hospital, Glen Oaks, N. Y. 3 Associate Visiting Physician, Hillside Hospital, Glen Oaks, N. Y. 4 Director of Research, Hillside Hospital, Glen Oaks, N. Y. 5 Medical Director, Hillside Hospital, Glen Oaks, N. Y. 67 �68 WACHSPRESS—BLUMBERG—FINK—MILLER large fixed doses of drug was selected as a technic of evaluation for this study. The evaluation of improvement in a psychiatric patient under therapy presents problems which are all too familiar to careful investigators in the field. In a hospital environment where the total therapeutic regime combines to produce improvement, the evaluation of the effect of a drug must be carefully controlled. Certain criteria must be established to differentiate between improvement consistent with the course of the disease, and improvement greater than what may be expected from the normal course of hospitalization. To properly attribute improvement to a drug the following criteria should be satisfied: the patient should improve while receiving medication; this improvement should be greater than at the time when the medication is replaced by suitable placebo medication; and improvement should be reproducible at a later date with a similar drug dosage. The use of a double-blind placebo controlled study provides a method for such an evaluation and it is doubtful if definitive conclusions are justified in the absence of such studies (3). To further minimize the subjective factor in the clinical evaluation, rating scales have been employed, despite their well-known limitations. In this study, the revised rating scale of Malamud and Sands (8) was utilized to provide further experience for the observers in standardizing their reports and to permit a constant frame of reference for changes in symptoms and behavior during therapy. METHOD The patients in this study were those who presented, both subjectively and objectively, severe anxiety and agitation. They were selected from the patients recommended by the resident psychiatrists for electroshock or drug therapy. The final decision as to which patients should receive reserpine was made by the two psychiatrists working on the study, who based their selection on the presence of severe anxiety and tension symptoms. Of the original group of seventeen, fifteen patients completed the study. Two male patients, one diagnosed as schizophrenia and one as psychoneurosis, discontinued the treatment because of increasing tension, agitation and nausea while on the drug regimens. Of the seventeen patients, eleven were diagnosed as schizophrenia, five as psychotic depression and- one as mixed psychoneurosis. There were eight males and nine females. The age range was 19 to 52 with a median age of thirty-three. �EVALUATION OF HIGH-DOSE RESERPINE 69 Each patient was observed for a period of twelve weeks. Every patient received an intramuscular injection of 2cc. of reserpine6 and five tablets daily throughout the twelve-week period. Depending on which regimen was selected, placebo tablets and injections were substituted for the drug. The four regimens were: reserpine, 10 mg. daily—5 mg. orally and 5 mg. intramuscular; (2) reserpine, 5 mg. daily—orally; (3) reserpine, 5 mg. daily—intramuscular; and (4) placebo only. (1) Regimens were selected in random order by the internist, and the regimen was unknown to the patient, therapist, evaluating psychiatrist or nursing personnel. Weekly psychiatric evaluations were done on each patient by an evaluating psychiatrist. A modified Malamud scale was employed as well as the subjective reports of the patient and the impressions of the observer. The patients were concurrently studied by the internist at regular intervals. Blood pressures and pulse rates were measured in a sitting position on casual examination at irregular intervals. Only two patients could be classified as hypertensive before treatment. Each patient was weighed weekly. A radioactive iodine determination was performed before starting treatment and repeated no sooner than three weeks after instituting treatment with an effective dose of reserpine. Routine blood counts, urinalyses and other laboratory tests were conducted as indicated. RESULTS Psychiatric Observations Of the fifteen patients, seven showed a significant alteration in behavior which could be related to drug dosage. Of these, three showed a relief of anxiety and tension, and four, an increase in depression, tension and agitation. The remaining eight patients manifested no change in behavior. In addition, the two patients who discontinued the drug regimens did so because of an increase in tension and anxiety accompanied by nausea and vomiting. We are indebted to the Ciba Pharmaceutical Company for the reserpine (Serpasil) and placebo medication used in this study. 