1 100 6561 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 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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/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/ce1a927f03a0885334cebe3e532e87fc.jpg a787b4faf4f9a825a0c61436412f1491 Dublin Core The Dublin Core metadata element set is common to 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 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/ebad71bc432e0d061b6d76102561eb88.jpg d26ec53ef5fc55ebe3fcacc96a4b2ac2 Dublin Core The Dublin Core metadata element set is common to 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 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). Format The file format, physical medium, or dimensions of the resource jpeg Photographs 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. 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 Evaluation of high dose reserpine therapy for the relief of anxiety. Journal of the Hillside Hospital, 5:67-77, 1956. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-18-022 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 Wachspress, Morton; Blumberg, Arnold G.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Miller, Joseph S. 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 V April, 1956 Number 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/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. Bol. mus. Hist. Nat., 5:313, Schultes, R. E. Natural History, 64: 120, Cardenas, G. F. Estudio Sobre el Principio Activo del Yagé. Thesis, Universidad Nacional, Facultuaa de Medicina y Ciencias Naturales, Bogota, 1923. 14. Albarracin, L. Contribucion al estudio de los Alcaloides de Yagé. Thesis, Bogota, 1925. 15. Goodman, L., and Gilman, A. Pharmacological Basis of Therapeutics. 2d Ed. New York: MacMillan, 1955. 16. MacDonald, J. M., and Galvin, J. A. V. Am. J. Psychiat., 112:970, 1956. 17. Bexton, W. H., Heron, W., and Scott, T. H. Canad. J. Psychol., 8:70, 1954. 18. Ardis, J. A., and McKellar, P. J. Ment. Sci., 102:22, 1956. 19. Hoch, P. H. Am. J. Psychiat., 111:787, I95520. Wikler, A. Am. J. Psychiat., 112 : 961, 1956. 21. Hoffer, A., Osmond, H., and Smythies, J. J. Ment. Sci., 100: 29, 1954. 22. Fabing, H. D., and Hawkins, J. R. Science, 123: 886, 1956. 23. Peretz, D. I., Smythies, J. R., and Gibson, W. J. Ment. Sci., 101 : 317, 1955. 24. Pennes, H. H. In preparation. 25. Gunn, J. 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/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-.. 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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/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/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/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/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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At mmmammwmww,uas«m qmmun.mmmtmmumm www.mmuutmuww. mummmummmmu m1“. Asnmmmmeut-umm �~21» cmumuuummmmm. wwmhmskWIWtW'“ “W'umWa thm). mum.uwmmwomuuu *m W. ��«so unmet-mum“. um,umt. mumsmmmunwum mmmamw;mw.mm wammdawmwm. mwm‘mummm mmw:mmmm~m Mummnmmuum. wan-am mum mm mm Wt ). at 2.2 «mtwwc mum'ap'ﬁhu‘ an mun-attain. m’WM-m an: unﬁt-Wlmdnutumm. Mm‘cmu mam”. ”mummmm',m. It. mt Win; it”. me WW �"35* mnunm u Mum mm mm «is: :W M w Imam” m t a M 3m: than was Mam u mad: mung: aunt's manna. MWWmﬂhﬁﬂWFn/nua m W WﬁﬂWbWMﬂl-de www.momzymmmu m Mm mMW‘fa a. mu» MWhhM‘WWan NuWWW. MW. “.mguummm nu WthuMW-mw. minim!» uwwmumtmmmmwm umwmmhawumw “WmmumuMMMu ��1. I. Wynn mmw W mat-tic Personality awoken“: ”in rmmmaa Eta-mu” W5 3mm 8.01m this, Fungal:V ' Mambm ‘. m Saginaw Pursuant: Far-a: misty Madam“ int mow- WW �I: CW, 15833 and» itiﬂili 9i ﬁﬁlﬂiﬁﬂisﬁﬁiﬂlﬂiﬂiaﬁi IZﬁE ﬂcxrtagiou �Wrww’ W ”mm m _.DEP.' RTMENT f“ GLEN 0M3: N. 1- - W w w— m" F’ .ma,, - 0! WEHRLHOSPITAL HILLS‘DE a a» -- rm , A fag—«m V ‘ ‘ U _ " �DEF'RTMENT OF ' ‘ .jy [mam-1231.1 Psvcﬂllm HgLleoE HOSPITAL . 1'be , ﬁg“ - ,_ ¥ ./'I /1AW ‘3 I / / ff"? ”'"ZA 1 1 / .’ I / LzlsA/L. / / \ / I ( / ,I s./\_ ( /r"—/lw*<’ ’ i .— I! V “MM/t ‘ ‘ I ,4 g.” x_/,- i“ ;/‘_ ‘1 I ‘ fA / / j "j :J“;¢L.p (Lx/VL I ‘ ‘ ��’ ( .~ 4, �_.%:&: —3 2w 2m_.o% . _ m 6‘ 3‘5 ��r—r-mv—I- humility but mum MW: Wt: mm lemme many mum We 33mm �‘ (a v mun Ramswmmmmmmm ’” «mmmmm. 311nm nomad W W mm W W Inward My W Waxy Mme. Slightly 1mm �”w.” .-,,--a-wvrv~w“7 w—z-‘wv ammwwwvmrmmg~ ‘ :memum �w-mun—um wNW~l www-n-wn cm m—WAI'WV-vrwwu A,.m~mmtrv-mlw-wmvﬂ.wn-memW-¢ "‘xﬁ'rlr¢MrW.m-wywﬂ“~va 4” .. vn' (>2 �v ‘nwv—cu. ""v- 'n’“ . wv— >vIFNIV‘W-ﬂ‘1-My—vlm uwrm. mW'IUF-ww.i' Ir-vw'I"-¥v‘~1www z; mm m—wﬂnmmJ—Fvw’ﬂarxﬂv -uww:vml,m mlx.‘ mW'naM‘s-ﬂreﬁurvv-Iw-‘fwarwmrxlv-Iwumvw av»- ., ~rv- . ��awn-n. "-WYN/E' ; cum—n .1 nu-men—w - m-v—w mimmmmv -..~ w mnnwm lg m. arr Wm! :w ":N..iv-" . Wm 'w‘mnw'pmw Wm at frat-nut Interinstitutional Differences in 23 aim Pom-mt �.mmuw—v m MY 1 “Wu.W, .«nv ., r“ ass-rw-mw—w - . W wmmfn‘w 2? 75 33 100 <20 57 20-39 20 28 79 ��n :v Vw-“Vu ,v -_. .y v ,y. A“. ”w — wwwww~mwwruw :vmimn: rm: mrrwmw Wmmmwwm mm . ﬁrm-row mar—rm“,mwlmrmm‘“ Aw 8mm .i xﬂ 62 82 55 35 89 37 29 35 me -. 37 65 ��‘74.? 5634 7r.o �E 53 65 10.29 3049 i 30 20 80 �79.6 9/ 1&7 V? 1 4L 43m ax? 737 «<97 7; _ . ?7 I)! v}.3 fo.o up 2L ��._ “Nu-u": n- vuw—n-anmwasw“):-.a~—m:wwvwmmwwwmqWn.r:wﬂ-wauwmwmvw-xmv-uwnwnmwuu ‘, t i v x- 20. mura- gown—WW .n 19 '0 o 11 ﬁg 17 1h 69 28 36 3h ,. . 11: 71 :u. ha 60 33 ' 20-39 59 . 20-39 5. ' <20 E ' 20-39 , 5 van-1 ‘w-n— our man �wwmmemI TABLE Munich V XIV and Duration of no v .mmtm am» in awaits]. ,rw—mqw gPu-‘cantz ‘ vamww Manon < W." 12 3 ~11 12* A 23 13 a 87 ’ w.~h.‘.w-, 12-15 51 20 22 £5 254 35 8 .. 12 21 5h 25 12-15 19 13 33 164‘ 9 21 21 w: 12 7h 17 9 may 57 39 h , ’ “Wm—r «gV\_..n..w_u_l_... w.” _._.._w MC 16*, c ��Wm.vwvlp.~ .- TABIE 1' . 1' Score 141' H ' 30449 33 10-29 30-119 50-70, m0 10-29 304:9 ’0» 0 Nation of 1mm < in. Ho Mimam ta; Paula 7.11 12+ 17 57 V 1“? 0-70 Score and IV m 33 ‘ 26 21 7 5 47h 4f: 1/ 1*: Ma? #3 29 15 33 17 69 6h 77 15 no 38 28 9 31 32 2 5 d4! 4 5!" g 93 US 214 O h o V 4 df 7? Or y‘ Y 05 ��" 3 . . u r." ~w-wm-aw‘m ' —L~"K'.uuhll a 'V'wlm m‘wmww.‘ -wmwmm ��M. +MI o I821. LC] 81.? K o 72.7 = 2. x" =/.-IO /:~s 20.9] 22.5 31.0 HH. 55%. “‘3 $8.6 =4 =5£7 X P = N5 MMHC ZED 49.4 25.3 22.2. 6!.0 w =3? x / =/VS 44.7 ��W“!- Aft-5 p< .061 N'- wmmm" ‘m'W-mmn“mm rum. V":I’ﬁwmﬂlﬂhm 1». ::-.. r u'< ��‘18.? 35’] 59,2. (0.0 . IA’. ‘2’ O 54,7. 52.7 9’51? MM (4C. 39% X’V 5/: / 1 r. P ‘ 77.0 91.8" 13.5’ 39,5- (47.3 53.8 9,/ . 9.7 7.7 ‘ .56 N3 ‘ V53 ��f 70 2 lé HEN” /.. / {’1’ 141.4 ' $29 2 ~- 32- é .5" �’<ZZ _ . 7" 1 I7 ' 7 '22 7 HS’ 5/ _______2__ . 39 ‘ ‘ FINN <7 o 7-— 6 . __ 0 " 3 I 11+ M?! [IQ 5‘ €=N3 5 33 4 7-" /$‘ ‘2. [If 5' O g I? a \\ NS ��W6’m 3 m mtmGoLﬁ. REE. 26. macalo 26. mam. mthnnhhmoﬂaimdmtommiw’mo' Hamnﬂquind,m'mw&m mu'nm.1,mtmmmwmca1.1.,nc. lawman analysis, the «en Gel. bum wmmm.29. 11m col. 29/ will b- mum-following 1,2,;th 29/6,?3 691.22/3 9.’ cal-dim“ 29/0 1111 m ho m. 5. ma far 29f]...2,3, ,5; 29/63; 29/5,? m and com «:3 an 601. 23 and 601. 26. aud-u Inmmamthath. mum‘s-um. WW 11:91»th Bogart-ant at Lunar Psychiatry, amino‘nybomm um, 61m Oaks, I. I. nmm. Rommel, 1: than. my difficulties um: um. any“, I my 3:. roach-d a mm. 3—7”, Monica 235. this mm, My“. to: Dr. shun}: yum-I. nth-ma. '3. mp1, mm. �iua1apuruhoxnclcnt Aspu¢1n or 311.21 L. Kain. rn.n.*, ﬂhﬁﬁauAul Ptrtiaitriu trcaﬁnautle In: rulxauu, r119. 51.5.1, ra.n. tad ﬁlm yank, «a. Buymrtntut a: r:«. 01¢: 8.3. Expurmsaneax Purch1a$ry, 3111116. cult, 1.1., I.!. AAdnt 11 putt. h; ‘11:! 31.209: at tug Iattsutx Ianiisato acuith. and 150 1.3113 Pabltc Buntth innpitnt. v.5 8.5115 lonrd. at 3.11:1 strvincz ”unﬁt! Unna¢uhurot§n $113!: Innis: the unaporuﬁitn-ox if It: ti. Icalth 6.31:: :31 1h. c.r. uonniusar ﬁaaorstl aaapatux 1: ¢9m313 cratnthllr aukunmloduuﬁ1 ; it ’I& 31v1u1on Srozgatﬁtgdrutts 13 2/63 . at Ptyuhtntry, nontuttaro ﬂcnpltal, �In innit liuﬁr or sun luv pupuxmtttn, Rtlltacthmnd 5a! 83"; ynxuhzutrta patient ildlilh rtpnrtaa atnatttc£ut rolntioulhtpo bitumen In innavzdnaz‘a yactt£¢a in tha tuuinl clams Itrusﬁura 3nd tan yrgv:13aan at trantnd illausu. typun or dilﬁﬁﬁltd aka-rduru Inn kind. and ﬂurutiau a: puruhtntvxt trvutunut aﬁstuxstgwod ( ). Char indimutté, tar txuupla, tht§l‘hig§ur vruyirttiu «f 1¢§nr alutn puﬁtinto in troutnunt wart alanattata yumitnma at It purnhntaa uppur 91:5: nae pcvtunnzity will. attairteuntzr high.» pmn¢ patiuuit Viv. eluaattioa at nauto‘ic etuurdtra. 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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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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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/6ae8392f9c68d3b213edf8358a9597ac.pdf bdf1e6bcabb4c1d8c82905940f4f07c2 PDF Text Text REPRINTED FROM E. 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/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. Kahn, and Max Pollack 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/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. Pharmacotherapeutic evaluation and the psychiatric setting. A.M.A. Arch. Neurol. Psychiat., 21. SABSHIN, M. AND RAMROT, 75: 362—370, 1956. ��We. lama-b.1031“! at tutu. cantata norm In: rum rum. and “no“. at. In rm IJ. no What a: mum»: manna-y ' mum mum ' In. v.1. at... at... a» 18-1715. ”-10,! of In“: an lulu-.1 mu it Intuit. put '0’. 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I“ Shh)“. 1!“. 7 4 * * W4, g. m. �at. 11. m, 3.3... hawk. It. 10 816, 195?. nu. m m, 3.: m . Wm. w. M. an run, In ,1: “S. to”. mm... 2.2;... '11.: In... «a I. «mot, rug. 1!“. m: I”, 3.3.: Mm. at can mum» mm. a. «a 1.1... hunk. m mu,“can a train“ «W. ma m. mm. Km. and u.‘ 17. 1.. 1!. 3;. n 0.33.! "at: “um“, twain-nun and m must. mcmwummm hm. W” um, um. mm... 3.3.: 111, m: an.” 19“. a. 1.. 1.: m mm, mu. Wk, tam-u. 5.3.; m: I... 1".- 1,5,. woman, n. on mu. 3.»... w. W, m.. “W. IO. 1.1. was... m kn. Ian ”5‘38’j 1,5‘0 m”... a. mm mu» 3”. ' In. 1:! m, 1’s‘a I. and M... m: g: “WW � Dublin Core The Dublin Core metadata element set is common to 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 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/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/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/83ffbada2aade577e8a98ad3651523e9.pdf fc1b31ed52223d2b16d46a30284791a4 PDF Text Text Borderland of Neurology — BASEL (Schweiz) Conﬁnia Neurologica Grenzgebiete der Neurologie - Les Conﬁus de la Neurologie Editor: E. A. SPIEGEL S. KARGER NEW YORK Separatum Vol. 16, No. 2/3 (1956) Proceedings of the Eleventh Annual Meeting of the Electroshock Research Association Atlantic City, New Jersey, May 8, 1955 Karin, H., M. Fink and S. 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/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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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. Inuﬁttntoa at laulth, Intlnall Innath, laatal Iorvtao. ’rnacutod a! nastiest fartholuntaul inuuctn‘aon. l.!.. luau-S 195? ‘ Vt: 10-59 �11¢."de nun-mints.” in mt �Iaaurtocrilnd Dinertllnntiaa Attor~xu¢n¢¢d llturnd Drain Flaottlu at «unplax $111.1 yﬁvucytaau with altartd brain :buattnn.£n man have lat ulnar: yiuldad Bill! or couuautaut rsIuZtu. an. dtn‘groanautn to at. to stay Inn‘oru, than ﬁtnuxgu I! dirtbrcncoa It: 1a populutluu s‘ua1ca, $39.: a: tools :34 pranocnrna unplayud. and a1:ttou1t1.a In 01.1;‘t13: ﬁlo d:¢vao a: Iltlritltt 1g bruit minuttaa. llaitrOOOBthttvo thnrupr (ref). houuvur, prcvs$un u uaaqnt oppurﬁuuaty for 1%‘431nc it: vitamin u: ctrubrnl irntinataan in ‘htﬁ no». acouruho .oltvol tan b. untacntnoa trot tin Cairo. at tndnata corubrul drutunntaau and its gonnur'nunt. will. invautiguttann at ﬁrstnntuanrud pdpnIntitnn hnvu ttauucod 10! it. loot part on ﬁat til. at loéittal‘of logttl on ht$aviur. nurroat ltultan at an! hurt taphutitad its manna rum- .3 manna: a» «mm... mun“: ton aim-n m- unupm; (a), “man: (h). and pmwmun (2.5) vtnpauttu ‘0 not. In Iﬁdl‘iia, Virii‘l portounlity (3) and loclal luster: (6.?) ﬂat. bat: rolntud ﬁoldtttortasau 1n rtuponno $0 ‘rcntuunt. In it. «attic a: la invautttgtSOI at ‘3. yorunptnnl :36 tchavtavuz thungca with Int. n.Iauvulotvo~osboouvnlutvo unailwz .5343 cat Indurtaktg. In ‘hiu roport. sh: partorunuca an outwit: vtnunl Qtakt it praaautud. splattaually, tho .1: 83' to ﬁattrnino utnﬁhnr purcoytlnl thing. iﬂdlﬂid up new it um suntan or an behavioral «minute and uhtilnr it; pvctrttﬁlnnt yarotpinul pttiurn is roxaind ﬁt plytitltciu chance: with troatannt. “um u «m; nuns um “um: �4". m ”and uni 1a a. menu “mun “mu and; m «- a Mini: m ”In"!!! at which bu tun unity“ a mum you: 1: than 0: ”run“: WI a: um ”um «I be“: Wu:- nﬁnh (1, 0. 16). �m: 1) gagglggﬁggo rttﬁy-£hrcc coal-cuttvc putt-mt. martyred for In! rare s‘n4114. 230.0 includcd 16 no: and 37 Human. I1¢h n30: ranging tram 1! to 66 utth a Isltil at £9 rinru. A «111604 tun rauduu gronyn. I!» patttutc var. at tat. can'tzntvo grin: or I? pntlnuta too-:vud [kind In: olonﬁrnu ' thorlpy'vttb ponto‘hnl pronndsuattln ﬂhrco'ttnna a aver. tutu; utﬁhar a lcdnrttﬁ t1tarna$¢u¢ entrant tustrllnnﬁ or u A e-hv olcc‘ruotSunlntar. mitt-I: at 1! ‘tOﬂﬁlII‘l lattir IaturIAnoa nmahar so$a1 troutnoi‘n c: given. III It: rut. by it. any-twining ,lrahlutvtlt an churxo at ‘ho truntncu‘ A 01 nubcaavnlltv: owls-via. 01:110.; basis unit 9» ti. (was: a: th patients van truttcd 1: nihilnr t‘nhina, uxcapi that only unbcouvuloivc a‘tln1n§1¢u van given following $30 polbthal. rbnrtctn of thy lubaoatavtn tho InbouthI-iva grin; wort cuinnq13ntly':1vun a rcgnlnr coura- ot couvulatvn tharupy. itch prior ﬁo-‘roctutut and I) £2:ggg§3g§_§gg§u In it. it. any tullantnc ‘5. 12‘3 ﬁction vtﬁh a nultttatttaa of nu tritiuunt can) pa‘taut an: hiddun £1113! oottaohnll‘ it. to.‘ dovulopo‘ by Itt‘orlby'3§_g§,(1). III Ittjltt is prouontod with I page containing two torn. ¢ a usual. cut-n$rtnl which QIH’XQI and in holov 1‘ in. atlulc ticuro a tantru, Illlft an ouhcdnod (11;. 1). tbs passlnt :- .akod ‘0 ﬁrst. I apoottio goo-attic ttxuro tram tin inchcrcund by outlining 1t vl‘h t col-rut 903.11. It: altars-tuition: range in noupluxaty :90. —-.‘q--_ 313. 1 Cunﬁoodu �~h~ such :5 tr. diucrtuiautioun. a .311!!! at tun uluuton 1. ullnuod tor onah. Portarnnaco as :¢¢rud in turn: 0: ﬁnial lllbir a: aurora. lb i181l1‘¢ a prautttn Itruct $ro tqslvaloaﬁ lawn. a: $3. iau£ any: unod. 2h. torn: var. nltaruntut vi‘h Inactnuav. yuttcu‘n ttlnttvaly ainplt ta hart couplux. that: “prawn-u ”um. mm: What a. ”unﬁt m ”umuu an» m an autumt tun um um mum”. 3) _ . .NMV . ,Jﬂ ,7 run Inalurol at ﬁrst: Stuntiou . tun cluatrnoacaphnlogrna and st. nasbattxtil taut (11) '0'. ctvuu in itih puttnnt grist in. uni at vigil: ‘1uﬁcrvu1n airing tronﬂnnut. 13. n1..tuuunaophn1&¢run In: tvdlnntid .- to th: dsxtno ct tutucod delta activity tcgor¢1nu to ctttcrtt prcvtoully publishud (s). Thu nuabarbttal tout nogn%1vu brain utt¢¢ for or pouttivc lycttnatiuu a. It. uncaritng t. ntsudnr¢1Qid critoria (11). it. rattlta u: this. during sh. sonata. third tad rourtb itch; of ironing»: turntlhod tho critcrin tar phwutolocacal litill. A «onhiuad 'Bhrlltltxtﬁil $34.: was obtntnud by usarihtn; to oath high inure. Salt. Ila UQIOIC nut 05:! poattiv. anotnrhttal tnnﬁ a lanai a: nut. 1h. rang. at phwitaloatcnl a1&nrat1nn thuu test: ruagnd tron h) atra'io nix. la tr *1: It Bash pctaauﬁ's hchnvtor In. cvnlnatud 3‘ wtokly intarvals. Artur ‘3: 12th trcn‘uant, a rtttal for it. dugvnu a: bnhtvinral thing. It: and. ¢os.vdll¢ ta tan! clnsucut unwind, nod¢rnto. Iantunl or menu. Th... rating: at «hang. vura ant VIII. audgnnnutu ta ta tho unaatty �.5. u “than“ in“ “my «unaba- uuntu‘ in boinvtov pu‘tnrau unit: tintlar mandatsana at uhocrv.‘10u¢ than. tuch‘bolnvtur psi$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. Intrusrtur‘uaalyaas that: thus tho ,Ititotvalaiva crazy aqdn utgnitivnntly tenor ovroro aartn; tru¢tnunt, whili thc.uguvultavu pn$1¢atu nun. stun:tt¢n&t11 . '3’“! naucc&ao§~ um I vriur to tvattunat, subconvulnzvu pattout: Inn. upprcun alnﬁnlr ﬁts can. nuuhur 0: cart»: 1: than: in tho annvula:v&. autumn of «1:05. Wing trauma {my vi“ a hatunda tiott gran»: (h.1 cfrorn) «aircrunnn hosuvwr, t3. an m untrumt a «an: «m an 1:: 1m: or wanna“. Intlywod tit) racpoe‘ to phyiiclazit cunnsc, utsutrlnuut xgcrtnuoa in error. art taunt out: ta than. pittnntu ut‘h 31.3%.! diurnal at plrltuloxin ohnagt. 2&1: rwluisunuhtp anabnrbttll taat and the it pvuuta‘ tn $hc analyttt or :36 ﬁt ¢:partta latte... 331 was: tit $20 tact: urn «unbluoi ﬂﬁnu tn. data 1: it. (Quilt 1!). “.‘.‘.*..mm it: fun raltttaauhtp intact: tn. 1032*. 01 bahnv1:rnl chant. a:& chtago ta nulkor of «pants dnrtng imattuant-ta inﬂux ti: or a... an: «an m. ”man “am want. a �at?“ bchlviar changcu £1: acﬁ than an uppgoainbio difiaruaeo untied bchnwilr chanson, In author a: Qtfl?Io Shag: with Errata-It. «trans uaAc crvarn nuratcnttiolatly lavorur, > tn‘woum 143%! 111 rnlnﬁtou tin arctroa‘I'It atttr 1:11:31. at 1n 17. thunk chango ta tail! of phauanlaciuul in tin ducts. roloﬁtkunhtp hetuuuu tin prothan uttnttlaaaﬁ a result. it: 00.9.. $3 phyat;lo¢tou1 change or incrno ‘roaﬁlcut crror chanco physiological with Itatnnl Pa‘iantu during trons-ou‘. a: had prntrhﬁﬁnalﬂ intro u than convulclvu ‘hnrnyy ‘ﬁfll' anrhad uh» phyniulogtoal duvclaycd ‘30:. 1.! aurora, tail. ﬁrst-21.1 13.3. 1:. at htd acct. protr:ntuunt a nut: trtoa$u, in rhyrt01131¢nl «hang: and corral-ﬁat. at protvan‘nunt tear. *33, ttgustaoaut t$ ‘ho .05 lcvul a: canttdtnoo. ”nan-unufllﬁl I? IOOIOI and 1h» W Altamitlcnn In a1:- 01 (aggro or in unit: unpuu‘: of ha‘h sot£1n¢ partoiac taping arrow at annual typo. no». (at: ear‘atn qualiﬁn‘tvo patiorua turn troqn.ntly'nuta¢ «‘21:; inuniuaat ho-Ivnt, which oacurrtd our rarely a: to I lancer alﬁon‘ 1: tin prttrultlun‘ portcd. It vat gonna: for putataﬂu �mu. I: m»: “I rum man. m m at 1'10th sun-mun” mu» ‘ 3 auto" m: mm: :6! mum“ a 1’. 2B 19.0 .7»? *2“! .0! h) 9.5 11.8 «.3 -.ea ' my“: 1“"!er 811mm now 0: mm "plant“. in this and aubuqunt “nu band on �. Iu‘rnctunp cuuparlaonn ,1331nataauaa Iran: Aaszsthéaa!_z:£& lung or on. ,- In: lI-bav It Izrnra nut-rt I Inc: Bittbrcnoo 1- 13 06.! ,‘Ci‘l’i :8 ‘30? loan or at. high «01‘. 23 01.7 pauzttv. 9!. or thrto turn. or401%. ﬁt. high 3’ Us and 'IleI p Int tinnittaon‘ 001 lat lttuttloant , ' 10 .3.) 33 *1.o :3 ‘30, .05 lat attaittcunt . 001 �-W and having Safari o: strata cunpurtllnu tor_IIuh¢r In‘rnur1up angrvo O! lohnvacrnl ﬁlingt . litttd ”liturunconilnbﬁr a: 03.6 01.0 ~0.h Eh lb locnrato hiatus: or that R¢1u$ton I lat: x W t: at Pritv‘nﬁnunt tutor. p x... .ﬂl lot aaanlftcaat Int atctitlnant xv'utunx 20;?!0 or rhrltolscidax 72353;; agggg‘ zggggggg , W! 9 $0 2 3 '3‘ ‘ I 1‘ 70’ I, 11.1 �«a. to ink: I6 nttcnpt tn tvtau ﬁt. hora cunplcx figures. was. v.1poncc uga ottou unnaaiatud lith I gsnarnltacd r1tbdrauu1 rcdctlun in witch ‘ha paticnt was unruuponniva $0 an: attnula: u! pracodura. ethnra b.3335 hua‘tlo and uncuttviuilu touted it. tasting. ratauntu with th- groaﬁu-t tumult or phytiologtanl thing. it‘an had ditticllty I‘llivtas tantruc%a.ag. 13¢: it‘ld in... ‘IC 113.. stalwartntn.tolr I1th¢:§ rognra 1.: it. #9001113 tigurt‘ic it uttlsutd; rtpousod a pruvitun txatr‘ doapitc august. 1: ti. #0:: figurn; draw 11:». uhnro aunt uc$nully Oxiiﬁad; and aﬁtnnutcd to trlcc tbs tttunluc tinny: Ital-'1cuorlig 1h: Into couplcx toot»:1:url. patleuﬁn VOID and uhuvud it.) might 11kuly ltttlu ﬁuah it rcupaud quickly and tawlzclvuxr. o-annvu about making an arrow 0": «tan apantanoiutly dounont, '1 luau $hst'n unt rich€.' �W! .9, bdiuuon $|o d.:run ruln‘ionnhip fit: Ot'ﬁi’ibrll‘ﬁyiflllﬁtlt and $ha aggro. u! parnuptual :Itcrn31ln taut. unbuddui PI‘tcutt eh. nunpurod on figiruu an h: crrurn ‘utth aubcolvnlsxvu uttlslntton-Iika shunt aurora an rotuattua. A ultghs dgcrauss or unwahanul tn Ottawa octurrnd in that. who riogtvzaz ahnitd cuntulitvo ally'haallnl thirty: pattlatt thing‘s. in. aunvulsivu pittcatl, houivor, ut‘t pkg-Intogtcul atudr‘luunlatrlitu - & 68. unit anvkud phamaglcgtcux altsruttnn, Ihnvtd a ctxuttlnnat tn¢r0330 1n number at strewn. 1‘4: lntorrnlntaoauhAp at bruit £una££un aha porcupiiuu or caboddcd tsguvuu is in actard wi‘t atudtnn of pu$tnutu with altarud tibia rua¢ttiu an. to htad wutaatoia u (10) uppaytng fwuﬁtr tad taunt. taint: ul-ilur inuhuta 1n QISI& with pauotrattng brain unuadt, tutu alldud that ycrrurllnan Inn_uarnln&ua to lien. or lonlua but ihat uphuuic pntttnto and. nixaittcnntly'unru arvnra thtu & unaunphnnlc bruinwtnjirol group. Pollack g§_g§, (9). 1113‘ ruporﬁod Qltc SI an taxation-t1, an taut atuty. tauntttul tit httuuul attain and ‘h. laaation a: 10010: &n tutor patsoutt. ﬁts rnlutol author at that rwporﬁad. tuntnnd, in: Irrort it!) to it: stvurtty o: amok unut¢1 changes an dzuaritatntiau. 1‘ should be yuanint o‘t «hat the total prc‘roatunnt than atom. tow I11 pntlcnt- r‘larraa lav upnvulntvo thnruyy ﬁn sauna hy saunt1¢a1 10.5 n linou‘ nun». tat! ctrurn. at. and brain nxmk 21.5%: (9) an um: man tw pltluu“. an” ‘ use populations It. auuparublc 3: turn: .1 a£hnr pntnntﬁura £11or1u1u.~ xvuund In $3. and lattata figurt ceuautiwa. a: as. two �‘16“ iii! oaunct in rugurﬁud an rntlntttvc o: notnhrtl 43:9inotaou an an inalnﬁad out$£y tbairna‘od (It. ﬁt. t¢tn11my at hchavtur. hasn‘t ‘hll beta; :- 3.0Io in tin rolatloatth, your parttvuuaau tn aunt inthu any be due to it: internation a: Ina: tn:$«rn. mu 117thth um. an); an. my “on m nu.»watt nation cnrnbrcl din... uh» lit! fi'tf hit!!! an $ht- iatk than ocntrul llhltt‘l viﬁh tn§n¢t turtbrnl tunataun. In in. prbouaﬁ otudy It. rtugc at altturoacou lull: $hn pattunﬁ: prior ‘0 ‘lﬂﬂildli nun cruator than thnﬁ uhintlud cvua‘ux‘h atrium: phyasalartall chlacu. “’11. patlaut in thy nahnoavnlatva group wish I high author at prutvtnilaut «trorn at: ants a yrlattcn attics In ritcnttn; watt a ruita£1on in crrtra, hit nbnulutc arrow near: :nr still bu hixhnr tits shut it n puiinnﬁ ronutvilu tournlntvn ‘hnaunr_uh¢ had Irv protv*ainnnt erurn 0“ I:s alum: auurtaacd dattxaulsy with trociunnt. than. obnnrvatioan tuccuuﬁ thtt isttanulty 1| ptrtotvtnc cnhaadad (tutti. ta tainted to acrintu ’Oviiilltiw unpocti tn v.11 n: it ﬁrst. ttwthnstailu Galituﬁalt with talc aanulptiou. ﬂttita (1!, 13) but thiod tha‘ ﬁt. Hurlid thtividi&1 dillnrwunua in tin porttptaoa-c: haddnu tautrla nuns; 0011.10 otudoatn If. rtlnﬁci to purnounIAtr tun$oro. its rvlatlllnhip or parucpintl altnruticn to bohavtornl 1.: clearly during u: u group an than haunt ,puiauntc at. thalud Qt. cystitis snaruutu in autumn during trouﬁuant viii than. vi. .130 lhlﬂtl tun swat yruaouncod ah$a¢u m t manna. �«11¢ mucmd mm puma: cult“: team”. may“. Wt... “mum. «aunt-ta a a: to “we“ m mum m“ m mutt" on a» mom: tutu an mm tun-Int. ham to may 1n or mu. pm» «at» «um tut m um‘ WW 1» in Inﬁnity um "mum u t pm.“ at «ml mu, “ton. A or raw- to an um In! of mm in wanna: "mm at non-um claim ”its!“ c: mm“ 1:. mun“ :- «W. m «$81th with «d mu. than” m. tho ”that“! to arr an.» «aim an n m mi: num. a. a 0: 0: m uuutm 1: tutu mum. am... a can N on mum.“ u Mutt“ an omit: ﬂﬂmm tut with or a m ammt. u it. ”won “and“: u W mmum to 0 in in rim . am nun“ :0:m 3m1¢1u1031 mum. in “an.“ manual» m In at no“ c: a «an “null". that». WI1: mm an 3m um I m mm“ cm“ «mitnm a Manna.” ﬂu at ﬂu t ”can.” «alum for at Ma pron-«mat mum M3. mulch. mm man»- that m in a» mum! wanna».- mover. at of a dam. mun-«u: “an a 4mm“ ma M at much "nut ”nanny. u m an (a, 5). to ”an": �all; taxman. manna ”than ”1‘qu hr in mm. m an: What “tummy an um; A: 4“ ms: an“: man «ma mm. that... 0: gm, a 0: I! united min-um ”an“ mu mi 1. m mm: i It“ mum: Man...n-mu‘m with ”nun-a My nun” ”ulna «hum. m In: a: It pmmutm my. I. a. madman “110'“; What M ' ' in»: an an “Mina: m “I! «am... ram as manual no» mu m tﬂlﬂﬂ'ﬂth in» tun-nu "nanny. mm an imminent” mum u ‘ ' ' 3. mumuotnwmmunmumnmnu “but!“ “use. p um um: mo autumn: of bran alum m «gm tutu“ amino! mm u In run-«hunt W Mm at ”nanny («my tmhmt. I'M 1.th mint“. “ﬂute!!!“ at “It! in .1 psi-«pm W10: mu“: “than chum: «1mm». no puns-u or human: 5. m M am �mm: M. 1|"le 11133th a: hut (ulna. m 1.: In.“ ma: man ﬂu u mutt as also.“ m1. "by 9.: Wk mug-ma um m an.“ u 3. n g m an: m tn um» Hm. «I: u “I“ an at“ m was “we. W m �«1 3a References I. Inttarahy, w.s.. traccnr. x.r., reliant, n. and nundlr. 3.3.: figuruogrcmnd ¢£unr£uannt1nu and the abatrtut uttitncn 1n putatuta with narchrax neayltnna. 5,555, ‘4 xi, '_'_, gaig.~;k;w., 19; 369, 195$. 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/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/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/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/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/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/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/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. 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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/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 ‘> . M=H Discharge Diagnosis . .. . A _ Much Improved 61 Unimproved 10 ,WWWWWr . x3=29.3; df=L- Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde <.OOl ~~_”__M 17 26 29 WmamWNW-w‘mm mmﬂmw —-_.——_...__.... . ~... �Hillside Menninger Hospital i Hospital Massachusetts Mental Health Years of Education ' F Score lBO-h9 ‘ 1 b1 l 50 i 38 �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Sindrome 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 �1. W um. mam. W. W W 9.11., “at“. . 1959. I law “mu-m. 4...: 1.1.: a. 3. I. 5. 1. Mun. am. m W W man at mu: tutu“. mama-u. tum-«Ina. 5.]. an nun». no. M rm. m- we Wm: ‘ M. In... ‘”.o m. 3.1... rum. 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'0'. mm. 1/0"" ��unmumm. mmrm nit-a ma lunar I m. in!" «an!» ma nth, :- ”unto annual Wthan: ”man“ an m (1.6}. no Mm“ m mun thorn”. “mulls“ In! a 0mm pm.mmnmmmummndumn and. mm that at tun not!” «an» an “h mm“ cam 1a mam «rant: n! ”’0th tan-taut nanny hmwammmmumuummm in arm unu- uu-u. mum... ma um nun-um to ~mum«cumin-nuns».non-mm“amounting“. 9.! the “Ian ca. ”and... 9.10.:th .. ma mm mummmwmmuommmn loam Nth an“! mm. Mn “tutu“!!! M «ant an“: with mof 01' tin mutton that that «no! ”that. nuns“. It In “than“ tint 1- than in in n «mum-u: an“ “that. W! mum tunianat a“ much In!) 1. a man mam. nth a than W WWW-what“ mammmuMum-Wmuan nu tun «pin-ha M W “at: and not!» rm: «Input-natahat nay-haw mm mm Wit "It“ “roam ”In“! a: voluntary nun-tn m «an ant ”and. «than: «an. ‘1’ mom-anarmauu-mmumm �as- mum mm»... «I m manual: I!“ in and I mm m mo“ In. was mm m. to it. “but man» a ”I.“ in: of o: mo a What. mm mama“. 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Mutation m “MI-pun M um auroral. «a m a m. imam «nu-um m «mum. am an on than in manual» it “uh-mu “mm and m; mm ”aunt ”mm. a sum “it my 1| cum-mu: um um Manual “0 his an an" .8 an and. awn «mom. Wan-numoumumm” or an dug-nut «an. I“ In. train“, a m cm “an a hat-o» a) m. 74.4-.2,‘ ; 4%.: s n. ham. :0:- muuuu ”am my!“ 'MQMMW“ mam. in» muu‘m. has... many a amnmauu m caucus. that a W ”M WWWWnammuwnnw magma m» ”as” m .mm loan“! A. m “in.“ u in. tout-u a» m pmmwu mu.” m manna M of "him :mamun an.» an. n lama mun: m 4mm a Who“ was“ um: in taunt. In“ n:- an mm mm. a �ol- M! mm.” mum «nuts... .0 moi-mm il- muuu pmmm. I. m«an m m “a“. u no human“: mm in!“ W‘ mm. at: not but m Wm manna» mau.. m on n o: mitt-u «01mm m Mo ration“. mmxuuu. ”cal mm... an" m m1“: sad-nu. m1 m6. at not Ion-tau an at mm a “I nun m Wu“ um num "mm 3»me n m mm for annual: mumt’a 1.. mamummuumumruum.um at out: out. Wc a“ mum W103 W“. Inuit-(u lupin}. Imam). manna-1 I») Wu rm m upland m “(ﬂu-1‘3. 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Will-M m mum in It :- «r m mm «Ilium «um m t. «(tum mutt» 1n in min- um: an win. 1.: must“ to”... muuum 1: «am at human» um aunt. u at. tho min“: of magma: rmuum, mmu Quinn-u. «Imam or punt-than”. m m «an. and Mt a: m“ «a. M. “van“. �~13- nkumMm'mlrrmo-um «mutumu a» man. mawdmmtmme-v«qu up“ a mu cum "mun «nun» Mn a- unummmmuummuumnm. «umummvmmtummm”mumsthe M nut Many m W1. mu. Mm mu: m ”an“ pm! mm, mun M W tummﬁmmmtmﬁmuauwu than m “law. in. «mu mmm rum» M m pom» What man. u m, mm. x... 3.. in u mi; who“. ma Mun-t. mm» mm ﬁlo which “I! ma It”. ”um“ IWQ mm. m in m and ummummuuuumuunmm. ill mm mm» mu“. m m it". usumumsuucwmmmtm It on nun» ”tram «ﬂow 9. manna. «a MI» III u “out.“ mm mm. mu mm pm: a. ham m: m m «scum m We Oh. at a! u» may u “an um. man a. m mu I. is. mumn'l m "um, I. um an m Mm Mat mutton :- tho W W m �«15. W W «Mm-Quantum. nmmmmm x. my mum. mxnm' at Mal-at mm vacuum u m a» an «sum at m (5) hwmm'tWMWMWu-num «that ”I". Ml In has nun-m mm a a. mum cw. rub WW «m t mm“ mm mumcmxnmummmmumm. MMMummnuuuMu-rmun nun-nu: mu m mu, It to II! mun“.- an mmomomumu$hmmwu ”but: u m "not a: m mum's my a m mn.mummammmmmwumm unqu- muo- u 'mm mt“. n ‘mm at" wanna". w mu “mun“ In“ «mu-m «nu-comm.» “Mina mm. “MI: W WI. manual. «1m M m m mthat“). m “no haw by m the win-hm not}... at mumm- W: mwmmmuunmumm. mm for tho” ‘8. maﬁa“ that to Mﬂm‘t it a aw “not” ”ﬂaw “in. Muwuum‘wmumnama a: mum). In a mu" than“... may nomad“. tummuuucmmmm. Mu Hum, am“. nm-mum a mu at ‘ �WW m We W Aspects of in mom L. Kuhn. Biol)... Mn: Volmmy Hospitals Pollack, Ph.D. Nlﬂ'micl 81.301, Bub.“ ski Max Fink, 11.13.”. �WMmdanwlmth-mﬂmsmumtudat th- Dcpu'tnnt of Psychiatry, Hillside Hospital, 61m Oaks, L.I., Wm N.Y., 1959-82. MWofﬁuauffsofﬁummmm thathOuTtwmmc.F.MminwaHo-pimismtem1y mm. Aidld, in part, by grant: Hit-2092 md bit-2715, of the Nttimal Institute cf Hontal Hulth, v.3. Mlle Health Sonics; and the Nassau Oumty Minn]. Halt!) 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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." "Discussion Section" the in "Results or done in be the whether this difficulties"...the latter Cole in Jonathan with be will visiting Please let us the evening want on spending us to plan I certainly Washington again. schedule I will on advance notice this have we a and if little together, know when you my time accordingly. My best to you and your family for a most happy 1965. Sincerely, Nathaniel H. Siegel, Ph. D. Acting Chief, Social Sciences Section Training and Manpower Resources Branch National Institute of Mental Health Enclosure �M L. W. liﬂunhﬂ.&hﬂn1,Ith" Kin. $.11... MI! nu! Nu m. 21.0.“ 31.9. �-n mmw — vvr-nwr w)v-x<v-'r v -, — 1‘... er—‘u‘ -~ ‘ m-vm.~—~v---ww—WVW-"— av uwvwx ':vtwv-‘uwvwav<< -... . >rv—zwv-Inl“ . wt. u-vww-wmw—m—m‘ vv'vi'ﬁ‘mrr w 4w.—’wn’.~w—V'WWV MIMmm-Mhmumwa mwdwmm.mmm. 3.3.. mm. m. mummmc.r.mmwnwmhmmuy m,mm.wmm~mmm~m.dmm Mahatma). mmua. muss-mm; mun mwammme-m Lain. mmmwam. mmuumm.munmmm Cmm: wmsmnwzm. mm". a: mm mm mm mm. W. 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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. Type abstract on attached card and mail promptly: a) Indicate purpose, extent, kind of study, materials and methods used. chiefly to new data—the high points—informational, not descriptive; criteria, technics, diagnostic new new new new statistics, apparatus, e.g., new evidence, new preventive measures, a new theory,new treatment.Do not use abbreviations. b) Refer 3. The abstract should not exceed 200 words. NOTE: Accepted abstracts will be printed concurrently with publication} of the original article. PLEASE TYPE THIS IS THE ONLY REQUEST PLEASE RUSH �DETACH PREPARE AN ABSTRACT OF YOUR COMMUNICATION WHICH I LL BE CONSIDERED FOR IiIVITATION...TO PUBLICATION IN THE JOURNAL OF THE AMERICAN EDICAL ASSOCIATION. Suggestions: 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. 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/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/. 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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 , . 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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/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/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/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/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/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/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. 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There were no inatmaaa‘ at amsma or oihar abnormal lawman hint in the day ramming its The Waimiim. timer, since mi «was mobarbiial paiimia, this my have Want.“ main in all oaaumnaaa. The 63.1mm md EEG rasponaaa in inimvanana Mamas manna similar to mum ihm am in mmmiial “liming ant-210431;: in when what-him ��tor in mm the mung We, hm». ma Wu dimming did £11130 mat. «that «ﬁxer swam, am we mam”. ��1.. WWW pmwm patients ﬁtment «relate: We were given arm Minds (mu, umwlamymunmm) Mum and «hints tratim af “ﬁnances 2. ”We prudence irregular dame mtivity, bursts of delta activity. we mike and emu Wﬁty in the elutrmoephelngm, mm to WMWGI (kiwi) . effects are 3. ﬂammable Sum agent. . The WM. the meant-y to h; A. grand mum variability mm in the amt er pram the" We ' u: «um um: inadvertently manage in m mum. «rum showed mm emanate the clinical, and was of the EEG W «hang the manage; and Mar to the alumna and the seizure 5. 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/ec4cf1a3f19d135cdae9a13c9adf5bf5.pdf 067f3d4f0480ecc6b50bb9561e8d4277 PDF Text Text Standardization of the Face-Hand Test Martin A. Green, M.D. and Max Fin/z, M.D. the face-hand test, has been introduced in previous studies and the responses of normal subjects and of patients with psychiatric disorders described in detail?“ The test consists of applying touch or pinprick stimuli simultaneously to the face and hand while the subject’s eyes are closed. The subject is then asked to describe and to localize the percepts. Two general types of responses occur. The two stimuli may be perceived and localized correctly, or the subject may perceive only one stimulus and either not perceive the other (phenomenon of extinction) or mislocalize the second stimulus (phenomenon of displacement).7 Most often the mis— localization or displacement occurs to another part of the subject’s body, but occasionally there is displacement into extrapersonal space or onto the examiner (exosomesthesia).R Displacement of stimuli across the midline of the body (allesthesia) may also occur.” Normal adults show errors in perception on the initial trials of the facehand test. Characteristically these errors consist of extinction of the stimulus to the hand whereas the face stimulus is perceived correctly (phenomenon of face dominance). As tests are repeated the errors disappear so that by the tenth trial nearly all subjects correctly perceive both stimuli and then continue to be correct on subsequent trials. This type of response has been termed a “negative face-hand test.” It occurs not only with normal adults but also in patients with schizophrenia, depression, or severe anxiety. In contrast, patients with an organic mental syndrome show extinction and displacement after ten trials of testing or as long as testing is continued. Such a response is termed a “positive face-hand test.” A “positive face-hand test” is also manifested by normal children, normal aged persons, and mental defectives. Because of the differential response of these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it has been noted that patients with an organic mental syndrome vary greatly in the type and A SIMPLE PERCEPTUAL TEST, From the department of neurology of the Mount Sinai Hospital and the Hillside Hos— pital, New York City. This work was aided in part by fellowships from the United States Public Health Serv— ice (Dr. Green) and the National Foundation for Infantile Paralysis (Dr. Fink). Reprinted from NEUROLOGY, Minneapolis, March 1954, Vol. 4, No. 3 211 �NEUROLOGY 21:2 frequency of perceptual errors. Also, subjects without organic brain disease occasionally manifest a positive face—hand test. The questions which arise from these observations are: 1) Is it possible to classify or standardize the different types of errors occurring in subjects with a positive face-hand test? 2) Is there a correlation between the types of responses and different groups of subjects? 3) Is there a type of response which can be said to occur only in patients with severe disease of the brain? The present study is an attempt to answer these questions. IVIETHOD AND RESULTS Previous records of the face-hand test were reviewed for almost 1,000 patients with organic mental syndrome, normal adults, and schizophrenic adults, as well as lesser numbers of normal children, normal aged persons, and sub— jects with mental deﬁciency, depression, and severe anxiety. Additional groups of some of these subjects were also tested in a systematic manner with dif— ferent types of stimuli. The criteria used to formulate a standardization of the face—hand test were: 1) type of perceptual error; 2) frequency of various errors with different stimuli (touch, rubbing or scratching, and pinprick); 3) effect on the frequency of errors when the subject observes the application of stimuli (factor of attention). Fifteen to 30 trials of the test were usually done for each subject. TABLE 1 FEATURES OF POSITIVE FACE-HAND TESTS (Persistent errors after 10th trial) One—plus Extinction only with touch stimuli. Two-plus Extinction with touch, rubbing, and pinprick stimuli. Occasional dis— placement with touch stimuli. Three-plus Extinction and displacement with touch, rubbing, and pinprick stimuli. F our—plus Same as three-plus with at least one of the following features: a) exosomesthesia, b) allesthesia, C) frequent perseveration, d) occurrence of errors while subject watches the stimuli being applied. Based on these criteria, it was possible to divide patients showing a posi— tive face-hand test into four groups. The characteristic responses for each group are summarized in table 1. These responses with examples are described more fully in the following paragraphs. One-plus face-hand test: Subjects in this group show errors only of extinction and not of displacement. These errors occur only with touch stimuli. When pinprick is used, both stimuli are perceived correctly, although errors will again appear when touch stimuli are reintroduced. Case 1.—A 64 year old man with mild diabetes was admitted with a history of difficulty in walking for the previous year and a half. For at least the same period of time he had been depressed, slept and ate poorly, and was impotent. The only neurologic ﬁnding was a slow, hesitant, shufﬂing gait. There was no evidence of peripheral vascular disease. The patient appeared depressed, showed psychomotor retardation, and cried readily. The sensorium was intact. Spinal fluid, electroencephalogram, and roentgenograms of �STANDARDIZATION OF FACE—HAND TEST 213 the spine were normal. The diagnosis was involutional psychosis, depressed type. The gait difﬁculties were thought to be secondary to the depression. This patient showed a one-plus response on the face-hand test. A sample of his responses follows: Stimulus touch touch touch touch touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick touch touch Location right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left cheek right hand—left hand right cheek—left hand left cheek—right hand left cheek—left hand right cheek-right hand left cheek—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand right cheek—left hand left cheek—right hand Response right cheek left cheek right cheek left cheek correct correct right cheek correct correct right cheek left cheek correct correct correct correct correct left cheek Type of error extinction extinction extinction extinction extinction extinction extinction extinction Comment: Although this type of response occurs in patients with cerebral disease, it is not always characteristic for this group. It is also observed in patients with depression, as this case illustrates, and may occur in anxiety states, schizophrenia, and, occasionally, in normal adults. T wo-plus face—hand test: In this group extinction occurs with pinprick and rubbing stimuli as well as with touch stimuli. These errors may be just as frequent with both types of stimuli or may be more conspicuous with touch than with pinprick or rubbing. Displacement is not present, as a rule, but may occur on an occasional trial. Case 2.—A 72 year old man had a ﬁve week history of mental and behavioral changes. These consisted of disorientation, confused behavior, and intermittent mutism. Examination showed an organic mental syndrome characterized by partial disorientation, defects in recent memory, evasions and circumlocutions in answering questions, denial of illness, and pain asymbolia. There were no other neurologic disabilities. The spinal ﬂuid, electroencephalogram, and skull roentgenograms were normal. A pneumoencephalogram showed an increased amount of air over the cerebrum and increase in the size of the ventricles. This patient’s responses on the face-hand test characterize the two-plus type of response. A sample of these responses follows: Stimulus Location Response Type of error touch left cheek—right hand left cheek extinction touch extinction right cheek—left hand right cheek left cheek—left hand touch left cheek extinction touch extinction right cheek—right hand right cheek touch correct right cheek—left cheek touch correct right hand—left hand touch extinction right cheek right cheek—left hand left cheek—right hand left cheek extinction pinprick �214 NE UROLOGY Stimulus pinprick pinprick pinprick pinprick Location. right cheek—left hand left cheek—left hand right cheek—right hand left cheek—right hand Response correct left cheek right cheek left cheek Type of error extinction extinction extinction Comment: This response occurs most often in patients with cerebral dis— ease, although occasionally patients with anxiety states, depression, or schizophrenia may also exhibit it. It is not seen in normal adults. Three-plus face-hand test: This group is characterized by the occurrence of displacement as well as extinction with both touch and pinprick stimuli. The frequency of extinction and displacement may be equal or unequal and, likewise, the number of errors with touch and pinprick will be variable. Case 8.——A 57 year old chronic alcoholic was found in the street in a stuporous condition. His breath had an alcoholic odor and there was a laceration over his right forehead. There were no focal neurologic signs. During the ﬁrst hospital day the patient gradually became fully conscious. Speech was rambling and at times almost incoherent. He was completely disoriented and had severe memory defects with confabulation. He expressed paranoid ideas and was hostile and assaultive. There were no hallucinations. Spinal ﬂuid and skull roentgenograms were normal. The diagnosis was acute and chronic alcoholism with deterioration. A sample of this patient’s responses on the face-hand test, indicative of a three-plus response, follows: Stimulus touch touch touch touch touch touch touch pinprick pinprick pinprick pinprick Location right cheek—left hand left cheek—right hand right cheek-right hand left cheek—left hand left cheek—right hand right cheek-left hand right hand—left hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand Response right cheek-left cheek right hand—left hand right cheek correct left cheek right cheek—left cheek correct right cheek—left cheek left cheek—right cheek right cheek ' left cheek Type of error displacement displacement extinction extinction displacement displacement displacement extinction extinction Four-plus face-hand test: This group shows the most severe perceptual errors. In addition to frequent extinction and displacement, as seen in the three—plus group, one or all of the following phenomena may be seen with touch and pinprick stimuli: l) exosomesthesia; 2) allesthesia; 3) frequent perseveration of responses; 4) occurrence of perceptual errors even while the subject keeps his eyes open and sees the areas stimulated. Case 4.—A 60 year old man had a three year history of disorientation, forgetfulness, and loss of interest. On examination he showed a severe organic mental syndrome manifested by complete disorientation, marked memory defects, and inability to calculate. He was alert and cooperative. There were no other neurologic signs. Spinal ﬂuid and skull roentgenograms were normal. The electroencephalogram showed moderate, diffuse, bisynchronous slowing with slow alpha. A pneumoencephalogram disclosed abnormal increased amounts of air in the subarachnoid spaces overlying the cerebral cortex. A sample of the patient’s responses, indicating a four-plus face-hand test, follows: �STANDARDIZATION OF FACE-HAND TEST Stimulus touch touch Location right cheek—left hand left cheek—right hand touch touch touch touch touch pinprick pinprick pinprick pinprick right cheek—right hand left cheek—left hand right hand-left hand right cheek—left hand left cheek—right hand right cheek—left hand left cheek—right hand right cheek—right hand left cheek—left hand pinprick ( eyes open ) right cheek—left hand Response right cheek left cheek— extrapersonal space right cheek right cheek correct right cheek—left cheek left cheek—left hand right cheek—left cheek left cheek right cheek left cheek— extrapersonal space right cheek— 215 Type of error extinction exosomesthesia extinction perseveration displacement allesthesia displacement extinction extinction exosomesthesia exosomesthesia extrapersonal space Comment: Three-plus and four-plus responses invariably indicate disease of the brain. They are never found in normal adults or in patients with psychogenic disorders. These responses have been occasionally seen, however, in normal children under the age of six,4 aged persons without manifest disease of the brain,6 and mental defectives.10 The distribution of responses of children and aged persons are related mainly to age. The youngest children and the oldest adults show three-plus and four-plus responses. With changes in age away from these extremes, one-plus and two-plus responses become more frequent. Of the subjects with mental deﬁciency, those with the lowest mental age have three-plus and four-plus responses, while one-plus and two-plus responses predominate in subjects with higher mental ages. Table 2 summarizes the distribution of the four different types of responses among the various groups of subjects. Only patients with an organic mental syndrome show three-plus and four-plus responses. Such responses may be considered diagnostic of an organic mental syndrome. DISCUSSION In answer to the questions raised at the outset of this paper, our results indicate that four general types of positive face-hand tests occur and that TABLE 2 PERCENTAGE FREQUENCY OF ONE-PLUS TO FOUR-PLUS POSITIVE FACE—HAND TEST IN DIFFERENT GROUPS OF SUBJECTS ‘ ............. ................... Patients with anxiety states ............. Organic mental syndrome Normal adults (below 60 years of age) Schizophrenic adults Patients with psychogenic depression (all age groups included) . . . ............. . Negative F-H test Oneplus 10 99 7 nearly all occasional occasional 70 22 all nearly l Twoplus 25 0 Three- plus 33 O F ourplus 25 0 rare never never rare never never 0 0 8 �216 NEUROLOGY these types can be correlated with different groups of subjects (table 2). Our attention was focused mainly on whether there was a type of response which occurred only in patients with severe disease of the brain. All adult subjects with a three-plus or four-plus response have organic brain disease. Such responses are never seen in normal subjects or patients with psycho— genic disorders, even though these groups may occasionally Show one-plus or two-plus responses. Patients with cerebral disease manifesting a four-plus response invariably show the severest or most advanced form of mental changes. Otherwise there is no good correlation between the type of positive face-hand test and the severity of sensorial defects. Some patients with severe mental changes may have only a two—plus response. In addition, 10 per cent of patients with an organic mental syndrome have a negative face-hand test. It is realized that the use of a one to four—plus nomenclature for the groups implies an increasof because used This nomenclature of cerebral was dysfunction. degree ing convenience and such an implication is not intended. This classiﬁcation of a positive face-hand test should be useful clinically. In testing neurologic patients, the exact type of positive face—hand test should be recorded, rather than the designation “the face-hand test was positive” as has been done until now. Such a procedure will make it easier to judge whether the type of positive face-hand test indicates deﬁnite cerebral disease or whether it may be a manifestation of anxiety or depression. The use of such a classiﬁcation will also make it easier to compare the response of patients at different times during their illness. In addition, it is valuable in clinical experimental work, for it has been applied in studies of the effects of drugs on perception and the responses of patients to electroshock treatment. In such studies alteration in perception can be measured by observing the duration and incidence of the variety of positive face-hand tests during the periods of testing. SUMMARY A standardization of the face-hand test is presented. A positive face-hand test is designated as one in which errors persist after the tenth trial. Four classes of positive face-hand tests are recorded. A one-plus face-hand test consists of extinction only with touch stimuli. A two-plus response is char- acterized by extinction with pinprick and rubbing stimuli, as well as with touch stimuli. A three—plus response consists of extinction and displacement with touch, rubbing, and pinprick stimuli. A four-plus response has all the characteristics of a three-plus response and in addition at least one of the following features: a) exosomesthesia; b) allesthesia; c) perseveration of observes while the of (1) applicasubject even errors occurrence responses; tion of the stimuli. Three-plus and four-plus responses invariably indicate disease of the brain in subjects over the age of six years. One-plus and twoplus responses occur in patients with brain disease but are also manifested disorders. with adults and of normal number small psychogenic patients a by �STANDARDIZATION OF FACE-HAND TEST 217 Patients with a four-plus response show the severest mental changes but the converse is not true. There is no correlation between the severity of the mental changes and the type of positive face-hand test manifested. Usefulness of this classiﬁcation in the study of patients clinically and in experimental work is suggested. REFERENCES 1. BENDEn, M. B., FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & Psychiat. 66: 355, 1951. [O . BENDER, M. B., and FINK, M.: Tactile per— ceptual tests in the differential diagnosis of psychiatric disorders, J. Hillside Hosp. 1:21, 1952. . FINK, M., GREEN, M., and BENDER, M. B.: The face-hand test as diagnostic sign of disease of the brain, Neurology 2:46, 1952. . FINK, M., and BENDER, M. B.: Development of perception of simultaneous tactile stimuli in normal children, Neurology 3:27, 1953. . IAFFE, J., and BENDER, M. B.: Perceptual patterns following general anesthesia, ]. Neurol., Neurosurg. 81 Psychiat. 14:316, 1951. 6. GREEN, M. A., and BENDER, M. B.: Cutaneous perception in the aged, Arch. Neurol. 6: Psychiat. 69:577, 1953. The phenomenon of sensory . BENDER, M. B.: displacement, Arch. Neurol. & Psychiat. 65: 607, 1951. . SHAPIRO, M. F., FINK, M., and BENDER, M. B.: Exosomesthesia or displacement of cutaneous sensation into extrapersonal space, Arch. Neurol. & Psychiat. 68:481, 1952. 9. BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neurol. & Psychiat. 64:501, 1952. 10. FINK, M., GREEN, M. A., and BENDER, M. B.: Perception of simultaneous stimuli by mentally defective subjects, J. Nerv. & Ment. Dis. 117: 43, 1953. �EIWRDIZATION OF m FAGEwm MT 3y “mm I. ‘0 “NC“, Do und In: rank. n. n. ibis tort 1;: e status Publia Hoalth dation of n‘% ' _ﬁ{ p 9'» 1 arson) and survioo (Br. thy Huttonnl ‘ <" ' ’ ' ” Faun- Infantila Paralysis (Dr. Pink). Eran an. Dognvunont or Hourology at thn noun: stnui Hospital and tho 311 lid. Houpitnl. �Introduetiunt In priviaul studies a tinplo poro‘ptuﬁl taut, uh. rnoia hnnd ﬁast. was intradnoed and tha rbnﬁonnon bf normal anbjtetn 1nd or pationta with ptyohittrio d1noranrl w¢r¢ dglcribod 1n dbttil (lab). Tho tout aanniuta or applying tough or pinpriok .ltinnli nimnltnnsounly to tha tact und.hund uhilo the aubjuot‘n ayes hr. closed. it. lubjoot in than aambd to annariba and to lootliso thn poraapta. Two gannrul type: or roaponsol Gaunt. who ﬁve stimuli may bu poreoivod and localized oorruotly. 0r, thn nubjoae may piranivo only on. atiuulus and cithor*nat porn enivo the oﬁhtr (phnnennnan at astinotian) or maniacaliaa thn sooand stimulus (phannmnnon or diuplacaannt) (7). ﬁaét ottcn ~ﬁh¢ mislaealiuntién or diaplaéqnnnt «can»! to anathnr pirt at tho wubjoot’s body, but oooailunally thtrn 1n dilplaaahont into oxtrtparuonnl apnea or onto thy axmnxncr‘(axoaamolthnaia) (8). Diﬁplgotnoht at stimuli turns: the midlino or thn body ($110.» thosln) nu: also onenr (9). ﬂornnl adult: show 0r§oru 1n perception.au tbs initinl ‘ r mu.- a: I tho tuna-hum 4 «at. cmctcrnuaaxy than error: sonaiut or oxxznetion of thy thinning to ﬁn; hand than... tho raga Itimnlna is perceived aorrcotly (phcnamonon at face again,nnuo). A: thn that: arc ropoatad thy error: d£luppoar so thnt by th. tonth trial nearly :11 subjcctu norraetly paragQﬁa both stimuli and than oontinnu to bq corruat on tubauqunnt trigll. This typo or roaponno has bran tonmnd a “nagativo raco~hnnd tout.“ It ooourn not only with manual adult: but also in pttzontn �2. ‘vith :6h1uayhruniu, dtproaaion. or savor. anxiety. Kn contrast to tho proo¢d1ng aubjaats, pa§1nnts w1th tn uorganio mnntnl nyndrumn aha! qxt1not1on and displnecnant Artur 10¢ tr1a1: or toating ar-II long It touting 1- continued. Such t npupcnlc~1n‘tpnmnd u ”posit1vu {nonwhind tout." A *poaitivu ftoo~hnnd tout" 13 claw unnLroutod by normnl uh1ldrtn, normal ugud,p¢auann. Ind:mantnl dofoat1vol. Bananas of thy dirforont1a1 rnlpenao of thaao aoviral swung! at luhjoetl, an. faoo~hnnd test has banana astral ul1n~ toally 1n dataating tho prosoneo or orggn1e brain d1aoAIo. During the court: or our stud1al, hawovor.,1t ha: boan noted >that pntiants with 1n grannie nantql syndrann Vtrylgrontly 1n the type and traquancy or porcoptuul Grrort. Also; nﬁbjactn I ' without organ1o brt1n é1aoalo occasionally mnn1t¢at a pauitivc raccuhnnd test. 1h: quantionn ﬁnish arias from that. abnorvutionn an: 1) .1: 11'. poneiblo to elmxﬁ or mandamus an. autumn 'typu: or orrafa aouurr1ng 1n'1gbjooti v1th I panit1v§ fteowhnnd 80:12:13) In ﬁbﬁro A oorrulnt1on botuuon thb typca or roqpannol and dirrorun1_gr¢upa or aub:¢atn?; 3) in than. a typ. or ronponno Ih1ah can bu ugid to ocaur gal: in pitiﬁntl v1th_nav¢ro 61301:et uh. bra1n? the proncnt Itﬁdy is an uttqipt to ‘nalur than. questionapv I. 04 1 d B! ‘ t lb roviornﬁ our provleus record: gt ‘ 1h! tuna-hand 103% in nlmnat 1000 pat1onta with organic mnntnl syndroma, normal adults, and Inhiaoyhrohia adults. an wall an in longer numdam. born of normal.ohildrun, normal 130d porlena, and ambient: with �3. m.nt:1ld¢rieigncy. dnprnaulon and lottrn anxiuty. Additional stamp! of menu of than. uubjcotl taro 31-0 toatna in a lyutmm— gtic mannar'viﬁh ﬁlrtoront typaa of stimuli. The aritoria ulna to fonmultt. a Itandnrdixntion or the raaouhrnd tout wire; 1) typo of poraoptunl 2) frnQunney of various arrays (touch, rubbing at nergtehing. and p1n~' crrnr: airroront stimuli prick): 3) offset on thy troguoney or orroru vh¢n tho cubjoet noes tha appliantion at tho I§1IM11 (taotcr or dttcntien). Firtaon to thirty tritla at tho tait wuro naually done for wiﬁh Onah cubjoet. « criterig, it in: possiblo to divida pa § tianti sharing a positive ftoomhnha tqst into {our group:. Th» oharaaterintie rouponnu: for etch gréup arc summarized in Tabla I. 'ThoIoAroapann g with oxnmplo; art angeribad morn fully in tho {allowing par‘grapha. Based an.thnUO Fuataruu a: Ponitzvo~nuac-aana’roatn _(vors1£tont prrorn attdr 10t§ ﬁriil) W 1 M." Situation Extinction W Wm» 1 am plan mt1not1on with tough, und dinpltéo— anly with tauah stimuli rubbing. and 'mant with P181314“ touch, rubbing stimuli. ,tnd pinpriak occasionul stimuli 41: laocmant Ii tauah ‘ u)oxolamauthsaiu b)nllaathsai‘ ‘ , nttmuli. a: thug... with n: loaat can or uh. following {autumn ‘ o)trnquont porn¢v~ «ration d)qc¢urr¢nen of errors while just watch»: sub~ ithmuli buing nppliod. uh? �h. gnoePlgn.Fheoen§gd Tout: Tho subjects in thia group that error: only at Ixtinatioh and not at displahanant. Thou. errata oaour only with tauoh stimuli. Whon pinpriak is usod. both utinnli up. poruoivoa aornootly, although arrhra will agnhn appatr lhln touhh stimuli urn rhihtroduaod. Gun. 1: tad with 3 A 6h your aid huh with mild dinhotpl pus t6n1ﬁ* xi your hiltary a! dittiaulty in walking. Fbr at I... patina 0: than hm had boon dnprogacd, alnpe .and ht. pearly. and It. impatanﬁ. 'Tho only unurologiaul finding was t slow, halitant, nhurfllng shit. Thor» was nh ovidnnn: 10am: tho ot‘poriphortl vuioulhr dis-coo. Eh. pationt‘nppoarud doproiaod, 'IhoVGd payahanotor rotnrdutian, tnd dried handily. The non» aorium in: intact. Spinal fluid, slactrocnhaphulogrtm, ertys at tho spin. ward normal; who tional psychoazu. dopranlod type. hheught to he sccahdnry to thi diagnosis In: involuu The gait difficultiau tar. dnpronhion. _ this patient thalcd l anonpluaerIpanlﬁ tout. A sample at his ruxponaaa follows: on tho tau-«hand ‘ ‘ Stimulus gggatiog touch right ohnak*lott hand ’ wypg of ﬁgugcns; ﬁrrar right shook: axeinotion hoxtinntion 10ft shack tough loft chock-right touah' right ehaokwright hand right South 10ft annex—loft hand touch right ohhak~lnrt ahock earnest» aerroet right handwlott hand right ohsaknloft hand right dhaok tauah touch and hand Int: chagh about» uxtinotioh cxtinotion ' extinction �5. lart ahnak~r1ght hand left «human 2mm tauah touch touch right man 101“: pinpriok pinyrick pinprl ck pinprick touoh> entrust eon-cot. riwt aha-ehwrigﬁ hand mud“: hand right absoknlort-hand lore dh¢ek»right hand right nhotkwright hand 1am; ehcokdgft ma‘ right «haiknlgrt hund wt ”chock-avian: hum loft . ~ chock check axnination «attraction aorrooh correct garnet“ «may ‘ aorroot 1st: abut: .munctxm ggggggﬁ; Althnugh thia typc or.rcnpanno aoaﬁra in patiwntl teach aorabrnl diuaano, 1t 1: not dlway: entruatcvistie for this group. It is Also abhcrvué‘tn patiunts Iiﬁhéaprolaion, wiﬁh : thlg anal illuitratas} aehisoﬁhranin, and. ocassiénally,'1n nunnnl a¢ulta; P; V,Eh.0+H Id ’rt In this graup axtinction ooeurt Iiﬁh pinpriek nag rubbing stimuli a: lull én‘vith taudh #tim» all. than; arrora mgy ha junﬁ an froqugnt with baﬁh.typta at stimuli er may be met. conspiauouj\vith-tauah‘ﬁhnn with pinﬁ prick or'rubbinga Biapluaunnnt 1; not yrbsnntg an a rule. and may occur xn anxioty at§t¢t, an & 7 L , but may auour on Case 1!: '1 tn,aoedligna1 téinls 72 year o;d man had a 5 ' . WIOK history of anneal and bahnxioral;ohangoae Eben. ganniatcd ar'éiaor10n~ tatian. confused bdhnviar. and intarldtéant muslin; On oxnmp inntion thara Inn gn organic mnntql lyndran. charactarisod by partial dinoriontation. 60:00:: in ruannt unwary, OthianI �Z~g‘ s7”! ind otteumloauhlann 1n annu¢r1ng quastians, daninl or 1113..“j and pain uuynhoiit. Thar. var. no oﬁhor nunrolagioal dilw mutton. mo spin-.1 mum. olootraonaaphuagm. and “all xnrnys Ibru ndrmal. A pnauﬁooneaphalognmn unusua'un 1n¢ro.nad «ﬂaunt of air ovor uh. aorobrum and inaroaaa in tha 3110 at tha ventricles. was: pat1¢nt§a raaﬁonloa'on tho tuco-hugd taut untran- torls. tho tvaapgul typa at ruaponao. spannon taller: samplc of thnsc raw A \ a ‘ 3352395; Tg£;o;t _“§au¢h aggntgan 1.x: abnohuright hand 10ft «hack axﬁinotian tcudh right ahaak~1at£ hnnd right thinstion ' 3tg55;un left r.t§ugna tbuah V. tough touch toudh ’ right right right right enaok~1a;m hand ‘” ' unsurpright hana din:k-1.ft-ahodk hundnlurt hand «hookvlhft hand lgtt ahnuk Oxtlnntinn right chnub extinction‘ about «errant eorruat ' pinpriek loft ghostwright hand right chock wyxtinstian 1.1: chuck oxtinctian pinpriok ptnprick pinpriok pinprlok right ahcokalort hand oorreat 1.x: ehaakwlort ngna right chant~r1ght hand lart ' oxtinutidn oxtinctian 10ft chick cxtinotion 1¢ft ahhek~right hind adamant: Thin ruaponaa eocuru mast urban 1n pntianta with cornbrul 6119110 altheugh oncasianally ptt£¢ntl with anxigty itibﬂlp dnprossion or duhinophronia naq'alto cxhibit it. It in not soon in nounnl ndulta. ahﬂak right ehnok �0‘: 75 gaggovgggg §33A~§g§§ ruAtt IhAA by thy ooaurrunco of diApLAeanAnt bath touch And pinprick atzmuli. group wall AA who And displaoumanm 1A chArAatAriAAd Axtinction with frAquAnoy of extinction AA , any bA’Aqual cr unsquAl And. likAAiAA, Aha number 0: errors Aibh touch And pinpriak'will bu AArAAbIA. 6139 III: strict in the holia odor There AArA hoapital ntuporoun oundition. A And thArA AAA thA pAtiAnt rumbling And caaplataly diacriuntod gnnfahulation. 31A brAAth hAd an Alena HA 3 lAAArAtion gradually bAoAAA fully oonaaioun. At tihnn Alnolt inoohArAnt. EA AAA. And had AAVArA salary axprAAAAd pArAnoid idAAA and A3AAA1§1VA._ whArA Aura And Akull X-rAJA AArA nanmAl. Th. diAgnosil Asamplq of thin pAtiAnt'a A tout. indiactivo or giggyggg saw. A ggaation my“ dunk-daft hand . touch loft touch right touch urt chum-hrs hAnd Quota-wright ham. ' mamm hum! touch right aha-kaloft uhAARArxsht hAnd hAnd loft hoatilo III aunt. fluid and taco-hand fallow-t right abuzz- ‘ with EpiuAl T§£§ogf 333223;; ' lnft AAA AAA rAAponAAA on Ah. thrAAapluA rauponsa, touch dAtAAtA no hAllueihAtianA. .Ahronie ALedholium with anteriorAhion. ” found in AAA ovor his right torAhAAd. no fooAl nnurologieAl signs. During uh. tirut AAy SpAAAh WA» 57 yoAr old chrenio Alcdhalio A chock ‘ diuplmmnt . hand;mm 1cm; hum! displaemne right about anemone»: came: lcts aback extination right diaplaeAaont loft ahAAk~ ohAAk �touch right hand-10ft pinpriak ; pinpriak hand comet right ahaok~lort hnnd A)right left an: 1m; chﬁokumght hand I pinpriak pinpviek Fb ' ‘ ' right chock-«right. hand lcrt «hank-lnrt‘hnnd Flu; Hand chaokn diaplaoamant «bank cheat» right ahnek right ohm: lﬁtt ; aback displaeﬁmnnt . oxemauon axtinutien ‘oat This greup shown tho aovcrast poréoptual arrara. In addiiion to rr$quont «xtination lné ainplaeomnnt, an noon in thn thrno~p1us group, on. or .11 at ﬁba folloiing , with touah and pinprlak aﬁimnli: 1) uxunanalthnninx 2) allouthoditi 3) truqnnnt pur~ agvcratian at responlttt h) tho oocurrcnnn or paranptunl arrorn ngn-uhzid ﬁnd aubjoat kaopu hxl'cytu opan and 109: tht Irilﬂ ﬁbenamnnn may be mean ﬂimuntud. Gas: 60 ycnr old man hgd a thrai your hiatary or disoricntution, forgatrulnnla. ‘ndVIOIl of intaraut. an axum~ 1n£ti¢u h. ahawqa a 3.1.». argania mantal nyndroun manirnqttd by cauploto disaritnt‘tian, marked,m¢mary actuati, and inabilo ity to atliulato. H. In: alart and cooporteivo. whore wire no other naurological algal. Spinal fluid gnd akull Xbrnya XVI ‘uuro manual. A EEG-abound anagruto, diffuse. biaynahranoul alaning with 110! alpha. A pneumnonnephalogrum discloscd dbnormal increasod amount: of air in th» aubnrachnoid apnea: overlying the anrobrti eortox. A Iamplo of tho pationt'u rnuponuua. indicating a four. plus tacowhnnd tott, tollavla ’ f �95 Stimulus. tough touah Typa . mastic»: ' right obnokuloft hand 19ft chnekhright hand ‘ » of Emu Rcaw‘ right aback axtinctian left oxosomoathoslu :- chatk~ oxtruporuonnl apa¢o tough right thehwright touch loft touch tnunh right handplaft hand right ahaak~lort hand tench loft aback-right pinpriak right aback-loft ptnpriak pinpriek pinpriok 10ft chookbright hand lart right ahookaright right 10ft ohuak~lort h:nd 1.1% chook- axoaanosthnaiu pinpriek right chopkwleft right oxaaamaathclia (ayes Open) . r. . . adamant: 1 hand chnokwlerﬁ hand right «hank right cheek torrent right aha¢k~ qxtinetion poraevoration aiaplaeanant hand 10ft chock 10ft ehaak10ft hand allouthaslt hand right displtaunant hand hand 10ft ohnak~ aback ohock . dho¢k «xeraporlonal span. shack» nztrtparuannl oxtinatien txtinctian :pton rhrno—plun and rouﬁwplul vniponsos invarisbly inninatogdinoani of thoﬁbrain. inn: 1:. nnvur fauna in normal ﬁdults or in patiants with plyahogonin diuordgru. I ﬁhnaa rbaponses have bash oocasionnlly noon, howuvor, 1n nerull childrnn undsr the as. at at; (h); agad potions withuut (6) had manual dnroetivna (19). manifoat disaaso or thﬁ brain rho diltrdbution of tha ruapanseu a! the ohildron and ugod poruanl are rolatnd ntinly ta ago. in. yaungnnt childrun and tho oldnlt adult. show thruo~p1u1 ind rourwplub rulponqon. �16. Wiﬁh thin. «hangs: in age away tram untruunu, ono~plun Ind Iroqunht. or the tubjccbs lith.nnntal dtfiei¢nny, than. with in. lowgat annual agthavo ﬁbroeoplun':nd teurvpluj roupannaa whila ona~plus and two91ua rcapensoa prndaminutu in nubjnota with highnr’mnntal twowplua rulponsaa baoama mare _ I aguu‘ II aummurises thn dintribution a: tbs four different typaa at rulpnnyeu twang tbs variau: groups or aubjoetl. Gnly Tabln ‘pgtlonts with In argania mmntal syndrana.nhow unreguplus and rourbplua teaponaoa. Such roapunaes may be aansidorad ditgu nbstio or an organic unntul ayndrumn. mm ;; Prwqusnay or 0n¢~P1uu to Faun-Elna Tﬁat in Dirforant Gwoupa nogntlvu Gaga Pku Organic Hantal syndruua adult: (below your: a: as.) Norunl taut 60 99% Schizophrtnia Adult. Patimntu with anxiety nnarly Patients with plyahn~ -7o% states , asarly genie dnproasian (all age grnupa inaludad) W! "' 19% Tue? Three Paar- Plgg‘ Plus 7% 25% 33% 25% 15 o o a dooaa~ :11 Paaittvo at Subjects Four~P1un P§uu P;ul rarg new.» navor ionglly oooas- ray. navar‘ novor all tonsil: 22% 85 o o , In unavor to the questions railed in tn» introduation, our rounltu indicnto that four gonoral typos of paaitiva �.11. faooahand touts occur‘gnd that than. typo: «an bo carrolatod with airfaront greupn at aubjoats (Tablc II). Our attention Ill fauna-d mainly on thg question cf ﬁhathar there in: a typ. or rouponse which oeaurrod only in pubinnts with savart 4180330 of chi bra1n._ All adult subjootn with u thrionplun . - or rourwplua v.3ponno haw. orgtn1o brain dictate. Suéh rua uponaou 1:3 nave: icon in manual subjgatu er patient: with payahogan1l disardnrn, even though than. group. any oocunlonnlly than onnnplun or twonplua traponnnn. ' Patigntn with atrabral dinette manifesting a four-plus nonpango invaritbly that tho novonast or must udvunnod foam of mantul abungal. Othorulao thaw. in nu good aorrolat1an botwoon thy typo at pou1tivo tiéowhand tout 1nd tho soverreyv 9f thn unhaorial daroatn. 3am: putionta with aovnro monﬁal ahnngps may'havo anxy; two«p1ua vouponso. 1n additian, 105‘ or pationtu with an orgnnIo manealinyndromn.hnvh a magazivo faaa~hand taut, It is rhalisod that tho use of I one to taut» plun nonnnoiutur. £6» Eh. groups umplies an inoronﬁing dagruc or aeropral'dyatunation. This namnnslntumo van used because of aonvonicnaa and aunh an implicition in not intended. Th1; olauitiaatlnn af 3 poauin rues-hand test should be useful elinioglly. 'In téuﬁing nouiologioal patients, uh. cxaat type or positive taco-hand tout Ihauld be renordpd. rather thtn tha datlgnation ”the tao§~haad test was positivo' until nan. Bach a proeoduro «111 makd 1t Judgo whatnot tha typo or poaitivo runomhand ﬁont as has buon don. aasiar to indicatcs dotinita oorabrnl discus. or whnthnr manifcptntiou at tnzitty or dapruauian. who it may be c use or much a ' �12. alanairication will also make it easier to ounpuio tho roayenno or patlontl at diffcrtnt tin»: during thuir illniaa. In ad» dition, 1t. 1. “1mm. in cumin). “perm-am work, for it has bean aypllod in studio: or thn urfpetn otdrugn on pircaption, and tho rutponlal at pat1¢nta t6 olootrouhook truatu want. in aueh Itudioa altnrution in pottuptian can be mat» . stand by abaovwing tbs duration and tho incidnnao cf thn varioty at positive tano~hnnd tests during tho period: of teating. Sulnagz: ' stundardizttian of tha {tonohand tout in prntontod. A positive faoouhnnd taut it danorihod In on. in uhiéh orrart portint .13.: tho_tunth trial. Pour clause: of positivo tuto— A hdnd teats urn racerdod. ann~p1ua fnoo~hand A tott aensiaﬁl of oxtination only with touch stimuli. A tro~plun renponso is charuatoriaod by axt1notion with p1npr1ck und rubbing atims uli, ﬂ as ‘ill an Iith touch stimuli. thrna~p1us nonponno tontlata or oxtinoticn and displaeumont 11th tough. rubbing, tad pinpriak stimuli. A rourbplup runyonao ha. til tho tharhl aotariatica of a throu~p1ul response and invadditian at least one at thn following ronturos: a) Oxasamntthoaia; b) ulleathnlinz A . c) poraovonntion af roaponnasz d) ooourrenao or errors even whilo tha subject 8063 tbs application at the stimuli. Throo~ plus and four-plus weaponnea invaritbly indicate dinette of tbs bra1n in subject: evor tho ago of :11 yours. 0no~plua and trauplun roapqnaea occur in ptt1antn with brain disnaac amall number of normal adult: and but are 3139 maniteathd by a ptt1ontn with paychogonia‘diaoranrt. Patients with a faur~plul �I “‘"’ 13l- tho ”want maul change; but ﬂan canny“ 1.8 not Ema. morn is no corraluion human t)» unrity of the manta), uhmgu m4 tho or punitive: rum-hind z'oapcmao show taut tn. awaited. m unfulnbu or this the study at panama clinically and in it indicatad. _ cluuu‘iutim in 01$“:de work �I -m...‘ ‘ ‘ hm W l: BEXEER, ‘BENDER. in hhn :nd GREEK, ﬂ.: .é.:355. 1951. K.B.: FINE, «option on sinnlt 2. . 3.3.; on: tout: of fans and hsnu. and FINK, Hg: airfarontill guﬁiglgﬁdo H032. Patterns in par» M. Arab. Tactile parcoptual taata diagnouia or payohiutriu diuordnrl. ital. 1952. 3. FIRE. 3.: GREEHA M. and BERDER, M.B.: The faoe~hnnd test. nign of diieasa of the bruin. yourologz‘g: :3 dig zontio .7. , FIKK, H. and.BENU£R. K.B.x . simmltnnnout 1327p 1953* J“FFE' Duvnlopmnnt tactilu stimuli in 5' ‘nd 333933* unsathanin. ggggral ,3 W md- 7. 8'. BENDER, a H.B.z SHAPIRQ. HiF0‘ BEHDER, M.B.: Th9 phcncmanun PM, . 3 «hi .‘ghzslé, . 'Wmcx. and nonnnl childronw agggggggz “'B-' Pofocptunl pace-an: follavinsj. .3 urcgﬂc a: ,GREBH. at pdrcqptian or .3 entanooun‘pcroaytion 1n uh. £29.35“. 1953» er Ionaory diuplucunynt. @607. E. and 1951- Vii-159””. “‘8‘; Exosmnthuin or displacannnt or outnnoonu nonnation inté axtraporaondl upuca‘ ﬁgg§.ﬂiggo;.&Pnzah15§. é§§hﬂl,‘1952. 9. ‘nﬁann, 3.5. and Hamunnaen, u.: Pattorna 1n alloltbouia tad thair rulation to disordnr of boay sebum. and other: scnsery phnnamann. Arah.xourol.&9azehiat. ég3501, 1952. 10. ﬂ.B¢t y.".Pt19n or I!" GREEN, MuAu ”4 51mm tanaaua stimuli b montully aorontiva subjects. J-nOPV‘aatnm:3; m1 3. 1953. m. W. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Standardization of the face-hand test. Neurology. 1954 Mar; 4(3): 211-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-14-018 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and Reprint. Reprint from NEUROLOGY, Minneapolis, March 1954, Vol.4, No.3 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/c779b264e0ba3e779d39ff5db1a0879e.pdf d5ea2d1f830983dbe61a4c62d8e73b61 PDF Text Text Significance of Individual Variability in EEG Response to Electroshock Martin A. Green, From M. D. the Department of ExPerimental Psychiatry, Hillside Hospital, Glen Oaks, N. 10-11-57 "r .50 �Significance of Individual Variability in EEG The assumption Response to Electroshock is often tacitly made in studies of nervous system function that the capacity for neurophysiological change is similar for animals or humans in the groups under study. Differences in response are ascribed to different parameters of the stimulus or to differences in the location and extent of lesions, either spontaneous or experimentally produced. tion may Such an assump» Perhaps another factor in the not be warranted, however. variability of response under these conditions is an individual variability in neurophysio— logical reactivity or responsiveness. The initial "base-line" may not be similar in all individuals. The possibility of different inherent patterns of reactivity has suggested by the studies of the alterations in the have been impressed by the high degree of EEG been during electroshock. variability in such We alterations both in their quantitative and qualitative aspects. Although this variability has been described by previous investigators, it has not been stressed sufficiently; nor have possible explanations been advanced or systematically investigated. present report concerns a description of the changes in the EEG Hillside Hospital during electroshock in the/' material. The concept of neurophysiological The reactivity is presented and studies that may clarify this problem are suggested. �MATERIAL AND METHODS: Eighty-nine patients were studied. The patients who received electroshock for psychiatric illness Hillside Hospital and were voluntary admissions to the majority had not received electroshock previously. The diagnostic groups and schizophrenia. psychosis manic~depressive included psychotic depression, The largest group was patients with depression. Agesranged from 20 to 68 years, with a median of #7 years. Treatments were given three times weekly, each patient receiving at least 12 treatments. The Medcraft instrument (alternating current) was used 61 for current) for 28 patients and the Reiter instrument (unidirectional patients. Electroencephalograms were taken prior to, and two weeks following the course of treatment. EEG was abnormal were to 36 weekly Patients specifically excluded from study. 2h (from day non-treatment a an at whose intervals during, pre-treatment Tracings were done on hours following the previous treatment) with eight channel Medcraft machine using needle electrodes. Frontal, motor, and earlobe vertex temporal, posterior temporal, anterior parietal, occipital, placements were employed with scalp to scalp and scalp to earlobe combinations. �RESULTS : I. Delta Activity. A. Quantitative Differences: delta activity The to the method described by Fink and (8). Kahn The was analyzed according duration of burst activity, the lowest frequency, the average delta index in several leads, the highest measured. were lead one in time delta and the percent highest amplitude, Re— cords were classified as showing a low, middle or high degree of delta activity (Fig. 1) according to criteria previously described (8). All patients developed delta activity during the course of but differences in the amount of the slow activity and were very apparent (Table I). Some early in treatment whereas other even after serial 12 EEG's. not develop in treatments. As treatments of development patients developed "high delta activity" patients showed only "low" or "middle" changes latter patients were followed further with treatment was continued, a high degree of delta activity did some of these patients until on a daily basis. This individual variability in treatments were given change. These its rate 12 20 or more They were EEG treatments, or until resistant to neurophysiologic response was independent of the type of electroshock current employed, being present both with unidirecticnal current applications. alternating and with �- h TABLE Degree of Delta I Activity in Serial Electroencephalograms during Electroshock (2-n records were taken for each patient) No. Activity EEG No change delta activity Low Middle High B. may be ity. - EST 1 delta activity delta activity of Records in Each Treatment Period u L:..§ 3 l 37 21 7 3 20 22 10 1 28 #5 25 1 16 amount of delta the activity Although total Differences: Qualitative activ~ and of delta voltage to frequency records as differ type, similar, One prominent qualitative difference during a course of 12 treatments. is in the form of bursts which as treatments are continued. is the ratio of irregular delta In some patients the become more The show burst activity initial delta change frequent, slower and of higher voltage irregular delta activity in such records is less prominent and usually occurs at faster frequencies. In other patients the reverse occurs. form. 12 0 5 activity to bursts of slow activity. Nearly all records much - 10 Although burst Delta activity appears chiefly in an irregular and scattered activity is also present, third group of patients the amounts of it is not conspicuous. irregular delta and In a bursts are approx- imately equal (Fig. 2). These differences in the form that the delta activity assumes is usually constant during the course of treatment. At times, however, burst activity will �. become more prominent - 5 than the irregular delta only during the latter part of the course of treatment; or burst activity which appears prominent early in treatment may be overshadowed and obscured in later records by a large amount of continuous irregular delta activity. The slow activity is maximal electrodes and less pronounced at the at the anterior temporal more frontal and posterior electrodes. Often asymmetric, being of higher voltage, slower, and in greater amounts anterior temporal Only and frontal electrodes as asymmetry occurs during treatment both with is at the left to the right (Fig. 2). compared rarely is the reverse true, i.e. accentuation it on the right side. This alternating and with unidirectional currents. Another type of abnormality, though an infrequent one, of rhythmic runs of delta activity which (Fig. 2). The may continue for 10 is the to 20 seconds regularity of the frequency and voltage of the slow these runs is very striking. appearance waves in These runs are usually infrequent, but may be the most prominent alteration in the record. In many records the amount of delta activity fluctuates during the tracing. At times, some in other parts of the This variation II. is portions of a record same may appear nearly normal, while record the delta activity may be quite pronounced. independent of the electrode combinations employed. Spike or Spike-Wave Activity: A large number of records or high voltage. Most show single spike activity of low, moderate often such spikes are slower and not as prominent as �- 6 - those present in patients with seizure disorders. show spikenwave A small number of records activity. This is usually at irregular, mixed frequencies and, again, does not resemble the regular rhythmic bursts commonly seen in patients with seizure disorders (Fig. 2). III. Alpha Activity: The alpha activity shows changes both in amount and frequency. As the amount of delta activity increases the amount of alpha activity usually decreases. Changes in frequency occur but are not pronounced. will be slowed by 1-2 cps but tracing. In a small number at times will remain the same The frequency as in the pre-ECT of patients the amount and voltage of alpha activity increases during treatment. This change persists during the post-treatment period after the slow-wave activity subsides (Fig. 3). IV. Beta Activity: The fact that activity in the EEG many and the induce fast barbiturates, particularly sedatives, of administration the in controlling difficulty these drugs in this population studied makes during the course of treatment. are minimal. activity. The most it difficult to evaluate changes In most instances changes in fast activity frequent change, when present, is a decrease in the �Discussion: is that of the individual variability in the As EEG described, electroshock therapy. and of during alteration degree type and of rate slow-wave amount of its the activity manifested in: l) this is (amount slow-wave the in activity differences 2) development; qualitative The problem being raised of burst activity vs irregular delta activity, symmetry, fluctuating appearof 3) slow activity); of presence rhythmic slow of runs ance activity, Spike or spike-z-rave activity; and LL) changes in alpha and beta Previous investigations (2, h, 5, 10, have ll, activity. 12, 1h, 17, 18, 19, 20, 25) stressed possible correlations with age , sex, frequency of treatment, and clinical change. diagnosis, employed, of current psychiatric type Increasin" the frequency of treatment, for example, will increase the degree of similar sex, age and the with same the frequency treatments at given are psychiatric diagnosis same type of electroshock current, variability in the rate of development of alteration in the EEG. However, when "ratients their type anc‘. degree are still very prominent. One explanation for this variability might be the distribution of the electroshock current in the brain. Perhaps minor differences in the resistance of changes in the EEG and and blooc‘ vessels of the distribution of the skull, in their penneability or taken the pathways in differences create of tracts nerve in the arrangement the of brain portions different such Unler circmnstances, the current. by may receive more or less current in one patient as compared to another. variously these by generated of the electrical activity Differences in type affected areas might account for variability in the EEG. Available studies employing direct intracerebral measurements indicate considerable diffusion of current throughout the brain (6, 9, 16, 21). �However, a concentration of current anteriorly and along: large neuronal pathways, such as the corpus callosmn, has been demonstrated. No further infon'ration is available as to amounts of current received. by more Specific cerebral areas. Due to the high resistance of the skull only a small portion of the applied. current actually reaches the brain. The amount of current entering different portions of the brain is said to be determined by the resistance of the skull overlying these areas; the anterior concentration of current being; the result of the thinness of the temporal bone with its consequent lower resistance as compared to other parts of the skull (9, 21). Several considerations, however, indicate that individual differences in these factors of resistance and amount of areas of the brain are of minor, during-g electroshock. It is if current reaching,- different any, importance in the ELG response the occurrence of the generalized seizure 291'. §_e_, rather than the passage of electricity, which is the primary factor. During a course of grand-mall therapy induced by non-electrical means such as metrazol, EEG changes occur which are similar, with electroshock (13, 1h). Diffuse slow-wave in general, to those seen activity, accentuated of The amount described. are activity anteriorly, slow—wave activity increases during treatment but shows individual variability unrelated; to the n unber of treatments. Another observation is that electroand 81‘.de or spike-wave shock therapy nhich induces petit-mal (7, 18) or focal (3) seizures rather than grand-mal, does not produce the characteristic build-up of slow-wave activity. In addition, there is no increase in the degree of delta activity in our patients in whom grand-mal tae rapy is given with high suprathreshold stimuli as compared to those in whom threaiold stimuli are used. �-9- . Factors of current cannot be entirely dismissed, however. Even with grand mal therapy, the type of current employed may influence the we haVe EEG change. confirmed a previous study (20) showing that the rate of increase of delta activity is slower in therapy with unidirectional current than in that with alternating current. Similarly, brief stimulus therapy is said to produce smaller degrees of alteration in the EEG as compared to alternating current therapy (15). The EEG other theory to be considered in explaining the variability in re5ponsiveness, and the one which is probably more determinant, involves inherent differences in neurophysiological reactivity. By this is meant both the quantitative and qualitative aspects of the inherent capacity of the nervous system to respond to stimuli or injury. Not only the degree of response, but also the type of response, type and degree of EEG may have these determinants. The abnormalities developed during electroshock therapy appear to be the reflection of such inherent individual differences in neurophysiological reactivity. Several types of investigation Methods other than electroshock may known serve to to produce test this hypothesis. EEG alterations could be applied prior to treatment. These might include lowering the blood sugar by parenteral insulin, intravenous administration of convulsants such as metrazol or Hegimide, photic stimulation, or the intravenous administration of drugs such as barbiturate. In addition, perhaps the actual electroshock seizure ﬂzreshold or the pattern 0: severity of the seizures measure of nervous system responsiveness. Data from such could be correlated with the degree an? types of shock. In this manner it might be ELG may be a investigations change during electro- possible to demonstrate different patterns �410- classify individuals accordingly. not only help in understanding the variability in reactivity of neurophysiological Such studies may and alterations during electroshock but would have wider application to other problems in clinical electroencephalography and neurology. For example, tie basis for the development of Spontaneous seizures secondary the EEG to traumatic, vascular, or neoplastic lesions of the nervous system known. Patients with lesions comparable in type, size and location or may not develop seizures. As previously described, spike or Spike-wave activity during electroshock. difference in not may subjects some show This suggests an inherent clinical seizures or he capacity to develop is EEG seizure is reflected in the whether the to injury nervous system, "injury" following activity spontaneous or induced. Differences in this capacity may be varying patterns of neurophysiological reactivity. Differences in neurophysiological reactivity in the pre-troatment abnormal (ll), EEG. Patients in whom "instabile" (22), or axons may also be manifested the pre-treatment record is a predominant alpha rhythm (S) LEG the in during electroshock. the alteration to said develop greatest are Other investigators have not confirmed these observations (2, 23). Actually, such correlations depend on the method of analysis of the pre-treatment criteria used for "abnormality." Further investigation of this relationship is necessary. Suggesting that neurophysiological reactivity is an inherent process does not imply that a physiological basis does not exist or cannot be in- record employed and the vestigated. This may reside in the central nervous system itself, consisting of individual differences in neurochemical systems or in the permeability of cells-or blood vessels; or it may be outside the nervous system. Individual �‘11- differences in hormonal or other humeral substances produced during the stress of electrosho k may serve to "sensitize" or "desensitize" the cerebrum with regard to developing ical activity. That such factors following studies. Trypan red different may be amounts and types of electr- operative is suggested by the injected intraperitoneally in cats before a course of electroshock decreased the permeability of the blood~brain barrier and reduced the degree of EEG changes as compared to control animals (1). Atropine and scopolamine adminstered during a course of electnodiock in man blocked the development of the usual slowawave activity (2h). Electroshock therapy affords an excellent opportunity for the experimental investigation of the problem of an inherent neurophysiological reactivity. animals. The One is able to apply studies directly to man, rather than stimulus to the central nervous system can be standardized and the degree of neurophysiological change changing different parameters. controlled, within limits, by Tests of 336 responsivity can be given before such dianges are induced as well as during and after treahnent. Re-study of patients is often possible then subsequent courses of treatment are necessary. �.12.. marl: l. Indiviéual EEG the in qualitative, changes during a course of electroshock treatment in 89 patients are éifferences, both quantitative and described. 2. These differences are pronounced and are not explainable by age, sex, type of shock current, frequency of treatment, psychiatric diagnosis, or clinical change. 3. An inherent capacity for neurophysiological change that has both quan- titative and qualitative aSpects may be the primary determinant of these differences. h. Variation in skull resistance and in the amount of current reaching the brain aspear to be minor factors. 5. Investigations that might serve to described. Such studies may test the hypothesis presented are lead eventually to a classification of individuals as to different patterns of neurophysiological reactivity and clarify other problems in clinical neurology and electroencephalography. �é 13 - REFERENCES l. Aird, R.B., Strait, (1956): S.C. and Bowditch, M.K., Hrenoff, L.A., Pace, J.w., Current Pathway and Neurophysiological Effects of Electri- J. cally Induced Convulsions. Nerv. Ment. & Dis., igg: Bagchi, B.K., Howell, R.W. and Schmale, H.T. (l9h5): alographic and The J. Pszchiat., lgg: h9-61. Am. R. (1953): and S. Feinstein, Berg, Impastato, D.J., P.S., Bergman, Electroencephalographic Changes Following Focal Seizures, Conf. Neurol.hl§: Electroshock, EEG. Chusid, J.G. and Pacella, B.L. (1952): Electric 271-277. Clin. Neurgghxs., g: Shock Therapies, J. Electrically Induced Slow Wave Phenomena Callaway, E. and Boucher, F. (1950): 157~162. Neuro. Ment. H. Dis., llé‘ (1953): shock on the Cortical and Intracerebral shock Process, M. J. Nerv. and Kahn, B.L.: & Response in Electroshock: Arch. Neurol. Hayes, K.J. (1950): Arch. Neurol. & The & 95—107. Electroactivity of the l3: 287-29h. Experimental Studies of the Electro- Ment. Dis. Relation of in Effects of Electrou Brain in Schizophrenic Patients, Conf. Neurol., M., Kabn, B.L. and Green, MLA.: in Intensive The Electroencephalogram Delgado, J.M.R., Alexander, L. and Hamlin, Fink, Electroenceph- Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders. Fink, 505-512. EEG (in press). Delta Activity to Behavioral Quantitative Serial Studies, A.M.A., Pszphiat. (in press). Current Path in Electric Convulsion Shock, Psxchiat., §§: 102-109. �-1hREFERENCES 10. LC. and Pincus, Hoagland, IL, Malamud, w., Kaufman, G. (19%): in the Electroencephalogram and in the Excretion of 17 Changes Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. , 8: 11. 216-251. Kennard, M.A. and Willner, MD (1908): Electroencephalogram M. lg: 13. Serial (1955): Results from Shock Therapy, 4AM ho-hs. P83111835” £02: Igtz, Which Significance of Changes in the Changes Due to Electrotherapy, Dis. Nerv. $35., 120-122. Knott, G.R., Gottlieb, J.S., Leet, Hull and Hadley, H.D. Jr., (1943): Changes in Electroencephalograph Following Metrazol Shock Therapy: A 1h. Quantitative Study, Arch. Neurol. 8c Psychiat., 29: 529-53h. Levy, N.A., Serota, mm and Grinker, R.R. (19142): Disturbance in Brain Function Following Convulsive Shock Therapy, Arch.Neurol. PsEhiat., ﬂ: Liberson, wur. (1951): 1009-1027. Current Evaluation of Electric Convulsive Therapy, Mento ASS. Nerv. PUbl. R93. D180, 0... nun-U. Lorimer, F.M., Segal, & M.M. and Stein, S.A. 2: 199-2310 (19149): Path of Current Distribution in Brain During Electroconvulsive Therapy, EEG. 17. Clin. Neurophysiol., 3;: 318-3148. Moriarity, J .D. and Siemens, J .0. (19M): Electroencephalographic Study of Electric Shock Therapy, Arch. Neurol. & Psychiat., 21: 712-718. �- 15 REFERENCES 18. Pacella, B.L., Barrera, S.W. and Kalinowsky, L. (l9h2): Variations in of Shock Therapy with Electric Electrocephalogram.Associated the Patients with Mental Disorders, Arch. Neurol. & Pszchiat., 51: 367—381l- 19. Proctor, J.E. (l9h5): Clinical and Electra-physiological L.D. and Goodwin, Observations Following Electroshock, Amer. J. Pszghiat., 39;: 707-800. 20. Proctor, L.D. and Goodwin, J.E. (l9h3): Comparative Electroencephalographic Observations Following Electroshock Therapy using Alternating and Unidirectional Fluctuating Current, 22: 21. Raw 60 Am. Cycle J. Pszghiat., 525-530. Smith, J.w. and Wegener, C.F. (19hh): On Electric Convulsive Therapy with Control??? Electrodes of Application Parietal to a Particular Regard Neurol., et Acta Measurements, Pszchiat. Voltage Intracerebral by lg: 529-5h9. Sulzbach, W., Tillotson, K.J., Guillemin, (l9h3): A Consideration of Some V. Jr. and Sutherland, G.F. Experience with Electric Shock Various to Regard with Special Mental Diseases, Treatment in Psychosomatic Phenomena and to Certain Electro~technical Factors, 23. Taylor, R.M. and Pacella, B.L. (19h8): The Significance of Abnormal Electroencephalograms Prior to Electroconvulsive Therapy, J. Nerv. & Ment. Dis., 291: 220-227. �. 16 - REFERENCES 2h. Ulett, G.A. and Johnson, M.W. (1957): Upon Electroencephalographic Changes Induced by Electro-convulsive Therapy, 25. W911, A.A. and EEG. Olin. Negggghxsiol.,.2: 217-22h. Brinegar, wgc. (19h7): Following Electric 21: Effect of Atropine and Scopolamine 719-729. Electroencephalographic Studies Shock Therapy, Arch. Naurol. & Pszghiat., � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Martin A. Green: Significance of Individual Variability in EEG Response to Electroshock, 1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-10-010 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Green, Martin A. Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/796682f73a8899c60e07650432e2be6b.pdf 47708d42bc2c57225df86d2abf4a24c9 PDF Text Text W“ m mate” om' n“, 0" a: “e, x I! ‘e swam mature: M Md." 'ene etmluletlon or the tune and the head.w1th cuteneeue etilull e ceneleteht pattern or reepanee hee been oheerved 1a which errore in perception ere Ib’. frequent an the head then on the reae. In thle ﬂeet eltuetlon the reee 1e eeld to he dullnent over the head. the pettern or teoe dullnenhe cen he found in nah-e1 end eohleophrenle ednlte hue 1e verticalerlr evident in petleute with oreehle eentel eyndruee end in children 3 to 6 yeere or eye. rhe pattern wee eo eoneplouohe thet 1t pranpted as to etuay different etilulue ooehauetlohe in order to detehelhe whether eoneletent petterue occur for body part: other then the reee end head. The eehhod at heeelns 1n hhe preeent etudr wee elesler to theh deeorlhed prevtouely. The euhjeet wee requeeted to alone hle eyee end twh perte at the had: were teuohed eteulteneauely. he wee eehed whet he felt end to loanltee the eel-ﬁll. Teenty heeleute with arsenlo wentel eyndehee due to altruee Meet» at the brain formed the sun group or etheote . The following pert: or the body were etudledz tece, ehoulder. head. heck. hreeet, ehdalen. aenltel eeglou. buttock, thigh end toot. All #5 peeelble ouehlnetlone between these body perks were heeted e9 the: eeeh or the ereee wee teeted 1n ouehtnetlon with every other eree. fen heehe or eeoh cuehlnetloh were done in every petlent in e tench-leed cheer. !heee included teetlnz the body ereee 1n hath hetereloeoue end haeoleterel reletlohehlpe. Flee hundred and tart: teat: or elehlteneune 0n elwulteneoue etheuletlon were done on each patient. eeoond group of 178* euhgeote eoneletlhs at 660 nereel edulte, 58! echleopheenlo edulte end she patiente with arsenic hence: eyhdrnee A �studied. the etheote in theee groove eere teeted with eiualteheoue etinnli out not in en hen: oomhinetione ee eee done in were eleo the previoue group. Only 13 or the t5 poeeihle bod: continetione were studied end different groove of petiente were need for each continetion. it leeet lo teete were done on every patient. Pertiouler ettention eel directed to the initiel reeponee. the reeponeee on eilnlteneoue teeting in ell euhjeote fell into two senerel groupe. rhe etheot either reported both eti-oli correctly or reported only one etieulue ooereotly end either did not perceive the eeoond eti-ulue (extinotion) or'nielooelieed it (diepleoeeent). rho totel number or errors in peroeption over one pert or the body ee ooeoeteo to the other part of the body in eeoh continetion eere euelyeed by etetietioel lethode. In the tiret group or 20 petiente with orgenie heeiu dieeeee teeted h: the aethod of multiple triele there were 27 oolhinetione in ehioh the difference in the mocha: of extinction end dieoleoenent in the two body perte teeted eee etetietioelly eicnirieent. this occurred in ell continetione in ehioh one or the two perte nee the reee, the genital tone (nele end tenele), or the head. In the continetione involving the teoe or the cenitel none errore ih per» oeption were more frequent in pert: or the body other then theee bod: ereee. the (poo end the genital zone ney be eeid to he dolinent to ell other ereee or the body. In combinetione involving the head there eere uooeerrore in peroeption or the head etinnlue then in en: other pelted part or the body. ‘rhe hand new be eeid to be the leeet dolinlnt are. or the body. there were four additional combinationin which dominance wee Innifeeted. !he hottook wee doniuent over the heok aha ehoulder. the breeet wee dolinent over the heck, end the heck lee douinlht over the thigh. �3. 4‘.“ in anniyuil of tho rcspensca or and accend group at pitiontn with organic Iantal nvndrunn who HUI. touted in u tingle bady ounbinatien with.» than in multiplt culbinltions ahowua a liliilr pattern. inn». unto I few important axooptionn howrvor. who race an: round to b. otvonsly dominant ever tha genital tout, the foot duuinunt over the thigh And tho buttock duninant over tho fact. .. _ they. relationuhipu wart not tpplront in in. group or patients tottod by tn. Inthod of multiple trials. Th. foregoing rcuuits that that an inns. or duubic uinuitanaaul ”manna in panama um auntie mm, swarm. the "rim part: or the bear cxhibit a infinite volttianship to on. another: ﬁhin 1i aunitoutcd hi Vlrvins accrue or dnlinnnoc which.lay ht can~ Iidorod a: gradient 0: nonnation. it the top of en. gridiont in V ' . m «um Ian. in slightly 1.» doninnnt um the he. the mu. but in dalinnnt «var all other part: of tn. bad: and i: thnrgby tho host bad: tron in tho order of dalinanoc. it tho 9th.! 0nd of tho gradient is en. hand. In. runninins aria. at thu body tail bctuoon tho no. Ind um and an acne. mu. body pm. mud in oeubinntion Iii: «ﬂab other failed. for tho most part, to yield differtnoos in duninuaoc’cnous than other. Th0 combinstionl in which daninanoc who Innitontod showed a tondcncy for the hulbek, than-0n. brains, and taat to ho tho mare dominant part: uni tho hack. magniﬁer, denim“ par:- within this ﬁrm. rand cum to be the In tun series or nanlni and nahisophrcnie adult: that. uvrc only tun «albinationl in uhieh Eh. dirrorgnoo in the number at error: men in“ between the two ptrti ati-ulatod it! statintioclly significant. duninant over eh. bruit: and the brnant wax dominant ovar tn. hind. In both instance: in. pitttrn or danintnoa in: ailiitr to that Icon in patient: with organic anneal Iyndrnnn. Th. rhea III �m mm or ammo. duomtmtod by suntan-m "Inns in ﬂinch the no. Ind tho him! for! 2!!! at"... of I Mont the body pain hu :1» been dam-tum 1n mucosa other than than with eman- «mm. or the mean. when include nomx 01:11am 3 to 6 or m, nut-t1 adults with transient damnation or the built: an. to imam“, unamor among m «lacuna-hook therapy, in! under 7 your: . not all th- :utnum mu, ma), «noun Mult- with mum use ymine we: ombmuona have been «an: Mu. ﬂavour, at then ammun- um have been smut! a pattern 1: atom: in mm the no. 13 the most dominant m: and ﬂu hind the lone 60.1mm. for n the»: to «at: u. mm or 4mm“ mun, none in It appear. to b. an inherent ”turn 9: organization within the mm}. ”an“: man 1.. exaggerated in tested in than ' u «than. patient: an: u m «an. or the pram. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Order of dominance in cutaneous perception. Trans Am Neurol Assoc. 1952; 56 (77th Meeting): 238-40. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Green, M.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, M.B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/718a29ec15d25cbb6a477d3556be0fdd.pdf da7a7236e5d976ec8ac1cfd95b801264 PDF Text Text EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADERMAN, M.D., AND MAX FINK, M.D.1 [Reprinted from THE AMERICAN JOURNAL or Vol. 116, No. 9, March, 1960] PSYCHIATRY, �1960 ] CLINICAL NOTES 839 EFFICACY OF DIVIDED AND SINGLE DOSE SCHEDULES IN INSULIN COMA THERAPY ARNOLD G. BLUMBERG, M.D., PETER LADEBMAN, M.D., AND MAX FINK, M.D.1 While many technics for the administration of insulin in insulin coma therapy have been advocated(3), recent reports(4) have assessed multiple divided doses as more effective and safer than other methods. Previous studies indicated that the production of coma was directly related to the level of hypoglycemia and its duration (1) and that deep coma for sustained periods was essential to the treatment result in insulin therapy(2, 3). It seemed reasonable to test the suggestion of increase-d efﬁcacy for a modiﬁed insulin administration by comparing the length and depth of coma and the blood sugar levels in patients treated both by single and divided insulin dose methods. If the divided dose schedule were more effective, it would be expected that the induced coma would be equal or greater in depth and duration; that the time for onset would be equal or shorter; and the blood sugar levels lower for divided dosage than single administration. the dose was increased in 10 unit incre— ments. At the time when coma was produced, a single dose equivalent to the 3 doses was given on the succeeding day. For each treatment, coma depth and the time of onset was determined. Coma was deﬁned as the loss of consciousness (failure to respond meaningfully to verbal signals), associated with the appearance of the Babinski reﬂex, and the loss of the lid reﬂex. An adequate coma treatment was deﬁned as the persistence of this depth of coma, or deeper (loss of pupillary or corneal reﬂexes) for at least one hour. At half-hour intervals true blood sugar levels were serially determined by the Somogyi method. The resulting blood sugar curves and their level at the time of onset of coma, were compared for each subject with the blood sugar curve and coma data obtained on a single administration of an equivalent dose. METHOD The blood sugar levels at various intervals after the administration of divided doses of insulin compared with a single dose of insulin in one patient is presented in Figure 1. This pattern has been reproduced in each of the patients studied. For each, the blood sugar curve drops rapidly in the ﬁrst hour without respect to the initial dose, and ﬂattens at progressively lower levels as the total dosage of insulin increases. Coma characteristically is reported in subjects in whom the blood sugar curve is below 21 mg.% for an extended period of time(1). The time of onset of coma and the blood sugar level at coma in each of the patients is presented in Table 1. In ﬁve of the 6 Consecutive patients referred for insulin coma therapy were given daily increasing amounts of insulin in 3 divided doses until a coma level was achieved. The same total dosage was then given in one injection. Six patients were studied in this manner. Each patient was started on the following insulin dose schedule : ﬁrst day—10 units; second day—10 units and 2 doses of 5 units each at intervals of one half hour; third day—3 doses of 10 units at half hour intervals ; and fourth day—20 units followed by 2 doses of 10 units. On each successive day From the Departments of Internal Medicine and Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. 1., N. Y. 1 [Reprinted from THE OBSERVATIONS AMERICAN JOURNAL OF PSYCHIATRY, Vol. 116, No. 9, March, 1960] �' 'n' 9 Ir" : 840 CLINICAL NOTES [ March I % TRUE BLOOD SUGAR LEVELS FOLLOWING ADMINISTRATION OF INSULIN IN DIVIDED AND SINGLE DOSE SCHEDULES 9 9° ~7‘ 9; 8° 3 O \\ .- _ \\ I \ 7o \.\ as INSULIN DOSAGE IN UNITS 20.20.20... —---— 10.70.70... .......... 90.90.90“. ———-— ...q’ \ \\ '\ ———- AT auo MINJNYEuRVALS “ " “ I20,I20.I20u." —'-— 360u. IN " " " SINGLE DOSE E K <1 0D U) D oo _J with divided doses in 4 of the 6 cases. It was identical in one and lower with the divided dose in one. As there was no evidence in these studies that the divided dose method was more effective in the production of insulin coma than the single dose method, the divided dose technic was discontinued. m CONCLUSIONS MI 3 a: [— O 60 90 IZO I50 TIME IN MINUTES AFTER ADMINISTRATION 30 IBO ZIO OF INITIAL DOSE 240 cases, there was no difference in the time required to induce coma by either the single or the divided dose methods. In one subject (Sc) coma was observed in 132’) hours with a single dose as compared with 3 hours with divided doses. TABLE 1 ONSET OF COMA AND BLOOD SUGAR WITH DIVIDED AND SINGLE DOSAGE SCHEDULES PT D G H c So V Time for Coma Blood Sugar Value (minutes) (mg. %) Insulin Divided Single Divided Single U nit: Dore Dore Dose Dose 330 360 270 390 360 210 210 210 210 180 210 135 190 210 210 90 210 150 4 14 15 12 12 8 0 4 15 7 8 20 The average blood sugar at the time of coma was lower with the single doses than The coma produced with the divided insulin doses did not occur earlier and was not deeper than that produced by the single dose. The increased effort in divided dose schedules is justiﬁed neither by increased safety nor by increased depth or duration of the induced hypoglycemia. There was no, evidence that the initial dose of insulin sensitized the subject so that subsequent doses produced a greater hypoglycemic effect. The total hypoglycemic effect of divided doses appears to be less, if anything, than the effect of a single dose. BIBLIOGRAPHY 1. Blumberg, A. G., Cohen, L., Croghan, J., and Kelsey, D.: J. Hillside Hospital, 5: 41, 1956. 2. Fink, M.: J. Hillside Hospital, 6: 197, 1957. 3. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and Other Treatments in Psychiatry. New York: Crune & Stratton, 1952. 4. Laqueur, H. P., and LaBurt, H. A.: Proc. Annual Meeting, American Psychiatric Association, Phila., 1959. �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Efficacy of divided and single dose schedules in insulin coma therapy. Am J Psychiatry. 1960 Mar; 116:839-40. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-43-009 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Blumberg, Arnold G.; Laderman, Peter; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint from THE AMERICAN JOURNAL of PSYCHIATRY, Vol. 116, No. 9, March, 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/abb942c109b57ff8986a7757e43563c2.pdf 23a7bbd876571d7517224c266ad15ea2 PDF Text Text Patterns in Perception on Simultaneous Tests of Face and Hand _ N...”- —-. MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK Reprinted from the Archives of Neurology and Psychiatry Septmnber 1951, Vol. 66, pp. 355-362 COPYRIGHT, 1951, .‘BY AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO 10, ILL. Printed and Published in the United States of America �Reprinted from the A. M. A. Archives of Neurology and Psychiatry September 1951, Vol. 66, pp. 355-362 Copyright, 1951, by American. Medical Association PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK it PREVIOUSLY was shown that examination of the cutaneous modalities by the method of double simultaneous stimulation elicited defects in perception which were not apparent on single stimulation. The defects, described as “extinction,” “obscuration,” “displacement,” and “allesthesia,” were observed in groups of patients with localized or diffuse disease of the central nervous system.1 In each group the defects in cutaneous perception obtained on double simultaneous stimula— tion were most apparent in the hand and least in the face. The object of the present investigation was to determine the patterns of in normal subjects, adults responses and children to simultaneous stimulation of the face and hand—the “face—hand” test.2 The observations on this normal were then compared to some extent group with the responses of patients with organic mental syndromes, aphasia, and schizophrenia. MATERIAL The “normal” subjects were children and adults. These subjects were persons attending hospital clinics in whom there was no evidence of disease of the brain, and school children, staff personnel, and students, in whom there was no manifest disorder of the central nervous system. None of them had been examined previously by the method of double simultaneous stimulation. From the Department of Neurology and Psychiatry, New York University College of Medicine; Bellevue Hospital, and the Mount Sinai Hospital. This work was aided (in part) by a research grant from the National Institutes of Health, United States Public Health Service, and (in part) by a grant from the Coordinating Council of Cerebral Palsy in New York City, Inc. 1. (a) Bender, M. B., and F'urlow, L. T.: Phenomenon of Visual Extinction in Homonymous Fields and Psychologic Principles Involved, Arch. Neurol. & Psychiat. 53:29—33 (Jan) 1945. (b) Bender, M. B.: Extinction and Precipitation of Cutaneous Sensations, ibid. 54:1—9 (July) 1945; (c) The Phenomenon of Sensory Displacement, ibid. 65:607-621 1951. (May) (d) Bender, M. B.; Shapiro, M. F and Schappell, A. W.: ., Extinction Phenomena in Hemiplegia, ibid. 62:717-724 (Dec.) 1949. (e) Bender, M. B. ; Wortis, S. B., and Cramer, J.: Organic Mental Syndrome with Phenomena of Extinction and Allesthesia, ibid. 59:273-291 (March) 1948. (f) Bender, M. B.; Shapiro, M. F., and Teuber, H. L.: Allesthesia and Disturbance of Body Scheme, ibid. 62:222-231 (Aug) 1949. (g) Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, ibid. 64:501—515 (Oct) 1950. 2. Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of the Face and Hand, Tr. Am. Neurol. A. 75:250—252, 1950. �2 The subjects were divided into three groups according to age: children of 3 to 6, and 7 to 12 yr., and “adults” over 12 yr. of age. For comparison with the normal group, we studied patients in the wards of the Bellevue Psychiatric Hospital. They were divided into three groups on the basis of their disease— schizophrenia, organic psychoses, and aphasia. No attempt was made to study separately the clinical types of schizophrenia. Most of the patients had the paranoid, mixed, or simple variety of schizophrenia. The patients with organic mental changes showed defects in memory, orientation, andcalculation, as well as other signs and symptoms. characteristic of diffuse disease of the brain. The clinical diagnoses for most of thesegpatients was Alzheimer’s’ disease, arteriosclerotic encephalopathy, severe cerebral trauma, brain tumor, or toxic encephalopathy. The subjects with aphasia were those who showed characteristic difﬁculties in communication. Those who had concomitant hemiparesis or ‘a hemisensory defect noticeable on single stimulation were not included in this series. MET HOD The subject was instructed to close the eyes. When this was done, the face (cheek) and either the ipsilateral or the contralateral hand (any part of the hand or digits) were simultaneously touched or stroked with the examiner’s ﬁngers. The subjects reported either one or two sensations. When only one percept was reported, the subject was asked if there was still another and, if so, to indicate its location and quality. After the initial trial, in each subject, the opposite cheek and hand were stimulated in the same manner. These tests were repeated and the results recorded, until the subjects consistently reported both stimuli correctly. In those subjects who failed to localize the two stimuli correctly ‘after six or eight trials, other parts of the body were tested in such combinations as face-face, hand-hand, face-breast, or penis-hand, these stimulations alternating with the facehand test. In a second, separate series of studies, pinprick stimuli were used in a similar fashion. In both series, care was taken to app-1y the stimuli at the same time and with the same intensity. It was apparent that subjects who made consistent errors in reporting would be correct as soon as the stimuli were applied consecutively rather than simultaneously, even if the time lag between stimuli was that of one or two moments. It was also necessary to use naive normal subjects, since subjects previously tested did not show the patterns noted below. RESULTS The responses obtained on the face-hand test fell into four groups: (a) a touch sensation on the face and the hand, indicating the correct and expected perception; (b) a touch sensation on the face only, implying no sensation in the hand; (6) a touch sensation on both sides of the face, and (d) a touch sensation on the hand only, implying none on the face. When only one stimulus was reported, the subject was asked if: there was any other sensation. The occasional reply was that there was another percept, and the subject correctly pointed to the second locus. Many subjects, however, reported that they had not perceived another stimulus, usually adding the statement: “I was not paying attention; do it again,” or, “I’m not sure; maybe it was somewhere over here,” and pointing in the direction of the side of the body of the poorly felt stimulus. In some instances, while correctly localizing the second percept, they volunteered the statement: “It was not as strong as the other one,” or “It doesn’t seem as sharp.” Before we proceed with the results, we must deﬁne the special terms used. In other communications the failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” 1”“ b The part of the body where the stimulus was perceived is said to be “dominant” to the part of the body where the simultaneous stimulus was not per— ceived, or perceived faintly. The latter diminution in the quality of a sensation was ' �3. termed “obscuration.” When the subject reported two sensations, but mislocalized one of them, the “displacement” of a percept is said to have occurred.1c Displacements are usually in the direction of the dominant stimulus and may be partial or complete. The displacements noted in this series were from the hand to the cheek of the same side. Rarely did the displacements occur to the neck or shoulder. Initial Trial—The results were analyzed from the standpoint of initial and subsequent trials. On the initial trial of the face-hand test with touch stimulation in normal subjects, face dominance was apparent in all age groups. More than half of such normal adults reported the sensation in the face and none in the hand. Three subjects mislocalized the sensation in the hand to the face. In the groups of normal children, 90% under the age of 6 yr. reported only the face percept or mislocalized the hand percept to the face. This pattern of face dominance is also seen in the children from 7 to 12 yr. of age, but to a less extent. Of the normal subjects, ﬁve adults reported the hand stimulation only on the initial trial. N 0 example of displacement from face to hand was noted. This pattern of face dominance by hand extinction or by displacement of the hand percept to the face was even more apparent in the patients examined. It was most evident in patients with organic mental changes, 93% of whom did not report TABLE l.—Response to Touch Stimulation on Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia (unclassiﬁed) ............ Organic mental syndrome ............... Aphasia ................................. Total 160 56 76 74 120 23 Correct Responses 77 10 38 26 9 12 Face Only 75 28 27 45 94 11 Face-Face Hand Only 3 18 9 5 0 1 2 14 3 O O 2 both stimuli correctly. In examinations of schizophrenic subjects and patients with aphasia, responses similar to those of the normal adult were observed in the initial trial. Hand dominance was occasionally seen in the patient and rarely in the normal subject. In cases of hand dominance the subject reported the hand, but not the face, percept. It was seen in the initial trial in ﬁve normal adults. These subjects reported both stimuli correctly on subsequent testing. In the patients with organic mental changes hand dominance was an inconstant response, and repeated testing the same day, or on subsequent days, demonstrated the more usual persistent pattern of face dominance. Subsequent Thain—Of the 83 normal adults who made errors on the initial trial, 43 made correct responses on the second trial and 12 on the third trial. In a few subjects, four, ﬁve, or six trials were necessary before the two stimuli were correctly localized. These subjects were assumed to be normal, although complete psychological tests were not made. It was noted that anxiety (tension during examination or a strong desire to please) interfered with the early correct recog— nition of the stimuli. In all normal subjects, including those with anxiety, once the correct response was obtained (even after many trials with errors), it was elicited on all subsequent testing. It seemed as though a number of trials was necessary for �4 the subject to get into the “set” of the examination, and that, once in the set, he reported the stimuli accurately, even after the lapse of many days. In testing the normal young child, it was apparent that in most cases many trials were necessary before the correct response was consistently elicited. Also, the child did not always give a correct response on subsequent testing. Repeated testing over many days, however, elicited the same patterns of face dominance. .This was noted in 36 of the 56 children tested. In a number of instances the child watched the application of the stimuli and thus reported the perceptions correctly. But as soon as the test was repeated with the eyes closed, the child again reported only one stimulus. It was evident that the child could not get into the “set” of the examination, even with visual cues. This difﬁculty was not very apparent in all children. In the older (ages group 7 to 12 yr.) only 17 of the 76 failed to give the correct response after the initial few trials. A\\A A\4*A\ ‘~ 90 ‘___-c\‘ ~ ‘c____ .¢—————-—._—_——__———-—c 89 Responses 70 60 Dominant Face 50 Organic Mental Syndrome c--c Children, age 5 to 6 o——o Schizophrenic Adult Normal Adult 40 % 50 20 10 1 2 3 4 5 6 10 Responses to face~hand test on initial and subsequent trials. The responses obtained on repeated trials of the face-hand tests in normal sub— jects also followed a consistent pattern. As on the initial trial, face dominance was prevalent in all subjects. It was manifest either by (a) extinction or obscuration of hand stimuli or (b) displacement of hand stimuli to the face, or, in several instances, in a direction toward the face. In contrast to normal adults, patients with organic mental changes were unable to report the two stimuli correctly, even after many trials. When the patient reported the percept in one test correctly, he frequently failed on subsequent testing. It was also apparent that testing on subsequent days still elicited displacement and extinction of stimuli. This is in strong contrast to the responses of apparently normal subjects, who seldom made an error on subsequent trials, days after the initial examination. The responses obtained in this group demonstrated the patterns of face dominance in most of the tests. Displacement of the hand percept to �5 the face was frequent. In some instances displacement or extinction was present despite the fact that the patient watched the application of the stimuli to the face and hand. Extinction was very common on homolateral or heterologous testing, while displacement was apparent mostly on heterologous testing. The schizophrenic and the aphasic patients gave reports which were similar to those of normal adults. After the ﬁrst two trials percentage of error in hand sensation was slightly higher than in the normal group. Persistent bizarre responses were elicited from a number of the schizophrenic subjects. These reports included mul— tiple responses to single or double stimuli, persistent displacements to one area from any other body area, and mirror reversals of localization. These were inconsistent during an examination and from day to day. As with the normal adults, testing the schizophrenic or aphasic subject on consecutive days failed to elicit extinction phenomena once the test had accurately been reported before. A comparison of the responses of each of these groups to multiple testing is shown in the accompanying chart. Pinprick Stimulation—It is known that the type of stimulus applied inﬂuences the results in perception. To demonstrate the importance of this factor, similar groups of subjects were tested using two pinprick stimuli instead of two touch M TABLE 2,—Respoinse to Pinprick Stimulation an Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia ........................... Organic mental syndrome ............... Correct Total Responses Face Only 68 45 39 50 49 51 16 25 15 26 14 36 9 ' 13 33 Face-Face Hand Only 2 0 2 1 0 0 3 0 1 2 stimuli. With pinprick stimulation of the face and hand, face dominance was again manifest in all the groups. However, the incidence of error in perception of the pinprick in the hand was lower than that with a touch stimulus. The results are recorded in Table 2. Repeated testing with two pins in the'normal adult subjects elicited the correct responses in the intial three trials. Fewer of the children failed to report the test accurately after the initial trials. It was possible in a number of instances to alternate touch and pinprick stimulations and to demonstrate extinction to touch, but correct localization to pinprick. Moreover, with more intense pinprick stimulation, extinction and displacement were less frequently observed. These phenomena, namely, extinction and displacement, were even more apparent in the patients with organic mental syndromes. Displacement of touch stimu— lation could be alternated with correct localization of pinprick stimulation. A combination of touch to the face and pinprick to the hand evinced the combination of displacement and obscuration, as the patient reported “a touch on the face, and a dull one on the other side (of the face).” Pinprick to the cheek and touch to the hand resulted in extinction of the hand percept. or, occasionally, the report of a pinprick on both the cheek and the hand. The schizophrenic subjects were able to localize the pinprick stimulus accurately after the initial few trials, as had the normal adults. �6 COMMENT By using the method of double simultaneous stimulation in tests of the face and the hand, a consistent pattern of responses has been observed in a variety of sub— jects. The stimulus to the face is more readily perceived than the one to the hand. Moreover, the face percept inﬂuences the hand percept, frequently causing the displacement of sensation. This pattern of responses has been repeatedly demonstrated in both the normal and the abnormal subjects and is manifest in extinction, obscuration, and displacement. Extinction is most, and displacement is least, frequent. In extinction, the face percept is correctly reported as to quality and locus, but the hand stimulus is not perceived at all. In all the foregoing tests of patient or normal subjects, whether the responses were accurate or not, it was noted that the subject almost invariably pointed to the faceixsti‘mulus ﬁrst. Occasionally the hand percept was perceived and correctly localized, but assumed a qualitative difference, always of diminution. In displacement the stimulus to the hand was mislocalized to the face, or in the direction of the face, e. g., to the shoulder or neck. In some instances if the face and the hand of the same side were stimulated, the subject occasionally reported two sensations in the face. None of these phenomena was haphazard. While the frequency with which any one of these effects was observed might be affected by attention, drugs, or variation in stimuli, its pattern was consistent. These responses to the face-hand test are modiﬁed by many factors. Some of the inﬂuencing factors are (a) attention, (b) age of subject, (c) simultaneity of stimuli, (d) type of stimulus, (e) strength of stimulus, (f) locus of stimulation, and (9) internal state of organism. These factors may alter the frequency with which extinc— tion and displacement appear, but they do not change the pattern of face dominance. The subject’s awareness of the test is a major factor in the appearance of the phenomenon of extinction. Both attention and previous experience can bring stimuli to awareness. In a series of 20 adults who were informed that two stimuli were to be applied, none showed extinction of percepts. Because previous experience can inﬂuence a response, it was necessary to record the ﬁndings on initial trial in naive subjects. By this method the factor of previous experience was minimized. At the same time, the subject was not apt to be on the “alert” for the number of stimuli he was to receive. Consequently, one might say that the reason the subject perceived only one stimulus, or perceived one stimulus and displaced the percept of the other, is that he was not paying attentio‘n.3 This criticism may be valid, but the signiﬁcant fact is that the error was always made in the hand and not in the face. If it were mere inattention, one would expect 50% of the single responses to double simultaneous stimulation to be in the hand and 50% in the face. But this type of chance error was not observed. Of the single responses to double simultaneous stimulation, 95% were of the face percept and 5% of the hand percept. This pattern of face dominance or hand extinction was further established during subsequent examinations. Moreover, when displacement was seen in normal subjects, it was to the face and not to the hand. This pattern of face dominance to double simultaneous stimulation was found to be exaggerated in normal young children, of whom 83% demonstrated either hand extinction or displacement of the hand percept to the face on the initial trial. Critchley, M.: The Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538—561, 1949. 3. �7 Moreover, this high percentage of responses of face dominance persisted on sub— sequent trials. In the older children, also, face dominance was consistently demon— strable. It was noted that the younger the child, the more distinct was this pattern of face dominance. Hand extinction might be attributed to an inability to perceive two stimuli at once. This particular defect has been noted in patients with severe mental changes by Goldstein.4 However, in patients with severe mental changes or in chil— young dren stimuli applied to both cheeks, or both hands, or any other two homologous body areas were correctly reported as two sensations. There was neither extinction nor displacement. Goldstein’s observation, therefore, cannot be used as an explana— tion of hand extinction. It is noted that face dominance was apparent no matter what type of stimula— tion was used. Simultaneous pinprick stimulations revealed the pattern of face dominance, although with a lower frequency than touch stimulations. Other cutaneous stimulation, such as application of two tuning forks or hot and cold tubes, repetitive rubbing, and repetitive pinprick stimulation, was used, and face dominance was manifest regardless of the cutaneous stimulation employed. The importance of the simultaneity of the stimuli has already been alluded to. In subjects in whom extinction was persistent, consecutive application of the stimuli invariably resulted in the perception of two stimuli. In normal adults consecutive stimulatiOn of the face and the hand, even on the initial trial, never resulted in extinction. In these studies the stimuli were of equal intensity. This factor was important in eliciting the pattern in the normal subject, for unequal stimuli were seemingly more readily perceived than equal stimuli. After the ﬁrst few trials the subject was able to perceive the two stimuli, even if one was painful and the other not. In patients with organic mental changes, however, extinction and displacement were manifest despite a wide discrepancy in the quality of the stimuli. By altering the strength of the stimuli, it was possible to alter the response from extinction of the hand percept (if the hand stimulus was weak) to displacement to the cheek (if the hand stimulus was strong). The change from extinction to displacement was also elicited by altering the quality of the stimuli, that is, from touch to'pinprick. Nevertheless, the pattern of face dominance was always apparent. The parts of the body being simultaneously stimulated is another consideration in studying these patterns. We have already alluded to the fact that extinction is commonest in the hand and least in the face. In testing other body areas, the incidence of extinction and displacement is less than in testing the face and the hand. That is, testing shoulder and thigh may not elicit extinction or obscuration, whereas the face-hand test may. Also, in patients with lesions of the brain or spinal cord, the pattern of relation of the body parts to simultaneous stimulation may be altered in a characteristic hemisensory or “level-lesion” syndrome. Further studies are necessary before the signiﬁcance of the pattern can be interpreted. Any deduction made at this time would be purely speculative. For instance, nothing is gained by stating that face dominance implies a rostral order of sensory dominance.5 Such a 4. Goldstein, K.:: The Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187, 1944. 5. Cohn, R., and Raines, G. N.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance ‘as Determined by Ipsilateral Simultaneous Stimulation, Tr. Am. Neurol. A. 74:162-168, 1949. �8 hypothesis is contradicted by at least one fact, namely, the observation that when the hand and foot are stimulated simultaneously the foot dominates over the hand. Perhaps after more data are accumulated a satisfactory theory may be obtained. SUMMARY _. “awn—a, elicited in normal and abnormal subjects by the method of double simultaneous stimulation of cutaneous modalities. Face dominance, manifest by extinction of the hand percept or by dlsplacement 0f the handmpercept to the face, is seen as a normal phenomenon, manifested1n the normal adults andin the patients with schizophrenia and aphasia examined in the series. It is exaggerated in young children and in patients with diffuse disease of the brain, in whom extinction and displacement are persistent after multiple trials. This pattern of face dominance is manifest regardless of the cutaneous modality tested, there being a change only in the frequency of extinction with change in type of stimulus. j Printed and Published in the United States of America / f / r: L/nAJ/C’ ..... . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. AMA Arch Neurol Psychiatry. 1951 Sep; 66(3): 355-62. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2b-004 Date A point or period of time associated with an event in the lifecycle of the resource 1951 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from the Archives of Neurology and Psychiatry September 1951, vol. 66, pp. 355-362. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/348b7ac617e184efef2c6c30c847fca6.pdf 36100719e5c813fdabfca556caa0ba68 PDF Text Text Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION 1950 PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER MAX FINK AND MARTIN GREEN NEW YORK In previous studies we found that the method of double simultaneous stimulation showed defects in sensation (extinction) which were not apparent on routine single stimulation. In testing two different regions of the body and various combinations it was found that extinction was apt to occur most often in the hand and least in the face. Conversely, “dominance” was greatest in the face and least in the hand. In the present communication we wish to report the results obtained on simultaneous stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syn— drome; 4) schizophrenia; 5) no disease of the brain (normal adults) and 6) normal children between the ages of four to ten years. Patients in groups 2 and 3 showed severe memory defects, confusion, poor orientation, difﬁculties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or ﬁngers) were touched Simultaneously. Care was taken to make the two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked to report what he felt, and following this, where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the ﬁrst examination: a) a touch on the face only (face dominance), implying no Sensation in the hand (extinction) ; b) a touch on both sides of the face (there being “displacement” from the hand to the ipsilateral face) ; or c) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that on subsequent tests he was expectant of more than one stimulus. In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislocalization was towards the face it appeared as if the face determined the direc250 �251 Perception in al.——Patterns Bender, et of type a this was that therefore, said, be might It than tion of the displacement. common less was displacement, or (b), Response dominance. face the patients in often most seen was (b) Response extinction. or (a) testing. response repeated despite persisted and with the organic mental syndrome, comment. special needs no and normal expected the was face The (c) response ipsilateral the when noted werealso Extinction and displacement including tested, subjects the all In tested. sides and hand were simultaneously left and right the between difference no was there aphasia, with those - ' of the body. the in shown is various groups the in obtained results Analysis of the following table: Hand ;/,’// Group Face Response Extinction or Displacement Number of Subjects 2 ‘4 22 20 5 53 ' 3 20 . 0 14 24 , 19 ‘ 0 6 20 ' Response _ 9 12 15 12 1 Face and Head Response ‘ 2 6 28 0 ' ‘ - 0 0 0 . j . l l of is dominance there whenever that obvious is it; foregoing the From. the hand in Dominance face. the in is it apparent another over sensation the in one "uniformly almost found was dominance Face once. notedonly did was patients These 2 and 3).. (groups changes mentalwithsevere in. _ subjects few a In repeated'testing. after hand even the not report sensation in were or stimuli, two were there told the were patients after even stances, percept one only reported they stimuli, of the of asked to watch the application sides both of stimulation simultaneous cases Inthese one. displaced these that or objection the excluding thus correctly, the face was reported once. things at _. two perceive do or able to not were those in and patients with aphasia subjects in dominance face of The'incidence, in .. patients 1 and 4) was less. In contrastto with schizophrenia (groups correctly sensations both 1 4 reported and in those groups 2» and 3, the hrst groups done not had soon if they trials, fourth third or second, the domiface on of. incidence the 5) adults (group normal of the In group the trial. on found only it was though even signiﬁcant, still but least, dominance nance was face of incidence the. children normal of series In trial. a dominance ﬁrst face children 3. In 2 and young in groups as the same almost was examination. ﬁrst the after trials several tested was present even hand were the than other body of the When theface and parts The apparent. still was dominance face 3, 2 and in" groups calf, simultaneously thigh, penis, (breast), trunk shoulder, face, was dominance order of hand. and foot, arm . . _ �252 Weights (IL—Discrimination of Bender, et CONCLUSION In a wide variety of subjects the phenomena of extinction and displace- consistent A demonstrated. stimulation simultaneous were ment on double dominant most face the which in was established of pattern perception was and abnormal the in both noted These ﬁndings were and the hand the least. the normal subjects. In the abnormal subjects with severe mental changes, be that consistent they may extinction were so face dominance and hand used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, be to brain diffuse disease, with in appear patients which are so prominent exaggerations of the patterns found in the normal subjects, especially children. �um II mama! 0' MES 0! I‘M! w 3mm my- A! Harris 3. Bender, ILD. Pink, IL». m and lax-tin anon, LB. of lumbar ﬁpi‘fﬁnﬁ '75; Buivenity cones. of Mieinc, 555 Sinai City. tort lelpiul, In m lupin ' 101E law c ﬁy Edi-y,1 and that Haunt 3.11m. from the mum; grant a ”starch by part) (in This work was aided a. by grant and part) (in service Public With of math, Institutes Inc York . city. in Cmbral of In council his: Coordinating the I‘m �1.' Previously it was shown thst exsnihstioh of the cutaneous uodelitiec by the method or double siuultsneous etisnlstion elicited defects in perception which were not sppsrent on single “extinctiont” ”obscuration,” The ss defects, desctihed etihhlstion. "displacement” and "eliesthesis'.were observed in groups of or the centrsi nervous disesse diffuse with localixed or patients systen (1) (a) (3). In esch group the defects in cutaneous per» most were stimulation double sismitsneous obtsined on ception of the rhe fece. hand the sud object in the lesst in appsrent or the was responses determine to patterns investigation present in nonnsi subjects, sduits and children,to simultaneous stisu1s~ Yarns "fece~hs.nd” observe~ head and teat the face of the tion tions in this nonnsl group were then cospsred to sole extent with the responses of pstients with orgshic mental syndrases, sphssis sud cchisophrenis. IAEIR£égc the ”non-s1“ subjects were children and sdulte. These there. subjects were persons attending hcspitsl clinics, in was no evidence or disesce or the brsin; and school children, start of disorder manifest who: no was there sud in students, personnel been had Hone of then previously system; the central nervous exslined by the nethod or double sisultsneous stimulation. the to according sge: three into groups classified were subjects 12 “adults” end 6 over end years. 7 to 3 children or to it years, For comparison with the noml goup we studied patients on 'There were three Bellevue wards of Psychiatric the iospitsl. the sod lo attempt sphssis. psychoses ~ organic schizophrenia, group: whom �2. .uno and. to separately study each or the clinionl typo: of schisophronil. ﬂoat of tho puticntu ours or the paranoza, mixed or iinplc vurietiel of Iohixophrenin. the patient: uith organic montnl changes showed doreota 1n nonorw, orient¢t1on and onloulution, a: wall In other signs and symptom: oharuoteriltio or dxtruoo dileIIO of tho brain. Tho clinical diagnoael in loot of,those onuou was Althoincr'n dilt&§c, urtorionolcrotio onoop~ haloputhy, severe oorobrll ordain, brain tumor or toxic ano¢p~ who with thou mm uphuu. lubjootl mommy. ohnrnotcriltio difficultiob in columnioation. Theta who had a oonoolitant hmnipnroail or I huuiscnlory aorta? noticeable on single Itilnlation war. not inorudod in thin Curios. m '3th maroon: 2h: subject val instruotcd to‘olouo tho cyan. When thia 1p3111tcéll (chock) and tho oontrav done or either tho-root it: our. hand ninnltnnooully on. (any hand digit.) at or part lateral touohcd or stroked with tho examiner‘s ringorl. the subject: whoa two sonsntionn; only one percept one or either reported no: reported tho subject was naked 1: than. at: 3:111 unothor, and 1: no, to indiooto its loontion and quality. Following the initial trial, in each subject, tho opposite chuck Ind hand aura stimulatod 1n the 1.80 nunnor. Those tout: poquepoatod and tho result: reoordod, until tho subject: oon~ who those In both auhjootl otinnli correctly. nistontly roportod toiled to localize tho two Itinuli oorruotly otter at: or eight word an touted t1oo~ttoc,'hand~ body the of 0th.: part: triala, room-hand tho with uumung ma, “mama, penis-hand, em, tout. �otinuleé eerie! ot.stndies pin prick tions sere used in s sinilsr fsshion.w In both series, cere use taken to apply the stimuli at the me time and with the em thst'snhdects who‘nede consistentt was spherent intensity. It he would correct as soon es the stinuli were errors in reporting rsther thsn sinnltsneoutly, even if the spplied consecutively tine leg betseen stinuli was that or one or two nonente. It was slso necesssry to use neive norssl subjects, since sthects previously tested did not show the.petterns noted below. In e second sepsrste 8 ones; lhe responses obtained on the tnce~hsnd test fell into four groups: (s) s touch on the face and the hsnd, indicstins the correct end expected perception; (h) e touch on the fees only, in the head; (c) I touch on both sides or implying no eensstion the tees: and (d) s touch on the bend only, implying none on the race. ﬂhen only one stimulus III reported the subject use ssked if there uss any other sensstion. the oocesionsl reply sue that there use snother percept, and the sthsct correctly pointed to the second locus. lhny hdhaects, however, reported thst they hsd not perceived snother stimulus, neuslly sdding the state-cut: ”In use not paying sttention - do it seein' or, ”I'm not sure - Isvhe of here" end somewhere the the was direction in over pointing it side of the body or the poorly felt stimulus. In some instances, second while correctly locslising the percept, they Iinnteered the ststenent: "It use not es strong es the other one,“ or "It doesn't seen as sharp.” Before we proceed with the results we rust define the connnnicstions other the failure or the need. In special terns �#. luhjoet to report ohm or two ninnltnnmaunly applied stimuli ha: of been called “tbs phhnhnenon gunnery extinction“ hr ”extinction“ 1n utid wharu stinmlu; tho poreeived or body the (1). the part Ill uxnultanuhulh to he "danihnnt” ta the part of thh body where thn Itinnlun nun net perceived, or parceivcd faintly. the latter aensatieh was terncd ”obnouration.' or a the diminution in quality whah tho uuhject ruparted tun nonnatiehn, hut ninloenlilod one or thun, the "ditplhccncnt' a: a peroapt in .315 to hire oeeurrea (2). ndsplaccnentu Ir. ununlxy 1n the direction or tht daninnnt ’ntinnxup and as: he puttinl hr eqnpxgte. rhe‘dilplaccucnts nttcd man» chock the side. of hand.to th1§.ner1gp tn. were :ran.the in Rarely did the displscahehts cedar to the hack or thauldor. tram the nthhdpoint {hm snalyuod result; \Ih1t1h1‘2r1hxs uqrt of initial and nuhluqnont thee¢hnnd test with touch trilla. en Ithhlltion tn. initill trial or the Inhjcetn, taco deninnnec uuu appurant 1h :11 use granny. 'lhrc_thnn half or such and none in thc race the in the schnation udulta rcported nonntl hand. lhrno Cubdoetn ninlaehlisod tho lentation 1n the hand to thn £160. In thn green: of hon-n1 children 90! under the use of hand the percept hiuloealizcd thee the or hereopt :1: reported only tha {teeddhinhnoe in a: also 1: seen face. the Ibis pattern to children tram 7~12 years of age hat.th a 10:30: extent. hand the adults‘reportod or the ham-ll suhjaotl, five indtidl or example dinplaeenont In thn an trial. only Ittnulus noted. hand was tram race to by hand extinction or by daninanee face or Ill pattern the more apparent was tune even th hind percopt of.the dinplncclant 1n nornnl �in thn patients aznninad. Xt uun.noat evident in patients with arggnic gantal chanset, 935 or when did not repert bath stimuli corrnctly. In callinntion. or uchixqphrunio lub:ectn and patinntu with aphnail runponneu lililnr to thnse of thc annual adult were observed on tum intill trial. land doninnnoe was accllionllii seen in the patient and vital: in tn. net-:1 Iahjpat. In «use. of hand dominance the race' not the reported the but percent; It was seen manual I in the initial trial on m five different net-11 Malta .. In the” instano§3. tun nubaoct ropnrtod both.ttanu11 carrectiy oh nubaoauunt tinting. In the patidntt with organic mental changes hand dauinnnee III In inconntant rtupanto and rcpeated touting the sale day or on unbloquant dawn danonntrated thy amt! usual poruiutunt pattern or dominanco. "" ' rm 1 stilulttion ,Rolponso on initini roueh 19ml Adult lam]. «mm, low emu. Totalicorrcot Pace Only luaowraae land Only 160 77 15 3 5 3-6 564 m 23 18 a 7.12 76 33 27 9 2 7: 26 n5 1 2 syndrome 120 9 9n n 3 o o Schisoyhranin (“malt-niried) mute luau: trill . i Apmu Submgguont I 23 Erialla or the 12 83 11 narnti adult. uh» nude errata initial trial, #3 were correct on the uecond and 12 on the third triul. In a to! sub: '“Vfﬂiaur. five at Ii: trill! var. the nucOIsary berare the tun stimuli Into corructly localised. than. on �6.‘ ta be annual, althuugh complete psychologiaal (tennion during that noted VII anxiety It the with to'ploaae) interfered desire strong callinltton,er.n annual :11 aubaeetl, In rncognition the of ntiauli.v torruct early aubjoets ware Inlunnd tent. wcro.not dune. the IIB correct once those rosponae with anxiety, including abtn1npd (oven all ﬁtter an was iith elicited error.) it trials number warn or if n¢cncd a an tritll It many aubnequont_teut1ns.: ”aét“ axmnlnntion, the at the into neoenuary_ror tn. anbaect'ta set evon cccurutoly, trtcr the ha ntinnli riported the once in tad set, of any WI; ”9,10.an in that was apparent child annual wanna th: it In testing inst canon Inn: tail: war. nocolsnry.h¢£ore the correct rotpanse was «enlistently elicited. Alta, tan child at. not tlltya dayu. many over tasting lopeutcd tubaugunnt touting. an correct of Ibis tuna daninlncc, in: shin tbs patterns hauever, olicittd natod in 36 of tho 56 childrtn tottqd, ‘In a number of instances than and reportcd tho stimuli appz1¢nttan can o; Intchcd en. child was thy But repeated an test noon corroetly. percept1onn tbs t; stimulus. on. repertod child tho «my with tm «you acted. min or “int” the tn» in: not into could tho get ehild evident that It oxtninntion, even with viaunl anal. 311 In children. in not wag apparunt vary thin diffieulty t6 the 76 give the failed 17 at anly (age: 7-12) the older group correct renponse utter th; inititl tau trials. 1.: at the nae-hand on the reports obtained repeated. A: relieved connintent s pattern. test: in mgr-:1 nubjecta also tubsocti. on tbs initial trial, face daninnncc was trivalent in all or or‘ obsmatien (a) extinction by It was: unite,” uthor " tr: m �8. or the autumn te displacement fees, or er me atmii ”.in aevertl insteneea the displacement we. in a direction tantra (1)) by O3 ' em taco. In contrast to normal adults, patient; with organic mental change: were unuhie te regert the two stimuli earreetly even utter many triele. When_the yetient reported the pereept in ane teet eorreetly, he frequently failed on tubuequent testing; It was tine Ipperent that touting en subsequent‘daye etiii elicited in and er stimuli. extinction dieeinemt m: u ntrang who made seldom unmet: to tn error apparently subject: centreet on subsequent tritiu, day: after the initial examination. the responses obteined in this group demanetrated the pattern: at tee. teetfﬂ deninnnee in meet or the niepiaeenent of the hind percept to the tune was frequent. In tame instances dieplneement or extinctien was preeent deepite the {get that the putiont watched the applitutiea of the etinnii to the fete and hand. Extinetien was very taxman en hencieterni or heterologoun teeting while ~ ﬁne apparent dilpieoenent neatly on heterolegeun teats. 514; the and nyhneie patient: the uehisephrenie reports gayb which were «1:111: te normal adulte. After the first tie trial: the pertentnge of errer in hand sensation was slightly higher than in the normal greup. reraietent bistrre reepoaeee were elicited from a number or the schizophrenic Inbdeetl. lheee reperte ineluﬁed multiple responses to mingle or daubie stimuli, pereietent displacement: to one area from any other body area, ineonsittent verve end 'mimrreveruls or localiutien. day: As normal the to free with an day examinetien_and eating consecutive an the aphasia subject Iehixephrenie touting or idnlt, M �days roiled to elicit extinction phenonehe once the been eccorltely reported before. test hen ‘ comparison of the reeponeee or each or theoe groove to nultiple teeting in chain in fig. 1. A ﬁrﬁ 54’” Pin Phick Btiuuietioh: It in known thet the type or etinuiue epplied influence: the result: in perception. To denonetrete the importance or thie rector einiier groups of subject: were tested ueing two pin prick ineteed or two touch etilnletione. With pin prick etinnieticn ct tece end hencﬂfece dominance wee egein uehiteet in all the groupe. however, the incidence of error in perception of the pin prick in the head III lower than with e touch etinnloe. Ihe reeulte are recorded in IhhﬂcIIt Elna! II :1 ' aﬁzaiiﬁfmﬁ’ﬁm lttei tor-ll Adult correct Pace only Feccqrece Hind an}: 68 51 15 2 c ﬂannel child, 3~6 yearn #5 lorlml Child,7~12 your! 39 50 Schizophrenin 16 26 2 1 25 1h 0 0 36 13 9 1 arsenic lentei syndrome #7 9 33 3 2 Repeated testing with two pine in the nccnﬁi adult subject: elicited the correct reeponeee in the initiel three trieie. Fever at the chiloren ﬁgiﬁcd to report the teat eccuroteiy after the initiel trials. ~It we: poeeibie ih_e hunter or instance: to alternate touch and pin prick etieuietiohe, end demonstrate extinction to touch, but correct localization to pin prick. loreover, with �m. abre intehae pih prick atianlatieh, extinction and diaplaeeaant were lean frequently ebaerved. vzheae phendaena, haaely extinction and diaplaeeaent were eveh.nbre apparent in the patiehta with erzahie mental ayadreaea. Bdaplaeeaeht or touch ltd-311 eauld be alternated with oerreet Idealiaatibn of pin brick atzaulatiah. A ddubihatxon or touch tb the fade had pin prick te the hand evinced the edubinetibn at displacement and obaenratioh, an the patient reported “a teach an the fade, and a dull the en the other aide {or the face).' Pin prick to the eheak and teach to the hand raaulted 1n extinction hand the pareept; be, oeeaaiehally, the rephrt or a pin prick of both an the cheek and hand. rhe aehizephrenie aubaeete were able to loealiae the pin prick accurately after the initial ten trials, an had the aerial mule: . Blﬂaﬂbazﬂl: mains the nethbd er dabble ainnltaneoua atinulatibn in teuta or the face and the hand a eenaiateht pattern bf reapeneea baa been observed in a variety hr aubaeota. the atinnlua to the m.’ 1: non readily perbeived than the one 1:: the me. «never, the pareept in the race influences the due in the hand, frequently canning the displacement of aehaatibh. 1h1a pattern a: reapbhaee haa been repeatedly deaehatrated in bath the annual and abnormal eubJeeta, and 1a aahireet 1h extinetibn, obaeuratibn and diablaeeaant. Extinction 1: abet and diaplaeeaeht :- leaet frequent. In eatinetien, the race pereept 1a correetly reperted aa te quality and leans, but the hand attanlua 1a not perceived at all; In all hf the rereading teat: or patient or abrnaz aubJeeta§*uhether By �11; ' tha reaponaaa were aaeurate tr not, it uaa notod that tbs stiuuius yointad to the face tirat. aubjaet almost invariably pattoived and 1a ourrectly hand perecpt tha Octaaianally iooaliaed, but anamnea a qualitative differonce, always of diaiﬁntion. In displaeunant tha percent in the hand 1: 113* such an the or rage, tho it direttitn the face, or localiscd tn to tan ahauldor er nuak. In aunt instance: if tha taco cud tho hand at the lama aid: are stimulated, tho lubaeet occasionally 1a thaae phnnancna of 1n lane the taco. raporta tut paroapta ah: or these un1eh one with the rrtquancy haphaaard. nail. varia« druga, be attention, observed affected by may erraeta 1: tion in atilnli, ate., it: pattern 1: eonaiatent. Thea. raaponaaa to tha face-hand teat arc undifiad by nan: (b) attenttan. factor] arc ﬂame influnnning of tbs fa) factora. or atinnlna, (a) type of stimuli, (0) simultanaity d: subject, aga (o) atrensth a: stilnlua, (t) locua of atilnlation and (3) internal with tha fragment, Etna; alter fatter! lax atate or organiaa. aﬁpeur do change net but and that displaccnaut which Ixtinetien tbs pattern or face dalinanso. 1a in factor of tha teat a.na:or Iuardnaaa the aubaact'a 80th attention extinntiun. a: thy phannncnon of tho appearance ’)( awarenaai€£)1n.a and priviona axpnrionoa tun bring stimuli to two to were informed who Itinnli that unra adulta atria: or twanty Baoauaa proviaua of applied abouad extinction parcepta. be non. tan abet-nary rcaerd ta uaa intluensa.a response it experience in.ha1ve ﬂatbed aw this aubjccta. tha.f1ndinga on initial trial At the Ian» wan aintniacd. experience or previoua en. tactar number the ”alert" for he the on tine tbs aubjcct was not apt to ' �of stimuli he an: ta reeeive. cannequently ene night nay thet the reason the subject perceived only one Itinulul or perceived ene and diupleeed the the other at he atinnluu in that peﬁfypt 4 was not peying ettentlen. this aritieinn may be valid but the Iiznifieant fact it 9 //¢w » % that the error III always aide in the hand and net in_the‘teee. I: it were mere inattention one utula expect 50! or the single response: ta dauble einultaneeue stimulation ta be in the hand end 50% in.the flee. But this type or ehance enter was not ebterved. it the single reepenaes ta double lilultaneeul Iti-nluticn 95% were at the fete percent and 5% at the hand pereept. Iain pettern of race daninnnee or hand extinction examinetionl. further during subsequent eitublilhed Ill lereovee, when dinplneenent II. seen in normal aubJeetn, it was to the race and not ta the hand. ihin pattern at face daninnnee to deuble tinultnneaul stimulation was fauna to be exnggereted in nan-.1 young children, when 83$ deuanetrated either 33nd.extinetion or displeoenent at er the hand pereept to the face an the initial triel. loreover, this high percentage of face duuinnet reiponnet peruisted on eubuequent trielE. In the elder children ulna tece delineate we: consistently demonstrable. It It: noted that the younger the ahild, the more distinct In: thie puttern of race daninnnee. awn extinetion night he Ittributed to an mummy to perceive two ltﬂluli at once. Ehiu particulir detect has been noted in patient: with severe until change? (“Zlf'ﬁﬁevm in patient: with severe lentel changed or in young children itinuli epplied to both cheek: or both hands or.eny other two hanglegonn body even: were correctly reported as tee uenentione. Ihere it: _ �neither extinetion nor displacement. aaldstein'eKohuervatien, therafere, cannot be used an an explnnetion for hand extinetion. what matter daninanne in noted apparent flee that at It is types or etimnlltion was used. Simulteheoun pin prick stimulation: revealed the pattern of face daninenee, elthaugh with e leaner frequency than touch etinhiltiona. ether duteneeua utinuletion such :1 two tuning forks, hot and cold telperature tuhel, rtpetitive rubbing and repetitive pin prick Itianletian were Ipplied and neniteet regardless of the cuteneeun utilnletiun race daninence is ﬂied. inphrtmee of the ainulteneity or the ”man. has nlrudy been alluded to. In eubJeetn in when extinctidn In: persistent, consecutive epplieetion or the stimuli invariably resulted in the permeption or two stimuli. In actual Idultn consecutive the nun-L1 the on the even of two trial, we ma. etiluletion extihetioa. never resulted in -euuni thin thy nerd ntinuli intensity. at these ethdien In aux-aux, the for in inn-pom: the in pattern mum eliciting ”I. stimuli here teemingly mare readily perceived than equal etiuuli. After the first few trials the etheet was able to perdeive the two stimuli, even it one we: pnintul and the other not. In and diaextinction mental hhuevee, with chnhses, organic patient: quality, the wide dinorepency in pleeenent were manifest despite a of the stimuli. aw Altering the etrength a! the Itinhli, it ran hand the at the tram extinction response pdlaihle to alternate th teak) the' ta diepleaenent were hand the stieuli percept (if .gheek (if the head stimuli were utrang). The sneeze than extinhtien ulst the the at by quality elidited altering run displacement to The ' ‘ �13. touch the to ,Ievertheleac, frna prick. pin that ia atiunli, a at. a,ua oe'aaa the part: of the body being aianltanecnaly atianlated are have patterna. theae I! etudying consideration in another already alluded to the fact that extinction ie anat cannon in the hand and leaat in the face. In teating other body areaa the incidence of extinction and diaplaceaent ia leaa than in teating and ahcnlder thigh nay hand. and the testing the face Ithat is, not elicit extinction or cbacnraticn,where the faceehand teat will. Alec, in patients with leaicnn or the brain or apinal cord, the pattern or relationahip cf the body parts tc aiaultaneoua atinnlaticn.nay be altered in a characteriatic haniaenaery or ”level leaicn' ayndreae. Aa fer the aignificance cf the pattern be can the leaning before prayer further atndiea are neceaaary would be time purely thin deducticn.aade Any at interpreted. that by gained atating ia nothing For inatance, speculative. dcainance (7). of inpliea order aenccry rcatral a daninance face Such hypetheaia ia ccntradicted by at leaat one tact, naaely the ‘chaervaticn that when the hand and fact are atimlated eimltanecualy data are hand. after'ncre Perhapa the dcninatea over the fact accumulated a aatiafactcry theory night he obtained. , QUIIIRI: hand haa and race the cf teata in pattern in perception method cf the abnaraal and anh:ecta.hy been elicited in actual dcnble simultaneous atianlaticn of cutanacua uhdalitiea. hand the of percent extinction by Face delinance, aaniteat an a in seen the hand to race, the or percent or dicplaceaent the~ and in non-a1 the adulte, in naniteatcd normal phancaencn, aeriea. the exasined in and anhaaie cchiacphrenia with patienta A �15. with in m in menu:It 1: mcntod young «mum and what ,of ditpnouont the «unﬁt.» bran in an...” mitten: utter may}. mun . . um. m 1: at run or unite“ denim” usual.” pattern m: 1n the a only clung. {chucking the autumn- nodanw team, a! 11th in type “mum. .cxtincuoa' at rmugnay am. ‘ �m, mm W :m. In,” Wtiﬂl m t ‘4; “1,5151 m m m «some. mm m.“ 1.!” Id. “.3. mo mm. m, 19”.Mum-sic 3.: (I) cum... mm m mm. m, at unusual than. ”pm ma. a; M ammo 3.1.: Aug-mu m m ' Mm m mummy Mmkwém Datum 81mm!“ 11W. m. mnnmuumumumwmm mum. £1. Pittm‘03.; I. w m mum m; m. u-mmmuormmomm -.-.m: 1. (I) W 3.3. 1‘ “ ‘3) 2. (a) 3. I ‘ if... .5 . --... 08 , and - ...., 610: «.5 an .LL. -. > , ' and 813-191, 5 . 1 am. 1.1. 11.3.;and in 11.: @1162!!! 5. mwﬂw W mm. mmm In ﬁt an 6. . W Warm. to mom chum- as «W 1M6 61m 72: 5 nth m to frontal am “so. «poets of m may W Auwmmmm 5mm mm manna-mm. cm, R. and m max. mam... at 1956. tn “1. 1959. and 501.515. ,5 -. ‘0 117.121., _ ‘ 8.3. ILL! (o) 50 phonon-manor 1n 5......- 1'. 9: 3.1.: 9:135:19: wholes“ 1 ”“33; of pm1p1uuea m and 11014: 11.8.: (h) m1 mm mum. an 6.1.: w by 191111101111 166-1685 19195 tuna-Mon. �PATTERNS IN PERCEPTION By: ‘I 0—m— ON SIMULTANEOUS TESTS OF FACE AND HAND Morris B. Bender, M.D., Max Fink, M.D., and Martin Green, In previous studies we found that the method of double M.D. simultaneous stimulation showed defects in sensation (extinction) testing In which routine were not apparent on single stimulation. ; the two of body and various combinations it was different regions \, found that extinction was apt to occur most often in the hand and least in the face. Conversely, "dominance" was greatest in the face and least in the hand. In the present commuhication we wish to report simultaneous on obtained the results stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syndrome; disease 5) of the no 4) schizophrenia; ,‘ brain (normal adults) and 6) four of between normal children the ages to ten years. 'Patients in 5 2 showed and severe memory defects, confusion, poor orientation, groups difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched simultaneously. Care was taken to make two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked tox°eport what he felt, and following this, Where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first-examination: a) a touch on the face only (face dominance), implying no sensation in the hand (extinction); . $1.1mMuTﬁzA kﬁWJqM 5.4.1:. �2. b) a touch on both sides of the face (there being "displacement" from the hand to the ipsilateral face); 0r 0) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that than one stimulus. on subsequent tests he was expectant of more In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislobalization was towards the face it appeared as if the face determined the direction of the displacement. It might be said, therefore, that this was a type of face dominance. Response (b), or diaplacement, was less common than response (a) or extinction. Response (b) was seen most often in the patients with the organic mental syndrome, and persisted despite repeated testing. The (c) responSe was the expected normal and needs no special comment. Extinction and displacement were also noted the ipsilateral face and hand were simultaneously tested. In all the subjects tested, including those with aphasia, there was no difference between the right and left sides of the body. Analysis of the results obtained in the various groups is shown in the following table: when �3. Group of Subjects Number 1 15 2 12 3 Face Response Extinction or Face and Hand‘ Hand Response Response ~ Displacement 9 6 O 12 O O 22 20 2 O 4 20 14 6 O 5 55 24 28 6 20 l l From - p . 19 o it is obvious that whenever there is sensation over another it is apparent in the face. the foregoing dominance of one p Dominance in the hand was noted only once. dominance Face was found almOSt uniformly in the subjects with.severe mental changes (groups 2 and 5.) These patients did not report sensation in the hand even after repeated testing. In a few instances, even after the patients were told there were two stimuli, or were asked towratch the application of the stimuli, they reported only one percept or displaced one. In these cases simultaneous stimulation of both sides of the face was reported correctly, thus excluding the objection that these patients were not able to<io or perceive two things at once. The incidence of face dominance in subjects with aphasia and those in with schizophrenia (groups 1 and 4) was less. In contrast to patients in groups 2 and 5, those in groups 1 and 4 reported both sensations correctly on the second, third or fourth trials, if they had not done so on the first trial.‘ In the group of normal adults (group 5) the incidence of face dominance was least, but still ' significant, a even though it was found only on the first trial. series of normal children the incidence of face dominance was In �In young children face dominance was present even several trials after the first examina- almost the same as in groups 2 and 5. tion. the face and parts of the body other than the hand were tested simultaneously in groups 2 and 3, face dominance was‘ The order of dominance was face, shoulder, grunk apparent. still When (breast), penis, thigh, calf, foot, arm and hand. In Conclusion: a wide variety of subjects the phenomena of extinction and displacement on double simultaneous stimulation were demonstrated. A consistent pattern of perception was established in which the face was most dominant and the hand the least. These findings were noted in both the abnormal and the normal subjects. -In the abnormal subjects withseVere mental changes, face dominance and hand extinction were so consistent that they may be used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, which are so prominent in patients with diffuse brain disease, appear to be exaggerations of the pattern found in the normal subjects, especially children. I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. Trans Am Neurol Assoc. 1950;51:250-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2a-003 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Two preprints] and a reprint. Reprint from Transactions of the American Neurol Assoc. 1950;51:250-2. (abstract). Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a>; Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/355c4b9504ee5dda4b99daee2b72cb14.pdf 32103451b1f3d9d0d60a0a834fb27af9 PDF Text Text Reprinted from—JOURNAL or THE HILLSIDE Vol. I, No. 1, January, 1952 HOSPITAL _ TACTILE PERCEPTUAL TESTS IN THE DIFFERENTIAL DIAGNOSIS OF PSYCHIATRIC DISORDERSl MD.2 and MAX FINK, M.D.3 New York, N. Y. MORRIS B. BENDER, Visual perceptual performance tests like the Rorschach, Thermatic Apperception and Bender Visual Gestalt tests are widely used in the evaluation of psychiatric disorders. Recently, a simple test of tactile perception—the face-hand test—has been described (2). By this test, characteristic performances of normal adults (2) and patients with diffuse cerebral dysfunction (3) have been differentiated. The face-hand test is an application of the technique of multiple simultaneous stimulation (1) . The examiner lightly touches, simultaneously, the cheek and the hand of the subject. The latter is then asked to describe and localize the stimuli. Normal adults readily name and localize the two stimuli within the initial few trials of the test. Once correct, they are thereafter correct on all similar tactile stimulation tests. In contrast to normal subjects, patients with psychoses due to disease of the brain are not able to perceive or correctly localize one of the two simultaneously applied 'stimuli, even after many trials of the face-hand test. They consistently make errors in the stimuli to the hand (and con.versely, they rarely make errors in the perception Of the stimuli to the face). This type of response has been observed in 90 per v ' From the Department of Neurology and Psychiatry, New York University College of Medicine, Bellevue Psychiatric Hospital and the Hillside Hospital. This work aided. in part, by grant #MH 139 from the U. S. Public Health Service, National Institutes of Health. 2Director of Neurologic Service, Hillside Hospital, Glen Oaks, N. Y. 3 Aided by a Fellowship from the National Foundation for Infantile Paralysis. 1 , 21 �22 BENDER — FINK cent of the patients with diffuse brain dysfunction, and has been described as a sign of the organic mental syndrome (3) . These simple tactile perceptual tests have now been applied to patients with hysteria, schizophrenia and psychic depression. The responses of these patients to repeated trials of the face-hand test will be described. SUBJECTS The subjects were patients from the wards of Bellevue Psy- chiatric HOSpital. These patients had one of the following conditions: schizophrenia, psychoneuroses, psychic depressions or organic psychoses. The patients with schizophrenia manifested the various clinical varieties of the disorder. The patients with psychoneuroses were those hospitalized for severe anxiety, reactive depression, or behavioral outbursts necessitating inpatient observation. The patients with depression in this group were predominantly young adults in whom the psychiatrist obtained a history of recent stress precipitating admission to the hospital. In addition, patients with diagnoses of “character disorder” or “behavioral disorder,” and without evidence of psychosis, were included in this group. Patients with depressions were studied in two groups. The young adults with “reactive depressions” were included in the group of patients with psychoneuroses. The second group were the older adults, in whom the diagnosis of involutional psychosis was made. In some instances, these patients presented evidence of impairment of memory, concentration, calculation, and orientation. The diagnostic differentiation of their disorder from psychoses due to disease of the brain was difﬁcult. The diagnoses were usually made after extended periods of observation and with the aid of psychometric studies. The patients classiﬁed as having organic psychoses manifested the usual memory disturbances, disorientation, emotional lability and confusion characteristic of the “organic mental syndrome” (3) . The etiology in these cases varied between central nervous system syphilis, posttraumatic states, senility, presenile dementia and alcoholism. �TACTILE PERCEPTUAL TESTS 23 METHOD During a routine examination, the face-hand test is applied. The patient is asked to close his eyes. In the sitting position, with his hands lying naturally in his lap, the patient’s cheek, and dorsum of the hand on the side opposite to the cheek, are simultaneously touched by the examiner’s ﬁngers. The patient is then asked “What did you feel?” The normal adult usually points to the cheek and states: “You touched me here" or “I felt something here,” making no mention of the stimulus to the hand. The patient is again asked to close his eyes, and the stimulation repeated. This time the opposite cheek and hand are touched. He is asked whether he had felt anything. The usual response is a correct localization and identiﬁcation of both stimuli. If only one stimulus is reported, it is the stimulus to the cheek. At this time, the examiner asks: “Did you feel another touch anywhere else?” The normal subject usually points to the hand stimulated and admits: “I felt something there—I thought you may have brushed against it.” On the third and fourth trials of the face-hand test, the cheek and hand of the same side of the body are stimulated—ﬁrst on one side and then on the other. Finally, both cheeks and then both hands are stimulated. This sequence of six tests is repeated. Subsequent to these trials, other parts of the body are tested in a similar fashion, such as cheek and foot, or breast and hand. Cutaneous stimuli other than a light touch have been used such as multiple light touches (rubbing), single pinpricks, multiple pinpricks, and less frequently, temperature tubes (hot-cold) and tuning forks (c128). With these cutaneous stimuli the obserVations are qualitatively the same as with touch stimulations, although the frequency of errors is much less (2). In each case where defects were apparent on face-hand tests, standard tests of single stimulation by touch and pinprick were applied. Only a few subjects, those with evidence of focal cerebral damage, myelopathy or peripheral neuropathy, made errors on these single stimulation tests. Their reactions were not considered in these results. ' ' �24 BENDER — FINK RESULTS The usual responses of the normal adults to the face-hand test were: (a) perception of one stimulus only—usually the one to the cheek, and only rarely the one to the hand; (b) perception of the two stimuli, correctly localized; and (c) perception of two stimuli, but one mislocalized. This mislocalization was almost always a mislocalization of the hand percept, which was displaced to the homolateral cheek. Such "displacements" were rare in the normal, but frequent in subjects with disease of the brain. Normal adults manifested incorrect type (a) and (c) responses on the initial few trials only. As reported previously, 50 per cent of the normal adults made errors on the initial trial of the facehand test; 22 per cent on the second trial; and errors became less and less frequent until by the tenth trial, less than 1/2 per cent still made errors (2). It is apparent that normal adults can readily discriminate two tactile stimuli and accurately localize these within the ﬁrst few trials of the test. Also, once the normal adult was correct on one trial, he was found to be correct on all subsequent trials regardless of the body part tested or the rapidity with which the tests were applied. Adults with Psychoneuroses: Most of the subjects with psychoneuroses responded in a fashion similar to normal adults on both the initial and on multiple trials of the face-hand test. Subjects with manifest anxiety, after identifying the cheek stimulus on the initial trial, perseverated in this response. Through many trials they persisted in naming only the cheek stimulus, even insisting that there was no other stimulus. This type of report was maintained until the examiner emphasized that there were two stimuli. As soon as the subjects realized that there were two stimuli they were correct both in naming and localizing subsequent simultaneous stimuli, as well as single stimuli interspersed at random. During the time that errors were apparent on multiple trials of the face-hand test, these anxious patients never displaced a stimulus, i.e., recognized that there had been two stimuli, but mislocalized one to another body part. It was as if they were in a mental set of “oneness," and this set persisted until broken by �TACTILE PERCEPTUAL TESTS 25 the examiner. When they got into a mental set of "twoness," they were correct on all subsequent trials, perceiving and correctly localizing the two stimuli. In a majority of patients with hysteria, including those with hysterical amnesia, the face-hand tests showed normal responses. In a few the responses were abnormal. Thus there were some who reported the sensation on one side of the body correctly, but denied all stimuli on the side which showed a hysterical type of sensory defect. There were some patients who showed "allocheiria.”4 They mislocalized a stimulus from one side of the body to a homologous part on the opposite side. This mislocalization or displacement occurred from the side with hysterical defective sensation to the side with normal sensation. Adults with Schizophrenia: Most patients with schizophrenia were able to discriminate the stimulus applied to the face and hand correctly on the ﬁrst few trials just as normal adults could. However, there were a number of patients in this group who presented bizarre responses. The touch stimuli were occasionally misidentiﬁed and were reported as “a burning” or “a ﬂy crawling.” Frequently, the number of percepts were multiplied. Instead of perceiving the two applied stimuli they reported three, four or even six percepts in a variety of body parts. Similarly, a single stimulus was reported as two, three or four percepts, occasionally omitting the locus of the original stimulus. Such patients usually persisted in the bizarre behavior on repeated testing on subsequent days. In two instances, there were bizarre responses even when the test was applied with the eyes open. A number of the paranoid patients refused to close their eyes and permitted examination provided they could see. Obviously, under this condition, they were correct on all trials of the face-hand test. Patients with schizophrenia, admitted to Bellevue Hospital for frontal lobe “topectomy” operations, were able to perceive and 4The term allocheiria should be distinguished from allesthesia. According to Ernest jones, the British psychoanalyst, the crossed sensory displacement manifested by patients with hysteria is to be called allocheiria, while that shown by patients with disease of the nervous system is to be called allesthesia. Based on our experience the distinction between the two is made largely on the total clinical picture. In one there is the long history and symptoms typical of hysteria, while in the other the history and neurologic signs show patterns characteristic of organic disease (4). �26 BENDER — FINK localize the two simultaneous stimuli during the initial period of testing. During the ﬁrst two weeks after topectomy operations, however, the patients manifested the “organic” type of response to the face-hand test. As will be described later, this pattern consisted of omissions and mislocalizations of stimuli on repeated testing. As the patients recovered from the operation, the errors on repeated trials of the face-hand test decreased. Ultimately, they correctly reported the simultaneous cutaneous stimuli and reacted in a manner no different from the nonoperated schizophrenic patients or normal subjects. Patients with Psychic Depression: Patients with “reactive depression" were co—operative and usually correct on the initial as well as on subsequent trials of the face-hand test. Their responses were most like the normal pattern. Of the patients with severe involutional melancholia, some were frequently unco-operative. They were suspicious of the request to keep their eyes closed and if they permitted stimulation, would report only one of the stimuli. The stimulus they reported was the one to the face. They omitted the one to the hand. Like the patients with manifest anxiety, they frequently persisted in giving one response through many trials— until the idea of “twoness” was apparent to them. Thereafter, they were usually correct in their responses (Case I). Patients with a manic excitement correctly identiﬁed the two stimuli on the initial trial of the face-hand test. On subsequent trials they were frequently unco-operative, commenting that the test was too easy, or silly; when co-operative they were usually correct on subsequent trials. Organic Mental Syndrome: The reactions of the patients with organic mental syndromes to multiple trials of the face-hand test are different from those observed in normal subjects or patients with neurosis or schizophrenia. Ninety per cent of all patients with organic mental syndrome repeatedly fail to report one of the two stimuli, or when reporting two, mislocalize one of them. Again the perceived stimulus is the one applied to the face. The Stimulus to the hand is usually not perceived or it is mislocalized. This type of response is consistent and highly predictable. A patterned response is also apparent in tests of body areas other than the face and hand. An “order of dominance” in tests �TACTILE PERCEPTUAL TESTS 27 of other body areas could be established in these patients. In this order the face is the most dominant with penis, trunk, breast, foot, thigh and hand less dominant, in descending order. When tactile stimuli are simultaneously applied to any two body areas, the errors in localization will occur in the part of lesser dominance. For example, if stimuli are applied simultaneously to the cheek and penis, the patient will report the cheek stimulus alone; but if the stimuli are applied to the penis and the hand, then the stimulus to the penis will be reported. These omissions and mislocalizations of percepts persist for many trials and on many days of testing. The inability of the patient with an organic psychosis to discriminate two cutaneous stimuli is so consistent, that it is considered a sign of the organic mental syndrome (3) (Case 2). Eﬂect of Electro-Convulsive Therapy: In patients with schizophrenia or psychic depressions, electro—convulsive therapy induces a similar “organic" type of reaction to the face-hand test. During the period of confusion immediately following the treatment, the patients consistently report only the cheek stimulus or mislocalize the hand stimulus to the check. This is transient during the ﬁrst few treatments, but near the end of a course of therapy these reactions persist for longer and longer periods, until they are apparent hours or even days after the treatment. Patients who had a course of electro-convulsive therapy and were readmitted to the hospital after a lapse of months failed to show this “organic” re- action. CASE REPORTS The following case reports are selected as illustrating the types of responses observed. Case I: S. S., a forty-year-old woman, was admitted to the neurological service complaining of backaches in recurrent episodes of eight years. During the past year she noted difﬁculties in recollection and in her ability to calculate. She had been a bookkeeper and now found herself unable to calculate accurately or rapidly enough to continue work. On occasions she had misplaced valuable family possessions only to ﬁnd pawn tickets in their place. �28 BENDER — FINK During interviews under sodium amytal she cried readily and related many recent family difﬁculties, including the suspension of her husband’s license as an auctioneer and her son's classiﬁcation in IA by Selective Service. Her difﬁculties apparently began with these events. Medical and neurological examinations were negative except for some varying areas of hypesthesia and hyperesthesia. Psychiatric examination revealed marked psychomotor retardation. There were deﬁcits in memory and calculation. She was able to relate details of her history and of world events, but was unable to relate details about her work or family affairs. These latter details were readily apparent, however, in interviews under the inﬂuence of sodium amytal. On simple calculation tests she made few errors, though she was slow in response. On more complex tests commensurate with her occupation as a bookkeeper, she made numerous errors and showed many hesitations. Many answers were reported questioningly. The admission clinical diagnosis was “organic disease of the brain.” This was based on such symptoms as psychomotor retardation, memory deﬁcits and difﬁculties in calculation. Face-Hand Test: On the initial face-hand testing the patient persisted in giving the cheek response only for eight trials, but thereafter, was consistently correct for twenty trials. There were no displacements of percepts. On subsequent days she was correct on the initial and all subsequent tests. These ﬁndings suggested that the symptoms were not due to disease of the brain. Course in Hospital: To exclude organic disease the patient was subjected to a series of tests. Neurological examinations, electroencephalography and pneumoencephalography revealed no evidence of organic brain disease. A psychological survey revealed an average intellectual capacity (IQ 106) without any evidence of organic deterioration. The personality survey revealed severe anxiety and depression, with some bodily preoccupations. The ﬁnal diagnosis was depression and the patient was discharged for further care in the psychiatric clinic. Comment: This case illustrates the problem in the differentiation of psychic depressions and organic psychoses. As a rule we found that the preservation of the ability to discriminate and �TACTILE PERCEPTUAL TESTS 29 localize double tactile stimuli speaks against organic disease. Only 10 per cent of patients with organic mental syndrome showed normal response to the face-hand tests. The converse was not true. There were no instances in which a normal person made persistent errors on face-hand tests. If errors are made, it usually turns out that the patient has disease of the brain, no matter how bizarre the mental picture may be. This is illustrated by the next case. Case 2: H. B., an elderly white male appearing about sixty years of age, was admitted by the police who found him wandering about the streets. He was unable to give his name or home address. He did not answer questions, though he spontaneously requested water and food. A few days after admission he began to speak freely, gave his name as “The Messiah” and his home as the hospital. He was facetious, quick in speech and coherent. A complete delusional system relating to God, the patient’s previous sojourn in heaven, his mission on earth, etc., was related. No other anamnestic data were available. Under further observation he showed the Ganser syndrome. For all questions of orientation, general information and calculation, he answered relevantly but was only approximately correct. He was almost but not quite right. He did not answer any questions of personal history except for the distant past and then he related a disjointed, rambling, confabulatory story. To many observers it seemed as if the patient had a “hysterical” type of psychosis. During examination on admission the patient appeared chronically ill. The blood pressure was 180/100 and urine contained four plus sugar. There were hemorrhages and exudates in the ocular fundi. Neurological studies showed absent ankle jerks, diminution of vibration sense in toes and ankles, with normal position, touch and pinprick perception. Other defects were apparent on special sensory studies. Face-Hand Test: On the face-hand test this patient presented an “organic" pattern. In the initial testing, he repeatedly reported only one of the two stimuli—that of the face. After many trials and a number of trials with eyes open, he began to report the two stimuli but now mislocalized the hand percept to the cheek. In testing on consecutive days, similar mislocalizations and omiso sions were apparent, both on the face-hand test and on similar �BENDER — FINK 30 tactile tests of other body parts. An abstract of the record, which evinces the “organic” pattern on double simultaneous stimulation testing with light touch stimuli is presented here. Stimulation Right cheek, left hand Left cheek, right hand Right cheek, right hand Left cheek, left hand Right and left cheeks Right and left hands Right cheek, left hand Left cheek, right hand Left cheek, left hand Right cheek, right hand Response Right cheek Left cheek Right cheek Left cheek Correct Correct Right and left cheeks Right and left cheeks 2 percepts left cheek Right cheek » Further neurological studies revealed a diffusely abnormal electroencephalogram; a symmetrically, diffusely dilated ventricular system on pneumoencephalography; and evidences of organic deterioration on the psychological tests. Course in the Hospital: Under observation the patient showed a gradual and persistent improvement. After six weeks in the hospital he recalled some facts whichled to his entering Bellevue. He remembered his address and social security number. As he improved clinically errors on the face-hand tests became infrequent. When the errors were sparse, intravenous administration of three grains of sodium amytal produced once again the persistent omission and mislocalization of percepts characteristic of the organic mental syndrome. Comment: Here is a patient who was thought to be hysterical but the face-hand test contradicted this impression. The persistence of errors on multiple trials of the face-hand test made us think of an organic disorder. The subsequent special Studies conﬁrmed this suspicion. CONCLUSION ‘ As with visual perceptual tests, such as the Rorschach, this simple tactile test- the face-hand test—has been found to be useful �TACTILE PERCEPTUAL TESTS 31 in evaluating psychiatric patients. Anxiety, paranoid attitudes, autistic thinking and misinterpretation of environmental stimuli are manifest on face-hand tests. Characteristic behavior patterns are seen in some schizophrenic and hysteric patients. In the evaluation of patients with mental changes due to dysfunction of the brain the face-hand test is of diagnostic signiﬁcance. The inability of these subjects to discriminate the two simultaneous stimuli on repeated trials and the characteristic errors of omission or mislocalization of the hand stimulus are unique. Such errors are not observed in normal, schizophrenic, hysteric or depressed adults. REFERENCES (l) Bender, Morris B.: “The Advantages of the Method of Simultaneous Stimulation in the Neurological Examination." Med. Clin. North America, 32: 755-758, 1948. (2) Bender, Morris B., Fink, Max and Green, M.: “Patterns in Perception in Simultaneous Tests of Face and Hand." Trans. Am. Neurol. Assoc, 75: 250-252, 1950; and Arch. Neurol. da- Psychiat., 66: 355-362, 1951. (3) Fink, Max, Green, M. and Bender, Morris B.: “The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome.” Neurology, 2, 1952. (4) Jones, Ernest: “The Pathology of Dyscheiria." Rev. 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'l‘lu pm“ humus-rm mummy crux. ammo-m mum-u mammumm. mmmmxnmu scanned m. madam �13. unumwmm.mamummmm mumuxomkmmmmtmmmzmuhm in ”mm Wax-10 nun». mm. mm cm”... ”Mm m WWI We!umwuum W mannmmwmmunoum. In man: ”I“. mmmmtudWm-W. mama» umwmuumnmmmmumun mummMMMouomdumuum~ xmun«mmumumu. “Immune! mum.m.mmunmmmm �1" 5.3.. In “tumA:tn mum mm. m. a! mom tn Imam”11mm“: tutu «am 12!. ISO-$52. 1950 (h) In Putt"!!! 1!! Mun I3. ’3‘. ﬁ lm I.“ or in“ a) g . m m. 2&3.ass-m.mum. 195;. 3131,! “m; 'o.nl I151! ﬂ“1» 3. ' u.’ 1:1...)t I M‘u m. m I.“ mac-In or u 11.3.; a». «mm» mm, “mum in m of M‘(coho a. “‘CM [mien II”. ' m minimum. Mini“! Wu: up ”may of Mama-n ‘99. 999» IL 1909 31, 755.753: m W: IMO o: ‘ MW ammu- � Dublin Core The Dublin Core metadata element set is common to 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 Tactile Perceptual Tests in the Differential Diagnosis of Psychiatric Disorders. Journal of the Hillside Hospital 1: 21-31, 1952. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-4-006 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from Journal of the Hillside Hospital Vol. I, No. 1, January, 1952 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/e80dbde06dd20201f1e94a10beff3999.pdf 14b484b6bedc00163228f7cd6f29a33a PDF Text Text Reprinted from the A. M. A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Copyright, 1954, by American Medical Association PATTERNS OF PERCEPTUAL ORGANIZATION WITH SIMULTANEOUS STIMULI MORRIS B. BENDER, M.D. MARTIN A. GREEN, M.D. AND MAX FINK, M.D. NEW YORK TUDIES of function of the nervous system by any one method will show patterns. This is a general law which applies to motor, perceptual, and psychic functions. Patterns of functions are present in the normal as well as in the abnormal state. For example, normal subjects show variations in the ability to discriminate two closely applied points in different regions of the body. Thus, the pattern for two—point discrimination is one in which the ﬁnest differentiation is at the tongue or ﬁnger tips, while other parts of the body, such as the back or the thigh, require a greater distance between two points before discrimination of “twoness” 2 be made.1 Pearson the pattern for the normal sense of vibration to According can is one in which the threshold is low at the clavicle and high over the sacrum. In vision discrimination of targets under daylight illumination is best in the central, and poorest in the peripheral, portion of the perimetric ﬁeld. And so it is with all other modalities. Each sensation has a pattern in space as well as in time. Each of these patterns is obtained by adopting procedures in which a single stimulus ﬁgure is used in testing the subject. In measuring sensation, we know that there are many factors which inﬂuence the perceptual response. Intensity and duration of stimulus, the stimulus ﬁgure, the locus in the sensory ﬁeld, the attention and intellectual capacity of the subject are but a few of the determinants. Recently we have stressed symmetry as having a bearing on perception.3 Still another factor is age.4 For instance, there are some perceptual examinations which could not be carried out in children because the ability to respond to these tests depends partly on the ability to concentrate on a particular problem and to cooperate over a matter of many minutes. These are two properties which most very young children do not possess. Moreover, we have found that reactions in the old are not the same as those in the younger subjects. Another condition which inﬂuences the perceptual response is the number of stimuli employed at one time. Two stimuli when applied simultaneously may yield responses which are different from those to stimuli applied in succession. Simultaneous touch of the face and hand may be perceived only on the face, whereas when each of these parts is successively touched with an interval of one or more Post—Doctorate Fellow, United States Public Health Service (Dr. Green). Paper read at the Fifth International Neurological Congress, Lisbon, Sept. 7—12, 1953. This work was aided, in part, by a fellowship grant from the National Foundation for Infantile Paralysis and the Neurologic Research Fund of the Mount Sinai Hospital. From the Department of Neurology of the Mount Sinai Hospital, and the Department of Neurology and Psychiatry, New York University College of Medicine. �2 seconds, the same subject perceives each stimulus. The simultaneous application of more than two stimuli may yield other types of perceptual reactions. Cohn5 applied three stimuli all at once and obtained results which were different from those elicited with conventional single stimuli in the same areas. In 1893 Krohn 6 investigated the effects of simultaneous touch stimulation of multiple (seven) regions of the skin in normal subjects. Parts of the trunk, extremities, forehead, and, at times, the chin were touched simultaneously by tambours. With these tests the subjects made errors in localization of the applied stimuli. However, no distinct pattern was sought. In analyzing Krohn’s material, we found a suggestion of a pattern in that there were less errors over the back than over the front. This study was interesting but not very illuminating. The technique of double simultaneous stimulation had been known since the 7 of 1882 time Hippocrates. In Oppenheim mentioned the method in his textbook. Since this description there had been few intensive studies of the method until 1943, when one of us began a series of investigations. During the past decade we have examined several thousands of subjects with this technique. As we gathered our data, it was noted that in tests involving asymmetrically placed stimuli certain regions of the body yielded correct .responses, while others yielded consistently incorrect responses. On numerous simultaneous stimulations of the face and hand a distinct pattern of response has been observed in which errors in identifying and localizing the stimuli on the hand became apparent. Conversely, there were very few errors in perception of the stimuli on the face. In this test situation the face was “dominant” to the hand. Face dominance has been found in normal adults, but it is particularly evident in patients with disease of the brain, in very aged persons, and in normal children, 3 to 6 years of age. This pattern of response, namely, face dominance, has been found so consistently that it prompted us to study body combinations other than that of the face and hand. The object of this investigation was to determine the order of dominance when various combinations of two parts of the body were tested in this manner. A preliminary note on this study was reported at the 76th Annual Meeting of the American Neurological Association, in June, 1951.8 METHOD AND SUBJECT MATERIAL The method of testing was the same as that described for the face-hand test in previous communications.9 The subject was requested to close his eyes, and two parts of the body were simultaneously touched or stroked. He was asked what he felt and to localize the stimuli. If only one stimulus was reported, the subject was then asked if another was felt. The subjects used in these studies consisted of patients and normal adults and children. Series I: Patients who showed mental changes or an organic mental syndrome* as a result of disease of the brain, such as arteriosclerotic encephalopathy, senile psychosis, severe cerebral trauma, Alzheimer’s disease, toxic encephalopathy, or brain tumor. In general, patients with severe mental changes who made many errors on simultaneous stimulation tests were chosen for a special study group. Patients with aphasia, hemiparesis, or a hemisensory defect were included in another group. Series II: Normal children and adults. The normal children were taken from a day—care center and an orphanage. The normal adults were patients on the wards of the general hospital, those attending hospital clinics, and Army inductees. None of the normal The mental changes which make up the organic mental syndrome consist of a combination of at least three or more of the following manifestations: impairment in orientation, memory, calculation, or general information; rigidity and concreteness in mental performance, and marked ﬂuctuations and inability to perform when there is more than one aspect to a situation. * �3 children or normal adults had manifest disease of the nervous system. They had not been previously examined by the method of double simultaneous stimulation. We also examined a group of older people. These were presumably normal, although cerebral arteriosclerosis could not be entirely excluded in people between the ages of 65 and 90 years. Series III: Patients with schizophrenia or manic depressive conditions. These patients were adults in the wards of the Bellevue Psychiatric Hospital and Manhattan State Hospital. No attempt was made to study the speciﬁc types of schizophrenia. Most of them were of the paranoid, mixed, or simple schizophrenic varieties. Inasmuch as previous investigations have shown that patients with severe mental changes due to disease of the brain and normal young children made frequent errors in tests of simultaneous stimulation, it was natural that we should make the most extensive studies on these two groups.10 Also, since normal adults make few errors after the ﬁrst two to three trials on double simultaneous stimulation, it was not possible to detect a pattern in these subjects. From these three series of cases we studied several groups in detail. Group A, which was studied in the greatest detail, consisted of 20 patients with organic mental syndrome (10 males and 10 females). These subjects were tested with the method of double simultaneous stimulation of different parts of the body and in multiple combinations. The following parts of the body were examined: face, shoulder, hand, back, breast, penis, pubic region in females, buttock, thigh, and foot. Patients were tested while they were completely nude and, for the most part, while they were standing. The speciﬁc areas stimulated for certain parts of the body were as follows: the dorsum of the hand; the dorsum of the foot; the anterior aspect of the thigh; just below the scapula on the back; close to the midline on the buttock; the nipple and areolar area of the breast; the lower quadrant of the abdomen; the tip of the penis or the mons veneris. Of these body parts there were 45 possible double combinations. It should be noted that the combinations were of regions distributed along the longitudinal axis of the body. Each patient was tested in all 45 combinations in. a random but similar order. Twelve tests were done for each combination. These consisted of ﬁve tests of the two body parts in a homolateral relation, ﬁve tests of the two body parts in a heterologous relation, and two tests in a homologous relation, one for each of the body parts. There were 240 tests in every combination for the total group. Each patient received 540 tests. The other group, Group B, which we studied in great detail, using thousands of trial tests, consisted of 40 normal children between 3 and 6 years of age. In 20 of these children (12 boys and 8 girls), all body combinations of two were tested except those involving the genital zone. In the other 20 children (12 boys and 8 girls), the genital region combinations were tested as well as some of the other body combinations. The testing was carried out in the same manner as described for patients with disease of the brain except that only half as many tests in each combination were done. The genital zone was usually touched directly, with the child partially nude. The remaining unexposed body parts were usually tested through the clothing. To supplement these studies, we also examined a group of 692 normal adults, 605 schizophrenic adults, and 664 patients with organic mental syndrome. However, these subjects were not tested as intensively as those of the above two groups. Different body combinations were tested in different subjects. Only one of the following body combinations was tested in any one subject for 10 trials or more; face—hand, face-breast, face—penis, face-back, face-foot, face— shoulder, shoulder—hand, breast—hand, penis—hand, thigh-hand, foot-hand, thigh-foot, breast-foot, breast-thigh, buttock—foot, penis-foot, shoulder—foot, and shoulder-breast. The two parts of the body were ﬁrst touched in two heterologous relations and then in the two homolateral relations. Particular attention was directed to the ﬁrst response. If an error was made in any one test, that particular test was repeated until the patient was correct, or for at least ﬁve times if the error persisted. At least 10 trials were done on each patient. Stimulation of the unexposed parts of the body, except for the penis, was done through clothing. The penis was touched directly. The pattern of dominance has also been studied incidental to other investigations on perception in groups such as Group C, comprised of patients with focal brain disease manifested by hemiplegia or aphasia 11; Group D, patients with long—standing or congenital blindness; Group E, patients who had congenital or long—standing deafness; Group F, normal adults recovering from general anesthesia or while under the effect of intravenous amobarbital (Amytal) sodium 12; Group G, psychiatric patients receiving electroconvulsive therapy; Group H, mentally �4 defective adults,13 and Group I, very aged or senile adults.4 It must be emphasized, however, that we did not test all the possible combinations of body parts in every one of these groups except in Groups A and B. The emphasis was mainly on determining the relationship of the face and the hand to the rest of the body areas. The results obtained in these incidental studies showed that the pattern of dominance was similar to the one obtained in this study of patients with severe mental changes due to disease of the brain. RESULTS The responses on double simultaneous testing of any two parts of the body fell into several groups. Using the face—hand combination as an example, the subject may report the following responses, as recorded in Table 1. Responses in which there was extinction or displacement“? of the stimulus over one area in any combination were tabulated as a single type of response. For example, in the face-hand combination responses in which the face stimulus was correctly perceived but in which extinction or displacement of the hand stimulus TABLE 1.—Pattem of Responses to Double Simultaneous Farce-Hand Tests Combination of Body Parts Simultaneous touch of face and hand ‘ Possible Response (a) Face-hand Classiﬁcation Correct (b) Face only Extinction Face Extinction Hand Displacement Face (c) Hand only (d) Face-face Dominance None (e) Hand-hand Displacement Hand (f) Face-other part of body Displacement Face (9) Hand-other part Displacement Hand (h) Face-and a in space part Exosomesthesia Face Exosomesthesia Hand of body (i) Hand-and a part in space occurred were tabulated together under “face” responses. Each of the responses indicates dominance of the face over the hand. Hence, the reason for grouping them under “face dominance.” Face dominance responses were much more fre— quent than any of the hand dominance responses. The responses for all the body combinations were tabulated in a similar manner. For the patients with organic mental syndrome and for the normal children tested in all body combinations, the “dominant” responses for one part of the body as compared with those of the other part of the body in each combination were analyzed by the t test. The initial responses of the normal and schizophrenic adults and of the other patients with organic brain disease tested in a single combination were analyzed by the method of chi-square. There were a small number of responses The failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” The part of the body where the stimulus is perceived is said to be “dominant” to the part of the body where the simultaneous stimulus is not perceived. When the subject reports two sensations but mislocalizes one of them, the “displacement” of a percept is said to have occurred. Displacements are usually in the direction of the dominant stimulus and may be partial or complete. Occasionally, one or both stimuli are displaced into the extrapersonal space. This has been termed “exosomesthesia.”14 1' �5 TABLE 2.—Res[>onses of Twenty Patients with Organic Mental Syndrome to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Other Total Errors* Face Part Face Combinations Face-genitals .................. FACE-abdomen i .............. FACE-buttock ................. FACE-breast .................. FACE-foot .................... FACE-back .................... FACE-shoulder ................ FACE-thigh ................... FACE-hand .................... 68 109 79 122 89 105 154 37 78 60 104 66 95 127 85 145 104 149 31 31 19 18 23 10 27 19 4 Responses Genitals Combinations Genitals-face ................... GENITALS-abdomen .......... GENITALS-buttock ........... GENITALS-breast ............. GENITALS-foot ............... GEN ITALS-back .............. GENITALS-shoulder .......... GEN ITALS-thigh .............. GEN ITALS-hand .............. Total Errors Geni- Other 68 121 78 106 138 98 90 124 143 Dominant Hand Combinations Hand-FACE .................. Hand-GENITALS ............ Total Errors Hand-ABDOMEN ............. Hand-BUTTOCK ............. Hand-BREAST ............... Hand-FOOT ................... Hand-BACK .................. Hand-SHOULDER ........... Hand-THIGH ................ 149 143 152 132 163 136 97 127 142 ____/Lﬁ Other Hand Part 4 145 132 131 109 134 117 69 107 114 11 21 23 29 19 28 20 28 H% Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-abdomen ............. Buttock-breast ................ .................. BUTTOCK—back ............... BUTTOCK-shoulder ........... Buttock-thigh ................. BUTTOCK-hand Buttock—foot ............... 79 78 99 94 118 104 93 105 132 Other 19 12 38 55 43 79 65 45 109 60 66 61 39 Part 75 25 28 60 23 Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-buttock ............. Abdomen-breast ............... Abdomen-foot ................. Abdomen-back ................. Abdomen-shoulder ............. Abdomen-thigh ................ ABDOMEN—hand .............. 109 121 99 111 104 97 90 115 152 r Foot-FACE .................... Foot-GENITALS .............. Foot-abdomen ................. Foot-buttock .................. Foot-breast .................... Foot-back ..................... Foot-shoulder ................. Foot-thigh ..................... FOOT-hand .................... 89 138 104 118 100 105 96 125 136 23 23 58 75 41 49 51 77 117 66 115 46 43 59 56 45 48 19 Breast Combinations Breast-FACE .................. Breast-GENITALS ............ Breast-abdomen ............... Breast-buttock ................ Breast-foot .................... BREASToback ................. Breast-shoulder ................ Breast-thigh ................... BREAST-hand ................. 122 106 111 94 100 77 121 85 163 Shoulder Combinations Shoulder-FACE ................ Shoulder-GENITALS .......... Shoulder-abdomen ............. Shoulder-BUTTOCK ........... Shoulder-breast ................ Shoulder-foot.................. Shoulder-back ................. Shoulder-thigh ................. SHOULDER-hand ............. 154 90 90 93 121 96 131 93 127 der Part 27 20 32 28 69 45 53 58 107 127 70 58 65 52 51 78 35 20 Responses ' ' _ﬁ 18 22 56 39 59 55 52 48 134 104 84 55 55 41 22 69 37 29 Responses Back Combinations BaCk-FACE .................... Back-GENITALS .............. Back-abdomen ................. Back-BUTTOCK............... Back-BREAST ................. Back-foot ...................... Back-shoulder ................. BACK-thigh ................... BACK-hand .................... Total Errors 105 98 97 104 77 105 131 127 97 r—A—ﬁ Other Back Part 10 15 53 25 22 56 78 86 69 95 83 44 79 55 49 53 41 28 Dominant Responses Responses Total Errors 21 Dominant Dominant f—A—‘l Shoul- Other 131 Total Other Errors Breast Part Responses Foot Combinations 29 61 55 46 44 58 76 78 92 38 56 58 53 32 39 31 Dominant Dominant r———A‘—ﬁ Other Total Errors Foot Part 37 29 12 22 23 15 20 30 11 ,__JL_____ Total Ade- Other Errors men Part Responses Buttock 31 92 66 84 115 83 70 94 132 Responses Dominant Total Errors Part Dominant Responses '— tals Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-abdomen ................ Thigh-buttock ................. Thigh-breast ................... Thigh-foot ..................... Thigh-BACK ................... Thigh-shoulder ................ THIGH-hand .................. Total Errors 104 124 115 105 85 125 127 93 142 r-_A_—ﬁ Other Thigh Part 19 30 39 60 37 48 41 35 114 85 94 76 45 48 77 86 58 28 Two hundred tests done in each combination were analyzed statistically. The remaining 40 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. i Capital letters indicate dominant part as evidenced by a t test value of 5% or less. * ‘ �6 which were difﬁcult to interpret, and there were a few that showed characteristic perseveration in behavior. These responses were not included in the statistical analysis. Extinction and displacement occurred in all of the body combinations tested in all groups. The incidence of these phenomena varied with the method of testing. On testing body parts in a heterologous but bilateral relation, extinction and displacement occurred with approximately equal frequency. With tests involving ipsilateral body parts, the majority of errors consisted of extinction. 1. Patients with Organic Mental Syndrome—In Group A 20 patients were tested in all the combinations of the body; there were 27 combinations in which the difference in the frequency of extinction and that of displacement in the two body parts tested was statistically signiﬁcant, as evidenced by a t test value of 5% or less (Table 2). This difference occurred in combinations of the face and TABLE 3.—Response on the Initial Trial in Patients with. Organic Mental Syndrome Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Body Part ,——-——A———ﬁ B A FACE * FACE FACE FACE FACE SHOULDER BREAST PENIS FOOT THIGH FOOT BUTTOCK PENIS Shoulder Shoulder * Hand Breast Penis Back Foot Hand Hand Hand Hand Hand Thigh Foot Foot Foot Breast N o. of r—A gﬁ Other Responses .. Subjects Correct 156 15 17 136 44 8 7 21 1 0 17 21 17 37 23 2 4 O 0 1 2 5 2 2 0 2 0 71 30 30 30 9 32 51 12 7 31 6 10 49 23 60 35 40 23 13 8 19 5 8 1 3 B 5 6 30 7 15 25 21 O 30 12 5 Capital letters indicate dominant part as evidenced by a chi-square value of 4 12 8 4 1 1 9 1 5 0 5% 1 or less. other parts, the genital region (penis in males and pubic region in females) and other parts, or the hand and other parts. In combinations involving the face or the genital region, errors in perception were infrequent. Therefore the face and the genital region may be termed as dominant to all other parts of the body. In combinations involving the hand, the opposite phenomenon occurred; errors in perception were more frequent in the hand. The hand may be classified as the least dominant area of the body. Thus, in face-hand tests the results may be expressed either as degree of face dominance or that of hand errors. There were four additional combinations in which dominance was manifested. The buttock was dominant to the back and shoulder, the breast was dominant to the back, and the back was dominant to the thigh. The remaining 18 combinations showed no domi— nance between the two body parts tested, as evidenced by t values greater than 5% (Table 2). These 18 combinations were retested in a different group of 20 patients. The method was similar to that described previously except that the order of testing was more randomized. When the statistical probabilities of the two series of tests were combined, all of these combinations again failed to manifest dominance. �7 An analysis of the responses of the group of 664 patients with organic mental syndrome tested in single rather than multiple body combinations showed a similar pattern (Table 3). There were no instances in which dominance in this group was different from that of the preceeding group. However, some combinations manifested dominance which was not shown in the ﬁrst group. Thus, the face was dominant to the genital region; the foot was dominant to the thigh, and the buttock was dominant to the foot. In summary, the foregoing results show that double simultaneous stimulation tests of parts of the body exhibit a deﬁnite relationship of one part to another. This is manifested by varying degrees of dominance, which may be considered as a gradient of sensation. At the top of the gradient is the face, the most dominant part of the body. The genital region is slightly less dominant than the face but is dominant over all other parts of the body and is thereby the next body area in the order of dominance. At the other end of the gradient is the hand, the least dominant part of the body. The remaining areas of the body fall in the gradient between the ‘ loo— I’ACE PERCENTAGE 0r ooutNAN'r RESPONSES GENITAL R [6| 0 N ABDOMEN BUTTOCK BREAST 6° 5° FOOT BACK SHOULDER TH IGH 4° HAND 30 20 no 0 BODY PART FIG. I. ORDER OF DOMINANCE IN PATIENTS WITH ORGANIC BRAIN DISEASE face and genital region and the hand. These parts include the shoulder, foot. thigh, and the areas on the trunk. W'hen tested in combination with each other, these body parts failed, for the most part, to yield differences in dominance among one another. There was a tendency, however, for the buttock, abdomen, breast, and foot to be dominant to the back, shoulder, and thigh. The order of dominance of all body areas may be illustrated by comparing the total number of dominant responses for each area in the group of 20 patients tested in multiple combinations (Fig. l). N ownal C lzildrew—It has been shown that normal children make errors in simultaneous cutaneous sensory tests just as do patients with an organic mental Syndrome. There was one striking difference, however, between the two groups. 2. Children tended to learn the correct response as the tests were repeated over a period of days, whereas patients with an organic mental syndrome showed but temporary learning tendencies. They soon forgot what they learned and again made the errors. When various combinations of two parts of the body were tested in the young children, an order of dominance became apparent, just as in the patients with an �8 organic mental syndrome. The order of dominance in normal children resembled, to a considerable extent, that found in patients with diffuse brain disease. The face was the most dominant and the hand the least dominant area (Fig. 2). The genital region was not so dominant as in patients with organic disease of the brain, since it failed to show dominance to the shoulder, back, and breast, although it was dominant to all other areas. In tests involving the genital region many children snickered, laughed, or showed other signs of special awareness of the sexual organs. Some refused to be touched there and became uncooperative. Because of this atti— tude, it was necessary to obtain the parents’ permission for the test. The order of dominance for the rest of the body areas in these children also showed little difference from that noted in patients with disease of the brain (Table 4). In only one of these combinations was dominance different from that demonstrated in patients with an organic mental syndrome. In children the foot was dominant to the buttock. The same combination tested in the group of patients with an organic mental syndrome showed the buttock dominant to the foot. IOO so PERCENTAGE 0‘ DOMINANT RESPONSES °° ,0 FACE GENITAL REGION SHOULDER roor co aurrocx BREAST so BACK THIGH 4° ABDOMEN HAND 30 20 l0 0 BODY PART FIG. 2. ORDER OF DOMINANCE IN NORMAL CHILDREN 3-6 YEARS OF AGE Normal Adults.—Several groups of normal adults were studied. In previous communications the responses of simultaneous touching of the face and hand were reported. The results showed a high face dominance. Examination of other body combinations showed a tendency to similar pattern, as recorded in the foregoing paragraphs (Table 5). However, the data obtained in combinations other than the face-hand were not very reliable, because the number of experiments were too few in number. It should be noted that the normal adult very readily grasps the idea of “twoness,” or the concept that two stimuli are being used. Consequently, his chances of yielding a single response on repeated tests are small, especially if he once correctly reports the perception of the stimuli. Thus, it would be most difﬁcult for us to get a large number of statistically significant data for other body areas. In order to obtain reliable data it would be necessary to test a very large number of normal adults by statistical methods. For the time being, most of our emphasis was placed on testing patients with organic brain disease, young children, and very old adults. Judging from our data, it may be presumed that the complete order of dominance observed in patients with organic disease would also be present in the normal subject if a greater number of subjects were tested. 3. �a m 9 TABLE 4.—Responses of Normal Children Three to Six Years of Age to Simultaneous Tests of Different Body Combinations Dominant Dominant Responses Face Combinations FACE-genitals i ............... FACE-shoulder ................ FACE-buttock ................. FACE-foot .................... FACE-breast .................. FACE-back .................... FACE-thigh ................... FACE-abdomen ............... FACE-hand .................... Total Errors* 57 79 52 77 74 74 47 66 71 Responses ,._—A_ﬁ Other Face Part 38 65 35 65 65 55 38 19 14 17 51 64 Genitals Combinations Genitals-FACE ................ Genitals-shoulder .............. GENITALS-buttock ........... GENITALS-foot ............... Genitals-breast ................ Genitals-back .................. GENITALS-thigh.............. GENITALS-abdomen .......... GENITALS-hand .............. 12 9 19 9 15 7 Total Errors r—Aﬁ Other tals Part Geni- 57 56 65 87 74 62 81 19 28 45 78 46 39 65 65 79 81 88 Dominant Hand Combinations Hand-FACE ................... Hand-GENITALS ............. H and-SHOULDER ............ Hand-BUTTOCK .............. Hand-FOOT ................... Hand-BREAST ................ Hand-BACK ................... ................. Hand—THIGH Hand-ABDOMEN .............. 71 7 88 66 72 72 79 85 76 86 9 7 5 9 17 15 27 15 Other Part Shoulder Combinations Shoulder-FACE ................ Shoulder-genitals .............. Shoulder buttock .............. Shoulder-foot .................. SHOULDER-breast ............ SHOULDER-back ............. SHOULDER-thigh ............. 64 79 59 67 63 62 70 49 SHOULDER—abdomen. .. . . . . . SHOULDER-hand ............. 71 Total Errors 79 56 67 63 77 84 59 Buttock Combinations Buttock-FACE ................ Buttock-GENITALS ........... Buttock-shoulder.............. Buttock-FOOT ................ Buttock-breast ................ BUTTOCK-back ............... Buttock-thigh ................. BUTTOCK-abdomen .......... BUTTOCK-hand ............... 52 65 67 66 59 76 66 56 72 Part 17 20 42 21 30 49 31 40 67 35 45 25 45 29 27 35 16 5 74 66 Foot Combinations Foot-FACE .................... Foot-GENITALS .............. Foot-shoulder ................. FOOT-buttock ................. Foot-breast .................... Foot-back ..................... FOOT-thigh ................... FOOT-abdomen ............... FOOT-hand .................... Total Errors 12 9 32 45 32 31 47 40 63 Breast-FACE .................. Breast-GENITALS ............ Breast-SHOULDER ........... Breast-buttock ................ Breast-foot .................... BREAST-back ................. Breast-thigh. . ................ BREAST-abdomen ............ BREAST-hand ................. 74 74 77 59 61 64 50 64 79 9 28 21 29 29 42 26 47 62 65 46 56 30 32 22 24 17 17 Dominant . Back Combinations Back-FACE .................... Back-GENITALS .............. Back-SHOULDER ............. Back-BUTTOCK ............... Back-foot ...................... Back-BREAST ................. BACK-thigh ................... Back-abdomen ................. BACK-hand .................... Thigh Combinations Thigh-FACE ................... Thigh-GENITALS ............. Thigh-SHOULDER ............ Thigh-buttock ................. Thigh-FOOT ................... Thigh-breast ................... Thigh-BACK ................... THIGH-abdomen .............. THIGH-hand .................. * 47 81 59 66 65 50 77 66 76 r—A—ﬁ Other Thigh Part 9 16 20 35 18 24 28 42 49 38 65 39 31 47 26 49 24 27 Part 65 78 31 21 29 35 18 17 9 Total Errors 74 62 84 76 66 64 77 61 85 r- Responses Back 19 23 29 27 35 22 49 27 70 Other Part 55 39 55 49 31 42 28 34 15 Dominant Responses Total Errors Other Dominant F—‘A—ﬁ Other Breast Part 65 28 42 32 21 29 20 26 7 Foot- 77 87 63 66 61 66 65 57 72 Responses Breast Combinations 14 28 25 31 56 55 Responses Dominant Total Errors Part Dominant __Jk_ﬁ Other tock der 39 48 59 Responses f—But- 9 Shoul- Other Dominant Total Errors 28 23 16 16 Responses r-“—"'"—-—\ Hand 9 Dominant Responses Total Errors 38 28 20 Responses Abdomen Combinations Abdomen-FACE ............... Abdomen-GENITALS ......... Abdomen-SHOULDER ........ Abdomen-BUTTOCK .......... Abdomen-FOOT ............... Abdomen-BREAST ............ Abdomen—back ................. Abdomen-THIGH ............. ABDOMEN-hand .............. r———*—ﬁ Total Ade- Other Errors men Part 66 81 74 56 57 64 61 66 86 15 16 26 16 17 17 34 24 71 51 65 48 40 40 47 27 42 15 One_hundred tests done in each combination were analyzed statistically. The remaining 20 tests in each combination were of homologous body parts and did not lend themselves to this type of analysis. 1 Capital letters indicate dominant part as evidenced by a t test value of 5% or less. �10 In testing normal subjects it was noted that they responded by mentioning the face as being the area touched and only when questioned further did they mention the hand. In other words, there was a preference for the face in the response. In another series of simultaneous tests of 20 normal adults the following method was used. Twenty normal adults were informed that they were to be touched on two regions of the body and that they were to report only one of the two places stimulated. The eyes were closed during these tests. Ten tests were done in 8 body combinations in a random fashion (tests involving contralateral and homolateral used in working out the order of in similar that of the to a manner body) parts TABLE 5,—Response on the Initial Trial in N ormal Adults Tested in a Single Body Combination Responses Indicating Dominance of Body Part Combination of Part r———&———-—m Body A FACE * FACE Face Face Face Face BREAST Shoulder Penis Thigh Foot Thigh Breast Shoulder Breast * No. of: B Subjects Correct Hand 160 94 17 30 31 30 76 30 30 30 54 30 30 32 18 77 58 Breast] Shoulder Penis Back Foot Hand Hand Hand Hand Hand Foot Foot Breast Thigh 9 25 22 26 40 24 17 17 44 16 23 19 9 78 29 6 4 6 5 0 0 2 0 2 2 0 0 3 2 2 7 2 6 7 2 1 3 9 6 7 6 o 1 2 4 3 of. 5% 0 or less. 6.—Simnltaneons Touch Stimulations of Various Body Combinations Body Combination Face-hand ............................................... Face-thigh ............................................... Face-shoulder ............................................ Face-foot ................................................ Shoulder-hand ........................................... Hand-thigh .............................................. Thigh-foot ............................................... Hand-foot ............................................... There were . . 0 4 31 2 11 . Other Responses 5 2 2 1 1 Capital letters indicate dominant part as evidenced by a chi-square value TABLE * ,———J\—-q A B 200 * r—«Choices Given—ﬂ Hand 40 Face 160 Face Face Face Shoulder Hand Thigh Hand 175 142 167 158 141 103 114 Thigh Shoulder Foot Hand Thigh Foot Foot 25 58 33 42 59 97 86 tests for each combination. dominance in Groups A and B. There were 200 tests in each combination. The 6. in Table recorded results The not are investigated. genital regions were From an analysis of Table 6 it is obvious that the face is the part of the body which is chosen oftenest when it and other parts of the body are touched simul— taneously. These ﬁndings support the results obtained by other methods. However, this method of selection, when the subject knows that two parts of the body are being touched, did not reveal the expected hand inferiority. This ﬁnding does not necessarily detract from observations obtained by the methods described above, where the subject was to report what he perceived after he was touched in two places without warning. After this series of tests each of these 20 subjects was asked to indicate which part of the body they were the most and the least aware of during testing. The results are tabulated in Table 7. �11 Of signiﬁcance in both sets of these experiments is the fact that the face shows a high dominance. However, it must be stressed again that the last two methods do not reﬂect the low order of hand dominance. 4. Adults with Schizophrenia—When these patients made errors, the errors were similar to those obtained in normal adults under the age of 65. Each patient showed signiﬁcant dominance of the face to the hand as well as to the foot, the breast to the hand and foot, and the penis to the hand and foot (Table 8). The relationship of all the body areas has not been worked out so completely in these subjects as in the preceding groups. The difﬁculty in demonstrating the a“ TABLE 7.——Responses of Twenty Patients as to Areas of Greatest and Least Dominance Body Part Most Aware of Face .................................. Face and foot ........................ Face and thigh ....................... Hand .................................. Foot No. of Body Part Least Aware of Subjects Thigh .................................. 10 Subjects 16 1 1 1 .................................. TABLE No. of 1 Foot .................................. Hand .................................. Shoulder and thigh ................... Foot and shoulder .................... Not asked .............................. 1 1 8,—Response on the Initial Trial in Schizophrenic Adults Tested in a Single Body Combination Combination of Body Part ,——————J% A B FACE * Face Face Face FACE Face Shoulder BREAST PENIS Thigh Foot Thigh BREAST PENIS Shoulder * 4 3 1 Hand Breast Penis Back Foot Shoulder Hand Hand Hand Hand Hand Foot Foot Foot Breast No. of Subjects Correct 72 24 52 23 29 25 81 30 42 37 13 31 77 43 2 19 29 2O 3!) 31 15 30 30 30 28 15 9 17 15 9 Responses Indicating Dominance of Body Part f————N———ﬁ A B Other Responses 46 2 11 2 4 4 2 2 14 3 7 12 8 8 44 19 11 8 4 19 8 3 0 3 3 0 0 1 3 3 9 1 1 6 2 10 1 1 1 2 3 8 2 1 Capital letters indicate dominant part as evidenced by a chi-square value of 5% or less. complete pattern in schizophrenic patients was the same as that encountered in normal adults. They showed fewer perceptual errors on simultaneous tests than did either patients with organic brain disease or children. These errors occurred only during the intial trials, so that one subject could be tested for only one body combinationi~ There were a number of patients with schizophrenia who presented bizarre responses. The touch stimuli were occasionally misidentiﬁed and were reported as “a burning” or “a ﬂy crawling.” At times the number of percepts were multiplied. Instead of perceiving the two applied stimuli, they reported three or more percepts in a variety of body parts. Similarly, a single stimulus was reported as two or more percepts, the locus of the original stimulus being occasionally omitted. Such patients usually persisted in the bizarre responses on repeated testing on subsequent days. Several of the paranoid patients refused to close their eyes but permitted examination provided they could see. I}: �12 Senile Adults.—Studies of body combination tests in senile adults 65 to 96 of the disease in with found those of similar results showed to patients age years brain and in very young children.‘ The most dominant region was the face and the least dominant the hand. In plotting the errors on face-hand tests in normal subjects of all ages, we found that children under the age of 6 years and adults over the age of 65 show the greatest incidence. 6. Supplementary Studies of Blind or Deaf Subjects.——While we were conducting the foregoing experiments, we, naturally, tried to ﬁnd an explanation for face dominance. One of the thoughts we entertained was that normal subjects developed the concept of the face being foremost in importance. It might be assumed that the earliest sensory image a subject experiences would be the sight of the mother during infancy. Therefore, the earliest memory of a person and his selfidentiﬁcation would be the visual image of a face. Moreover, young children who are asked to draw the picture of a man draw the face ﬁrst and foremost, paying less attention to other parts of the body. Goodenough 15 made similar observations on the drawings of mentally retarded persons and patients with disease of the brain. Since visual memory and imagery of a face would seem to be important in one’s sensory experience, it was thought that the congenitally blind might not respond as the normal subject does when he is tested with cutaneous stimulations. With this in mind, a series of congenitally blind children and another series of adults with an organic mental syndrome and long-standing acquired blindness were tested with double simultaneous stimulation of the face and hand. Results showed that there was no difference in the pattern of response between the blind and the normal subjects. A. Blind Subjects: I. Children. Forty-two normal children (3 to 14 years of age) with congenital blindness were tested in face-hand and hand-foot combinations. Ten tests (heterologous and homolateral parts of the body) were done for each combination in a random order. The results obtained were as follows: 1. Of all children 6 years of age or younger who were congenitally blind, 79% showed persistent errors after 10 trials of testing. 2. In the face-hand combination tests the following responses were obtained: 5. Face Only Face-Face Hand Only Hand-Hand 202 34 2 1 3. In the foot—hand combination tests the responses were as follows: Foot-Foot and Partial Displacement of Hand-Hand Hand Stimulus Hand Only Foot Only 51 26 26 9 4. The pattern of all errors throughout the testing was the same as that for normal children without blindness. II. Adults. Ten adults with an organic mental syndrome and blindness acquired after childhood were tested with multiple face—hand tests. All showed persistent errors. The analysis of all the errors are as follows: Face Only 100 Face-Face 7 Hand Only Hand-Hand 1 1 From this analysis it is obvious that preservation of vision in infancy is not essential for face dominance. �13 B. Deaf Subjects: We also thought of other causes for face dominance, namely, that the touch applied to the face was not only felt but reinforced by the sound stimulus produced by the touch on the face, which is so near the ear. To establish or exclude this possibility, we studied a series of deaf people. Thirty-two adults with deafness acquired in early infancy or childhood were tested with multiple face—hand tests. These subjects were otherwise normal. They had no evidence of disease of the brain. The results are indicated in Table 9. Again we found face dominance. Hearing did not seem to be a factor in face dominance. COMMENT From the foregoing studies it is obvious that we have been investigating perceptual functions from the standpoint of patterns. For many years Lashley§ has been stressing the fact that the data obtained on neurologic examination should always be analyzed with reference to pattern of activity. We did this in the compilation of our own results. By clinical observation we learned that when the cutaneous sensory ﬁeld is examined under conditions of simultaneous stimulation a distinct pattern is discerned. The pattern is most apparent in testing two non— TABLE 9.—Incidence of Errors for Deaf Subjects, Initial and Subsequent Trials Total No. of Initial Trial—*ﬁ—ﬁ Subjects Correct Face Only Face-Face 32 Hand Only 9 19 2 2 r—-———~—Initial and Subsequent Trials———ﬂ Face Only 86 Face-Face Hand Only Hand-Hand 1 4 0 symmetric regions, far removed from each other and situated along the longitudinal axis of the body. The resultant interaction between these two sensory stimuli yields a characteristic pattern. In studying the data, it was learned that the face is the most dominant region of the organism. The genital zone is next in the order of dominance, while other parts of the body follow in a gradient, with the hand mani— festing the least dominance. Thus, the most conspicuous gradient is between the face and the hand. The pattern of response we obtained by testing with the method of double simultaneous stimulation has been found consistently on numerous occasions, under a variety of conditions, and in many groups of subjects. In considering our results, we naturally ask what the organizing principle of this perceptual pattern might be, or with which neurophysiologic or psychophysio— logic data it may be correlated. Why is the face the most dominant and the hand the least dominant? Why does the genital region show a high dominance? What determines such an order of dominance? Is it acquired by learning; is it inherent, or is it a product of each? If it is inherent, what role does the body image play? Anatomic or Neuro-“Electrical” Studies—In considering the anatomic substrate, we ﬁnd no apparent correlation of ﬁndings elicited on electrical studies of the cerebral cortex with areas of the body which show dominance by our method of stimulation. Some aspects of tactile sensory interaction have been discussed by § References 16 through 18. �14 1" in their and Bard Marshall, Woolsey, mappings of the cerebral cortex of the cat and monkey by the method of evoked action potentials. The map of the “sensory cortex” as determined by electrical stimulation or evoked action potentials does not serve to explain the order of dominance. It might be supposed that the degree of dominance found in a part of the body would be proportioned to the area in the cerebral cortex in which this part of the body is electrically represented. However, this is not the case. The face and the hand, the most and the least dominant areas. respectively, in our system of testing, have approximately equal representation in the homunculus of the human cortex as determined by the method of electric stimulation of the cerebrum.20 It is not certain whether electrical studies on neuron action will give us the answer, for, as Lashley has repeatedly pointed out, most studies are made on surgically isolated or anesthetized animals, and these are far from being in a physiologic state. Our own clinical studies show patterning of sensory interaction in the physiologic state of man, whether there is or is no disease of the brain. This is a physiologic fact. The meaning of this fact, however, is not as yet clear. This patterning of sensory interaction does not occur in any one region of the cortex. It is the result of integration of perceptual function, which takes place in the entire brain at the cortical, thalamic, and even lower levels of the nervous system. There is no doubt that sensory interaction occurs, but that this interaction is patterned and how it is patterned is still a mystery. Psychophysiologic S‘tudies.—Our own psychophysiologic data also fail to shed any light on our problem. Studies of thresholds of cutaneous sensations, types and nature of stimuli, and attention of subject and sensorimotor responses did not offer clues to a solution. Critchley,21 in his interesting article on tactile functions in the blind. suggested that face dominance may be due to the sensitivity of the skin. It does not seem to be a matter of thresholds,” for we have been working with crude supraliminal stimulations. The stimuli we employed consisted for the most part of ﬁrm taps or scratching and slapping of the face and hand, or repetitive or moving stimulations, such as rubbing. Moreover, the tactile thresholds. as obtained in different regions of the cutaneous sensory ﬁeld by use of the method of von Frey,23 using von Frey’s hairs (Table 10), or with a stimulus such as pinprick (Table ll), show no strict correspondence to the “dominance” values obtained by the method of simultaneous tactile or pinprick stimulations. The use of stronger or more noxious stimuli, such a pinpricks, will reveal a lower incidence of errors, but the pattern of dominance will be the same. Nor is there any correlation between the acuity of the sense of two—point discrimination and the order of dominance. It will be recalled that the ability to discriminate two points at the ﬁnger tips or at the hand is much greater than that at many other parts of the body, excluding the lips and tongue; yet the hand shows the lowest order of dominance. This lack of correspondence is contrary to the hypothesis proposed by Denny-Brown, Meyer. and Horenstein, who studied patients with lesions of the parietal lobe.“ In our studies of normal subjects and of patients with disease of the brain, including that of the parietal lobe, we ﬁnd no correlation between incidence of errors as elicited by the method of double simultaneous stimulation and the two-point discriminative potentialities of a given cutaneous area. �15 Still another factor to consider is that of attention. Critchley,“ in a series of papers, claims that it is a lack of attention which causes the imperception of one of the two simultaneous stimuli in patients with lesions of the parietal lobe. As expected, this type of sensory defect is apparent only on the side opposite the cerebral lesion. It is especially pronounced in the hand and least manifest in the face, thus reﬂecting a pattern with an order of dominance similar to the one illustrated in normal children and in subjects with diffuse disease of the brain. If this pattern in the parietal lobe lesion is interpreted as due to a lack of attenTABLE 10.—5timulus Threshold for Pressure, in Grams per Square Millimeter, After von Frey Cornea ................................... 0.3 Conjunctiva ............................. 2.0 Tongue ................................... 2.0 ...................................... 2.0 2.5 ....................................... Finger tip ................................ 3.0 Eyelid (edge) ............................. 3.0 Infraorbital area ........................ 3.0 Forehead ................................. 3.0 Hollow of palm .......................... 7 Dorsum of ﬁngers ........................ 5.0 Upper arm, ﬂexor surface ................ 7 Thigh, inner side .......................... 7 Forearm, ﬂexor surface .................. 8 Nipple .................................... 8 Anterior edge of deltoid ................. 9 Anterior edge of axilla .................. 11 Xyphoid process ......................... 11 Mucosa of. check .......................... 12 Nose Lip 12 15 16 16 16 16 17 26 26 26 27 27 27 28 Prepuce ................................... Spinous processes ........................ Medial edge of scapula ................... Deltoid muscle ............................ Upper arm, extensor surface .............. Abdomen .................................. Oriﬁce of urethra ......................... Thigh, outer side ......................... Areola of breast .......................... Undersurface of breast ................... Sole, noncalloused part ................... Tibia ...................................... 28 Forearm, extensor surface ................ 33 Inguinal area ............................. 48 Glans penis ............................... 111 Sole, calloused part ....................... 250 11.—Stimulus Threshold for Pain, in Grams per Square Millimeter, After van Frey TABLE Cornea .................................... Conjunctiva .............................. ..................................... Abdomen ................... ............... Forearm Flexor surface ........................ Extensor surface . E yelid 0.2 2 10 15 . Upper arm ................... Flexor surface ........................ Outer condyle of humerus ................ ..................................... ....................................... Cheek Calf Hand, dorsum ............................ Foot, dorsum ............................ Calf ....................................... 20 30 30 30 30 30 Upper thigh Outer surface ------------------------ 30 Inner surface ......................... 30 Extensor surface ..................... 40 50 FOOL dorsum ............................ . 1v Edild’ dorsum 100 llbla """""""""""""" ...................................... Internal malleolus ....................... Hand, palm .............................. Sole, callouscd portion ................... Finger tip ................................ 00 110 130 200 300 tion, it must be that the inattention is only on one side of the body, and particularly in the hand. In other words, the term inattention becomes synonymous with defective perception produced by the parietal lobe lesion. Nevertheless, attention tends to modify perceptual responses. According to William James, “when the things to be attended are small sensations and when the effort is to be exact in noting them it is found that attention to one interferes a good deal with the perception of the other.”46 But does this explain the pattern in dominance or in errors in perception as illustrated in Figures 1 and 2? It might be claimed that man pays most attention to the face because he is most interested H References 25 through 28. �16 in this part of the body. Such reasoning may explain face dominance, but it does not account for the frequent errors made in the hand stimulus. The latter ﬁnding would imply that man pays the least attention to the hand, less than to any other part of the body. Now, it is hardly likely that one pays less attention to one’s hands than to one’s back. Yet, according to our data, the back dominates over the hand, implying that man is more interested in his back than in his hand. This is contradictory, and it becomes obvious that attention does not account for the order of dominance as depicted in Figures 1 and 2. A defect in attention may crystallize but not determine the pattern of perception as elicited by the method of double simultaneous stimulation. Further evidence against the attention theory are the recent experiments by Hooker.29 He found an order of dominance in sensation, using double simultaneous touch stimulations, in the human fetus. Eventhough the response to stimuli in his experiments involves an order lower than that implied in our results, there was a distinct pattern under his conditions of testing in which attention was not a factor. When there was simultaneous cutaneous stimulation of the face and hand, the dominant motor response was that typical of the face. An important principle to consider in the study of patterns of response to sensory stimuli is that every sensation has a motor component. Thus, when we request the subject to report what is felt when the face and hand are touched simultaneously, there must be an efferent, or a motor, element. The patient replies verbally and tends to point to the spots touched. In a series of face—hand combination tests or in combinations involving the face and another body part, it was shown that the face is the ﬁrst to be indicated, whether it is pointed to with the hand or announced verbally (Table 6). Since the hand is used in the pointing, it would be the last of the two (face and hand) perceived regions to which the sub— ject would point. On the contrary, the face would be the ﬁrst to be indicated. This, however, is not always the case, for when both stimuli are perceived, the hand is sometimes the ﬁrst to be indicated. This is particularly evident in combinations which do not include the face. When both hands are stimulated, the incidence of errors is very low and the subject often uses either hand to point to the other. Learned and Inherent Perceptual Organization—Perceptual organization or sensory correlation may proceed along two lines: (1) learning or individual acquisition of perceptions and (2) inherited or genetically determined perceptual patterns. Acquired perceptions are organized in the course of experience by the postulated mechanisms of pattern identiﬁcation, by a selective process, by sym— bolization, and by conceptual organization. As Nissen states, “Symbolization helps in perceptual organization also in connecting percepts with concepts to speciﬁc 30 responses.” 1. Learning Factor: There are many who believe that all perceptions and perceptual patterns are acquired. Most perceptual reactions are learned during the maturation period or infancy. In our own studies of perceptual patterns under conditions of double simultaneous stimulation, we believe that awareness of the part of the body, such as the genital region, is an example of learning. Infants or children learn of and become aware of their genitals. Initially, when the pattern was demonstrated in adults with disease of the brain, the high dominance manifested in the genital region was not too surprising. The interpretation was that, due to its special sexual connotation acquired by learning, there is more “awareness” of �17 stimuli applied in this area. The question then arose as to what the pattern would be in very young children. If sexual “awareness” was not yet operative, that is, if the child had not yet learned of the social signiﬁcance of the genital organs, one might assume that there might be less dominance of the genital zone than in adults. However, in our studies we found that young children were indeed “sensitive” about their genitals. Most of the children under 6 years of age, even the very youngest, who were just about able to cooperate in the perceptual tests, were reluctant to expose this area or showed some form of embarrassment or curiosity when their genitals were touched. Some refused to have more than a few tests done at one time. Evidently this increased “awareness” is learned prior to 3 years of age. Since we found a high dominance for the genital area in children, it might be inferred that this high dominance is related to a sexual awareness which was probably learned in the ﬁrst two to three years of life. Schilderﬂ pointed this out in his discussion of the principles concerning the libidinous structure of “the body image.” # He stated: The attitude toward the different parts of the body can be determined by the interest the persons around us give to our body. We elaborate our body image according to the experiences we obtain through the actions and attitudes of others. The actions of others may provoke sensations when they touch and handle us. But they may inﬂuence us also by words and actions which direct our attention to particular parts of their body and our own body. . . . Early infantile experiences are of special importance in this connection but we never cease gathering experiences and exploring our own body.31 These principles of symbolization in perceptual .organization apply to genital as well as to other regions of the body. From the psychoanalytic, or Freudian, point of view the face and the mouth participate in the oral stage of body image, or, more correctly, of body schema development. The same school emphasizes that the genital region plays a great role in the development of the organism. Therefore, it should not be surprising to ﬁnd the face and genital regions almost on the same level of dominance as determined by double simultaneous stimulation. References 31 and 32. # Smythies,33 in a philosophical paper, criticized the confusion and the loose use of the term “body image.” Thus, (a) there is “the body image” which describes “a visual, mental, or memory image of a human body, one’s own or someone else’s.” Body images are experienced. (b) Body schema should be used only in its original sense. It is part of the subconscious mind, and thus its presence is inferred, and not experienced. The experiments of Stratton are a good example of almost a pure disorder of the body schema. (c) Body concept is a conceptual constellation and depends largely upon the proper function of the relevant memory mechanisms. Anosognosia is an example of disorder of the body concept. (d) “The perceived body,” or another name for it, “postural model of the body,” a term to be applied to the somatic sensory ﬁeld—directly experienced inside central consciousness. An example of this is the experience of having a phantom limb or autotopagnosia. The perceived body is identiﬁable with the “body image in the brain.” (e) Actual physical body is a physical object and not the same as the perceived body. What one perceives as to body parts does not always correspond to the actual position of the physical body and vice versa. An example of this is found in the patient’s experiences in mescaline intoxication, where the perceived body is not the same as the physical body. Also the postures assumed in some of the dyskinesias are not always perceived. (f) Body image in the brain of the physical body (theory of psychoneural identity). The homunculus as determined by electrical stimulation or destruction of brain tissues is an example. While we agree with Smythies criticisms, it is sometimes extremely difﬁcult to use his classiﬁcation of “experiences and description of the human body.” Nevertheless, in our subsequent discussions we shall try to use his terms wherever possible. ﬂ �18 Even though Schilder * proposed these theories, there are no clear—cut experi— ments to show that the face is sensitized the most, and, for that matter, that the hand is sensitized the least, in the maturation of the normal infant or child. As a matter of fact, in the same book Schilder emphasized the importance of other structures in the construction of the “body image.” In considering “sexual sensitization” of body parts in adults, one must compare such erogenous zones as the breast and buttock with the genital region. Yet analysis of our data reveals no undue dominance of the breast and buttock over nonerogenous regions, such as the foot or abdomen. Perhaps there would be no incongruity in dominance of erogenous zones if we interpreted our data from the standpoint of age, sex, personality, and social background of the subject. Under such conditions we might have found different gradients in each group and concluded that sensitizations of the body parts by learning are, after all, important, but not necessarily the principal factor in determination of the pattern. In this connection the question of the development of the “body image” arises. How does the “body image” develop? Schilder admits that we have no reliable information as to how this development takes place. He said that there is “reason to believe that there is an inner development, maturation, . . . and there are inner factors, which are given in the organism and comparatively independent of experience which determines this development.” He also believed that “the process of maturation gets its ﬁnal shape through individual experience.” Thus, there is a factor of maturation which forms the basic structure of the body image, whereas experience and learning inﬂuence the trends of the development. Maturation and learning are essential features of all types of development, whether it is body image, body schema, body concept, perceived body, or perception itself. These conclusions are partly supported by the experiments of Gesell.34 If this sort of reasoning, namely, development of the body image in infancy, accounts for face—genital dominance, what explains the inferiority of the hand, as determined by this series of tests? When the hand is considered in the spectrum of the “body image,” there seems to be no prominent reason for its inferior position. According to Schilder, the hand is an important structure in the formation of the “body image.” The “body image” is continuously inﬂuenced by the almost constant optic image of its hands. One sees his own hands more frequently than any other part of his own body. In fact, perceptually and from the motor standpoint the hand is one of the most important structures in the “perceived body.” Katz 35 says that the hand makes the most vivid impression. Despite this, it is curious that the hand is least dominant when it is tested simultaneously with another body part. 2. Inherent Factor: Thus far we have discussed the factor of learning in perception as the basis for the pattern we obtained on double simultaneous stimu— lation. It is possible that “learning” during infancy might explain part of, but not the entire, pattern of sensory organization under conditions of double simultaneous stimulation. However, our results show that the factor Of “learning” did not enter in our own tests. An analysis of the responses obtained on the ﬁrst trial in many children showed that the face was most dominant and the hand was least dominant. In this situation there was no opportunity for learning; yet this pattern was found on the initial tests in most subjects. The same consistent initial response was obtained * References 31 and 32. �19 in tests of combinations of other body regions, such as the hand and the thigh, etc. These ﬁndings strongly suggest that the patterns we obtained are not the result of a learning process during testing but may be due to inherent sensory organization. This theory is supported by the preliminary studies of Hooker.29 Working with human fetuses, he found that double tactile simultaneous stimulation of the face and hand resulted only in the face reactions. When the hand and foot were tested, there was only the hand response. Thus, there was an order of dominance in which the face dominated over the hand and the hand over the foot. Although the pattern Hooker obtained in the fetus is not exactly the same as the one we obtained under our conditions of double simultaneous stimulation in young children, the fact remains that a pattern has been observed before the organism had an opportunity to learn. Carmichael,36 after reviewing the available experimental data, concludes that there is only little evidence that learning modiﬁes fetal behavior. If it is assumed that the pattern is determined inherently, one should consider the role the body image plays in organization of perception or in the order of perceptual dominance. 3. Organization of Perception in the Perceived Body, Body Image, and Body Concept: (a) Perceived body. In a discussion of the inherent properties of perception we must consider the role of the “perceived body.” There is a theory that mid— line structures of the body dominate over the lateral or peripheral parts. In his monograph on the body image, Schilder emphasized the dominance of the midline structures. This theory considers the long axis of the body as being the dominant over other regions. Part of the same theory is that proximal parts of a limb dominate over distal regions. In our own experiments it is true that the face and the genital region, both midline or axial regions, are the most dominant parts of the perceived body. However, this axial theory does not account for the gradients as depicted in the graph we plotted from our data. There are some midline or axial structures which show no signiﬁcant dominance over the lateral parts. Thus, the foot, a lateral area, is dominant or equal to the thigh, which is a proximal area, and to the buttock, which is an axial structure. Moreover, there is a differentiation of dominance along the longitudinal axis of the body itself. Thus, the face or the genital region is dominant over the abdomen, buttock, or midback. A second hypothesis is the one proposed by Cohn.37 This is similar to the ﬁrst. Cohn proposed that the pattern of dominance, as elicited by the method of double simultaneous stimulation, is inherently organized on the basis of rostral dominance, i. e., the theory that the face is the most dominant part of the organism, while the remaining body areas show a descending gradient along the longitudinal axis. The rostral parts are dominant over the more caudal areas. This theory is consistent with the extensive observations on the development of the vertebrate nervous system, in which a rostral—caudal gradient is demonstrated in phylogenesis.38 This gradient is manifest in the progressive differentiation of the rostrum until, in Mammalia, the cerebrum is fully differentiated. The gradient is also manifest in biochemical and physiologic reactions at each phylogenetic level. Similar gradients have been demonstrated for the musculoskeletal and gastrointestinal systems. A rostrocaudal order of sensory development has also been shown to exist in onto— genesis in studies of the fetus with single stimulations.39 More recently, Hooker 29 found such an order in human fetuses when the face and hand, or hand and foot, were touched simultaneously. Our own data support this theory of rostrality only in part, inasmuch as there is face dominance. However, other facts tend to contra- �20 dict the theory of rostrality. There is no continuous downward gradient between the rostral and the caudal region. Even though the face is most dominant, there are caudal body parts which are dominant over some of the more rostral regions. For example, the foot is dominant to the hand and the thigh. Most signiﬁcant is the dominance of the genital region to all more rostral areas except the face. From the foregoing data one must conclude that the concept of rostrocaudal order of be the fetal There the is not beyond applicable stage. organization may sensory factor of learning and maturity in the postnatal stage. More studies of double simultaneous stimulation in different parts of the body of the human fetus, particularly the genital region, may shed more light. Similar studies in the ﬁrst year of life will help us in understanding the development and organization of perception in man.40 (1)) Body image and body concept. Another theory can be evolved in considering the relation of the body to its inner self or that of the ego to its outer world. This concept implies that the ego has a center and a periphery region, just as the perceived body has an inside and an outside. We observe ourselves (inside) as we observe others (outside). When one thinks of himself, what Schilder called autoscopy,32 there is an image of one’s own face. This is a good example of what is meant by body image. Children in making drawings of a man indicate the face, while other parts of the body are less often illustrated.15 Even congenitally blind children, in whom the hands and ﬁngers are of especial importance, model the head 41 and the region of the mouth as being the most conspicuous”? too large as being In expressing the concept of the ego in terms of body parts, the face is visualized is face the most The other than structure. the to more foreground comes any or distinguishing part of the organism itself. The face represents the most central or inner portion of the ego. In narcissism the self-interest in one’s body is directed chieﬂy to the face. Claparéde,42 in his studies on localization of the self, concluded that the ego is conceived as being in the head. More speciﬁcally, he believed the center of the ego is situated between the eyes. As for the genital region, there are of the this would who body the identify area psychoanalysts, particularly many, with the inner part of the ego. The part of the body which has to do with reproduction is probably just as “deeply in” or central in the organism’s concept of the body as is the head, with its face, mouth, eyes, etc. In considering the genital region, it is not always easy to determine whether the importance attached to this part of the body is due to inherent or to acquired factors. There is a great deal of literature on this subject, but it is still difﬁcult to ascertain what role the inherent factor plays as opposed to the learning factor. Applying the theory of centrality, i. e., that the face-genital regions are innermost in the ego and in the body concept, we are faced with the problem of ﬁtting the hand into this theory. In contrast to the concept of the face or genitals being central, the hand is mostly on the periphery. The hand is the medium with which we or our ego makes contact with the peripheral or outside world. The hand is on the periphery of our ego structure and, with the aid of vision, is the most important tool for exploration of the outer world. One might argue that the foot, although a distal structure, also makes contact with the outer world. However, in this task the 1' von Stockert, F.: Quoted by Critchley.21 �21 hand, in most instances, is used more than the foot. Moreover, the impression gained is that the foot is more inward—it seems more protected and hidden by shoes. In summary, it would appear that from the standpoint of body concept organization within the ego, the face and the genitals are the most inwardly situated, while the hand is least centrally or most peripherally situated in the conceptual organization of body parts within the ego. Now if we correlate the latter hypothetical pattern with the pattern we found in our perceptual tests, we create some sort of congruity between the two, namely, (a) face dominance as obtained on perceptual tests with face as the most inner portion of the ego, and ([9) hand inferiority with hand as the most peripheral portion of the ego. From this it might be inferred that the ego may play a role in the determination of the perceptual pattern. We realize that this is a highly theoretical explanation. Obviously, the concept of the hand being the most distal, and the face the most central, portion in the organization of perception in body image needs testing. We also realize that our results may be colored by an obscure artifact, although we have checked our data by a variety of methods and conditions of testing. If this concept is at all valid, it should be applicable to functions other than those of cutaneous senses. Thus, the concept of “central” portions dominating over the periphery may be found in studies of vision. Observations drawn from patients with mental changes consequent to diffuse brain disease show domination of central over peripheral vision. Goldsteini and others have found that in these patients constricted ﬁelds of vision are not uncommon. When such a patient is instructed to ﬁx at a central target and report whether he sees another target simultaneously in the periphery of the ﬁeld, the response is that the central target is observed and not the one in the periphery.45 In studies of visual responses of these patients to rapid exposures of images with groups of ﬁgures, it was noted that they reported what they saw in the central portion of the ﬁeld only, often not observing the peripheral ﬁgures. Similar results were obtained in tachistoscopic examinations of mentally defective persons. In all these cases the results were uniform, namely, the perception of the central, but not of the peripheral, ﬁgures. Thus, when the cutaneous sensory ﬁeld is compared with the visuosensory ﬁeld, the face seems to correspond to the macular region, and the hand, to the most peripheral part of the ﬁeld of vision. On further com— parison, it might be inferred that central vision is identiﬁable with the ego in the same manner as is the face. The optic image we have of ourselves or of others is situated in the central portion of the ﬁeld of vision. Our ego is projected in the central regions of the perceptual ﬁeld. In considering these patterns for perceptual function, we touched on the topic of conceptual functions. When the subject of the ego is discussed, a pattern for thinking becomes obvious. It is well known that most of our thoughts are pointed directly or indirectly toward ourselves, and we think least of what is most peripheral to or away from the ego. This subject has been amply discussed by William James in his “Principles of Psychology.” The object of mentioning the parallel was to point out the principle that similar patterns exist in all types of perceptual functions, as well as in conceptual and motor functions. :1: References 43 and 44. �22 SUMMARY Tests of simultaneous tactile stimulation involving many different body combinations were applied to patients with an organic mental syndrome, normal children, normal adults, and schizophrenic adults. By the use of these simultaneous touch stimuli, a pattern in cutaneous perception was demonstrated in which the face, as well as the genital region, was the most perceptive or dominant body area, whereas the hand showed the least dominance. The remainder of the body regions fell between these two extremes in the form of a mild gradient. No one theory adequately explains the organization of this pattern. Learning and maturation are probably factors, but it appears to be mostly inherent. The pattern is found in the normal subject but is accentuated in the presence of disease of the brain. REFERENCES Head, H., and others: Studies in Neurology, London, Oxford University Press, 1920. 2. Pearson, G. H. J.: Effect of Age on Vibratory Sensibility, Arch. Neurol. & Psychiat. 20:482-496, 1928. 3. Jaffe, J., and Bender, M. B.: Factor of Symmetry in the Perception of Two Simultaneous Cutaneous Stimuli, Brain 75:167—176, 1952. 4. Green, M. A., and Bender, M. B.: Cutaneous Perception in the Aged, A. M. A. Arch. Neurol. & Psychiat. 69:577-581, 1953. 5. Cohn, K: On Certain Aspects of the Sensory Organization of the Human Brain: III. Patterned Response to Three Simultaneously Applied Cutaneous Stimuli, Neurology 2‘»:140-143, 1. 1952. An Experimental Study of Simultaneous Stimulations of the Sense of Touch, J. Nerv. & Ment. Dis. 20:169-184, 1893. 7. Oppenheim, H.: Diseases of the Nervous System, Neurol. Centralbl. 4:529—533, 1885. 8. Green, M. A.; Fink, M., and Bender, M. B.: Order of Dominance in Cutaneous Perception, Tr. Am. Neurol. A., pp. 238—240, 1952. 9. Bender, M. B.: Disorders in Perception, American Lectures in Neurology, No. 120, Springﬁeld, 111., Charles C Thomas, Publisher, 1952. 10. Bender, M. B.; Fink, M., and Green, M. A.; Patterns in Perception on Simultaneous Tests of Face and Hand, A. M. A. Arch. Neurol. & Psychiat. 66:355—362, 1951. ll. Bender, M. B.; Shapiro, M. F., and Schappell, A. W.: Extinction Phenomenon in Hemiplegia, Arch. Neurol. & Psychiat. 62:717-724, 1949. 12. Jaffe, J., and Bender, M. B.: Perceptual Patterns During Recovery from General Anesthesia, J. Neurol., Neurosurg. & Psychiat. 14:316-321, 1951. 13. Fink, M.; Green, M. A., and Bender, M. B.: Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects, J. Nerv. & Ment. Dis. 117:43-49, 1953. 14. Shapiro, M. F.; Fink, M., and Bender, M. B.: Exosomesthesia or Displacement of Cutaneous Sensation into Extrapersonal Space, A. M. A. Arch. Neurol. & Psychiat. 68:481-490, 6. Krohn, W. 0.: 1952. Goodenough, F. L.: Measurement of Intelligence by Drawings, Yonkers-on-Hudson, N. Y., World Book Company, 1926. 16. Lashley, K. 5.: Problem of Cerebral Organization in Vision, Biol. Symposia 7:301-322, 15. 1942. Lashley, K. 8.: Functional Interpretation of Anatomic Patterns, A. Res. Nerv. & Ment. Dis., Proc. (1950) 30:529—547, 1952. 18. Lashley, K. 5.: Serial Ordering of Action, in Cerebral Mechanisms in Behavior, edited by L. A. Jeffress, New York, John Wiley & Sons, Inc., 1951. 19. Marshall, W. H.; Woolsey, C. N., and Bard, P.: Observations on Cortical Somatic Sensory Mechanisms of Cat and Monkey, J. Neurophysiol. 4:1-24, 1941. 17. �23 20. Penﬁeld, W., and Rasmussen, T.: The Cerebral Cortex of Man: A Clinical Study of Localization of Function, New York, The Macmillan Company, 1950. 21. Critchley, M.: Tactile Thought, with Special Reference to the Blind, Brain 76:19-35, 1953. 22. Berlin, L. ; Goodell, H., and Wolff, H. G.: Relation of Pain Threshold and Pain Intensity to the Phenomenon of Extinction, Tr. Am. Neurol. A., pp. 229-231, 1953. 23. von Frey, M.: Beitrage zur Physiologie des Schmerzsinns, Ber. u. Verhandl. konigl. siichs. Gesellsch. Wissensch., Leipzig, Math.—phys. C1. 47:185-196 and 283-296, 1894. 24. Denny-Brown, D.; Meyer, J. S., and Horenstein, S.: The Signiﬁcance of Perceptual Rivalry Resulting from Parietal Lesion, Brain 75:433-471, 1952. 25. Critchley, 26. Critchley, M.: The Parietal Lobes, London, Edward Arnold & C0., 1953. M.; Russell, W. R., and Zangwill, 0.: Discussion on the Parietal Lobe Syndromes, Proc. Roy. Soc. Med. 44:337-346, 1951. 27. Critchley, M.: Problem of Awareness or Non-Awareness of Hemianopic Field Defects, Tr. Ophth. Soc. U. Kingdom (1949) 69:95-109, 1950. 28. Critchley, M.: Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538-561, 1949. 29. Hooker, D.; Early Human Fetal Behavior with a Preliminary Note on Double Simultaneous Fetal Stimulation, A. Res. Nerv. & Ment. Dis., Proc., to be published. 30. Nissen, H. W.: Phylogenetic Comparison, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 31. Schilder, P.: The Image and the Appearance of the Human Body, Psyche Monograph No. 4, London, George Routledge & Sons, Ltd., and Kegan Paul, Trench, Trubner & C0., Ltd., 1935. 32. Schilder, P.: Mind Perception and Thought in Their Constructive Aspects, New York, Columbia University Press, 1942. 33. Smythies, J. R.: Experience and Description of the Human Body, Brain 76:132-145, 1953. 34. Gesell, A.: Maturation and Infant Behavior Pattern, Psychol. Rev. 36:307-319, 1929. 35. Katz, D.; Gestalt Psychology, translated by R. Tyson, New York, The Ronald Press C0., 1950. 36. Carmichael, L.: Ontogenetic Development, in Handbook of Experimental Psychology, edited by S. S. Stevens, New York, John Wiley & Sons, Inc., 1951. 37. Cohn, R.: On Certain Aspects of Sensory Organization of the Human Brain: A Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation, J. Nerv. & Ment. Dis. 113:471, 1951. 38. Child, C. M.: Origin and Development of the Nervous System, Chicago, University of Chicago Press, 1921. 39. Hooker, D.; Prenatal Origin of Behavior, Porter Lectures, Series 18, Lawrence-Kansas City, University of Kansas Press, 1952. 40. Carmichael, L.: Onset and Early Development of Behavior, in Carmichael, L., Editor: Manual of Child Psychology, New York, John Wiley & Sons, Inc., 1946. 41. Bakwin, R.: The Blind Child, J. Pediat. 35:120-128, 1949. 42. Claparede, E.: Note la localisation du moi, Arch. Psychol. 19:172, 1924. 43. Goldstein, K.: Constriction of Visual Fields, Arch. Neurol. & Psychiat. 50:486-487, 1943. 44. Goldstein, K.: Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187-208, 1944. 45. Bender, M. B., and Teuber, H. L.: Ring Scotoma and Tubular Fields: Their Signiﬁ- cance in Cases of Head Injury, Arch. Neurol. & Psychiat. 56:300-326, 1946. 46. James, W.: The Principles of Psychology, New York, Henry Holt & C0., 1890; reprinted by Dover Publications, 1950. Printed and Published in the United States of America �F‘J‘ 5‘ ~24" amass or by Doctors: PM“. cameraman urn axmrunous mm: lorriskl‘. lender, sum A. a... m In: nun Several series of noraal adults, norsal children. patients with organic aental eyndroee and patients with schisophrenia.were tested‘ i for the1r ability to perceivesiaultaneoue tactile stiauli. Iith his eyes closed. the subject was touched sisultaneonelyx on two different areas of his body and ashed to report what he perceived and to localise the percepts. the responses to this aethod of testing , in all subjects fell into two general groups. The subject either reported both stisuli correctly or reported only one correctly and either did not perceive the second stiaulus (extinction) or sislocalised it (displaceaent). If the right face—left hand were tested, for 'esasple. the subject sight report the face stiaulus correctly and either not perceive the stisulus on the hand or aislocalise the hand stianlns to the left cheek and so report that he felt a single stisulus on each side of the face. *1sentyy patients with organic sental syndroae and 20 noraal children 3-d years of age were tested in all possible coabinations of two between the aajor body areas. lach subject received 540 tests in a randos order.. Testing was done with the subject cospletely nude. When the incidence of errors in the different body areas was analysed by statistical sethods, a significant and similar relationship between these areas was found in both groups of subjects. lrrors were least fequent in the face and genital sons. These were designated as the scat dominant regions. lrrors were aost frequent in the hand when it was tested with any other body part. when all the body parts were thus coapared, a gradientias established with the following order of dosinance: the face and genital region. followed by abdoeen. breast, buttock, foot. back. shoulder and thigh. Bosinance was least apparent “in the hand. �Thros other groups consisting of 593 norssl adults, 53: schizophrsnio adults sod 527 pstionts with orgsoio’ssntslisynorons ' sore tsstodwin.vsrioos body ooshinstions. In those coshiostions is lvhich.¢osinsnos was sppsrsnt, the order of dosinsnoo sss.sinilar. 'to that found in tho prooooding groups. this ordor oi.dosinsnco on oisoltsnoous stinulstion sppssrs .to ho so ishsrsnt psttsrn or organisation. It is prosont in nor-31 children 3~8 yosrs of sgs sad in nor-slisdults. Tbs psttsrn is sxsggorsfod sad Inch sors sppsrsnt in pstissts with disosss of tho brsin. h I I V _ lerioos thsoriss oxplsining this psttsrn, particularly.tho‘ closonsss of tho toes sud gsnitsl rsgions, sill ho disousssd. ,' , '.‘ 4 I C’v w?” 4.4/{L4/1A r” . If- 7” (Ia . .\ ﬁn. .‘ " , an.“ "the 1 ‘3 a, , v .h ‘7“ ‘v‘ _. A ‘ ,3. '1 I" .iv / as“ f’ M “ , a 3i“ x' - ‘ , ' z’ i » � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns of perceptual organization with simultaneous stimuli. AMA Arch Neurol Psychiatry. 1954 Aug; 72(2): 233-55. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-7b-011 Date A point or period of time associated with an event in the lifecycle of the resource 1954 Creator An entity primarily responsible for making the resource Bender, Morris B; Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from the A.M.A. Archives of Neurology and Psychiatry August 1954, Vol. 72, pp. 233-255 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/00442514cc7c4740e6535ae86cb27a98.mp4 ca0462dd7c4eebcdd294288b69b8223c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biographical Files Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Interview with Max Fink, MD: World-Leading Expert on Electroconvulsive Therapy Subject The topic of the resource Neuropsychiatry (MeSH) Suicide (MeSH) Electroconvulsive Therapy (MeSH) Psychoanalysis (MeSH) Catatonia (MeSH) Description An account of the resource <span>Max Fink, MD, Professor of Psychiatry and Neurology Emeritus, Stony Brook University, was interviewed by Lorraine Botti on March 18, 2018. The location was Special Collections in the Melville Library at Stony Brook University, where his archive is housed. In the interview, Dr. Fink discusses: the circumstances which brought him to Stony Brook University in 1972 including his appointment by Dr. Stanley Yolles; his administration of electroconvulsive therapy (ECT) services; the Second World War and Sigmund Freud; psychoanalysis vs. ECT then and now, and its effect on suicide; and catatonia verification and treatment.</span><span> </span> Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548">Fink, Max, 1923-</a> Publisher An entity responsible for making the resource available Stony Brook Medicine Date A point or period of time associated with an event in the lifecycle of the resource 2018-03 Contributor An entity responsible for making contributions to the resource Interviewer: Lorraine Botti Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> <a title="https://rightsstatements.org/page/InC-EDU/1.0/?language=en" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">https://rightsstatements.org/page/InC-EDU/1.0/?language=en</a> Stony Brook University owns the rights to this video. Max Fink, MD owns the Intellectual Property Rights. Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource video/mp4 Type The nature or genre of the resource MovingImage Identifier An unambiguous reference to the resource within a given context mfp_MaxFink_videos_20190301 Source A related resource from which the described resource is derived Stony Brook Medicine's YouTube Channel published this video in 2019: <a title="https://www.youtube.com/watch?v=_dxp3N12uAY" href="https://www.youtube.com/watch?v=_dxp3N12uAY">https://www.youtube.com/watch?v=_dxp3N12uAY</a> Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/dd6aa613ad864b41d42710aa943de4df.pdf e331912b9bfc1f22ac2706d3f155e8a5 PDF Text Text 5 ,ﬁ, . 1 Confinia Neurologica 9/ NEURQPHYSWLUEY [ABQRMURY HILLSIDE HOSPITAL GLEN OAKS' N' Y- Borderland of Neurology -— Grenzgebiete der Neurologie Les conﬁns de la Neurologie Edidit: E. A. SPIEGEL Basel S. KARG ER Separatum Vol. 12, Fasc. 4 (1952) : 3 . New York Printed in Switzerland From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellevue Hospital, New York City A Clinical Evaluation of Carotid Angiography by MAX FINK and JOSEPH M. STEIN ._.I I ‘ f .3 I Since carotid angiography has become a routine procedure in the management of intracranial conditions, an evaluation of its use is necessary. Both the indications and hazards of the procedure must be considered in recommending it for diagnostic purposes. It seemed valuable, therefore, to review the angiograms done on the neurological service of a general hospital. During the past 20 months, 117 percutaneous diodrast angiograms were completed by members of the resident house staff. The majority were done di- rectly by the authors. A variety of neurological conditions including suspected brain tumors, vascular anomalies, subdural hematomas, vascular diseases and diffuse degenerative diseases were selected by the attending staff as suitable candidates for angiography. In each case, a percutaneous carotid angiogram was performed according to the usual descriptions (1). Either local inﬁltration by novocaine or general anesthesia by pentothal or surital was used. A CournandGrino needle was inserted into the carotid artery at the level of the thyroid cartilage. In most instances the common carotid artery was cannulated; in a few instances the internal carotid alone. Ten to twelve cc. of 35 % diodrast solution were used in each injection. A simple manual multiple cassette holder was used. This permitted three consecutive lateral ﬁlms and a single anteroposterior (A—P) view. In each case the A—P and lateral ﬁlms were immediately developed, and, if indicated, the injection was repeated. If no pathology was noted on these ﬁlms, the procedure was repeated on the other side whenever advisable. Bilateral procedures were carried out in 26 subjects. �182 Max Fink and Joseph M. Stein Results Diagnoses of various conditions were made prior to angiography. Of these, “brain tumor suspects” made up the largest group; suspected vascular anomalies and subdural hematoma were the next largest groups (see Table I). The interpretation of the ﬁlms was based on descriptions by Moniz (2 a), Lima (2b), and Green and Arana (l b) . Brain Tumor Suspects Of 55 patients in whom intracranial masses were suspected, angiographic diagnoses of brain tumor were made in thirty. Of these, 25 were conﬁrmed by subsequent surgery or air studies. Conﬁrmation was not obtained in three patients because further studies were contraindicated by patient’s age or family’s refusal to give permission. In two cases the angiograms were interpreted incorrectly and these cases are described. Case I: D.H. a 48 year old woman was admitted to Bellevue Psychiatric Hospital because of headaches and progressive confusion. The examination revealed early papilledema, left central facial palsy, skull tenderness on the right and memory deﬁcits. An electroencephalogram showed a right cerebral focus. Bilateral carotid angiography under general anesthesia revealed deﬁnite elevation (displacement) of the parietal branches of the right middle cerebral artery. Subsequent to this procedure the spinal ﬂuid syndrome was noted to be positive for active syphilis. Anti-luetic treatment was instituted and the patient improved rapidly. Five weeks later, the right carotid angiogram was repeated. These ﬁlms showed the parietal vessels to have a normal conﬁguration. Case II: 0. 