6 �WACHSPRESS—BLUMBERG—FINK—MILLER 72 total scores, an item analysis of the individual behavior items was undertaken. Those representative items were selected which clinical experience suggested might reveal changes due to drug action. The items chosen were: feeling, mood, motor activity, and thought processes. An analysis of these scores failed to indicate any consistent difference in these characteristics in the patients as a group. Regarding the differences in the drug regimens, it was the clinical impression of the evaluating psychiatrists and resident therapists that more moderate doses of reserpine were preferable, giving fewer objectionable symptoms. Six of the fifteen patients were subjectively worse on the daily dose of 10 mg. These six included A. 8., one of the patients who improved on drug regimen, and two of the four patients whose condition became worse. Toxic Symptoms Of seventeen patients who started on the study, two stopped because of side effects. These patients manifested increased tension and anxiety, in which nausea and vomiting became prominent symptoms. Numerous other side elfects were observed, and the incidence of each is noted in Table II. Drowsiness and dizziness were seen in most of the patients, but caused serious difficulty in none. Six TABLE I BEHAVIORAL RATINGS—TOTAL SCORE H.C. G.W. ES. M.C. R.S. R.D. A.S. F.G. S.G. LE. M.D. S.K. P.M. A.L. M.B. Sex Age F F M F F M F F F M F F M M M 24 52 45 19 19 20 46 28 37 50 42 37 22 37 22 Diagnosis Schiz. No Medica tion Placebo 27 Invol. Mel. Schiz. Schiz. Schiz. Schiz. Invol. Mel. Schiz. M.D.D. M.D.D. Invol. Mel. Schiz. Schiz. Schiz. Schiz. 23-36 20 35,36 30,35 37-46 29-35 34,30 12-19 20 27 36-45 16-22 27,25 27-38 6-9 23-43 16-30 18-29 18,9 19-33 26-28 53 46—57 51,64 57,66 Oral Intramus- Combined cular 15 17 28-34 50,53 23,25 27,26 38 29-39 2542 18 20-31 26 40 15,3 45,31 22,15 47,31 25,28 28 27 34 16-28 20-26 23,27 28-36 12,15 29-40 20 29 27 18—26 16—30 53 44,61 53 32-51 51-56 27 825 12,13 37,39 29—38 19 25-38 63—55 �EVALUATION OF HIGH-DOSE RESERPINE 73 patients developed a Parkinsonian muscular rigidity, which disappeared within a few days after the drug was discontinued. Four patients had one or more episodes of generalized flushing lasting up to twenty-four hours. This occurred in patients on placebo as well as on drug, and was interpreted as an allergic reaction to impurities in the intramuscular solution. TABLE II TOXIC EFFECTS Incidence ................................. ................................. ...................... Nausea .................................... Parkinsonism ............................... Painful legs ................................ Hot flashes ................................. Restlessness ................................. Swollen feet ................................ Drowsiness Stuffy nose Dizziness and Weakness l4 13 10 7* 6 4 4 3 l In 2 patients nausea was accompanied by vomiting and was a factor in discontinuing treatment. * Depression The enhancement of existing depressive symptoms was noted in three patients, and in another, depressive symptoms appeared where none had been evident before reserpine therapy. In each instance, electroshock therapy was recommended and improvement resulted. Electroshock therapy induced a remission of the anxiety and tension components of the illness, as well as the depressive. Of the eight patients who manifested no change with reserpine, two were eventually treated with electroshock, without clinical improvement. Physiologic Observations The systolic blood pressure was reduced in fifteen of the sixteen patients observed over an extended period of time. The magnitude of this lowering was between 10 and 20 mm. Systolic blood pressures between 90 and 100 mm. were not unusual while on treatment and were not accompanied by adverse symptoms. Table III represents average figures for the highest and lowest blood pressure and pulse rate recorded during each regimen. There �74 WACHSPRESS—BLUMBERG—FINK—MILLER drop in both systolic and diastolic blood pressure and in pulse rate with reserpine therapy. There is no difference in the hypotensive or bradycardiac effect of intramuscular or oral administration of 5 mg. reserpine; nor is there any indication that a dosage of 10 mg. produces a greater effect on blood pressure or pulse rate than 5 mg. These observations are consistent with previous reports of the flat dose response curve for reserpine (1). is a significant TABLE III Medication Range Systolic Range Diastolic Pressure Pressure Range Pulse Rate Placebo 135-117 5 mg. p.o. 5 mg. i.m. 10 mg. combined 116—108 118-106 119-109 84-69 70-64 71-63 68-61 98-7 8 74-67 74-68 78-68 Most patients on reserpine reported an increase in appetite, and there was a tendency for these patients to gain weight. In seven patients, such gains varied from 3 to 20 pounds on the entire treatment program. Three patients lost weight and four showed no change. There was no consistent change in the radioactive iodine (1-131) uptake following the administration of reserpine. Nor could a correlation between weight change and this index be found. Thus, only two of the patients who gained weight had a decrease in the iodine uptake. One patient who lost weight had a rise in iodine uptake. It was concluded that the weight gain and increased appetite were not related to alteration in thyroid function. DISCUSSION High-dose reserpine therapy did not affect the symptoms of anxiety or tension in these patients. For the most part, patients were made uncomfortable by the high doses used in this study. Of the three instances where a relationship between changes in anxiety and tension could be related to drug dosage, two were noted in severely ill patients in whom overactivity and agitation were first controlled. The relief of anxiety was secondary to the decrease in motor excitement. The previous study at this hospital demonstrated the limited usefulness of low-dosage reserpine therapy for the relief of anxiety. Considering this, and the results of the present study of �EVALUATION OF HIGH-DOSE