0., a 64 year old male was admitted because of recent onset of grand mal seizures and left-sided weakness. Examination revealed a mild left hemiparesis, most marked in the lower extremity. There was a positive Babinski response and increased reﬂexes. The cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under local anesthesia was performed and demonstrated good ﬁlling of the anterior and middle cerebral arteries. There was straightening and depression of the pericallosal artery on the lateral views; and increased vascularity near the termination of the anterior cerebral artery on the A—P ﬁlm. These changes were interpreted as evidence of a parasagittal tumor mass displacing blood vessels. A pneumoencephalogram was done and this did not demonstrate the mass. The patient improved without treatment and was discharged. He was readmitted a few weeks later with evidence of an acute brain stem syndrome. In View of the course of the illness and multiplicity of lesions, it was believed that the patient’s symptoms were due to degenerative changes, and not a neoplasm. No further studies were undertaken. In this group of suspected brain tumors 22 angiograms did not show any pathology. Eleven of these were conﬁrmed by air studies or autopsy. In two patients, however, satisfactory angiograms failed to demonstrate lesions later demonstrated by other studies. �A Clinical Evaluation of Carotid Angiography 183 III: F. M., a 57 year old man was admitted to the hospital because of left hemiparesis, bladder and bowel incontinence, and grand mal seizures of 4 weeks duration. On examination, there were severe personality changes, and a spastic left hemiparesis with pathological reﬂexes. Cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under pentothal anesthesia was done. Two sets of lateral ﬁlms and one A—P view were taken. The ﬁlms showed no evidence of cerebral tumor. One week later a ventriculogram demonstrated a large right fronto-temporal mass. The presence of a malignant glioma was conﬁrmed by surgery. Case IV: J. S., a 49 year old man developed left sided seizures and aphasia during hospital treatment for furunculosis. On neurological examination there was evidence of a lesion in the right hemisphere. On skull x-ray the pineal shadow was shifted to the left. An arteriogram on the right side under general anesthesia was done and no pathology demonstrated. A pneumoencephalogram, however, revealed a deformity of the right frontal born. The patient expired one month after angiography and at postmortem, multiple cerebral abscesses were demonstrated bilaterally. Case Other erroneous angiographic diagnoses were made in patients who proved to have vascular thromboses. In two patients with signs of a brain tumor, the angiograms revealed an avascular area in the parieto-temporal region with displacement of middle cerebral vessels. Surgical exploration revealed edematous necrotic brain tissue, without evidence of tumor. Each case came to autopsy, and TABLE I ANGIO GRAPHIC DIAGNOSES Group No. of Patients Intracranial Mass Vascular Anomaly and Aneurysms Suhdural Hematoma Occlusive Vascular Disease Other (f) 55 _ Pos. 30 Pos. Neg. Not Diagnosis Diagnosis Incorrect Neg. Diagnostic (3) Conﬁrmed Conﬁrmed Diagnosis 22 3 25 1 2 21 17 9 9 (d) ll 11 7 13 2 4 10 8 — — l ll 4 (b) 1 (c) 9 6 (e) 7 — 1 —— 5 —— —— Notes: (a) Technically unsatisfactory ﬁlms. (b) Two cases conﬁrmed by surgery but 7 other patients'with anomalies demonstrated on arteriograms were not subjected to further studies. (c) The 11 patients with negative arteriograms were not subjected to further study. ((1) Includes seven diagnoses of subdural hematoma, one of intracerebral hematoma and one of brain tumor. (e) F ailurc of the anterior or middle cerebral, or internal carotid artery to ﬁll on at least two consecutive injections, while the remainder of the circulation ﬁlled well. (f) Includes three “follow-up” angiograms, seven patients with diﬁuse degenerative disease and three patients with lesions of the skull. �184 Max Fink and Joseph M. Stein in both, thrombosis of a branch of the middle cerebral artery was found. The angiograms could not be differentiated from those seen in cases of tumors in the same region. Vascular Anomalies: Twenty-one patients suspected of intracranial vascular anomalies or aneurysms were subjected to angiography. The angiograms were bilateral in only three of these, and unilateral in the other nine. One set of ﬁlms were not satisfactory and were not repeated. Seventeen of these patients had manifested spontaneous subarachnoid hemorrhages. In nine cases an anomaly was clearly outlined on the arteriogram. Five of these were aneurysms at the base, and four, vascular malformations of the hemisphere. No anomaly was demonstrated in eleven cases. Conﬁrmation of ﬁndings by other methods of study was most difﬁcult to obtain in this group. In the nine cases where the anomaly was demonstrated, further conﬁrmation was achieved in two cases. In one, an angiomatous malformation was amputated at operation. In the other, an aneurysm of the anterior communicating artery was dissected at post mortem. Air encephalograms were normal in two patients, despite the angiographic evidence of a large angioma of the cerebrum. The speciﬁcity of angiography in the diagnosis of vascular malformations is demonstrated by such cases. Of the eleven patients with negative angiographic ﬁndings, two were subjected to air studies. These ﬁlms were normal. The other nine patients were discharged without further study. Subdural Hematoma: The diagnosis of subdural hematoma was made angiographically in seven of seventeen patients suspected of traumatic intracranial hematomas. The characteristic separation of the vascular patterns from the internal table of the skull as seen on the A—P projection was the basis for these diagnoses. In each of these cases the diagnosis was conﬁrmed by trephination. Furthermore, in the eight patients in whom a diagnostic vascular pattern was not seen, diagnosis of no blood in the subdural space was made. These diagnoses were all conﬁrmed by pneumoencephalography. In two patients angiography demonstrated an intracerebral mass, rather than a subdural process. In one case, this diagnosis made it possible for the surgeon to approach the lesion by a well localized and deﬁnitive procedure. The diagnosis was conﬁrmed in the second at autopsy. Vascular Disease: Angiographic studies were done in 11 patients in whom occlusive vascular disease was believed to be the basis �A Clinical Evaluation of Carotid Angiography 185 for their neurological ﬁndings. Failure of a portion of the vascular distribution to ﬁll on two consecutive injections was observed in seven of these cases, and normal vascular patterns were seen in the other four. In the ﬁrst group incomplete ﬁlling of the middle cerebral artery was seen in four cases; of the anterior cerebral artery in one case; and of the internal carotid artery in two cases. The vessels which appeared involved on the ﬁlms were in each instance the same vessels as indicated by the patient’s clinical syndrome. In four of these patients pneumoencephalography demonstrated areas of atrophy in the involved region of the brain. In one case, post mortem studies conﬁrmed the angiographic ﬁndings. No conﬁrmation was obtained in the other six cases. Miscellaneous Group: Of the 13 angiograms in the group, seven were done in patients with diffuse cerebral disease of a degenerative type. These ﬁlms were not characteristic but in each case air studies demonstrated an enlarged ventricular system without shift or deformity. In three patients with lesions of the skull angiography failed to demonstrate any cerebral involvement. Pneumoencephalograms were done in only two of these patients and were normal. Complications: In an evaluation of the indications for a diagnostic procedure the incidence and severity of complications must be considered. In this series of 117 angiographic studies, 36 patients suffered a total of 43 complications. There were ﬁve cases with severe and permanent complications. In all other instances the complications were mild and transient. Of the transient complications, 22 hematomas of the neck were recorded. This was recorded only when the hematoma was large. In one case, in a child, the hematoma was large enough to cause tracheal shift and respiratory difﬁculties. It was necessary to intubate the patient and maintain the airway during the evening of the procedure. Transient hemiparesis or transient increase in an existing hemiparesis was seen in 7 cases, and a grand mal seizure was observed in 2 patients. In each instance the phenomena disappeared within 48 hours. In 4 cases urticaria, chills and vomiting followed angiography, and seemed to represent an allergic response to the diodrast. In one patient, in whom a vascular anomaly was demonstrated, fresh blood was manifest in the spinal ﬂuid the morning after the procedure. Of the severe complications, death occurred within 24 hours of angiography in two patients (cases V, VI). In three other patients �186 Max Fink and Joseph M. Stein severe complications were directly related to angiography. In a young child an osteomyelitis of the transverse process of the ﬁfth cervical vertebra resulted after a difﬁcult cannulization (case VII). A permanent mixed aphasia (case VIII) and an intensiﬁcation of a pre-existing hemiparesis (case IX) were also observed. Case V: G. B. male, 62. Craniotomy, three months before arteriography, had demonstrated a right middle fossa spongioblastoma polare which was spreading along the sphenoid ridge and had crossed the midline. The patient completed a course of x-ray therapy and was alert and ambulant. A vertebral angiogram was suggested to evaluate the intracranial mass. The patient was sedated with demerol, scopolomine and luminal. Three injections of 11 cc. each of 35% diodrast, were made. The record states that: “while attempt was made to enter right common carotid, patient became cyanotic, respirations shallow, and pulsations of the artery, which were strong, became weak.” The patient expired within 20 hours after developing hematemesis, melena, and two grand mal seizures. No autopsy was obtained. Case VI: R. W., a 40 year old male, was admitted because of sudden onset of headache and stiff neck. The spinal ﬂuid was grossly bloody and the diagnosis of a spontaneous subarachnoid hemorrhage made. Patient developed pneumonia and ran a septic course. This responded to antibiotic therapy and patient seemed well one month after admission when he developed a second episode of subarachnoid bleeding. One week later, while patient was comatose, a right carotid angiogram was done. The ﬁlms were not diagnostic and patient expired within 18 hours of the procedure. An aneurysm of the anterior communicating artery with hemorrhage extending into the lateral ventricles was seen at post mortem. Case VII: N. B., a 5 year old girl, was admitted because of petit mal seizures for two months. Examination demonstrated left homonymous hemianopsia and an electroencephalographic focus of abnormal activity on the right parieto-occipital region. A right percutaneous carotid angiogram was done under general anesthesia, with difﬁculty, and a normal vascular pattern demonstrated. Patient had a large hematoma of the neck with tracheal shift, necessitating intubation that night. Patient recovered rapidly, but complained of pains in the neck and kept the head ﬁxed with chin turned to the left. Repeated x-ray examinations eventually disclosed an area of rariﬁcation in the transverse process of the ﬁfth cervical vertebra. This responded to immobilization and chemotherapy. When seen six months later, the child had recovered completely. Case VIII: M. C., a 30 year old male, was admitted to the neurological service because of left sided headaches of a few years duration and three episodes of loss of consciousness during the previous six months. On examination there was diminution in perception of tactile stimuli in the right hand. This defect was exaggerated by double simultaneous stimulation. Electroencephalography demonstrated a persistent focus in the left parietal region. The pneumoencephalogram was normal. A left percutaneous carotid angiogram was done. Four injections of diodrast were made. After the last injection a complete hemiplegia, hemisensory syndrome and hemianopsia was observed on the right. The patient was totally aphasic but responsive. During the ensuing weeks the weakness and sensory changes cleared, so that when seen one year after the episode, only minimal sensory changes in the �A Clinical Evaluation of Carotid Angiography 187 right upper extremity were observable. The aphasia, however, after some initial resolution, persisted. The patient expressed himself with difﬁculty and made many errors, could not carry out complicated commands, and made errors in imitating mouth and hand movements. The angiographic ﬁlms were interpreted as within normal limits except that the vessels of the middle cerebral group were few in number and widely separated. Case IX: E. B., a 64 year old man, was admitted because of headache and “nervousness” of some months duration; and repeated episodes of loss of consciousness without convulsive movements for one month. On examination there were mental changes, hyperreﬂexia and a positive Babinski on the left, but no manifest weakness or sensory changes. A right percutaneous angiogram was done with local anesthesia using four injections of diodrast. Immediately after the last injection the patient lapsed into a torpid state, his eye movements became dissociated, and the left upper and lower extremities were ﬂaccid. During the ensuing days, the torper diminished until the patient could respond verbally to command, but the hemiplegia became spastic. It persisted until the patient was transferred to another hospital one month later. The angiograms were interpreted as normal. A pneumoencephalogram revealed bilaterally dilated ventricles Without shift or distortion. A number of factors such as sensitivity to the contrast medium the amount of drug and rapidity of injection (3b), and existing hypertension (3 c), have been suggested as causes for complications. In the present series, these factors are not outstanding in the patients who developed complications when these are compared to the uncomplicated cases. Either conjunctival or intradermal diodrast sensitivity tests were carried out in every subject. In one case, the onset of wheezing, sweating, and palpitation after the intradermal test caused us to cancel the studies. In all other subjects, including the patients with complications, the sensitivity tests were negative. This was notably true in the four patients who developed “allergic-like” reactions of urticaria, chills, and vomiting, following the angiography, but who failed to react to the test dose. There is no apparent relation in the data between complications (excluding hematoma of the neck) and the number of injections of diodrast (see Table 2). (3 a), TABLE II No. of Injections No. of patients with complications No. of patients without complications * 1 1 3 more than 2 0 9 3 6 4 5 6 6 2 1 6 0 27 22 13 8 3 Total" 16 85 Excluding 16 uncomplicated cases in whom total dosage was not recorded. Similar analyses of the factors of anesthesia and the number of carotid punctures at one session (unilateral or bilateral angio- �188 Max Fink and Joseph M. Stein graphy), reveal no signiﬁcant correlation between these factors, taken singly, and the incidence of complications. Arterial hypertension was not a contraindication in the selection of patients for angiography. Ten hypertensives (all with diastolic pressures of 100 mm. Hg. or more, and systolic pressures of more than 160 mm. Hg.) were subjected to angiography, and in none of these were there any complications. Of the patients with severe or transient complications (other than hematoma of the neck) none had hypertension. Discussion Recent reviews have emphasized the diagnostic reliability of carotid angiography in vascular anomalies (4), suspected brain tumors (lb, 5), traumatic cerebral states (6), and occlusive vascular diseases (7). Our observations conﬁrm the recommendations of the authors in the ﬁrst three groups. Prior to angiography’, the diagnosis of vascular anomaly could not be conﬁrmed except by surgical exposure or autopsy. Since air studies are not reliable in demonstrating vascular anomalies or is choice of in establishing the procedure angiography aneurysms, such diagnoses. In 43 % of the patients in this series in whom such a lesion was suspected, the anomaly 'was satisfactorily demonstrated by angiography. In an unpublished series of similar cases studied by one of us (Fink) at Monteﬁore Hospital, ﬁve aneurysms were demonstrated in 14: suspects. Similar results are recorded by other authors (4), and numerous recommendations have been made to increase these results. Routine vertebral injection, combined with bilateral carotid punctures, will demonstrate anomalies in the posterior portion of the Circle of Willis (14). Oblique A—P views at 45 degrees have been recommended to demonstrate small aneurysms of the carotid (4 (1). With these modiﬁcations in the procedure, it is to be expected that the incidence of positive identiﬁcation of anomalies will increase. The role of angiography in the management of spontaneous subarachnoid hemorrhage is not clear. Recent reviews emphasize the importance of demonstrating the lesion where surgical intervention is indicated (4b, e). The effect of angiography during the acute phase of bleeding has not been clariﬁed. Many authors have recommended angiography only after the bleeding has ceased. Others, such as Wechsler and Cross (7 b), suggest early use of angiography during active bleeding. This principle of waiting until bleeding ceased was adhered to in the cases in this series, and no statement of the effect of angiography on bleeding can be made. �A Clinical Evaluation of Carotid Angiography I89 Angiography is the diagnostic procedure of choice when a supratentorial brain tumor is suspected. It is recommended for lesions located in the anterior two-thirds of the cerebrum. Occipital lobe, posterior fossa and some midbrain tumors are not consistently demonstrable by this technique. Angiography is recommended in subjects with papilledema, since this procedure, unlike air studies, does not make immediate surgical intervention necessary (5, 7). Furthermore, numerous reports emphasize the differences in the patterns made by gliomas, meningiomas, intracerebral hematomas and vascular tumors (1, 2, 3c, 5). Such clues are helpful to the surgeon in planning the operative procedure. In a few of our cases, multiple foci of a metastatic tumor were demonstrable on the ﬁlms, clarifying the management of the case. Such discriminations are usually not possible by other diagnostic techniques. The diagnostic reliability of angiography in cases of brain tumor is high. In this series, 25 of 29 conﬁrmed brain tumors were outlined by angiography. In a series of 96 brain tumor suspects, 39 of 42 veriﬁed neoplasms were demonstrated (5 a). In the series from Monteﬁore Hospital angiography revealed the neoplasm in 45 of 52 conﬁrmed cases. Similar satisfactory correlations are seen in the negative angiograms of these three series. This diagnostic reliability of 88 % compares favorably with encephalography. The value of air studies in brain tumor diagnoses has been frequently reported. In one such study by Grant (8), ventriculography demonstrated the lesion in 130 of 150 cases—an incidence of 87%; while pneumoencephalography in 69 cases, revealed the tumor in 81%. Further indications for angiography are in cases of traumatic intracranial hemorrhage. Numerous reviews emphasize the displacement of the anterior cerebral artery and separation of the ﬁne vessels from the calvarium on the A——P ﬁlm as diagnostic of subdural hematoma (6). Furthermore, angiography differentiates intracerebral and subdural lesions, altering the surgical approach (6 a). This was clearly demonstrated in two of our patients in whom subdural hematoma was suspected, but in whom the angiogram demonstrated an intracerebral mass. In cases of cerebral vascular accident angiography appears less helpful. Failure of a vessel to ﬁll may be due to a variety of reasons including slowing of the circulation, vascular spasm, and anomalies of the system. These factors have been emphasized (7b). Angiography, however, is not contraindicated in vascular disease. It provides a useful means in differentiating a thrombosis from an intracerebral clot, or from a tumor, in cases where the diagnosis is unclear. �190 Max Fink and Joseph M. Stein While the indications for angiography are many, they cannot be evaluated without a discussion of the risks involved. The complications of the procedure are of three types: (a) transient local phenomena; (b) transient cerebral vascular phenomena; (e) permanent severe deﬁcits. In the ﬁrst group of transient phenomena are burning pains in the head during injection, hematoma of the neck, and allergic reactions. Hematoma of the neck is a potentially dangerous complication (see our Case VII) but in a recent review no sequellae were observed (9). Allergic reactions are infrequent and usually mild. It was noted in this series that the routine intracutaneous or conjunctival testing for sensitivity was not found satisfactory in predicting these complications. Transient hemiparesis, aphasia, seizures and elevated blood this In (10). have been following angiography reported pressure series these complications were observed in nine cases—an incidence of 8%. A similar incidence was observed in the Monteﬁore Hospital series. That these phenomena are probably due to temporary vascular insufﬁciency (spasm?) is evidenced by the clinical pattern of neurological ﬁndings and their duration. Of seven patients with hemiparesis, the deﬁcits had disappeared within three hours in three patients, while in three others it was gone in 24 hours. In one of the subjects angiography was repeated in the other side six days later, without complication. In the seventh patient, arteriography had demonstrated an aneurysm of the internal carotid artery on the left and the common carotid artery was ligated on that side. One month later, angiography was repeated on the right side and following the ﬁrst injection of diodrast, the patient developed a right hemiplegia. This disappeared during the ensuing 72 hours. Vascular syndromes of the anterior and middle cerebral arteries have been observed. In one patient a lower limb monoplegia developed after two injections of diodrast. A third injection on the same side was done within 15 minutes of the appearance of the defect. The arterial views obtained showed good ﬁlling of all branches. The monoplegia disappeared within 12 hours. These complications were not observed in patients with hypertension. Deterioration of a patient’s condition or death following angiography has been reported in a number of instances. Bull (5d) summarizes the mortality rate of the procedure as 3 per 1000, which he states compares favorably to ventriculography. More recently, Dunsmore, Scoville and Whitcomb (10b) report three fatalities in 147 cases, and Olsson (11) reports three cases of “deterioration of patient’s condition” in a series of 360 angiograms. �A Clinical Evaluation of Carotid Angiography . 191 There were two fatalities in our present series, and one patient had a severe aggravation of a pre-existing hemiparesis. Each of these patients, like those of Dunsmore, Scoville and Whitcomb and Olsson, were severely ill before the procedure. In contrast to this are the large series of Curtis (5b), Wickbom (1 c), Torkﬂdsen (Sc), Lindgren (la), and Green and Arana (1b) wherein no deaths were related to the procedure. It is possible that with widespread use of angiography, subjects with more advanced cerebral lesions are selected for these studies and the risks thereby increased. A number of reports by Olsson and associates (3b, 11, 12) emphasize the summation of the toxic effects of large doses of diodrast given over a short period of time. They indicated the nature of the toxicity as an increased permeability of the blood vessels and a change in hemodynamics. Furthermore, the relation between concentration of diodrast and toxicity was demonstrated by Cross (13) when he introduced diodrast for angiography. His observation that seizures follow the use of 50% and 70% diodrast has been conﬁrmed by numerous investigators. Despite the use of 35% diodrast and low total dosages of diodrast, in this series, complications ensued. There was no signiﬁcant relation between dosage and complications. Other factors must be operative and some hint has been given in the observation on circulation time (41') and the effect of other injurious agents summating with diodrast (3). Conclusion Angiography is preeminent in the management of cases of intracranial disease suspected of vascular anomalies, supratentorial tumors, and traumatic hematomas. It is a satisfactory non-surgical method of demonstrating a vascular anomaly, malformation or aneurysm. In the diagnosis of supratentorial masses it will outline 90% satisfactorily. In addition to establishing the presence of a tumor, arteriography is superior to other diagnostic technics in yielding evidence as to the type of mass and its locus. In cases with papﬂledema, surgery is not made immediately mandatory by the procedure. It is not a satisfactory method in demonstrating obscure and diffuse lesions of the ventricular system, or tumors of the posterior fossa or occipital lobe. In cases of traumatic intracranial lesions, angiography is a satisfactory method in outlining subdural hematomas, and differentiating such lesions from intracerebral hematoma or tumor. �192 Angiography is Max Fink and Joseph M. Stein thromboses cerebrovascular in not clearly helpful and hemorrhages. would and not transient, the for most part, Complications are, are The complications in cases. most the limit procedure seem to bilatnumber or anesthesia, not directly related to hypertension, factors a Other play diodrast. of erality of injections, or amount is necessary. further and role study more important Summary reviewed were carotid angiograms A series of 117 percutaneous in involved angiography. risks and for indications the to evaluate studied including supraconditions were intracranial of A variety and hematoma traumatic anomalies, vascular tentorial tumors, of intraevidence with disease. patients Fifty-ﬁve cerebrovascular cranial tumors were subjected to angiography, and a positive in conﬁrmed were These diagnoses diagnosis was made in thirty. ﬁlms misinterpreted. the were subjects In two only of the cases. 83% in in conﬁrmed 50%; were the diagnoses Of the negative ﬁlms, demonlater lesion show fail a to did the angiograms only two cases intracranial with suspected 21 Of patients strable by air studies. of In two outlined angiography. by vascular anomalies, nine were air manifest on not revealed anomaly an these, the angiograms traumatic of suspected of seventeen patients studies. In a group in made seven was diagnosis positive intracranial hematoma, a in cases, eight ﬁndings the well negative as as These diagnoses cases. all conwere in two demonstrated cases, intracerebral tumors and lesions cerebrovascular of In studies. cases ﬁrmed by subsequent complications Transient value. of diagnostic not angiography was consisted and of the one-third patients, in of angiography were seen In urticaria. and seizures, of hematoma of the neck, hemiparesis, These and severe permanent. ﬁve patients (4 %) complications were discussed. factors the and described cases are cerebral of angiorisks limited the conclude that authors The of the in usefulness management its from detract do not graphy intracranial vascular malformations, suspected supratentorial tumors and traumatic lesions. Zusammenfassung 117 durch perkutane Injektion in die Arteria carotis gewonnene und Indikationen der Gesichtspunkte Angiogramme werden vom Gefﬁﬁanomalien, Tumoren, Gefahren besprochen. Supratentoriale der GehirngefﬁBe und Erkrankungen Haematome traumatische �A Clinical Evaluation of Carotid Angiography 193 werden besprochen. 55 Patienten mit Zeichen von intrakraniellen Tumoren wurden mit Angiographie studiert; in 30 wurde eine positive Diagnose gestellt. In 83% der Falle wurde die Diagnose bestatigt. In 2 Fallen wurden die Filme falsch gedeutet. In 50% der negativen Filme wurden die Diagnosen bestatigt. Nur in 2 Fallen vermochte das Angiogramm nicht eine durch Luftfiillung demonstrierbare Lasion zu zeigen. In einer Gruppe von 21 Patienten mit vermuteten intrakraniellen GefaBanomalien wurde in 9 Fallen die GefaBstﬁrung demonstriert. In 2 dieser Falle zeigte Angiographie die Anomalie, wahrend Luftfiillung ein negatives Resultat ergab. In einer Gruppe von 17 Patienten mit Verdacht auf traumatisches intrakranielles Haematom wurde eine positive Diagnose in 7 Fallen gestellt. Diese Diagnosen, wie auch die negativen Befunde in 8 Fallen, und intracerebrale Tumoren, die in 2 Fallen demonstriert wurden, konnten durch weitere Studien bestatigt werden. In Fallen von Gehirnlasionen, die durch GeféiBprozesse bedingt waren, hatte Angiographie keinen diagnostischen Wert. In 1/3 der Falle kam es zu voriibergehenden Komplikationen (Haematoma des Halses, Halbseitenlahmung, Kréimpfe, Urticaria). Bei 5 Patienten (4%) waren die Komplikationen schwer und dauernd. Diese Falle und ihre Besonderheiten werden besprochen. Die Autoren gelangen zu der SchluBfolgerung, daB die begrenzten Risiken der cerebralen Angiographie von der Anwendung dieses wertvollen Verfahrens in F ﬁllen von GefaBanomalien, supratentoriellen Tumoren und traumatischen Lasionen nicht abhalten sollen. Résumé Les auteurs passent en revue une série de 117 angiographies carotidiennes percutanées, dans le but d’évaluer les indications et les risques qu’elles comportent. La série d’aﬁ'ections intracraniennes étudiée comprend des tumeurs supratentoriales, des anomalies vasculaires, des hématomes traumatiques et des affections vasculaires du cerveau. Cinquante-cinq patients présentant une symptomatologie de tumeur intracranienne furent soumis a l’angiographie et un diagnostic positif put étre fait dans trente cas. Ces diagnostics se conﬁrmérent dans 83% des cas. Chez deux patients seulement, les radiographies furent mal interprétées. Parmi les angiographies négatives, 1e diagnostic clinique fut conﬁrmé dans 50% des cas; dans deux cas seulement les angiogrammes ne montrérent pas de lésion qui, plus tard, put étre mise en évidence par injections d’air. Parmi 21 patients suspects d’anomalie vasculaire �194 Max Fink and Joseph M. Stein intracram'enne, 9 purent étre révélés par l’angiographie. Dans deux cas, les angiogrammes révélérent une anomalie que les ventriculogrammes n’avaient pas rendu manifeste. Dans un groupe de 17 patients suspects d’hématome traumatique intracranien, un diagnostic positif fut conﬁrmé dans 7 cas. Ces diagnostics, de meme que les résultats négatifs de 8 autres cas, et les tumeurs intracérébrales démontrées dans 2 cas, furent tous c0nﬁrmés par des études ultérieures. Dans les cas de lésions cérébrales d’origine vasculaire, l’angiographie est restée sans valeur diagnostique. Des compli— cations passagéres de l’angiographie furent observées dans un tiers des cas et consistérent en hématomes de la région du cou, hémipareses, crampes, et urticaire. Chez 5 malades (4%), des complications durables et plus graves apparurent. Ces cas sont étudiés en détail et les facteurs on cause discutés. Les auteurs concluent que les risques limités de l’angiographie cérébrale ne sauraient faire renoncer a une méthode aussi utile pour le diagnostic des malformations vasculaires intracraniennes, des tumeurs supratentoriales et des lésions traumatiques. REFERENCE S 1. a) Lindgren, E.: Br. J. Radiol. 20, 326, 1947. — b) Green, J. B., and Arana, R.: Am. J. Roent. and Rad. Ther. 59, 617, 1948. — c) Wickbom, 1.: Acta Radio]. Suppl. 72, 1, 1948. — 2. a) Moniz, E.: “L’Angiographie Cérébrale”, Masson & Cie, Paris, 1934. — b) Lima A.: “Cerebral Angiography”. Oxford Univ. Press, London, 1950. 3. a) Olsson, 0.: Acta Radiol. 35, 65, 1951. b) Broman, T., Forssman, B., and Olsson, 0.: Acta Radiol. 34, 135, 1950. — c) Torkildsen, A.: Acta Psych. and Neur. Suppl. 55, 1, 1949. — 4. a) Lowman, R. M., and Duﬁ, S. D.: Amer. J. Roent. and Rad. Ther. 53, 341, 1945. — h) Poppen, J. L.: Radio]. 53, 347, 1949. — c) Wickbom, I.: Acta Radiol. 34, 387, 1950. — d) Lo'fstedt, S.: Acta Radiol. 34, 339, 1950. e) Wechsler, I. 5., Gross, S. W., and Cohen, I.: J. Neur. Neurosurg. and Psych. 14, 25, 1951. — f) Raney, R., Raney, A. A., and Sanchez-Perez, J. M.: J. Neurosurg. 6, 222, 1949. — 5. a) Culbreth, G. E, Walker, A. E., and Curry, R. W.: J. Neurosurg. 7, 127, 1950. — b) Curtis, J. B.: Brit. J. Surg. 38, 295, 1951. — 0) List, C. F.: Radio]. 55, 327, 1950. ~ d) Bull, J. W. D.: Postgrad. Med. Jour. 26, 157, 1950. — e) Fabritius, H. F., Frovig, A. G., and Kristiansen, K.: Arch. Neurol. and Psychiat. 61, 352, 1949. — 6. a) Wickbom, I.: Acta Radiol. 32, 249, 1949. — b) Kristiansen, K.: Surgery 24, 755, 1948. — c) Webster, J. E., Dawson, R., and Gurdjian, E. S.: J. Neurosurg. 8, 368, 1951. ~ d) Raney, R. B., and Haney, A. A.: Calif. Med. 73, 342, 1950. — 7. a) Govons, S. R., and Grant, F. C.: Arch. Neurol. and Psychiat. 55, 600, 1946. — b) Wechsler, I. S., and Gross, S. W.: J. A. M. A. 136, 517, 1948. — c) Lusignan, F. W., and Gross, G. 0.: Calif. Med. 73, 240, 1950. — d) Alorris, A. A., and Fulcher 0. H.: Surg. Clin. North Amer. 30, 1783, 1950. — 8. Grant, F. C.: Arch. Neurol. and Psychiat. 27, 1310, 1932. — 9. Berdal, P., and Emblem, L.: Acta Psych. and Neurol. 26, 1, 1951. — 10. a) Chusid, J. G., Robinson, F., and MargulesLavergne, M. P.: J. Neurosurg. 6, 466, 1949. b) Dunsmore, B., Scoville, W. B., —— -— —— �A Clinical Evaluation of Carotid Angiography 195 and Whitcomb, B.: J. Neurosurg. 8, 110, 1951. — 11. Olsson, 0.: J. Neural. Neurosurg. and Psychiat. 12, 312, 1949. — 12. Broman, T., and Olsson, 0.: Acta Radiol. 30, 326, 1948. — 13. Cross, S. W.: Arch. Neurol. and Psychiat. 46, 704, 1941. — 14. Sugar, 0., Holden, L. B., and Powell, C. B.: Amer. J. Roent. and Rad. Ther. 61, 166, 1949. �[ha / A M777, APP/f5; (#4)/7.rz. omen tummu W mm “KW W II: link, 3.». ma asap}: :1. Stein, IL». .7"*'*‘ , 9W .m § "v.1 "t; , ‘ waiver-1w canon of Indiana and the lam-01931.11 8min if the aura mun-u. hollow Rental, lav mark 633:. - .V T?!“ 1* ' = ' �line. antacid aaczozruphw tn mum of 1:1th an: bocgnn a ruuttun proaoﬁuro'xn cautions. In ovulation at 18.. no in nun-um. lath 15h. inﬂation and mm at cm proa«dun mt be amid-M in humans it for «lacunae aux-pom. It «and valuable, thereto”, to an.” tn «non-m am on tho Wei-clan um.“ or u acuml human . Min; m put to math, :17 panama“: Mount animu- nn can» put“ him-n or the minim hm amt. m mama were «at directly by tho “than . 5 variety of “urological amnion: including 11min Mon, moan: alt-mun, ”Maul hunts-nu, vascular dunno: Ion “law by tho dam“ and arm. “twang um: u with» «Midﬁe- ror WWW. In «ch mu, 9020qu met“ mien-u was performed «cording to the W1 «Manama (1) .' mum.- 10011 infiltration by normal” A 01f 3mm manhunt. by mutant}, or «mm m and. Gem-Grin» mu. m inﬁrm into the mend artery at tho 101010: 1'.» thyroid M11130. In no“ mum» the «non «3th WM" 0.. carotid artery 13th “an. .‘ m mm; in a In butane“ tho into!!!) M 1:0 mm: u. ref 35! “can“ inﬂation. A solution were and in «on «1:91. mm). “18133110 auntie Miner m and. that amounts." luau). 11m tad a um. mun. m: 130th yuurior (5-21 view. m In «on me the Au! and lateral £11m mantel: «#010904. lad, 1: indium. the injection In mutant. 1: no It: noted on than mm, the other 11¢. than» manna. pathology the vacuum at Bilateral mum on panam- urn �2. «aid but in 36 gnaw». .. mm amtlm‘ mu nu prior mum. Wu at the», ”bum W mu“ am 1m.“ my. :0 of " up the muted moun- manna lad «mu but... an an mt “m “wanna” or the film's!" («0 m1: m: mod tn «mimic» t7 In“ (a). amt»),- md ﬁrm I Am: 1m.» 1-). (1b). ‘ ‘ ' m amount). mm «spotted,at ammo nun-u «WWMMthMy. than. nu «ma «haunt sum or as: .m». continuum m not attained in turn ”that: boom mm than m quM B: gaunt“ m or “all”: W M cm ”mm“. In on» the mom I»! 1&th described. than» of 55 pun-nu in were by 25 - two tumour m m» m an A; 3.3». a #8 na- a:s.“ W m «Ilium to 1011mm humane mam been“ mm m manna" amt-n. m ail-inﬂux mallard «1-11 mum-u, 10ft mm rum pa”. mm Wu 0:: the ”at and nun «11:18:. m An rim 3mm}. “on Ilium-n1 mm magma under new“ mamas mound donut. olmtim (”apnea-ant} or the mum Who. of tho right W). Mm. museum in this ﬂaunt/annulus”: the a. .-. w. uphill mm Indra” m not“ to be We posits." for “’61" until” . Annama- mm: m taunted ' 11pm“ with. nw inks later, the right and the mum: mum mum as meat“. �“ > luv In want-um“ m ﬁr NHI II , mkamm WWW (Minimum: mutant—imam m» H CW u (CHI-um m ‘ . .‘ WWW‘rude-buﬂm �3. it... (11:: Innuud tho par1ota1 vantols ta have n nomlll cen— figuration. 6.3. II: 0.0., a yin: 91¢.la10 an: Idlitted buotule at roeunt onset at grina.unl aniline. .nﬂ lortantdcd untknoia, lxnuhntion rO'Dnlid a I114 10th bullpIrCItl, taut unwind in the 6% lénbr caﬁrunity. lhnru in: a punitive llbiulki response and incr¢:sod rutlaxtn.Moorutvuop1n31 fluid OIRQrUID III nounu1. A right curatld nn¢1o¢run undar local unauthonia III pur~ rarlnd and dIInnIttltod 390d 21111n¢ at tin Interior and l1ddlo oorobrn1 uttering. that. Ill straightening and dcprognian at tho pertain“). mar: am- the an... on up mm; um; and manned yum-mt: “mum. at cm manor mm: at»; on the 1.1- an. changes wort intorprutod Ian- 41-piuozn; blood vetucln. ll avtdlnoo at a pnruaagsitnl tumor ‘ pnnunninaophnlocrul,ula done and thin did not dclnnntruec thy IIII. It. patiant anarovud withaut troutncnt and lit dinohnrsod. In It: rtlanattod a to! lick! 1:10: with avid-not or an aunt. talin Ital syndronn. In '10! a: tin ¢uuruo a! uni 111ncll and.nultxplxoity of 1051.33, at in: bolicvod that the pntiaut'n uyggtanl A 1 ' taro duo to doccatrntiio ahnaccs, and net a unoplaun. lo turthgr Itudiou var. andnrtaknn. In this group or lunpcatod brain tumors 22 ausiogruln 414 not than any pathnlo;7. ilovcn at that. 10:. canrialnd by I1! studio: or tntapsy. In tun pationts, houovcr, untilrtotery angiogra-s failed to dalunltrutc lesions lttcr other Itudicl. mum to m danmmstrntod by an. m; n... .1 57:»:- em m m hospitdl koala-c of lift Inilplroutu, bladaor and and mud no.1 gum: or 1; inks aux-«zen. 6:: bcuul incontinence, man. than �#. never. poroonnlity ohoncoo, and o opootlo loft honiporoo1o with pathological roam: . embrupinll nun snare-o was nor»). . were right oorottd onciogron.undor pontothnl onoothnoin on: dono. outs of lotorll £11.. and on. to? via! Into taken. in: films A two thouod no ovidonoo or lorehrol tumor. can rock Into: a vantrtoulogrln dolonotrotod a large right con“ trontooto-porol IISI. Ibo protons. of a malignant slioln ill tin-0d by ournory. : Goo. IV; 3.3.é°:bzzkzoor old man developed loft stood toizuroo Iphlliu during/$rottlont for turunonlooil. on anurolucicll ennuinltion chore woo ovidonoo at n lotion in tho risho honiophoro. en Ikull x—ro: tho piuill outdo! In: shirtod to tho 102%. An ortorioaru on on right nu scum). mom-1a m and done ond no pathology dononotratod. ma A pnounoonoophnlosrln, houovor, revollod a dofornity of the right frontal horn. in: patient uzpirod on: lonth otter oust-graph: and ot pout. norm, mum} emu-u 0”qu mm anon-mm autumn. 9th.: erroneous onaiocrlphio d1oanoIOI our. and. in patient. who provod #0 have vooonlor throubosoo. In tlo potionto with Iisnl the oncxosru-o rovoolod on oraoaulnr are: in tho poricto-tonporol vision with dioplooonont o: Iiaolo oorohrll voooolo. Surgical exploration rovoolod odouotono necrotic brain tilooo, without ovidonoo of tolor. loch oooe oono to antopoy and in both or I brain only». man:- or . branch or. on. man «mm mm m rm. o:m angiogruno onulo not be dittoronttotod from thou. noon in on... tnnoro 1n the Inn: raglan. Vaoogggg.tnoup11oog ﬂuonty~ono patient: Iuopootod or intro» ' ornniol vaooulor Inouolioo or Quintin-o not. oubjootod to lnslo~ stools. 1h» Insaosrunl wort billtdrtl in only throo or thooo. and ��7. mt N contact“. um“. m nu In this aorta of 117 WWMB 36 ”tum- “from a to“: at is «unusual. and peanut «mutation. In an mm can with the «mutation and at in Of the a»: mo «Quantum. 22 m «W mm m an mum. man: mm. mm MmmuMuHthmm-uw. ammo. in am. mutumnmwummmmm' manta: mun It as mm to tntubtn m yum: mmmmmmmmmumpmmm; mun mom mm: man a «um mummuwmu. mnmmnmmomm a nun“. :3 Wk mm. m within . an ou- pm mm #8 W. talcum-Wont... cummmuurmmwowhy. all no.“ to rcpt-aunt an mung mpm h m atom-Mt. Inmautmh umummmmmmmrua Hummutumnmauammmm W.a: m mm causation. loath um um Mr. in in ”man (mu 7. n). In tum ash-r W or 1“ mm. Inamcuul‘uumum otmmvmupmuat th:mn mm mm mm m s difficult W31“ (mo m). W: m spa-nu (em um m mmmuu-n a: Mum mm“ («m I!) m an. «W. mum: sum emanation we «may “um 80 an A m mm. panamamumnmmmmmmmmmuu a Wow. than. 11mm Mm m twink“ I mm mm. tau ”Omnimtm ma. all... 63. elm was... an muons am and Mt. A completed a 13W and as most“ to «3.1qu war» a: may mm mam was ��10. at 1a.; or np1nud¢c on. mth. aunne1ausntgt u1thout convulu1vo unvunnne: for «nan-11:11:,» and a pou1t1vt lub1nlk1 on than mm mm tbs 10:1.ths no I sensory «Itasca am», Winn lua1tcut weaknass a: ‘ 1 31331 percutancona In31u3zun was inns u1th 10011 tainthna1n nn1n3 {our 1njoot1ons of diodralt. >xllad1a$oly Ittcr tho last 1nJ¢¢t1an thy pat1ont lapsed 1319 a 102911 3:11., M1: cyuruovanantt 3101.0 d1llo¢18ttd, and tan loft layer and In!!! tatul1t1o§ I09. N mum nonpanﬂ anon. am the tmu Mum mm m Vtrhully to «allnnd. but tum han1pl¢31t booinpit10at 00114 tplnt1c. It porn1ltad ant11 tn. put1on1 its trunnruraod to ancillt anap1¥I1 can nanth 11102. tn31usrnll I110 tatcrprttod an annual. A pnaulalnoaphnlo~ 3run.rovualtd b1latcrnlxy 61.301 vuntr1c10u u1thout nh1tt er 1%. .d1lvort1an.1 walker (31) the at stator: that’s: Ions111v1ty tn the eonsrust Indtwn, amt a; m me many at 1111009103 (33), and mum tar «aupl1ant1onl In in. prusuat 19:10., till. {natori It. nut ant-taun1n3 1n tn. pat1enta uh. 107110301 «unpliont1aa- when tunic tr. 01.31301 10 tin hwptrtonn1un (38), havu bola a133Ot$ed as OIIIOI _ unoonpl1enta1’onacs. l1thsr eonsaapt1v11 at 1ntaadnrlal aiadrnst gonn1t1v1ty tent: turn cnrr1od out 13,0?!93 luhaoot. In out cute, in: cane: at «humus, means, an: myzuum mu- the m: am» an to ouncol tan I9I11II. 3111th mm 1B1: In 111 1mm: 1n51ud1n3 an. athgr turnouts, amuuum, m Im1t1uty to». m mun. Ill notably true 1n tbs {tar pat1outs who dtvu1opod “n11.331c~ rsaot1ons of urtiolr1t, oh111n,“ van1t1n3, tolleu1a3 tho In31osraphy. but who £11101 to rule: to tbs tent 4916. Shaw. 1: an apparent rolae1an 1n tho ant: bntanon «anp11out1ons 11km” �13.. (luntudias hunttuun If In. it. acct) and tin ms it 13:00t10an 1 2 3 mania: or 1n1¢otzunn t 5 6 Iﬂﬂ"th‘ﬂ‘6 lo. .1 patiouta 11th cu-pzioctiaun'l e 6 6 I 1; lo. at pt... without «uncanny 3 9 1m :38 ' it Ebﬁazﬁ ' o 16 '3 as *Ixnluata; 16 Inna-plsnusad «Isa: 13.1huu tutu: data.» uua ngt rocordnd. o: m t’utoru or nae-than and m' author I: carotid punstaraa at on. Ion-1:: (unilaturtl or bilaterll Iagiacrlph!) rtvttl as significant entrolltton botluon thtao riotorl. 3mm mm» t3. inolaunno at calvlaltxaau. Arm-1n max-«mun m in a eonmuuan in m. poxootxon or patzants tar Ingtosrlphy. ihn.hw)hrtoanzvoa (:11 with diastnlia prisaurio at zoa-n. It. or'nnvi. and urtialto ar0§turtu at more than lﬁaun. In.) It». subjueted to nasitgrOphy, and in nan. at Shut. the. that. lay tonplioaticna. .0: thn paticnta with Icvorc up titan singly. and -- ‘tsnnszont oclplzsaﬁiaan («chit than hGIRQﬂlﬂ ot‘tho unak) aunt and V hrpdrﬂlnlzan. unseat mortal: hart alphlatlid tan diagnottta rtlzuhalat: it alrutid lasincruah: 1n vascular nan-alto: (k), auapoetod brutu talnru (lb. 5), tram-I310 aurchmt1~utdbn (6). tan ooaluntvu vascular axsaaaon (7). our ebucrvataons coatirn.thn rocounnadatzana at tho ham 1:. um run m m.in. _ diagnnst- a: van¢u1nr nan-n17 could nut he ountlmuld Cincpt iv insulin} Impaiurt at luttpuy. Itnte sir trudiyi are nut vuiiuilo 1n dlnanntrntins vautnlur annualaos a!”IEIIrIIIITMInﬂtﬂcrlrhr“tﬁmiﬁlﬁpiiﬂtiuri"ttwin%00w%nwiiitblllhins Iran? to ausiouruphw. �13. sign ailsnnsts. Xn-haﬁ at th@“p&t10nﬁs in this surint-An shun.nnth , n luntan was unspoctea, tho yam-p1: was natzutaggarilr“dauauntmatad um «am: or miagrap‘hy; man ‘mnu‘blishad w am» um“ lbnte£tta0lnbsp£bai, five anenrwnnn wore dn-waatritoa-an la anapoota. ﬁtnilar ”caulk: are rooardea by tthar ﬁlth!!! {¥), can anagrams mmemuona have. hem nae ta inn-cue than Wis. Routine mtehml injectim, scanned with bilateral 6:th panama. will «laminate maladies 1n the posterior portion at the 611-010 at ‘ﬂillin (1!). Oblique A.P views tt #5 403:... have been ruoanuoadnd to damonltratc until aneurysms er tn. aaratid (#d). with thtne noditicatiana 1n~the prooed&re, 1t 13 to—bq§gxpeoted that the incidence at positive 1d¢ntﬂiut1m at will the rule of angiogrnphy 1n the management or apontansaua am” mm. Iuharaahnoid hannrrhnes 13 not alear. Recent review: emphlstxo in. 1n»9rt&a¢e of alnnnltrtting tha Xenian nhmrs turaiaal intervaattun 1! indiettnd (ﬁt. a.) !hc affect of Iaszonxlphw 03:13: twat. it. 53:10 a: blending his act beta a1nr::1¢d. lung nuthnra tutu roan-acalid :a;1¢lxnphy only :ttor tho blending has 09:306. 0th.». such an (m. mm «:1: m u mama-v man m nun mm. m. mun um... um um mu m tn in 5::o0t in mum: and adhorul at 4 or the cases thin 3095's, and no ntutqnnnt of tho Inciozraphw an binoding can be undo. Aagiogrnyh: in tho diagnoctio panoodnro o: «halt. visa a Quaratoatawiil human tumor :1 auspoetod. it 1: rcounnandnd tar Ionian: lecaﬁol in :3. Iatortcr tlu~thsrds a: tht_¢¢rolvun. ana$p1tt1 1th.. posterior toast and nuns unabrszu innnru a». uni conntttnntly Mutable by this Hath pip111@dama, team”. 11mm“! in lawn” WW ant unltki ztntc than venucdnro, lit ntuditc. anon ��1‘. In snot: or cnrcbgll vuucniqr;acutdant,Inciﬂlllvi¥~tnrﬂﬁrl,1003 helpful. .rlilurv 0:,a rental to £111 any Do an: t. u.vurtety t: mamas 310m»:ntm1umut1m. .mmm min. in! ”mm at m sum. mm mum mm boon ”but!“ (75). 1;- aot ,imwmwludzu Mimi!» mum man. It proud” \- mam. mu 1i: arm-gamut” o. twain tron m tntrusarnhmtl 010%, or f!!! a tunes, in OIIOI Ihnre tho I1tsnonll-as mucus W. unelcwr. ' ﬂhile the indications tar angiography are many, that cannot be evaluated uithuut ; aincuauian at thy risk: involved. ‘iha emm911a1~ ,tiuau or the praceanre are a: turccthpoat.(n) trunnient latul phcnunanlg (b) trannient cerebral vascular phenlnnnlg (o) pcmlanant 2mm «£1411». , xn the vburaias Dﬂlnl 1n the :1“:ng at trmniont mama m m It‘d during 1nJooeton, hauttuul in.tho noak, and ullorzie venetiann.. numatann.1n the acek in a potentially dangcraus samplicntien (see aur.Caso VII) but in a ragent review no Inqucllas varc,aha§rve¢=(9). »Allor¢10 notation: «we larreqaant and usually llld. .1: in: nat¢¢ in thin action that ﬁns manila. intvaautlanouu or csngunntivua talking tar sensitivity It: not fauna untitraotorw $n prudiottus ﬁnale-clnpliotticnl. lblnninat,hun1paanszs. aphlltl. :eiunros nna citritod blaod pruuunre haw: hath reported fallouina unstogrtphv (16). In that series than. qunmlieationn n!!! OttarVQdfin nine canal »~ an incidenae of 35. {A similar tantdanao uni-nhucrvud In tho lbntcrluao Ibnpaell 30:103. lint.th030 Philll'n!.!rﬁ pribttly in: to tunporary vaaaulnr innutriuionﬂr (I’lﬂlﬂ) 1: I71lnnn¢d by the cliniunl pattorn at nourolngzctl findings and thair‘dnrutzun.. at asv¢u 3:310:90 with �it. M101” 15. m an tin-00 unwanted 01ml: than. 0m:- it no so” in an laws. In m panama, mu m of the amsun autograph: m "mm in a. 0M um 01: an um, 01MB «manna. In tho 0mm: mum, Woo-0m banana-«10, and tm mammmuumamummuamnmm left me the 0min 1mm that m m»: later, in» first 0m may m 0100. an mm m mind”that run an tho 0100 and mum M01090! 0 right M4- 13:00:10! 0: 01941-0“. tho MWMmth-Wﬂm. Vacant OW M 0mm mm.» 9103“. of that mun-101- hue been observed. 02:0: m 13300151”: in: do» within 15 010010 plant 0 1000: am manna 007010904 0:? “can”. third Quintin 0: m "I! 0140 In an. A mm 0: tin 09m“ 3: m «rent. an. m mumnmnwsmnmgumma. within Wu. omnuum m0 not unwind: 61mm m. 19 in ”#103150 01th W103. 6menoun-1mm.» a: 0 ”um '0 condition or men nun-1a; wemyhymummmmammumm. mud) , them-.1319“: ormpmuamxm. mam Mm :um «mare; “may to «unanimity. um many. and mu.» (1») mart «no 1080110100 mm.and80011110 0: “data-imam u: clown (11) than 1n mu mm. anus, 1." ”that“ ”mum” in a «£100 a! 36° won-000. no" mo in «hung: in an:- pmmt 005-100. an: m patient and 0 «m. nunvation 0f than at 0. pvt-mung Mum. 111 b01020 W10. 80071110 and tin pmodm‘e. in contrast 00 this In! 0! than 90810330, 111:. mum at 910003. 1:090 0010:“: m the 10:30 has.“ of M1: (53); , �(5e), Won (14), m um he), muten w deaths ﬂare related ta precadure.‘ (1b) thawein no 16. and mm It 13 tum passablc adrlannd that with vidnupread use a: angzoeraphr, Iubﬁeatu titl.naro cerebrul lesions tru selccted far these stud1eu and tha rink: ﬁharlhv 1n¢rcanod. A what 9: mm: by 01:36:: am manta: (BB. 11, 12) alphantxs tho-launntxon at tho taxis atteatn o: 31:30 limit a: diodmalt given ovar a abort 99:10! a: ﬁans. '1hor tailgatic in. nature at the toxicity Is an inoréégea permanbility at tho blood 1.33:1! and u chanxe 1n hennaynlaieh. 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In,udﬂ1t1¢u to catnblzlhinz thn pzoqanao at a kunnr. :rtorauarapny 1! unparacr ta 0th.: asnannstto tookaios 1n yialazna calling. I: to it. typo ot’lnul lad 1t. local. In Cl!!! with In �17. a not and. Wkly “at”: by tn mm ohacuro 13 mined-II». It alt a Inttlthstaww'litind'13.!UIlaatulﬂmaa or ﬂu. and mm. mum of tho nah-unlu- min, or mimic: fun w ”0199.15”. I»... 1. a in «us of tantrum mam, m Mm» «turns»: arm "ﬂunk: mm proucdnri. m: mm mm. a intricarutrll hilatlll tiastlt-Ilah MW m emu mum «now am» mu. at taunt. 10.113» tram 1: 1. eon-punts” mg. “I? tho mt pm, Wink. and would not in no“ mu. he savanna.» m no. tn was ﬂu not "mm u human-1m math-nu, min or tutor: uncanny d: tunings. a sum: of «mu. r010, and "My 1. mum. pm a mu W mm m W «mud Woman part-mt Mm m rm an: m mm "an“ mm: mm”no: a: A 117 hum. mam o: ta risk: of Ingiography. no author. «mum: that the 1mm taliﬁttionl and mt: ot at the mum” do «mu m autumn: an the meant or mean: alumna”, mum mmtarial brain Wm ms! was not 13th 1.1;- 10am. ' u ,____ __ _#».47.L_...;M._.z _,_..._.,___L__, .__u “A, . �RUIIARY eeriee a: 117 pereuteneoue oerotid ensiosreee were revieeed to eveiuete the indidetione for end rieke involved in engiosrephy. Petieute with e veriety or intredreniei conditione were etudied including eupretentoriel tenure, veeeuier endeoliee. A treaeetio heeetaee end eerebroveeduler dieeeee. titty-rive petiente with evidence at intreoreniel tenure were eueJeeted to engiogrephy, end e poeitive diesnoeie eee eede in thirty. fheee diesnoeee were auntie-ed in 83$ or the eeeee. ’ In duly tee eabjedte were the tiiee eieinterpreted. or the aegetive tilee. the diegnoeee were dentineed in 50!; in only tee men an the ensiosreee teii to aim e leeion um- deeenetrehie b7 eir etudiee. or 21 petiente eith euepeeted intreereniel veeduler endedliee, nine were outlined by ensiosrephy. In tee of theee, the engiosreee reveeled en end-e11 not eeniteet on eir etudiee. In e group at eeveuteen petiente euepeeted o: treneetie intreoreniei heeeteee, e poeitive diesnoeie wee eede in seven eeeee. Theee diesnoeee ee well ee the necetive findinse in eight ceeee, end intreeerehrei theere deeonetreted in ten ceeee, eere e11 contimeed by euheeeuent etudiee. In oeeee at cerebroveeduier leeione ensiogrephy wee not at diecnoetio veiue. Treneient ddeplieetione of engiogrephy were eeen in one—third of the petieute, end edueieted or heeetaee or the neck, heeipereeie. eeieuree, end erticerie. In five petiente (I!) eoepiicetiene eere eevere end peeeenent. Sheee oeeee ere deeerihed end the restore diecueeed. Ehe ‘Vl eethere deecrihe the ueetulneee or engiosrephy in �“Hermann“ been»: intact-mill condition: . they canal“. that tho united risk: of cerebral miomphy 69 not data“ from it: ”0mm”. in the summon: a: mammal vacant alternations. unopened «panama-1.1 man and human hum. the variety or ��mm rams. LG. and mummy, L: mum...» my... warms,anion-mph: ma cox-chm than”. mu.lgu_gnl.mz¢hiat. omml Q}, 359“"368: ‘9’11: 39”intmmiu (1) new. I. : mummy in polt~trmtio 2w¢2583 “tam; 19‘9. 910‘ ES. 4““ WWI. m at in the (1») lumbar, 19W. intmmid 3.: 9mm}. maximum? 755468, W001: (o) 5. 6. WI! New ' . _ mm. 3!; 3.8.: m dammit er mum. B. m 3.!" mm, by intact-unis! tutu-mic humane axiom”. J. Imam- . (6) Q5, 363~376o N17. 1951- LB. and um. ‘.l.8 Eh. contribution at «roam 1950. mm. angina-mm in “tannin. «mam. : m $2-3m, catcher, of (3) mm. 3.3. and mm. 1.6.: Wriemphic visualisation 600-618, 251. lesions. mh.!m1.ggzehiu. ammuni19‘6“3.; (b) mm. 1.3. and mm, mm carom}. Marion-why in191.8. nub-mountain Mum. g.i.l.i.. 1.36: 517-581, M... (a) mzm. 1.1:. am mm. 6.6.: mum-min autograph: in the tmmnt at «1'0an maul” accident: . can: .M. , m (4) 7. ,_ V (a) LA. and mm, 9.3.: carotid minmtw; It: ".1130 sum. in pun-.11 t 121th conditim. M£11mgorth “or. , 8. m, the mmmolwruzohint. 31; : thrionlmaphy m mmmmw. mu- um. be. 1.31m: . localization had tram: or 111%”:er 1310-13“. June, 1932. m, P. and Pmuunum «mud miouaphy: m, "farm” ine“ iota blob. laurel” I»: complications in th- and pun-ms. ‘10 . 11. b with special 11: been to the larynx. 16;; 1-6, Juan-r1. 1951. 1. sad mum-amen, 1.2.: umimt 3.6., trauma,with. cyan. union-why. Lima“. unbnl 32-191. in unpainted 19‘9466 “ll, number. g; of (b) mm, 3.. 36mm. VJ. and unseen, 3.: cmuaum 1951. 110418, angina-why. g4, mum. , g; ham, India a: tar emtmt 0. cerebral unplug £01m» won, 312-316, lov.,19't9. a: dim» type. 1 .lmu Joni-elm. "paint. E; (u) a » to a aid 01,8861. 0.: 103.3ch of «mm: bland vouch 336~3#8, Indian or the “adult group. mm We}... 32; lava-tho, 1m. pines in aux-01min]. 13. @038, am. u 8mm}. ”tomography: It: 704-711., Oct... 12 . 1*. mm, contra-t ‘1'. ‘ «lanolin. Arch.lm¢1.ﬂgguat.. 53!. 6.. mm , run. and 3.3.: Vertebral 'W tokﬂﬂnt. ‘ rm. 166.5182, "bm’lg‘g. ‘ u‘doMc; £12. 19“. Wm. 83131 o � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A clinical evaluation of carotid angiography. Confin Neurol. 1952; 12(4): 181-95. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-5-007 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Stein, Joseph M. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellvue Hospital, New York City. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published http://exhibits.library.stonybrook.edu/mfp/files/original/0cb0657cbbdab38351d56e14b15f8cbf.pdf 7766c5312815a1dcb5171a3528e92d6e PDF Text Text Reprinted from The Journal of the American Medical Association April 12, 1958, Vol. 166 Copyright 1958, by American Medical Association COMPARATIVE STUDY OF CI] LORPROMAZINE AND INSULIN COMA IN THERAPY OF PSYCHOSIS Max Fink, M.D., Robert Shaw, M.D., George E. Gross, M.D. and Frederick S. Coleman, M.D., Glen Oaks, N. Y. With the advent of “newer” drugs for the treatment of psychiatric illnesses and the concomitant awareness that the effectiveness of insulin coma therapy was limited, a control drug therapy—insulin coma study was undertaken. Preliminary trials with various medicaments available in 1954 demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports had noted its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. The study was designed to assess the therapeutic efﬁcacy and indications for intensive chlorproma: zine therapy, compared to classic insulin coma therapy, an in open-ward, voluntarily hospitalized psychiatric population. Subjects and Method All patients referred for insulin coma therapy during the period Sept. 1, 1955, to Dec. 31, 1956, were observed. Supervising psychiatrists made the recommendation for insulin coma therapy independent of the research group. Their criteria for referral were those implicitly held by the hospital administration and were not altered for this study, Randomly selected patients were placed on chlorpromazine therapy instead of insulin coma therapy. This selection was made by the psychiatrist in charge of the insulin therapy unit without prior notice of the referring therapist or the supervising psychiatrist. Sixty patients were referred for insulin coma therapy during the study period, and half of these received chlorpromazine. Insulin Coma.—The standard technique of Sakel for insulin coma was used. All patients received 50 comas, each of a duration of at least one hour, at the physiological level of Babinski reﬂex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous administration of glucose. Treatments were given ﬁve times weekly for a period of three to four months. Chlorpromazine.—To establish an equivalent group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased until well-deﬁned physiological effects were observed. These included rigidity, drooling and ﬁxed facies, seizures, or severe dermatitis. In most instances this was achieved below 1,400 mg. daily, although dosages were increased to 3,600 mg. in one patient. In each instance, the drug dosage was slowly reduced until From the Department of Experimental Psychiatry, Hillside Hospital. The effectiveness of chlorpromazine was compared with that of insulin coma in 60 patients referred for insulin coma therapy. One- half the group, selected on a random basis, received chlorpromazine by mouth for at least three months in doses adjusted so as to fall just short of toxicity in the individual patient,- this dosage varied from 300 mg. to 2,000 mg. daily, with a median of 800 mg. The insulin coma was induced by a standard technique 50 times in each patient. Although many minor differences were noted in comparing the effects of these two methods of treatment, the ultimate results at the time of discharge were essentially the same for the two groups of patients. Neither treatment affected the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management. a maintenance dose, just under that producing toxicity, was obtained. This varied from 300 mg. to 2,000 mg. daily with a median of 800 mg. To determine the comparability of the subjects in the random sampling procedures used in this study, the groups were compared as to their psychi— atric diagnoses and ages. Table 1 shows a comparison of the groups as to diagnoses and demonstrates an equal distribution of subjects in each category. In the analysis of the age distribution, the median age for patients subjected to insulin coma was 24 years, with a range of 17 to 38; the median age for patients receiving chlorpromazine was 28, with a range of 19 to 42. Here, too, the distribution shows no signiﬁcant difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals. After completion of the treatment period, reports of the patients’ behavior were obtained from the therapist and supervising psychiatrist. The “improvement” rating was determined by the medical director at the patient’s discharge conference and was based on the fourfold scale of recovered, much improved, improved, and unimproved. Neither the authors nor the supervisor of the insulin therapy unit participated in these evaluations. �THERAPY OF PSYCHOSIS—FINK ET AL. Vol. 166, No. 15 Observations Clinical Observations—The following clinical effects were noted in patients who received chlorpromazine and in those subjected to insulin coma therapy. Chlorpromazine: Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and patients became more tractable, less negativistic, and less violent. The nurses’ and therapists’ records noted patients as “less easily excited and frightened,” “cooperating TABLE l.—P.s-ychiatric Psychoneuxosis ....................... Schizophrenia, paranoid ..... Schizophrenia, catatonic ............ Schizophrenia, mixed ................. Schizophrenia, hebephrenic .......... Manic-depressive psychosis ........... Diagnoses Insulin Coma Chlorpromazine 1 2 10 7 10 7 8 3 1 6 2 3 better in ward activities,” and “less restless and less panic-ridden.” One-third of the patients were more sociable and less seclusive and were noted to care for themselves in a more presentable fashion. In instances where severe motor symptoms supervened, however, the patients were less able to care for themselves; they became sloppy and failed to dress themselves. Such periods were usually short and could be signiﬁcantly modiﬁed either by a reduction in drug dosage or by anti-Parkinsonism drugs. Affective changes during chlorpromazine treatment were varied. Four patients became increasingly agitated, tense, and tremulous and either refused to continue on the drug regimen or were induced to do so only with difﬁculty. Such an affective “storm” appeared early in the treatment and persisted. In four other patients, depressive symptoms were relieved with an increase in affective lability and responsivity. Depressive ideation increased, associated with complaints of insomnia and anorexia in two patients. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of chlorpromazine therapy in 12 patients. Eight had a loss or a signiﬁcant diminution of their psychotic ideation. In ﬁve, hallucinatory and referential experiences were no longer reported even on inquiry, and, in three others, delusional ideas were less prominent. In one patient, phobias were relieved and the patient could once again participate in ward activities. In another, hypochondriasis was sufﬁciently modiﬁed to permit a more meaningful relationship between therapist and patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration and resulted in discontinuation of the drug regimen. 1847 Insulin Coma: The clinical observations in this group were similar to those reported by others.‘ Alteration in behavior was prominent in all patients once repeated comas were induced. Overactive, hostile behavior rapidly diminished and was replaced by alternating periods of somnolence, irritability, and withdrawal. In most patients, nausea, abdominal distress, belching, sweating, and lassi— tude were common sequelae each afternoon and assumed prominence in the recorded reports. These symptoms often interfered with the patients’ ability to care for themselves, and they became unkempt in their dress. Changes in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, dis— appearing in these on direct inquiry. Suicidal and outWardly directed destructive thoughts were modiﬁed in three patients, only to recur in each at the end of the treatment period. Mood changes were small. Increasing agitation, tension, and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms was noted early in the treatment and was sustained. In the usual practice of the treatment unit, con— current electroconvulsive therapy was instituted when behavioral control by insulin coma alone was limited. In six patients, such combined treatment was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well deﬁned alteration in behavior, but this was unsustained. None of these patients was rated as improved on discharge. Discharge Evaluation—All patients were dis— charged from the hospital within four months of the end of treatment. Table 2 lists the hospital discharge evaluations for patients treated with chlorpromazine and insulin coma. Ratings in Patients Treated with Chlorpromazine and Insulin Coma TABLE 2.-—Discharge Treatment ........................ ........................ Recovered, no. Much improved, no. .................. Improved, no. Iinimproved, no. ..................... Chlorpromazine Insulin Comaﬁ 2 0 4 17 5 15 7 10 Included in the group of patients treated with chlorpromazine who were rated as unimproved were four who received inadequate course of therapy (less than one month) because of complications of the therapy. Of the 10 patients treated with insulin coma who were rated as unimproved, four had inadequate courses of therapy, two because of complications (seizures and prolonged coma), one be— cause she became more disturbed, and one because of administrative transfer to another facility. �‘ THERAPY OF PSYCHOSIS—FINK ET AL. 1848 It apparent that there is no difference in the clinical evaluation at the time of discharge between the group receiving insulin coma and that receiving chlorpromazine. To determine whether this sample was biased because of its small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported.2 In table 3, the discharge ratings for both is TABLE 3.-—Discharge Ratings Compared for 1950 and 1956 ............................. ....................... Improved, % ......... .................... Unimproved, % ........................... Recovered, % Much improved, % _ Present Group (30 Subjects) 1950 Group (48 Subjects) 0 14 17 19 42 50 33 ‘25 years are compared. The percentage improvement rates for each category are not signiﬁcantly different. Toxicity and Complications—Patients receiving chlorpromazine and those subjected to insulin coma therapy were compared as to toxic reactions and complications, with the following effects noted. Chlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to a level producing symptoms of toxicity. In this context, all patients developed signiﬁcant drug effects. Rigidity of extremities, accompanied by a decrease in facial expression, drooling, and festination, was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Most patients became drowsy, retarded, and less active in ward activities. In four patients increased tension, agitation, restlessness, and excitement supervened, leading to a discontinuation of the drug regimen in two. Seizures occurred spontaneously in three patients. Pretreatment electroencephalograms had manifested no dysrhythmia, and no history of seizures had been elicited. In each, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema to mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine hydrochloride therapy was substituted for chlorpromazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from that noted in patients receiving chlorpromazine. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than 0.5% of subjects treated. In the preliminary studies at Hillside Hospital, 3 patients of a group of 20 developed transient clinical jaundice. J.A.M.A., April 12, 1958 Electroencephalograms were obtained in 20 of the patients who received chlorpromazine. With increasing doses, the modulation of the record became more irregular in each. A moderate amount of low-voltage 4-7 cps delta and theta activity was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. Insulin Coma: The complications of insulin coma therapy in this series were not unusual. Insulin resistance was noted only once and was eventually overcome by the method of alternating dosages. Prolonged reactions occurred in three patients. In each, neurological examination and electroencepha— lography demonstrated signs of persistent central nervous system dysfunction for at least 10 days. Aphasia, hemiparesis, and paresthesias were frequent in ﬁve patients and transient in eight others. Seizures occurred in ﬁve patients and were recurrent in three. Frequent secondary reactions, nausea, vomiting, abdominal distress, sweating, pallor, lassitude, and generalized weakness occurred in all patients with varying frequencies. The complications of both forms of treatment are listed in table 4. Certain effects, such as dermatitis and hypotension, secondary reactions, and prolonged coma are individual for each therapy, and seizures, agitation, and refusal of therapy were noted with both regimens. The frequencies of these are not signiﬁcantly different. Effects on Psychotherapeutic Relationship—Pa— tients were referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. TABLE 4.-C0mplicati0ns of Treatment with Chlorpromazine and Insulin Coma Treatment _______./\—————5 Agitation and panic .................. Dermatitis, severe ..................... ............................... Refusal of further therapy .......... Hypotension .......................... Secondary reaction, frequent ........ Prolonged coma (>6 hr.) ............ Insulin resistance ..................... Seizures Chlorpronmzine Insulin Coma 4 3 3 3 2 5 2 2 6 3 . . . 1 Chlorpromazine: During the period of effective drug action, 15 of the patients treated with chlorpromazine were described by the therapist in response to an inquiry as “more accessible,” “speaking more freely,” and “more amenable to psychotherapy.” The behavioral changes could be classiﬁed in two groups: subjects in whom tension and preoccupation with somatic symptoms became much less, and those in whom hallucinatory or delusional preoccupations ended. Such changes in �I Vol. 166, No, 15 THERAPY OF PSYCHOSIS—FINK ET AL. in— described as an we1e frequuitly '.*‘-1;welationship stww‘arease in “contact In 13 subjects, psychotherapy either was still‘not feasible” or had become less feasible because of increasing uncontrolled tension, anxiety, or preoccupation with the side-effects of wthe drug regimen. Insulin Coma: Similar observations were made in the patients treated with insulin. Of the 30 patients, 7 were noted to be less tense and less anxious during therapeutic sessions. The theiapists noted that the patient “verbalized more freelv” and was more aware of his environment.” Four patients were speciﬁcally treated with a “modiﬁed anaclitic” approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional tactics. In the remaining patients (19), while supportive, educational, and environmental manipulating techniques were applied, the therapists were no more successful than prior to insulin therapy. In 11 patients, the physiological effects of the treatments (secondary reactions, sweating, nausea, vomiting, and weight gain) were reported as interfering with psychotherapeutic attempts. Comment Clinical Considerations—In these patients, nei— ther chlorpromazine in high therapeutic doses nor insulin coma speciﬁcally modiﬁed the psychotic had of 88% these Since a diagpatients process. nosis of schizophrenic illnesses, we concluded that neither treatment has a speciﬁcity in altering the schizophrenic process. When given in adequate dosage, however, both treatments are potent methods for the alteration of behavior. In the discharge evaluations, the treatments are similar. In only 20% of the patients were induced behavioral patterns persistent, with the rating “much improved” or “recovered.” For the others, the induced behavioral changes were transient or minimal. Since these therapies fail to induce a recovery from the psychotic process, consideration should be given to their ameliorative, palliative, and supportive aspects. Symptomatic relief was frequent but generally limited to the treatment period. Patients were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is little advantage in either therapy. Both methods were said to enhance relationship therapy, although the therapists’ evaluations favored chlorpromazine therapy. Excluding those who deveIOped increased agitation, patients were more comfortable, more alert, and physically better able to discuss their feelings and experiences while on chlorpromazine treatment. It is clear that“interpretive” psychotherapy is not enhanced, rather, 1849 supportive, educative, reorienting, and directive types of therapy are. When there is a modiﬁcation of agitated, hallucinatory, depressed, manic, or aggressive behavior, both the therapist and the patient are more comfortable and better able to discuss the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assume decisive signiﬁcance. To maintain such therapy after discharge and continue thereby the relationship established in the hospital setting may be an important element in sustaining the behavioral changes induced by hospitalization. Other Studies.—While many reports of the treatment of psychosis by chlorpromazine have appeared, we are aware of only one similar comparative study. Boardman, Lomas, and Markowe,3 after a review of the problem, reported a study of 100 patients randomly divided into two groups of 50 and treated with either insulin coma or chlorpromazine. The chlorpromazine dosage was lower than that used in the present series (average 300 mg), but the drug period (three months) was the same. Their observations are directly comparable to this study. They reported no difference either in discharge evaluations or in symptom assessments for either treatment group. The patients treated with chlorpromazine, however, remained in the hospital an average of 6.2 weeks less than the subjects treated with insulin. This was a signiﬁcant difference between the groups. They concluded, “There is inconclusive evidence that chlorpromazine has advantages over insulin in the treatment of schizophrenia [but] insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the ﬁrst treatment of choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been conﬁrmed by an adequate follow-up study.” Boardman and his co-workers emphasize the problem of evaluating the therapeutic efficacy of insulin coma. They note a number of reports that raise doubts as to the efficacy of insulin coma therapy in schizophrenia. Bourne,4 in an extensive review of the merits of insulin therapy in schizophrenia, concluded, “There is no proof of any speciﬁc therapeutic effect, and the long term prognosis is in no way influenced.” The recent observations of insulin treatment of 5 schizophrenia by Ackner, Harris, and Oldham are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbiturate coma in the same ward and under similar conditions. Evaluations of results were made by psychiatrists without knowl- �1850 THERAPY OF PSYCHOSIS—FINK ET AL. edge of which treatment the patients received. The authors noted a similar outcome, whether the loss of consciousness was induced by a barbitufate or by insulin, and concluded that insulin was not a speciﬁc therapeutic agent in the outcome. In the follow-up studies done in this hospital,2 the therapeutic results of insulin coma therapy were disappointing. Patients referred for insulin coma had the longest period of hospitalization (6.5 months, as against 6.04 with'psychotherapy and 4.95 with electroshock), the poorest discharge‘ rating (33% recovered and much improved as against 63% with psychotherapy and 67% with electro— shock), and, within four years, a 50% rehospitalization rate (compared to 33% with psychotherapy and 29% with electroshock). While these observa— tions reflect the idea that the more severely ill patients are referred for insulin coma, they also support the belief that insulin coma is not a specific treatment for the patients referred. From these reports we would conclude that, despite considerable study and the passage of many years, insulin coma therapy has not been shown to induce persistent behavioral changes more frequently than other nonspecific, less dangerous, and less expensive therapies. To the list of alternate therapies of limited value in the management of psychosis we may now add Chlorpromazine, not— ing, however, its advantage of lesser risk and ease of administration. Dosage of Chlorpromazine.—F0r the purpose of assuring an adequate level of Chlorpromazine dosage for evaluation, the amount of medicament given was increased in all subjects to t0xic levels. This level was too high for its behavioral effects, as evidenced by the reduction in all responsive cases to maintenance levels of 300 to 2,000 mg. It is our impression that Chlorpromazine affects the function of the central nervous system (as evidenced by changes in modulation and per cent time delta in the electroencephalogram and the systemic phenomena of rigidity and lassitude) and results in a nonspeciﬁc alteration in behavior.6A Such behavioral change is varied and is dependent on a variety of factors, of which the personality organization and the expectancy of the milieu are signiﬁcant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness, and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances where an affective “storm” supervenes, continuation of therapy at ].A.M.A., April 12, 1958 higher levels, with concomitant administration of trihexyphenidyl hydrochloride (Artane) and benztropine (Cogentin) methanesulfonate should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology and to the present concept of the mode of action of electroshock therapy.6 Summary In a.study of patients referred for insulin coma therapy in an open-ward, voluntary psychiatric hospital, patients received randomly either insulin coma therapy or intensive Chlorpromazine therapy. Chlorpromazine was found to be as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications, or effects on the psychotherapeutic relationship for either therapy. In comparison to insulin coma, Chlorpromazine is safer, easier to administer, and lends itself to long—term management. Patients receiving chlorpromazine therapy are more comfortable than those receiving insulin coma. No evidence has been educed that either therapy has altered the basic schizophrenic process, nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. 75—59 263rd St. (Dr. Fink). This study was supported by the Board of Directors" search Fund of the Society of the Hillside Hospital. Re— The chlorpromazine used in this study was supplied as Thorazine by Smith, Kline & French Laboratories, Philadelphia. The promazine hydrochloride used in this study was supplied as Sparine by Wyeth, lnc., Philadelphia. References and Hoch, P. H.: Shock Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry, ed. 2, New York, Grune and Stratton, lnc., 1952. 2. Rachlin, H. L., and others: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. 5:17-40 (Jan) 1956. 3. Boardman, R. H.; Lomas, J.; and Markowe, M.: Insulin and Chlorpromazine in Schizophrenia: Comparative Study in Previously Untreated Cases, Lancet 2:487—494 (Sept. 8) 1. Kalinowsky, L. B., 1956. 4. Bourne, H.: Insulin Myth, Lancet 2:964—968 (Nov. 7) 1953. 5. Ackner, B.; Harris, A.; and Oldham, A. J.: Insulin Treatment of Schizophrenia: Controlled Study, Lancet 2: 607-611 (March 23) 1957. 6. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A. M. A. Arch. Neurol. 81 Psychiat. 78:516— 525 (Nov.) 1957. 6A. Fink, M.: Uniﬁed Theory of Action of Physiodynamic Therapies, J. Hillside Hosp. 6:197-206 (Oct.) 1957. �Printed in U. S. A. �Cjéz,,4./rv./¢ COMPARATIVE STUDY OF CHIDRPROMAZINE AND INSULIN COIvIA IN THE THERAPY 0}”? PSYCHOSIS *- Max ColemanAM.D. Fink M.D., Robert Shaw M.D., George E. Gross M.D., and Frederick S. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. Supported by the Board of Directors' Research Fund of the Society of the Hillside Hospital. 7-22-57: IV �Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Peychosis for the treatment of psychiatric illnesses, and the concomitant awareness that the effectiveness of insulin With the advent of "newer" drugs limited, a control drug therapy-insulin coma study was undertaken. Preliminary trials with various medications available in l95h demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports coma therapy had noted was its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. study was designed to assess the therapeutic efficacy and indications for intensive chlorpromazine therapy compared to classical insulin coma therapy in an openaward, voluntary hospitalized psychiatric population. The Subjects and Method All patients referred for insulin coma therapy during the period September 1, 1955 to December 31, 1956 were observed. Supervising psychiatrists made the recommendation for insulin group. Their criteria for referral coma therapy independent of the research were those implicitly held by the beepital administration, and were not altered for this study. Randomly selected patients were placed on chlorpromazine therapy instead of insulin psychiatrist in charge of the insulin therapy unit, without prior notice of the referring therapist or the super- coma. This selection was made by the vising psychiatrist. Sixty patients were referred for insulin during the study period, and half received chlorpromazine. coma therapy �.2... a) Insulin Coma: The patients received standard technique of Sakel was used. All 50 comes, each of a duration of at least one hour at the physiologic level of Babinski reflex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous glucose. Treatments were given five times weekly, b) Chlorpromazine: was given team and To for a period of B-h months. establish an equivalent group, chlorpromaziner for at least three months. Dosages were determined by the research were rapidly increased until well defined physiologic effects were observed. These included rigidity, drooling and fixed facies, seizures or severe dermatitis. In most instances this was achieved below lhOO mgm daily patient. In each instance, slowly reduced until a maintenance dose, just under although dosages were increased to 3600 the drug dosage toxicity, was was obtained. a median of 800 mgm in This varied from 300 one mgm to 2000 mgm daily with mgm. To determine the comparability of the subjects resulting from the in this study, the groups were compared as to their psychiatric diagnoses and ages. Table I compares both groups as to diagnoses, and demonstrates an equal distribution of subjects in random sampling procedures used each category. ‘M% c: such-on .m & Chlorpromazine supplied as "Thorazine" through courtesy of Smith, Kline 3 French, Inc. �.3TABLE I PSYCHIATRIC DIAGNOSES Insulin Psychoneuresis Coma Chlorpromazine 1 2 10 10 Schizophrenia, Catatonic 7 7 Schizophrenia, Mixed 8 6 Schizophrenia, Hebephrenic 3 2 HaniooDepressive Psychosis l 3 Schizophrenia, Paranoid In the analysis of the age distribution, the patients was 21; for the insulin with a range of 17 to 38 ; while the chlorpromazine patients had a median age of 28 and a range of 19-122. shows no median age Here, too, the distribution significant. difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals . Following completion of the treatment period, reports of the patients' behavior were obtained from the therapist and supervising psychiatrist. Medical Director The "improvement" at the patient's Discharge four~fold scale of recovered, rating was determ‘ned by the Conference and was based on the much improved, improved and unimproved. None of the authors, nor the supervisor of the insulin therapy unit, participated in these evaluations. �Observatigns 1. Clinical Observations all subjects. Overactive, destructive behavior rapidly disappeared, patients in ghlgrpromazine: Chlorpromazine induced motor retardation a) became more tractable, less negativistic and less violent. and The therapists' records note patients as "less easily excited and frightened," "cooperates better in ward activities," and "less restless and less panic ridden." One-third of the patients were more sociable and less nurses' and seclusive, and were noted fashion. In instances patients were to dress. modified to care for themselves in a more presentable where severe motor symptoms supervened, however, the less able to care for themselves; Such periods were usually short, became sloppy and significantly and could be either by a reduction in drug dosage or by anti-Parkinson drugs. Affective changes during chlorpromazine were varied. became failed increasingly agitated, tense continue on and tremulous and patients either refused to the drug regimen or were induced only with difficulty. affective "storm" appeared early in the treatment other patients, depressive affective lability and symptoms were medication was persisted. In four relieved, with an increase in patients. The continued, however, with an eventual alleviation. In most mood changes were Ideation and Such an reaponsivity. Depressive ideation increased, assoc- iated with complaints of insomnia patients, Fbur was and anorexia, in two small. dramatically altered during the period of chlorpromazine therapy in twelve patients. Eight had a loss or a significant diminution of their psychotic ideation. In five, hallucinatory and referential experiences �.5. inquiry were no longer reported even on once in three others, delusional patient, phobias were relieved and the again participate in ward activities. In another, ideas were less prominent. In patient could and One hypochondriasis was sufficiently modified to permit a more meaningful relatedness of therapist became more prominent. and patient. In one patient, paranoid ideation This was associated with increasing anxiety and panic during drug administration, and resulted in discontinuation of the drug regimen. b) Insulin similar to those reported prominent in all patients clinical observations in this group'were others (1). Alteration in behavior was The Coma: by once repeated comes were induced. hostile behavior rapidly diminished, of somnolence, irritability and and was replaced by Overactive, alternating periods withdrawal. In most patients, nausea, distress, belching, sweating and lassitude were common sequellae each afternoon, and assumed prominence in the recorded reports. These abdominal symptoms often interfered with the patient's ability to care for themselves, and ﬂiey became unkempt in their dress. in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, disappearing in these on direct inquiry. Suicidal and outwardly directed destructive thoughts were modified in three patients, only to recur in each Changes at the end of the treatment Mood period. changes were small. Increasing agitation, tension and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms were noted early in �-6the treatment, and was sustained. In the usual practice of the treatment unit, concurrent electroconvulsive therapy was instituted when behavioral control by insulin limited. In six patients, such combined treatment was coma alone was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well defined alteration in behavior, but this sustained. None was un- of these patients was rated as improved on discharge. 2. Discharge Evaluation All patients were discharged from the hospital within four months of the end of treatment. Table for both the chlorpromazine and II lists the hospital discharge evaluations insulin coma TABLE treated patients. I}; DISCHARGE RATINGS Chlorpromazine Insulin 1. Recovered 2 O 2. much Improved h 5 3. Improved 17 15 h. Uhimproved 7 10 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate course of therapy (less than one month) because of complications of the therapy. four Of the ten unimproved insulin had inadequate courses of therapy (seizures, prolonged - coma patients, two because of complications coma), one because she became more fourth by administrative transfer to another facility. disturbed, and the �-7. It is apparent that there is no difference in the clinical evaluation at the time of discharge between the insulin coma treated groups. To determine whether this sample and the chlorpromazine its was biased because of small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported (2). In Table III, the discharge ratings for both years are compared. TABLE Present Group 1950 Group (30 subjects) (h8 subjects) 0 1h% 17% 19% Improved 50% h2% Ikrhmproved 33% 25% Recovered Much The III Improved percent improvement rates for each category are not significantly different. 3. Toxicitx and Complications a) ghlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to symptoms of toxicity. In this context, all patients developed significant drug effects. Rigidity of extremities, accom— in facial eXpression, drooling and festination was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Host patients became drowsy, retarded, and less active in ward panied by a decrease activities. In four patients increased tension, agitation, restlessness and excitement supervened, leading in two. to a discontinuation of the drug regimen �-8Seizures occurred spontaneously in three patients. Pre-treatment electroencephalograms had manifested no dysrhythmia and no history of elicited. In seizures did not develop at the seizures each, the drug medication was reduced, and had been lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema ato mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In dze third, promazine* therapy was substituted for chlorpromazine, with a was relief of the dermatitis. The indistinguishable in this patient behavioral effects of the promazine from that noted for the chlorpromazine group. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than %% of subjects treated **. Electroencephalograms were obtained in twenty of the chlorpromazine patients. With increasing doses, the modulation of the record irregular in each. activity A became more moderate amount of low voltage h-7 cps delta and theta was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow wave activity b) series were and the drug dosage; Insulin Coma: The complications of insulin not unusual. Insulin resistance eventually overcome by the method of coma therapy in this was noted only once, and was alternating dosages. Prolonged reactions * Supplied as "Sparine" through courtesy of Uyeth & Co. as In the preliminary studies at Hillside Hospital, three patients of a group of twenty developed transient clinical jaundice. �-9occurred in three patients. In each, neurologic examination and electroencephalography demonstrated signs of persistent central nervous system dysfunction for paresthesias at least ten days. Transient aphasia, hemiparesis, were frequent transient in eight others. were recurrent in three. Frequent in five patients, Seizures occurred in five patients, and and secondary reactions, nausea, vomiting, abdominal lassitude and and generalized weakness occurred distress, sweating, pallor, in all patients in varying frequencies. The complications of both forms of treatment are listed in Table IV. Certain effects, as dermatitis and hypotension, secondary reactions and prolonged coma are individual for each therapy, and seizures, agitation and refusal of therapy were noted in both regimens. The frequencies of these are not significantly different. TABLE IV COMPLICATIONS Chlorpromazine Insulin Agitation and Panic h 3 Dermatitis, severe 3 - Seizures 3 5 Refusal of further therapy 2 2 Hypotension 2 — Secondary reaction, frequent - 5 Prolonged Coma ( + Insulin Resistance 6 hours) 3 l Coma �.10.- h. Effects on the Psychotherapeutic Relationship In.this setting, patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effective drug action, treated patients were described by the fifteen of the chlorpromazine— therapist in re6ponse to an inquiry as "more accessible," "Spoke more freely" and were "more amenable to psychotherapy." subjects in The behavioral changes could be classified into two groups: whom tension and preoccupation with somatic symptoms became much hallucinatory or delusional preoccupations ended. Such changes in relationship'were frequently described as an increase in "contact." In thirteen subjects, psychotherapy was either still "not feasible" less, and those in whom less feasible because of increasing, uncontrolled tension, anxiety or preoccupation with the side effects of the drug regimen. Similar observations were made in the insulin treated patients. Of the thirty patients, seven were noted to be less tense and less anxious during or had become therapeutic sessions. more freely" The therapists noted that the patient "verbalized and "was mere aware of his environment." Four patients were specifically treated with a "modified anaclitic" approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional ive, educational therapists tactics. In the remaining patients (19), while support- and environmental manipulating techniques were were no more successful than applied, the prior to insulin therapy. In eleven patients, the physiologic effects of the treatments (secondary reactions, sweating, nausea, vomiting and'weight gain) were reported as interfering with psychotherapeutic attempts. �-11Discussion 1. Clinical Considerations In these patients neither chlorpromazine in high therapeutic doses nor insulin specifically modified the psychotic process. Since 88% of these patients were diagnosed as suffering from schizophrenic illnesses, we concluded thatiieither treatment has a specificity in altering the schizocoma phrenic process. shen given in adequate dosage, however, both treatments are potent methods for u1e alteration of behavior. the treatments are similar. ioral patterns persistent In only and others, the induced behavioral Since these therapies 20% rated as of the patients were induced behav- much improved or recovered. For the transient or minimal. Chang 5 were fail to In the discharge evaluations, induce a recovery from the psychotic process, then consideration should be given to their ameliorative, palliative and supportive aSpects. Symptomatic to the treatment period. Patients relief was frequent, but generally limited were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is advantage of either therapy. Both methods were said to enhance little relationship therapy although the therapists' evaluations favored chlorpromazine therapy. Excluding those who developed increased agitation, patients were more comfortable, more alert and physically better able to discuss their feelings and experiences while on chlorpromazine, than on insulin coma. It is clear that "interpretive" psychotherapy is not enhanced, but rather supportive, educative, re-orienting and directive types of therapy. When there is a modification of agitated, hallucinatory, depressed, manic or aggressive behavior, than both the therapist and the patient arernore comfortable and able to discuss �-12the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assumes decisive significance. To maintain such therapy after discharge continue thereby the relationship established in the hospital setting an important element in sustaining the behavioral changes induced by and may be hospital- ization. 2. Other Studies While many appeared, we reports of the treatment of psychosis by chlorpromazine have are aware of only one similar comparative study. Boardman, Lomas and Harkowe one hundred (3), after a review of the problem, report their study of patients randomly divided into two groups of SO and treated either insulin coma or chlcrpromazine. The chlorpromazine dosage was lower than that in this series (average 300 mgm) but the drug period (3 months) was the by Their observations are directly comparable to same. no difference in the discharge evaluations, nor in this study. They reported assessments for symptom either treatment group. The chlorprcmazine treated patients, box-raver, remained in the hoslaital less than the insulin treated subjects. This was a significant difference between the groups. They concluded that: "There is inconclusive evidence that chlorpromazine has advantages over insulin in the an average of 6.2 weeks treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness on the nurses. Chlorpromazine is the phrenia, but this conClusion and has is for the patients first and greater strain treatment of choice in schizo- based on the immediate results of treatment not yet been confirmed by an adequate follow-up study." �«n13- his co-workers emphasize the problem of evaluating the Boardman and therapeutic efficacy of insulin coma. They note a number of raise doubts as to the efficacy of insulin coma reports that therapy in schizophrenia. (h), in an extensive review of the merits of insulin therapy in Boume is no proof of any Specific therapeutic the long term prognosis is in no way influenced." schizophrenia concluded that "there effect, he and recent observations of insulin treatment of schizophrenia by Harris and Oldham ( S) Aclmer, are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbit- urate coma results in the same ward and under were made by patients received. similar conditions. Phraluations of psychiatrists without The knowledge of which medication the authors noted a similar outcome whether the loss of consciousness was induced by a barbiturate or by insulin, and concluded that insulin was not a specific therapeutic agent in the outcome. In the fol] oar-up studies in this hospital (2), the therapeutic results for insulin coma therapy were disappointing. In that report, patients ferred for insulin coma had re— the longest period of hospitalization (6.50 months for electroshock), poorest discharge rating (3325 recovered. and much improved, 1?. 63:5 for psychotherapy and 67% for electroshock), and within four years, a 5015 re-hospitalization rate (compared to 33% for psychotheram and 29% for electroshock). while these observations reflect 1g 6.0).: for psychotherapy and 14.95 the observation that the more severely coma, it also ill patients are referred. for insulin supports the belief that insulin coma is not a specific treatment for the patients referred. From these reports and the passage of many we would conclude years, insulin that, deepite considerable study coma therapy has not been shown to �.mpersistent behavioral changes more frequently than other non~specific, less dangerous and less expensive therapies. To the list of alternate induce therapies of limited value in the chlorpromazine, noting, however, management of psychosis we may now add its advantage of lesser risk and ease of adninis tration . 3. Dosage of Chlorpromazine for For the purpose of assuring an adequate level of chlorpromazine evaluation, the medication This level was too high duction in was increased in all subjects to toxic levels. fox-its behavioral effects, as evidenced by the re- all responsive cases to maintenance levels of 300 to 2000 mgm. our impression that chlorpromazine affects the function of the central nervous system (as evidenced by changes in.modulation and percent time delta in the electroencephalogram and systemic phenomena of rigidity It is results in a non-Specific alteration in behavior. Such behavioral change is varied and is dependent upon a.variety of factors, of which the personality organization and the expectancy of the milieu are sigand lassitude) and nificant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity, and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances uhere an affective "storm" supervenes, continuation of the drug at higher levels, with concomitant artane and cogentin, should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology, and to the present concept of the action of electroshock therapy (6). mode of �.15Conclusions 1. In a study of patients referred for insulin open ward, voluntary insulin coma psychiatric hospital, patients coma therapy in an randomly received either therapy or intensive chlorpromazine therapy. 2. Chlorpromazine was as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications or effects on the psychoﬂaerapeutic relationship for either therapy. 3. In comparison to insulin administer, and lends itself to coma, dilorpromazine long term management. is safer, easier to Patients receiving chlorprcmazine therapy arernore comfortable than those receiving insulin coma. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. b. No evidence has been educed �REFERENCES l. Kalinousky, L.B. and Hoch, P.H.: Shock Treatments, Psychosurgery, and. other Somatic Treatments in Psychiatry, Grune and Stratton, 13.15. 3 1952. Rachlin, H.L., Goldman, (3.5., Gurvitz, $1., Lurie, A. and Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. §_: 174.0, 195 6. 3. Insulin and Chlorpromazine Comparative Study in Previously Untreated Cases, Lancet, Sept. 8, 1956, pp. 1:87—1:91. Boardman, R.H., Lamas, J. in Schizophrenia - and liarkma‘e, M.: A Boume, H.: The Insulin Myth, Lancet, Nov. 7, 1953, pp. 961;~968. Ackner, B. , Harris, A. and Oldham, A.J.: Insulin Treatment of Schizophrenia - A Controller} Study, Lancet, March 23, 1957, pp. 607-6110 Fink, 1-1. and Kahn, R.L.: Relation of ETTG Delta Response in Electroshock: Quantitative Arch. Neurol. and Psychiat. (in Activity to Behavioral Serial Studies, AJ'LA. press). �January 31, 1957 Subject: Drs. From: To: - Insulin Control Chlorpromazine Max Study: Interim Report Fink, Robert Shaw, George Gross and Fred Coleman Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser and the Research Committee of Medical Board Following insulin During is a summary of the observations in the control chlorpromazine- study, instituted September 1, 1955 and completed January 1, 1957. coma this period, 59 patients were referred for insulin coma Half therapy. of the group was placed, by random sampling, on chlorpromazine * therapy in- stead of insulin coma. Four patients received both insulin and chlorpromazine therapy. of the patients of therapy of less than who received chlorpromazine, seven received courses one month. patients, three had an of the 29 insulin inadequate course of therapy. I. During the period l95h—1955, preliminary PROHLEH: azime resulted in the awareness and safe. In view of the unusually poor trials of that the drug showing of was the insulin chlorpromp both potent coma populat- ion in the 1950 Fbllowaup Study (1), and the appearance of numerous articles in the psychiatric literature recommending chlorpromazine as a therapy schizophrenia, a comparative study of chlorpromazine taken. The a) - insulin for coma was under- following questions were postulated: What b) What is the clinical effect of adequate doses of chlorpromazine? is its therapeutic efficacy'when compared to insulin coma therapy? 0) ‘Ehat are the indications (and contraindications) for the use of chlorpromazine and/or insulin coma? * Chlorpromazine supplied as "Thorazine" through the courtesy of Smith, Kline and French 00., Philadelphia. Rachlin, H,L., Goldman, G.S., Gurvitz, M., Lurie, A., and Rachlin, L.: Follow—up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside HOSp., _5_: 17-ho, 1956. (1) �«2. II. All patients referred for insulin SUBJECTS: coma therapy during the period September 1, 1955 and December 31, 1956 were observed. Supervising psychiatrists made the recommendation independent of the research group. Their by the hospital administration, patients made by coma therapy criteria were those implicitly held and were not were placed on chlorpromazine for insulin altered for this study. Selected therapy. selection The was random and the supervising psychiatrist of the physical therapy unit, without prior notice of the referring therapist. III. a.) Insulin nga; EETEQQ: standard technic of Sakel was used. The All patients received 50 comes, each of a duration of one hour or longer at the physiologic level flex or deeper. Recovery ous glucose. of Babinski reflex or absent was induced by gavage and lid re- occasionally by intraven- Treatments were given five times weekly, for a period of 3-h months. b.) Chlorpromazin : To establish a complementary therapeutic group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased clear-cut physiologic effects ifest rigidity, drooling, ere dermatitis. were observed. These included and fixed clinically mans facies; or toxicity, as seizures or sev- In each instance, the drug dosage was slowly reduced a maintenance dose, until just under toxicity, was obtained. until This was maintained for the duration of the observation period. Laboratory blood counts, tests were carried out at irregular intervals liver function tests, glucose tolerance tests and included and electroenceph- alogramS. In both experimental groups, behavioral observations were made at'weekLy intervals. Following completion of the treatment period, reports of the ther- �4-3- apist and supervising psychiatrist were obtained. The rating of "improvement" Conwas that established by the Medical Director at the patient's Discharge ference. IV: RESULTS: Chlorpromazine A. l. until signs creased rapidly of was achieved in daily dosages to 3600 in mgm. 2000 mgm. one patient. of chlorpromazine was in- The dosage QEEEEE.22.22EQEEEEEEEEEEF rigidity appeared. In most instances this below lhOO mgm. although dosages were increased The maintenance dose varied from 300 mgm. to daily. 2. Clinical effects of chlorpromazine: motor retardation in all subjects. Chlorpromazine induced a Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic and less violent. The nurses' and therapists' records relate that patients are "less easily excited and frightened," "cooperates better in "less restless and less panic-ridden." ward activities," and One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves; became sloppy and failed to dress. by Such periods were short or could be significantly modified anti-parkinson drugsn Affective changes during chlorpromazine were varied. In four instances, the patients became increasingly agitated, tense, tremnlous and either refused to continue on the drug regimen or were induced only with difficulty. Such an persisted. In four other instances, depressive symptoms were significantly relieved, with an increase in affective lability and responsivity. In two patients, deaffective "storm" appeared early in the therapy and �.u. pressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of-chlorpromazine therapy in twelve of the patients. Eight patients had a loss or a significant diminution of psychotic ideation. In five, the hallucinatory and referential xperiences were no longer reported even on inquiry; and in three others, delusional ideation was less prominent. In one patient, phobias were relieved to a degree that the patient could participate in ward activities. In another, hypochondriasis was sufficiently modified to permit of a more meaningful latedness of therapist and re— patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regimen. 3. Effects en the psychotherapeutic relationship; Patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effectiwadrug activity, ten of the patients were described by the therapist in reSponse to an enquiry as "more accessible," "spoke more freely" and were "more amenable to psychotherapy." The responses could be classified into two groups: the subjects whose tension and pre— occupation with somatic symptoms became much less and those in whom halluc- inatory or delusional preoccupations ended. In each instance, the therapist described the change in relationship as an increase in "contact". In twelve subjects, psychotherapy was either still "not feasible" or "less so because of increasing, uncontrolled tension." �-5. In no instance did the problem of drug addiction or drug dependence play a role, nor was there an appreciation that drug therapy altered the therapeutic relationship adversely. h. §g§igg§ twenty four have left the hospital. thirty patients in this series, or the 93 "improvement": Table I lists the number of patients evaluated by the Discharge Conference, according to the four-fold classification in use in the hospital. For comparison, the discharge ratings of the insulin coma therapy patients, following the TABLE same criteria, have been included. I DISCHARGE RATINGS Chlogpromazine Insulin l. Recovered 1 O 2. Much Improved 3 1 3. Improved 15 10 h. Unimproved S 8 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate courses of therapy (less than one month) because of complications of the therapy. or the eight unimproved insulin coma patients, four had inadequate courses of therapy - two because of complications (seiz- ures, prolonged coma), one because she was a severe the fourth by administrative transfer to the V. A. 5. Toxicity g£_chlorpromazine: management problem; and Inherent in the design of were the high doses of chlorpromazine, pushed to symptoms of this study toxicity. In this context, all patients developed significant drug effects. In all, rigidity of extremities appeared; frequently accompanied by a decrease in facial expression, drooling and festination. In a number of patients the pafkinsona. �~6— ian features appeared as the drug dosage was reduced. symptoms were became drowsy, relieved when retarded, the drug and was discontinued. less active in ward In.each patient the Almost all patients activities. In four pat- ients, increased tension, agitation, restlessness and excitement supervened, to a degree that led to a discontinuation of the drug regimen. Seizures occurred in three patients. Ineaach, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. Severe, intractable skin reaction occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine * therapy was substituted for chloru promazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from the chlorpromazine group. All patients developed a skin photosensitivity so that on exposure to sun, transient erythema developed. Refusal of further medication because of drug effects occurred in two patients. Both developed severe tension and agitation. In two other instances, agitation resulted in the therapist insisting upon a change in treatment regimen. Table II lists the complications of both treatments. Certain effects are individual to the type of therapy, as dermatitis for chlorpromazine; and prolonged coma, severe secondary reactions and nausea and vomiting in insulin coma. 0there, as seizures, fainting spells, and increased are seen in both. *- Surplied as "Sparine" by the courtesy of Hyeth and Co. states of agitation �'77“ II TABLE COMPLICATIONS Insulin _Chlorpromazine Coma “ Agitation h and Panic 2 - Dermatitis, severe 3 Seizures 3 3 Refusal of further therapy 2 2 Hypotension 2 - Secondary reaction, frequent - 5 - 3 ~ 1 Prolonged Coma (+ 6 hours) Insulin Resistance In this chlorpromazine series, no patients developed clinical jaundice. This complication has been variously reported as occurring in less than %% of the subjects treated.* Liver function and blood element studies were done in this group of patients. Changes were small, and at the recommendation of the medical consultant, the studies were discontinued. Electroencephalograms were obtained patients. and On in fifteen of the chlorpromazine adequate doses, a moderate amount of low voltage theta activity was induced. This activity h—7 cps.delta was exaggerated by hypervent- ilation. There was a suggestive relationship between the degree of the induced slow wave activity and the drug dosage. 6. Adjuvants tg_Chlorpromazine: With the development of rigidity, festination, and drooling, patients received cogentin or artane medication. Both drugs relieved the symptoms, and in a few instances, to a significant * In the initial studies at Hillside twenty developed Hospital, three patients of a group of transient clinical jaundice. �-8degree. Concomitant with the relief of the rigidity a feeling of euphoria and wellabeing was occasionally noted. In one of the patients who developed effect. therapy, anti- an affective "storm" the administration of artane had a salutary In patients who developed seizures during insulin coma convulsant medication (dilantin, phenobarbital) has been routinely employed. Such agents were on lowered not used with chlorpromazine as the seizures did not recur dosages. Insulin B. Coma Theragz clinical effects, complications, the treatment results of insulin ccma therapy have been exhaustively reported. In this series, twenty-nine patients began insulin coma therapy. Of these, nineteen have completed their period of hOSpitalization and ten are either completing their treatment perThe iod or are awaiting discharge. The over-all ratings of "improvement" are listed in Table I. When comp pared with the Hillside HOSpital Follow-up Study of 1955, the percent improve— ment in each category is not significantly different, although the trend is less optimistically than the 1950 group. In Table III the percentages are listed for each evaluation category of this to rate the present series somewhat group compared to the 1950 populatidn. TABLE INSULIN III COMA THERAPY Present Group E 1. Recovered 0% 2. Much h% 19% 3. Improved 52% h2% h. Unimproved hh% 25% Such a Improved difference in trend, if sustained, 1h% may reflect a variety of factors, including changes in criteria of "improvement;" prior administration �.9... tranquillizing agents exerting a selectivity on the population admitted to the hOSpital; and changes in staff criteria for referral for in» of the newer Sulin coma therapy. complication rate in this insulin group is comparable to published studies. No unusual complications, and no deaths were observed. The role of psychotherapy in patients undergoing insulin coma therapy The is complex. In this group, four patients were treated with a "modified anaclitic" approach and an effort at establishing a working psychotherapeutic relationship was made. In the remaining patients, no unusual efforts at psychotherapy were made, with the consensus that a supportive, educative, enviru onmental-manipulative, reassuring type of therapy was achieved, to varying degrees. Therapists reported (in 7 instances) that patients were less tense less anxious during sessions while in coma therapy. In eight patients the physiologic effects of the treatment (secondary reactions, sweating, nausea, vomiting, weight gain) interfered with relationship therapy to a significant and degree. C. Therapeutic Results in Relation to Final Diagnosis Table IV lists the final diagnostic categories for the patients in each group. All diagnoses were represented in each series with an equivalent distribution. TABLE IV EBYCHIATRIC DIAGNOSES Insulin Coma Chlorpromazine Psychoneurosis l 2 Schizophrenia, Paranoid 0\ we U1 O\ U1 \n \» to +4 DD Schizophrenia, Catatonic Schizophrenia, Mixed Schizophrenia, Hebephrenic Manic Depressive Psychosis �~10— No diagnostic group had a significantly better treatment response than any other with either form of therapy. V. DISCUSSION: A. Comparison of Chlorpromazine and Insulin Coma Therapies: Neither chlorpromazine in high therapeutic doses, nor insulin are Specific treatments for schizophrenia. The discharge evaluations both treatments are not significantly different. There is, coma, for however, a def- inite tendency for more patients in the chlorpromazine group to be rated in the better classifications than in the insulin coma group. The trend assumes significance when both the type of sampling and the qualitative aspects of the treatments are taken into account. the The random sampling is exemplified by resultant matching of diagnoses. Since these treatments have not resulted in a recovery from the psychotic process, then their ameliorative, palliative and supportive aSpects must be considered. The insulin coma patients are usually uncomfortable throughout their treatment period. Nausea, vomiting, secondary reactions, are Prolonged coma common. loss of is a and drowsiness realistic threat; as well as the threat to life. The chlorprcmazine patients also suffered considerable disagreeable side effects. Parkinsonism, drowsiness, and skin reactions are significant, must be considered as concomitant management problems. and Seizures and jaundice are the most severe reactions, and to date, have not been permanent. It is possible to modify the significance of these side effects to a considerable extent by anti-parkinson and anti-convulsant medication. There is no question, furthermore, as to the ease with which chlorprom- azine can be administered, in contrast to insulin coma. A significant element in the use of these agents in the therapy of schiz- �.11... ophrenia is concomitant psychotherapy. Such relationship therapy by both It was therapies. apparent in the therapist's evaluations, however, that the chlorpromazine regimen was apy. Patients, excluding those comfortable, alert iences while on and was enhanced more conducive to concomitant verbal who developed ther- increased agitation, were more physically able to discuss their feelings and exper- chlorpromazine, than insulin coma. In another respect, the ease of administration of chlorpromazine advantage. Patients who respond to drug therapy can is of be maintained on such therapy for as long as needed, even on an outpatient basis, while the "course" of insulin coma is limited. Are these treatments equivalent? Can one be substituted for the other? While these questions cannot be answered by the data the negative can be denied. groups are not The in a positive assertidn, results of these treatments in equivalent different with regard to the discharge evaluation. The changes in behavior noted and the symptoms alleviated are not significantly different. In this series, three patients had adequate courses of both regimens. Two have been discharged"improved," and the third is still in the hospital. There has been no significant differences in their reSponse to either form of therapy. Comparison With Other Studies: B. While many studies of chlorpromazine in schizophrenia have appeared, only one report of a controlled study is available. gt_al_ (2) after an excellent review of the problem, report their results in one hundred patients, coma randomly divided into two groups of SO and Boardman, treated either by insulin or chlorpromazine. Their chlorpromazine dosage was lower than in this series (average 300 mgm) but the drug period ( 3 months ) was the same. Their observations are directly comparable to this series. They noted that the over(2) et a1: Insulin and Chlorpremazine in Schizophrenia — Study of Previously Untreated Cases, Lancet g5 h87-h9l, Comparative (September) 1956. Boardman, R.H. A �all clinical results were slightly more favorable in the chlorpromazine group than in the insulin group judging both by interview status and by a rating scale of difference was not of high statistical signif- The symptom change. state, however, that the chlorpromazine patients remained in the hospital an average of 6.2 weeks less; and that this difference was statistically significant. They concluded that: "There is inconclusive evidence icance. They did that chlorpromazine has advantages over insulin in the treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the first treatment of -choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been confirmed by an adequate follow-up study." In Boardman‘s review, due cognizance therapeutic efficacy of insulin come. He is given to the problem of the notes the number of'dissident re- ports that raise doubts as to the role of insulin In this regard, for insulin it is therapy in schizophrenia. important to note the results of the Hillside Follow-up in which patients referred for coma, coma such therapy had the period of hOSpitalization, poorest discharge ratings, and a ization rate (compared to 33% for psychotherapy and 29% 50% longest rehosPital- for the electroshock therapy groups). Two other control studies of chlorpromazine in psychoses are relevant to this report. "blind" study ment at Feldman gjgggp (5) Topeka reporting the observations in a controlled, State HOSpital noted a significant degree of improve- for chlorpromazine. They<eoncluded that "thorazine was found to be useful in converting acutely disturbed psychotics into tractable, accessible patients who could (S) Feldman, P.E. then participate more actively in the hOSpital rehabili- et al: A Controlled, Blind Study of Effects of Thorazine Clinic, a9; 25-h7, 1956. on Psychotic Behavior, Bull. Men. �.13... tatidn program." Tenenblatt and Spagno (6), describing the St. Elizabeth's Hospital eXperience, in another control study, noted significant behavioral effects in psychotic illnesses other than involutional psychoses. Effect of Study D. An on Staff: inherent factor in a control study of any therapeutic modality is the effect that the knowledge of random selection of patients or the use of placebos has on the therapist in his choice of therapy. sulin coma referrals were to be given Knowledge that in- either chlorpromazine or insulin coma created a feeling of insecurity and impotence in the therapist. Their control of the therapeutic situation was in a decrease in the drug effects, and number of felt as severely constricted. This resulted referrals, an exaggeration of the physiologic in the patients expressing doubts as to the therapeutic efficacy of the drug despite significant changes in ward behavior. On numer- therapists called to enquire which therapy their patient, referral for ICT had not yet been made, would get. Prior prejudice ous occasions, ‘whose suitability of either therapy resulted in the therapist's expressing disappointment at the modality used. In two instances, such preabout the judices led to early discontinuation of chlorpromazine therapy, when the pat~ ient experienced eanLy signs of drug effects. E. Dosage of Chlorpromazine: For the purposes of assuring an adequate level of chlorpromazine for evaluation, the medication was "pushed" in level in was too high all all subjects to toxicity. This for its behavioral effects, as evidenced responsive cases to maintenance levels of by the reductidn hOO-lOOO mgm. The effects of parkinsonism, drowsiness and lassitude are prdbably necessary concomitants (6) Tenenblatt, 3.8. and Spagno, A.: A Controlled Study of Chlorpromazine Therapy in Chronic Psychotic Patients, Quart. Rev. Peych. & Neurol., �1":114- of the therapy; and should be induced effect is desired. In instances where in all patients in an whom a therapeutic affective "storm" supervenes, con- inuation of the drug at higher levels, with concomitant artane or cogentin, should be considered. VI. CONCLUSIONS: In a control study of patients referred for insulin coma therapy, chlorprcmazine therapy was found to be as effective in modifying psychotic behavior patterns as insulin charge ratings to be coma therapy. is There better for the chlorpromazine a tendency for the group than dis- for the insulin coma group. In comparison to insulin coma to administer, more controllable in therapy, chlorpromazine is safer, easier its effects, and has fewer side effects. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity for either form of therapy for schizophrenic illnesses. No evidence has been educed �February 3, 1958. that at a bucuti 1.. t :1 1251 : or EEG Dona Maturity to Bohuioml Quaint-Adv. 801-111 Studiu, “Hg, . kaponn in metro-hock: a: Arch. chhnt. 18; 516-525. 1957. Fink, H. and Kuhn, my a.L.s 3818321511 . Mime ﬂux-spin, Units.“ Theory of the Action of 1957. 197-306. g. Hillside 3032. 9: ILL: Significance of Individual Variability in ma human to moctmlhock, g. Bullio- Raga. Q: 229-21“), 1957. link, 91.: A 3. m, h. Join, 5. Kuhn, 3.1.. and $. him, 8.1... J. «In An abacus.” Study of Went-.1031 £111.16. Hog. 9,: 207.215, 1957. link, In blink, PchhiaMc Interview, Figural Artur Induced mm (1957). g: Perception of m5. Puma)... mum, Altered Bruin 1n 361 H. and Pink, 15.: Social Salaam of Factorl 1n 216-228, 1957. 7. 3. and Pink, Ha Role or Stimulus Intensity 1n Pomcpuan tom, ' Simultaneous Gunman: Electrical Stimuli, 1. munch Hog). 9" 2181.250; 195?. at ‘ mama“ 8. Karin, 8. (With Tameka, 8. and Friedman, 8.): Pomeptim Stw o: Ambit-lanai, mg, hard, I: inching.. 1Q: 1&7-176, 19 7. 9. Punter. in; H. (with Geldfarb, Lgﬂé. knack, H. LE. 322‘ E a g Md it): gaunt. ﬂ! (with‘marb, m): Test in Schilophrcnic 0111mm, 6354-6132, 1957. htum of Orientation in Childm in 303.1de Instant. for 8mm Bonnier Daemon, her. J. Mama . 213538-552, 195?. n. (with Battarnby, v.3. and Radar, 14.3.): Tnchia’wteopic hunk, “minimum of Contour 1n ﬂuent: with Brain mange, J, Cog. algal. gm 61° ﬂ. 3’ 220.227, 1957. Pollack, K. (with Battersw, $1.3. and War, 11.3.): Visual Deficit After Brain Damage in Man as Hammad with Rupidlyakpoud chromatic Stimn, mr. BIS-“2.9;. £2} 7’ 1‘68, 19570 0 13. Pollack, u. (with 00161111), in): cum-a1 ma Ehviromntal Factors attracting Complex Exception in the Institutionaliud Aged, ,1. Gomntolu l2“: ’1, “374‘38’ 19570 �Wf— ,. . , , . ~v-wwwavw—wmvwwnw—wu—va . «m <-~w—-~ uv-v—r rvs—«wv ﬂv‘w—I-‘V n V'Wuzwr- may, mm "—31-— "Wu Flbmuy 3, 1958. Imagination! in Pro”: 1. 3., Mfo, J. humor, with mantra-hook 2. Pink, 3. Pink, IL, Shut, R... Grass, 0. and Colo-Inn, F.3d and Kuhn, Yuma“, J, 3.1.: chhomompenuc Techniques Hang. (in press). was 8.. [$11, 3.1.. tad anon, 14.1.: ﬂuctuahook Prone-l, m, luv. “perinatal M. mama). J. r ‘mo (in Phi.)i and Insulin Cm in the Studio: of the (in press). Omani» Study of Therapy of Psychosis, * h. Pink, 5. ma, LL. 11.: 2E8 Laura}. Gnu Gun. In macaw. a u m- Indu a! the Sedation Munch}, in press). W. and Pink, 24.: humanity Factors (in nutmnhock Therapy, in Buhuioral mu). name to .- v- w. 1r, ,mrnv .7 w K, - �Luvzuv-amwnvww «7,. w—nwrruwm...»~.\,..—... W. WA R .. ran n-«cmvrrme—u»:‘v' February m. »u r’er’I-‘vs 3 , 1958 . many: in m Rayon-buy. Inﬂow“ York, Pom-my 1957. 1. Fink, IL: Individual 2. ﬁnk, Mu cut-m 3. Pink, 3., Kuhn, 8.1:. 1nd km :1; the Sociow no scanty, In 1n Enluation of Clinical Bolivian}. physiologie Alp-ct... Presented at LBJ... at Motropoutan Band Change: Neuro- ma tabla, Chicugo, by 1957. Exporiunm Gm, LL: of Biological Pm“. Juno 1957. Studio: of the msctmahock Psychiatry, Atlantic City, H. and Kuhn, R.L.I mum of amt-wean: Role of Alteration in Brain Function in Bah-dot. Pnsented at. Int. Congas: of Pnychntry, Zurich, Sept. 1957. h. ﬁnk, S. I!” xﬁn, 3.14. ”d “an, 3.! “ICC“ Qt 01:!qu “tend 3w m’Function on Pomaption. Pruemad at the 17 Int. Congrats of Psycholog, Ema-1c, August 1957. ' 6. Fink, II. and him, 3.1“: Random Pattoml in Induced Stat» of Aland Road at w. New Ion Divisional Hating, A.P.A. 1m. 1957. Brain 7. Pink, Mu 8. on m ma sumnwm tar hoary of Le Enact. or M,Pmaou of Conwlaivo Thu-um. Read It. Mom “Inﬂation of manna mum. of m quancy Shirt for Plychintz-y. Simian“SOQCW‘ HoY: 30'. 1957- ”Mum EEG 13101313511). anecphalographm, Nov 9. 10. Road at. M30, 4.: 1621:, Doc. 1957. Bahamian). chug” Plyohomum in Evaluation of Clinical Round Tabla, Chicago, Hay 1957. lingnhuc “pom. Fromm at A.P.A., in hymn-Le Interview. NationA.P.A.. Nov. 1957. MIC, J.: Lu Obj-«tin Study of had at um How Iork Divisions). Mating, in Buhuioral Euponu to metre-hock Thonpy. haunted at meta-omen}: Research “mention, [11:21, 3.1.. and Pink, 11.: Pomonality Factor! Chicago, Ram, New 1957. LL. and link, Aland Brain Mu Pompticn or Function. Road We! Figures Arte:-InInduood Ierk, August 1957. at Ann. Plyehol. Luau” Karin, H. (with runabout, S. and Friedman, 84): Pomption Expouunu in a Study of Allah-Amen. End at Suction on lourolog I: Plychintry of Ed. of Kodiak)! and LY. Roux-01. Socioty, NJ. Jm. 1957. low �__. _.__ .7...._—M wvwwﬁwww «V . ., m«m1.1m: 1. _ (5....»“1 .._ _ w. ....,._-,_..,..._.. «1...; .I.-....._.L,,.r..». w“ynw-WMW r‘m-vnr—Vwﬂtnﬂw’all ' 7 I-vrn" “rm” ‘ nun—mm.—.,.m~ I2 (Iith Italahau; s. and lhindnan, 3.): th- Relation a: Ambasulnneo Mansion and Monty 1n Wan-antic mum... and at Amt. Mabel. Ame. Sept. 1957. (New Kerk). 15. Karin, B. (with Tarmac»: and Mama, 8.): Stun” in “bitumen. 1h. lbrin, H. to Pnlantad boron Sahildar Sociew, M York, 00%. 1957. 16. Pamak, H. (with Galena), W. and Dam, 14.): Pain mucus in Schumann 02:11am. Haunted at Mr. Orthapaychntrio mac. Chicago, Marah 1957. 17. ‘ M.‘(v1th Integer, H.P.)I.Oan1mtor'and Bantam Put-m 1n o: lamina, Sahisophnnia Wldran. P's-mug! at Mr. knack, Am 18. Pollack, H. (with Butterﬂy, v.3. and Bond-r, 11.8.): ﬁgure-mane! Pamphlet: Tumor. But! *Enmm Payahol. uses... In York in Plunges with 13111 0“.an 19 7o it Pollack, K. (with Batu-thy, H. 3. and Bondar, 3.3.): Datum in Visual Phraoption in Brain mm:- Patten“. Flaunt-d baton Int. Congrats or ngcha1., aux: 1957. (Brunloll). .20. anuok, K. (with Battarnby, v.3. and Bondar, 14.3.): Visual M1611: After with Rapidly-kpand Chmtia 9mg. a Mutant! Assoc" Nu Int-k, Sept. 1957. Pmud at Ann. PaychoI. Brain 1:: Man Stimuli. Pollack, H. (with Goldhrb, A.): Cultural and Environ-um Factor: Aged. Presented “hating (De-plan: Pox-caption in tin Institutiamliud at the “analogical Society, Cleveland, 00%. 1957. 22. Pollack, 11.: Brain Dung... Pmanud It. Nil mm Inhalation and Childhood Sauomania. Hating, MPJ. new. 1957. York Divisions). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-31-008 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Shaw, Robert; Gross, George E.; Coleman, Frederick S. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint and reprint]. Reprint from The Journal of the American Medical Association April 12, 1958, Vol. 166. Observation letter. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/ee9acc31c3d43280c2889e28c2a5cbdf.pdf bf2464ff0c5b85a41fb05f4bcfd6dfb6 PDF Text Text Inlnary tor All (—1143 . turner 0’ Ilill'lﬂﬁﬂﬁ IA‘IIIHIhTI 6' Pllﬁlpilﬂﬂ In: #13:. u.n.. Horton lathnnsoa. I¢E., villi: a. nits-an, I‘D. tad Harris I. laudmr, l.n. ottoat at antravuaona barbiturutu an tbs parcnptxen of Itltlpl. saunltunoauu antantoun atmnuli In. obsnrvud in lawn. groupa o: nor-s1 subjectt. puttantu with Iiitﬂlt and lawn! our.» bani 41:051., tptlul word 10-103. and psychoconic disordqu. Itch in. attain-d hetero and utter the :10! idltltltrtm ties of 2 1/25 uulution of Indian snytsl tn dost: o: 3‘15 to 6.50 an. to nyatusnnu. slurred upcoah, ‘ttxza and drauaantsu upponrcd, The haltnd tun simulttunoua tacit}. tints war. :9plind. 2h: assaincr ntunltaanounty tauahnd tn. lubjout In two plaacs - such ll tn. abbot and tho hand - and tutti his ta p.9ort that wt: ialt* ib3t§ tart rupaatnd with Vtrtoul boa: «ouhtlltiens. tad thu report: rueardod. It» ottcnts a! median atrial on Indul1:30: 0th.: than touch ‘Qf. sane inronttgntcd. In :11 labJoctn Indian ‘Iﬂt‘l etuuod arrow. in tin par~ caption a! tbs uisnltaaaaﬁn stimuli. Ibrﬂtl nuhjoats taunt tun tnxxuaact e1 tn. barbiturate trcqauntly rcportod only «In at tho two stinnlt (onttantton); a. ., tn tho acubtnutton at £30. and hand only the stimulus to tat tnao was royortud. It‘s. trrarn into tt3nsannt :nd tlnntuntod during tho parted a! «was :atton. tn. indoetlan was 31.11:: bohavtar van untod £3 »»1¢, duproauian. paticntniv1th paychoanatu dtnovdurn schisophrnntu)¢ - 1 u �In puttoats with acrobrnl disease, uaytul brought out anioets ant privaoualy appaiunt or oxnguuruttd oxinttng .113: of 63:1uautioa. In this group tun orrnru U‘t. not. pronounced, porstntcd tor lessor porleds, ind abound 1's: tluatuttlon thﬁn :3 ch. nor-n13. 1h 9&ttontc with~£oanl carohrul dlﬂitit with 00:50:: daftots continua to any urea at thn body. anytaz brought out utter: which var. ant apparcnm ova: vith Ixnnltnanou: test: Ind 1t daftnnd tort nightly tho oxtnnt of tho teaser: disturbanco. Qttiuntn with diffuse aorubrul dyntuantion rho pruvtounly and. no orroru on atuultnnnoun tnatllo tautg, lhﬂﬂid rcpoatod Otters a: cxttnntton tug diuplnecnnnt as both 314.: at tn. body utter anal: dalos o: a-wtal. Pntxonts who angina uxtinattan or displgoonnnt prior to tha anytnl pertornod attiarantly sitar tin drug tn: xtvcn. Errata heath» nypnrnnt in body part: which print to tho naytnl ‘DIO rupartad oarruatly. Furthnr-oru, tho phannuoa: o: oxouounuthnsia (displaoalant to astrupﬁrnoall apnea), allcun than (duplwmnt to tho «man. an) «mom» son: (incenplntc apailatcrsl displneoaunt) var. also ovidont. In ‘11 pationta with orgnnio unatll uyndron. tn. duration at tho porcoptuul otter: ‘3: troqunntly 1033.: than the OUOrt 31.3; of drug sattan. Th. porcuptuﬁl ahtﬂlhi lustod lancer thin in noruul m mt»: “suchctu attor stutznr downs tad var. norc canntstcat. :3 10310:. of tho aptnal nard, tho scanary dl£octn banal! not. ;ppnront: cutinntion could ho clxaitod «var : mutant unit and tho 1.?!1 at sonnet: 4.103: bouts» not. ﬂittinct. In two �inntsnoOI. hounvur, t prsvtounly duturnlnod tensor: 1:!31 could not be olinltod :ttur tho anytul. In tout. o: othor century functions, nystncuun on datcct torvnrd can. In: ‘holiuhod during the potion at drug n¢tten, tad ch. concomitsat vxlutl disturbunncn (blurring and oaalllopllu) use unwed. suzmu, ”that: an tiuitm «mm a shelttton uanll d1.1:ution of this syupton nttor tho insection at of unytul. ow downs val thorn ta ultor tho porcupttoa a! ntuult¢nooun tacttln stimuli in all nubjoots. Thar. was an nltaratson in annnrtl paracptutl tauntian as wall as th. 19¢t1~ laud porutptunl luantlout. ’laistzng nonuary dyltuactiau its oumutod with the ”actuation of «not: not previously mm at. it... slt-tntxonn 1n porecption var. 31.11:: to thou. lollowtax prolonsud unsuthnutn er cloctrolhuck thortpv. Intrsvonoun barw bituruto any to a «metal tdaunat in oltattin; or oxnggnrutlnc nournl dystunottun. that. routtnn nuanzaatiou yield: equivocal 53553513 rumults. Xutruvonoau unytul �\V‘ “I ' Reprinted from TRANSACTIONS AMERICAN NEUROLOGICAL ASSOCIATION 1953 NEIIRIIPHYSIIILIIEY LABZ’IIA'TII'W’ HILLSIDE HOSPITAL GLEN OAKS, N. Y. EFFECT OF INTRAVENOUS BARBITURATE ON PERCEPTION MAX FINK MORTON NATHANSON PHILIP S. BERGMAN AND MORRIS B. BENDER NEW YORK The effect of intravenous barbiturate on the perception of multiple simultaneous cutaneous stimuli was observed in large groups of normal subjects, patients with diffuse and focal cerebral disease, spinal cord lesions and psychogenic disorders. Each was examined before and after the slow administration of 2% per cent solution of sodium amytal in doses of 0.15 to 0.50 Gm. As nystagmus, slurred speech, ataxia and drowsiness appeared, the injection was halted and simultaneous tactile tests were applied. The examiner simultaneously touched the subject in two places—such as the cheek and the hand—and asked him to report what was felt. Tests were repeated with various body combinations, and the reports recorded. The effects of sodium amytal on modalities other than touch were also investigated. In all subjects sodium amytal caused errors in the perception of the simultaneous stimuli. Normal subjects under the inﬂuence of the barbiturate frequently reported only one of the two stimuli (extinction) ; e.g., in the combination of face and hand only the stimulus to the face was reported. These errors were transient and ﬂuctuated during the period of drug action. Similar behavior was noted in patients with psychogenic disorders (psychoneurosis, depression, schizophrenia). In patients with cerebral disease, amytal brought out defects not previ— ously apparent or exaggerated existing signs of dysfunction. In this group the errors were more pronounced, persisted for longer periods, and showed less ﬂuctuation than in the normals. In patients with focal cerebral disease with sensory defects conﬁned to one area'of the body, amytal brought out errors which were not apparent even with simultaneous tests and it deﬁned more clearly the extent of the sensory disturbance. Patients with diffuse cerebral dysfunction who previously made no errors on simultaneous tactile tests, showed repeated errors of extinction and displacement on both sides of the body after small doses of amytal. Patients who showed extinction or displacement prior to the amytal per— formed differently after the drug was given. Errors became apparent in body parts which prior to the amytal were reported correctly. Furthermore, the phenomena of exosomesthesia (displacement to extrapersonal space), allesthesia (displacement to the opposite side) and partial displacement . 244 5’) «L I �Fishman—Intracranial Pressure 245 (incomplete ipsilateral displacement) were also evident. In all patients with organic mental syndrome the duration of the perceptual errors was frequently longer than the Overt signs of drug action. The perceptual changes lasted longer than in normal subjects after similar doses and were more consistent. In lesions of the spinal cord, the sensory defects became more apparent; extinction could be elicited over a larger area and the level of sensory defect became more distinct. In two instances, however, a previously determined sensory level could not be elicited after the amytal. In tests of other sensory functions, nystagmus on direct forward gaze was abolished during the period of drug action, and the concomitant visual disturbances (blurring and oscillopsia) also disappeared. Similarly, patients with tinnitus reported an abolition or diminution of this symptom after the injection of small doses of amytal. Summary: Intravenous amytal was shown to alter the perception of simultaneous tactile stimuli in all subjects. There was an alteration in general perceptual function as well as the localized perceptual functions. Existing sensory dysfunction was exaggerated with the production of defects not previously apparent. These alterations in perception were similar to those following prolonged anesthesia or electroshock therapy. Intravenous barbiturate may be a useful adjunct in eliciting or exaggerating neural dysfunction, where routine examination yields equivocal results. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effect of intravenous barbiturate on perception. Trans Am Neurol Assoc. 1953; 3(78th Meeting): 244-5. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-12-016 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Nathanson, Morton; Bergman, Philip S.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprinted from Transactions American Neurological Association. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/8d591c235c58b9d455d7cbdd43d00916.pdf ebb607fbcf115668ef8fa3c0792cd5b3 PDF Text Text PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY MAX FINK, M.D., ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. Reprinted from THE JOURNAL or NERVOUS Volume 128, N0. 3, March Printed in U.S.A. AND MENTAL DIBEABE 1959 �JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 128, No. 3, March 1959 Reprinted from THE Printed in U.S.A. PSYCHOLOGICAL FACTORS AFFECTING INDIVIDUAL DIFFERENCES IN BEHAVIORAL RESPONSE TO CONVULSIVE THERAPY1 MAX FINK, MD.,2 ROBERT L. KAHN, PHD. AND MAX POLLACK, PHD. INTRODUCTION While convulsive therapy is generally considered speciﬁc for the symptomatic re— lief of depression and agitation, and for the relief of such “illnesses” as manic-depressive and involutional psychotic reactions, the behavioral response to such therapy is highly variable. In initial attempts at understanding this behavioral variability, differences in physiologic response were sought. Neurophysiologic change was measured in various ways (4). The quantitative measures of induced EEG delta activity (1) and changes in language after amobarbital (3, 7) provided the best indices. Considerable variability in these indices among patients with equivalent numbers of treatment was observed. We concluded that the development of an alteration in brain function, as measured by a high degree of EEG delta activity (1) and positive amobarbital tests (7) was a prerequisite to behavioral change in convulsive therapy. It was apparent, however, that such changes, although necessary, were not sufﬁcient for improvement (2). Indeed, among patients with maximal neu— rophysiologic change, all patterns of behavioral adaptation were manifest, and ratings of improvement ranged from “re— covered” to “unimproved” and “worse.” Equating segments of the observed popu— lation according to nosologic or sympto— matic categories also failed to explain the variability in behavioral response. While among patients in the manic-depressive and 1Aided in part by Grants M-927 and MY-2092 National Institute of Mental Health, US. Public Health Service. Read at the Section of Convulsive Disorders and Brain Function, American Psychiatric Association, San Francisco, May, 1958. EThe Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. involutional depressive groups a higher inci— dence of hypomanic and euphoric modes of adaptation were observed, and thus ratings of “recovered” and “much improved” were more frequent, there still were many subjects in these groups who manifested paranoid and somatization modes, and were rated “unimproved.” In the investigations of convulsive therapy, various tests of perceptual organization and indices of sociologic background have been studied which reﬂect the individual differences in the subjects. Of these, some measures correlated highly with the behavioral response to convulsive therapy. The psychological measures employed have been Rorschach responses (11), “explicit verbal denial” tendencies as measured in structured interviews with family members (12), and scores on the California F Scale (8, 10). The sociologic variables have been chronologic age, years of education and place of birth. It is the purpose of this report to summarize the observations of the relationship between these indices and the variability of the behavioral response to convulsive therapy as reﬂected in evalua— tions of improvement. METHODS The population has been consecutive referrals for convulsive therapy in a voluntary, non-proﬁt, urban psychiatric hospital. Patients were generally Jewish, of low and middle socio-economic classes with a mean educational level of 10.5 years. Ages ranged from 16 to 67 with a mean of 41 years. Diagnoses included schizophrenia, manicdepressive, psychoneurotic and involutional depressive reactions. As segments of the population were studied by various procedures at different times, the tables reﬂect 243 �244 FINK, KAHN AND POLLACK the different numbers of subjects that were included in each procedure. All patients received electroconvulsive therapy three times a week, using either unidirectional or alternating current instruments. The various psychological tests were administered Within the week prior to treat— ment. We have previously described the be— havioral changes in convulsive therapy as variations of ﬁve modes of adaptation (euphoric, hypomanic, somatization, paranoid withdrawal and panic), and emphasized that the evaluations of “improvement” in convulsive therapy are value judgments of the induced behavioral changes (2). Patients who manifest euphoric and hypomanic adaptive modes are those generally rated as “much improved” and “recovered” by therapists and administrator, while those who manifest paranoid-withdrawal, somatization or panic modes are generally regarded as “unimproved” or “worse.” For this report, evaluations of the patient’s behavior and ratings of improvement were made either two to three weeks after termination of treatment (Tables 1, 2, 3) or at the time of discharge from the hospital (Table 4). TABLE 1 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Much Improved N Moderately Improved and Unimproved Movement 39 11 (28%) 28 (72%) No Human Movement 48 28 (58%) 20 (42%) Human (M) x2 = 676* p < Form Color (FC) No Form Color 34 7 53 32 Both M and FC Either M or F0 Neither M nor FC 24 4 25 10 38 25 (21%) 27 (79%) (60%) 21 (40%) x2 = 11.57* p < .001 I X2 * .01 (17%) 20 (40%) 15 (66%) 13 = 14.83 p < (83%) (60%) (34%) .001 With Yates’ correction for discontinuity OBSERVATIONS RORSCHACH TEST PATTERNS The Rorschach tests were administered in conventional fashion and scored according to established criteria (13) for speciﬁc factors as number and type of movement, color, form, shading and total number of whole responses. For each of these factors, signiﬁcant differences were observed be— tween the group of patients rated as “much improved” and the combined groups of those patients evaluated as “moderately improved” and “unimproved.” Subjects with human movement responses were evaluated as “much improved” signiﬁcantly less often than subjects without such responses. The presence of form color responses was signiﬁcantly correlated with lack of improvement, and when this factor was combined with human movement, the ratings were signiﬁcantly poorer than when neither form color nor human movement were reported (Table 1). Similarly, patients rated “much improved” gave fewer total responses, fewer total movement responses and fewer content categories; but the per cent whole, popular and form responses were signiﬁ— cantly greater than in the groups rated as “unimproved” and “moderately improved” (Table 2). “DENIAL PERSONALITY” SCORE In their study of denial of illness, Weinstein and Kahn (14, 16) described the characteristics of an “explicit verbal denial” personality type.3 In an initial group of convulsive therapy patients, the hypothesis was tested that those patients who most closely approximated this personality type would be most likely to be rated as “much improved.” “Denial personality” scores were 3“They were people with compulsive drives, a great need for prestige and the esteem of others, and a record of always having denied felt inadequacies. ...Life experiences had been valued not for their intrinsic satisfactions but as a means of maintaining prestige and “security.” (14). �245 PERSONALITY ASPECTS OF CONVULSIVE THERAPY established pretreatment in independent structured family interviews. Fifteen spe— ciﬁc areas of behavior were assessed and scores of 0, 1, and 2 were assigned for each of these areas according to whether the subject least, moderately or most approximated the characteristics of the “explicit verbal denial” personality type. In interviews with relatives of 47 patients, scores ranged from zero to twenty-ﬁve, with a median of eleven. Subjects with scores above eleven were classed into a high denial group, while those with scores below, into a low denial group. Patients with high denial personality scores were most likely to be rated as “much improved,” with only one patient rated as “unimproved.” Of patients with low denial scores, clinical ratings occurred on a chance basis in each evaluation category (Table 3). The difference in the denial scores be— tween the much and moderately improved patients, when compared to the unimproved patients, is statistically signiﬁcant at the one per cent level (12). In a further elaboration of these personality types, studies of the total in—patient population were undertaken. Certain sociologic and psychological factors were studied in all patients in residence on March 7, 1957. These included the California F Scale, age, years of education and place of birth (8). TABLE 2 Relation of Rorschach Factors to Clinical Response in Convulsive Therapy Dif— N Mean S. D. ference Number of Responses Much Improved 3813.00 6.7 Moderate, Unimproved 48 19.5 12.8 52 ' 7*... 6 Per Cent Whole Responses 38 37.6 21.013 Much Improved ' 23 ' 0*... Moderate,Unimproved 4824.4 18.2 Per Cent Popular Responses Much Improved Moderate,Unimproved Number Movement sponses Much Improved 38 37.7 21.6 11 1 2 8** ' ' 48 26.6 14.3 Re- Moderate,Unimproved 38 2.3 48 4.9 Number Content Categories 38 3.8 Much Improved Moderate, Unimproved Per Cent Form Responses Much Improved Moderate,Unimproved 4.9 48 2.7 5 1 2.2 2.3 2 ' 62 ' 7,“. 1 ' 12 ' 1* 38 71.8 19.0 9 ' 92 ' 2* 48 61.9 21.4 Signiﬁcant at .01 level Signiﬁcant at .05 level ** * TABLE 3 Relation of Denial Personality Scores to Clinical Response in Electroshock Mod- N CALIFORNIA F SCALE The California F Scale consists of a series of extreme or stereotyped statements con— cerning social and personal attitudes. The subject reads each statement and then reports the extent of his agreement or disagreement. Originally presented as a guide to a subject’s capacity for ethnocentrism and authoritarianism, the method has recently been explored as a measure of stereotypy and rigidity in communication (8, 10). The test was presented to all patients prior to treatment and scored on a scale of ten to seventy. The ﬁgures represent maximal dis- t Personality Score High Denial—(11—25) Low Denial—(040) 24 23 NEE] erately ImImproved proved proved 14 7 9 9 l-| 7 agreement (low score) and maximal agree— ment (high score) with the statements. There was a signiﬁcant relationship (p < .05) between the pretreatment test scores and evaluations of the clinical response to convulsive therapy (Table 4). For patients rated as “recovered,” the mean F score was 53.1, while for those rated as “unimproved” �246 FINK, KAHN AND POLLACK TABLE 4 Relation of Social Factors to Discharge Ratings in Convulsive Therapy N Recovered Much Improved Improved and proved Unim— 8 26 23 $3 “*3 a ‘3 >§ E5 2 2 2 a. &° 53.151.6 9.4 50 41.843.810.6 35 39.732.312.3 17 the score was 39.7, reﬂecting greater degrees of agreement with the stereotyped statements of the test for the “recovered” group. SOCIOLOGIC FACTORS When analyses were made of the relation between improvement ratings in convulsive therapy and age, years of education and place of birth, signiﬁcant relationships were observed for each of these variables. The “recovered” patients were signiﬁcantly older (p < .001) and had signiﬁcantly fewer years of schooling (p < .05) than the “unimproved” group. While a larger percentage of the “recovered” patients than the “unimproved” patients was foreign-born (50 per cent vs. 17 per cent), the differences were not signiﬁcant. In each category, the “much improved” subjects fell in between (Table 4). DISCUSSION We have noted that measures of perceptual organization, personality traits and sociologic data are related to the degree of improvement shown by subjects with cone vulsive therapy. These observations pr0v vide an understanding of the individual variability in the behavioral response to convulsive therapy under conditions of ap~ parently equivalent degrees of altered brain function. In their studies of patients with brain disease, Weinstein and Kahn described be— havioral patterns as ludic behavior (15), increased smiling and laughter, denial of illness, minimization and displacement of symptoms, and altered sexual behavior achieving prominence in the milieu of a1— tered brain function. They suggested that the manifestation of these behavioral patterns also provided the basis for the evaluation of improvement in convulsive therapy (16). In these studies of patients in con— vulsive therapy the same patterns of laughing and smiling, denial, displacement, minimization and altered sexual activity do indeed occur in the milieu of the induced altered orientation and discrimination (2). It is the patients demonstrating these altered behavior patterns who are rated as “recovered” or “much improved”; while those patients failing to show these patterns or doing so transiently are evaluated as “unimproved” or “improved.” Recent studies of changes in language with convulsive therapy have further ampliﬁed an understanding of these behavioral responses. Alteration in syntactic aspects of language has been related to clinical ratings (9). Patients evaluated as “recovered” and “much improved” demonstrated signiﬁcantly greater use of the past or future tense and the third person mode with qualiﬁca— tion, evasion, denial, displacement, clichés, and cryptic and stereotyped expressions during treatment than did “unimproved” patients. More recently, Jaffe et al. (6) reported that formal speech patterns also were characteristically altered. In dyadic interactive speech analyses (5), increased repetitiveness and stereotypy were associated with syntactic language changes during convulsive therapy. In the studies reported here, aspects of personality organization have been deﬁned which are related to the type of behavioral response incident to convulsive therapy. The Rorschach patterns of the more favorably rated group are generally associated with greater degrees of conventionality and stereotypy, and little introspectiveness, imagination, empathy and creativity. Similarly, the higher F scores of the more favorably rated group is consistent with greater �PERSONALITY ASPECTS OF CONVULSIVE THERAPY degrees of ethnocentrism, authoritarianism, rigidity and conventionality. In present day urban culture older patients generally have less formal education and a greater number are foreign born than younger patients. These sociologic factors are also associated with greater adherence to conformist ideologies and ethnocentric identiﬁcation. We may conclude that those patients who ap— proximate the “explicit verbal denial” personality type, and who are non—empathic, non-introspective, stereotyped, rigid and conventional are most likely to manifest the euphoric and hypomanic modes of behavior under the conditions of altered brain function induced by repeated convulsions. Such patients also rely primarily on nonverbal patterns of communication, and with treatment evince increasing use of the lan— guage patterns of repetitiveness, denial, displacement and third person. These changes in language and behavior are the cues to which psychiatrists and administrators respond in their evaluations, and thus provide the basis for the clinical ratings of “re— covered” and “much improved” (9). In contrast, those subjects who are em— pathic and introspective, who are not rigid, conventional or stereotyped, and who rely primarily on verbal patterns of communica— tion are less likely to manifest the ludic behavioral modes of euphoria and hypomania. With the induced alteration in brain function they manifest increased somatiza— tion, withdrawal, projection, anxiety, panic and intellectualization. Their speech is pre— dominantly in the present tense and in the ﬁrst person mode without displacement, denial or clichés. Clinically, such patients are rated as “unimproved” or “worse.” Thus, while altered brain function is essential for a behavioral change in convulsive therapy, individual differences in personality organization provide the basis for the variability in the types of behavioral changes and in the clinical ratings of improvement. In another report (12) it was suggested that the personality attributes 247 which provide the background for improve— ment with convulsive therapy also provide the basis for the depressive adaptation ini— tially. It was noted that numerous authors had described a characteristic pre-depressive personality type, with a prominence of the features of perfectionism, rigidity, con— scientiousness, and stereotypy. The social factors, Rorschach and F scale patterns described here also support such a suggestion. Ludic patterns of depression and mania are more prominent in older, less educated sub— jects. The conventionality, rigidity and stereotypy associated with the ﬁndings on the F scale and the Rorschach test are also prominent in depressive illnesses. It is probable that the depressive psychotic reaction and the euphoric-hypomanic behavioral re— sponse in convulsive therapy may be as— pects under different neurophysiologic con— ditions of an adaptive pattern in subjects with a personality organization marked by stereotypy, rigidity, conventionality and poor capacity for introspection and em- pathy. CONCLUSION In studies of convulsive therapy, differences in personality organization and sociologic aspects of history have been related to differences in behavioral response. Persons who are stereotyped, rigid, non-empathic and non-introspective, as deﬁned by explicit criteria in Rorschach, F Scale and structured family interviews, and who are less edu— cated, older and foreign born are more likely to manifest behavioral modes of euphoria and hypomania and to be evaluated as “recovered” and “much improved.” Patients who are introspective, empathic, non-stereotyped, native born, better educated and young are more likely to manifest somatiza— tion, paranoid—withdrawal and panic modes of behavior with convulsive therapy, and to be rated as “unimproved” or “worse.” While an induced alteration in brain func— tion is necessary for behavioral change in the convulsive therapy process, personality �248 FINK, KAHN AND POLLACK organization and sociologic factors are de— terminants of the type of behavioral change, and of the clinical ratings of degree of improvement. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock: quantitative serial studies. A. M. A. Arch. Neurol. & Psychiat, 78: 516— 525, 1957. 2. FINK, M. AND KAHN, R. L. Behavioral patterns of induced states of altered brain function. Presented at the NY. Divisional Meeting A.P.A., Nov. 1957. 3. FINK, M., KAHN, R. L. AND GREEN, M. A. Experimental studies of the electroshock proc— ess. Dis. Nerv. System, 19: 113—118, 1958. 4. FINK, M., KAHN, R. L. AND KORIN, H. Relation of tests of altered brain function to behavioral change following induced convulsions. In Proceedings I nternat. Congress N eurologic Sciences, Brussels, 1958 (In press). 5. JAFFE, J. Language of the dyad. Psychiatry, 21: 249—258,1958. 6. JAFFE, J., KAHN, R. L. 7. AND . 216—228, 1957. . KAHN, R. L. AND FINK, M. Changes in lan- guage during electroshock therapy. In Psychopathology of Communication, Hoch, P. and Zubin, J., eds. Grune & Stratton, New York, 1958. 10. KAHN, R. L. AND FINK, M. The relation of F score to behavioral and physiologic response with altered brain function. Presented at Eastern Psychological Assoc, Phila., April, 1958. 11. KAHN, R. L. 12. 13. 14. FINK, M. Com- munication patterns with altered brain function. Presented at Eastern Psychological Assoc., Phila., April, 1958. KAHN, R. L., FINK, M. AND WEINSTEIN, E. A. Relation of amobarbital test to clinical im— provement in electroshock. A. M. A. Arch. Neurol. & Psychiat, 76: 23—29, 1956. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in selection of therapy in a voluntary mental hospital. J. Hillside Hosp., 6: 15. 16. M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. System (In press). KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock therapy. Conf. Neurol. (In press). KLOPFER, B. AND KELLEY, D. The Rorschach Technique. World Book Co., New York, 1942. WEINSTEIN, E. A. AND KAHN, R. L. Personality factors in denial of illness. A. M. A. Arch. Neurol. & Psychiat., 69: 355—367, 1953. WEINSTEIN, E. A. AND KAHN, R. L. Ludic behavior in patients with brain disease. J. Hillside Hosp., 3: 98—106, 1954. WEINSTEIN, E. A. AND KAHN, R. L. Denial of Illness. C. C. Thomas, Springﬁeld, Ill., 1955. AND POLLACK, ��m.v..ww.. _._’—_w L. ��unma‘mww ”WNW. mwmmmmmmem M'Wt Wmemwmmg mmmmmm a .‘ Wmimﬁmxmtmmwwu mummmammmmhum MWWFW(%M}§ mwmmm mwmmatmmmmum. mum umwamm‘ ‘ “at“ - ��wmmmwummumtmm Wm»m:mwwm,m,rm WWWMrotmm. mmdmu ﬂuMWu’MWWWaWWM «in» ' m W “W“ mwmmmmmvmmm mm w «- and “mmuwmawmmmuWa-m WMWMMmemuImeW (ma). mm,mummww”tw mmmwwcmm. mm ‘ ��ms s: 3 {8 a 5 M 3.5:: flat? 8.2. h! 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Punt _ �Psychologic Variables and Neurophysiologic Reaponsivity In Convulsive Therapy Max Fink 14.13., Robert L. Kahn Ph. 13., PollacK Ph.D., Max Eric Karp B.A. and George Krauthamer Ph.D. / MiConsecutive referrals for convulsive therapy of psychologic were studied by a measures prior to treatment, and by variety; electro- encephalogram prior to and at weekly intervals during treatment. Alterations in brain function, as reflected Wm and amplitude were examined EEG frequency, modulation, pattern variables’W in relation to these and improvement on in by changes to behavioral change and a clinical gating of teminatMtreafmren‘t . Significant relationships ”if”; were observed induced change and the following pre-treatment variables: EEG (W m W (a) Educational level > ‘ between the degree of -”M(b) . i5- Rorschach criteria ' (c) ‘ (d) . 0} . Mnemr, 8.4,, M Ma... {@3/apmaw {magmg /,~:.,W2M7/5,,+. - «1' Jul deft“ WW 4% significant relationship ia-legiesee existed between alteration of brain function and treatmet induced behavioral change. degree Metfffrﬁfiﬁfrtmm_.._.a,._m.,...,hz:€.5...» 7‘» «9 a' “W” ' delta a ~- . A clinical rating of improve“be!” 0 ,mx fwﬂ’ A h #5.» da » - QC . (Hréy 50’4”“? “ﬂaw mentm‘honever, was contingent” upon high degree delta activity4ude pretreatment psychologic pattem‘W) , sociologic status and environmental '- “)2, «Km , expectationxr. Conclusions: ﬁ’ehavioral change was related to electrographic change. while—a— rating of "improved" socio—psychologic 0b Iivz'taa-additionally dependent upon a factors. Mor-eover, neurophysiologic (rate ﬁgme of change) to induced convulsions \ pretreatment psychologic variables. ,1' , ' constillation responsivity of 46“ significantly related to ’4' �l' “ s —2- W .. Past studies of the relation of electrographic change to behavioral change M have yielded con radictony results. These variations in outcome may be due to differences in the personality characteristics of the populatioz%tudied since L... patternsm related not only to the type and duration of socio-pscyhologic induced behavioral change but to the degree of electrographic change as well. ) , present results underline the fact that a univariate analysis of neurophysiologic and. behavioral relationships is no lonser adeouate to the problems of experimental psychiatry, and the application methods of The multivariate analysis is From / recommended. the Department of Experimental Psychiatry, Hillside Hospital Glen Uaks, _ of” L.I., 3/31/60 1,12 ‘W'o Am. N.Y. EEG �Peychologic Verieblee end Heurephyeielogic neeponeivity In Convaleive Therepy H.D., Robert L. Kehn Pb. B., Hex Polleek Ph. 9., Eric Kerp 8.1. end Gear‘s Kreuthemer Ph. D. Hex Fink caneecutive reterrele for convulsive therepy were etudied by e veriety of psycholcgic neeeuree prier to treetnent, end by electreeneephelogrene priortc end et weekly intervals during treat» sent. Alterations in brein funetian, ee reflected EEG by changes in frequency, modulation, pattern and emplitude were exemined in relation ta these verieblee, retinx of impraveuent an and to behavioral chense and e elinieel termination at treatment. aignificent relationship: (ch12) degree otinduced EEG change end the were cheerved between the tellewin; pro-treatment verieblee: / (e) Educetianel level (b) Borechack criterie at Movenent, cola: end number at reepanaee Embedded figures tent 5c) d) Alphe index A eignificent reletionnhip also existed between ulteretien of brain functien and treatment induceé behavioral change. a: behavioral chenge clinicel retina wee The releted to the degree at doth activity. degree A of improvement an the ether hand, wee contingent net only upan high degree delta activity but 1139 upen pretreatment �-2psycholozic puttcrna, acciolugic atatuu and :nvironmontal czpoetu» tians. In convulsiva thornpy, bchuvieral china. 1: concluaianl: rolntnd tn oloctrojruphic ahango. ally doplndont upon n A rgtin; at "iaprovod" is udditienu conttullutien of nocia-puychalogic fucters. Haruovor, nourophyniologie rolponnivity (rate or dogrco or chug.) to induced convulntian any :13» be ainnitiauntly rulgtod to prttrtat~ meat 0! p'ycholugic itriabloa. Putt studio: at tn. rclution or uloctroxrnphic chums. to bchnvieral chancc 1n aonvnlaivo thar¢py hgvo yieldod contradietery results. Thoad variations in outeon. may be due to dirtcraneca in the per-antlity ehnrtgtoristtel at the papulntinns atadiad sine. aocio~puychelogic pattorno may be relatud act only ta th. type tad durntion of induced behavioral chang¢,but to the dagrue a! cloetron graphic chance as well. The proutnt ralultu undarlino tho itct that a univtriato unllyais or nouraphyaiologic and bah;vioru1 rolatianahipa is no lengur aduqutto to the prablonl a! prorinonttl psychiatry, und the npplication or methods or From rocommandad. the Dopnrtuqnt of Exporinontnl Psychiatry, Hillaido Hospital Glon Oaks, 1v: nultivaridn analysis in h/l/éc 3.1. L.I., Am. 320 �‘ ,é?" /' / (o 1/, "y .4 Psychologic Variables and Neurophysiologic Responsivity In Convulsive Therapy Max Fink M.D., Robert L. Kahn Ph. D., Max Pollack Ph. D., Eric Karp B.A. and George Krauthamer Ph. D. Consecutive referrals for convulsive therapy were studied ﬁg: a. variety of psychologic measures préer—te treatment, by a and by electroencephalograms priogﬂb and at weekly intervals during treatment. Alterations in brain function, as reflected 91/ ~EEG “ﬁg; r5313r «35? a». in affﬂzf‘ﬂgﬁ" Qi’e‘u frequency, modulation, pattern and amplitudeﬂwere examined in relation to these variables, rating of improvement on and to behavioral change and degree ofinduced a ébg: m Educationa Rorschacﬁ e \.of reaponses Embedded figures test Alpha index 0 "d A and the 25% a clinical termination of treatment. Significant relationships (chizi xi, 3F 5.3,“,change of 2‘33; by changes were observed between the following pre— treatment variables: A, ovement,A color, and number of significant relationship also existed between alteration brain function Aand treatment induced behavioral change imbald£££§§WW, WW C56Mamet, (Wheg “Mbehaxlnnalxchangemuas.relaxed.tewthedegreeofwdglﬁ33%;:gﬁrw £17MM4/sgéf “3...: W clanaeelwrati“g“cﬁmimprgyementan“: an s: {:Lﬂﬂu 49; ‘odZEfMM,4 9% only upon high degree 3%”;ng Clzbwi ,1? W4 'Mcthermnaﬁdwwwas My»: delta activity but also upon y A 'x contingent not pretreatment �\ -2psychologic patterns, sociologic status and environmental expectae tions. Conclusions: In convulsive therapy, behavioral change is i related to electrographic change. ally dependent upon a A ' is addition— rating of aou:;;:::ew3‘ constgllation of socio—psychologic factors. Moreover, neurophysiologic responsivity (rate or degree of chage) to induced convul€2§0n§may also be significantly related to pretreat— ment ,/ psychologic variables. Past studies of the relation of electrographic change to behavioral change in convulsive therapy have yielded contradictory results. 'These variations in outcome may be due to differences in the personality characteristics of the populations studied)since socio—psychologic Kﬂwaaah patterns meynbe related not only to the type and duration of induced behavioral change,but to the degree of electro— graphic change as well. dwadﬁfffﬂ present results mad-niIl-Iib-iﬂiit thatdﬂ‘univariate analysis or ngﬁsﬂb 4o of neurophysiologic and behavioral relationships gﬁkno longerﬁadequate The \ tojthe problems of experimental psychiatry, ’ and the . application of 1 methods of multivarian analysis is recommended. From the Department of Experimental Psychiatry, Glen Oaks, L. I. 1v: h/1/60 Am. N. Y. EEG Hillside HOSpital - �01:? ////’ m ' Individual Differences in Neurophysiologic Responsivity to Convulsive Therapy Previous studies indicated that an alteration in brain function was requisite to/tkéfbehavioral change and ratings of improvement in convulsive therapy. has been The type of behavioral change related to various perceptual,psychologic, and social aspects of the individual's history and behavior.The present study demonstrates significant relationships between the degree of 037' -convulsive neurophysiolegic change and amobarbital test (EEG slow wave activity response) and pro-treatment perceptual{MW‘ 4, , ' personality functioning (educational level, Rorschach, figure5 \ . {A 1‘ 1 groun While Mylo “W“; ’/ f relationshipeztsﬁuu'n neurophysiolegic “a. 3mm meeewneﬁ a-dL J3 ”(a[7w // ,3 5‘ 1%?!” ”Z personality measures have generally not been-establisheéi these observations indiate that the rate and degree of change] in neurophysiologic .m (mm/Me may indeed be related to personality cognitive Illﬂlllﬂr(perceptualenillI-Ig style). 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological factors affecting individual differences in behavioral response to convulsive therapy. J Nerv Ment Dis. 1959 Mar;128(3):243-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-36-002 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Pollack, Max Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 3 items. 1: Reprint from THE JOURNAL or NERVOUS AND MENTAL DISEASE Volume 128, N0. 3, March 1959. 2: [preprint]. 3: 2 drafts and one abstract. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/261abbc7e46388bc86f6597be731bd1c.pdf 0134e8d9c4e023061da7cfc3c500f0f0 PDF Text Text t Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, McDo Robert L. Kahn Ph.D. and Hyman From Korin Ph.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks,N.Y. Institute of Mental Health, National Health Service. United Public States of Health, Institutes Aided by Grant M-927 of the National (in part) at the Divisional Meeting A.P.A., Montreal, November, 1956, and International Congress of Neurological Sciences, Brussels, July, 1957. the at Read 12-3-57 “W5, $9; WW7 A“! �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous studies have been.reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and meaningful conclusion regarding the it is difficult to arrive at a relation of such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organictype reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various tests of brain function were applied serially to patients in mhom‘behavicr was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. METHOD: Definition of "organic mental changes": conventional conception The of organic mental changes includes such behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; and loss of interest in one's appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following by tests of simple electroshock. The memory loss is usually measured recall, information, personal events, digit memory span, �~2r etc.: while disorientation is place, date, determined by questions the examiner, 323, name of Such tests of relating to present memory and of orientation, however, discriminate primarily only severe degrees of dysF function. In the present studies, cognizant of the difficulties inherent in clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, simple types of dysfunction. The four'measures selected as being sensitive to varying aspects and degrees of cerebral dysfunction.were: a) The degree of delta activity in the electroencephalogram (1). b) in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain Changes disease (2, 3). c) Alteration in perception of multiple simultaneous d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists tactile stimuli (h). words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. Observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram is memory changes have disappeared and week following an extensive �-BIn the present studies, the electroshock treatment schedule was main- tained at three times per week with Reiter electroshock, during the all patients receiving conventional initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimmn intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination: of therapy, weekly testing was continued until the tests returned to their initial level. third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical Behavior Ratings: response to therapy A is a subjective value judgment by the therapist or adninistrator which reflects a divergence of goals, judgments, and compromises. Significant variables in the evaluation of "improvement" are the type, severity and duration of the pets“. ent' s illness, his premcrbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the institution, of the patient and of the family. of the evaluation of the treannent result is also a the therapist, of Furthermore , the time most sigaificant variable. The parameters of evaluation have not been satisfactorily delineated. In this study, the following compromises have been made. All evaluations qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are made by an independent are seen weekly and conferences are held with the therapist to assess the �.Ll. therapeutic goals before treatment and the therapist‘s estimate of the respOnse after treatment. The finai evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. we have used a three-fold classification of improved" and "uninmuoved," with the and "unimproved" "much improved," "moderately intent that the categories respectively "much improved" would describe patients at the extremes of the response continuum. The patients rated as those "much improved" were showed the symptoms which brought them.to the who no longer hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior who manifested no clearly or'Who became worse. The "moderately improved" patients showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �.5. RESULTS : Twenty-four consecutive electroshock patients were studied. these, eleven and were Of "much improved," seven as "unimproved," rated as six as "nmderately improved." (a) Electroencephalogrems: EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the Slowest frequency in the record; and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as "high delta activity" and the lowest 1/3 as "low delta activity." pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It No was apparent within the on the third with high first week following EEG week of treatment and the 7~9 treatments. The usually reached a peak results for those delta activity are seen in Table I. TABLE EEG - % I High Delta Activity 1-3 h—é 7-9 10-12 25 80 91 88 Moderately Improved (6) 0 16 50 ho unimproved (7) o o o 20 Treatment Period: much Improved (11) �~6(b) AmObarbital Test: In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal response, reflecting a change in brain function ascribed to “organic brain disease" (2). The results are noted in the next table. TABLE II Amvtal Test -.% Positive Treatment Period: 1-3 11-6 7-9 10-12 13-15 Much Improved (11) us 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence I and II have been graphically portrayed in Figure of the observations of the degree of delta activity EEG l. and test responses is demonstrated. (Fig. 1) Tests: In this test (5) a list of three letter common the per cent positive amytal (c) Memos! words were presented for 10 to patients by flash cards. trials. After this, lists interpolated. The of 3 recall of the first The cards were presented letter nonsense syllables list were of'wordStmas.then tested, and the number of words recalled in each session was scored. An impairment in recall function decrement was maximal in the second was apparent and third in all subjects. This weeks of sustained as long as treatments were administered treatment, 3 times a week. and was �-7The decrease in ability to recall the word list is noted in the next table o TABLE III anaiment in Recall - Marked Decrement % Treatment Period 1-3 1456 7-9 10-12 Improved (9) o 11 33 o Moderately Improved (h) 0 SO SO 0 Unimproved (7) 0 1h 0 0 Much the scores are compared with the mprovement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to When two times per week indicates that this more severe degrees test is a measure of only the of cerebral dysfmction. tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localize the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to (d) Tactile Perceptual Tests: In these report the stimuli or to mislocalize a stimulus beyond the tenth indicative, in adults, of altered cerebral function (h). one of trial is In all subjects, this test was negative before patients. In nine patients, two observed, and of these, six were in the much responses were observed in 19 of the consecutive responses were improved and three treatment. Positive 21; in the moderately improved groups. �In the next table the positive responses were charted with relation to the treatment period and of positive regaonses is to the clinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive 1-3 h-6 7-9 10-12 13-15 Much Improved (11) 16 no in h3 60 Moderately Improved (6) 60 1:3 2:3 30 o o 16 12 11 o Treatment Period Unimproved (7) �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and the and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and evaluation; and after treatment to the clinical the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function'was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for one to three weeks fOIIOWing treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changes but these appeared late (in the 2nd and remained week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another‘variable, it is important, the operation (or test) and the Because these tests have varying change in brain function therefore, to clearly define both sensitivity of the operation which forms the basis for the estimation of altered cerebral function. sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �~10- treatment, while changes in recall function and simultaneous tactile perception are rapidly 0f the function, clinical lost, when treatment frequency reduced. correlations possible with these tests of brain many we have selected the relation of these test results to the improvement rating. ‘With the EEG-and amytal relationships between the appearance of test changes improvement are is clearly observed. In the positive amytal tests and high degree were more marked, and were sustained EEG tests significant and much improved clinical patients, abnormality appeared early, for longer periods (on the treatment regimen) than in the unimproved patients. The same moderately improved patients were in between. relation between altered brain function and clinical response This is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-ptreatment test results. This divergence is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of this prdblem. These Observations can also be mode of action of electrochock. related to an understanding of the In 1952,'Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to "initiate the production of a state of altered brain function in which the patient his problems." These observations support the first part of this hypothesis. namely, that a state of altered cerebral function is can deny induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �, those who fail to improve. Of the eleven positive amytal tests (while positive test); and ten had high had one of the unimproved .11.much improved patients, all 5 of the 7 unimproved never had a EEG abnormality records, while only patients had such a record. It is our condlusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early? sustained and �4.2;» W: In a study of the relation of tests of altered brain function to improvement in electroshock, of change it was observed that while indicators in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on and early, sustained that electroshock therapy and marked changes may be in mental function; described as the non-Specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. �REFERENCES 1- Fink, M. and Kahn, R.L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neural. & chhiatﬂﬁ: 516.525, 1957. _ Kahn, R.L. and Malitz, 3.: Serial Administration Test" for Brain Disease. Its Diagnostic and of "Anvtal Prognostic Value, A.M.A. Arch. Neural. & Psychiat. 217-226, 1951;. 2. Weinstein, E.A,, _’_?_I_: 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M,A. Arch. jieurol. 8c Psychiat" Zé: 23-29, 1956. and Bender, M.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, NeurologX, _2_: h. Fink, M., Green, ILA. h6—58. 1952. H. , Fink, M. and Kwalwasser, 8.: Memory and Learning to Improvement Neuron-o, $6.: 88'96’ 1956. 5. Karin, Relation of Changes in in Electroshock, Conf. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat., 109: 22-26, 1952’. �--- .. anEu’mlJ-Jﬁal from , “T'he FLSL , ,.. -n Congress of Neur-ofogical ’, Brussels, 1.;7. Vol. III. EEG, Clinical Neurophysiology ces -pllepsy. Pergamon Press; London, New York & Paris 1959 "Emmi , RELATION OF TESTS OF ALTERED BRAIN FUNCTION TO BEHAVIORAL CHANGE FOLLOWING INDUCED CONVULSIONS DANS CEREBRALE FONCTIONNELLE ALTERATION D'UNE ROLE LE CHANGEMENT DE COMPORTEMENT SUCCEDANT A DES CONVULSIONS PROVOQUEES MAX FINK, ROBERT L.KAHN and HYMAN KORIN New York, U.S.A. Numerous studies have been reported assessing the type, duration and significance of mental changes following electroshock. These reports vary widely in their descriptions and it is difficult to arrive at a meaningful conclusion regarding the relation of such mental changes to clinical the in vexing observation differences to are these Basic response. problems of the definition and the ways of measurement of organic—type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definitiOn of the problem. In the to function of applied serially brain were various tests present study, of inductions grand altered whom behaviour by in repeated was patients mal convulsions (Electro shock). The data comparing the serial changes in these indices are presented. MET HOD Definition of 'organic mental changes' The conventional conception of organic mental changes includes such of of discrimination the and of behavioural changes as impairment memory differences on perceptual tasks; disorientation for time, date, or place; handle to and more inability caICulation 0n distractibility tests; errors than one situation at a time; per serveration in speech and behaviour; emotional lability; and loss of interest in one‘s appearance and in the environment. Most studies assess the relationship of memory loss or clinically manifest disorientation to improvement following electroshock. The memory loss is usually measured by tests of simple recall, informa: while disorientation is etc. tion, personal events, digit memory span, determined by questions relating to present place, date, name of the examiner, etc. Such tests of memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, to sensitive selected four being The as of measures types dysfunction. varying aspects and degrees of cerebral dysfunction were: (a) The degree of delta activity in the electroencephalogram (l). (b) Changes in language and orientation following the administration of amobarbital sodium - the 'amytal test' for organic brain disease (2, 3). 613 ‘ �614 M. FINK, R.L.KAHN and H.KORIN (c) Alteration in perception of multiple simultaneous tactile stimuli ((1) (4). Changes in tests of recall of common words, both with and without the interpolation of reading lists of nonsense syllables (5). Time of Testing A second factor to be considered is the time of application of these tests in relation to the treatment program. Numerous observers have reported the development of organic changes in the few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third week following an extensive course of therapy the electroencephalogram is at pretreatment levels, memory changes have disappeared and orientation is re-instituted. In the present studies, the electroshock treatment schedule was maintained at three times per week with all patients receiving conventional Reiter electroshock, during the initial three weeks. In the fourth week, treatment frequency was occasionally reduced to two times per week. All patients received a minimum of tWelve treatments. All tests were carried out at weekly intervals on a day following a treatment during the course of therapy. Following termination of therapy, weekly testing was c0ntinued until the tests returned to their initial level. Behavior Ratings A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definitiOn and evaluation of 'improvement‘. The evaluation of clinical response to therapy is a subjective value judgment by the therapist or administrator which reﬂects a divergence of goals, judgments , and compromises. Significant variables in the evaluation of 'improvement' are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectatious (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactOrily delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of ‘subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the therapeutic goals before treatment and the therapist's estimate of the response after treatment. The final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behaviour. We have used a three-fold classification of 'much improved' , 'moderately improved' and 'unimproved' , with the intent that the 'much improved' and 'unimproved' categories respectively would describe patients at the extremes of the response continuum. The patients rated as 'much improved' were those who no longer showed the symptoms which brought them to the hospital, their physicians ' �Relation of tests of altered brain ﬁmction to behavioral change 615 believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The 'unimproved' patients were those who manifested no clearly noticeable change in behaviour or who became worse. The 'moderately improved' patients showed some change in behaviour, but continued to manifest signs of mental illness. They typically showed some symptomatic relief, which was transient. RESULTS Twenty-four consecutive electroshock patients were studied. Of these, eleven were rated as 'much improved', seven as 'unimproved', and six as 'moderately improved'. (a) Electro enc ephalogr am s EEG records, using conventional leads, were measured for the average per cent time delta activity, and highest per cent time delta in any one lead; the slowest frequency in the record; and the duration and amplitude of delta bur st activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. The upper 1/3 of the records were described as 'high delta activity' and the lowest 1/3 as 'low delta activity'. No pretreatment records showed delta activity. During the course of electroshock delta activity appeared in all records to varying degrees. It was apparent within the first week of treatment and usually reached a peak on the third week following the 7-9 treatments. The results for those with high EEG delta activity are seen in Table I. TABLE I EEG - % High Delta Activity Treatment Period: Much Improved (11) Moderately Improved (6) Unimproved (7) (b) 'W .....'-.——-—- a .- 1-3 4-6 7-9 25 80 91 50 10-12 —-——————__.____—_~__ 0 0 16 0 0 88 40 20 Amobarbital Te st In these tests (2, 3) the patients are asked a series of questiOns relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in orientation and awareness of illness are scored as 'positive' amytal response, reflecting a change in brain function ascribed to 'organic brain disease' (2.). The reSults are noted in the next table. �616 M. FINK, R.L.KAHN and H.KORIN TAB—Ly; Arnytal Test - % Positive Treatment Period Much Improved (ll) 1-3 4-6 7-9 10-12 45 20 Moderately Improved (6) Unimproved (7) 64 100 33 67 14 16 16 89 20 33 13-15 100 25 0 (c) Memory Tests: In this test (5) a list of three letter common words were presented to patients by ﬂash cards. The cards were presented for 10 trials. After this, lists of 3 letter nonsense syllables were interpolated. The recall of the first list of words was then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. The decrease in ability to recall the word list is noted in the next table. TABLE III Impairment in Recall - % Marked Decrement Treatment Period Much Improved (9) Moderately Improved (4) Unimproved (7) 1-3 4-6 7-9 10—12 0 0 0 ll 33 50 0 50 l4 0 O 0 are compared with the improvement rating, there is no significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the more severe degrees of cerebral dysfunction. (d) Tactile Perceptual Tests In these tests the patient is touched by the examiner simultaneously on the cheek and the hand, and asked to localise the stimuli. The tests are repeated for 10 trials using varying combinations of cheek, hand, shoulder and thigh. Persistent failure to report one of the stimuli or to mislocalise a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (4). In all subjects, this test was negative before treatment. Positive When the scores �Relation of tests of altered brain ﬁmction to behavioral change 61 7 responses were observed in 19 of the 24 patients. In nine patients, two consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. In the next table the positive responses were charted with relation to the treatment period and the clinical evaluation. A high incidence of positive responses is to be noted in the first two groups, and many fewer such responses in the unimproved group. w Face Hand Test - % Positive Treatment Period 1-3 4-6 7-9 10-12 13-15 Much Improved (11) 16 Moderately Improved (6) Unimproved (7) 60 O 4o 43 16 47 43 12 43 3O ll 60 0 0 DISCUSSION Three aspects of these observations warrant elaboration. The sensitivity and stability of these indices of altered brain function and the significance for a definition of altered cerebral function; the relation Of these indices during and after treatment to the clinical evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions and remained persistently positive for one to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perceptual tests also showed changesbut these appeared late (in the 2nd week of treatment) and disappeared rapidly when treatment frequency was reduced. Tests of recall function and tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced change in brain function to another variable, it is important, therefore, to clearly define both the operation (or test) and the sensitivity of the operatiOn which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and amytal tests significant relationships between the appearance of test changes and clinical improvement are clearly observed. In the much improved patients, positive amytal tests �618 M. FINK, R.L.KAHN and H.KORIN and high degree EEG abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment‘regimen) than in the unimproved patients. The moderately improved patients were in between. This relation between altered brain function and clinical response is noted only with the data obtained during the course of therapy. There is no correlation of improvement ratings with post-treatment test results. This divergence is related to the timing of test applications, and may explain the discrepancies in the conclusions of other studies of this problem. These observations can also be related to an understanding of the mode of action of electroshock. In 1952, Weinstein, Linn and Kahn (6) postulated that the function of electroshock therapy was to 'initiate the production of a state of altered brain function in which the patient can deny his problems'. These observations Support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who improved, the altered state is more prominent, appears earlier and is more persistent than in those who fail to improve. Of the eleven much improved patients, all had positive amytal tests (while 5 of the 7 unimproved never had a positive test); and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion that early, sustained and significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. ' SUMMARY In a study of the relation of tests of altered brain function to improvement in electroshock, it was observed that while indicators of change in brain function vary in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. The reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study and the difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is dependent on early, sustained and marked changes in mental function; and that electroshock therapy may be described as the non— specific, traumatic induction of states of altered cerebral function in which the subject reacts with new patterns of adaptation. REFERENCES l. 2. 