RESERPINE 75 high-dosage reserpine, it may be concluded that reserpine therapy, either in low or high doses, has limited use for its relief of anxiety symptoms in this hospital’s population. Its use is further limited by the exacerbation in depression which was observed. Our observations, however, tend to support the reported usefulness of this medication as a sedative in the control of destructive and overactive behavior. This is seen in our two cases (R. S., M. B.) and in a series of other overactive patients at the hospital who were noted to respond to the sedative action of reserpine when this was introduced in lieu of restraints and massive sedation. The doses of reserpine in this study were generally too high. Patients were unable to tolerate 10 mg. without uncomfortable side effects. In no instance were the side effects severe or disabling, however, and in each instance the symptoms responded to a decrease in drug dosage. The symptom of depression, however, has assumed special significance in these patients. Reserpine exaggerated this symptom and, in one instance, elicited a depression with suicidal trends. The reports of increased depression (9, 11) are thus confirmed; and the usefulness of electroshock therapy in relieving these depressions can be re-emphasized. In this regard, the earlier enthusiastic reports of the usefulness of reserpine as a substitute for electroshock therapy (10) need reassessment. Reserpine is no substitute for electroshock therapy in the treatment of depressive states. It may substitute, however, for the use of electroshock as a sedative in the management of overactive and assaultive behavior. This study exemplifies the advantages and disadvantages of a drug evaluation study by the double-blind placebo method. With a limited number of subjects, it is possible to obtain a meaningful evaluation of the primary effects and complications of a medication. The drug effects may also be separated from the natural course of the illness, and from the investment of the therapist in the conclusions. Such a technic has the following limitations: rigidity of dosage; inability of the therapist to separate drug-induced effects from alterations in the disease process during the study period; and the necessity of the selection of patients who are tractable and can tolerate discomfort for extended periods. Furthermore, such a study may rob the therapist of his faith in the drug as a therapeutic vehicle, and thereby limit the patient’s response to the physiologic effects alone. It also limits the therapist’s control over the care of his patient, and thereby arouses feelings of helplessness and apprehension in the therapist. In such instances, the cooperation of a mature �76 WACHSPRESS—BLUMBERG—FINK—MILLER therapist is essential because there is considerable opportunity for the manipulating, demanding, and paranoid patient to arouse the therapist’s anxiety and hostility to the experimental program. This study also provided an opportunity to assess the usefulness of rating scales. In assessing the changes seen during treatment the rating scales failed to provide any information not available in the descriptive statements. They did provide, however, a frame of reference for the many items of the psychiatric interview that needed rating, and provided a base for the comparison of observations made by different observers. ' SUMMARY AND CONCLUSIONS In a double-blind placebo evaluation of 5 mg. and 10 mg. doses of oral and intramuscular reserpine, fifteen voluntary hospitalized psychiatric patients with severe, overt symptoms of anxiety were studied. Three patients manifested relief of anxiety related to drug dosage. In twelve patients no relief was noted, and of these, four exhibited severe depressive reactions which eventually responded to electroshock therapy. Cardiovascular effects of high doses of reserpine were not significantly different than previously reported effects of low dosage. There was no evidence that reserpine altered thyroid function, although weight gain frequently occurred. The usefulness of high-dose reserpine therapy in the relief of anxiety symptoms is limited. The dangers of induced depressions, as well as the rationale of placebo studies and psychiatric rating scales are discussed. REFERENCES (l) A. M. A. Report of Council On Pharmacy and Chemistry, J. A. M. A., 159: 1206, 1955. (2) Barsa, J. A. and Kline, N. 8.: Treatment of Two Hundred Disturbed Psychotics with Reserpine. J. A. M. A., 158:110, 1955. (3) Beecher, H. K.: The Powerful Placebo. J. A. M. A., 159:1602, 1955. (4) Blumberg, A. G., Cohen, L., and Miller, J. S. A.: The Effect of Rauwolfia Serpentina on Anxiety States. This Journal, 3:140-146, 1954. (5) Cowden, R. C., Zax, M., and Sproles, J. A.: Reserpine—Alone and as an Adjunct to Psychotherapy in the Treatment of Schizophrenia. A. M. A. Arch. Neurol. c9" Psychiat, 74:518-522, 1955. (6) Drake, F. R. and Ebaugh, R. G.: The Use of Reserpine in Office Psychiatry: Preliminary Report. Ann. N. Y. Acad. Sci., 61:198. 