3. Fink, M. and Kahn, R.L. Relation of EEG delta activity to behavioral response in electroschock: quantitative serial studies. A.M.A. Arch. Neurol. and Psychiat. , 1957, 78: 516-525. Weinstein, E.A. , Kahn, R.L. and Malitz, S. Serial administration of 'Amytal Test' for brain disease. Its diagnostic and prognostic value. A.M.A. Arch. Neurol. and Psychiat. , 195.4, 71: 217-226. Kahn, R.L. , Fink, M. and Weinstein, E.A. Relation of amobarbital test to clinical improvement in electroshock. A. M. A. Arch. Neurol. and Psychiat. , 1956, 76: 23-29. �Relation of tests of altered brain function to behavioral change 619 Fink, M. , Green, M.A. and Bender, M.B. The face-hand test as a diagnostic sign of organic mental syndrome. Neurology, 1952, 2: 46-58. Korin, H. , Fink, M. and Kwalwasser, S. Relation of changes in memory and learning to improvement in electroshock. Conf. Neurol. , 1956, 16: 88-96. Weinstein, E.A. , Linn, L. and Kahn, R.L. Psychosis during electro‘ shock therapy: its relation to the theory of shock therapy. Am. J. Psychiat. , 1952, 109: 22-26. Dept. of Experimental Psychiatry, Hillside Hosp-ital, Glen Oaks, N. Y. , U.S.A. ‘ ��Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Max Fink, Rebert L. IIOD c Kahn Ph.D. and Hyman From Karin Fh.D. the Department of Experimental Peychiatry, Hillside Hospital, Glen Oaks,N.Y. Aided by Grant M~927 of the National Institute of Mental Health, National Institutes of Health, United States Pablic Health Service. (in ,art) at the Divisional Meeting A. P .A., Montreal, November, 1956, and at the International Congress oi Neurological Sciences, Brussels, July, 1957. Read 12—3-57 �Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions Numerous and studies have been reported assessing the type, duration significance of mental changes following electroshock. vary widely in their descriptions and meaningful conclusion regarding the it is difficult These reports to arrive at a relation cf such mental changes to clinical response. Basic to these differences in observation are the vexing problems of the definition and the ways of measurement of organic; type reactions; the time relation of the measurements to the treatment process; and the definition of improvement following therapy. Each of these factors bears an integral relationship to the final definition of the problem. In the present study, various applied serially to patients in whom tests of brain function were behavior was altered by repeated inductions of grand mal convulsions (Electroshock). The data comparing the serial changes in these indices are presented. . METHOD: Definition of “organic mental changes": conventional conception The of organic mental changes includes sudh behavioral changes as impairment of memory and of the discrimination of differences on perceptual tasks; disorientation for time, date, or place; errors tractibility and inability to handle perserveration in speech on more than one and behavior; emotional calculation tests; dis- situation at a time; lability; interest in one's appearance and in his environment. the relationship of memory tests of simple loss of studies assess loss or clinically manifest disorientation to improvement following electroshock. The memory loss by Most and is usually measured recall, information, personal events, digit memory span, �«2- etc.: while disorientation is place, date, name of determined by questions the examiner, etc, Such tests of relating.to present memory and of orientation, however, discriminate primarily only severe degrees of dysfunction. In the present studies, cognizant of the difficulties inherent in simple clinical assessments, we measured changes in brain function by four different measures, hoping thereby to determine varying degrees, or even, types of dysfunction. The four measures selected as being sensitive to varyinD aspects and degrees of cerebral dysfunction were: delta activity in the electroencephalogram (1). b) Changes in language and orientation following the administration of amobarbital sodium - the "amytal test" for organic brain a) The degree of disease (2, 3). c) Alteration in perception of multiple simultaneous tactile stimuli (h). d) Changes in tests of recall of the interpolation of reading Time of Testing: A common lists words, both with and without of nonsense syllables (5). second factor to be considered is the time of application of these tests in relation to the treatment program. observers have reported the development of organic changes in the Numerous few minutes of recovery following each treatment. Others noted the appearance of mental changes during the course of treatment, and reported that treatments at periods more frequent than the conventional three times per week induced earlier and more severe changes. The transient nature of the changes are frequently noted, so that by the second or third is at pretreatment levels, orientation is re-instituted. course of therapy the electroencephalogram memory changes have disappeared and week following an extensive �.3In the present studies, the electroshock treatment schedule was main- tained at three times per all patients receiving conventional initial three weeks. In the fourth week, week with Reiter electroshock, during the treatment frequency was occasionally reduced to two times per week. All patients received a out at weekly minimum intervals of twelve treatments. All on a day following a tests were carried treatment during the course of therapy. Following termination of therapy, weekly testing was continued until the tests returned to their initial level. Behavior Ratings: A third factor crucial to a study relating the significance of organic mental changes to electroshock results is the definition and evaluation of "improvement." The evaluation of clinical is a subjective value administrator which reflects a divergence response to therapy judgment by the therapist or of goals, judgments, and com- promises. Significant variables in the evaluation of "improvement” are the type, severity and duration of the patient's illness, his premorbid personality, the sociologic (family) constellation to which he will return, and the expectations (both conscious and unconscious) of the therapist, of the institution, of the patient and of the family. Furthermore, the time of the evaluation of the treatment result is also a most significant variable. The parameters of evaluation have not been satisfactoriLy delineated. In this study, the following compromises have been made. All evaluations are made by an independent qualified psychiatrist who has no responsibility for the selection of subjects or application of the treatments. Patients are seen weekly and conferences are held with the therapist to assess the �.44.. therapeutic goals before treatment and the therapist‘s estimate of the final evaluation used here is the clinical state of the patient during the second and third weeks following the last treatment, and describe only changes in clinical behavior. reaponse after treatment. we have used a The three-fold classification of improved" and "unimproved," with the "much improved," "moderately intent that the "much improved" and "unimproved" categories respectively would describe patients at the extremes of the response continuum. The patients rated as "much improved" were showed the symptoms which brought them those who no longer to the hospital, their physicians believed them to be better, and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. The "unimproved" patients were those noticeable change in behavior or The who became "moderately improved" patients manifested no clearly Who worse. showed some change but continued to manifest signs of'mental illness. some symptomatic relief, which was transient. They in behavior, typically showed �-5RESULTS : Twenty-four consecutive electroshock patients were studied. "much improved," seven as "unimproved," these, eleven were rated as and Of six as "moderately improved." (a) Electroencephalograns: EEG records, using conventional leads, highest lead; the Slowest frequency in the record; were measured for the average per cent time delta activity, and per cent time delta in any one and the duration and amplitude of delta burst activity (1). Using these measurements, the 180 records in the series were placed in rank order according to the degree of delta activity. were described as "high delta activity" and The upper 1/3 of the records the lowest 1/3 as "low delta activity.” No electroshock delta activity appeared in was apparent within the on the activity. pretreatment records showed delta third with high first week following EEG all records to varying degrees. week of treatment and the 7-9 treatments. delta activity are seen in Table TABLE EEG . % During the course of The usually reached a peak results for those I. I Hiqh Delta Activity Treatment Period: 10-12 1-3 h—é 7—9 25 80 91 88 Moderately Improved (6) o 16 so ho Unimproved (7) o o o 20 ﬁnch Improved (ll) It �a (b) ~6- Amobarbital Test; In these tests (2, 3) the patients are asked series of questions relating to their illness and to orientation. Sodium amytal is administered intravenously until nystagmus and slurred speech are observed. The questions are then repeated. Changes in a orientation and awareness of illness are scored as "positive" amytal reSponse, reflecting a change in brain function ascribed to "organic brain disease" (2). The results are noted in the next table. TABLE Amytal Test - II % Positive Treatment Period: 1-3 h-6 7-9 10-12 13-15 Much Improved (11) £15 61; 100 89 100 Moderately Improved (6) 20 33 67 20 25 Unimproved (7) 1h 16 16 33 o The data of Tables The congruence of I and II have been graphically portrayed in Figure 1. the observations of the degree of EEG delta activity and the per cent positive amytal test reSponses is demonstrated. (Fig. I) (0) Memory Tests: In this test (5) a list of three letter common words were presented to patients by flash cards. The cards were presented for 10 trials. After this, lists interpolated. The of 3 recall of the first letter list nonsense syllables were of words wens then tested, and the number of words recalled in each session was scored. An impairment in recall function was apparent in all subjects. This decrement was maximal in the second and third weeks of treatment, and was sustained as long as treatments were administered 3 times a week. �.’ ~7The decrease in ability to recall the word list is noted in the next table. TABLE Impairment in Recall III - % Marked Decrement 1-3 Treatment Period Mnch Improved (9) Moderately Improved (h) ' Unimproved (7) When h-é 7-9 10-12 O 11 33 O 0 SO SO 0 0 1h 0 0 the scores are compared with the improvement rating, there is significant difference between groups. The rapid return of recall ability to pretreatment levels when treatment frequency was reduced to two times per week indicates that this test is a measure of only the no more severe degrees of cerebral dysfunction. tests the patient is touched the cheek and the hand, and asked to (6) Tactile Perceptual Tests: In these by the examiner simultaneously on localize the stimuli. The tests are repeated for combinations of cheek, hand, shoulder and thigh. report one 10 trials using varying Persistent failure to of the stimuli or to mislocalize a stimulus beyond the tenth trial is indicative, in adults, of altered cerebral function (h). In all subjects, this test was negative before treatment. Positive two responses were observed in 19 of the 2h patients. In nine patients, consecutive responses were observed, and of these, six were in the much improved and three in the moderately improved groups. �In the next table the positive responses were charted.with relation to the treatment period of positive responses and is to the dlinical evaluation. be noted in the first A high incidence two groups, and many fewer such responses in the unimproved group. TABLE Face Hand Test IV - % Positive Treatment Period Much Improéed (11) . a Moderately Improved (6) Unimproved (7) ~ 1-3 h-6 7-9 10-12 13-15 16 ho h7 h3 60 60 h3 AB 30 O 0- 16 12 11 O �DISCUSSION: Three aspects of these observations warrant elaboration. sensitivity and stability The of these indices of altered brain function significance for a definition of altered cerebral function; the relation of these indices during and after treatment to the clinical and the evaluation; and the relation of these observations for the theory of electroshock action. All tests showed changes during electroshock therapy, indicating that a state of altered cerebral function.was induced. Certain tests, as the EEG and the amytal test, were altered after a few convulsions persistently positive for cne to three weeks following treatment. In this regard the electroencephalogram manifested the earliest and the most sustained changes. The recall and tactile perand remained ceptual tests also showed changes but week of treatment) and disappeared . was reduced. Tests of recall function and these appeared late (in the rapidly when 2nd treatment frequency tactile perceptual tests, therefore, are less sensitive indicators of the state of cerebral function. In any evaluation of the relation of an induced to another variable, the operation (or it is test) change in brain function important, therefore, to clearly define both and the sensitivity of the operation which forms the basis for the estimation of altered cerebral function. Because these tests have varying sensitivities, the frequency of treatment and the duration of the treatment regimen become important variables in any assessment. EEG changes are maintained by infrequent �{-10- treatment, while changes in recall function and simultaneous tactile perception are rapidly lost, when treatment frequency is reduced. Of the many correlations possible with these tests of brain function, we have selected the relation of these test results to the clinical improvement rating. With the EEG and clinical much improved patients, relationships between the appearance of test changes improvement are clearly observed. In the positive amytal tests and high degree EEG tests significant and amytal abnormality appeared early, were more marked, and were sustained for longer periods (on the same treatment regimen) than in the unimproved patients. The moderately improved patients were in between. relation between altered brain function and clinical response This only with the data obtained during the course of therapy. is noted There is results. no correlation of This divergence improvement is related to the timing of test applications, in the conclusions of other studies and may explain the discrepancies of ratings with post-treatment test this prdblem. These observations can also be mode of related to an understanding of the action of electroshock. In postulated that the function 1952, Weinstein, Linn and Kahn (6) of electroshock therapy was to ”initiate the production of a state of altered brain function in which the patient can deny his problems." These observations support the first part of this hypothesis, namely, that a state of altered cerebral function is induced by electroshock. Also, in patients who.improved, the altered state is more prominent, appears earlier and is more persistent than in �.11.. those had who fail to improve. Of the eleven positive amytal tests (while positive test); 5 of the much improved 7 patients, all unimproved never had a and ten had high EEG abnormality records, while only one of the unimproved patients had such a record. It is our conclusion significant degrees of altered cerebral function are a prerequisite - a necessary, though not a sufficient requirement - for improvement in electroshock therapy. that early, sustained and �SUMMARY: In a study of the relation of tests of altered brain function to improvement in electroShock, of change in brain function vary it was observed that while indicators in sensitivity, all tests indicate the development of organic mental changes during electroshock therapy. reason for the conflicting results reported by others can be accounted for by the variations in the tests used, the time of study The difficulties in evaluating improvement. It is our conclusion that clinical improvement in electroshock is and the dependent on early, sustained and marked changes in mental function; that electroshock therapy may be described as the non-specific, traumatic induction of states of altered cerebral function in'which and the subject reacts with new patterns of adaptation. �REFERENCES l. Fink, Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & PsychiatJﬁ: M. and Kahn, R.L.: 516‘5251 1957. Kahn, R.L. and Malitz, 5.: Serial Administration of "Amytal Test" for Brain Disease. Its Diagnostic and Prognostic Value, A.M.A. Arch. Neurol. Psychiat. 23;: 2. Heinstein, E.A., <3». 217-226, 19st. 3. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electro shock, A.I'I.A. Arch. Neurol. a Psychiat., 19: 23-29, 1956. h. Pink, Grren, HA. and Bender, H.B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurolo ﬂ. , _2_: 116—58, 1952. 1-1., H. , Fink, 1'1. and Kwalwasser, 8.: Memory and Learning to Improvement 5. Korin, I‘Ieinstein, 13.A., Linn, L. and Kahn, shock Therapv: Relation of Changes in in Electroshock, Conf. R.L.: Psychosis During Electro- Its Relation to the Theory of Shock Therapy, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of tests of altered brain function to behavioral change following induced convulsions. In L. van Bogaert and J. Radermecker (eds.), First International Congress of Neurological Sciences. Pergamon Press, London, 1959, 3:613-619. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-39-005 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Two [preprints] and one reprint. Reprint from The First International Congress of Neurological Sciences, Brussels, 1957, Vol. III EEG, Clinical Neurophysiology and Epilepsy. Peramon Press; London, New York & Paris, 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/86dcc852ef57150af5b9234a4c32a667.pdf 0ab52ac497e61e2b06bc38b78babd96f PDF Text Text EFFECTS OF DIFFUSE ALTERED BRAIN FUNCTION ON PERCEPTION BY MAX FINK, ROBERT L. KAHN and HYMAN KORIN ( Hillside Hospital, New York) PROBLEM Recent studies of the relation of perceptual alteration following brain damage have emphasized the role of focal damage. To determine the patterns Of perceptual changes with diffuse alterations in brain function, the following studies were undertaken. SUBJECTS AND METHOD Consecutive subjects in a psychiatric hospital referred for electroshock therapy were studied. Alteration in brain function was induced by varying the frequency, number and severity of the induced convulsions. The following tests were applied before treatment, at weekly intervals during, and two weeks after treatment terminated. A) Measures of altered brain function: Two quantitative indices were used to determine the degree of altered cerebral function: 1) the per cent time, amplitude and lowest frequency of the induced delta response in serial electroencephalograms; 2) changes in orientation and in language following the administration of intravenous amobarbital sodium. B) Perceptual Tests: 1) Tactile: Threshold perception (100 ‘X, point) of square wave electrical stimuli was determined for different body areas. Stimuli were then applied simultaneously to two body areas, with interspersed single stimuli in random fashion, and the subject was asked to report where he felt the stimulation. 2) Visual: a) Figure—Ground: Using embedded ﬁgures (Gottschaldt) of increasing complexity, subjects were requested to identify a simple geometric ﬁgure in a complex background. b) Tachistoscopic recognition: paired words were presented at rapid exposures to subjects. The words were matched according to tables of frequency in common usage, and were of two groups: relating to illness or to the body, and those not relating to illness. Words were matched \ randomly. ‘ �2 THEME 9 RESULTS With increasing degrees of altered brain function, there were increasing errors in reporting the simultaneous tactile stimuli. There was a concomitant rise in the threshold of perception. With high degrees of cerebral dysfunction, mislocalization of responses appeared, in addition to the persistent failure to report one of the stimuli. 2) The ability to isolate embedded ﬁgures was impaired in direct relation to the severity of the alteration in brain function. 3) Threshold for the perception of words increased and subjects were unable to identify two words with increasing degrees of cerebral dysfunction. 4) Changes in perception were highly correlated with other behavioral changes, indicative of an altered interaction with the environment. 1) CONCLUSION Diffuse alteration in brain function, as measured by electroencephalographic delta and orientation tests after amobarbital, results in alteration of perceptual patterns marked by an increase in threshold, impaired discrimination of stimuli, of which the ability to discriminate a ﬁgure from a complex background is a special example. 2) Alteration in perception represents one aspect of an altered behavioral interaction with the environment, rather than a speciﬁc physiological defect. This factor should be considered in perceptual studies in focal brain lesions as well. 1) ape. Inf. (Dong. ﬂieﬁoa E .- /f57 - gVH-SJa/S �3mm of Emma Altered Brain mum on Pomepticm m Fink, 11.13., mm; L. Kuhn, Bun. md than Karin, 31.33. mm gt the IV International Wrens of Psycholow, annuals, My 30, 3.957. �m at mm» Alton! Brain mum on Pauptian m of this study at alteration in Won fol-loving Mg» in «abut; mum ha been devoted to ram Mom u in nus-31m imam, dials 1!: head’ m md brain tumor. Litﬂn emphasis usually placed an the We effects of such hum on the pommml prom». In tha acme of this :tudiu in 1:ka therapy, we charred that may 13th aanaidonble neutral 0: the down at induce-d alteration of brain mum. In these studies we ware impressed with the wide variability in the behavioral and nmphyaiologie response 91‘ our subjects to apparent ‘ aquivalent mailbox-n of convulnima. madam We have Max:815? reported the a! the belaviaral napmsaa and the W: inter- dew of apparent new Widow-c manna-grandma mortistodowribgpomoptualchanmmrm conditions cf differing determine the down of diffuse alum brain relatiwahtp of the function, and 150 136th We to the indueed amm- physiologie change. I Three perceptual M113 Visual Visual mm mm utilised: perception of Gamma“ mm wave electriwl 1.3QO or mad gamma stimuli figure; :04»th of tachistooaopdcally presumed wows. �_...___.1 em: subjects were 2310 53 meetive hospitalized patients, rerun-ed fer electroshock. Brain mention was altered by meaning remitted grand m1 cemuleim under penteﬁml pmdicetim. a rmqwncy of three time per week. The convulsions were given For a control group, randomly eelected therapy; with equivalent umber of patients received eubeomalsivo Wimtim at pontothnl but with web» eonvuleive doses of electric current. All weluetiwe and same as in the experimental gmup at ~ and the type or each subject was not known to any of the tests were the thetmt in we fer investigator: until the experiment we ended. We Wmmgic indie“ were used. mameMz-ama, taken at weekly intervale an a day after an indueed maveleian, and mﬁtetively measured for the degree of incheed delta activity; and mobarbital taste for main disease. In this test, the language responses on a etenéandiled interview, are ”use“! after intravenous mobarbital. Mammal, 1W altered eembral fxemtice. denial, disorientation, and eyntuetieel as an 1nd!“ of Both changes have been enema these tests erem applied lure-armament and during the 2nd, are and 5th week: of treatment. The technique ef etch of the three pemeptual tasks will be doaeribad with the eomspmding results. For mm: a! thin mamtetien, the m mm to the quantitative «pacts only, and aa them is a wide variability in mangle response, we idu meant group data for obamatim apex-junta). and control groups wording to» the dogma at ﬁrst; mum ded- than were physiologic change. the observation: �__.____1 _. In this talk, isolated square WWW 1mm ma emu-ital atimuli were 81ml» We mmugh attnclwd 1 on .. dine electrodes. delivemd to two body point.) valwa were doteminod :or «ﬁx my part and $11“th the tasting, random single stimuli were interspersed to Meme errors due to ﬂuctuatien ef threshold. Subjects were whed to threshold (100% _ localim the npplieﬁ atimli. Slide 1 deem-1b“ the mean number of errors mtreament, and at the Widogic effect, which is manly after the 12th tram-b. The mzbeouvulsiw (mtml) group shes: a drop in the number of errors, the Mod pmotioa effect.» This canvulsivo group, tamer, Ihm height a? the induced & Meant increase in errors. patients with a who had first The immune in we: were _ manna. Pn-tmtnent,the In Slide 2, the group differences are diffemce in the number of more in the treatment course the difference: In Slide 3. the ineWimt, because ml. of the induced In the firm; section, the subjects in than Waive, and later m—tmtad been treated by a Waive course of thumpy. marked but at the height on? significant mum We is “tossed. who have had two new or thus positive to those with either no uobcrbitn tests during tmtmt are panties new. or only am. The number of errors: are higher in patients with mom positive moberbital responses. diffemnee 101' rm the pmmtmatmnt score, the group with the greater 601%! the Mm m aignificantlv different Wiologie avenge. In the second section, the encephalograpme Furthomom, in comparing the me melts response; and in physiologic inclines are oompared. ﬁlm are noted for the electro- third motion, the two new �«hm Errors in the 5:9er of ammo“ tactile mm 1mm with increasing degree: at altered brain function. 3: Bamegtim ‘01 W FM, 3: In true task, goo-atria figma embedded in a. complex dasigmd field are premtod «ml the subject is asked to tame the 9112913 figm. The slide 14 shown and subcmvulaive minim or Bath ﬁeld. simple figure is: simultaneously pmmted above thh complex the man manor warm». 'i'ha 91‘ art-era before and anhconvﬂaivo or control group, with no mnmphyaiologio change, thaws a drop Waive gramme show utter eumulaiva in the amber of an increase in true tugboa- or W mm. «mm. compared aide 5, the aubeomulaiw and Gamma” m bath befm am} mg the 5th week of treatment. man mamas, m difi'amwe in the who: of arrow is acted. It the height of tha cleara— In shock effact, the convulsive Wits We group makes aigzrii‘iomxtly more Change. the group. (31163 6) . visualized next tha in than calmly new am are divided warding to than degree of effect in Here, the Mrs than W a: the mutual to“, W Magic the oluctmonaaphnlngm, and tha mama data, there is a simficant diffemca in the mmbar of mm undo. Patients with higher dame: cf hummimgic chums mks ﬁn mt errant ”100th for their equivalence in fmmncy in mush matched, was mounted at rm. diffemnt speed: of mum Pairad words, usage and :3de taming from m to 250 rimmmdu 2130 of for a total mm. mum 13311607, the The mm m puma tn u wen-act morainewhgmupmpwmteﬁ. Harem, thumb- Wimt eonvulsive or control gmup ohm a amp in the number of while the group sham a much smaller practice effect. minim emu, �.59 In the are mud M 313.60 (8), the proutmtmat. and post-treatmnt «com The groups urination 1n the are 11611 More, untamed number of. arrears with alters-d and in both there is a brain function, Mt, the is greater than the convulsive. Thou are mt simifiaant. reduction in the aubconwlaive groups differences are and}. and In Slide 9, the role of neurophysinlagic change is again assess'eﬂ. toe, as in the wading slide,» them in a deem it: the pmtiae This is clearly effect with the greater the change in carebml now in tha canwlaxva Wagon seem, uhomtha patients with mm but Waugh Mags show a decrease in armra, while theme with the mam“. Hero, tam. Mainlogio change show a small umber of arrears. Ia this tank, in mtmat to the two pmeding on», the effect of altered 13min functim is not manifest in an increase in the umber or errors, but is seen only when the enacted immanent in performance fails WW1? mm thou-gum in «row mum In: m NM in psychiatric patients by the remand 92mm“). induction at grand m1 control Win emu perceptual in and experimental to chanson in degree when perceptual tasks, portion to the dogma er «smut-a1 cmlsim. in emu“ mp9, the mammalian) at on? «tubal ﬁguration hm baen obsozvod. increasing arrow" in pemaptian in pro- mm dwmﬁm in muréphyaiologic. indie” at mum m be observed. In addition to these pomeptual ml: changes, humor, there arm commmt altamtim in behavior, language. ariontatien, attitude and mad, and these am: highly Mama Mending upon individual 612mm“: 1n the subject“. ”the panorama). altemtima ducrihco’ here :3me but �we upset at tbs clung» in the Mom: 111th Farmer studiuﬁ cf this in ”spouse to mmbral lesions are mm hater in pmgrcsa. 91' tam. at” organism. indium mmw � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Effects of diffuse altered brain function on perception. In Proc. XV Int. Congr. Psychol. North Holland, Amsterdam: 1959:15: 238-239. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-35-001 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Korin, Hyman Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and a publication copy. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a85dc880c126770a2f4471ab91c4072.pdf 44a73db773213930685e535c3d7c50a0 PDF Text Text Inhalant—lnduced Convulsions MAX FINK, M.D.: ROBERT L. KAHN. Ph.D.: ERIC KARP. B.A. MAX POLLACK. Ph.D.; MARTIN A. GREEN. M.D.: BARRE ALAN, MD. AND HENRY J. LEFKOWITS. M.D. GLEN OAKS. LONG ISLAND, N.Y. �Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259— 266 Copyright 1961, by American Medical Association llHllllllll|llllllllllllllllll||llllllllll||llllllllllllllllllllllllllllll MAX FINK, M.D. ROBERT L. KAHN, Ph.D. Inhalant—Induced Convulsions Signiﬁcance for the Theory of the C onvulsive Therapy Process Despite many years of investigation of the convulsive therapy process, there is still much controversy concerning the importance of the seizure itself. Most studies have concluded that the convulsion is a necessary index of cerebral change essential to clinical behavioral change.9'1°'1‘53?"39 Some investigators, nevertheless, have assigned signiﬁcance not to the seizure but to such factors as the psychological meaning of the treatment to the patient, feelings of fear, and the repeated loss of consciousness.3'4'28 The early studies of Kalinowsky et a1.24 and Pacella et al.,3‘0 demonstrating both clinical and electrographic differences be— Submitted for publication Aug. 26, 1960. From the Department of Experimental Psy— chiatry, Hillside Hospital. Aided by grants MY-2092 and M—927 of the National Institute of Mental Health, US. Public Health Service. g ERIC KARP, B.A. MAX POLLACK, Ph.D. MARTIN A. GREEN, M.D. BARRE ALAN, M.D. AND HENRY J. LEFKOWITS, M.D. GLEN OAKS, LONG ISLAND, N.Y tween grand mal and petit mal treatments indicated the signiﬁcant role of the seizure. The various studies comparing convulsive with subconvulsive treatment demonstrated that techniques culminating in a convulsion were uniformly associated with measurable degrees of neurophysiologic and behavioral change, while subconvulsive techniques were not.1‘5'1’7"°’3‘40 In recent studies from this laboratory, similar differences in the 2 treatment types were observed for such aspects of behavior as EEG slow-wave ac— tivity,8’10 language changes after amobar— bital,19"21 and perceptual tasks. 1'3 22 25 A second aspect to the problem of under— standing convulsive therapy concerns the relation of the method of inducing the seizure to the therapeutic outcome. Seizure duration, type of current, and electrode placemerit are among the variables that have 65/259 �ARCHIVES OF GENERAL PSYCHIATRY been studied. While the investigations indicate that changes in behavioral and neurophysiologic indices are related to these parameters, the differences reported for the various seizure—producing methods are small and statistically insigniﬁcant. Major differ— ences, however, are observed between seizure and nonseizure groups. For example, in a recent monograph, Ottosson reported an increase in the duration of unmodiﬁed electrically induced seizures compared with those modiﬁed by premedication with lido— Although the lidocaine—treated pa— tients showed less change in indices of anxiety, retardation, and global behavior than patients treated with unmodiﬁed seizures, the differences were not signiﬁcant. In our studies, while seizure duration 17 and type of current 11 have been related to the degree of behavioral and neurophysio— logic change, there were no differences with relation to therapeutic outcome. Thus, while parameters of the seizure method may bear some relation to therapeutic efﬁcacy, the differences are slight among the techniques, provided that grand mal seizures have been induced. Further exploration of the importance of the seizure was made possible by recent experimental interest in seizures induced by inhalant (hexaﬂuorodiethyl ether, Indoklon,7), and intravenous (PM—10906) agents. This study was undertaken to com— pare the electrical and inhalant seizure—pro— ducing methods with regard to effects on clinical behavior, interseizure electroenceph— alogram, and psychologic test performance in order to clarify the role of the mode of seizure induction in the convulsive therapy process. caine.’29 ‘ In a voluntary psychiatric hospital 27 consecutive unselected patients referred for convulsive therapy were randomly divided into 2 groups using a Gellerman order.16 In 12 patients, convulsions were induced by a Medcraft alternating current in— strument using suprathreshold currents, and in 15 others by inhalation of hexaﬂuorodiethyl ether, following the method of Esquibel et al." Premedication in all cases was limited to sublingual atropine (1.0 mg). Treatments were administered 3 times per week for 10 to 24 applications, the total num- 66/260 her being determined by the clinical judgment of the staff psychiatrist. Ages ranged from 19 to 58, with a mean age of 38.5 years in the electric convulsive therapy (ECT) group; and 19 to 49, with a mean age of 35.5 years in the hexaﬂuorodiethyl ether group. The mean years of education were 11.5 years (ECT) and 12.6 years (hexaﬂuorodiethyl ether). Of the 27 subjects, 12 were classiﬁed as depressive psy— choses, 8 as schizophrenia, mixed type, and 7 as schizophrenia, paranoid type. The distribution of diagnoses, age range and years of education within the 2 samples, did not differ signiﬁcantly. Behavioral change was evaluated weekly in interviews by the patient’s therapist and by the staff psychiatrist. Such aspects as mood, ideation, memory, sleep, appetite, speech patterns, participation in group activities, and relation to staff and to other patients were recorded and changes assessed qualitatively. Electroencephalograms were done prior to treatment, weekly during the treatment course on a day after a convulsion, and 2 weeks after the last treatment. Records were measured for the amount of induced slowing (6 cps and slower) in anterior temporal-vertex leads, in 66 second samples.8 Various psychologic procedures were administered prior to treatment, during the fourth week (10—12 treatment period), and 2 weeks after the last treatment. The measures included Wechsler— Bellevue subtests (information, digit span, object assembly, and digit symbol) ; Gottschaldt type embedded geometric ﬁgures”; perceptions of pseudo— isochromatic embedded colored ﬁgures at high-speed tachistoscopic exposure,31 and a modiﬁed California F Scale.28 In addition, spine x-ray studies were done prior to and at the end of the treatment course. Observations Clinical Behavior.—The inhalation of hexaﬂuorodiethyl ether regularly resulted in a grand mal convulsion, similar to that induced electrically. For the hexafluorodiethyl ether group, induction was slower and the initial cry and opisthotonic posturing were often omitted. In clonic and tonic manifestations, postseizure apnea, and post— seizure behavior, the groups resembled each other closely. In short term evaluations of clinical be— havioral change, the types of behavior manifested were similar in the two groups. Patterns of denial, hypomania, withdrawal, somatization, paranoid excitement, and confusional—memory loss were observed in both 1. Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS TABLE l.—Beham'0ral Patterns TABLE No. of Subjects Recovered Much Improved _—A_. ,_._ Indoklon * ETC Eupho;ia, denial, hypomania Somatization, withdrawal Severe confusion, memory loss 6 6 3 7 2 3 Improved Unimproved Indoklon 7 .5 E C ’1‘ 3 6 5 1 x2 * 2,—Discharge Evaluations < 1.0, not signiﬁcant. Hexaﬂuorodiethyi other. populations with approximately equal frequency (Table 1). Complication rates were similar. While patients tolerated the inhalation procedure, there were frequent episodes of breath holding and leakage about the mask, making this induction less reliable. Fractures were observed radiographically in 3 patients treated with hexaﬂuorodiethyl ether and in during ECT. Administrative evaluations of clinical improvement at the time of discharge from the hospital were equivalent (Table 2). Ratings of recovered and much improved were recorded for approximately half of each group. 2. Electroencephalography.—Interseizure serial electroencephalograms, both qualita— tively and quantitatively were similar in the 2 groups. Progressive symmetric slowing of dominant frequencies and an increase in voltages were apparent in all leads, with frontal and anterior—temporal preponderance. Burst and occasional spike formations were noted in both. Quantitative measures of induced slow—wave activity during each week of treatment were not signiﬁcantly different (Table 3), although the maximum EEG change appeared earlier in the hexaﬂuorodiethyl ether group than in the ECT group. 3 TABLE N o. 3. Psychologic Measures.—Intergroup analyses (Mann Whitney U Test) of the observations for each of the psychological tasks revealed no difference prior to treat— ment, during the fourth week, and 2 weeks after treatment for the 2 treatment groups. Intragroup analyses, however, showed con— sistent changes in various measures from pretreatment to the fourth week; and from the fourth week to 2 weeks after treatment (Table 4), both in the hexaﬂuorodiethyl ether and in the ECT groups. In the Wechsler—Bellevue subtests, group means showed a signiﬁcant decrease in scores (poorer performance) for each sub— test during treatment, and a return to pre« treatment levels in the post-treatment period. One subtest, object assembly, demonstrated signiﬁcantly increased scores after treatment. Similar patterns were observed for the tachistoscopic measures and the F scores. While increased errors on the embedded ﬁgure tests were observed during treatment, the difference was not signiﬁcant. After treatment, the errors in this test decreased signiﬁcantly from pretreatment scores. On the F scale there was an increase in scores with treatment, and a decrease following treatment. For each of these measures, both treatment groups reﬂected a similar pattern of change. 3.—Postconvulsive EEG Slow-Wave Activity (Average % Time) Pretreatment 4-6 Rx 7-9 Rx Wk. After Last Treatment 2 10-12 Rx Indokl'm 15 6.0 29.4 50.3 51.2 16.8 E CT 12 4.0 29.8 39.2 47.5 18.0 Fin/a et al. 67/261 �ARCHIVES OF GENERAL PSYCHIATRY TABLE 4.———Eﬂect of Hexaﬂnorodieth'yl Ether and Electrically Induced Seizures on Psychologic Test Performances (Scores Expressed as Mean Differences) Pretreatment and Fourth Week 1. Wechsler-Bellevue (weighted subtcst score) ((1) Information (b) (c) ((1) 2. 3. 4. Digit span Ind ECT Ind Ind ECT Ind Digit symbol ECT Ind Tachistoscopy (errors) Ind ECT Ind ECT F scale +1.5 1 +1.7 T +2.7 T +2.3 1 +4.1 * +4.81 +3.3 1 +2.3 1 —1.3 —2.4 * +0.2 T -—0.7 —l.9 * +0.8 . —0.4 +2.7 ‘ +3.5 +0.8 1‘ —0.1 —6.5 —4.9 +9.7 * +8.2 * +2.0 +3.3 +7.7 1 +5.2 1 ECT Embedded ﬁgures (errors) Fourth Week and Post-Treatment —2.7 ’ —1.4 —1.3 —2.5 ’r —2.4 I EC‘I‘ Object assembly Pretreatment and Post-Treatment —16.2 —13.1 i ——4.1 1 ——2.1 ——2.6 t ‘ —-—5.9 I --11.6 I —3.9 +1.2 ——4.0 T Ind = Indoklon (hexaﬂuorodiethyl ether). Using Wilcoxon’s T for paired replicates: * p < 0.02' ’r p < 0.05. EEG Correlations. The changes in performance on the psy— chologic tasks from the pretreatment to the fourth week testing period were signiﬁcant— ly related to the degree of induced EEG slow—wave activity for both groups (Table 5). Rank order correlations demonstrated that decrements in performance on the 4. Test Performance: Wechsler-Bellevue digit span and object as— sembly subtests, tachistoscopy, and em— bedded ﬁgures tasks were signiﬁcantly related to the amount of electrographic change. Similarly, an increase in F score was associated with increased EEG slowing. When the observations in the hexaﬂu— orodiethyl ether and ECT groups were individually analyzed, signiﬁcant correla— tions were noted for various tasks. In the hexaﬂuorodiethyl ether group, the deerement TABLE ~ Indoklon ECT Indoklon and ECT ‘ p < in < 68/262 :0 < 0.01. in the Wechsler—Bellevue information and digit span subtests and in tachistoscOpy was related to the degree of EEG slowing. In the ECT group, similar relations were noted for tachistoscopy, Wechsler-Bellevue digit span, and object assembly subtests and the F score. Comment Mode of I ndnction.——The inhalant and the electrically induced seizure groups were indistinguishable on the various measures of behavior at each stage of the treatment process. Since the factor common to both treatments was the induction of seizures and not the method of induction, we may conclude that the method of induction is not a signiﬁcant variable in the therapy be— in the Speciﬁcally, changes process. 1. 5.—Change in Task Performance and Degree of EEG S low—Wave Activity (Pretreatment vs. Fourth Week; Rank Order Correlations) Wechsler-Bellevue Form , I 1 Information Digit Span Object Assembly Symbol 0.73 " 0.28 0.25 0.54 i 0.72 i 0.61 ‘ 0.31 0.60 0.46 0.38 0.34 0.31 1‘ T Digit Tachistoscopy 0.62 0.80 0.67 T * * Embedded Figures 0.13 0.37 0.43 T F Scale 0.12 0.66 0.38 ’r ’r 0.01 0.05 Vol. 4, March, 1961 �INHALANT—INDUCED CONVULSIONS _ havioral and neurophysiologic indices are sider these results as reﬂecting differences dependent upon the induction of seizures, both in population samples and in methods and not dependent on any single property of scoring behavioral change. While acute of the electrical or the inhalant mode of illness and affective-depressive reactions are induction. described for the majority of subjects in Kurland et a1.26 and Chatrian and Peter— the positive studies,1‘°'27'38 70% of the sub sen5 have also compared electrical and jects in one 4 negative and 100% in another 28 inhalant seizures. Kurland and his co-work- were classed as having schizophrenic re— ers assigned convulsive therapy referrals actions. The facilities in these investigations alternately to hexaﬂuorodiethyl ether and serve chronically ill populations, and prior ECT groups. They reported that behavioral courses of convulsive therapy were recorded ratings, complication rates, psychologic test for nearly half the subjects in one group4 performances, and cardiovascular reactions and 90% in the other.” The failure to obwere similar in the 2 samples. Chatrian and tain signiﬁcant differences may also lie in Petersen, studying schizophrenic subjects the small samples used to test the null with implanted intracerebral electrodes, re— hypothesis. ported identical electrographic patterns dur— Changes in behavior are observed in all ing seizures and at various postseizure subjects receiving a course of convulsive periods for hexaﬂuorodiethyl ether, pen- therapy,1052930533,38 but those changes evaltylenetetrazol (Metrazol), and electrical uated as clinical improvement occur only techniques. in some. While induced convulsions are a In studies of seizures induced by various sufﬁcient condition for behavioral change, electrical means, equivalent behavioral, psy— they are only a necessary condition for chologic, and electrographic effects have improvement. Thus, measures of behavioral been reported.3’11’29v39 While these studies change, such as memory,25 language,19'21 equate the effects of different convulsive and perception 1332 readily demonstrate sig— techniques, various nonconvulsive methods niﬁcant differences between convulsive and such as subconvulsive, brief stimulus, uni— subconvulsive techniques within the individ— directional stimulating, monopolar stimu- ual differences in personality organization lating, and focal “convulsive” techniques of the subjects. Ratings of “improvement," have been described, and each in turn however, with the personality organ-vary discarded in routine therapy as ineffec— ization of the subject in adap— as expressed tive.1‘°"27'39'4‘° For example, Bergman,2 in tive patterns and ﬂexibility for change; describing the electrographic effects of the with such environmental variables ther— as “focal—seizure” technique noted that 75% apist, staff, and family expectations and of patients had normal records after 15 tolerance for the elicited adaptive behavior. such applications, while 70% had “abnor— and with the duration and degree of induced mal” records after grand mal seizures. Ulett neurophysiologic changes. In global esti— et al.39 have reported differences in the im- mates of “improvement” the environmental provement rates of patients receiving con— variables become prepotent. The failure to vulsive treatments (60%—80%) and those observe signiﬁcant differences in improve— receiving subconvulsive (33%), or controls ment ratings in convulsive and noncon1‘0 (38%). Our own studies also demon— vulsive groups may be related as much to strate signiﬁcantly greater degrees of these environmental variables and the perbehavioral and physiologic change for con— sonality characteristics of the subjects as vulsive than for subconvulsive treatments. to the induced physiologic changes. A number of investigators, however, have 2. Signiﬁcance of the Convulsion.——The failed to observe differences in improvement evidence indicates that convulsions are, or rates for patients treated by convulsive and reﬂect, the signiﬁcant physiologic events subconvulsive means?”8 We would con— which are basic for the therapeutic efﬁcacy Fink ct al. 69/263 �ARCHIVES OF GENERAL PSYCHIATRY of convulsive therapies. The speciﬁc role of the seizure is, however, not clear. That neither the motor aspects of the seizure nor the accompanying psychologic factors are determining variables is demonstrated by the efﬁcacy of treatments under condi— tions of muscle paralysis and anesthesia?"2 That the loss of consciousness, itself, is not the signiﬁcant variable is seen in the relative inefﬁcacy of repeated administrations of thiopental (Pentothal) or noncon— vulsive techniques under thiopental.1°'2'7’39 Although the means by which various agents achieve such changes are not speci— ﬁed, it is probable that the seizure is but one expression of a diffuse alteration in cerebral functioning?” It is this alteration in brain function which provides the neces— sary conditions for the behavioral changes of convulsive therapy.14»2°v40 Among the behavioral changes we would include the im— mediate alteration in consciousness, recall, motor patterns, and breathing; and the more persistent psychologic, perceptual, vegeta— tive, physiologic, and hormonal patterns, characteristically described in convulsive therapy. Alterations in brain function are reﬂected in neurochemical changes as the acetylcho— line and cholinesterasef"7 transaminase,36 and serotonin '34 content of the spinal ﬂuid. They are also observed in such neurophysi— ologic measures as increased delta and theta 1‘8 decreased and beta in activity8 activity electroencephalograms, and in altered elec— 33735 20"21’4‘0 behavioral re— and trographic sponsivity to intravenous barbiturates and to anticholinergic and sympathomimetic agents"!12 The correlations between the degree of neurophysiologic change and changes in perceptual test performance re— ported here are a reﬂection of these central changes, as are the perceptualf‘ovl‘?”22 lin— guisticf‘w1 and clinical behavioral 10,20 changes described in earlier studies. In a recent review'9 the signiﬁcance of the acetylcholine—cholinesterase system in these neurochemical alterations was dis— cussed. Observations With various anti— 70/264 cholinergic agents and reports of similar patterns with antihistaminic and sympatho— mimetic agents indicate the necessity for a broadly based View of biochemical and brain function relations, with emphasis on synaptic models.” A suggestive mechanism for the prolonged alterations in brain function is seen in the blood—brain barrier studies of Aird,1 who noted persistent changes in cerebrovascular permeability following in— duced convulsions. He related these to the seizure and not to the passage of electric currents, and suggested that these changes may be the enduring physiologic basis for the induced behavioral change. Thus, we would conclude that the convulsion, per se, is not a necessary condition for behavioral change, but neurochemical change, of which the convulsion is the im— mediate reﬂection, is prerequisite. Indeed, were persistent neurochemical and neuro— physiologic effects induced as readily by other means, “convulsive” methods would no longer be necessary. In this regard, the nonspeciﬁc nature of the convulsive therapy process has been repeatedly emphasized.14v4‘° Summary and Conclusions Consecutive patients referred for convulsive therapy were randomly assigned to treatment courses by an inhalant (hexa— ﬂuorodiethyl ether, Indoklon) or electrical inducing agent. There were no differences in the two groups on behavioral, electrographic, or psychological measures prior to, during, or 2 weeks after treatment. Hospital discharge ratings were equivalent. Intragroup test dif— ferences were noted on all measures in both groups during treatment. These differences were related to the degree of induced neuro— physiologic change and the pattern of such changes were similar in both treatment methods. It is concluded that the observed alterations in, brain function are equivalent to seizures induced by inhalant or electrical means. The nonspeciﬁcity of convulsions induced by hexaﬂuorodiethyl ether and the greater difﬁculty of administration are con— Vol. 4, March, 1961 �INHALANT—INDUCED CONVULS‘IONS sidered as deterrents to the continued clin— ical use of this treatment. The mode of induction of seizures is an insigniﬁcant factor in the convulsive therapy process. Seizures are viewed as one index of the persistent neurochemical alterations which are requisite to the behavioral changes of convulsive therapy. These observations are discussed within the framework of the neurophysiologic— adaptive model of the mode of action of somatic therapies in psychiatry. _ The cooperation of Smith Kline & French Laboratories in providing the hexaﬂuorodiethyl ether (Indoklon) used in these studies is grate— fully acknowledged. Department of Experimental Psychiatry, Hillside Hospital, Long Island, N.Y. REFERENCES Aird, R. B.: Clinical Correlates of Electroshock Therapy, A.M.A. Arch. Neurol. & Psychiat. 1. 79:633—639, 1958. Bergman, P. S.; Impastato, D. J.; Berg, S., and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Focal Seizures, Conﬁnia neurol. 13:271-277, 1953. 3. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. 1.; Richards, R. A.; Strassman, H. D., and Unger, A. A.: Investiga— tion of the Therapeutic Components and Various Factors Associated with Improvement with Elec— troconvulsive Treatment: A Preliminary Report, Am. J. Psychiat. 113:997-1008, 1957. 4. Brill, N. Q; Crumpton, E; Eiduson, S.; Grayson, H. M.; Hellman, L. I., and Richards, R. A.: Relative Effectiveness of Various Com— ponents of Electroconvulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 81:627—635, 1959. 5. Chatrian, C. E, and Petersen, M. C.: The Convulsive Patterns Provoked by Indoklon, Metra— 201, and Electro—Shock: Some Depth Electro— graphic Observations in Human Patients, EEG Clin. & Neurophysiol. 12:715-725, 1960. 6. Edwalds, R. M.; Experimental Studies with PM—1090, Int. Rec. Med. & G P Clin. 169 :469— 2. 472, 1956. Esquibel, A.; Krantz, J. C.; Truitt, E. B.; Ling, A. S. C., and Kurland, A. A.: Hexafluoro— diethyl Ether (Indoklon) : Its Use as a Convulsant in Psychiatric Treatment, J. Nerv. & Ment. Dis. 7. 126:530—534, 1958. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 78:516-525, 1957. 8. Pink 61‘ al. Fink, M.; Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Signiﬁcance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 80:380—387, 1958. 10. Fink, M.; Kahn, R. L., and Green, M.; Experimental Studies of the Electroshock Process, Dis. Nerv. System 192113—118, 1958. 11. Fink, M., and Green, M.; Electroencephalographic Correlates of the Electroshock Process, Dis. Nerv. System 19227, 1958. 12. Fink, M.; Effect of Anticholinergic Com— pounds on Post-Convulsive EEG and Behavior, EEG Clin. & Neurophysiol. 12:359—369, 1960. 13. Fink, M.; Kahn, R. L., and Korin, H.; Effects of Diffuse Altered Brain Function on Per— ception, in Proceedings of the 15th International Congress of Psychology, Amsterdam, North— Holland Publishing Company, 1959, pp. 238-239. 14. Fink, M.; Alterations in Brain Function in Therapy, in Psychopharmacology Frontiers, edited by N. S. Kline, Boston, Little, Brown & Company, 9. 1959, pp. 325-332. 15. Fleming, T. C.: An Inquiry into the Mechanism of Action of Electric Shock Treatments, J. Nerv. & Ment. Dis. 124 :440-450, 1956. 16. Gellerman, L. W.: Chance Orders of Alternating Stimuli in Visual Discrimination Ex— periments, J. Genet. Psychol. 42 2207-208, 1933. 17. Green, M. A.: Relation Between Threshold and Duration of Seizures and Electrographic Change During Convulsive Therapy, J. Nerv. & Ment. Dis. 131:117—120, 1960. l8.Hoag1and, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroenceph— alogram and in the Excretion of l7—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 19. Jaffe, J.; Fink, M., and Kahn, R. L.: Changes in Verbal Transactions with Induced Altered Brain Function, J. Nerv. & Ment. Dis. 130:235-239, 1960. 20. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Psychiat. 76:23-29, 1956. 21. Kahn, R. L., and Fink, M.; Changes in Language During Electroshock Therapy, in Psy— chopathology of Communication, edited by P. Hoch, and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126—139. 22. Kahn, R. L.; Pollack, M., and Fink, M.; Figure-Ground Discrimination After Induced Al— tered Brain Function, A.M.A. Arch. Neurol. 2 :547551, 1960. 23. Kahn, R. L.; Pollack, M., and Fink, M.; Social Attitude (California F Scale) and Con- vulsive Therapy, J. Nerv. & Ment. Dis. 130:187192, 1960. 24. Kalinowsky, L.; Barrera, E. S., and Horwitz, W. A.: The “Petit Mal” Response in Elec71/265 �ARCHIVES OF GENERAL PSYCHIATRY tric Shock Therapy, Am. J. Psychiat. 98:708-711, Succinylcholine, Dis. Nerv. System 16:237-242, 1942. 25. 1955. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁnia neurol. 16:88-96, 1956. Kurland, A. A.; Hanlong, T. E.; Esquibel, A. J.; Krantz, J. C., and Sheets, C. S: A Comparative Study .of Hexaﬂuorodiethyl Ether (In— doklon) and Electroconvulsive Therapy, J Nerv. & Ment. Dis. 129:95-98, 1959. 27. Lancaster, H. P.; Steinert, R. R., and Frost, I.: Unilateral Electroconvulsive Therapy, J. Ment. 26. Sc. 104:221-227, 1958. 28. Miller, D. H.; Clancy, J., and Cummings, E.: A Comparison Between Unidirectional Current Non-Convulsive Electrical Stimulation Given with Reiter’s Machine, Standard Alternating Current Electroshock and Pentothal in Chronic Schizo— phrenia, Am. J. Psychiat. 109 2617—620, 1953. 29. Ottosson, J. 0.: Experimental Studies of the Mode of Action of Electroconvulsive Therapy, Acta psychiat. & neurol. scandinav. Supp. 145, 3521—141, 1960. Barrera, E. S., and Kalinowsky, L.: Variations in the Electroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. 47 2367-384, 1942. 31. Pollack, M.; Battersby, W. S., and Bender, M. B.: Tachistoscopic Identiﬁcation of Contour in Patients with Brain Damage, J. Comp. & 30. Pacella, B. L. ; Physiol. Psychol. 50:220—227, 1957. 32. Reitman, H. J., and Delgado, E.: Technique for the Modiﬁcation of Electroshock with 72/266 M.; Kay, D. W. E.; Shaw, J., and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG & Clin. Neurophysiol. 9:225-237, 33. Roth, 1957. E: Acetylcholine and Serotonin in the Spinal Fluid, J. Neurosurg. 14 222-27, 1957. 35. Shagass, C.; Mihalik, J., and Jones, A. L.: Clinical Psychiatric Studies Using the Sedation Threshold, J. Psychosom. Res. 2:45-55, 1957. 36. Stevens, J. D.; Majka, F. A., and Humoller, F. L.: Transaminase Activity in the Spinal Fluid in Neuropsychiatric Conditions, Dis. Nerv. System 20 :460-465, 1959. 37. Tower, D. B., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Spinal Fluids, Canad. J. Research 27: 34. Sachs, 132-145, 1949. Ulett, G. A.; Gleser, G. C.; Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock, Bull. Menninger Clin. 18:138-146, 38. 1954. 39. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive Shock Therapies Utiliz— ing a Control Group, Am. J. Psychiat. 1121795802, 1956. 40. Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects, Springﬁeld, 111., Charles C Thomas, Publisher, 1955. Printed and Published in the United States of America ��A-4t - signattscunt at Iuhultnt Inna-ad Guuvulttoun to: thrhucrr at ‘8: canvalnavu rhuranr Pronun- MI". IN; “.8. “It; 4‘. '0”. ’0‘... ”03., In It“ m. M“ m. ,“h“. MO ‘1‘“; “an“ m WM“. '0”. tho nuihud tn tndncanc cotstrc at at stunstxnanoc t8. it. In: in ”09.; m nzoc‘rncouvu1ISVI ﬁhnruyy an. tuvcsttsuﬁod ﬁr culpartn. tn Ila. ilhllﬂl‘. hllatincradilihrlothur (IndOkIOI), with it. ciuvunﬁtnnsi ozaatrical staining tnahatqun. fvuntgbnovuu can-mun Mamas“ mum‘wiu ”an" we and“ um GU» randunxV atticnld irtttlsni gringo. fruuunoaﬁ van Id3131ltnru¢ at to m m: than mi: anus-um. y» mu Thiri ﬁll at datturnann xu sun in. stein! in.bohav10ra1. aloatrlanaophnlggrnyhzu I? 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Stature 6.1.3101, twp. at currunt lad olsttrodo pInGUIauﬁ 3r: anon; tho vnrttblou that hat. boon atudlod. 33:10 it. zuvcltixattuna indicatc shit chanson in b¢hnvlorsl cad uturophyniolwcie 11415.: it. rclattd £0 £8... paranotorl, th§ dittoruncul rcyortad to: thl various icinuro trodunln; lathoda Arc anal}, tad ntutatttn‘lly tn:£¢nittesn£. lajtr d$£fﬂr¢nc$l, hivcvor, tr- ahltrvtd bntwunn totuurc and non*teisuru groups. For .xnuylu. in u raounﬁ nancarqph. 0t‘anaon roplrtad 5n incrcanu 1a tbu aurntioa it ‘nuadtticd oluctrtaal indugcd antitru: campsrud with thou. unattaod by prtnodicuﬁiun with lidocnlnt (29). Althcuah tho 1:60:1130 ﬁriatcd pttacutl ahtwtd Ital Ghana. 1: indict! of anxiety, retardaticn Old [105:1 behavinr than pttisnta truntta with anuadttxcd Itisurgs. tun datzcrtncoo worn not Iacuttxeunt. In nut attains, chili tutunro dur;t10n (17) and typf at current (11) huvc b... ttlatnd t: thu dogruc a: huhnviural gnd unit.» phyltclogic ahsnco, taut. v¢ru no ditturonccs with rolctztu to thorupoutic nutounq. this, wail. ptranttcri a: £hu saith». nu‘hod may hot: sun. rnlntion ta thnrgpo:%1a efficacy. tbs dittorcncon arc clichﬁ nians {ht tcahntguso, yrovidad that grand uni a¢tsurut havc hO$n 13¢ucod. rlrthur taplcrttsaa it thu taptrtaneo of ﬁn. IoisurQ wt: and. poautblu hr ruetst txpartutntal tntcrant 1n Itiﬁﬁrﬁl induct! by Anna» (1) ). and tau-“roam (911-1090, (6) 1 than“, ) �as)» am». n3 an “um“: 4» with um" My“. ”a“: "cm am» am. and: um «mum 50 «mm m Wt um»: “um. tum-utm- alumnmmum In an ”rim“ «m u clarity an m. o! m m. of alum “(um a a. mum» them: "maul-n mun. an �Klflﬁb: triatwutovun cantooutavu ‘sntluctnd puttanti in u vaiuatary plyehintraa hcapttal ruttrrnd tar canvu1n1Vt ﬁhcrapy Hurt rtadonlr dividtd tat. ti. gram». aging n allarn¢u ordor (16). In twlavu pattonta, convulltans utro indusod by a H¢dcrnt% alturuating entrant tanQrtnnut antic nupruthroahuld narrtntcs und in (txtton Othtrn. by inhnlntiou mt htxutlunrtw dio‘hylothnr (Inﬂation), following tn: nothcd a: Sunnibol ggﬂgm. (1). Prunodicttsou in :11 euro; vat 11311.6 to unbltnal¢1 atropaum (1.0 :3). Srcuiuantn u‘ro adniuistarcd thr¢c tint. pow v.0: tut 10 ta 2h npyllcatiin! with tan ‘otnl lllhlr ao‘arn£aod by in: clinical Judxuncut it uh: It!!! p1y¢h&ntr1at. 13¢: rtlcud iron 19 ta 58, with a rota ‘3. or 38.5 1“!au in. 3c: group; and 19 ﬁt by. with a noun ‘3. at 35.5 rust: in thc tnﬁoklun (rump. tn: Ina: what: If aducttinn nut. 11.5 yncra (83?) and 13.6 (Indaklan). 01 tho tvcntronovun libaoots, tuolvc worn «13.113106 in daprtaltvo parohnnct, light at aehsnophrnuit, 11:16 ﬁwpu. and lovnn :3 schascphr.u1a, partatid twat. Tit dil‘ributiou it diaclanol, a‘. rang. and yuar: o: tduoatloa watts» ta. tug unuplta, did not ditto: ut:ut£1u&nt1y. Ichnvisral eight. wt. tvnluaiod rockly in tattrviuun by th- pacxuat'u thgrnpiu$ aha by an. stat: piratintriut. Such nnpoctn as hand, tdantton, :anorr. $1.0», aypotitn, tycoon puttutna, participatiua in :ronp nativiﬁtua. and rclattta 8. rucnrdod $0 0950? and ¢h3n301 SIIOIIQG p£tianta wurc utttf tad quulttativoly. �lloctrocncophxlagraun var. Geno print ‘u ‘r¢ntnuat. wtokly during in: ‘ruatntut «guru: in a any ut$ar a ounvnlniau, Rocgrdn acunnrod 1.3% troatnon‘. stﬁcr sh. taro ‘8. llé I'lkl 6 ( inﬂated or uuiuat tinting ‘8. up: and cluwor) in ;ut0210r (at 66 0.0.34 tIIy1:I (a). in Icadt, tauptrtI-vurtax erliﬂﬂ plylhblnaie proooduruu var. n¢u133¢arud prtor ‘9 tritiunnt, during tan tourth your (16.12 tron‘naus pawiud). tad tun v¢¢ka uttcr tin Ina! tronilnat. 2h: unapurql xuolndtd wichalor-Iollcvun‘nib‘aa‘c (anttrnntaoa. digit tutu, 083.3% a:ncnbly and digit urah¢1)s Oottnohaxd‘ my». udhcddod guanotrla tigvron (22); parceptinnl yr ptunﬁotcachranatac Inboéd:d c.1ur‘d figure: at high Ip§ad"ueh11talatpta :xpouur: (31); and I nodal“! 6.113% I 80.11.: (23). In ﬁddltitl, lpino tori; Utmdtus «are Gnu. prior ‘c tad In than «a a: “a am”. ‘ tutu” �it. inhalatIQa ﬁt tn‘nﬂitu Insularlr ranaztua in a grand all douvulttln, 91:11:! it taut taimuut clottrinnllyu fur inc tuﬂntlou grimy, intuition «an alarm: an; the intitdl try and «patchytanto pnuturin; Hurt ﬁf‘iﬁ ouittci. In tldttc tad tonic nunttoatntisun, ycst atsnaro taunt, uni goat Intuit. botanist, in. sunny: rattnhltl ulna oﬁhtr «103.12. In chart Guru tvnltutiaun it 12in£¢d1 bahnvsural «huuxu. it. ﬁght: it buhnvltr nﬁutttaﬁud aura nilmlnr 1: tin tut urcupl. rnsttrua a: dautul. tryonnas:, uﬁﬁh‘rarax, tunntttatxnu. paranata tzuitnntut sud iontuntdniX—Innary 10:. air! htilrvﬁl in it‘s populu‘inuu watt uvpvumﬂlattly'tqnal trltittﬁr (tail. 2). I campaiaa$10n rates Etna! I “ﬁamnauau wore statics. viii. patluntn ‘oxcrutna the Inhalation priﬂlllri. Chart '0'. Iroquﬁuﬁ Upilodii a! hroathwhnltias nut lamina. Ihﬁﬁ§ tin muck, naktng ‘hin inttctiia 1:1: :vlhhlc. fruwt‘rta new. obntthd radiogrupttcgllr 1: £lrvc Indolian irattod pciﬁuﬁtn and in throw during 36!. Adminaatrattvu tVIlnnﬁiaaa a: cizuiaul ingravanaut u. £30 an at “an". :m a. was”: an msnzus "an. t). a: Itcnwnrtd and anon tnyravcd nypruxinutvly half at taah ﬁrst». Inﬁdnsu first a warn rucordui fur �inturitasuvu aiﬁina tianrocuunyhaloxruun, town qualtiai$vuiy and qumttttuttvoxy, aura aluilur in the two gvﬂtyic Frucrncnsvu arunntrtn attains ct inhinant trucuuucxtp and an tactvuuc tn Vil‘icil 1;: I’pllih‘ in :11 lnatu. with trintnl in! naiovttrmtaupiwul yruyduiarunaa. lava: and «human an. swam m «m u an. Mann” antt¢tey tutti; tilt such it ivcnI-lnt warn Ilﬁ Iaanltiauliay isttcrwut {tibia 3). taﬁhntgh tan anti!!! III stanza uypntrai «stilt: in ﬁt. thiuklnu trim! than 1: it. In! grin}. nuanurwn OI indsaud ulna Hutu tiltt 3 “~w«.*...u~ mm: 1:1er uhtorvattvau tut tack tic poyvtalociaux twat: (in. man” has It t: or ﬂu rmvuulad a. dattbruaca yriir t9 iroutulnt, ﬂaring tho lihrih unnk, and it! itch: ptntattcutnmnt for ﬁtt it! tsua$naat grﬁ‘ps. Iatrtm hiiivnr, iatlynoa, li‘l!‘ Gduttttcut ataugul in vurtuuu grit: allltfit (was pruutrautuaut it $ha tutti! tuck; and tron ti: Sturﬁh 9“! £3 two that. titty trtatnnat (luﬁli £3, bush in tho Intttiiu sat in tha IQ! grunpo. ....*.....um: I: �an,» x: it: waohalirulililvng tuhsotts, grit; lﬂﬁtﬂ unasud a ﬁllhificnﬁt «ontnama an wcortt (y‘awcr yuvlorannct) tn! Cunt .3h‘nct iuriaa irtgiunnﬁﬁ and u v-ﬁurn t. yruatrnttunut 10'!!! 3: sh: poabwtvcn‘nnut yurtod. 03¢ Ithioxt, «33.6% Inatuﬁlr, dtntastrntui tlzntrlscatar~inuvouocd Ct0r00«’ditv ‘iﬂdilil‘¢ stntltr pattern: 0": oha¢rvud fur thy tnotxutoacapiu unusarca use it. I «tints. will. incrcnund arrow: as ch» «abaddﬁd tight. tutti warn uhtuvvud daring ﬁvtutunas, t3: dt!£:roano an. naﬁ alaniriaﬁut. Paatutrautuunt, tin arrays in its: tunﬁ itartlnca signattcnutlr from prontrouﬂuaat no.9... an tha 1 anti. that; an; incrutso in isﬂrit utth trottunnt, and a Guavaauv tullduan; ‘runinust. in: each at that. unnausol. tic un clmamtl 13>psr£bmnmn¢a an £ha ynruhnaagta tucks tram tun prumﬁroniuuuﬁ riirtt itch tnttinu pnrild warn t. ti: uttnllltauttr rulttad ﬁt til angst. orstuiuuud 3!! 310' all. activity to: tutu urtupa (inhia 5). Isak grant inrcllﬁiun: inunnctvaﬁod thgi attriunuSn in porttruuntu on the'wlnluicvu Inlluvu¢ atgit cyan and thattt unocth: aubtttta; tuthiutnueupy tat rtsaruu stat; wart gignitiacntlr rtlutti to ‘ho anniat .1 oltatxagruphlc ahlnst. stuxxnrly, an innrquac in ? utcrn It! ssndaiatod hath 1nﬂriittﬂ £13 tilting. anh¢¢d¢d -a..*....., till! 5 �mmmumummzummm amalgam mt mama» mm. immt m W tum-mummy. mewmmm. ml was it. mm“... umwmnm «at a mmmuummmmnumum‘mu at: 31m. m m m. umm nun-m an and hr Wm, mnmnm in“ m at out“ numb}, mm m m min-m W 2-. l‘ �1. W!h: crimp. wuro behaviar tt aloctrioul tudnncd iatxlra £n¢£tttnguinhahlt tn ﬁn. variant statur¢t a: etch ttuxo at tun ‘RUtiliﬂt proocsl. 813:: in: 1nh&1:nt and tho taatar ens-tn ‘0 bath trOainuntu vns tn. induction st natuurit tad not thg unthnd a: inauotian, u. may Gﬂﬂﬁlud. thu$ it. netted or 1nduet1¢n 33 has a signtttctnt variihlc in th. £h¢rnpy arsenal. apceatie¢lly, chanson in tho bah:v10rn1 and attraphyiitlnsic inﬂicts ;ro dupcudant tutu the induction 0: taiinrtu, Ind not dapaudout nu nay '1ng1c property or the tluntrieul it tho inhtltnt nod. of induction. Klrland.g§J;;. (26) lad Chutriau and P¢taraoa (5) bath alto conpnrad ¢1natrtea1 ind tahnluut '013Irt3. Karinue and ht: agowurkcru niutgnnd convulylvn thnrapy ruttrraln tltcrw uttoly to Induklua and so: trontnamt cranps. :huy rapcwttd £hnt b¢havtural rataagl, acnyIScutiou rut-a. payehalagia tclt portaru£aeta and aardithluulur roaa‘itun var. 11:11:: in tho tun £3.91... ¢ha%riu| uud itnrn¢a, Itudying schano~ phrcala tahstata with anplantnd inttncurohral altatrodon, ropqrtnd 14¢:Q1aai ultc‘raarsphi¢ pttsoran durzng ncxnurna ind uﬁ vurtonn puttwltialrt psrzcﬂn It: Instilon, untrtlua and tlaatrtnsl tuchniauat. In studtu‘ it :dburan inaun¢d by varituu dlcutr1c¢1.n¢tal, Ignivnloa‘ bﬁhnviorll. ynyahtlogia and �.11. olootrocrophio ortooto hovo boon rovorﬁod (3,11,29,39). Vhtlo thooo otudtoo oqnoto tho otroeto or ditforons convuloivo ‘oehaiquoo, voriouo nonooonvuloivo nothodo ouch oo oubconvalotvo, hriot otinuluo. unidiroetlonol otionlotinx, oonopolor otiouu Intang, and tonal *oouvu1311o* toehniquoo hovo boon dooorlbod, and ooch in turn, diocordod in routino thorny: oo inotroctivo (10,27.39,h0). For oxouplo, Borgnon (2), 1n doocrthinu tho olootroarophio ottonto of tho '1ooo1-oo1:nro* touhntquo uotod that 751 o: potionto bod noraol rocordo ortor tlftoon ouoh opplicottooo, whtlo 703 had 'obaornol' records alto: aroma moi ooiauroo. Blott ggﬂg;& (39) hovo roportod diftoronaoo in tho taprovoaont rotoo at potiouto roooiviag oouvulotvo trootuonto (69.301) sad thooo roooiviag oubconvuloivo (33$), or «outrolo (385). Our own otudioo (10) also dononotroto oignirioontly groooor dogrooo of bohoviorol ond phyoioloaio ohonco zor.eon~ vnloivo than onbaonvuloivoVtrootoonto. A author or inventigotoru, hooovor. hovo toilod to oboorvo dittoroneoo 1n loprcvonout rotoo for potionto trootoa by. convuloivo ond subconvuloave noono (3,h,28). Ho would conoldor thooo rooulta to rolloctiag d;:£oronooo both in popuiotion oonploo and 1a oothodo or ocartng bohovtarol ohonco. whtlo oonto illuooo and orroetivo-dogroooivo rooottono oro doooribod for tho nojority or oubjocto to sho poolttvo otudioo (10.27.38) 70: at tho “Moots 1:. mo and! (h) and 100! 1a anothor (28) voro elooood oo schizophronio rooctiono. rho rootlitioo in thooo 1nvoot1gottono oorvo ohrontoolly 111 ‘ "an“ �~12. populottooo, ond prior oouvooo or ooovuloivo thoropy voro rooordod-tor hourly halt tho oobaooto 1n ouo group (h) and 901 in tho othor (28). 73o toiluro to obtoiu oiguttlolat dittoronooo on: oloo 11o 1n tbo atoll oooploo mood to.toot tho null hypothooto. Chongoo 1n hohovlor oro oboorvod 1a o1! onbaooto roootvio: o oouroo or oonvuloivo thoropy (lo,t9,30,33.38), but thooo chongoo ovoluotoo oo oltntool thyrovooont, occur oaly 1o oooo. whilo induood oonvuloiono oro o ooftiolont condition for hohovtorol chango, tho: oro only o noooooory condition for inprovooont. Thoo, nooouroo or bohovioro1 ohoago, cook to monory (25), longuogo (19,21) ood porooption (13,22) roodtly doooaotroto signittoont d1xtoronooo hotwoon ooavolotvo ono ouboonvuloivo toohniqooo within tho 1nd1vtdoo1 dittorooooo to poroouolity ergoniootlon of tho oohaooto. Iotlago of ”1-provonont', howovor, vary with tho poroonoltty orgootootloo of tho oubaoot oo oxprooood 1n odoptivo yottorno and Iloxibility for ohoogo; with ouch onviroaooutol vortobloo oo thoroptot. ototf and tonily oxpootottono ono toloronoo for tho o11o1tod odopttvo bohoibrg and tho ﬂotation ood dogroo of indoood nourophyoiologio ohougoo. In globol ootiuotoo of “inprovo-ont' tho onvtroa-ontol vortotloo booooo propotont. rho totloro to oboorvo significant dittoronooo 1n taprovolout voting. to rolotod on lock oonvoloivo and noo~oonvu1otvo zroopo no: to to thooo ooviroonontol voriobloo and tho yoroonoltty ohooootorlotion of tho oobaooto, oo to tho indoooo phyotolocio ohoagoo. �.13. 2. Signirtaeuee at the convulsion. The evadenee indicates thet eenvnlaiene ere, er retleet, the eigniticent phyeiolegic event: thigh ere beets tor the therepeuttc ettteeoy e: convuleive therapies. the epeeitie rele e: the eeleure 1:, however, net olenr. Thet nelther the note: eepeete e: the eeteure new the eeceepeuyiux peychelegie fectere ere determining veriehlee 1e deleuetreted by the etrioeey et treeteente under eeudltleue er neeele perelymte end eneetheeie (3!). rhet the leee or ceneeteueueee, iteelf, in net the etzuitteent veriehle 1e seen in the relative luettteeer e: repeated esuintetretiene e: peatethel or not. eenvuletve teehniquee under pentethel (10,2?,39). Without epecityinx the neeae by which verieue egente eohieve eueh oheaxee, it to vrebeble thet the eeieure 1e but one expreeeien e: e dittuee alteration in oerebrel functioning (9.13). It in this elteretien in brain fluetien which prewidee the neeeeeery canditiene for the hehevierel eheasee at oeuvuletve therapy (1h.2o,50). teen: the behevterel chengee we would include the innedzlh exteretten 1a eeueeteueueee, reoell, leter petterne, breethiaa; end the eere pereietent peyehelegie, perceptual, vegetative, phylielacto end heeeenel petterne, characteristically deeerthed in oenvulexve theeepy. titeretieue 1n hretn :enattea ere retleeted in heaven chee1ee1 chengee ee the eeetyleheline end oheltneetereee (3?), trenemueee (36), end "retain (3h) «intent of the epinel fluid. They are elee eheerved in each neurophyeielecle eeeeuree ee inereeeed delta had theta eetivitr (8) end end �«1h. outtvtty (18) out oltorod olootrocrophtc (33.35) and bohovtorol (20,21.h0) rooponotitty to introvououo borbttorotoo sad to outtoholtnorglo and oyspothoolootio ouonto (?,12). rho oorrolotiono botoooa tho dogrno or nooroyhgotologlc choos- ond changoo 1o porooptuol toot portorlouoo roportod how. oro o rotlocﬁiou of thooo coastal chongoo. oo oro tho porcoptool (10.13.22) linguiotto (19,91) ond sliniool hohovtorol (10,20) ohoagoo éoooribod an oorlior doorooood boto 1o oloctroouooyhologrooo; studios. In o roaont roviou (9), tho oicattioonoo of tho oootylnholiuéaholxnootorooo oyotoo in thooo nouroohontool sltoéotiono woo «ioouoood. Oboorvoticno with vortono onticholsoorglo ozonto out roporto or oioslor pottorao with antibiotoointc and oynpothoolnsttc ooooto. indieotoo tho noooooity for o broodly boood vtoo or hioohooiool one broth tunotton rolottoao, with oophooto on oyuoptte Iodolo (12). A oocgoot‘vo ooohoaio: so? tho prolougod oltorotioao in broin tnaotlou :- ooon in tho blood~bro1u borrior otodtoo a: Alva (1) who uotod poroiotont «honaoo 1a oorohrovooonlor porooobillty tollovinx induood couvulotouo. ﬁo rolotod thooo to tho ooiluro and not to tho pooooxo of noon-to cox-routs. out! ounootod that tho-o chongoo ooy ho tho enduring phyo1olo¢1¢ booio for indueod tho bohoviorol chongo. Thus, to would concludo thot tho ounvuloion. or no. to not o nocoooory condition for bohoviorol ehoogo, but nonro~ choliool ohongo, of which tho oouvuloion to tho ionodioto "nation, 1o pronoun“. Indood, won pox-noun noun. �015 a aha-10.1 3nd nauraphyalolosie attoeto image-d a: roadily by bu unthodn Ivnld no loncnr uooonlary. 'convuluivoﬁ other manna, In thin rogurd, tho noun-poclxta nature or «a. couvulatvo therapy proocuu has he’s ropcncndly ouphantuad (lh,h0). �an I mg. cg.mm s, conuauuttva put£¢n£u rotnrrid 1.! 5.3131317. therapy var. tunic-1: assign-i to trtutncut tour... (Ind-klcn) or ulnatrtaal inducing tgcnt. by an inhalant Thor. were no dittoroucau in tho two group. on bohavlnrﬁi, cloatregruphio or psycholcgioul natsuroa prior to, dnrtng. tr lotyttal dicohtrzc rnttnuu var. oqutvalont. tutti-group taat dirt-rtucls unto notad on 311 tun wtcka artor treatunnt. unnanrau in both granps during trnatnont. In... dittuvouaﬁl var. rclutcd to tho dcgrto a: indueod nourophyaioloxie «hang. pattern at such chanzaa not. similar in both troutlau‘ and tho I. th“‘ 0 It is concluded thut tho abhorvod nltarntioul in br‘in function :r. quivnlont with nature: inane“! by inhnlnut or alootrtctl Hanan. rho nououpceitietty of Indaklauconvulnionn and tho ctoattr difficulty of aduintatruston continued the aonnidorod to «ctorrunta clinical at. 3a if. or th£a trtatuant. The nod. or induction or nuisuroa 1: In tuntgnitic.nt (cater in tho convulsivo thornpy process. $e1uutoo tr. “and u on. two: of the ponistont autumnal"). eaavulsiio bchnvicrnl ﬁnance: a: uhioh rcquiaito to tho durum- er tharupy. Th... abuortn£ion| at. discus-ad within the tranoutrk at tho nourophyu1olozie-Idupt1vo nude! or thu of abnttic Vﬁhcr.p1nn 1n payohintry. node of action �0’17. the oo¢90rntion 0! Smith £113. a French Lahcra%orsco in providing the hazarluovodiothyiathar (Indcklon) It’d 1n tho-u atudioo 1n gratefully toknoviodgud. �.15. 1. 11rd, 3.3. clinical Gerrsllﬁta at Electroshaok Thnrapy, Pazphittg lg: 633n639, 1958. 2. larguan, P.8., rapt-tutu, 9.6., Bars, 3. and foinntoiu, a. ﬁloetrounonyhalocraphic changes talluving olqctrioll induced £0331 a-lunrca. cant. laurel. $3, 971-277, 1953. 3. lrtll, 3.0., Ornlp‘el, 8.. Iiduncu, 3., Gray-on. 3.8.. ﬂollnnn, L.I., Richards, 3.4., stra;tnan, 3.9., and Unsor. 1.1. Invuatigntioa a: sh. thorapouﬁto coupounnta and variant raetcrl .saoctatnd with tlpruvousut with olectro~ convulsive trontaontt A preliminary vapors. An, J, Ag; Arch, Huurol. & 3&2, 997e1008, 1957. Ptzghint. h. Drill, 1.0., cr‘upton, 3., atducon, 3., arnyaou, 3.I.. lilllll. 1.1.. and Richarda, R.L. Balattvn eruct$vonaao of tartan: coupon-at: a: oloctrcaonvnlotvo thurapy. nu non. lmal. a "paint. 9;, 627.535, 1959. chattiln, 6.3.. and Itoruun, u.a. Thu convuloivo paﬁt-rnc provokad by Indcklen, Hotrauol and slcetraouheck. Solo dopth clootroxruphio obscrvuticnl in hunnu patiautu. BIO Olin. lturoghzgiol. 33: 715-?!5. 1960. ldvaldn, 1.x. Bxportlnntal utudtoo with Pnn109o. Int. Rue. nod. 1- cm». a g 32;: 1:69-4:79, 1956. 7. lsquthnl, 1., lrants, J.0., tru1t£, 3.3.. Linc. ;.s.c.. tad lurltnd, 1.1. loxntluorodtothyl nth-r gindnklaa) ~ It: us. as a oonvuluant 1n psyuhtctrto trau‘ucat. ' J. larv. ﬂout. nil. 33$: SJO-SJh. 1958. �.19“ EEG end delee activity to of B.L. Kenn, 3. Ieletien link, behesierel reepeaee an electreeheck: Geeetttettve eeriel etudiee. Ant arch. leerel. e Pezehtet, E!) snsasas. 1957. 9. link, I. street of enticheItnercie egent, nietheere. ea :30 eud behevteru atsntrieenee for ﬁheery er aenvuleive theeepy. A5; trek, leurg;. e Pezghte . £21 380~387. 1958. 10- tier, I., Kenn, 3.3. ens Green, I. lapettleetel etedtee e: the eleatreeheek preoeee. Die. lerv. 813, £23 113.118, 1958. 11. r1nk, I. end oreen, n. sleetreeueepheleerephte eerreletee er ‘ the electrocheek preoeee. Die. [eyes a; . g2; 11?, 1958. 12. rink, 8. street e: entteheXLaerste eeepeunde on peetaeeaveleiee 230 end behavior. 380 clin. leergghzetel. 33: 359o369, 1960. 13. fink, ﬂ., Kenn, R.L. end Kevin, 3. Erteete or dattnee eltered brein funciieu en perception. ?ree. 1' Int. Cong. vgzphel. p. 238-239, lerth lullead Pub1., teeterden, 1959. 15. Flat, n. Alteretiune 1n bre1n reaction in therepy. Pezghe~ ghereeeolegz zgenttere, [113e, I.. ed., p. 325~332, 1959c» 39., ”.tCB, ‘1‘”., ”M Fleetng, r.c. An annuity into the lecheniee o: ectzou of electric eheek treeteente. J. lerv. lent. Die. 12h. k hho~h50, 1956. elteruettnc etienli 1n dieerininetien experieeute. I: eeuet. Patchegg 16. cellereen, L.V. v1eue1 chance orders e! g5, 207-208, 1933. 17. Green, H.A. Reletien between threshold end duretten e! eeienree end electregrephio ehenge during ooeveletve therepy. a.n.n.n. (in preee). �.2918. nugzlsnd, l.. nultnud, w.. xguruan, 1.9. and Finest, a. chant-u 1n aluotroauaophtlogrnu and in £h¢ excretion of 1? - kutorctaraoida aceonpnnyiug aluotroshook thcrnpy or agttntud doproallou. razohouon. and. g. ' ab6~251, 19h6. 19. 1n vorb:1 Ghanaoa an! Kuhn, 3.3. u. Jattc, J.. tint, trunlaataono with inducod :ltorcd hrtiu function. 1960. 23$~239, 52g: 91a, nunt: Icav: J. 90. Kuhn, I.L.. tint, a. and wuinutotu, E.A. lolntton of anubnrhttal 1.1% to clinical inprovcuont 1n oloctraé thank. Arch. laurel: and Puzohint.‘1gs 23-39. 1956. 21. Kuhn, 3.1. an: Pink, H. change. in language during electroshock thorupy. ?: who Ithola' at Communicatian, noun, P. and & Bruno 126~139, Struttou, N.Y.. 1958. Zubiu, 3., tau., 9. 22. tuba, n.L.. Pollack, I. tad rink, n. figuro~gronnd diaerintuutian ARA arch. laurel. inéaood tnnotiua. brain sitarad arts: 3,: Sim-551. 1960. R.L.. Pollack. n. and link, a. soc1;1 attitudo (California I Saul.) and convnlcivo thornpy, 1960. 187-192, ggg, J,l,l,3. 25. laltuovuky. L., Darrora, 8.8. and lorvits, v.1. The “Potst unl' roaponst in olnctrtc shook thcrtpy. Al. J. Pszchiut., 2;. 708-711, 19kt. 25. Kevin, 3., link, I. cad Kwalwnuuor. 3. Relation of ehtnxtu in aviary and luarnlns to inprovununt 1n aloctrouhaek. Gout. 303301. gg; 88-96. 1956. 26. Karinnd, 1.1.. Ibuloug, 1.3., Enquibﬁl, A.J., Kr¢ntn, 3.6. and Shoots, 6.5. A coupsratlvu utudy of hoxntlnoro~ dicthyl Rthc1 (Indoklon) and cloetraconvulaivo therapy. 19590 ”‘WQ 95"”, 21 ﬁght. 1: I‘m. 23. Kuhn, �.21. 97. Lnnouatqr, H.P., stcincrt, 3.3.. nan trout, I. ﬁntlltornl oluetroconvulstvt thcrtpy. J. Hunt. 3&1. 323: 221-997, 1958. 28. Killer, 3.8., 61:30:, J. conpnriocu between unidiroétioanl entrant nou~oanvnllivc olcatricul uttnulntaon ngon 31th nuttarta nuoh1ao. standard and cunninga, B. A ultornntaa; carraat electroshock and pontothtl in chronic uahtsophronta. An. 3. ?Izghint. £92: 617—620, 1953. 29. citation, 4.0. Exportuontll stndIGI or ‘hn node at nation at clootrooonvull1vo thnrtpy. tot; Pazghtat. & lturol. 86:34. 8322. ;§2,‘§£, 1960. 30. Pnoolla, 3.1.. Darrcra, 8.8.. Illinovlky, L. Varitttono in the oloctrocuecphnlograu unuoota‘od with aloctriu shook therapy in patiga‘a with nuutgl diaurdorn. 19h2. 367~38h. 31, laurel. szohtnt. 31. Pollack, n., Butt-ruby, v.8. and Sander, H.B. rashictosoopio identitiotttnu of content in putzcutu with brain dalnxo. J. Gagg. ’El'3°1° Pczphol. £9: 220~t27. 1957. 32. Boitnnn, !.J. and 3013140. I. technique for tho Iodxtlcatlon or cloutroshook with nuccinyloholinu. Bin. UOIV. szp. 3g: 237«2h2, 1955. 33. Roth, H., x§y, D.H.l., shat, 3., 3nd Brocn. J. Prague-1n :ad poatothal induced olcctvocncuphnlozrnphic changes in olcctroeonvulatvo trontucnt. £36 c113. luncgghzytcl, Arch. Q 2; 925.237. 1951. 3h. agent, a. tootaioholtau and lavaton1u J. louroourg. Akp 2t-21. 1951. 1n the spinal fluid. �.22. 35. Shaun... 6., ﬂxh‘lik, 4., tad Jouco, l.L. cltnxcal pirahiutrie aging tn. nodntaon thrcthuld. J, Patchoaoag a... g; h5~55. 1957. atovoaa, 4.9.. naakn, r.1. and I‘IOIIOP, I.L. Tflﬁltltutﬂl in activity 1: ﬁt. spinal fluid neuropuyehiutric EGO-hﬁs. 1959. condtttonl. 91a. Harv. gin, g2; attest. 36. 37. I taunt, 9.3., o: choliuottcrason and Bazacharn, B. It: 1n hung» nontnnt and chartuaorluattoa spinal 31:16.. Bahia, g, 31.03roh, 31: 132-1h5. 19h9. 38. 331th; and 0.A., x. 3.x. caldvoll, aloaor. o.c.. Blctt, The to. or natchod group: in thc ova1u§t1¢n at ooavulaivu and Iubeonvulttvo photo-hook. 3311. Inna. czan, 18: 138-1h6, 195k. I. 6.6. Evaluation 0: convultivo thank thoroptcn utilising a control group. £5&4£g 195$. 795-802, ;;ga rgzchtlt. ho. walnutotn, 1.5. sad Kuhn, l.&. Dania: of zllgclns ango;1c and ggzltolo‘tual nggusi. 0.6. than... sprin3t101d, 111., 19550 39. Ulc‘t, 6.1., saith, and 61.00:, �'Ws. mum, um «Mum, W In: macaw». 3mm Wu, ' 6 T 4 a 3 3 �am: as. 0 W haunt“ nun-n Electrical 7 6 iv , an: mm: 5 S :8 < 1,9, mm 1 wt “mm-is �W last-convulstvu Ila slow ﬂuv- antavt‘r $51.33;. ’ggggggt gins} :“Cu“ until"! lo. 1". 15 6.6 ”ah 50.3 51.! 1‘03 1! 30° fl.” ”o! 5705 1‘10 had I: 7*! In 10ml! I: fit Vick: A£$or �£A!§£.h 331.0% of :ntchloa an: Ilooiracllly Ialhltﬁ satsnroa an Puyulalagtn 133‘ tortﬁrlnncca (aiitil Bxprsantd us Iran 3:110:03...) MWW Prtotvnntunnt Pruntrncinnnt ﬁnd an! 1. 30.331.2«In110vun (witgltnd littcut scorn) t. III-rustic! Inc ' ‘1 new t“ ’1‘“ ant.‘ (l""') m I“ :32 3. libiddod iaulrul 13d to h. '"“C“‘C”" ' (l"'*I> ‘.‘1. lush; Ullucacu'u ! - H’.7*‘ “10‘ ~1.3 1“ ‘..”h1’ ‘ < . ‘t?’ 4 ¢ﬂ.h 1.1: *inﬁ‘ﬁi .’Q'” 9 ‘11“ o htlndﬁ 03.5% ¢ _. ,0,“ § 1.)... “'9‘”. W58 “901 ’ .907” ”6.5, ”'1‘"... oo.:~u c1.o ¢3.: 1" .'.T. ’5!” £0! puaruﬁ rcpltt.tun ﬁ ’ 4 .03 (L Q“ ’ ﬂ ‘0’? #9.: 0 1.90 “’0" net “I 00.! ”'oh" ~;.9*o Ind 36! and w- ~1.J&O m h. 31.1% [3.3 .0 ”3.3“ u fours! v.0! «h.9 .g,; ~a.6no ﬁ,.’ .10. ~13.1*0i “ - h.1ii0 $.90uu ““0“. “' It.“ �«all» 31653333 g §§u§~3m§i§g§h5§:§3nﬁ 4.. basin-«gm gov it: �� Dublin Core The Dublin Core metadata element set is common to 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 Inhalant-induced convulsions. Significance for the theory of the convulsive therapy process. Arch Gen Psychiat. 1961 Mar; 4:259-66. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-52-018 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Karp, Eric; Pollack, Max; Green, Martin A.; Barre, Alan; Lefkowits, Henry J. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry March 1961, Vol. 4, pp. 259—266 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/549693df019a0cabd2aa7cfa90ad3ced.pdf 62db1d0b502fce82996214e0276f034a PDF Text Text ’i' WM 3mm; lacunae Whammy mum. a: convulsive ma Ems in 1:33,“;ant W Mhim Fth mm m 1-. 0-. A. 3.1% of mmm mmm, m the mam. mm m, 34.1., $1”. W Hakim}. W? of the Unﬁml Wﬁm%_ a! Manta Insti‘MkaWWith, mm ﬁﬂm mm: mm 80m“. He: 33.113169 -' Aldus! 3.33.1513, 01' a Se Wolagiaal W an arm mmg, Howof1m 3mmandm- ammal Psychiatry, Kw Yam assuming mum may, of 10-613mm, ﬂu: Kerk, 13., 1953:. Promtud a mama: . » ‘ 5.. #- sky and Mb �II: 3-1148 Experiment-3. Shame at cmvuhive and 13mg momma: in Psychiatry: Maﬁa mummy mum e the vapor rule a: the We pearly Mined. adequate aw sumac therapies in This results, in part, femhﬂon of their we at aetian. increasing evidence for a frw In the the leak at an put an: yam mmﬁyaiolaﬁemptiw view of electromoek therapy has been presented by Wemtein and Kuhn, Bath, and view, the madam Wynne prawn 1n electrocheek is [319128. in thin Mex-1m to a Imminent. alteration in cerebral function mm: madden the milieu for a change in adaptatim of the aubjwt in his anvimmnt. having the past four years in the we have attuned the autism between mum and the behavioral name physiedynemic therapioa .. laboratariu of Hillside hospital, alteration in urinal: indicate of brain at psych “trite patients ta three of the emmmwk, Win one and *tmqullieere." me nemyhyaielogcudapuw view at sleet-manna has been Wind in the” studies; has been preheated. and widenae Recently, the mar “trimmers.” :5qu we for a similar View of insulin coneep’t. em has been fruitfully extended to the The» studies provide the hands for a gmmlimtim �«2* «meaning ta a! W the. mode of the experimental mum at these therapies "idem measurable éetomine whether or not the be tenight male mean I’m their ability ta inane: manned- may altemtian in aembral function; it in ear PW the" therapist. nation of and the wrelluy questing, alteration in eerebral fumtion is efficacy of these thempiea, or mether me}: a, necessary whether mﬁtien for the We: in brain aunties: m a “maimﬁan” er "11331th when" have used We View). mime indie» of brain {Manon including mar llama, m mule pomoptual mice, and uhangea in orientatian patterns at new both clinically and utter intmmua mbarbital which be generally knew me the ”m1 test." the delta index In electroencephalographic studies, ehanges in in meuutod words mm at altered brain mum. For have been “and to be a mauve latm this mica, ehangos in this W will be ctr-eased. In the initial rotomd for mmleive nudism of normative patients therapy, oleetrmcephalogram were amazed before, tmemnt at weekly intmala timing therapy. m1 therapy three time a week, fer a total of The and an a day ate: a patients rewind 312-20 applieatim. m6 �a, thte 31w were nativity. In the mun}. We Wt the 01' the heme witty tenet, m quantitatively Mum delta eetivity during by determining the per tee-t time maintenm » each we}: at eeeh mﬁﬂty, the and the duretiee amt WW, e: berets in selected team were then new we the W thin! were at treatment We. the emm ae "high," theeeeenethieeeeﬁnieﬂcﬁmdﬁmmethMuVW demure! Mite entirety. “tee tee their We: he met meets the noted in the rim. short term emu rem (he make poet Wheat) new means: peyehutuc trauma, and were “Mentally moved“ and "We” elseeed as ”wet theme,“ �.h... In the first toms of mutants, a Want relationship human the early inﬂuation of high degree: of delta nativity, and clinical rating. at ”math Wad” m crammed. may put: «at at the “cm-ids in tho 313.1: much mma group mm high dogm mu by this 14-6 Manning pemntaga my unstained at um 91‘ the unimproved first ulna mks, 90% in the third and fourth mm. and the In mtmt, pawn“ dumped 121$ dogma! data «cards in tho and only 20% of the records in the tenth-h week are to elusifiod. Baud can those mum, u wanna nudy m undertaken. mum-d: obtained during the amend ﬁnd Wad for that. 15h:- dogroe a: W w; third mic: or mutant. mm delta nativity, and it tun 0:31:1de than patients the had high degree: a! (with activity during then periods would that better ratings of ”Wat“ than puma“ in two when �~s~ such damn mm. of delta activity were not This prediction was Fig. 5 m“ ' 1mm 1mm, an occasions were 67% at the patients with high degree records ”mach improved," “minprmd” 705 were while m: ”moderately 31‘ on both patients withaut such "earth,- tamed." Further aorrabomtzlon was obtained in a canvulaivoumbeonvulaiva control ”My. Connemara m convulsive who car of. middlo waiving referrals were plum aims:- an mboonvulsiva therapy on a random remind aubaonvulaim antivity 3110 chrothampy trauma, mm min. a: Wmm slow wave or high dogma in any use): of treatment. Waive therapy, patients 27 or; 28 EEG subjects high degree records were observed in 20 rimming the second to 1‘0qu weeks of treatment. Or 23, and the 27 mboomlsive patients, at the“, 19 mm retomd for ml elactromock induood no change 3. ”cont! in behavior coma of tmtmnt. high dogmas of delta antivity in 1h in each, a significant behavioral Me was notad. in was when! at" Grand We, and In the rim panama �«a. Iii-ham; Inch ‘ delta chug», «my m ahead a m cm“ of mutant hehmiwal W183.“ thumw indium that m slaw mo nanny 1-: as: 1nd»: at tbs chums in «ma imam man are promise to the Maria“ ' aha-nae in this turn a: ﬂwpoim or their elmtmaophdogmpma 1 moaningml W. and a mum. annual manage attack, renump Luther: um dogma ma type of mam W m mmbml function and the clinical behavioral rum is observed. The Waxing agents to imam aim of central nervous system @atmtion, a motor rigidity, deputation, «summit and. MW ability of the aver m Wu Imam. - mod on ohmumm nude in mm expat-1mm am in We manual: at various ms in ms mama-r143 partisan, m have also bun notoé. than me «that: m be clusﬂiod awarding to men in the {macaw spectrum, and m at three broad Wu: " met �“1.? 1. mm new we mum II. Instance 111. high voltage Bethrmiution WWW- with that activity. with voltage and {macaw Singularity we irregular that». activity. at the drugs that induce increased slew have mtivity the phonothiaeiha enemies. pmiee and Wine m elm We. Each drug also induce; aims in mmeptim, megawatts mum in ﬁerivatim, I epilogue shadow, and induce; enamel “thin-mien naming“ pumm. ’In the enamel eat-vice at amazes Hospital, pneumonia but in all patients reaching Mammalian, 10% of and «um: have been observed in Whit: patient. ﬁthent 3 Wm history Renee-pine how induced of ”18mm else moms delta nativity, but only when gim in it high dosage levels, it the mggmm Mum: in opium, Munroe in mm», the clinical are elemet maples. Indeed We tut nativity, barbiturate “than agents differ from the phanethiuinee and "sperms in not warming «hum. and whenoeim in me. at drugs that induce immune high voltage ah merchants hm dean. Woman, or mm their anhiamlmt nativity is measurable. �.3. minimum in readily “Mum. and ”ism: hm hm charred. Varima drug: indwo EEG domabrmiaatiw with varying «ﬂaw. lamina and damning; bamamina mm W a: mama two reports either of . MW, in mt bean «baa-wad with miss: will. than eat that: drugs, user have ”isms nr parkinamiam in. than clinical «tents «gm: at phnnothimM derimtiws, ma Wad «synchroninmm with Dalia activity has and «ﬂaw. we found Ilium-azure. mama“, dimm and WWW have been that: to mam-unis. the EEG delta moral! or patient! undergoing 010W tummy. ’16-: 6x '3': 3» M the» minor 9. Winery, ahlorpmsim, parphonuim and ”amino haw been amiatontly annually reported as paymwio barman:- panama. in me frequancioa to the most. mus are also the ma. range. mini in $3ng drugs that. mmbmte, Mm momma and groan the man. 1:6an �m 01mm 1m mm. in tha than an m agents we pmdueo m man-ea mum at :m tmunwiw er doaynchwniuum. mum, an delta range is t mcmtmt at signifimt behavioral in cumulus.“ therapy, an .3 (i5) " may, 12: the m tnqumay shut in the situate. “ magma ofinmlmemthampymbcamodina 13.22113:- rwhim. During usually pal-auto for «an am, EEG delta mmuw 1: manna, mm: to a few hams-a after gauge. not. 23212222 Mmumm, . 1— V mo third of patimta waiving hospital, 131mm” aphasia or prolonged EEG change: or alarm activity am, far “the: m 2231:! relation bahmgral am mey in this am and“. an» such pomt fer elm, and 122 «mm: mu of pmlmgad mm. how 13th am, ﬁtmd brain function am! mama has: been (anew at length by various authan Him (20220121233 that. dam. He We study. sloop Woman”: is related be 22;: 1226226321921 of organia brain haw abnamd a 31:11“ relationship, and reported am «nah A 322 you old aabimphme puma“. with puma“ 13mm: �«It» Now a loft magnum eating mm: em thmpyi efmurMe fom: With the unset nmmmamwmmmmmW. paw « withdrawal cooperative attitude. the» mm pattern we Hie mum by I Mmdly We: can wemmd by delta clung“ in the We, (6) W: While in him net bad the perennial opportunity to etudy lobetw intimate from the $93.11*. of View at this awry, mmeebumere clearly dome a of delta aetivi ty are present for W in 3 1’30 relatienmih me in all subdue“ peatwpcneivoly arm periods, up to three yours. «1mm the report: at We and peniet ﬂux-them, pests-operative m a frequent ”museum, being varieealy report“ a new 26% of subjects. �D‘IESE: has, what: "Mm “Moi thumpiw point of ﬂaw of an alteration in brain node at whim. Those m We of the imam, we may in!” a. chanson in hahnvior. «he» at these madman puma a m mum aﬁmﬁm a! the mam alteratian in brain taxation. mum 115an by am in than in Miami at W the 111.1101: «hangs data range, mm is signiﬂaanaa a: that-aw; um with an W “we“. Man :0: the mucus af faction with reaultmt Ghana“ in brain . thawing m swayed rm the apoctm of 1mm in aynahrmuatien, mat. «mouths in altering Mmatin EEG mung” immunity: proud“ the mum m delta shirt has boa: alearly dwamtmtod in elmtroaonvulsin ﬁlm m be mama iron the available data for the W pmm» Wattage agents, whammy and insulin can. mat a «mummy mu. m 3mg, mg drug atfce'aa. and maarpina m Manet” mm Wed mmmauon. has am apoaificity is Thou drugs tam .. have been at paychntic mutton soon in the analyses 61‘ mm a delta shift - thc mmﬁﬁum mandamus! mom as effeetivc Miriam and 31m.» aa Potent mumminogans. �4%." ma mt‘ma a. synchronimman in 1210 have strum of ohms: in lawn beta range, as in contrast, are poor Viki“ ( aha ) . « 03.80 in has potent. Drug: a hammme, dict-hum am! ”mains, Wars: mm and illusory Momma. mamlihathat WW“: and «9:9me sedation and trwquinsaﬁm, but that man“ we avmahmnuaticm, with than; of mam mooted by manna-d and in 11191 dosage inch-1m maisty, obnmtians are clarity maniatent when awclw in him mam of marginal: and . . raga-Glen of the mm“ a: am am amum, shifts in tha pattern a: m alwtrmaephalogrm in thy dimtim of domchmiumm new in “mam um Maw, >ha11ueimtiom, fantasies, illusions or tremors, and in with mgriu, mlmtian 801: alum and Mammal of mahmniuuam ‘meﬁ pursuant clung” in mabrai imam “feat behavior mm mm»:- m with an ﬂ'heﬂtiﬁn in tbs in. 91' than we; *memd' or 'abutomtéd.‘ antral mam mm mum, thaw an upon“ a: mam:- including .mpmn, ma, arm, attitudo. mo aéaptive :11 not Rather, is an alarmist: mam-Wt. We mdar an“ conditimn in variable �.43.. fer eeeh eebJeet end is Gee-Wt mm. W puma-3.1m and the duration of the dieeueeed in behavior are “Wamhtﬂ matteetere es the type at teierenee, nether abut-term with; . ehenge 1d net "do eve-Tented by the The” rating; “may hem no value psychiatrist as 3W, mentions. a. . «2qu In this meta-e3" the Mamie men”, they men in «relented ale inpmtehent. Ahmed the Wed behavioral name, Mm temwmnw The induce a hehmveral alteratim or eerehrel Imam themem net I ‘cmlieetien' or [In *entemw «new but the chaired goal ef these fame of during the peat the therapy . Mum. u automate w the individual hehevierel new. to the degree of upon and alteration in brain renewal: have The inﬂated ehe’epe e W “mm mm mmmm and mix-Wm on harem. er the may tine-guest therapies intmchxeeé thirty rem, me eppehenﬂye has been a. epeeitie agent fer a: psycho»: (in the tense mat penieil‘lin 1e emeiﬂe Tar WW! and nieetmic mid for pellegm émntia) , but rather with greater or lesser degrees of epplieehmty behavior by altering the hombre}. when. and mm etiieaey in altering �, in m, we hm: mm the nmmsiologie upsets at, mm WW3 woman, and hm «minded am; the therapeutic pram of ammonia, insulin can, mtw and trmqnilimrs my Mutant Ilka-mum in «new in uhptaticm at ﬁn mama. mm; pmm the silica a» s. be 3.36de to tha inductian at .J‘mbsactb his 1- , a em Wt. the «ﬂaw at web mutant. mthod in mm to its mmw w W a pursuant. «hung: in! mmbml functim, of mm m «It: shift in the m 'speom with Wad mum“ may but a, amuimt W. management of Such a ' a» bu appliabﬂity in m m at those thumping to the scram of m payohophﬁmuolngia agents. and as 3 arms of mnmﬁzysioﬁmwu atom m further new of Matter and" � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of convulsive and drug therapies in psychiatry: theoretical implications. Arch. Neurol. Psychiat. (Chic.), 80:733-734, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-33a-010 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/b574305356446714449f347eaa71e515.pdf 4bf163bfe85fee82b5e7d9be3ad5c243 PDF Text Text Experimental Studies of the Electroshock Process MAX FINK, M.D., ROBERT L. KAHN, In the last seven years, increasing study by various authors“5 of the neurophysiologic alterations occurring in electroshock has resulted in a re-assessment of the mode of action of this form of therapy. The present neurophysiologic-adaptive hypothesisly2 states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in the continuing evaluation of the electroshock process in this laboratory. These include: The relation of changes in neurophysiolog‘ic indices to behavioral change; 2. Types of psychologic response expressed and factors in the evaluation of “improvement;” 1. 3. and The role of personality in the behavioral response. and Method: The studies have been carried out in groups of consecutive, unselected electroshock referrals. The subjects are voluntary patients in an open ward psychiatric hospital. All patients are treated by resident psychiatrists, who make the referral to the elec— troshock therapy unit. The duration and type of therapy, however, are determined by the supervising psychiatrists in charge of the treatment unit. Patients varied in age from 20 to 66, and have been diagnosed as suffering from depressive and schiz0phrenic I. Subjects illnesses. (a) Tests of Brain Function: Two indices of cerebral function have been stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,6 and changes in orientation and aware— ness of illness after amobarbital sodium.7 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided, in part, by grant M-927, National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N. J ., June, 1957. PH.D., and MARTIN A. GREEN, M.D. 1) EEG: Electroencephalograms were done weekly prior to treatment, and on a day following a treatment. Bipolar recording was used, and selected leads were measured fOr the degree of delta activity. The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and slowest frequency of delta, and, the longest duration of bursts were the measures utilized in the classiﬁcation of the recOrds into “high degree]? "‘mod— erate degree” and “low degree delta activity.”6 Amobarbital Test: This is a structured interview, in which the patient is asked a standard set of questions pertaining to ori— entation and awareness of illness. Amobarbital is then administered intravenously, in a concentration based upon body weight, at a rate of 1 cc to every 40 seconds, until nystagmus and slurred speech are induced. In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold} the procedure was modiﬁed to allow for weight differences of subjects. The same questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called “positive” and are indicative of states of altered cerebral function.7 Tests were carried out before electroshock, and at weekly intervals during elestroshock on the day following treatment. (b) Evaluation of Behavior: In addition to the notes of the patient’s therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and 2-4 weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these descriptions. Ratings of improvement 'Were based on the behavioral response two to three weeks after the last treatment, and reﬂect a short term clinical rating. The patients were divided into three groups: much improved, moderately improved and unimproved, based on criteria 2)_ described.2 Reprinted from Diseases of the Nervous System, Vol. XIX, No. 3, March 1958. �(0) Evaluation of Personality .' The initial method of personality assessment employed has been a structured family interview. In their original observations, Weinstein and Kahn described the characteristics of the maintenance of high degree delta activity and short term clinical ratings.6 Of the pa— tients who were rated much improved, 90% had high degree delta EEG records in the 3rd and 4th weeks of treatment, While of the unimproved patients, only 20% had such records. The relationship between delta activity and clinical ratings is seen in Figure 1. “explicit verbal denial personality.”9 To determine the signiﬁcance of this personality type for behavioral response, a structured questionnaire was developed. In interviews OO .— MUCH IMPROVED (u) with two members of the family, the patient’s usual attitudes and interests in 15 90 .-—— moo. IMPROVENG) UNIMPROVEDW) .-.— characEach speciﬁc areas were explored. 80 teristic was rated as being absent, moderately present or markedly present. Scores 7O of 0, 1 and 2, respectively, were assigned, '60 and added—the resulting score being termed 50 the “denial personality score.”1° (d) Treatment: Electroshock was admin- 4o istered on a schedule of three treatments 3. 30 12 week. A minimum of treatments was given, except in a few cases where a. severe 20 confusional state appeared earlier. The course of treatment was determined by the supervising psychiatrist in charge of the lO-lZ electroshock unit, based upon clinical criteria. Treatments were grand mal, using either a Medcraft alternating current instruobservations In these series, subsequent ment or a Reiter C-47 electrostimulator. Pain Based extended predictive were study. a tients were generally premedicated with inthe earlier it on was suggested observations, travenous Pentothal prior to the treatment. those the much that were improved patients In the past year, a subconvulsive therapy been in had whom delta high activity degree group was instituted. Randomly selected induced in and the of treatment course early electroshock referrals received 12-42 suband Records second sustained. the during convulsive treatments, under Pentothal preweeks of third treatment, therefore, were medication. These patients were subjected in 54 consecutive The results assessed. pato the same test procedures and the same bein Table Of I. the noted tients patients are therevaluations mal havioral as the grand delta who degree developed activity high makthe Neither psychiatrist apy subjects. weeks of third second the and treatduring ing the evaluation, the patient’s therapist, while much rated 67% improved, were ment, nor the patient was cognizant of which pawithout the such of 30% aconly patients tients received which form of therapy. The rated. so were tivity data for this series of patients is now being evaluated, and reference will be made only TABLE I to the general observations. Patients With High Delta Activity During II. Observations: Second, Third Weeks of Treatment RATING CLINICAL in Cerebral Role Function of Altered (a) '8 >. Behavior: i’ 75w: a: Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and a 1. .c: EEG Delta Both High (18) One High (16) None High (20) S E to. E 5 8 a 5 12 (67%) 4 (25%) 6 (30%) a; 8 ’5‘ Q sE (22%) 8 (50%) 7 (35%) 4 a D 2 4 7 (11%) (25%) (35%) . �Amobarbital Test In the initial series of 24 patients, ‘previ: ously reported,‘-’ eleven patients were rated as much improved,,andall had positive aniobarbital test reactions after 7 to 9 treatments and sustained this response. Of the unimproved patients, 15% had positive amobarbital responses in the third week and 28% in the fourth week, but these were not Sustained. A comparison of both the EEG observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. In 77 patients tested to date, observations during the second and third weeks of treatment were examined for the presence of high degree delta activity and positive amobarbital test results. Of the much improved patients, 75% had both positive amobarbital tests and high EEG delta activity during this period. Of the unimproved patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a signiﬁcant one; and equally signiﬁcant is the cluster of negative amobarbital tests, low and moderate EEG delta activity and clinical rating of unimproved. TABLE II EEG and Amobarbital Test Results During Second, Third Weeks of Treatmenﬁt 2. :, .c: 8 2 8 Total .................................................... 33 .01 E 3 8 E e s E Both Positive Amobarbital and High EEG Delta Activity ........................ 25 Either Positive Amobarbital or High EEG Delta Activity .......................... 8 Neither Positive Amobarbital nor High EEG Delta Activity .............. O *Significant at better than 2 2 Q E sD 10 3 12 5 3 11 25 19 level of confidence. (b) Clinical Patterns of Behavior: In these patients, we have observed varied responses to electroshock including the absence of noticeable symptoms with a return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic com.plaints and pre-occupations, states of in— creased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of’behavioral change is seen to be related to the degree of alter'a} tion in the neurophysiologic indices. During electroshock, with the gradual induction of states of altered brain function, and their restitution in the weeks following cessation of therapy, behavior shows characteristic patterns. The following are but a few of the gross patterns that are observed during the period of increasing and waning states of altered brain function. An early change in behavior in retarded subjects, for example, may be a change in the degree of participation in ward activities and increased neatness and interest in personal care. This is succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial of illness, and insistence upon going home. At this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest in the future becomes prominent. Premorbid patterns of behavior are in evidence, and the EEG returns to normal and the amobarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed during treatment, withdraw from participation in hospital activities, and complain increasingly of memory loss, physical distress and insomnia. Amobarbital tests and electroencephalograms may show the same degree of change as in the ﬁrst group. With cessation of treatment, there is either a return to the depressed state, or a persistent emphasis on the memory loss and physical complaints of the treatment. Another pattern, seen in hostile, negativistic and withdrawn patients, is the development of hyperactive, hypomanic, and impulsive behavior. Memory loss is marked, and clinical disorientation and confusion may be noted at the height of neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional for.3 �mation become prominent, to be followed by withdrawal and mutism. (c) Eﬁect of Subconvulsive Therapy: The interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by obser— vations in the subconvulsive group. TWentyseven subjects received subconvulsive therapy instead of grand mal. Minimal changes in the electroencephalogram and in amobarbital tests were induced, and the changes in clinical behavior were limited. The electroencephalograms demonstrated either no delta or a minimal amount of such activity. In no patient were moderate or high degree delta activity records observed. In the amobarbital tests, only three patients had positive tests during treatment, and in each instance it occurred only once. No change in symptoms or behavior was noted in twenty—three. Nineteen were referred for a second course of treatment. Grand mal electroshock in— duced changes in brain function of high de— gree delta activity and/or repeated positive amobarbital tests in fourteen of these. All fourteen showed signiﬁcant changes in behavior; While of the ﬁve patients in whom the physiologic indices showed only minor changes, only two patients showed a deﬁnite behavioral change. (d) Role of Personality in the Adaptive Respouse: Another variable in the adaptive response of the patients is the personality—the habitual attitudes, patterns of perception and behavior and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients showing denial mechanisms to the clinical result. The relatives of 47 patients were interviewed, and denial personality scores assessed. Scores ranged from 0 to 25, with a median of 11. The scores were divided into two groups: scores from 11 to 25 were classed as the “high denial group” and those from 0-10 as the “low denial group.” Of the patients with high denial personality scores (Table III), 58% were in the much improved group, and only one patient (4%) was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random—'4 about one third appearing in each rating category. TABLE III Relation of Denial Personality Scores to Clinical Response to Electroshock Personality Score 11-25 0-10 Total Much Improved 14 Moderately Unimproved Improved 7 9 9 1 7 21 18 8 Total 24 23 47 The difference in the denial scores between the much or the moderately improved patients, when compared to the unimproved patients, is statistically signiﬁcant. That the personality ratings were indeed reﬂective of the patients’ adaptive response under the conditions of altered brain function is noted in the correlation of these scores with actual changes in language patterns which had been described11 as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classiﬁed according to whether he showed three or more explicit language changes. The group of patients With high denial personality scores showed a signiﬁcantly greater number of language changes than patients with low personality scores. The coefﬁcient of correlation is +.71, which is signiﬁcant at better than the 1% level of conﬁdence. Discussion: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn,1 and again by Kahn, Fink and Weinstein,2 and the observations of Roth,3 Aird,4 and Ulett.5av Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. We have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital as indices of altered brain function. Other measures, applied in the same serial fashion, will, we believe, demonstrate the same relation to changes in behavior or alteration in brain function. Under the conditions of the induced 111. ‘0 �change in brain function, altered patterns of adaptation are expressed.» The type of adaptation varies, apparently dependent upon the personality organization. In these studies we have noted the relationship of an “explicit verbal denial” personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews.11 We have observed that patients with high denial scores are those who are more likely to be evaluated as “much improved” (Table III). The type of adaptation is varied, however, as we have described here. In this context, therefore, the conclusion is afﬁrmed that electroshock is a means of inducing change in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. We have emphasized “change in behavior” in this report. In previous studies, we related our observation to “improvement.” “Improvement” is a derivative evaluation of the induced behavioral change, which is dependent upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, who had been withdrawn, crying, and had expressed suicidal thoughts, no longer is seclusive, and is jovial, friendly and euphoric, denies his prob— lems and sees his previous thoughts of suicide as “silly,” a rating of “much improved” is made. To the extent that a schizophrenic patient is perceived as less delusional, less excited, and less Withdrawn, he is rated as “improved.” When, however, the induced behavior is one of increased anxiety and fear— fulness, or persistent complaints about memory loss, pain or other physical symptoms, or excitement and delusional thoughts, a rating of “unimproved” will be made. These studies amplify the present neurophysiologic-adaptive hypothesis of electroshock action. Further studies, deﬁning the signiﬁcant aspects of personality and of the expectations of the environment on the patterns of behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquilizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. IV. Summary and Conclusions: 1. This report summarizes continuing experimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an alteration in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The pattern of behavioral alteration is shown to vary markedly, depending upon the degree of induced cerebral dysfunction, the personality of the subject and the environmental situation. 4. “Improvement” ratings are seen as a special case of behavioral change dependent upon the type of adaptation elicited, the expectation of the therapist, administrator and family, and the tolerance of the milieu. 5. The extension of this neurophysiologicadaptive hypothesis of electroshock action to other forms of somatic therapies is suggested. 1. REFERENCES Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109: 22-26, 1952. 2. Kahn, R. L., Fink, M., and Weinstein, E. A.: Re- lation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. and Psychiat., 76: 23-29, 1956. 3. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Signiﬁcance for the Theory of EST Action. EEG 01m. Neurophysiol., 3: 261-280, 1951. 4. Aird, R. N., Strait, L. A., Pace, J. W., Hernoff, M. K., and Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. Arch. Neurol. and Psychiat, 75: 371-378, 1956. 5 a. Ulett, G. A., Smith, K., and Glesser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. J. Psychiat, 112: 795-802, 1956. 5 b. Ulett, G. A., Glesser, G. C., Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock. Bull. Merm. Olin, 18: 138-146, 1954. 6 a. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Olin. Neurophysiol., 8: 158 (Abst.) 1956. �6’ b. . . Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. Arch. Neurol. and P31chiat, 78: 516-525, 1957. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112: 889-894, 1953. Shagass, C.: The Sedation Threshold. A Method for Estimating Tension in Psychiatric Patients. EEG Clin. Neurophysiol., 6: 221-233, 1954. : . Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol.» and Psychiat, 69: 355-367, 1953. . Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock. Therapy. Conf. Neural. (In Press.) 11. Kahn, ;R. L., "and Fink, M.: Changes in Language During Electroshock Therapy in Psycho~ pathology of Communication (Hoch, P., and Zubin, J ., Eds.). Grune and Stratton, N. Y., 1957. (In press.) 10. _ ��.thv- AyiAuu. .gypZZILu Experimental Studies of the Electrcshock Process Max Fink, 14.13., Robert L. Kahn, 31.1). and Martin A. Green, M.D. From the Department of Experimental Psychiatry, Hillside HOSpital, Glen Oaks, N.Yo of Mental Health, part, by grant M—927, National Institute Service. Health Public U.S. of Health, National Institutes Aided, in Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N.J., June, 1957. Read Vo at the 6‘27-S7 �-2Experimental Studies of the Electroshock Process In the last seven years, increasing study by various authors (1-5) of the neurophysiologic alterations occurring in electroshock has re- sulted in a re-assessment of the The mode of action of this fcnm of therapy. present neurophysiologic-adaptive hypothesis (1,2) states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in this laboratory. in the continuing evaluation of the electroshock process These include: relation of changes in neurophysiologic indices in behavioral change; 1) The 2) types of psychologic response expressed and evaluation of "improvement;" and 3) the role of personality factors in the in the behavioral response. �II. -3“ Subjects and Method: studies have been carried out in groups of consecutive, unselected The electroshock referrals. ward subjects are voluntary patients in an The open psychiatric hospital. All patients are treated. by resident psychiatrists, who make the referral to the electroshock therapy unit. type of therapy, however, are determined by the supervising unit. Patients varied in age from charge of the treatment have been diagnosed as sufferina from depressive (a) Tests of Brain Function: have been Two duration and The psychiatrist in 20 to 66, and and schizophrenic illnesses. indices of the cerebral function stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,(6) and changes in orientation awareness of illness after amobarbital sodium (7). 1) Egg: Electroencephalograms were done.weekly ment, and on a day following a treatment. selected leads were measured and prior to treat- Bipolar recording was for the degree of delta activity. used, and The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and Slowest frequency of delta, and the longest duration of bursts were the measares utilized in the class- ification of the records into "high degree," "moderate degree" and "low degree delta activity" (7). 2) Amobarbital Test: This the patient is and awareness asked a standard set of questions pertaining to orientation of illness. Amobarbital is then administered intravenously, in a concentration based seconds,% is a structured interview, in which upon body weight, until nystagmus and at a rate of 1 cc slurred speech are induced. to every ho The same 1"“.% In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold (8), the procedure was modified to allow for weight differences of subjects. �~12.- questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called "positive" and are indicative of states of altered cerebral ftnction (7). Tests were carried at weekly intervals during.electroshock out before electrodiock, and day on a after a treatment. (b) Evaluation of Behavior: In addition to the notes of the patient's therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and Z-h weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these on descriptions. Ratings of the behavioral response reflect a short term groups: much improved, described ( two to three clinical rating. weeks The improvement were based after the last treatment, patients were divided and into three moderately improved and unimproved, based on criteria ). (c) Evaluation of Personality: The initial method of personality assessnent employed has been a structured family interview. In their orig- inal observations, Weinstein and Kahn described the characteristics of the "explicit verbal denial personality" (9). To determine the significance of this personality type for behavioral reSponse, a structured questionnaire was developed. In interviews with two members of the family, the patient’s usual attitudes and interests in 15 Specific areas were explored. Each characteristic was rated as being absent, moderately present or markedly present. Scores of 0, l and 2, reapectively, were assigned, and added - the resulting score being termed the "denial personality score" (10). (d) Treatment: Electroshock was administered on a schedule of three treatments a week. A minimum of 12 treatments was given, except in a few �cases where a severe confusional state appeared ment was determined by earlier. The course of treat- the supervising psychiatrist in charge of the electro- unit, based upon clinical criteria. Treatments were grandznal, using either a Medcraft alternating current instrument or a Reiter C-h? electro- shock stimulator. Patients were generally premedicated with.intravenous pentothal prior to the treatment. In the past year, a subconvulsive therapy group was instituted. Randemxy selected electroshock referrals received 12-h2 subconvulsive treatthe ments, under pentothal premedication. These patients were subjected to same test procedures and the same behavioral evaluations as the grand mal therapy subjects. Neither the psychiatrist making the evaluation, the patient's therapist, nor the patient was cognizant of which patients received which.form of therapy. The data for this series of‘patients being evaluated, and reference will be made only is now to the general observations. �III. Observations: A. Role of Altered Cerebral Function in Behavior: 1. Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and maintenance of high degree delta activity much and short term clinical ratings (6). or the patients who were rated weeks of improved, 90$ had high degree delta EEG records in the 3rd and hth treatment, while of the unimproved patients, only relationship between delta activity and 20% had such records. The clinical ratings is seen in Figure 1. In subsequent series, these observations were extended in a predictive much study. Based on the earlier Observations, it was suggested that the improved patients were those in high degree whom delta activity had been in the course of treatment and sustained. Records during the ant third weeks of treatment, therefore, were assessed. The results induced early second in Sh consecutive patients are noted in Table 1. veloped high degree delta ment, such 67% rated were activity were activity during the second much improved, so while only EEG High Delta and who de- third weeks of treat- of the patients without I Activity During Second, Third‘weeks of Treatment. Clinical Rating Much Imgroved Delta 30% the patients rated. TABLE Patients with Of Mbderately'lrunnved Unimproved (11%) Both High (18) 12 (67%) h (22%) 2 (16) u (25%) 8 (50%) h (25% None High (20) 6 (30%) 7 (35%) 7 One High (35%) �a7; 2. AmObarbital Test: In the of 2h patients, preViouSly reported (2), initial series eleven patients were rated as testreactions after 7 to much improved, and all 9 treatments and sustained had positive amObarbital this response. 0f the positive amobarbital reaponses in the third week and 28% in the fourth week, but these were not sustained. A comparison of'both the EEG Observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. unimproved In 77 patients, 15% had patients tested to date, observations during the second weeks of treatment were examined activity 75% and had both and third for the presence of high degree delta positive amobarbital test results. positive amobarbital tests Of the much improved and high EEG patients, delta activity during patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is this period. Of the unimproved the cluster of negative amobarbital activity and tests, low and moderate EEG clinical rating of unimproved. delta �9 ..—-- m TABLE EEG II and Amobarbital Test Results During Second, Third Weeks of Treatment.* Much Mbderately Improved gnimprovsd Improved Both Pbsitive Amobarbital and High EEG Delta Activity 25 10 3 Either Positive Amcbarbital or High EEG Delta Activity 8 12 5 _£L_ L (25) Neither Positive Amdbarbital nor High EEG Delta Activity (33) (Total) B. 1.1 (19) Clinical Patterns of Behavior: In these patients, we have observed including the absence of noticeable varied responses to electroshock symptoms with a return of yrs-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations, states of increased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of behavioral change is seen to alteration in the neurophysiologic indices. brain During electroshock, with the gradual induction of states of altered function, and their restitution in the weeks following cessation of therapy, be related to the degree of behavior Shows characteristic patterns. The following are but a few of the are observed during the period of increasing and waning gross patterns that states of altered brain.function. Anearly change in behavior in retarded subjects, for example, rO-‘ﬁ’lt. * Significant at hotter than .01 level of confidence. x»,-~-n---.' ~rmw-n. may it...“ �be a change in the degree of neatness and participation in interest in personal care. This ward is activities and increased succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest of illness, and in the future insistence upon going home. becomes prominent. Pre-morbid evidence, and the EEG returns to normal At patterns of behavior are in and the amdbarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed and during treatment, withdraw from.participation in heapital activities, Amocomplain increasingly oi memory loss, physical distress and insomnia. barbital tests and electroencephalograms may show the same degree of change as in the first group. with cessation of treatment, there is either a return to the depressed state, or a persistent emphasis physical complaints of the treatment. Another pattern, seen is the loss is on the memory loss and in hostile, negativistic and withdrawn patients, development of hyperactive, hypomanic, and impulsive behavior. Memory marked, and clinical disorientation and confusion may be noted at thelieight o£1neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional formation become prominent, to be followed by withdrawal and mutism. C. Effect of Subconvulsive Therapy: interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by observations in the subconvulsive group. Twenty-seven subjects received subconvulsive The �~10; electroencephalogram therapy instead of grand mal. Minimal changes in the behavior and in smobarbital tests were induced, and the changes in clinical limited. The electroencephalograms demonstrated either no delta or were a minimal amount of such activity. In patient no were moderate or high activity records observed. In the amobarbital tests, only each instance three patients had positive tests during, treatment, and in it occurred only once . No change in symptoms or behavior was noted in degree delta treatment. twenty-times. Nineteen were referred for a second course of degree Grand mal electroshock induced changes in brain function of high delta activity and/or repeated positive amobarbital tests in fourteen of while of the these. All fourteen showed significant changes in behavior; five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. of Personalitywin the Adaptiverg‘e‘spggg: the Another variable in the adaptive response of the patient is and behavior - the habitual attitudes, patterns of perception 1). Role personalitw and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients mechanisms to the clinical result. The showing denial relatives of h? patients were inter- Scores ranged from viewed, and denial, personality scores assessed. O to 25, scores were divided into two groups: scores from and those from O - 10 as 11 to 25 were classes as the "high denial group" with a median of 11. the “low denial The gar-mp." 0f the ,.latients with high denial personality scores (Table 58%; were in the much improved group, and. only one patient (1%) was III), in �911- the unimproved group. The ratings of for the patients with - about one third appearing in improvement low denial personality scores were random i each rating category. lean; Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Unimpmved Total M9&1}EI., §9ar£ 11 — 25 1h 9 1 2h 0 - 10 7 9 7 23 21 18 8 h? Total The difference in the denial scores between the improved patients, when compared to the unimproved much or the moderately patients, is statistically significant. That the personality ratings were indeed reflective of the patients' adaptive reaponse under the conditions of altered. brain function is noted. in the correlation of these scores with actual changes in language patterns which had *een described (11) as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether or not he shone 6. three or more explicit language changes . The group of patients with high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The co- efficient of correlation is +.7l, which is significant at better than the 1% level of confidence. �IV. Discussign: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn (l) , and again by Kahn, (3), Aird (’4), and Ulett (5a, b). Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. He have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital Fink and 'E-i‘einstein (2), and the observations of Roth as indices of altered brain function. Other measures, applied in the serial fashion, will, we believe, demonstrate the in behavior or alteration in brain function. Under the conditions of the induced change same same relation to changes in brain function, The type of adaptation altered patterns of adaptation are expressed. these varies, apparently dependent upon the personality organization. In studies we have noted the relationship of an "explicit verbal denial" personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews (11) . We have observed that patients with high denial scores are those are more likely to who The type of adaptation be evaluated as is varied, "much improved" (Table III). however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. means of inducing: change We have emphasized " change in behavior" vious studies, we in this report. In pre- related our observation to "improvement." "Improvement" �:13- derivitive evaluation of the induced behavioral change, which is dependend upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, is a who had been withdrawn, is seclusive, and crying, and had expressed suicidal thoughts, no longer is jovial, frienc‘ly and euphoric, denies his problems and sees his previous thoughts of suicide as is made. To "silly," a rating of "Inuch improved" the extent that a schizophrenic patient delusional, less excited, and less however, the induced behavior one is perceived as less rated as "improved." When, of increased anxiety and fearmlness, or loss, pain or other physical symptoms, or delusional thoughts, a rating of "unimproved" will be made. persistent complaints about excitement and is t-Iithdrawn, he is memory studies amplify the present neumphysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of These behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquillizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. �V. gunnery and. Conclusions: 1. This report sumarizes continuing esperimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an altera- tion in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The depending upon the subject 1;. pattern of behavioral alteration is shown to vary markedly, the degree of induced cerebral dysfunction, the personality of and. the environmental situation. "Improvement" ratings are seen as a Special case of behavioral the type of adantation elicited, the expectation of the therapist , adninistrator and family, and the tolerance of the milieu. change dependent upon this neurophysiologic-adaptive hypothesis of electmshocl: action to other forms of somatic therapies is suggested. S. The extension of �m REFEIUQI‘ICES l. Juno‘s—t Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its relation to the Theory of Shock Therapy, Am. J. Psychiat” 109: 22-26, 1952. of Amobarbital 1. and Weinstein, E.A.: RelationA.I—-I.A. Arch. Neurol. Electroshock, in Test to Clinical Improvement 1956. and Psychiat., IQ: 23-29, Roth, 1-1.: Changes in the EEG under Barbiturate Anesthesia Proclucec‘v by Electro-Convulsive Treatment and their Significance for the Theory of EST Action, EEG. Clin. Neurophysiol., _3.: 261-280, 1951. Kahn, R.L., Fink, 3. h. Pace, J.EI., Hernaff, M.K. and Bowditch, 5.0.: Neurophysiologic Effects of lectrically Induced Convulsions, A.:-I.A. Arch. Neurol. and Psychiat., 15: 371-378, 1956. Aird, Ran, Strait, L.A., . G.A., Smith, K. 5a. Ulett, Subconvulsive Shock and Gleeser, G.C.: Evaluation of Convulsive and Therapies Utilizing a Control Group, Am. J. Psychiat., 112: 795-802, 1956. 5b. Glasser, G.C., Caldtrell, B.M., and Smith, K.: The Use of I'iatched Groups in the Evaluation of Convulsive and Subcommlsive Biotoshock, Bull. Mann. 015.11., 6a. 6b. _1__8_: 138-1h6, 1951.. H. and Kahn, R.L.: Quantitative Studies of Slow Wave Followi.n:_; Electroshock, EEG Clin. Neurophysiol” _8_: 158 Fink, Activity (Abst.) 1956. EEG Delta Activity to Behavioral and ___: Relation of Response in hilactroshock: Quantitative Serial Studies, A.itI.A. Arch. Eleurol. and Psychiat. (in press). 7. E-Jeinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.:Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain F‘lisease, Am. J. Psychiatu .133: 889-89h, 1953. 8. Shagass, C. : The Sedation Threshold. 9. Weinstein, E.A. and Kahn, R.L.: Personality Factors in Denial of illness, in Psychiatric Patients, A.1-I.A. Arch. Neurol. and EEG A Method for Estimating Tension Clin. Neurophysiol., Psychiat., _6_: 221-233, 1951;. 99;: 355-367, 1953. Parsonality Factors in Behavioral to Electroshock Therapy, Coni‘. Neurol., (in press) Response 10 . Kahn, R.L. and Fink, 14.: 11. Kahn, R.L. and Fink, 141.: Changes in languAge During Té‘lectroshock Therapy, in P cho tholo g; Comunication (Hoch, P. and Zubin, J., 13623.), Grune and tratton, N.Y., 1957. (in press). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of the electroshock process. Dis Nerv Syst. 1958 Mar;19(3):113-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-30-007 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Diseases of the Nervous System, Vol.XIX, No.3, March 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/130db8be85bd0b48cc58aa475a58b045.pdf bc509f8c91b02a75587679edc6e65f4e PDF Text Text J4» M 4‘ \ G: 3/22/57/ s ' Electroencephalogram in Electroshock: Role of Delta Change in Behavioral RBSponse Following the original x observations that electroshock induces changes in the electroencephalogram, clinical studies correlating snob changes with numerous In an exhaustive review of these improvement were undertaken. studies, Chusid and Pacella (1952) conclude their survey with "in our opinion, the slow wave formations after electric shock treatment bear no direct relation- ship to clinical improvement. favorable therapeutic response depends The primarily upon the administration of a certain number of treatments in each particular case,and since patients vary considerably in the degree of abnormality noted with the relationship between changes and EEG it of treatments, same number follows that any clinical recovery is largely coincidentalai. A}; A (. if‘kt" if: I /(/.fr ~”/ his/((9 F ,7 .6- , 221 [ff & \ ('1 F621,!” if , CWA/Ll’ﬁi/I {‘QJ/QJ { (44.1. l '41 [L .6 o ’ f l! if; ,0 a’,,.€"5.,‘ \ 2x )4,er 1. '7 1‘ L-ﬁ ! :13 > I" Bdké’vttfi’ , ”1’ ‘ ‘ ﬂit)"; I , , , .. f, \ Mix/4.x. U ' R.» '4‘) ‘ 1/6, , I. 1| EEG (MA gr,“ I, , p. in 7,1,, V” ‘ 5 .9 4,, (3., "M /QM{ ﬂ’szf/lff’ ,' {.4 L J“ \ (’2‘: / f’ :3 «m 1‘; .- in" O v’ w.» 1 ,2”, 41 ” A £146.11” kg,” (1 r14; 1 Q41 47‘4”! "4 1.0 7’ (nt/Z/ﬂ/f 'I"l.-',v rr c F x9 if; 'A-b- :t {f I , x a ’, A; 5’, ﬂ I”? (11"! ! /‘) "(Wk , /‘ (1.. 1 f) ,- $.44 , a ,c r ., ,7 ‘a K 1 �‘ -' J ’13]? .f‘ 5‘ V In an early report, Hoagland . §§L§;;(l9h6) noted a correlation between changes in the per cent time of more j disturbed behavior tr I /J"‘Z3’fa,t~x V than 13 cps activity and independent clinical ratings became more As -. T} ‘ manifest‘I, the fast activity increased. With treatment induced behavioral improvement, this activity diminished; only to reappear with a ,_‘ if '9‘!“ ‘AlerA ‘ 1“ A 3:419:4{F’ﬁnf reéitumu-ne of symptoms. ~35; ('1 I a! ‘ I .~ ‘ " v I f A“ delta response an activated by intravenous thiopentone, elicited characteristic in the treatment course, there EEG was random changes in every subject. Early irregular slow wave . A... "‘--"'-~—.. tre;;;;;E“‘EQE;eaee3¢%o <§¥¥§:nore a highly rhythmic, amplitude f £41 "I, clinical correlation. Roth (1951), reporting the high I . / Similar observationsﬁwere reported by Kennard and Wilner (l9h8),without a V .v‘ 1/1 4 runs and bursts. These were chiefly activity whicht bilaterally 2 up to 200-350 microvolts and continuous duration of 30 to to synchronous cps, with voltages 3 80 seconds. When the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its area and decreased its basic its frequency. Ebth believed that these changes were related to the process of recovery, and concluded: "the development of a typical 10 of the 36 patients two weeks. But who transient EEG change does not insure recovery and obtained such change failed to remit for longer than improvement in clinical condition seemed to be related l,‘.' , . , I �to the the EEG EEG change even in these patients. If changes with the therapeutic effect, are correct in connecting we it would seem.since most of the patients developed typical changes, that the physiological basis for improvement is acquired effective in promoting recovery." «amen-«AW... mzu/vx-W it may or may not prove by the majority of cases; ( urn ) y‘a—wnup-H‘QOMﬂh-MIAN-mwﬂmhﬁia m m «WiniWW.iwm~mm , ., 7_ _, W_ni__u..aw»r Iz=tsagillunily agreed'that electroshock induces diffuse slowing and Meade,” (iég increased voltages in the electroencephalogram. There is 1iII some inW dam/a w dication that fast activity’, both in voltage and in per cent timel'aasae dice! dell-Ilia; enlistiées in nlxlxli; patients 2” are intensively treated, -CL¢€- who a slowing of the persistent alpha frequencies. degree, duration and The extent of the delta activity is directly related to the frequency and the number of grand mal convulsions. bInch activity is usually symmetric, and with anterior placed electrodes, appears maximal in anterior electroenceph- alographic leads. In patients received twelve to twenty treatments who have d‘xuet on a twice a week schedule, the electroencephalographic effects usually “WNJw‘A ; “ﬂmwui_w-i «- -‘ disappear in h -8 weeks following the last treatment.§ Studies of the prep it»? p treatment \ EEG 7 characteristics failed to demonstrate any relat’ ship with " _ po;t\seizure the electro cephalogram or clinical \ onse. Similarily, there ,2,. tax: has been n report of \ r C/ﬂu 1 L/{L-"Ligﬂa :14 SM K rum—i If /“ .\ a relation betwe K/ fat 6 Leg/2x,” ﬂu”? K) J M. f.” ( thexpost treatment record x” A v, f a [If ‘ ’ _ .- V: t . �Both of these. reports emphasize a. W relation between the degree of electro- encpphalographic change and current behatioral response. Mﬁﬂferent aSpects are emphasized, namely delta response to barbiturate activation and the beta response .2 m —‘ m-...-‘.......—...7...—....- Had other‘swlstematic studies been done, ha been that n correlation etween elec oencephalographic changes and M f: ”tax-:74“ 5": W” Cu X4,4! .z/f, behavioral response of electroshock exists. / Lack of such if indeed 6W .--, ‘ 5 r \‘p/‘ a relationship arm W Wei “)2” 40 /W does exist, may W # behavioral change, , -.’, ‘K" A_Iff measures of I, — 72:! r.«L.1/€ALI':" elm/7 ”r: ﬂ-the relationship between EEG "’-/ g EEG Chaﬂ geg “(W:tﬂ/f a” kg"; I?! or time or c) methods/of evaluating behavioral response, Whiéfux elucidatgun to reflect ' ' M/E‘C {if (vise/ZZ‘K; response and 44. . "M ‘ ��“NM messwnaithink' human” change was not clearly noticable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing somewhat whom / improved. #1 But the changes were not sustained, so they appeared much that by the end of treatment, as they did before. are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, by We MW.— using this threefold classification, the differences between the groups will be distinct.“ M‘ﬁe ‘i first . ,, third subjects. these4“me ,w mgﬂﬁﬁwgﬂhuﬁgyé‘wﬂewww“L»?«up,she?w M. and WA“ s...,. 3...... suggestion of Dr. Hans Strauss (Clinical ; cou‘oinﬂtidﬁb three lead or (fnontal. '2’90' 0:" *NWt‘M *0-gis?¢ﬂm av .J,v pgg‘gggja;“1%ngformléqﬁesmefEMMMSMAa‘EE.3.9“‘3' '5" lW-s‘i «#33253 AIWJrrrw-sv‘am . ' ‘ _ ' "‘c~"‘"“M:= 5.»... ,V :4. , �. V .‘4 ,2 C. Minimallzfor Unimproved: In this group were placed seven patients was not cleanLy noticable or who showed only equivocal or change transient improvement. Some showed fluctuations in times appearing in whom behavior, at somewhat improved. But the change was not sustained, so of treatment, they appeared much as they did before. ,\‘\ that by the end are aware of the difficulties in.evaluating improvement Others J» might have differed in the estimates of change in these patients. In any case, by using this threefOld classification, the differences between the we 1 first and third groups will «*K‘EVALUATION OF EEG RECORDS: C ) be A distinct.” 1_”, 1.4 “MW, ”1, total of 160 records were obtained in these subjects. Fbllowing the suggestion ofillluills determined for three lead! and (frontal-parietal, anterior temporal;:vertex, parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined as the per-cent time occupied by waves of 7 CpS /°ebdéﬂbb or slew-n. The average delta-index for the three leads, and the highest delta index in any lead were'éég'indices used in the final tabulation. Simultaneously, the record was scanned for the slowest frequency inn identified at least twice in any lead; the highest voltage of any delta wave; and the dhration of the longest burst. Uther aSpects recorded, but not used in the final e/aluation, were the regularity of burst act- ivity, slowing of alpha activity; and.the degree frequencies d'amplitude of fast act1v1t1es. These indices did not lend themselves to s atistical study; and were not identifiable in all the recordsp.’ Fast activit'es were �.u- 7 j. ,2; pézfzn Air. {in //e 4/4; xiv-sea administered by the staff psychiatrists, using electrostimulator. Treatment schedules were three times a 52/ As 9-to showed from number and of 33. varied the treatments week; patients a Reiter h? C greaémae’b clinical fewer tended the to give treatments, psychiatrist , spaced. There were 15 women and 9 men in the series, and and more __,_____.__ 49/ the ages ranged from 2h to 68 with a median of h7. EVALUATION 93 CLINICAL RESPONSE: All the patients were observed for at least eight weeks after termination of ﬁiéemé; the basis therapy. The patient's response to electroshock was of the resident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervi§gaidxlcharge of electroshock. The patients were<ilvided into three groups - markedly improved, moderately improved and unimprovedJﬂaeduaa3lﬁ§EEEEEEZEEEEJEEEEiBnIhs) response—tejeieetreshock:§ [3 A. Markedly Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the symptoms which brought them into the hospital; their doctors were better; felt they and the nurses' notes confirmed.such aSpects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hOSpital activities. B. some improvement These six patients in this group showed but continued to manifest indications of mental illness. Moderately Improved: patients typically The showed symptomatic relief, 33;, acute depressive features might be gone, but the dramatic change so evident in the group was not apparent. Each patient continued to show some first noticable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation. �medication could not be; controlled our evaluations of fast activity follow- 1", ing electroshe’cié are not satisfactory, and the results of Hoagland W’“‘"‘“W .m M ~ v 7,; ,,._,_.,.r..:.:..-.eew.u ttaal, ”Mina-x... .. On the basis of tho the records were placed in a rank order from the greatest abnormality to the lowest. The 160 records were then divided into third = 3 abnomality and lowest third high degree EEG m positive correlation groups = Low - i__e."upper degree abnormal- ity . , ,,,. Wﬂm.wrmnp~4ohm»wz 1..“ cheek? max .. __I . __' and improvement “Wm h. ,.wu...—.mmM ' om muc high een early ahno eA dc of tre tment. Tlie reco ds of the I :psyThese ) Mr"."W“, BydtiliZing these quanfications of slow wave abnormality in\ \ such EEG we be electroshock, abnormalitydnduc d duced conclude that { the in first 3 weeks ,r'response. 2. What M fur“ of treatment is essential for t ﬂea; "3 e short term” clinical k exist between the clinical reaponse»; and then amongeach '1 1. ach of the indices, 0 er? fi\st with ity �//' I, -w _‘ Quantitative Studies of Slow Wave Activity Follgging Electroshock Despite repeated attempts: correlations between slow wave activity induced by electroshock and subsequent therapeutic outcome have been unsuccessful. tain conclusions from previous studies are warrented,.heue¥sih All Cer- patients sub- electroencephalogra‘z;b electroshock the therapy suffer alterations in jected to pliilllﬁ. Three patterns are generally described as 1) the slowing of the alpha frequencies; 2) the appearance of random, symmetric SIOW'wave activity, generally activitygcigiNB) diminution of beta which of high voltage progresses to burst frequencies in rate and amplitude. There is a direct relation between the degree of these changes, and the number and frequency of treatments. saturation point of change is described, which can is not increased. ment, but which, seemingly, changes are reversible. The In many be maintained by subjects a further treat- Also, such electroencephalographic rate of return of the cerebral patterns to the pre- treatment levels is generally 1 to h weeks, depending directly again on the number, frequency and the type of treatment. Another area of agreement among the cited authors ship between degree of manifest roencephalographic abnormality. few treatments and without memory is the lack of direct relation- loss and confusion and the degree of elect- Mamba» cited-of severe Cases are memory changes significant electroencephalographic change; and also of severe changes in cerebral rhythms without manifest clinical confusion or laid memory on such impairment. O Mam! 6f 5. £257 In these reports, emphasis isfrequently organic confusion also correlating poorly with clinical results 0 ,Euﬁada, with �studies, however, Two cited may be 6L0 71t7¥éodf which—noted a correlation between Electroencephalographic changes and clinical improvement. amud, Kaufman and Péagcus Hoagland, Mal- +1924)» in this 19h6 study of involutional in the electroencephalogram and in the excretion of -(changes women ketosteroids 17 accomp panying electroshock therapy of agitated depression, Psychosom. Med. 8' 2h6-251,19h6lg, reported a relation between changes in their clinical me, rating scale and the per cent timeJlB cps activity;AL the bediszirbed havior became more manifest, the 13 cps activity increasedi Sivtreatmeht W induced behavioural improvement, 13 cps activity diminished. of symptoms, there was an increase in the More recently, Roth (6hanges in the % time 13 cps EEG With recurrence activity. under Barbiturate Anesthesia Produced by Electroconvulsive Treatment and Their Significance Theory of action, ECT EEG for the and Clin. Neurophys. 2: 261-280, 1951) described ekseTies-e£.sindies_in_nhieh a relationship between thiopentone induced EEG changes and the recovery process. was—elicited. Roth noted that slow Pod“ $12.94!. wave activity as seen in a routinenrecord was irregular in appearance, and he confirmed the reports that it could not be satisfactorily related to improvement. ; By administering an intravenous solution of‘;fbarbiturate thdoperitone, Beth elicited characteristic changes in the shock in every subject. Early there was random EEG irregular slow after electro- activity, which, with more treatment, increased to a highly rhythmic, bilaterally synchronous, high amplitude delta runs and bursts. These were chiefly wave 2-3 cps, with voltages of 200-350 uv and continuous durations of 30-80 seconds. pentone th: resting record increased its voltage and its basic When W duration, spread activity, thén- its area, and decreased frequency. Roth believed that these changes were related to the process of recovery,‘§i$haagh,;the a typical evinced rhythmic delta EEG ‘4” concluded: “’Enuaner, the development of change does not ensure recovery and 10 of the 36 attained such a change failed to remit for longer than patients two weeks. But who �Similar analyses of the relation of each of the indices and clinical result showed identical curves to the group curve shown before. Slide 2 shows the the relation of the delta index to improvement. to much improved group jumps index in by the 7-9 treatment; while the mod- 52% erately improved and unimproved groups 10-20% by The mean show a gradual, slow increase to the 10-12 treatment. similar set of curves is demonstrated in slide highest percent time delta in one lead. A In the next slide the mean slowest frequency 3 for‘the is recorded, mean and this too shows the same significant relationships. While the much improved patients show delta waves down to 3 cps or less by the second week of treatment, the other two groups barely reach h cps by the fourth week of treatment. Slide the 5 shows correlations for the same The much improved group show mean higher voltages by the second the fourth week the differences are perseatent for Finally, slide 6 shows highest amplitude the mean all three duration of bursts. week and by groups. The records of the much improved patients show longer bursts, averaging more than 7_ seconds by the third week of treatment. Bursts are less frequent in the unimproved and moderately improved groups and are significantly shorter here:€E:::¢::Mthe in duration. Not noted factor oﬁaregulgzgity of bursts. In the lonéﬁbursts, wave forms frequently were more regular in frequency and amplitude, than in the other two groupsl These studies may be measures of slow wave interpreted as demonstrating that each of these activity arise from the same physiological process, and assuﬂe the same significance function induﬁed by electroshock. in relation to the disturbances in cerebral �3. Finally, can these alterations in the aSpects of cerebral function which may EEG have been be correlated with other altered by electroshock? In these studies, three other indices of cerebral function were assayed! the amytal test of Weinstein and Kahn) tests of double simultaneous tactile g?) Si) stimulation/and tests of memory and recall. of these three indices, only “gigpﬁﬁt' V/ the amytal test showed a positive correlation withimprovement and with A); stoma; WW may.4, 41:2th Julia“ We 0’ is this test, the subject is interViewedm uestions o Ahbbld atdkhuus nae: alas/d autbaeaawae cafhﬂa ation of int venou sodium amytal, the stions are repeated errors in thQ/I-vm . e orientation, coniabulation, denial as "POSitive" amytal t:‘t, and illness and reduplicatioh are scored are indicative of cerebral dysfunction. “Ms”r Ab tal test. 9"” ,, .1, #ﬂwwf yyyﬁr” \ In the next,slide, #7, the pe centage positive amytalthSts are if“ if“? compared for edéh of the three groups, «hf weeks of treat- ‘3 - , jge’difference between the much impror -i the other two groups is strfiing. While every patient in the mu_;‘; oved group had a positive gonna al by the third week of treatment, the abno \ity persistedgF ment. M was it W#7 ation with improvement. In this that there are various types of cerebralﬂgyeﬁ function and that”g;:ﬂcannot speak in gross terms of a ”Absfgeeﬂ'thew 0“,.“ n .rvn w..,,«wm.~~m—we rm«Antw-12mm gﬂMéorrelat1on lath and cerebral dysfunction or organighpsychoses. muv maxim» we. \\I ‘\ \ 111; {ZENWWf’IﬂWW showed no can be concl EEG ‘\ ‘15 um! recall? These indices respect, \ \f transient despite continue. treatment. ‘ WW“ Rh “met”. WWW”, ‘ "New“ ewes V4799» “new“.y‘d ”fI M 51““? ﬂag“ ”Why �* Semen, these ethe:ee pemttethe �5M5? Vt m WWM in mamm: Relating at Induced Mu nativity to WMum, Roam Dunno midonblo study and shock mom Wind ahcck 1: menu. the man at Recent tho m enema (9.6mm, at wow-1cm «that. In Mm own... chanson u a, the basin no have: obnexwd n mum at chasm of am. And) hm tor tho 01mm- rolnucn comm chum inmaumdhmmncMmaadthamquRw. hmmmm hum batman clinical Wt 1'ch emanation taunting orientation and olcctmahock nit-h changes in Mam whnrbi’cal ( mummmhngmgcf ).ondmxyandmu1( “My in 1mm: an mluaticn of ”mm mums change: function, and behavioral M, '11: our no mama 1::th mm. 0mm nan and Panama (1952) minim, up direct an an incur W. the observation b y various observers that clontrcmm change: in the olentmencoptulogm, with clinical syn-- ). Thoprcmt in thc thmnnoophalnsx-nm, a» ), slow alumni}: ta Imma- «mung In an exhaustive amm their may W mm c: than nth-tho sum nan fez-mum arm clam-la shod: mm Wmt. such a! Watt tmmt but the favorable therapeutic mmmmmmmommwnmmrﬁ �tmm in tha dame of tone» Wt Maul” each m can, we we abnormality noted with the hem my rahtionuhip patient: vary comidenbly in am number of hmmts, it Em mango: and is War anneal largely wincidental or maul-11y mini-ad to othrrr factors.” Yet, the alwtmcephalognphie chmgu mmnt. and Most new Wen wltagt 611:8.an that fast. tin; and in tho who activity is dimuy mum mnﬂsm ( Bach L» law. ﬂuent: wha have intensively In View electromock, or the it dam, ), The to than {W appears than is a duration and mummy m W ind» in percent slowing at tho meat of delta Mar afar-and m1 and tho and with mtarlor mind in anterior aleetmmeﬁmomphic received twelve to wimpy ramming my be 1:: voltage and W. ( of wires treatments per wok, the diuppear in us new uWhock are con:- The” in considerable nativity in mud]: ”metric, plum mutant. «hatred», In dootrowophﬂm. no Imam. by mart that elactmshock Mm mm» ) ( accrual» ), bath wtivity in paint“ persistent alpha ( Maud mutants dammiognphic a» last mama; ctr tho ( mum: am mu bum max-meme and humeral a. schedub effects usually ). olcotmmephalumphic to an weapons. to that a mktionahip dam changes. Tia swan �.3... do ”human. indicate we}: a Mod a relation human ﬂung» in than :3 spa) and WW MW MW“, behavioral Wm: pentam, elicited characteristic of tmﬁwmt tandem thin xeuuiy EEG Vchanges ungular to m 209—350 m! mum, ”than and. continua-nu m banana that thaw eluded: want-d by 113sz men buﬁenlly m mum its mm changes were (39th of and to 3 which in» Mm, high cps. with voltages up 30 $9 60 seem. when the its thiopsntono increased «creased mum ta typical a. 2 at activity, mu We spread “ﬂy in the ”sunny appomd, slam warm harm. than. mm unravel“ resting more! mm and tmta only to ran in every subject. continued treatment. with to Winnie, cmsgd «puma. Whoa; an. ‘ mapma del‘hn' Wang... A: fem. nativity inerumdu with W” of (3.91:6) w ”want #130 tut activity (mu 9mm, aw; (1951), reporting the cm apart. Renal-ad 33 9; Momdont clinical mung; atbomionl behavior beam man: with 3 m Iﬁ an m its bum tummy... the games: at Waxy, and cam m change does not insure mmzy mmﬂmﬁpmtnmoewmmfailadtaréxd‘bfwlongw h * i’mﬁ and 1mm G (1'9 H u ”I ) won-m “a “mm the behaviaml comﬁtim. ‘ ‘ " :51, 9" L‘lig Yr ' II": .,,i‘3l’ ‘ V �4‘. he than tmiunf. wants; ﬁat ulaudtothcmmnge 1:33 the EEG mm militia“ patient» clung“ with ﬂat therapeutic effect, tin patianta dueloped typical dung”, pmt in 0.1mm audition sound is W by tho lager-1w cf 1.9 b- «mammotof «on, we Ifmara it most» 10111:! that. the physiological hula far in. W311: any or my not pm affective in mixing waver-y." Bow thee» mmmogmphie are Mixed, ”pom «pm-m 1 solution batman the dams of elect“? change Ind cement-mt behavioral suspense. Different aspect: namely delta mm to barbiturate activation and beta. not. ivity. In tho present impetigation, quantitative aerial studio! of the dart: anyone. were undertaken to timer the following quuuonls (1.) What. in tho "lama! of the elomcophalqmphie mama to be- havioral responu 1n electroshock? (2) I: a "hummus: «mm, :1an aubgocta 931; what signification my W’ at prior ta a) In the tmtmt, 8 chums). ﬁnder-It. bipolar, hm tor an under. of tho process of electromoek therapy? 1mm semi, tmnty-four Maw wa- ianta referred for chetmhoek were studied. do!» 11-. mammalogrm an tad at. weekly intervals during and after treatment. wing destromcwphnlognph and noodle and hyperventilation chem. bonding in mmum m mum emu each molding. �' mm Commuting, the at least .6. was scanned for the slowest frequency identified twice in any land; the highest voltage of any delta wave; and. , the dur- atian of the longest period or delta bum activity. mm basis or these five indicate! eleven” nativiwma racom were phoeduinnnkordar,tmthomtmmto£dauwmﬂtytotho lowest. recordanudividod into The 160 3 mu m- m thirdm classiﬁed as “high degree deli: a records"; the middle third, as fmdemto dag-no Fignm delta a records”; I, II, and and than lowest min! as now degree delta III portray pin-mm mama.- and treatment records taken am- inguwlwtmatmntpomodtoemlitythethm rangeaofdel’aamtiuty indwed‘hy electmahock. b) In a second shock some at raw-tour mun, patients, ehctmncopmlogmpluc moon!- lent. ,Mﬂng tin treatment. second and third 531133 records, the wore obtained mks of try-stunt, initial observations were tested in weeks x after «comm W m: mum on A11 of max-aw. after first eerie: of 160 I predictive haw ofthemu patients were The prior to treat-- and two ween the named of analysis developed in the pantie response. mmmxg unselected electro- W m- at 1am «at. patient“ mupomo to the bani: at the resident “psychiatrist’u 15leth m mm, the nut: > �.7... opinion, the man's not» apex-visa in and the 61111130. evaluation of tho charge of elwbroahock. The pntients were dived-d into three groups a mob academia]: uprated and mama, A. WM! mama which «an aim: themaa‘lmtu «coming to the following criteria; :3,an These punts no longer shmd the mm Th. 11 or Inn-had immanent. hmgIt than into mm .. group were mended the 116mm; their doctors folt they warn mum and ﬁleepuithoutmdscant-ad mkupactaasbomgamn to nation, better appetite, an! capmw to gut along with others improved and ‘ participate in B. mm Mimi pmmnt but cmtimed to try'picany shared gm, Each activities. but the The units” mm mun amt!» 01111130 K. idea, or We: m when than; a , m less 111. The a» haunt! teatum night he evident in tho first. group val not apparent . no m noticablo disturbance such an obsession). somatic pmccupauon. raved: mum not clearly noticablo, mo or who beam worse. may showed tons é! loam illness. mane 1.1191, 3&2.” mute dopresiive patinnt conﬂwd to thaw thinking, paranoid lb: patients in thisgmp showed change: were not mmn placed showed equivocal new patient-in or transient changes, ﬂuctuations in bshnvior, at sum, treatment, they appeared Inch as before; however, no that times- appearing by the and of �Mesa the analyses of the mlatian batman the delta activity and clinical ratings, denominated between the proved" early appunnce of high @3290 delta nativity and the classified 861 were in the third week in patients and 88$ who were or third in m who ”lunch won rated 13. u nah high degree 691%! in the second week; 91% mutant. 0: the raced: fourth week of rated as migrated, none wan high degree delta in the weeks at tmtmnt, aim ‘1: The and 20% tare high degree delta 21 the mnsudin mu 1, ma graphical; in ﬂgun h. can fourth week. a induced significant relationship clinical rating» 0! the meow in mucus. mmved, second 1 acme or m a i m 99am Delta mom m Indian W (7) Wed Imam-d 85:113.:- measured Mam: k} (u) 6. ( analyses mm indies: 91‘ of bursts, highest Men M 25 an 91 as o 3.6 50 M o o a an for the rolation hem-n each of mm (avenge S-Mm delta, mm, M. 133 and slowest highest 5mm an... they duration frequmy.) me the clinical rating!- In each instance, the relationship or degree or induced delta index and the clinical rating was sustained. This data will be pramud in detail in a �submmt ”port. taunIndaxotnu- 2. Em mmﬂmtaﬁm, contubulation art! dmial ion: 1' B of. 11111033 in a ”matured latex-via after the: administration or intravenous mobsrbital in patients ﬁrm brain lacuna have ham sum-mm as signs of 13mm arm noted such patterns to ba illness, unless than. was evidence «and probable, themfora, that persistently tum mum or new” cerebral 11' mot subjects, ). ( We had m- m putientl hospitaliud with mm. mum elsutmahock indmed patina nmbarbim tam Wild «ﬁbril be produced. mmmmmu ( ). It dysfunction, This was indeed mp0M< ). 1n ma, mm (58%) and 10-42 fourteen an 7-9 the m period, an am mum that um; report, nu mm cerebral dysfunction (671') at the 2h subjects, had positive period. In than Maw—four subjeotl, than new ninety-one to". sessions during the mac ital tests of therapy for which smear-rem; chumphalogrm and ambush- are availnble. Pro and poet mutant. records are not. mcludod. mmmmnmuummummamdmmmumuw sham a high relationship, both ratings of immt delta wﬁviw a for the tests to each other, during therapy. In Tabla W II, as. and to clinical degree of induced with the results a: the concurrent mbarbihl mu. �W TABLE KEG II 22m .. An___%mm W rat. at Hicidle 313x Low Positive (25) 29 a 8 Negative (us) 10 15 20 Watan relation between the test data and clinical ntings of am also simiﬁmt. In Tabla II, the ma and uobubital tout. results The me'dingtothoevomnl mmmmedgmp 27%,(5 m had n umber of with. gamma test mctm; sad” that tho cluster at with. nomad, high Em delta activity and mummy in» clinical rating. W Vi M proved rating 3.: 3 negative mm Wits). mung a: om. Email: alluifieant in the cluster at test, 19' 1nd Mo me an: activity and clued. Wand. Rat /m m\ rod ma Hunk High Dam and roman Amebazbital (29) Either Positive 33' Dam or obaz‘bital (26) hither High Dalta not Positive Amobarbital (35) Iv Immed r. M W Result! an Moderately Impmvcd 25 3 10 11 s S 1.0 21 3. Thedatain'kbluEmmnhumtommorotabmmtimdum n Simiicant by elm-aqua :t hotter than 2! 1m). of conﬁdence. �the course of therapy in the any are rater} uriy m the It and at We initial twenty-atom petimte. ra’cdsrxzvttl who me): improved tend to develop high degree a: treatmnt, Table 1) similar and sustain ohnmtionl, it throughout mde for the are gnphically portrayed in figure 5. A EEG delta. activity the period. (ﬁgure murbitel test result” Waite of figures it and 5 presented in figme 6, which chm e mmrkable eongmm of the two 3. am to 0n» ‘ » Following the observation: event? is test date. 2 in this group, that the mch :1de patients had developed a high degree delta neurity earl: end had untamed such activity, electroememalogrm were obtained during the week: of treat-ant in undertaken Sh second and lelectmdxock consecutive patients. This study to detenine whether or net the demo «at-delta response in third in pro— dictive of the wort-eta“ thermontic outcome The recent: were sound hand during both, one a to whether h1g1 degree delte activity was who or neither of the h~6 and 7-9 treatment periods, and the data was related to the clinical «elation TABLE I? (Table IV). �Ono "W, um (16) 20 um High (1:) h (25$) a (50%) h (25$) 6 (30%) 7 (35$) 7 (35$) . Total (9‘) "' ' m 31mm 22 at the 2% 19 level of confidence; 13 �«42:» or the 131518!” the Mint 111$ delta ”tawny during tho ”00nd and third mksoftmtnant, éﬂmmuduuwhimmd,mhmly3motp:mu diluent high delta are so mud. The sum inﬂation and dome delta activity in rebut! to the Short ton The arbitrary solution of ma second based upon an 12.15 6100ka trauma. mtotmm Further sax-ion and in which the W delta beauty, persistence of 6113100. mlmtim. third week: of tmmnt was mags tmtaont of this data Wul 1&1“th m course m that the div-lop» 1211le fort. at mm:- of weeks, in round to mum: at of immanent regardlesa of tho tine in the course of thump: II continua: treatment in after 15-20 am trauma, m delta mhngea no first. manifest. subjects resulting in high is associated with 9. MM this later period. Patients given many m dolta activity Won]. msponm at mama n the at. per weak, without the mention of high dogma delta activity, a United behavioral responu an - one that is M mwm mt 5.10 placebo responu ( Diﬁuaaig g of three tines Wm“ significantly different than ). Intansiw uranium. at a. fmqmoy of relultant induction or high dogma dam act- was: per ivity, will damn-cu not. Thu, :1 aignifimnt behavioral name. mesa studies duonstmte a consistent missionship batman the degree and duration or induced uhctrooneephalognphie delta utivity and clinical �‘13- enlmtim at behavioral change. 3ymetr1o 1m been and automated» We at tho evidence of dysfunction (mama; centers and dyerhythuo delta system) mam (own nativity WW Strata»)... and Such indioative of an alteration in the state of consciousness, also activity is new alteration bang unouy related to the aunt-10h, mum with more and frequency and (Strauss slow Bid] wane June, et the :1, of aotivity Brit). and behavioral between Muted one. rolationohip county We m the further electroshock permit: after aspen” on. mmepmm mm no: attendmt pluliologio basis of tho electroshock shock process thus physiologic “mat We conclusion that ohangee in aunties: prom. in consciousness an 1L o No upset: of the electro- elaboration: the mention of the to the behavioral response mm neuro- .. and the eigniﬂoanoe of these observations for a theory of the node, of action of electroshock tangy. (a) Role Won]. cerebral 2mm. change Changes and perception, prone”, whatever cause, ore In this dependent 9%. \mieteot 1: a moo-pennant in mm, Mt extmively mm, I of alteratim in ltti‘budl, judgent,thooght attending changes in cerebral Motion, documented rm liter-store. in the noumlogic electmahook has hem mum to consistently teat emanation, in a {whim Mob we alter two in- have con- to associate with �431). i has biochmm substrate or this mu- away. mm mm has hem placed an tho noctylchonm—ohonmstomso changes a (ﬁnest-in, KeEwhun), tho “Iteration 1n blood-brain burner (Aird), chug» Tower and in ionic prance” has and promnqunbm [9’99 “/fsrué /'(ﬂ’ I‘M? 7 ,r‘ L. j 44“! [Z (3916301 and 31113391 x w A“? 5 1:34: ; I; ' ‘ 3 g a f ff V M v 1 .-‘ - mm), L; z r g» ﬁggéfiten/ �orient-p with extensive In impatience an function. cerebral of altered states am after wherbitel, tests” mama ( Wemauin and his ) ( J ( o be” dmnetmted the pmdictiw mm of this test for arsenic cerebral Winn. Davie workers by ee extensive met-cue experience likewise, Oawendom( )and-ng ).( ), Oatmmdstnnae( ). mum“ ()huefﬂmdthe altered in e hm Matias. W ‘smu signiﬁcancecfdiffuee other tests of unbral mm been applied seriel reunion, it. is anticipated that than, too, mule! dum- mum sponse, within the in cerebral 30.6 delhectivityueninduet chengee W tmtmt salmon to vacuum re- and e units a! the sensitivity of the test. to reflect change! mum. lame mam, elmmwbeuidtcbeenthcdormmge muctﬂundMiantoerMMOmrwachime behevicral respcnae. «diam The mac of belmvioral patterns induced under these is wide. 'Inprcvemnt' being a subjective evaluation On 1e 3 special one at behavionl the part. cf the name, charter that the patient 1: ‘bottor.’ Electrcehcck due not induce “immanent“; diffemt than it indwcs a mum of cmbml activity in men behavicr To the extent that. the induced behavior in deprecaed permeate is perceived as lose whining, depressed, mane 18 or move, before electroshock. or in achnophrenic patients, �.1;- 1m maximal, proved". behavior, Wham complaining, or typo 9! “an. evaluated to. as is patient mm, wmmry or harm, am, 1+. 1.. in pamuivod a: mom, mum, «ammo a; 'milprovld.‘ The paranoid, woman- Warm. pattern induced by electroshock, is «pendent on a m mm, «mammumauyam-mmtt )ummotpmm. lumbar cramp]: o! the relation be to is laﬂw dolt( ) ( Meow m on the of. electroencephalographic mural mom me: to be- of epileptic patients. ban» )deaeribuoymgapﬂspucmm ordinarilypleaant, and cooperative for his clinic visits. consistently dyarhytmc. drnm, and his 1336 0:: on. occasion he 12. than. no: cum}, an ‘1th delta activity. on the that, records m unable and 31th- mbaoqmt visit, tho m was again dynamo-ac and o a behavioral 'zhtpromnt' nu ma. 51:11::- obumtionawm roporwdbyﬂntt( )mdnnnndor( ). (b) Theo Our , of Electron a . 7 _ studies of the electroshock procesn have demonstrated tho ing. ntemtion in brain function in induced only in whom the greatest degrees of behavioral change max deem delta. activity in the taste as indiceu or altered indioea and sustained as noted. Wannalogm and follow— in patimtl is have mailed positive mobarbitll «:0an function, with the knowledge that other at altered brain Motion, applied in the m sex-1&1 fashion, my �‘16-'- alee show We 3mm alteration and a relation to behavioral change. have been mmeeed that the rating: pf impmvemt are value Judg- ment- of the behavioral response. L11 patient-e induced by electroshock in when cerebral wrest changes in behavior. changes are My certain patterns ere evaluated ee immved, believer. while other! are regerded u "unmoved” Immutiaeeenuespeemeeeeefthebehaviorﬂ. mammoftheeuba of the conditions brain altered function. We Jest recent etudiee have netted a relation of the indueed botanical Our Home was to epeeific peremlity aspecteC ).. Patten“ the neat close]: apprm-mte the “explicit verbal denial" personality greater degrees of denial, dieplem, mu ), ( euphoria and Indie beim'ior (tuning electrosheck therapy. and: edeptetime are frequently rated alarmed", and no clinical my mum at! ”m that the reletieaehip between nationality, behavioral response mm is met clear. to the behavioral reepenee The mutton of other upeete of an new ﬁnder investigation. bother new in the nun: of taproment to the induced W103. 1a the environmental w new endeegativill ledificetim Tb of inﬁll, withdmel to excitement, overactivitw and irritebility my be considered e positive movement by may. The the met-cps.“ but a disorganization by the and maiden or goals of the therapist and the family, and their meantime �4.7 bSnoh phyeiologic milieu for an ultomtion the altered cerebral tmotion provides of the organin‘e edeptive interpersmol behavior. Changes are induced in percep- tion, language, mod. recall, and Judaism mick ponit adaptive intonation: new with the omirmmont to unfold. the type of adaptive behavior induced under these conditions which the is dependent upon the pereondity of the subject; the environment in intonation occurs; and the duration or the state or altered cerebral Man. i similar view of the electroshock process m initially expressed by Weinstun, Kuhn ( Linn and chungoe and behavioral ). who mailed the interrelationship or neurOphyeiologic room”. These etudies amplify clude anothar index or oltered broil: function and «e their obeorvotione to in- the eiootrooneuphlograme delte also broaden their initiol empheeie on the denial pmcoeo fol edeptative response, to include no the only cameo. 0. wide variety of indtcod behavioro under the conditions of altered brain faction. The description of the electroshock procese is also comietent with the observations of more 335;( ), Roth ( .) and Lire 59,5 ). This neurophysiologc-edeptive interpretation of electroshock pronides on operational definilan o! the process which has procaine or further elaboration and obeemtiono. Such an hypothesis also hoe application to an understanding of therapeutic process in insulin com. therapy ( ), lobotav and tronquillieing agents ( )e �.3transient in clinical condition improvement seemed to be related to the in these patients. If we are correct in connecting the EEG changes with the therapeutic effect it would seem, since most of the patients develop typical changes, that the physiological basis for imp EEG change even provement is acquired by the it may or majority of cases; may not prove I effective in promotingxrecovery." In the course of studies of‘g§:ered function brain induced by electro- at the Hillside Hospital\in New York, further data on the relationships between EEG changes and clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the shock EEG with electroshock were confirmed, but between EEu effects and the ailgs‘ca,~ clinical result a demonstrated. was \ I are presented today: (l) The definite relationship . Three foci \\ Engpatterns following electroshock and thein\re1ation to K improvement. (2) yThe intercorrelations of different quantifications of delta activity. (3) The relation of these observations to /////X ”WM SUBJECTS aﬁcijLQn.1 "ﬁ-"MW‘ _ i.-..mwm_w~w T /{1 Ionic ﬂ _ merm”wwww‘wmmm,._V.-c.-»...«——v—~~-"'” aim,” Twenty-four consecutive patients U” §§2_MEEHOD:Z§ _ -m “ﬁlm“-..— a theory of electroshock shock were studi d. "“‘m'w-"MW referred for electro- m4 Electroencephalo rams were done "511* few} 1/4?! Lot/W a“: channel Medcraft instrument , needle electrodes, prior to_treatment? “Ki 8 and bipolar recording was used. Hyperventilation wea-the-ealy-activation 6034’ (L. WLALF Q44. a, ‘ technic g treatment, records were taken earths day'aitasrar?;ézﬁé'"v*ﬁ‘ gurum fitter treatment. generally 25 to 31 hours MLWe 0%, 3» 1'9 CL �this point I should like to summarize our findings and express some thoughts as to their significance for a theory of electroshock action. There is little doubt that electroshock induces delta abnormality in the EEG. It is symmetric, chiefly frontal, but with increasingrtreatment, the'gequencies With became treatment leads. to spreads increasing all At slower, the amplitudes higher, the burst activity longer and more regular. While delta abnormality is present in every repord after electroshock, its degree is variable. Roth's experiment's inducing increasing delta abnormality with barbiturate are significant in predﬁting the later changes induced by further electroshock. In mality some subjects however, a high degree delta abnor- is not induced despite extensive treatment. Our correlations of degree of delta abnonuality with improvement are fgggziéam:ch ism of electroshock.therapy. significant An alterationm cerebral“function and also by the ' as measured by the magma as, amytal test,* ,t'necessary pre-requisite for improvement. EEG, zaﬂkﬂ early, sustained Where such 232:::: (and in the amytal test), chan es fail to occur in the a significant clinical improvement will fail to occur in the patient's behavior. not4ﬁghent The fact that the correlations were with memory loss, points to the possibility that this is not a significant factor in improvement. EEG In conclusion, these studies lend lapport tp a theory of EST enumerated action recently by Weinstein and one of us (Kahn). These authors postulated that improvement following electroshock is the result of the creation in the patient of a milieu of altered brain function in patterns of adaptation, particularly those of denial, may be maintained. Theib EEG studies demonstrate that an altered milieu of cerebral which new function as measured by delta abnormality is a pre-requisite for improvement. To supported. this extent the first part of the Heinstein-Kahn hypothesis is 4M.-. .1 �~5During the tram generally 25 be 31 11611113131381an ( the ) was period. words not. noun lam. Emu-mm, We... may“! Wu on a» ﬂy, following a trauma, all Wit”. test 101' at many intervals, berm, during ”mat “him the Wmtnont WI. manly been mported pntieats organic brain and study mm hi" ). ( thaw-ml electromook tharapy m manicured w the mt: manhunt“, tins using a Bauer 0 h? eleabmatdnulator. Treatment schedules. war. three a week; and the number of ,, Won arm- thorapy, reﬁll“ at this The all!!! wore studied by matmnu varied from to 33. 9 As patients show-d a clinical response, the psychiatrist tended to give fiver and more widely spaced treatments. Thorn are 15 women and 9 man in the can“, and the ages authaudiuoth'h mezhto EVALUATIOE 93‘. ject... 33 3'0nt for three lead “natal-ear W: total at 3.60 records were obtained in muse sub- Stmﬁss ( ) the delta index was the suggestion of minnow 10210) A 69%:de (frontal-parietal, anteriar “moral .. vertex, for 180 seconds of recording for each lead. 1: defined as the per-cont tine occupied by waves at 7 0:16 The delta or SWCI'. and 1W The <36;th and load the highsat kit: for, three the combinations, average 1mm in any om lead combination mm the indim used in ma fin-1 inasmuch. �«17end tolermm', are significant factors in the behavioral nepense of the petieet to therapy, am also, in the rating! a! mane effect. sue teeters an signiﬁcant in the The induced changes improvement. duration of the electroshock in cerebral function persist for 24: weeks only following even intensive courses of ti‘xerepy. In respenee ‘ W eases, the behavioral tenatedtemepeﬂodotalmmmmniologyo patterns of behavior we not adaptive in the mum Thackunged of the patient, and the behavior 'regreeees' to pun-treatise“ patterns. In other instance, the induced behavior in adaptive to the envirement. end, we assume, sustained therett‘ter not by the initial change in brain Noam, developedintencﬁenof subjectuithenﬂmmt. is seen by the milieu is may embd. linen in which 13 cheereetm have doctor, have, and peanut. stem a 1:1in or many. led to the conclusion that electroshock a non-specific induction or pernietent discharge mptive (pemnlihy) utilize devices not otherwise available ta - the mm when Altered cerebral fmetion the subaeeb’e different interaction with the envimmenﬁ These matmiswm only to have a mazrrence of disgusted or discharge in prelude: the pbyeiologic preceesea the newly fmeent mememl adaptation of the patient to the hospital after electroshock, planning but. b y of altered cerebral than” mm. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of Electroencephalographic Changes and Improvement in Electroshock Therapy (research) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-7-007 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/97daec70fcaf9223c3cc93bef9185f48.pdf ea0a277a541fba43d45012096746cae2 PDF Text Text W, ;_ . » _ . ‘g wA .73.- ..g c 7... ._.‘ .v —.—‘.n, we“--- , V ,_ m- V ,7 , v.‘ -,v V. - , — xv- .r f.»--,—- ,.v—.-“.....:v«u..w,amw . .mmng—W (tr/33‘; «waver—u... .Mwm—V w... _ - . Electroshock and in Improvement Charges of Electroencephalographic Relation Therapy * Max Fink, M.D. Robert L. Kahn, Ph. D. This study was undertaken as part of an investigation of the relationship between V ”0.4",“ ., altered brain function to electroshock therapy. Twentyb prior to and at weekly intervals duringanki following the course of treatment. The total of four consecutive patients referred for A. awn-wmw and response 160 records so obtained were age percent time time delta at EST were given EEG'S classified according to five criteria: the aver- delta for three given lead combinations, the highest percent any one lead combination, the slowest delta frequency, the durb ation of the longest bursts and the highest delta amplitude. On the basis of the percentile scores obtained for each factor, the relative position of each record was determined. in the upper third of the distribution were Those considered to have high degree abnormality, while those on the lower third were low degree abnormality. By this method found between improvement and the EEG showed a high degree abnormality after weeks and over 90% after three weeks. of analysis a definite correlation was rating. Of one week of first three had such a record by the fourth week of treatment. for each of the EEG treatment, 80% A factors analyzed separately. week two weeks and only one similar relationship The was findings were con- firmed in a subsequent investigation of 30‘patients in which the tained in the second and third after 25% In the unimproved patients, however, none had a high abnormality record during the found the improved patients, EEG data ob- of treatment were used to prognosticate �nﬁi m\ improvement. It is as determined by concluded that early and persistent altered.brain function, this method, is a necessary prerequisite for improvement after electroshock therapy. * From the Research Service, Hillside HoSpital, Glen Oaks, New York. �sawmm MMW§WM w, VJ'IWWVWMM-ﬂmmﬁmm hula-«ﬁght ﬁwﬁymgmrmwt mm“ Wmmunmwm; W mmummawmmmwwmmm W - ’3 mmmmmmmammmm mummmmmmummm» "$01:me ‘-;:wamaf w*:.mmuumwmm_ m h zwm .»,wmawmmmuwwwm m Eegmuﬂ) , W3¢MW.M: ��WMWWnMﬂmmemW-,' W mmmmwmummwt tmmttnwWmhmhmz-Mnnmhmumtnmw thatmatmm WM” mmmmmt Wanm mummm Mahatma: Wmmmm “ mmmm mum mammmmmm manpmuummmmm,mmmmmm mwmmhm «mmmmmmm mmmwmm ammumthlm mm Wrmmiarmm Wthanntht mmnmm% my were” mmww Mmgmhhu hmwwmm mwmmmmmmwmmmwm WWWmtmrm-rammwww Wag“ mm hm mamwmmmmmmmmmmwm - , - pa. �Relatidn of Electroencephalographic Changes and Improvement in Electroshock Therapy ( 3 M , 7' W41] Fink M .D Robert L: Kahn, Ph.D. Max fir/V v, , .y This' study was undertaken as part of an investigation of the relationship 41/4er between altered brain function and reaponse to I/mt—wju? Twenty-four consecutive ’P—EII‘P patients referred for were given EEG-'5 EST prior to during and following the course of treatment. The .« and at weekly intervals total of . 100 records‘ were classified according to five criteria: the average percent If time delta for 'Mbmﬂavv I three given lead, the highest percent time delta at any one lead; the slowest WM frequency; amplitude, w“ H, mm. W the tame- of the longest On the basis of )‘n. MAJ bursts and the highest 601/9“— percentile scores ob- samba-med ' tained for each factor, the relative position of each record was determineg gose in the upper third of the destribution were considered to have 1 high degree A W MW W“ correlation tau/inc. Ml‘tW/‘au‘ abnormality, By this method of analysis improvement and the FE . after ‘ 1gh’abnorma11ty was found between _ 6f the oniy‘one week of treatment, 80 a er two weeks and over ' g . , A weeks. In the 'mimproved patients, during the A w a marked first c'atrately. The I I was found I I I I loe-ether-kand, g three weeks and only one similar relationship 313 ‘ had. such a each of the $in yw EEG 90% 4’ improved patients after three none had high abnormality record b% the fourth factors as . . 30 ‘ were usedﬁ progn altered bain EEG data obtained in the second and third week of treatment concluded that early and persistent W1 W im«Lu function, as determined by this method, is a necessaryﬂfor provement after electroshock therapy. W MM”- week?” analyzed findings were confined in a subsequent investigation of patients in which the 24’? " � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of Electroencephalographic Changes and Improvement in Electroshock Therapy (research) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-4-004 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/12764b529d79f1eb96174bc90f2534b6.pdf ca3411637648ce13d529a98dea9e5b2f PDF Text Text Behavioral Patterns in Convulsive Therapy MAX FINK. MD. AND ROBERT L. KAHN. Ph.D. GLEN OAKS. L. |.. N. Y. �Reprinted flow the Archives of General Psychiatry July 1961, Vol 5, [71). 30— 36 Copyright 1961,]1y Agzeiican Zl/[edical Association Individual differences in the behavioral response to convulsive therapy are marked. In psychiatric practice, patients with similar psychopathologic syndromes, and of similar sex and age, show a variety of clinical responses: Some improve and sustain such change; some improve, only to relapse quickly; and some fail to improve. These differences have been related to the degree and duration of induced neurophysiological change?“6 premorbid patterns of personal— ity,""11'15 sociopsychological characteristics,13' 15 and psychotherapeutic approaches.1 While these studies have emphasized ratings of improvement, the derivative nature of this evaluation and its dependence on staff attitudes, expectations, and family tolerance have been stressed.2""5'8 The manifest behavioral patterns provide the basis for the evaluations of clinical response. It is the purpose of this report to describe behavioral patterns in patients undergoing convulsive therapy and to relate these to problems of the evaluation of improvement and to an understanding of the convulsive therapy process. Behavioral Patterns in Convulsive Therapy Of consecutive patients referred for electroshock therapy during 1956-1957, seventy-three patients were subjects of the analyses described here. The patients were selected for treatment by the resident therapist and the supervising psychiatrist -——the investigators playing no role in their selection. These observations were made during a lllll|llllll|Illllllllllllllllllllllll|lllllllllllllllllllllllllllll|lllllllllllllllllllllllllllllllllllllllllllIlllllllllllllllllllllllll|lllllllllllilllllllllllllllllllllllllllllllllllllllllll MAX FINK, MD. AND ROBERT L. KAHN, Ph.D. GLEN OAKS, L.I., N.Y. convulsive-subconvulsive electroshock study in which subjects referred for therapy were randomly assigned to courses of subconvulsive or con— vulsive treatments. Electroshock was administered 3 times weekly under thiopental sodium (Pentothal) premedica— tion, using either a Reiter unidirectional or a Medcraft alternating current instrument. Grand mal or subconvulsive treatments were administered by altering the strength of current. Neither Submitted for publication Jan.6, 1961. From the Department of Experimental Psy— chiatry, Hillside Hospital. Present Address: Division of Psychiatry, Monteﬁore Hospital, Bronx, N. Y. (Dr. Kahn). Read in part, at the New York Divisional Meet— ing, American Psychiatric Association, November, 1957. Aided by Grant M- 927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service 52 �CONVULSIVE THERAPY 31 ﬂecting the patient’s adaptation 2 to 4 weeks fol~ lowing the last treatment. patient, therapist, nor evaluating physicians was aware which course of therapy each patient received until after the evaluation period. Changes in brain function were measured at weekly intervals by tests of language patterns both clinically and after amobarbital and by the degree of slow-wave activity in electroencephalograms. The intercorrelation of these indices and their relation to behavioral changes have been reported previously?” The manifest symptom patterns of the referred patients were variable and included suicidal preoccupation, retardation, disturbances of mood and affect, excitement, agitation, panic and tension, delusions, ideas of reference, negativism, withdrawal, and somatic complaints. The clinical diagnoses were depressive psychoses of manic-depressive, involutional and reactive varieties, and schizophrenic psychoses of paranoid, mixed, catatonic, and pseudoneurotic types. Clinical behavior was assessed in weekly psychi— atric interviews, structured perceptual task situa— tions,“'15 and by conferences with the patient’s therapist. In these observations, the evaluation of improvement along the continuum of “recoveredunimproved” appeared inadequate and was supplemented by a rating of the degree of behavioral change. The degree of change in clinical and ward behavior was rated on a 4-point scale of “marked,” “moderate,” “minimal,” or “no change. H These evaluations were not value judgments as to the quality of the change, but rather quantitative es— timates of differences in behavioral patterns under similar conditions of observation. The assigned rating was based on changes observed during the treatment period and for 2 weeks post treatment. Evaluations of improvement response were made on the 4—point scale of “recovered,” “much im— proved,” “improved,” and “unimproved or worse.” These evaluations were value judgments, based upon the behavior of the patient, the therapist’s expectations, the tolerance by therapist and patient of those aspects of behavior often called “side— elfects of the treatment,” and the therapist’s judg— ment as to the family’s attitudes to the patient’s behavior. These evaluations were short—term, re- Observations A. Behavioral Change and Improvement. A comparison of the behavioral ratings and the improvement evaluations is presented in Table 1. That ratings of recovered and much improved were associated with high or moderate degrees of behavioral change is an expected observation. Similarly, that patients with minimal or no change in behavior were evaluated as unimproved or improved, is also expected. The signiﬁcant relationship, however, lies in the patients showing high and moderate degrees of behavioral change and still rated as showing a poor clinical response. Of the 30 patients observed with high degrees of behavioral change, 17 were evaluated as recovered and much improved, and 13 as improved or un— improved. B. Modes of Adaptation—Analyses of the behavioral patterns of the subjects during and following treatment permitted the description of various modes of adaptation. For illustrative purposes we have described 4 behavioral patterns under the titles of euphoric—hypomanic, somatization, paranoidvuithdrawal, and panic modes. Euphoric-Hypomanic Mode: These subj ects appeared pleasant, affable, and friendly. They dressed neatly, spoke quietly, and participated in ward activities with increased interest. Occasionally they dressed gaudily and smiled and giggled excessively. Pretreatment symptoms were not manifest, and premorbid attitudes and behavior were again prominent. 0f Evaluations of Behavioral Change and Clinical Improvement (Convulsive and Subconvulsive Therapies) TABLE l.——C0mparison Improvement Rating Ichavioral Change High degree change Moderate degree change Minimal degree change No change F ink—K ahn Recovered (30) (17) (10) (16) Much Improved 9 6 0 0 8 3 0 L? 53 Improved Unimproved and Worse 8 6 2 5 5 1 15 5 �32 - In their psychotherapeutic interviews they described their illness in a detached manner, emphasizing “it” (illness) as having “dis— appeared.” They denied having been ill and facetiously suggested they were at the hos— pital for a rest, or that the institution was not a hospital, but a resort or a school. Symptoms were described in the past tense, and the quality of having been a different person during the illness was reiterated. Speech was marked by denial, displacement, evasion, qualiﬁcation, and cliches.