1955. (7) Hoffman, J. L. and Konchegul, L.: Clinical and Psychological Observations on Psychiatric Patients Treated with Reserpine: A Preliminary Report. Ann. N. Y. Acad. Sci., 61:144, 1955. �EVALUATION OF HIGH-DOSE RESERPINE 77 Malamud, W. and Sands, S. L.: A Revision of the Psychiatric Rating Scale. Am. ]. Psychiat., 1042231, 1947. (9) Muller, J. C., Pryor, W. W., Gibbons, J. E., and Orgain, E. 8.: Depression and Anxiety Occurring During Rauwolfia Therapy. J. A. M. A., 159:836, (8) 1955. (10) Noce, H., Williams, B., and Rapaport, W.: Reserpine (Serpasil) in the Man- agement of the Mentally Ill. 1. A. M. A., 158:11, 1955. (ll) Schroeder, H. A. and Perry, H. M.: Psychoses Apparently Produced by Reserpine. ]. A. M. A., 1592839, 1955. (12) Smith, S. K.: The Use of Reserpine in Private Psychiatric Practice. Arm. N. Y. Acad. Sci., 61:206, 1955. (13) Wilcoxon, F.: Some Rapid Approximate Statistical Procedures. New York: Am. Cyanamid Co., 1949. (14) Zeller, W. W., Graffagnino, P. N., Cullen, C. F. and Rietman, H. J.: Use of Chlorpromazine and Reserpine in the Treatment of Emotional Disorders. 1. A. M. 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MWMWthyummmdnm mamaamumm. mwmmtm-I mammmtmwmmmmmmmmmm www.mha‘Mdnhrm-twmm imammmnummMMnm-mmmnmmrm cumin-um». ”mummmmwwmmm ‘ �htW,M'W£5mmmn.Mdonl WWII: Wt: mm W ammgmfiWd-mtymm Mupmmm «a mtmcnlnr mm, mm nmpamummm mammumw; MmamummmmWWnWMmW WhWW. Wmuudmmammmmummw ‘ ~ 7 mmmum wommmmmmamm mt. mummy mama. wand mun, awwwu w.» mm aw mmdmmmwnmmam magnum mmawmiamJummm mammmmmnmnmmmmm ��70 WACHSPRESS—BLUMBERG—FINK—MILLER In the improved patients, an alleviation of anxiety was apparent and related to drug administration. M. B., a 22-year-old male, diagnosed as paranoid schizophrenia, was anxious, depressed, withdrawn, blocked, delusional and hallucinating. He had been hospitalized for three of the previous five years, and had received courses of insulin coma and electroshock therapy with only transient periods of improvement. After five months of hospitalization at Hillside Hospital he showed no improvement. During the drug regimens, there was a diminution in his anxiety, depression, agitation and preoccupation with delusions. These symptoms recurred when on placebo medication. Introduction of the drug regimen again resulted in the alleviation of these symptoms, with the progressive amelioration of his depressive feelings. With the reduction of his drug dosage to mg. oral, he again manifested a recurrence of symptoms, only to have them relieved by the combined (10 mg.) regimen. The patient was maintained on this treatment and discharged, improved, six months after the treatment was instituted. A. S., a 46-year-old hypertensive woman, manifested severe tension, anxiety, depression, tremulousness and insomnia, which had fluctuated over a two-year period. Her diagnosis was involutional melancholia. While on 5 mg. drug regimens, there was considerable relief of anxiety with a decrease in tremulousness. Insomnia became less, but her depression was unaffected. Placebo regimen resulted in a recrudescence of her symptoms. The combined (10 mg.) drug regimen increased the feelings of depression, induced somatic complaints and failed to abate the anxiety. A lowering of her medication to 5 mg. resulted in a repetition of the period of relief of anxiety and tremulousness. The patient was discharged, improved, on this dose of oral reserpine. R. S., a 19-year-old girl with hebephrenic schizophrenia, was overactive, anxious, tense, fearful, and manifested both ideas of reference and auditory hallucinations. Electroshock and insulin coma therapy afforded her only transient relief. While on 5 mg. drug regimens, she became less active, less anxious but more depressed. Her dress became bizarre. When placebo medication was introduced, her hallucinations ceased, her anxiety was more manifest but the depressive features were less. On combined drug regimen, she became calmer, more controlled in her behavior, but the bizarre appearance and ideational disturbances persisted. In these three cases, a relationship between drug regimens and the relief of anxiety symptoms could be demonstrated. In both M. B. 5 �EVALUATION OF HIGH-DOSE RESERPINE 71 and R. S., the overt manifestations of severe schizophrenia were sufficiently modified to permit participation by the patient in milieu and psychotherapeutic programs. In the other twelve cases, no such relationship could be demonstrated. Of the four cases in whom the drug regimen induced increased symptoms, each manifested severe depressive feelings, crying spells, and one, suicidal preoccupations. The following case exemplifies the group. G. W., a 52-year-old single woman, was admitted with a sevenyear history of depression and hypochondriasis. A previous course of electroshock therapy was not completed because of injuries sustained in a fall. She was tense, anxious, tremulous and depressed. While on drug regimens she became more depressed and retarded. Her anxiety and agitation increased. With placebo medication there was some amelioration of these symptoms. Electroshock therapy was instituted. She received fifteen treatments, with a rapid relief of her tension, anxiety and depression. She was discharged one month later, much improved. There were eight patients in whom the drug regimen or placebo periods were indistinguishable. There was neither a relief nor an exaggeration of symptoms. The following case history illustrates the group. F. G., a 28-year-old woman, had a two-year history of severe anxiety, tension, feelings of depersonalization and obsessive ruminations which followed the birth of her first child. She had previously been treated with insulin coma and three courses of electroshock therapy, with only transient relief. During the periods of reserpine study, she showed no change in her symptoms while on drug or placebo regimens. The changes in behavior determined by psychiatric interviews and rated according to the Malamud scale are represented in Table I. In these tables, the figures represent the total scores for each observation period. The higher scores indicate deviation from more “normal” behavior. The “control period” is a period of observation without any drug medication. While the table lists the different regimens in a definite sequence, the actual sequence varied from patient to patient, in a random fashion. A statistical study, using Wilcoxon’s method of paired replicates, (13) demonstrates no significant difference in the group between any of the drug or no-drug periods. Because no significant change was demonstrated in the study of � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Anna Lowenthal Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-001 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Maternal grandmother of Max Fink 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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Title A name given to the resource Bronia Lowenthal Fink in medical school anatomy class, Vienna, 1922 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1922 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/c9bcff7ab808daf91947155abc826b10.jpg bb5f4ea36367e11b5dd3430512e88499 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Bronia Lowenthal Fink in Vienna, undated Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-003 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/4ba5e96b945ff650600fd8eebc62b978.jpg 9e63d62436644f7352adb6c407f61300 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Bronia Lowenthal Fink in Vienna, undated Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-004 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/98f5a5a06c57d2e2f02f1dbcc6c9195d.jpg 6777b73026075a1d135fcdc9d1219af9 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Bronia Lowenthal Fink and Max Fink, 1923 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-005 Date A point or period of time associated with an event in the lifecycle of the resource 1923 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/afa39731a22de12de18235e077c0ce23.jpg 9bcf59795660f4bd6becb133f38a52a1 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Herman Lowenthal (bottom, center) and Bronia Lowenthal Fink (top, second from left) Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-006 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Maternal grandfather of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/c1adcfc50e8cb270487b43e0a89d86d3.jpg 957379d25c584165ba4c98583bc8031f 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, high school, 1939 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-007 Date A point or period of time associated with an event in the lifecycle of the resource 1939 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/65ba6297e407443e5b645f06440831eb.jpg 5742bf256de9eb414b435ed69af6dfe5 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Julius Fink and Bronia Lowenthal Fink Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-008 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Father and Mother of Max Fink 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/51e43c2b6279ed3231fc821d51cd7972.jpg f293003cd763a906c079bb313411d56f 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, ship surgeon, American Export Line, 1948 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-009 Date A point or period of time associated with an event in the lifecycle of the resource 1948 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/9bde6be6bc795aa367e0ff3ce1a1cf46.jpg d63c5320d960711e3a969b3b25f295ab 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, research director at Hillside Hospital, 1955 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-010 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/e2dfa694e56791492ce34290f8ee13c6.jpg f4908ca956dd101ab6f2236cb1a3dcb7 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Lieutenant, U.S. Army Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-011 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/f1e473fb184518ae72cd1702ef7a72f7.jpg 16b46e52874c84a7ad290c767850e3ff 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Lieutenant, U.S. Army Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-012 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/e9c35b476f08f9def6067c31e43766ba.jpg 0f5e91adefcf1752e635029b5132d222 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Private first class, U.S. Army, 1943-1945 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-013 Date A point or period of time associated with an event in the lifecycle of the resource 1943-1945 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/2f578bbf612a73467db6914635f7abd6.jpg d2a0de5cef8c03d255fbfb5d6d39ea67 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, 1940s Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-014 Date A point or period of time associated with an event in the lifecycle of the resource 1940s Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/e1f21df7afd232472e755adf61dbe7da.jpg bf0b847c6a59f57ea858fac0fdd5e2ac 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Copenhagen, Denmark, 2007 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-015 Date A point or period of time associated with an event in the lifecycle of the resource 2007 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/f3d9fb14b2a5f8dfecb2862c52e52124.jpg 647fa901e61ae5e59271252d4c9e96e7 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right) and Edward Shorter, 2006 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-016 Date A point or period of time associated with an event in the lifecycle of the resource 2006 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/13115a9834bd57ad71f18d39e4271f96.jpg cba9cbd3d43c44914abb6877a0b218ee 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, pilot identification and license record, 1971 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-017 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/2ef50e7d426e02889a9c9b6b41b9e30a.jpg 3c467e087aafb1b312cac2a541d432a4 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Nykoping, Sweden, 2010 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-018 Date A point or period of time associated with an event in the lifecycle of the resource 2010 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/b3fea1439cf39d58481542317f0d7a56.jpg d037cfc6cb6328a0c5288a49b0743fdc 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (center) and Martha Fink (left), undated Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-019 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/5ce7d73c53b35688ef49c36f129295be.jpg 4fa67e66a351f53004b75184ec87b37b 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (left) and Jean Bobon, 1969 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-020 Date A point or period of time associated with an event in the lifecycle of the resource 1969 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/f0e5d9d531f56323cca97665c0ea6a6c.jpg 21e4fe4b2a226656434d73519da09973 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right), Danish University Antidepressant Group, 2011 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-021 Date A point or period of time associated with an event in the lifecycle of the resource 2011 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/9b0194e8e6e41306ad3951920053d280.jpg f8c888b317c4eb6d66b8b1b4bc7e8c55 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (fourth from right) with Journal of ECT editorial board Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-022 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/75d624085f8c0afe37811fb0be99c244.jpg f4b44170ab8e177aece10929c0bc2fcf 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, MD (left) and Charles Kellner, MD (right) of the Journal of ECT editorial board Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-023 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank" rel="noreferrer noopener">Photographs</a> Relation A related resource The Max Fink Collection 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" rel="noreferrer noopener">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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/21957d69cdbec75a3af3c92b80ba3139.jpg 2c3423c56c5b26408e8014d9fe1ae6cb 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (center), Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-024 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/34ffc14c69353beb28205e3d083f74c1.jpg 15d767820d5675ff4b8227daac69b607 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (second, right), Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-025 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/f44d0c2625f1389edfd0c676eea438c3.jpg 207003d989abb5a29d50b834f258c445 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right), Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-026 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/1d2bcbef57a00fd9c29be83dab6e11c2.jpg a350b40dfa079384f6e458cb8cd13966 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink, Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-027 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/9bec4d07db9cc7bbdca592d03c5631f1.jpg e27ee77bdf6e164226f11d4601b974de 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right) and Jules Angst, 2005 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-028 Date A point or period of time associated with an event in the lifecycle of the resource 2005 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/8fb21cedddcd09ee293085e8ddd43092.jpg 4ccc01813c057ee2539defeddfe0f394 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right) and George Kirov, Edinburgh, Scotland, 2010 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-029 Date A point or period of time associated with an event in the lifecycle of the resource 2010 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/c5ea573b4bf4da79451f414252f59775.jpg ceab7141f10775850d473faf1dabf449 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 Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. 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 Max Fink (right) and Turan Itil and Helen Itil, Las Vegas, Nevada, circa 1970s Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-030 Date A point or period of time associated with an event in the lifecycle of the resource c. 1970s Subject The topic of the resource Photographs -- Photographs Relation A related resource The Max Fink Collection 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). Photographs