“ The third person mode was frequently used, as in such statements “the doctor says I am ill” or “my wife should have come here.” Gross changes in memory were either not apparent, or were described for the treat— ment period only. The patients expected and accepted these deﬁcits, and neither connection with treatment nor apprehension was expressed. They looked forward to home visits and made realistic discharge plans. While conﬂicts with family members were described, these were minimized and expressed mainly in the past tense. Referential questions were answered in a referential manner and with— out an arousal of affect. For the more hypo— manic subjects, questions about home planning were responded to nonreferentially, with marked use of inappropriate clichés. When pressed with referential inquiries, they quickly exhibited anxiety and discom— fort, minimized their feelings, and changed the focus of the session. Such adaptations were sustained throughout the discharge planning period. The more hypomanic features were rarely sustained and within a few weeks were replaced by a more stable euphoric or somatization type of adaptation. Somatization Mode: In these subjects, in— cessant complaints about bodily symptoms and loss of memory, demands for reassur— ance and relief, and preoccupation with feel— ings of unreality and confusion dominated behavior. They remained unkempt and their rooms were untidy. When such an adapta— tion appeared early in therapy, further treatment was refused. ARCHIVES OF GENERAL PSYCHIATRY Speech was principally in the present tense and in the ﬁrst person, with few third person references and a minimal use of clichés, denial, or qualiﬁcations. In psycho— therapy sessions, they were demanding and hostile, reporting their problems in terms similar to those used prior to therapy. They complained that the treatment caused addi— tional and more incapacitating difﬁculties. To referential questions, answers were gen— eraly correct, but associated with complaints of memory impairment. They described their family relations in pretreatment terms, with an occasional “I don’t remember” in response to experiential inquiries. Discharge planning was difﬁcult, since they insisted that their new symptoms prevented any home adaptation. On the ward, their hostile demands for attention and relief of symptoms increased with treatment. Participation in group ac— tivities increased, however, for those sub— jects who had previously been withdrawn and seclusive. Memory complaints were preeminent. Pa— tients demanded reassurance that their memory would return and repeatedly asked if treatment would be harmful. They de— scribed feelings of derealization and con— fusion. Events, bodily feelings, and relations to friends and relatives seemed strange, fuzzy, unclear, and out of focus. While they complained chieﬂy of memory impairment, they also complained of back pain, headache, tingling of ﬁngers and toes, nausea and weakness, and ascribed these to the treatment. At the end of treatment, the symptoms for which hospitalization had occurred were no longer present, and although complaints were many, their relation to the treatment and their transience was so universally ac— cepted by both the staff and the patients, that the results were evaluated as beneﬁcial. This adaptive mode was sustained into the postdischarge period. Paranoid and Withdrawal Mode: Another pattern was the appearance of paranoid ideation, suspiciousness, hostility, ideas of reference, and delusions. These patients Vol. 5, July, 1961 �CONVULSIVE THERAPY failed to care for themselves and remained unkempt in their dress. Their rooms, in which they remained much of the day, were untidy. Speech was sparse and not spontane— ous. When questioned about their illness, they were hostile and demanded to know why they were questioned. They refused to answer inquiries or categorically denied or agreed to all speciﬁc questions. Experi— ential questions were answered referentially. When inquiry was insistent, they denied illness and minimized the symptoms which had resulted in their admission. They refused or avoided sessions with their therapist and insisted convulsive ther— apy be ended because it was harming them. When treatments were continued, they demanded release from the hospital, or pre— cipitated discharge by elopement, suicide attempts, or aggressive and destructive out— bursts. They were unable to discuss their relations with family or friends and focused on demands for either release or relief from somatic symptoms. Hostility was overt and engendered a fearfulness in the staff. On the ward, when coaxed out of seclusion, they were loud, aggressive, and demanding. They were suspicious of attempts at friendliness and expressed thoughts that others wished to harm them or talked about them. While insisting on discharge, no realistic discharge planning was achieved. Their View of the environment was grossly distorted and self—centered, preventing adequate care. In testing, they were uncooperative, and voiced angry suggestions of being experi— mented upon or abused. Complaints of memory impairment were infrequent and occasionally denied even when clinically manifest. On such occasions, they were en— raged at the implied deﬁcit. Panic Mode: These patients became increasingly anxious, agitated, restless, sleep— less, and anorexic. In their dress, they were neat and cared for themselves. Speech pat— terns were unchanged and continued with emphasis on ﬁrst person and present tense modes. Symptoms were distressing and prominently voiced. When asked about pre— treatment symptoms, these were expressed . Fink—Kuhn 33 in the same terms as those used earlier, with the complaint that treatment had made everything worse. Patients feared treatment and hid on treatment days, or pleaded with the staff to forego further applications. They threatened elopement and if this failed, submitted administrative requests for discharge. On the ward, they continued their pretreatment patterns of minimal participation. On treatment days, they were withdrawn, sullen, and negativistic, and cooperation was poor. They demanded to see their therapists and on such occasions insisted that treatment be discontinued. They were unable to discuss family situations or their attitudes to others, being preoccupied with their feelings of fear. In discussing their home, they insisted on immediate discharge, while stating they were severely frightened, anxious, depressed, and unwell. Ideation was unchanged with fearfulness as the principal affect. Fears of damage to the brain or mind was expressed, accompanied by the awareness that memory impairment may be a Sign of such damage. Complaints of memory impairment were infrequent and when present, were ex— pressed as a speciﬁc reason for discontinuation of treatment. Patients were uncooperative and fearful of testing and participated only if encour— aged that such tests may be helpful in the therapist’s decision about further treatment. Occasionally, when treatment was discon~ tinued, a more stable adaptation of relief, acquiescence, and denial appeared. C. Adaptive Mode and Improvement Ratings—Thus, for the various adaptive behavioral patterns, a range of short—term evaluations was observed. Those subjects who developed and sustained the euphoric— hypomanic modes were generally rated as recovered or much improved. Patients with somatization and panic modes were oc— casionally rated as improved, although unimproved ratings were frequent. The paranoid—withdrawal mode was evaluated as unimproved or worse, as were patients exhibiting the panic modes. The relation be— �34 ARCHIVES OF GENERAL PSYCHIATRY TABLE 2.—Adapti7/e Mode and Improvement Improvement Rating Modes Euphoric-Hypomanic Somatlzatlon Paranoid-Withdrawal Panic No adaptive change‘ ‘ Includes subconvulsive (36) (10) 7) ( 7) (13) ( Recovered Much Improved 11 14 0 0 0 0 l 10 5 0 0 0 2 2 l Improved Unimproved, Worse l 4 5 5 12 treated subjects Without second course of ECT. tween adaptive modes and ratings improvement is summarized in Table 2. of Studies relating physiological or psychological aspects of convulsive therapy to clinical outcome have reported inconsistent results}6 Thus, it has been reported that depressed patients respond favorably to convulsive therapy while schizophrenic or neu— rotic subjects do not; while other observers indicate that neurotic depressive patients re— spond badly, and that some schizophrenic subjects do have favorable outcomes. Vari— ous measures have been suggested as predic— tors of improvement, only to fail on more extensive testing. In such instances, the differences in results and discrepancies in convulsion can be related to the utilization of a variety of global estimates of improve— ment as the criterion of behavioral change, without adequate speciﬁcation of the standards used in the evaluation. Such standards differ widely, depending on institutional populations and staff attitudinal factors. Varying attitudes toward “side-effects,” the use of global rating scales, and varying psychosocial attitudes affecting goals of treatment have each served to make results from different laboratories incom— patible. Thus, in our evaluations of con— vulsive therapy, the development of changes in memory, recall, and orientation have been considered as temporary manifestations of therapy and disregarded in the clinical eval— uations.3'19 Patients developing the euphoric or hypomanic modes, despite concomitant memory loss, have been rated as much im— proved. In a comparable study by Johnson et al.,10 the Lorr global ratings of behavioral change were utilized. In this type of evaluation the changes in memory and orientation are in— Comment These observations emphasize the variety of behavioral adaptations that occur during convulsive therapy and relate short—term evaluations of improvement to the type of behavioral change. Earlier observers of con— vulsive therapy have described a range of behavioral patterns, ascribing the changes to ego adaptive responses, to the trauma of the treatment, organic brain changes, or psychologic signiﬁcance of the treatment.7' 9'21 These observations that subjects with similar psychopathologic syndromes receiv— ing similar treatment may exhibit discordant behavioral adaptations and be variously rated as recovered or unimproved, are of signiﬁcance for an understanding of the convulsive therapy process. In earlier studies, the conclusion was reached that persistent alterations in brain function were a necessary condition for behavioral change in convulsive ther:«ipy.2""6 With changes in brain function, all aspects of behavior undergo modiﬁcation. Percep— tion, mood, affect, judgment, attitude, mem— ory and recall are altered, and with these, the subject’s adaptation in the environment. Not all behavioral changes are viewed as improvement, however. Improvement ap— pears to be a special type of behavioral response, being the subjective estimate by an observer that the patient is “better.” It is based, not only on the patient’s behavior, but also on such nonspeciﬁc aspects as the observer’s expectations, and tolerances, and those of the family and environment. 56 Vol. 5, lily, 1961 �CONVULSIVE THERAPY cluded as negative scores in the improvement scoring, so that a high number of subjects were reported as “unimproved or worse.” Besides population differences, this single factor is sufﬁciently potent to alter the rela— tionships between the 2 studies and justiﬁes the discrepant observations. The use of global estimates of behavioral change in evaluating therapy has other signiﬁcant deﬁciencies. Psychiatric therapies are rarely focused, or effective in modifying a single symptom. The induced changes affect a spectrum of behaviors, with varying rates of change for different aspects. Global estimates tend to lose differences in individual elements within the medial designations necessary to deﬁne the whole response. In such situations changes in behavior which may be prominent, though not pervasive nor enduring, may dominate the evaluation as to overshadow other, potentially more signif— icant changes. Thus, alterations in memory and recall, or increased somatization or in— creasing withdrawal may dominate unim— proved evaluations; while explicit verbal denial, clichés, and euphoria may lead to recovered or much improved designations. The use of improvement ratings may be empirically justiﬁed as an early approxima— tion in studies of a new therapeutic meas— ure, but further analyses of the behavioral ‘ observations are required for understanding and adequately applying the treatment. The typologies described in this report are one approach—one that has been helpful in our understanding of the convulsive therapy process and one that is now being tested in studies of psychopharmacologic agents. In addition to the differences in improve— ment evaluations occasioned by attitudes to “side—effects” and the use of global ratings, there are differences due to the attitudes of therapists toward various sociocultural pop— ulations. The adaptation of explicit verbal denial in a lower class patient in a community institution is welcomed by therapists and family, but the same adaptation in an upper class professional in a psychothera— peutic hospital is considered poor or psy— chotic. The display of rationalization. Fin k—K01m 35 minimization and displacement, even when accompanied by a return to premorbid work levels, is considered marked improvement in one setting, but is viewed as a lack of improvement in another if goals of insight had been set by the therapist. Interference with memory and recall may be disregarded by therapists for one sociocultural group, but arouse empathic solicitude for patients of another social class. Such factors affect not only institutional attitudes, but within an institution, therapists of different thera— peutic orientations may have differing atti— tudes towards evaluations and therapies. The many recent sociocultural studies of thera— pists, and their attitudes towards selection of therapies, are indicative of these attitudinal differences.13'17-18'20'22 It is our impression, therefore, that im— provement ratings are no longer useful devices in evaluating psychiatric therapies. For the symptomatic therapies extant today, which are seemingly not directed toward the alteration of an etiologic factor, typologic descriptions have a greater applicability and empiric justiﬁcation. Typologies based on concepts of diagnosis, target symptoms, or on dynamic—structural formulations have attempted to structure the pretreatment clusters in which therapies may be effective. Treatment and post—treatment symptom improvement scales have been used with utility. These are limited approximations, however, and there is a need for a broader approach to both the pretreatment and the treatment behavior, and a phenotypic, adaptive be— havioral typology, using multivariate tech— niques of data analysis, seems worthy of assessment. Summary An analysis of the variety of behavioral adaptations of 73 voluntary psychiatric pa— tients undergoing convulsive therapy resulted in the description of 4 major patterns. These are described as euphoric-hypomanic, somatization, paranoid—withdrawal, and pan— ic modes. The relation of these modes to clinical ratings of improvement is described. The �36 ARCHIVES OF GENERAL PSYCHIATRY derivative and generally nonoperational nature of improvement ratings is empha— sized. The difﬁculties in a communicative deﬁnition of this variable is seen as a major factor in the discrepant studies of indices predictive of improvement in convulsive therapy and in understanding the processes of somatic therapies in psychiatry. Therapy (With and W'ithout Atropine), Arch. Gen. Psychiat. 2:324-336, 1960. 11. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, edited by P. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126-139. 12. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Psychiat. 76 :23-29, 1956. 13. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings, and Diagnosis, A.M.A. Arch. Gen. Psychiat. 1:565-574, Max Fink, M.D., Department of Experimental Psychiatry, Hillside Hospital, 75—59 263rd St., Glen Oaks, L.I., N.Y. REFERENCES H Esecover, H.; Jaﬁe, J., and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. 7:17-25, 1958. 2. Fink, M.: A Uniﬁed Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 1. 1959. 14. Kahn, R. L.; Pollack, M., and Fink, M.: F igure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 2:547-551, 1960. 15. Kahn, R. L.; Pollack, M., and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. Ment. Dis. 130:187—192, 197-206, 1957. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electro— shock: Quantitative Serial Studies, A.M.A. Arch. Neurol. Psychiat. 78:516-525, 1957. 4. Fink, M.; Kahn, R. L., and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19:113~118, 1958. 5. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Aﬂ'ecting Individual Differences in Behavioral Response to Convulsive Therapy, J. Nerv. Ment. Dis. 128 :243-248, 1959. 6. Fink, M.; Kahn, R. L.; Karp, E.; Pollack, M.; Green, M.; Alan, B., and Lef‘kowits, H. J.: Signiﬁcance of Inhalant Induced Convulsions for the Theory of the Convulsive Therapy Process, Arch. Gen. Psychiat. 4:259-266, 1961. 7. Frosch, J., and Impastat, D.: The Effects of Shock Treatment on the Ego, Psychoanal. Quart. 3. 1960. 16. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and other Somatic Treatments in Psychiatry, New York, Grune & Stratton, Inc., 1952. 17. Kaplan, A. 1., and Lefkowits, H. J.: Inﬂu— ence of Staff Attitudes and Environmental Factors on Treatment Selection, J. Hillside Hosp. 1961, to be published. 18. Klerman, G. L.; Sharaf, M.; Holzman, M., and Levinson, D. J.: Sociopsychological Charac- teristics of Resident Psychiatrists and their Use of Drug Therapy, Amer. J. Psychiat. 117:111-117, 1960. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁn. Neurol. 16: 19.. 88-96, 1956. 20. McIver, J. and Redlich, F. C.: 17:226-239, 1948. 8. Frosch, J.; Impastato, D.; Ottenheimer, L., and Wortis, S. B.: Some Reactions Seen After Electric Shock Treatment, Amer. J. Psychiat. 102 Patterns of Psychiatric Practice, Amer. J. Psychiat. 115:692- 311—315, 1945. 697, 1959. 21. Millet, J. A. Glueck, B. C.: Psychopathologic Reactions and Electric-Shock Therapy, New York J. Med. 42:1553-1557, 1942. 10. Johnson, L. C.; Ulett, G. A.; Johnson, M.; Smith, K., and Sines, J. 0.: Electroconvulsive Psychosom. Med. 6:226-237, 1944. 22. Pasamanick, B.; Dinitz, S., and Lefton, M.: Psychiatric Orientation and Its Relation to Diag— nosis and Treatment in a Mental Hospital, Amer. J. Psychiat. 116:127-132, 1959. : P., and Morse, E.: On Certain Psychological Aspects of Electroshock Therapy, 9. 58 Printed and Published in the United States of America ��Putt-ran at Bohgvioral chant. and Inprorcnnnt 1n canvullivo rhcrapy In: Pink, x.n. and nobcrt L. Kuhn, Ph.D.* from the Dapartncnt or Expnrinontnl Psychiatry, ulna oakn, L.I., n.x. Hillside noupitsl, gratt K~927 of tho lattcnal Initituta a: nontal noulth, lutional Institutua a: Hatlth, United Status Puhlie Hualth survzoo. Reta in part, gt th.".!. 91'1319311 looting, American Payehintric Aidod by Association Northbor, 1951. : Btvﬂiomit o: Psych-try. Mutation 30-91%“. *Pruont Bronx, 1.1. VII: 1/61 “an" �Individuol ﬂittoroncoo in tho bohoviorol roopouoo to oonvoloivo thoropy oro oorkod. In poyohiotric proctico, potionto with oanslor poyohopotholoxtc oyudroaoo, one or oililor varioty or olinieol rosponooo: oooo toprovo old ouotoin ouch chongo; oooo 1-provo, only to rolopoo quickly; ond oooo toil to taprovo. rhooo dittorooeoo hovo boon rolotod to tho dogroo ond duration or indoood nourophyoiolociool ehongo (3,6) prooorbtd pottorno or poroonoltty (5,11,15), ooulopoyeholoctool chorootoriotioo (13,15) and porehothoropontto opprooehoo (1). Vh11o thooo otudioo hovo onphooiood voting: 0: taprovooont, tho dorivotivo unturo or thin ovoluotion ond 1t: dopondonco on otort ottttudoo, oxpoctotiono ond tooily toloronco oox ond ago, ohow o has boon strooood (2,h,5,8). rho oonttoot bohoviorol pottorno provido tho boots tor tho ovo$uot1ono of clinical rooponoo. It 1o tho purpooo o: thto roport to doocriborbohovtorol pottorno 1n pottonto nndoraoinz oonvolsivo thoropy, ond to roloto tho-o to problooo of tho ovolootioo of taprovooont and to on ondorotondinx o2 tho coo- vuloivo thoronyIProcooo. �gethod: or consecutive pe$$en$e reterred for electreehoek therepy 63:13; 1956—57. teveatybthree pettente were subjecte e: the eaelyeee eeeeribed here. the patients were selected tor treeto sent by the reeident therepiet end the aupervteiuc peyohietrteﬁ - the inveetzceterp playing no role in their selection. These convulsive—euhcenvulaSve electroc 3 during were III. obeervettene eheok study a; whieh subject. referred tar enereyy were rendenly unsigned to entrees e: cuboenvuletve er convulsive treetnente. Electroeheek wee edginietered three tines weekly under pentethel preunedieetiea, using either e letter unidirectional er e xederett alternating entrent inattenent. arena eel or enbeenvnleive treetnente were eduin1utered by titering the etrongth of current. leither patient, therapist not eveluetinx phyeiaiene tee evere which entree e1 therapy each pétient received until titer the evaluation period. weeiiy intervals cheese: in urea: tunetion were neeeered at by test: of leagues. petterne both 011336.11: eta etter eneberbitel, and by the degree e: 310: were activity in electroencephelegrene. 2he interoerreletien e: theee indieee 3 �.3cooplointl. rho alinicol dioxnoooo woro doproootvo of nonio—doproooivo, involutioaol ond rooetivo and ooaotic poyuhoooo voriotioo; one oohioophrontc poyehoooo or poronoid, aixod, oototonto and pooudonourotie typoo. clinical bohovior woo oooooood in vookly poyuhiotric intorviovo, otrootorod porooptuol took oituotiono (1h,15) and with contorouooo tho potiont'o thoropiot. II thooo ohoorvo~ by tiono, tho ovolootion of :Iprovouont along tho continual of 'rooovorod-untnprovod' oppooroa inoaoquoto, and woo topplonontod by o roting of tho dogroo of bohoviorol ohongo. rho dogroo of chonzo 1n olinieol tad word hohovior woo totod on o four point ocolo or 'norkod', “nodoroto', 'nininol' or'ho chango'. Thooo ovoluotiono woro not voluo Judznonto no to tho quality of tho ohonxo, but rothor, quontitotivo ootinotoo o: ditforouooo in hohoriorol pottorno undo: oinilor condition: at otoorvotion. rho oooigood voting woo hoood on ohongoo oboorvod during tho trootnont poriod and for too vooko poot~ trootaont. lvolootiono or ingrovonont roopoaoo woro undo on tho four point ocolo or 'rocovorod', 'nuoh taprovod', ﬁtnprovod', and “nailprovod or onroo'. rhooo ovolootaono ooro voluo Judgnouto, hoood upon tho bohovior of tho patient, tho thoroptot'o oxpoctotiono, tho toloronoo by thoropiot and potiont of thooo oopoeto of bohovior otton oollod *oido-orroeto of tho trootnont’, and tho thoropiot'o Judgnont on to tho tonily'o ottitudoo to the potioat'o hohovtor. fhooo ovolnotiono ooro abort-torn, rotlocting tho potiont'o odoptotion two to tour wool“ following the lost troutnOHto �gbaorvationo: (a) Donatioral chango and Ingrovonont coaparioon at tho bahavioral ratingo and tho iaprovoaont ovaluationo 1o proooatod in tabla I. that ratings at rocovorod and nuch iaptovod woro aaaociatod with high or moderate dogrooa at bohavioral change it an oxpoctod obaorvation. similarly, that patioato with ainiaal or no chango in behavior taro avalaotod ao uni-proved or iaprovod, io aloe oxpootod. tho aixaitioant rolatianahip, hovovor, lioa in tho patianta ohooing high and oodorato dogrooo or bohavioral ohoazo and atill ratod ao ohaoiaz a poor oliniaal roopoaao. at tho thirty patioato obaorvad with high dogrooa or hohaviaral ohango, aovontoon voro ovaluatod aa raeavorod and much iaprovod, and thirtoon ao inprovod or aainprovod. l .. --.. . ZLBLI (b) undo: at Adaptation I -“ﬂ--. o: the bohavioral pattorna at tho oobaocto daring and tailoring traataont poraittod tho description or variauo today of adaptation. For illoatrativo purpoooa vo havo doaoribod tour bohoriorol pattorna undo: tho titloa a: oaghorie-hzgoaanio, oaaatiaation. garanoid-withdraoa; and Analyooo Rania nodoo. Bughorio-lzzoaanie Roda: Thooo oubjocta appoarod plaaaant, atrablo and friaudly. they are-sod neatly, opako quiotly, and participated in word activitioo with ineroaaod �Zlﬂﬁﬁ I atnpgrtann 0t Evaluationl Qt nohavttrnl change and clinical Inpruvcnont (c0uvu1317c and subconvnlutru 1h0r&pico) ﬁtting XIErOVOIORt locovorod » _ Itch Inprdvod ﬁninpruvod and Ingrovod 39:30 Bahaviorll Ghangc nigh dogroo change (39) ﬁ lodorato (17) 8 9 8 5 3 6 6 2 Juana (‘10) o a 5 S (16) o 0 1 15 I. change ' ' I' �. ~5-. interest. 'oeeeeieeelly they dreeeed aeadily, end exiled end giggled excessively. Pre-treeteent eyepteee were net eenifeet end preeerbid ettitudee end hehevier were egeie prenieeet. In their peyohetherepeetie interviews they deecrihed their illueee in e deteched leaner, eepheeieieg ”it“ (illneee) ee they denied having-been ill end feeetieeely eeggeeted they were et the heepitel fer e reet; er thet the inetitutiee wee net e heepitel, but e reeert er e eeheel. Syeyteee were deeeribed in the pert teeee, end the geelity of keying been e different pereen during the illeeee hevins “dieeppeered’. reitereted. Speeeh wee eerked by deeiel,.diepleeeeeet, ereeiee, quelitieetiee end eliehee (11). the third pereen wee ' eede wee frequently need, ee in eeeh eteteeeete the doctor eeye 1 en 111' er *ey wife eheeld here eeee here.II Greee ehenzee in neeery were either not eppereat, or were deeeribed fer the treeteeet period only. the petieete expected end eeeepted theee defieite, end neither eeeeectiee with treeteeet her eppreheneien were expreeeed. they looked forward te here wieite end eede reelietie dieeherge pleee. While conflicts with feeily eenbere were deeeribed, theee were eieieieed end expreeeed neiely in the peet tenee. heferentiel qeeetieee were eeewered in e referential nearer end without en ereeeel of effect. for the mere hypeeeeie eebaeete, queetiene eheet here planning were reepended te nearefereetielly, with marked nee of inepprepriete eliehee. When preeeed with referentiel inquiries, they quickly exhibited �.5anxiety and dieeeatort, aiuiaieed their feelings and changed the teeua.e£ the eeeeien. Seek adaptatiene were euetained throughout the discharge planning period. The mere hypeaaaie features were rarely suetained, and within a for weeks were replaced by a mere etable euphoric er aenatizatien types of adaptation. ,8enatizetien Hades In theee_enbdeete, incessant eeaplainte about bodily eyaptene and lees e: eatery, deaands fer reaeeurenee and relief; and preoccupation with feelings of nnreality and eeeteeion doainated behavior. Ehey retained unkempt and their When each an adaptatien appeared early in were untidy. reels therapy, further treatment wee refused. speech nae printiptlly in the present teaee and in the first pereen, eith fee third peraen references and a ainiaai use at clichea, denial er qualifications. In peyohetherapy eeeeiene, they vere-deaandies and hostile, repertihg their prehieae in terae eiailar to these need prier to therapy. !hey eeaplained that the treatment eaaeed additieeel and mere incapacitating difficulties. re referential queatiens, answers were generally correct, but associated with eenplainte of aeaery inpairaent. they deeeribed their taaily relations in yreotreatneet terns, with en oecaaional '1 den't reaenber' in reepenee to experiential inquiriee. Discharge planning eaa dittiealt, as they insisted that their new eynptene prevented any home adaptation. their heetile demands for attentien and relief at eyupteas increased with treetaent. Participation in creep activities inereaaed, however, tar these eabaeete who had an the ward, �-7. previeaely been withdrawn and eeoleeive. Heaory eeaplainte were pre-eaiuent. ratioate deaanded reaaaaranee that their aeaery would return, and repeatedly asked if treatment would he hararul. they deeoribod feelinge of derealiaation and confusion. Erenta, bodily feelinge and relatiena to friends and relativee eeeaed etrange, teeny, unclear, and out of :oeue. While they oonplained ehietly e: book of alao ceaplained pain, headache, they iarairnent, aeaory tingling o: tinsera and teee, aaaaea and roakaoee, and aeorihed there to the troetaent. which end symptom: the for the at treatment, heepitalit iaatioa had occurred were no longer present, and although and to the treatment were relation their their aany, eoaploiate transieaoe eae eo univoreally aeeepted by both the start and the patients, that the rooalte rare evaluated or beneficial. !hie adaptive node wee eeetained into the peat-dieoharge period. Paranoid and Withdrawal lode: Another pattern tea the appearance or paranoid ideation, euepicieuaneea, hostility, ideae of reference and deleaiene. These patients failed to care for theaaolvee, and roaained unkeapt in their dress. Their reeaq.in which they reaained each or the day, were untidy. Speech eaa eparee and not epontaneeaa. when questioned about their illneae, they were hostile and demanded to know why they were queetiened. they retaeed to anewer inquiriee er categorieally denied or agreed to all epecixio queetiene. Experiential caeetiena were anewerod roterantially. When inquiry was ioeietoat, they doeidd illneea and ainiaieed tho ayaptena which �~8- resulted 3: their ednieeien. they retueed er eveided eeeeieee with their therepiet, end ineieted eenvuledve therepy he ended beeeeee iteee herningy then. When treeteente rere continued, they demanded releeee free the_hoepite1, or precipiteted dieeherge by elepeneut, euietde ettelpte er eczreeeive end deetreetdve outberete. They were uneble to diecuee their reletiens with relily or triende, and teeeeed either en deaende fer releeee or relief tree resette eynptoee. Ieettlity wee overt, end engendered e teertelneee 1n the etett. an the nerd, rhea eeexed out of see» Ineien, they were lend, eggreeetve end deeend1ng. They were eeepieieee e: etteepte at friendlteeee, end expreeeed theeghte thet other: edehed to here the: or talked ebeﬁt then. while ineieting en dteeherge, no reelietie dieeherge pleating wee eehseved. their View er the envirtneent wee creeely distorted end eelreeeutered, preventing'edeqnete care. In testing, they were uneeeperetive, end rained angry eeggeetiene a! being experirented ugen or ebueed. Complaints at nenery impairment were intrequent, and occeeienelly denied when even clinicelly meniteet. on such occasione, they were eareged et the inplied deficit. Peale Bede: Theee'pettﬂate beeene increeeingly enzione, eglteted, reetleee, eleepleee end enorexie. In their dreee, they were neet end eered ror themselves. Speech patterns hed were unehegged end eontinued with eepheeie on tiret pereon and preeent tenee nodes. .synpteme were dietreee1ng end prentuentiy voiced. When asked about preetreetment eynptore, �.9. theee were expreeaed in the aaae terae ae theee need earlier, with the eaaplaint that treataent had aade everything weree. Patienta reared treat-eat and hid an treataent daye, er pleaded with the etatt to forage farther applications. they threatened elepeaent and it thie tailed, enhaitted administrative reqaeata fer discharge. an the ward, they continued their preatreataent patterns at participatien. 0n treataent daye, they were withdrawn, aalien and negativietie, and cooperation wae peer. they deaanded te aee their therapiete and on each eceeeiene ineieted that treataant be discontinued. they were unable to diecnee {anily eitaatiene er their attitudee to ethere, being preo eeeayied with their feeling: at tear. In dieeaeaieg their minimal heaa, they inaiated en iaaediate dieeharge, while atating they were aewerely trightened, anxieaa, depreeeed and unwell. ’Ideatien was unchanged with tearfulneae ae the principal . affect. reare te the brain er aied wae expreeeed, aeeeapaaied by the awareaeee that aeaory iapairaeet may be a sign at each damage. ceaplainta at aeaery inpairaent were in~ ex daaage frequent and when present, were expressed ae a apeeitie reason (or dieeeatinaatiea of treatment. Patiente were uncooperative and fearful at testing, and participated only it encouraged that such decision about further tests may be helpful treataent. occasion. in the therapist's ally, when treatment wae diacentinued, a more stable adaptation of relier, aeqaieeeenee and denial appeared. �' (3) 29:9" tivo H96. and rovunoat n;¢1 3 Thus, fo:_th¢ var1oua_gdaptivq bohnvitrnl ptttornl, a runs; or ihort term evaluations were obsorvad. thus: subjects aha devolaped and sustained the euphoric-hyponanie nodou were generally ratoﬁ us rocaverod or nueh inpravod. Patients uith ponatizatian gnd panic modes were ocgusiantlly rated as improved, nithgugh uninprevod ratings were frequent. The paranoid-with. ﬁgural node was evaluated as unimprGVad or worse, as were model. The relation batucon the panic pn§;ontl czhibiting adaptive node and ratings or improvonent are Ialnnrilod in ' d‘ fable 1!. 1133! II -‘C- “CC- �tivo.ﬂndc 3nd Ada rovonoat Ingrovcnont Rating Rtoovered 3.4.. anh Improved Inprovcd ﬁninpravod, Horn. Euphoricvﬂyponanic (36) 11 1h 10 1 Selatinttion tiranotdniithdrauul (10) o 1 5 h ( 7) 0 o 2 5 Psntc ( 7) o o 2 5 ndaptivo ohtngoi (13) 0 0 1 12 I. alnoludas snbcenvulsivo trcntod unbaoctu without cocond course 01 not, �Bieeoeeien: fheee ebeervatiene eaphaeiee the variety of behavioral adaptatiene that-occur daring eonvaleive therapy, and relate abort tern evaluatieee or iapreveaeot to the type of behavioral change. larlier obeervere at oooveleive therapy have deeoribed a range of behavioral patterns, aeoribing the ehaogee to age adaptive reepenaee,to the traaaa of the treataent, organio brain changes, or peyehologio oigoifioanoe of the treataeot (7,8,9,21). These ebeervatione that subjects with eiailar peyohopethelegio eyndreaee receiving aiailar treatment aay exhibit dieoordaot behavioral adaptatiene, and be varioaely rated aa recovered or aaiaproved, ie o! eigoirieanoe for an onderetahding e: the eonvnlaive therapy prooeee. In earlier studies, the ooholoaioo val reached that pereietené alteratioea in brain tanotioo were a neoeeeary eonditieo to; behavioral change in oonvaloive therapy (2,h,6). With changes it brain tuaotioo, all aepeote of behavior undergo modification. Perception, need, affect, Jadgaent, attitude, aeaery and recall are altered, and with theee, the eabaeot'e adaptation in the environment. let all behavioral ebaegee are viewed aa iapreveaeot, however. Improvement appeare to be a special type oi behavioral reepooee, being the eobjeotive eetiaate by an obeorver that the patient ie 'hotter’. It ie baled, not only on the patieot'e behavior, but also on each oeo-apeoitie aepeeta aa the obeerver'a expeotatione, and toleraooee, and these at the taaily and eovirenaent. Studies relating physiological or peyehologioal aepeote �-12or oonvnloivo therapy to clinical inreported that deproeeed ontoone have reported been hae Thne, (16). it ooneietont roanlte eohiaowhile oonvnleivo therapy to patients reopond favorably oheorvore other while do not; oabjoota nonrotio phrenio or and badly, reepond patiente dopreeeive neurotic that indioate ontooaoe. do favorable have enhaeota that ooae aohiaophronio of inprovoaa predictora been enggeeted have Various noaanroe each inetanoea, In extensive tootinx. on aoro to lent, only tail can eonolneion in and diaoropanoioo in results the dittorenooe or oetiaatoe of global of a variety be related to the utilization vithoot behavioral change, of the criterion ilproveaent an evaluation. the need in etandarde of the adequate epooitioation Snoh etandarde differ videly, depending on institutional atatt attitadinal taotore. Varying attitudeand eoaloe of rating global the nae toaard 'aide-otteota', popelatione and o: treataent goale afteoting attitndee varying peyohoeooial have baoh eorved to lake reenlte tron different laboratorioe oonvnloivo therapy, o: ovalaationa in our fhne, inooapatiblo. and orientation recall in ohangee neaozy o: devolepaont the , and of therapy aanitoetatione have been considered ae teaperary dieregardod in the olinioal ovalaatione (3,19). Patients oonoonitant doepito aodea, hypeaanio the euphoric or developing anon been on ieproved. have rated neaory loee, In a ooaparable etndy by John-on gngg, (lo), the Lorr global of In type thie utilized.“ were change rating! of behavioral inolndod and orientation are in ohanxee the neaory evaluation �-13- negative oeoroa in the inprovenent nearing, no that a high nnaher or enhaooto were reported an 'aninproved or nerao.‘ Booidoe population ditterenoee, thia einglo factor in eattioiently potent to alter the relationehipe between the two etadios, and Justitieo the diooropant eboervationa. the nae or global eetinatea or behavioral change in evaluating therapy hae other significant detieieneiee. Psychiatric therapiea are rarely toenaed, or effective in modifying a single eyaptea. the induced ohanxoo affect a opeetrna oi hehaviera, with varying ratoa of change for ditterent aepoote. Global aetinateo tend to loae differenooe in individual ole-onto within the nedial deoignatione neeoeaany to define the whole reeponee. In oneh oitnationa ohangee in hehavier which nay he preninont, though not pervaaive nor enduring nay doninate the evaluation an to overehadoe other, potentially nore aignitioant ehanzee. than, alterationo in aenory and recall, or increaeed eonatination or inereaaing tithdrawal nay daninato nninproved evaluations; while explicit verbal denial, olieheo and euphoria nay lead to recovered or each iaproved designations. the nae o: inprevenent ratings nay he enpirioelly Jaatiried an an early approxiaation in studies of a new thorapeutio aoaonre, but inrthor analyoea o: the behavioral eboorva~ tiona are required for anderatanding and adequately applying the treatnent. rho typologiea deooribod in this report are one approaeh - one that hoe heon helptal in our nnderatanding or the oonvaloive therapy prooeea, and one that in non being teatod in etadiee o: payohepharaaeoloxie agento. on �ulhIn sddltlen to the differences in leprevesent evelestlens eeessieeed by attitudes to 'elde-effeets' end the use ef glebel due to the ettitedes ef thereplsts differences there ere retinls, tersrd rsrlees seeleesltsrsl peeeletiens. The edeptetien of explicit verbsl denial in s lever clues pstient in e eennenlty lestitntlee is welcomed by therspiste and really, but the seas sdsptstleu in en upper elese professional in e peyehethsrspeetle The displsy ef or psychotic. is hospital considered peer when and even nintnisstlen displscenent, retlensllsstien, eeeenpenied by s return to preeerbid work levels, is eensidered nsrked leprevenent in ens setting, but is viewed as e leek ef inpreveneet is enether if ceels of insight hsd been set by the thersplet. Interference with memory end reeell say he disregsrded by therspists fer ene seeieeeltnrel group, but sreese espethle eeliettede fer petlente ef endkher seeiel eless. Seek feetere effect not enly institutienel,%tt1tedee, but riteln en 1nst1ts~ tion, therapists of different therepeutie erlestétlees sey here evglestieae nsny thersples. towards sad the differing ettltedee recent seeiecnlterel studies ef therspists, end their sttitedes tevsrds eelsetion ef thersples, sre indiestive of these sttitndinsl differences (13,17,18,2o.22). It is our impression, therefore, thet inprevenent rstlngs are no longer useful devices in evslusting psyrhietrie therepies. For the eynptometie therapies extent today, which ere seemingly net direeted tewerd the slteretien ef en etiologic fecter, typelegte deecriptiens have s greeter spplleebility sud enpirie �-15. Justification. typologies haaad on concepts at diaxaaaia, targat aynpaaaa or on dyaaaio-atractaral formulations harattaaptad to atructara tho pra-traataaat clusters in witch thoraptaa nay be attaativa. fraatnant and paat—troatnant ayaytan impravaaant acalaa have haan used with utility. Thaao ara linitad approxinatiaaa, howavar, and thara 1a a naad far a broader approach to bath tho pra-traataant and traatnant bahaviara, and a phanotypio, adaptiva bahaviaral typolacy, aaing aaltivariata taohniqnaa at data analysis, aoana worthy a: aaaaaaaant. �w in enelyeie_er the veriety e1 beheviorelvudeptetiene or 73 velnntery peychietric petiente undergoing convulsive therepy reeulted in the description er tear nejor patterne. These are deecribed ee eupheric-hypenenic, eenetizetien, paranoid-withdrawal end penie nedee. the reletien er the-e nedee te clinical retinge e: ieprevenelt ie deecribed. the derivative end generally neu-eperetienel unture e: ieyrevenent retinge in enpheeieed. the difficulties in e cennunieetive detinitien e: thie veriehle ie eeen ee_e nejer teeter in the dieerepent etudiee et indieee predictive e: inprevenelt in cenveleive therapy, end in underetendinc the preeeeeee e: ee-etic therepiee in peywhietry. �-17- W' 1. Ieeeever, 1., latte, J. and Iain, R.L.: Peyehetherepeetie rechaiqaee with lieetreeheek Patiente. J. lilieide .3332..1; 17~2§, 1958. link, 1.: i ﬁaified theory of the ietiea e: Phyeiedyuanie rherapiee. J. lilleide legg. é; 197-206, 1957. BIG and of Delta Activity te telatien 1.5.: lake, link, I. lehavierel leepenee in lleetreeheek: Quantitative serial Stadiee. A.!.i. ireh. laurel. & Pezdhiat. 19: 516-525, 1257. n.: prerinental Studiee or «a. lleetreeheek Preeeee. Die. lerv. slat. 11: 113-119, and 3.1. Pellaek, a.a Payehelegieal rector. take, 3., tier, rant,§a.. lane, 1.1. and Green, 1958. Affecting Individual Differences in Behavioral Reapenee to canvaleive Therapy. J.l,!.B. 13g. 2k3-2h8, 1959. 6. Fiat, u., Kenn, 3.5., tarp, 3., Pollack, 1., Green, H., Alan, B. and Lei‘kewite, LL: Significance of Inhalant Induced neural-ion: tor the Theory er the convulsive Therapy Preeeee. L.H.i. Arch. Gen. Pezehiat. (in press). Preach, J. and Iepaetate, 9.: the Effects of shock Treataent on the 3:0. Pezgheenal. Quart. l1: 226-239, 19h8. Ireeeh, 6., Inpaeteto, 9., attenheiner, L. and Wartie, 8.3.: Some Reactions Seen After Electric Sheet Treatment. Amer. J. Pezghiat. 1021 311-315, 19h5. �.13- 3.0.: reyehepethelegie Reactiene end Bleetrie-Sheek Therapy.‘ 1.1: State J. led. g3. 1553-1557. 19h2. 10. Jehneen, L.c., Ulett, G.L., Jehneen, H., Snith, I. end Sines, 3.6.: Electreoeavuleive therapy (with end 9. alueek, Hithaut Atropine). Arch. Gen. Pazghie . g; 32h-336, 1966. 11. Kenn, 1.1. end Pink, l.c change: in Language Bering Elactroahock therapy. re ehe‘ethelo er colnunioetien, Ed. Roch, P. and Zubin, 3., Stuns e Stratten 126-139, 1958. 12. R.L., link, x. end Weinetetn, B.A.i Reletien of tnoberbitel rest to Clinical Inprevenent in Electroehock. Arch. neural. e rezehiet. lg: 23-29,'1956. 13. Kuhn, R.L., Pollack, H. end flag, 3.: Seeiepeyeheloxie Aspect; a: Peyehiatric Ireetnent in A Velentery Mental Hospital: Duretien or Hoepitelixetiea, Discharge hating: end Biegaeeie. 1.x.1. Arch. Gen. Pezehiet. ;} Kehn, 565-57h, 1959. 1k. Iehn, R.L., rolleck, H. end rink, H.a Figure-around Discriminetien After Induced Altered Brein Functien. A.H.L. Arch. lea-oi. g: 5&7-551, 1966. 15. Kuhn, R.L., Pollack, I. end tint, H.c Sociel Attitude (alliternie W ? Scale) end Convulaive Therepy. gig: 187~192, 1960. J.I.H.D. 16. lelileweky, L. and Heck, 2.: Shack trout-eats, Peychoeurgery end eﬁher Betetie Ireetnente 1n Peyehintry. Grtne end ___________._________________________.____ strn‘t.n. 3.1. , 1952e �lethed: 9t eeneecetire petiente referred fer eleetreeheek therepy during 1956-57, eeveety-three petiente were eebjeete of the ehelyeee deeerihed here. the pettente were selected fer treetnent by the reetdeut therepiet end the eupervieies peyehietriet the inveettsetere pleying he rele in their eeleetten. theee eheervetieee were nede during e eeeveletve-eeheeevuletve eleetreeheek etedy in which euhaeete referred for therepy were rendeely eeeirned to eeereee e1 eeheenveletre er eenreletve treeteente. Bleetreeheek eee edeiaietered three tinee weekly under pentethel pre-nedteetien, eeing either e letter unidireetienel or e heeerett elternetieg eerrent instreeeet. Greed eel or enheenvuleive treeteente were edninietered by eltering the etreexth a: current. [either petieht, therepiet her evelueting phyeieiene tee ewere which eeeree e: therepy eeeh pitieet received until etter the ewelnetiee period. eheugee in hreie tenetiee were neeeered et weekly intervele by teete e: leexeece petteree heth alerteelly end etter eeeberhttel, end by the degree e: elew eewe eetivity in electroencephelexrene. the intereerreletien e: theee indieee end their reletien te heherterel eheagee here been reperted prewieeely (3,1g). the senateet eyeptee petteree e: the referred pttiente were reriehle, end included euteidel preeeeepetien, reterdetieu, dieterheneee e: need end erreet, exeiteneat, egitetien, penie end teneaen, deleeiene, ideee et reference, hegettrien, rithdrewel 1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Behavioral patterns in convulsive therapy. Arch Gen Psychiat. 1961 Jul; 5:30-6. 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Archives of Neurology (“7 Psychiatry November 1957, Vol. 78, pp. 516—525 Copyright 1957, by American Medical Association Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshoek Quantitative Serial Studies MAX FINK, M.D., and ROBERT L KAHN, Ph.D., Glen Oaks, N. Recent theories of'electroshock therapy 1'3 have emphasized the role of neurophysiologic changes as. the basis for the therapeutic ac— tion of electroshock. Consistent with these theories, we have observed a relation between changes in certain measures of brain function and behavioral response. We have noted that evaluations of clinical improvement fol— lowing electroshock are related to changes in orientation and confabulation after intra— venous amobarbital,4 learning and recall,5 and syntactical aspects of language.6 In view of these observations, it could be expected that electroencephalographic studies would show a similar relationship. Numerous observers have reported consistent changes in the electroencephalogram after electrically induced convulsions. There is diffuse slowing with increased voltage and dysrhythmic activity?"12 Fast activity decreases, both in voltage and in percent time}3 and in patients who are intensively treated there is a slowing of persistent alpha frequencies.14 The degree, duration, and extent of delta activity are directly related to the frequency and number of grand mal convulsions?"14 Such activity is usually symmetric and appears maximal in anterior leads, and the electroencephalog— Received for publication June 18, 1957. From the Department of Experimental Psychia— try, Hillside Hospital. Presented at a meeting of the Eastern Associa— tion of Electroencephalographers, Washington, D. C., September, 1955. Aided, in part, by Grant M—927, National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Dalian Foundation for Medical Research, New York. Y. raphic effects usually disappear in the four to eight weeks following the last treatmentfgi9 In contrast to the consistency of these observations, studies of the relationship between the electroencephalographic and the clinical changes show conﬂicting results. Chusid and Pacella,15 after an extensive review of the literature, concluded that the number of treatments rather than the degree of induced delta activity, was the primary factor related to a favorable therapeutic re— sponse. On the other hand, Hoagland et al.16 reported a relation between changes in the percent time fast activity (more than 13 cps) and independent clinical ratings of be— havioral change._ Roth2 similarly reported a relationship between changes in the clinical state and alterations in the delta response induced by intravenous thiopental sodium. The divergent observations reﬂect variations in methodology. The present study is an attempt to apply quantitative methods of analysis of serial electroencephalographic records to this problem. The purpose of this study is to determine (1) the relation of changes in electroencephalographic delta activity to the behavioral response in electro— shock, and (2) if a relationship does exist, the signiﬁcance it may have for an under-standing of the electroshock process. Subjects and Method 1. In the initial series, 24- consecutive patients referred for electroshock were studied. Electro— encephalograms were obtained prior to treatment and at weekly intervals during and after treatment, using an eight—channel Medcraft electroencephalograph and needle electrodes. Recording was bi— polar, and hyperventilation activation was utilized 516 ,. “(34.x �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE during each recording. During the treatment pe— riod, records were taken on the day following a treatment, generally 25 to 31 hours later. Grand mal electroshock therapy was administered by staff psychiatrists, using a Reiter C-47 electrostimulator. Treatment schedules were three times a week, and the number of treatments varied from 9 to 33. As patients showed a clinical response, the psychiatrist tended to give fewer and more widely spaced treatments. There were 15 women and 9 men in the series, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of EEG Records—A total of 160 records were obtained on these subjects. Following the suggestion of Strauss,17 the delta index was determined for three lead combinations (frontal— parietal, anterior temporal-vertex, and parietal-ear lobe) for 60 seconds of recording for each lead. The delta index is deﬁned as the percent time occupied by waves of 7 cps or slower. The run of each selected lead combination was scanned, and 180 cm. (60 seconds) of recording that was artifact-free was noted. An additive map measure was run along the base of all waves of 7 cps or slower, determining the number of centi— meters occupied by such slow activity. The ratio of this ﬁgure to 180 was the delta index of that combination. ’ After these measurements were made, the rec— ord was scanned for the slowest frequency clearly The total record was also scanned for burst activity. The duration of burst activity, the regularity (modulation) of the waves in the burst, and average voltage were noted. In the ﬁnal estimates of degree of delta activity, the average delta index for the three lead corn— binations, the highest delta index in any one lead, the slowest frequency, highest delta voltage, and duration of longest period of burst activity were listed for each record. The 160 records were ar— ranged in sequence for each index and the per— centile rank determined. The ranks were added and the records then arranged in rank order ac.— cording to this score. On the basis that the higher score reﬂected a greater degree of delta activity, the upper third of the records was classiﬁed as “high—degree delta”; the middle third, as “moderate-degree delta,” and the lowest third, as “lowdegree delta.” An example of each is shown in Figures 1, 2, and 3, respectively. High—degree delta records were characterized by an average delta index of at least 18%, a delta index of 21% or more in one of the three measured leads, a slowest frequency of less than 3% cps, a highest delta voltage of more than 100pv, and a burst duration of at least two and a half slow waves. LF-LO WWWAWWWNIWW WWW RF'RO LAT- LPT WWWVWWW RAT-RPT WWW/WWW PRE-EL seconds. Low-degree delta records were characterized by an average delta index of less than 2%, a highest delta index in one lead of 3% or less, frequencies no slower than 5% cps, voltages of less than 60pv, and burst duration of less than one—half second. W “WW W W identiﬁed at least twice in these selected lead combinations, and for the highest voltage of these R P‘E AMNVWWWNVW L F _ LO «wanjVMImWW-ﬂm WMWMWMMW RF- RO awmwwm WW LC-LMT LC-LMT RC-RMT “WW RC-RMT LP-E WWW WW RP-E RP‘E WWWNAMMMMMWMW WWW WWW LAT' L PT LAT-LPT RAT-RPT PRE- ELECTROSHOCK ISECOND , 24 HOURS AFTER EST Fig. 1.—Low-degree delta activity. Fink—Kuhn I50 M, it l2 5-17 . ‘ WWW RAT-RPT WWW PRE-ELEC .maﬁ-” _,__._---_., __..-_t r-.- 518 �vs WWWWﬁ ., .v. h A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY LF LO WMWWWWWW WWWWWWWW LC-LMT WWW RC-RMT LP-E KEN-W LAT- LPT WWWWWNWWNWMNA W WWW»! I RAT RPT VWVWWNWWWWWWNwWV‘WWW/wm PRE-ELECTROSHOCK 24 HOURS SECOND 1:5on AFTER EST 4* IO Fig. 2.—Moderate-degree delta activity. L F “ LO WWEJVANWWWJWWWMk/‘W‘mgfaNJWW‘AMW R F - RO JVWMWWWWAW WWW LC'LMT RC-RMT LP-E WWW-”WW . RP-E WWW“ LAT- L PT WWW RAT-RPT PRE-EL ECTROSHOCK WW ISOMV WWW/meﬂwx 24 HOURS AFTER EST 4* M Fig. 3.—High-degree delta activity. 518 Vol. 78, N07J., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE I Moderate-degree delta records were between these two groups, with an average delta index between 2% and 18%, a highest delta index in one lead of 3% to 20%, a slowest frequency of 4-5 cps, high— est amplitude of between 60yv and 90,uv, and burst duration of one-half to two seconds. 2. In a second series, of 54 consecutive, unselected electroshock patients, electroencephalo— graphic records were obtained prior to treatment. during the second and third weeks of treatment, and two weeks after treatment. These records were analyzed using measures identical with those in the initial series. Using the original cut-off points, these records were classiﬁed as high-, moderate—, and low—degree—delta records, and the initial observations were tested in a predictive study of therapeutic response. Evaluation of Clinical Response—All patients were observed for at least eight weeks after termination of therapy. The patient’s response to electroshock was determined on the basis of the resident psychiatrist’s impression, the staff opinion, the nurse’s notes, and the clinical evaluation of the supervisor in charge of electroshock. The patients were divided into three groups—much improved, moderately improved, and unimproved—according to the following criteria: A. Much Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer presented the symptoms which brought them into the hospital; their doctors felt they were better, and the nurses’ notes conﬁrmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with others and participate in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but continued to manifest symptoms of mental illness. These patients typically showed symptomatic relief; i. e., acute depressive features might be gone, but the dramatic change, so evident in the ﬁrst group, was not apparent. Each patient continued to show some noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally or Unimproved: In this group were placed seven patients in whom change was not clearly noticeable, who showed equivocal or transient changes, or who became worse. They showed ﬂuctuations in behavior, at times appearing less ill. The changes were not sustained, however, so that by the end of treatment they appeared much as before. activity and clinical ratings demonstrated a signiﬁcant relationship between the early ap— pearance of high—degree delta activity and the “much-improved” clinical ratings. Of the records in patients who were rated as much improved, 80% were classiﬁed as high—de— gree delta in the second week, 91% in the third week, and 88% in the fourth week of treatment. Of the records in patients who were rated as unimproved, none showed high—degree delta in the second or third weeks of treatment, and only 20% were classiﬁed as high—degree delta in the fourth week. The data are expressed in Table 1 and graphically in Figure 4. TABLE 1.—Electroencephalographic Percentage of High-Degree Delta Records Degree of EEG Delta Activity and Clinical Ratings.——The initial analyses of the relation between the degree of induced delta F ink—Kahn 1. MUCH IMPRO +——Moo. IMPRO\ 50_ .---- UNIMPROVEI TIME A ‘13 A. 4‘“ PERCENT o: C? -.__~_ ,. m <.3 AVERAGE ...__.—_____.-._, c3 MEAN WAVES I50} .—- MUCH +——Moo. IMPROVI IMPROVI ---~ unmpnovso DELTA Treatment Period Much improved (11) OF 1-8 4—6 7—9 10—12 25 80 91 88 Moderately improved (6) 0 16 50 40 Unimproved (7) 0 O 0 20 IOOAv AMP(LITU)DE u- c.’ HIGHEST Indices and Clinical Ratings.——An analysis of the relation between each of the ﬁve indices used in the ﬁnal estimate of the degree of delta activity and the clinical ratings also show signiﬁcant correlations. In Figure 5A to E, each index is related to the number of convulsive treatments and the eventual therapeutic evaluation. The curves 2. Delta OOACTIVITY 90. 80- DELTA MUCH IMPROVED .—— M00. (III IMPROVE-10(6) ._-— UNIMPROVEDU) ‘ 70' 60‘ DEGREE 504 HIGH 40‘ 20I 0‘ o. O / '\. / 3O~ PERCENTAGE Results DELTA / I-3 / / ' / 4-6 __/' 7-9 NUMBER OF TREATMENTS MEAN L Fig. 5.—A-E, rt each index of delt: ' \\ /' / IO'IZ Fig. 4.—.Re1ation of clinical ratings to development of high—degree delta activity. 519 for the highest—am 5C) and the slow are most similar tc of delta activity ( The other three clearly differentia group from the p2 520 �/\ A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY f3 __J g . MUCH IMPROVEDUJ) IMPROVED (-6) 50_ pgmoo. o----UNIMPROVED(7) < 60’3 . w 2 40- E ,: PD 4 z as. 8 a: ling a: 30m a. aLu > ‘1 qz m 2 - lO- . _,e-’::.—// 0 "5' .V / U 3 :5 .J, Lu o a- //’ 53 a +— m u: I I9Z < g O 0 ________-_ . .......... _______ o 8 g 2 3 g 4§ E g. x «e —«' w D- W to 5 onZ I 4-6 ’ T 7-9 " IMPROVENS) .._.. UNIMPROVED(7) ' T IO-IZ ' -. ' —-—:—-—-"/ ,,«+ / / / {,x’ ”x” 5~ .t’ ----/’/ ,./ " /‘ ,xf “i3u Q (ll) MUCH IMPROVED o——MOD. Z 6-3 IL] +,.__._-,——‘ 0— 3- 6- a2 . 1—3 I 7-9 ----' C OK. 100- 50- ' 4—6 IO-‘IZ I50- ._Muc|-.1:|MPROVED(II) +——MOD. mpnovsom) ,_.- ummpaovso m 0 IL V" T I _. 7-9 A <>K //i1/ ------- °- -----MA’65... x 2 1m 5 NUMBER! OF TREATMENTS (I) . /// // i 2 . NUMBER OF TREATMENTS 4-6 1-3 3 ‘2 /+ ,, ........... ., -—-“"” ’4' , ‘ A -------2’ a: I l— // /" 20 o IMPROVED(II) 0--MO‘D. IMPROVED (6) °~--~U~NIMPROVED(7) LU p— {‘3 -— MUCH m D . o ‘‘‘‘‘ ———— -4ﬁ‘” 415 1-3 719 NUMBER OF TREATMENTS 7 r D I0--I2‘ NUMBER OF TREATMENTS B .9. g 7‘ 3a: 6‘ m n: lL , .9 ,r—e ' -— MUCH IMPROVED (u) +——MOD.IMPROVED(6) o----UN‘IMPROVEO(7) l0-l2 '\. I A .m 5.. 22 9 8 4— .— Fig. 5.—A-E, relation of clinical ratings to each index of delta activity. 33. 3: 3o V 3-. z a 2 2a l _ . I” +’/” //’ “““ ---------- o-""" .ﬁu‘idiﬁ“ , a _ O O ”_‘..—°V ° I ‘l ‘l l. l-3 4.96 7-9 IO‘IZ NUMBER OF TREATMENTS E for the highest—amplitudedelta activity (Fig. 5C) and the slowest frequency (Fig. 5D) are most similar to the curves for the degree of delta activity (Fig. 4). The other three indices (Fig. 5A, B, C) clearly differentiate the much improved group from the patients with the other two 520 ratings, but fail clearly to distinguish the moderate and unimproved groups. With in— creasing treatment, however, the separation of classes becomes clearer. Each index of delta activity, therefore, demonstrates a relation to the eventual short— term clinical rating which is much like that Val. 78, Nov., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE TABLE I i/ " . ” Average delta 2.—Interc0rrelati0ns of Individual I ndices and Degree of Delta Activity - - Average 63%qu Longest Dﬁﬁiéi‘é“ 350831153 +0.72 +0.67 +0.80 +0.72 +0.68 +0.84 —0.78 —0.47 -—0.90 Delta One Lead FkZVJSEEy Aﬁié’ﬁiie - +0.98 —0.79 _ Degree Highest delta in one lead +0.98 _ —0.67 Lowest frequency Highest amplitude —0.79 —0.67 __ +0.72 +0.72 —0.78 -- +0.57 +0.88 Longest duration bursts +0.67 +0.68 —0.47 +0.57 __ +0.63 Degree of delta activity +0.80 +0.84 —0.90 +0.88 +0.63 -- demonstrated for the combined index of de— gree of delta activity. The intercorrelations of each of these in— dices are shown in Table 2. All correlations are signiﬁcant at better than the 1% level of conﬁdence, although the highest correlations with the degree of delta activity are noted for the frequency and amplitude measures. The lowest correlations are noted for the duration} of burst activity. These observa— tions indiCater that in future studies or in clinical application frequency response and amplitude changes may serve as criteria for the degree of induced delta activity. 3. EEG Delta Activity as Index of Clinical Outcome—Following these observations, a study was undertaken to determine whether the degree of delta response was predictive of the short—term therapeutic outcome. On the basis of the observation that the much improved patients had developed high—degree delta activity early and had sustained such activity, electroencephalograms were obtained during the second and third weeks of treatment 011 54 consecutive electroshock patients. The records were scored as to whether high—degreedelta activity was achieved dur— ing both, one, or neither of the four—six and seven-nine treatment periods, and the data TABLE were Both high (18) 12 (67%) One high (16) 4 (25%) None high (20) 6 (30%) * (Table 3). Of the patients who manifested high—degree delta activity during the second and third weeks of treatment, 67% were rated as much improved, while only 30% of patients with- . 1 out high—degree delta activity were so rated. Thus, the early induction and persistence of high-degree delta activity are seen to be re— lated to the short—term clinical evaluation. Comment The present study demonstrates a con— sistent relationship between the degree and duration of induced electroencephalographic delta activity and clinical evaluation of behavioral change. While it is conceivable that the difference between our results and previous reports may be due to a variation in population, it is more likely that methodo— logical aspects are important factors. Serial records were obtained during the course of therapy, so that the sequence of electro encephalographic change was evident. The records were obtained at a constant time in— terval following a treatment. Finally, quantitative analyses of the records were made instead of relying on clinical impressions. Of other investigators of this problem, both Moderately Improved 2 (11%) 8 (50%) 4 (25%) 7 (35%) 7 T ship between ind havioral respor therefore, perm changes in the o attendant alterat the physiologic process.* A simil. by Roth 23 on the *The Unimproved 4 (22%) ac’tivity.18’21’22 we. biochemical received limited stu on acetylcholine-chi tion in blood—brain and protein equilibri without deﬁnitive C( (35%) Signiﬁcant at the 2% level of conﬁdence. Fink—Kuhn the induced neu1 behavioral respoi these observation of action of elect 1. Relation ofi Behavior.—Beha accompaniment function. Chang tude, judgment, and insight atten tion, from what extensively docu literature. In this study, e consistently to alt in a fashion whic with states of altc studies of Davis Strauss,19 Ostow have afﬁrmed the activity as an in< tion. Symmetric, has been interpre tion of midline centrencephalic s also indicative oi of consciousness being directly rel: tude, and freqi related to the clinical evaluations. Clinical Rating Much Improved 21 further elaboratii 3.—Patients with High-Delta Activity During Second and Third Weeks of Treatment* EEG Delta Roth 2 and Hoa out systematic E to demonstrate variables and be] Two aspects oi 521 522 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY Roth 2 and Hoagland et al.,16 who carried out systematic EEG analyses, were also able to demonstrate a relationship between EEG variables and behavioral changes. Two aspects of these observations warrant further elaboration: the relation and role of the induced neurophysiologic change to the behavioral response, and the signiﬁcance of these observations for a theory of the mode of action of electroshock therapy. 1. Relation of Neurophysiologic Change to Behavior.—Behavioral change is a consistent accompaniment of alteration in cerebral function. Changes in mood, language, atti— tude, judgment, thought process, perception, and insight attend changes in cerebral function, from whatever cause, and-- have been extensively documented in the neurologic literature. In this study, electroshock has been shown consistently to alter the electroencephalogram' in a fashion which we have come to associate with states of altered cerebral function. The studies of Davis and Davis,18 Ostow and Strauss,19 Ostow and Ostow,2‘0 and Jung 21 have afﬁrmed the signiﬁcance of diffuse delta activity as an index of altered brain func— tion. Symmetric, dysrhythmic delta activity has been interpreted as evidence of dysfunc— tion of midline hypothalamic centers—the centrencephalic system?9 Such activity is also indicative of an alteration in the state of consciousness, more marked alteration being directly related to the duration, ampli— tude, and frequency of the slow—wave activity.18'21’22 The demonstrated relation— ship between induced delta activity and beafter electroshock, havioral response the conclusion that therefore, permits in the centrencephalic system with changes attendant alteration in consciousness are the physiologic basis of the electroshock process."< A similar conclusion was presented by Roth 23 on the basis of his studies of the *The biochemical substrate of this process has received limited study. Emphasis, has been placed on acetylcho-line-cholinesterase change,”25 altera— tion in blood-brain barrier,8 and changes in ionic and protein equilibria 26"” by different investigators, without deﬁnitive conclusions. 522 effect of thiopental on electroencephalo— graphic delta activity. Another example of the relation of the electroencephalographic delta activity to be— havior is seen in reports of epileptic patients. Landolt 28,29 describes a young epileptic who was ordinarily pleasant, friendly, and cooperative for his clinic visits. At these times, records were consistently dsyrhythmic. On one occasion he was surly, irritable, and withdrawn, and his EEG was without delta activity. On the subsequent visit, the EEG was again dysrhythmic, and a behavioral “improvement” was noted. Similar observations have been reported by Brockman .et £11.30 and Fabing.31 In a previous study4 we had applied the amobarbital test for brain disease 32 in a serial fashion to this group of patients and reported a relationship between changes in this index of cerebral function and be— havioral change. Were other tests of cerebral function to be applied in a similar fashion, it is anticipated that these, too, would demon— strate consistent changes during treatment and a relation to behavioral response, within the limits of the sensitivity of the test to reﬂect changes in cerebral function. In this context, electroshock may be said to be a method of inducing a state of altered brain function for extended periods, in order to achieve changes in behavior. From this point of view, the development of a signiﬁcant degree of electroencephalo— graphic delta activity may be a readily determined guide in the rational management of electroshock therapy. In these studies we have examined various delta indices and/or the intercorrelations and have noted that the amplitude and the frequency of the induced slow waves are the best guide to the degree of delta'activity. In patients in whom the behavioral response to electroshock is inconsistent with the therapeutic expectation, examination of the electroencephalogram may provide a criterion for clariﬁcation. If the induced slow—wave activity is faster than 4 cps and lower than 100,u.v in anterior temporal—ear lobe or anterior temporal— frontal lead combinations, then there is Vol. 78, Nata; 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE presumptive evidence of inadequate electro— shock therapy. When frequencies less than 3% cps and voltages higher than lOOuv are maintained for a number of weeks, the assumption may be made that an adequate degree of altered brain function had been induced and that other factors (environ— mental, personality, pathophysiologic) were operating to preclude a favorable behavioral response to electroshock. A similar applica— tion can be made for amobarbital tests 4 or syntactic language after intravenous amobarbital.6 2. Theory of Electroshock Action—These studies of the electroshock process have demonstrated that alteration in brain func— tion is induced early and is sustained in patients in whom the greatest degree of behavioral change is noted. We have em— phasized high—degree EEG delta activity and positive amobarbital tests as indices of altered cerebral function, with the knowledge that other indices of altered brain function, applied in the same serial fashion, may also show signiﬁcant alterations and a relation to behavioral change. We have been impressed that the ratings of improvement are value judgments of the behavioral response. All patients in whom cerebral changes are induced by electroshock manifest changes in behavior. The range of behavioral patterns induced under these conditions is wide. Only certain patterns are evaluated as improved, however, while others are regarded as “unimproved.” “Improvement” is a special case of behavioral response, being a subjective evaluation on the part of the observer that the patient is “better.” Electroshock does not induce “improvement”; it induces a milieu of cerebral activity in which behavior is different than before electroshock. To the extent that the induced behavior in depressed patients is perceived as less complaining, depressed, agitated, or anxious, or in schizophrenic patients as less delusional, hallucinatory, or excited, the patient is evaluated as “im— proved.” When behavior, however, is per— ceived as anxious, agitated, paranoid, complaining, or withdrawn, it is evaluated Fink—Kahn as “unimproved.” The particular type of behavioral pattern induced by electroshock is dependent on a number of factors, such as personality.33 Another aspect of the rating of improvement is the environmental response to the induced behavior. The modiﬁcation of mutism, withdrawal, and negativism to excitement, overactivity, and irritability may be considered a positive movement by the therapist but a disorganization by the ward physician or family. The goals of the therapist and the family, and their expectations and tolerances, are signiﬁcant factors in the behavioral response of the patient to therapy, and, also, in the ratings of improve— ment. These same factors are signiﬁcant in the duration of the electroshock effect. The in— duced change in cerebral function persists for only two to eight weeks following even intensive courses of therapy. In many cases, the behavioral response is limited to this period of altered brain physiology. When in— duced changes in behavior are not adaptive in the milieu of the patient, the behavior reverts to pretreatment patterns. In other instances, the induced behavior is adaptive to the environment, and, we assume, sus— tained thereafter not by the initial change in brain function but by the newly developed interaction of ‘the subject with environment. That this is indeed true is seen by the fre— quent successful adaptation of the patient to the hospital milieu after electroshock, only to have a recurrence of symptoms when dis— charge planning is discussed or discharge is consummated. Altered brain function provides the physiologic milieu in which there is an altered interaction with the en— vironment—the doctor, family, or society. These observations lead to the conclusion that electroshock therapy is a nonspeciﬁc induction of persistent states of altered cerebral function. Such altered cerebral function provides the physiologic milieu for an alteration of the organism’s adaptive interpersonal behavior. Changes are in— duced in perception, language, mood, recall, and judgment which constitute a mode of 523 interaction with of behavior indu is dependent up subject, the envii action occurs, an of altered cerebrz A similar View was initially exp and Kahn,1 who tionship of neu: behavioral respor electroshock pr0( the observations Aird et al.3 The neurophys tion of electrosh( deﬁnition of the of further elabor: a hypothesis also standing of ther coma therapy, 1( agents. j Summary Serial electroe: weekly intervals referred for elect analyzed for the A signiﬁcant tween the degrec delta activity an( behavioral chang ﬁrmed in a predi 54 patients. Differences bi those obtained It terms of differen A neurophysi tion of the electrt It is concluded t] speciﬁc inductio: altered cerebral physiologic miliei tive interpersona Improvement as a special case c these conditions. by an observer factors, including 1 r' 524 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY interaction with the environment. The type of behavior induced under these conditions is dependent upon the personality of the subject, the environment in which the inter— action occurs, and the duration of the state of altered cerebral function. A similar view of the electroshock process was initially expressed by Weinstein, Linn, and Kahn,1 who emphasized the interrela— tionship of neurophysiologic changes and behavioral response. This description of the electroshock process is also consistent with the observations of Ulett et al.,34 Roth,2 and Aird et al.3 The neurophysiologic—adaptive interpreta— tion of electroshock provides an operational deﬁnition of the process, which has promise of further elaboration and observation. Such a hypothesis also has application to an under— standing of therapeutic process in insulin coma therapy, lobotomy, and tranquilizing agents. Summary and Conclusions Serial electroencephalograms obtained at weekly intervals in 24 consecutive patients referred for electroshock were quantitatively analyzed for the degree of delta activity. A signiﬁcant relationship was found be— tween the degree and duration of induced delta activity and the clinical evaluation of behavioral change. The results were conﬁrmed in a predictive study in an additional 54 patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A neurophysiologic-adaptive interpreta— tion of the electroshock process is presented. It is concluded that electroshock is the non— speciﬁc induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after electroshock is seen as a special case of behavioral response under these conditions. The rating is an evaluation by an observer depending on numerous factors, including the type of adaptation, the 524 and expectation of the observer (therapist, family, or administrator), and the setting in which the behavior occurs. goal Mrs. Helen Donovan, Miss Gayle Wankel, and Mrs. Hannah Mosquera gave technical assistance in this study. Hillside Hospital. REFERENCES l. Weinstein, E. A.; Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat. 109 :22-26, 1952. 2. Roth, M.: Changes in the EEG Under Bar— biturate Anaesthesia Produced by Electro—Coxnvulsive Treatment and Their Signiﬁcance for the Theory of ECT Action, Electroencephalog. & Clin. Neurophysiol 3 :2612-80, 1951. _ 3. Aird, R. B.; Strait, L. A.; Pace, A] W.; Hrenoff, M K. and Bowditch, S C.: Neurophysiologic Effects of Electrically Induced Con— vulsions, A. M. A. Arch Neurol. & Psychiatl- 75: 3371—3781956. 4. Kahn, R.L ; Fink, M., and Weinstein,,E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A. M. A. Arch. Neurol. & Psychiat. 76 :23—29, 1956. 5. Korin, H.; Fink, M, and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁnia neurol. 16: 88-96,1956. 6. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communications, edited by P. H. Hoch and I. Zubin, New York, Grune & Stratton, Inc., 1956. 7. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electro— shock, Electroencephalbgi&-Clin. Neurophysiol. 8: (abstract), 158 1956. Pacella, B. L.; Barrera, E. S., and Kalinowsky, L.: Variations in the'Electroencephalogram Associated with Electric Shock Therapy in Pa— tients with Mental Disorders, Arch. Neurol. & Psychiat. 47:367-384, 1942. 9. Proctor, L. D., and Goodwin, J. E.: Clinical and Electrophysiological Observations Following Electroshock, Am. J. Psychiat. 101:797-800, 1945. 10. Bagchi, B. K.; Howell, R. W., and Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders, Am. J. Psychiat. 8. 102 :49-61, 1945. Levy, N. A.; Serota, H. M., and Grinker, R.: Disturbances in Brain Function Following 11. R. Convulsive Shock Therapy, Arch. Neurol. & Psychiat. 47 :1009-1027, 1942. 12. Mosovich, A., and Katzenelbogen, S.: Elec— troshock Therapy, Clinical and ElectroencephaloVol. 78, N00,, 1957 ��mum m 3%: «u mmwgmwzum,mm muJ.MiMMﬁW3MhWW m if mwmum. “ w. Mr maummwmmmmmd W. mam. mm W. ‘ ��Wﬁmmmamhmmuwmmuw (mﬁmumlmwmmumwmm MQ}WW#WWWMWW W“Nmmmuwmﬁummxmwmmmmm Wan. 'meummmmm-umm m MW‘Mﬂqumemmuw-ua MW“ ' “- MWWW manna a) mxmmmmmmmwmm ��I ‘1“ A— �Wgwmmwmg MWMﬂmmmgw MWmmtmmum4h mwmm. wmmamm.mwm«mm* ��. v ,9 M» ﬂ..V 4%5.. ��..: 3 0%» .4 4L, “.4 .:‘ ».:4, J ��«ﬂit WWMM. m twmnmmmm ��.14. u J, wring >,R �‘ ’ ,. "M :jﬁ" W; Walt ��W W M“ WWW!» mu?Wmmm mm: at W mm: in. {1. a» a) mum at *1?" mm in W WW; W m m at ��77 was“W r I €25” 0551: (”n-hum or Inn-I 4 -5«-r.:.5“......”"55. {/7 m mu “$17115: to Word mm. in Whack: wants." Serum. Studies . "v a» 5, g an m HDandRoborbL ma. 3.5.5» I: M. ' ﬂ at mammal WW; Hillside Hospital, 01m Oaks, truths Want. lbw but. Aid-d, m m by gum. 14-927. mama mum. at Kent-.1 Health, mum). of ﬁnd/m, v.3. mm Health San-1a.; and the mm mem mum for Mad. Ragnar-9h, nWJa-rlcM mt: , of mammeephalcmphoro, Won, Present!!! aththe mum Duct, WWI} 1955. m: M57» ‘ ' . ' “mm .— ; �Relation 5?? -.._.. a: _ Meet w {Mari-ea m, Delta Activiw to More}. mm in Wanna: antiutive Serial Studies; a: electroshock therapy m ( 1, 2,. 3) have emphasized the rule of neurophysiologic changes as the basis for the therapeutic .1 . mutant with these ,L theories, we have observed auction of a mutual: bum changes a: new means of brain function and behavioral name. We have noted an... $73 WW 40 electmsheek/‘aﬁ- changes in orientation embarbital (2;), flaming and <6) . null and clinical hpmment following cmfabuletion after 111th (Shana syntactical aspects at ' 1% In view of these observations it. could be expected that. electroencephala ogrephie shudiee mld report-ad inﬂamed relationship. Nmaerous observers have eminent changes in the electmeneephelogm utter eleetzically Mime. rhyﬁMc em 1 similar utivity There 18 6.1.th9 slewing with increased voltage and dye. (7 ~ 12). Feet percent—tum (13), and utivity decreases, both in voltage and in in patients we are intensively trauma, there is e naming of persistent alpha frequmcies (1h). The degree, mum and extent or éelte amenity is directly rented to the r'nquemy and amber of grand ml I Wane (8 -- 11;). Such activity is usually swede, appears maximal effects usually disappear 1:1meme in anterior leads, and the in ma mks renewing the 1m treatment-,3. 9). In contrast to the comiateney or them observations, studies of the relationship between the elmtmmephelogrephie and the dilated conflicting menus. ohmic: and mean: (15). after an mag” show mun review of the literature, £9011ch that the amber er treatments rather then the degree of named delta. activity we: the primry factor pantie response. 011 the other hand, rented to a fwomble there- 21qu 93 g}; (16) :0pr a relation how changes in the percent time feet eetivity (more than 13 cps) and ��.4... In the rim]. estimates or degree of deli: activity, the average delta index for the 3 load oombimtiono, the highest 3011:: index in any one load, the ulwest frequency, Most delta. voltago and out-aunt: of longest period of burst activity was listed for each macro. The 160 noorda were mangod in aoquemo for one): index and the percentile ram: dotemined. The ranks wen oddod and the the ﬂoor!!! than Imnged in rank order awarding to this score. a: that the higher score refloctod a. grotto; agree of delta activity, the upper third of the mom were classified as “high dogma the middle mm 58 "mm. degree delta“ and the lowest third as ﬁlm dogmo‘ “main dolu:~, delta? . ohmotorizod by an ﬂange delta index delta 1mm of ‘2135 armors in one o! the three High degree «sum record- wore of at. least. 18%; a mound 1m; voltage mm second», w slam“ frequency of loss than m madman; m: a Inn-at. 3 3/1; ops; highest mu mum of u least 2 1/2 ‘ Low degree dorm noords was characterised by an loss than 2%; slower than S meat. delta 1m in one lead of 1/2 ops; volt-.93 loss than 60 loss than 1/2 nomad. ’Hodornto degree delta groups with an 60-80 20%; Mormons; and 31m“ from Inn-at indoor or or 1am mquanom no naming and burst duration 3% room-do won Minoan ”lose two mugs delta index between 2% and 18%; no load of 3 to mugo delta ‘ mm ﬁnite 3mm in of h-S cpl; highest amplimdo bemoan duration of 1/2 to 2 seconds. fiftyafour omomtivo, unselected electroshock patients, oloctmonooplulogmphic records worn obtained prior to trustmne, during the We! and third weeks of treatment, and tam weeks after 13) In a. second aortas of mama‘s. mesa rooonin were mlyud using: the identical moms as in the initial ��W degree the” %%Ru.® was WW3 to datamine whether the at delta response was Mauve of the short bum theramutic cum. m the baéis of thﬁ observation that the much improved panama had dweloped high dtgrae delta #ctivity unﬁt-1y and had. sustained such activity, chew mamalogms ware obtained tinting; the second and third weak: of mutant in pltiants. The records- were Scored as ta whether high degree dolta actiut‘y was acldwed timing; both, on: or with: of the h—é and 7.9 treatmnt pariah, the data was muted to the clinical evaluatimm (Table III). Sh eonsecutiva electroshock and mm III ' ‘ EEG man Delta. _ (18) Both High One mgr; .. “Home High (16) (20) f who pntienta without. mm W 2 (113) 12 (67%) h (225‘) u (292:) a (sex) h (25;) 6 (30%) 7 (35%) 7 (355) // anwx‘uaummm,m M down delta activity?» rated. M, the surly 1n- ducbion and persisteme of mg; dogma delta the short mm. clinical 4» Moderatelx manifest high degree delta activity during tha second and onlgrBOSof attainment. or the patients 'mm - ma activity is seen to be related multim Meant at the m1 of cmm. 2% to_ ��J We “WWW“ 1111111111: delta activity has m integrate as evidence of dysfunction at manna centers {mtmmphmc systoml (19) . mpothalandc and Such activity is also indicatim of an alteratim in the cuts of consciousness, with more marked alteration being directly related to this duration, mum. activity (If, 21, 22). me dmstmted roala‘bianchip between induced delta activity and behavioral response after electric and tmquency of the slow wave hint- conclucion that. changes shock, themfom , permits the cephnlic 3513mm with attondant. alteration in conscimmnesa basis of the electroshock pmccas. m the basic cf his stwiea of the Another example of the behavior is tut-h seen £81 ~11 A ‘ 11.:1‘rect . M of me b visits. cooperativefar hie 01.111111 MW”. occaa11m be was 1153110111; mic 9.1213 :1 ported by we delta activity, belmvioral On At. an WW $133114. (23) '1'?—“1/1'54"? W 55130) reports of epileptic patients. Landon ordimrlly pleasant, fﬁendly and them times, records the subsequent and 118 warn mimuy unit, Similar was mated. ram 111111 the EEG was again ﬁgsrhyth- obaomtionaﬁ ﬁre?” (31). applied the Maximal test 101» brain h nthembml serial fashian to this group of patients, and reporwd a mlatiomhip between changes in this index fwtion and behavioral changci. Herc Other tests of ccmbml {metion to be applied in a disease (32) an a 31:13:: 331131 fashion, 11'. is anticipated that thou, tab, would demonstrate bicchmcal substrate of this process has received 11mm: cm placed 011 acctyldlommholineatemse changes (2 ) (25), W818 has1nbean blooMrain barrier (3) and chasm in ionic and pmtoin nautical (£6) (2{) diffcmnt by aquilibria investigators, witho 1t definitive: con- it The 13111810113 . m surly, inﬂame and withdrawn, and his 1% ”13111101791331” In a prcvionl atudy (h) wwé‘gm relation Iof clactmcnceﬁulograpmc delta to (28) (29) describes a young synaptic: who was 011 the Gem-im- % the pigsiclcgic mansion similar 3.11 ��«18‘ {gnawing mu intents.“ name is courses of therapy. In limited to this 40f ,peziari many cases, the behavioral altemé! brain phys‘iolégz'f. When induued in behavior are net. aﬁaptive in ﬁhe mien of the patient, £16: behavior be pwmamm patterns. In cther instances, the induced behavior is Idaptive to the environment, and, we assume, sustained thereaﬁer not. by the changes" mm in brain function, but by the newly dmleed interaction at M2 subject with envirmmnt. Theft. miss is indeed true is sea: by the fremwnt suscaasm adamuon at the patient to we hospital milieu after electroshock. initial only change to We a marten-ea of symptoms when discharge planning is discussed or is mummied. Altered brag». function provides the Manage Mm: in which there is an altered hibernation with the environment -- the diIcharge doctor, famﬁly er society. I These ’ obm’cim lead to the canclusion that electroahack tirxerapy ﬂﬁmum Such Wyenﬁfic induction of persistent states of altered altemd mm; hid. rum um provides the physiologic milieu for m: altera- a -' tion of the organism‘: adaptygtexfgersoml behavior. in pemwp’oion. “a Changes WW3,W, mé‘m, and MW: which Max-scum with the ‘mirmn‘o. Mead ms:- than oonditim is deg-3mm I is The type of upon are induced m constitute 31 new behavior the personality of the 813123“, the environment in which the interaction occurs, and the duration of the stat. cf altered cerebral function. A similar View of the electroahock pmeesa ﬁas initiélly expressed by rm and Kuhn Heimtein, Minibar: (1), who mﬁmaized the interrelationship of changes and behavioral msponse. This doseription of ma shock pmoess is also consistent with the observatians of Ulett Roth (2) and Aird (3). 533 new electro- $3; (31:): gig}. Th5 meioloMptim Mode. interpretation of electmmock pmviaiea m mutational definition of the pmaaa uhie‘n has promiaa of further 3mm ' 49’ �“on and wax-mum. _ Such a. a; Wilma ‘ standing of therapeutic procesa in quillizing agents. . also has appliuticn to 1mm coma therapy, lobobono' an man». ané tran- �«is. J ‘ , ‘ 1. Serial aloutmmoyhnlogmma Waive W ohm!“ at many intervals in patients Mama! for electroshock were quantitatively for the degree of delta activity. ’ 2. 215 W aimifioant relationahip was found between the degree and aux-aﬂoat of induced delta activity and clinical ”elation of behavioral change. The results wen: confirmed in a meditative study in an additional 51: patients. A 3. Diffemnooa between them results and mono obtain-d by others are explained in toms of differences in m'modolow. h. A mmphyeiologic use is presented. It is duction - adaptive interpretation: of the elootmshock pro» concluded that electroshock is the non-Specific in- pomatantvatatea of altereri cerebral function, providing the ogic 31113:; in inch changes in adaptive interpersonal batman: occur. oi". 3. laymen)“. maponz—ze afar abotroshoch is under those conditions. " The seen u at 81300131 case of #133191“ botanical rating in an evolution by an observer (lemming on numerous faahora, including the type of adaptation. the goal and expectation of the observer (therapist, family or sminiatrator), ting in which the behavior mm. and the set- �4-43.6- Acknﬂedgemnt : We wish to Ranks]. and m. 31pm: our asppreciation to Mrs. Hahn Ewan, Miss Gayle Hannah fer their mammal assistance in this study. Wm �~17».- 1. Weimtein, E.A., Ling max-spy: Psychiat., z. MW 13., and Kuhn, R. .2 Psychosis During Its Rahtion ta the Log: 22.26, 1952. "zeory of Elan-maxed: J. Shank Thempy, Am. ‘ ' Bui‘biturato Anesthesia Produced by Changes in the m:m, wmm: Electra-convulsive Wmt and Their Significamo for the Theory EEG » act Action, Em. (315.11. Neurophys" 33 261-280, 1951. 3. Aim, R.B., Strait, LA" Pace, Jﬁ'q Hemoff, 14.x. ind Witch, 5.0.: of ﬁe‘grophysialmc Effec'ta of Electrically Induced Gomulsions, Adidmam. a: Paychiat” 15.: 371-678, 1956. Arch. a; 3.5.: Relation a: mom-banal Test to Clinical Imgmemnt in mctmmack, AJLA. Arch. Neurol. Kahn, 3.1,... Pink, 5:. and Heinatein, 2;; chum... 163 23.29, 1956. S. Hg Fink, aR'Z'Efrim, M. to Legging 19 1o 6. Kahn, 3.1.. and Fink Wt and Fur-- 8.: Relation of Changes in Mmery and Nasser, in Electmahmk, Cont. Mauro]... ya: rm; Changes in 8M6, Language During Electmshoek Therapy, in “PSy‘chopathangy of Cmmication," Trumaaticns Amr. Psychopaﬂml. Lame” 1955, Gram: Stmttan, Raw York. 7. an», m. ané Hahn, Ram Quantimm Studies of Slaw wave Activity Faun£2 Elactmshock, 8. 1236.. 63.111. Haumpkys" Q: 1538 (Ethan), 1956. 13.1." Barrera, 31.8. ant-3 Kalinowslgr, 2...: Variations in the Elect» encephalogm Maociateé with Electric: Shack Theta: in Patients with ﬁen’oal Eiisordern, Arch. neural. {é Psychiat” :1: 367-681;, 192:2. 9. Metar, Id)... and Goodwin, J.E.: Clinicnl and EleuhroMiologioal Observation! Following mammhmk, Am. J. Psychiat., 391.: $7.800, 1925.. 33336113., ' 3-“ 10. Bagahi, ' '11. My, 3.211., Ewell, 3.33., and Somalia, 8.1.: The Electreencepmlegrarphia Clinical Effecta of Elegtrically Induaegi Comnlsicms in the reament of Mental Disorders, Am. J. Paychiam, gag: 1&9~é1, 1915. HA... Beret... Km” and Grinker, R. Ru Disturbances in 3min Function I“ ComlsiVe Shock ’Faerapj. Arch. fieurol. Pay1914-2a MI 10094027, plain.” cum 12. Hamish A" and Katzenelbgen; 3.: Electmshock themm, 51mm. and 517'éacti‘oﬁgcehhalogmphic isms-Ems) J. Harv. ‘I Mani... Dis... 39, 9 we» m: ‘ 13. 24A. and “111mm 3.13.: Significance of Changes in Elect. mm, alogram Zhsults from Shock "therapy. J. chiat" 105 ,' 'va'hicit: 11045, 19%. Am. PB ��’19.. 29.’ Landau, Ru Uber )9 undw Vemer-‘mm W:- fur zguatwdsbilder be: PW3hmm$g 1?} 313‘331’ a 1mm,I' 19%50 schizophmxe Neurologio mu! Goo. 918178, W”, Related Type of TrutG.A.: to Thaw ‘3erE} 97-10%a1956. mnt, Confinia neurologica, 30» Bm:m,.ﬁoJo Bmcm, 31.. Ming, IL: Personal cmmication, .3:»:. Veins’oein, ‘EJ... Kuhn, 1m... Sugaxman, Ink. and 1mm; 1“: The Diagmstic Use of murbital "Sedan (”Am-tel sodium“) in Brain Disease, Am. J. Psychiat" ngﬁsws’h, 1953. ngaa 1n JOC.’ Jaebbsm’ 1956. $16: U... ' Pemmuty raetor‘a 1n mum: Psapmae to m,a.s hilactroahock Tharapy, Gent. Kennel. (in prose). Kahn, R.L. and 833%, 8A., Smith, K. and thconvulsive 6 ham, (3.6.: Evaluation of Convulsive and Shock Therapies W‘.’ at 79m, 1956. Utiliniqg 2., Control. Group, Am. J. �~20- 136mm m 1. Lou Dogma Delta Activity . m Figure 1.1. Moderate Dogma Delta Activity “M 3.11. High Degree Delta Activity Figum 1?. Relation of Clinical Ratings to Development of High Degree Delta Activity. Figure v.0. - 6) Ralation Clinical Ratings to Delta Activity. (11' ill-Ia EAL-k M Index of �12.5553" ’53?! $3.4 vii. ‘ '3 �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263m: STREET GLEN OAKS. N. Y. Flaws-ran: 3-7800 s. A. MILLER. M. D. MEDICAL DIRECTOR JOSEPH MAURICE BAC‘HRIACH ADMINISTRATOR SHRON KWALWASSER- M. D. ASSOC. 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Kiwﬁ’ H. Ea: ”P19163336. 1113111111 $193k dimm.“ Shaﬁkdu VMO Gottlieb, J.S., Ashby, PLO", and Kimble; L.L.:'mamamlogi¢ study of schimphn min and depressim. IV. Ina fluence of electriu cenmlaiva them on, the aodium mm]. reapmua of the saleabmencephalcgrm.‘ Am. J. Psychiat. 10 : 6869696§ 1958:: » Harris, Roma, W.A.:"ﬁsa of cur-are in mtraxol mnmlaant timer: with 15 3 5376 £1 19111“ observations.” maniatric Land 2mm, and Panama, E. Wt electmencephalograﬁxiu England, Hr, whim, Mum, and Cinema, D.E.: " me electroencephalogram hypoglycemia and recovery." 7 J" Wigton, Hughes, Arena Neural. Ward, Am. 13., and at 13816111312. 14.11., and Rims, Jardon, F.:“Electmencephalogmphie studies on patimam meshing electm~shoek mamnt.” 19141. “SWiamm of L.F.: «hmgas in thy alecmenecphu ﬂagram whichmsult from Each, ‘1'. 0., and autumn, Ed 251.13.. Arch. Neural. MO “The other effact of benmdrine and @2th ant: upon the (21mm Shank) EEGJIi'amatiun Pmc. 5:62“ 12%,. 8mm, mm, and Grinkar, 12.3.: Diaturbanaea in brain pastconvulsiw Levy, therapy." 53: shew}: W. ehiatu 50f 53§¥537g 12h3 8: 1mm, mm, 1' Payehnt. & m; J; Haul, B; H0; of schizophrenics curing insulin 1202 559‘5791 3.9;}; Gottlieb, J.S.: ”Chang” in. the eleetmeneephalogrm renewing insulin shack therapy." Neural. and Page and «1.12., J. $1131.01. as: ﬁgumg _ Jg.P§Fdhiﬂta 105‘,h0*h53 19h5v Knott, , mum reﬂuxing wnmlsiw shack mummy.” 1:7: 1009402“: 192:2. Go»; Wu, { G; Rn, Pma‘bor, IN Dr; and 600%, J“ E03 "Parallel psychologisal, psychiatria and Whalesinn). findings: in sahimphmnie patieats undar insulin ahcmk treatment." Am. J... Psychiatr.» 933 1422-4129. 121:1... lbriaﬁy, LB... and Siam, 573 112*.»718‘ 1913!. maevich, A" nut. and, shoal: therapy.” Arch. Neural. g mint. Katzenelogen, 8.x “meatmslmck therapy, alibical and 10?: 517620. , J. 0.: “Ehctmmeemalogmphm study of electria 1214 8. encephalograpmga studiem J. 03.ch ant... Mex-v. 5: �«2. Pacena, B. Bax-rm, S. W" and Kalinawaw, I“: I“, elwtzic‘ shank therapy or ?: Hawk 1122 . V498— ’ ” Variatim in the 319nm.811661312310ng assaeiated with patina with mm mm". , 60 m .9341“; is _ _’ N. . Wt. . ; 13m. and Goodwin, v1.8.3 tit)” mm ‘. andﬁliactmuﬂxyaiologiaal churnefanwm aleﬂmﬂhgakc M». J. ngaik‘bt :“x ilk H‘ \ Ibsen, 8. R5, Samaria, L., and Finlay, P3192» 11 (315.113.1331 101: 79%3094L 19kg; 111nm. ' J. 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Jﬂm '2 ’1 wri-ryn 334/ m ; "‘ “ :~ <- W V 3K3»: -;M " HJWAM �Levy, N.A. and Grinker, and 8.3., ”Electroencephalogranhic and ElectriC9llylln- Clinical Studies Following Metrazol . duced Convulsime herany of Affective Disorders", Archives of Neurology and Psychiatryh7, 19h2. 1009-1099. L., "Variations Pacella, g. L., Barrera,.3. E,, and Kalinowsky, Electroshock Therany with Associated ~in El’ectroencenhaloggram Archives of Neurology Disorders." Mental of Patients with and Psychiatry A7, 19h2, pp. 367-38hk Sﬂnon, A., Yeager, C.L., and Bowman, K. 5., "Studies in Electronarcosis Therapy IV EEG Investigationsﬂ' J. Nerv.and Mental' Dis., 118, on. 131-1M33 "Clinical and Electrophvsiological 3.. Following ileotroshock". Am. J. Psych. 101, Proctor, D., and Goodwind, Observations laué, pp. 7a7-8a0. of Electricéghock TreatKarliner, W.,A "Neurolowic Comnlications review." J. of Nerv. and Mental Dis. 107, on. 1-10. ments: Rosen, A. R,, Secunda, L., and Finley, K. H., "Conservative In— Mental ' of Shock Therapy in Illness, Tracings Before, Electroenoenhalographic of cluding Study Therapy". Quarterly r"sychiatric and After ghack , During Approach 17, 19h3, to Use pp.6l7-6hl. Turner, W.J., Lowinger, Lg, and_Huddleson, J. 3., "The Correlation of Pro Electroshock Electroencephalogram and Theraneutic Results in Schizonhrenics? Amer. J. of Psych. 102, lghg, I ﬁa+41?1 r8}+d*uw~ CZ-2§ (hﬁwt lqﬁi ; :ryfugzo a9m~ﬂ¢3 _ _ ”—4“; «-4 �’5? [Evy—q“ .. x“. 7v , “aw—.77“ . ...,-._:$.. .1 , . fa?" Em: E». \‘a H :1 . .7 . , . . 1 ”way"- ,7 m ”V. '55: A“: - . Pup-<12: ‘ F.» 7“" ,s-n , Bagchi, B. K., Howell, R. W., and Schmale, H.T.: "The electroencephalographic clinical effects of elecmental disorders."Am. J. Psychiat. of treatment trically induced convulsions in the and 102: A9-61, 19A5. Barrera, S. E., and Pacella, B. L.: findings associated.with electric Shock therapy in patients with mental disorders." "EEG J. Physiol. 133.: 206,71951. Goldfarb, W., Laughlin, J. M., and Kiene, American H. E.:."Prolonged.insulin shock." Am. J. Psychiat. 101: 827, l9h5. Ashby, M.C., and Kinble, L.L.:"Pharmaoologic study of schizophrenia and depression. IV. Insodium the amytal response of the electfluence of electric convulsive therapy on 10h: l9h8. Am. 686-696, J. Psychiat. roencephalogram." Gottlieb, J.b., of curare in metrazol convulsant théerapy with electroencephalographic observations." Psychiatric Quart. 15: 537—5h3, 19h1. Hoagland, H., Rubin, M.A., and Cameron, D.E.: ” The electroencephalograms of schizophrenics during insulin 120: 559-570, 1937. Am. J. Physiol. hypoglycemia and recovery." Harris, M.M., and B. L.and Horwitz,‘w.A.:"Hse Pacella, 7 ‘ Wigton, R., and Jardon, F.:"Electroencephalographic studies on pat— J., Hughes, Arch. Neurol.& Psychiat. us: _ 7h8—7h9, ients receiving electro-shock treatment." l9hl. Kennard, M.A., and Nims, L.F.: "Significance of changes in the electroenceph- J. Psychiat. l9h8. 105: Ao—AS, alogram whichresult from.shock therapy." "'Am.“ Knott, J.R., and Gottlieb, J.S.: "Changes in the electroencephalogram following insulin shock therapy." Arch. Neurol. and P532 chiat. 50: 535-537, l9h3 a. Lennox, M.A., Ruch, T. C., and Guterman, B.: "The effect of benzedrine and Other chemical agents upon the postconvulsive (Electric Shock) EEG."Feraration Proc. 5:62, l9h6. Levy, N.A., Serota, H.M., and Grinker, R.R.: ‘Arch. Neurol. & Psychiat. D7: Disturbances in brain function following convulsive shock therapy." " 1009-1027, 19h2. Neel, B. H., Dswan, J. G., Myers, C. R., Proctor, L. D., and Goodwin, J- E.: "Parallel psychological, psychiatric and physiolog— ical findings in schizophrenic patients under insulin shock treatment." Am. J. Mo _ Psychiatr. 98: h22—h29, l9hl. Moriarty, J.D., and Siemens, J. 0.: "Electroencephalographic study &of electric shock therapy." Arch. Neurol. Psychiat. 57:712-718, l9h7. Nbsovich, A., and Katzenelogen, Dist. 107: 517-530, l9h8. 8.: "Electroshock therapy, clinical and &electroencephalographic studies. J. Nerv. lent. V �-2Pacella, B. L., Barrena, S. W., and Kalinowsky, L.: " Variations in the electro- encephalogram assbciated with electric shock therapy of patients with mental disorders. Arch. Neurol. & Psychiatric. h? 367-38h, (March) 19u2. Proctor, L.D., and Goodwin, J. E.: using raw 60 cycle alternating Egychiat. 99:525-530, 19h3. and Comparative electroencephalographic ob- serVations following electroshock therapy unidirectional fluctuating current. J. “““‘ Am. observaProctor, L.D. and Goodwin, J.E.: Clinical and electro-physiological Am. J. Psychiat. tions following electroshock. 101: 797—809, 19h51 Rosen, S. R., Secunda, L., and Finley, K.H.: conservative approach to the use of shock therapy in mental The illness. Psydhiatric Quart. 17: 617-6u1, 19h3. Sutherland, G. F.: experience with electric consideration of shock treatment in mental diSeases, withspecial regard to various psychosomatic phenomena and to certain electrotechnical factors." Am. J. Psychiat. 99: Sulzbach, W., Tillotson, K. J., " A Gullemin, V., and Jr.,some 519-52h, 19h3. Taylor, R. M., and Pacella, B. L.: . J. Nerv. _> & 1VLent. significance of abnormal electroencephalograms prior to electroconvulsive therapy. The Dis. 107: 220, l9h8. Lowinger, L., and Huddleson, J. H.: The correlation of pre-electro— shock electroencephalogram and therapeutic result in schizophrenia. .Am. J. Psychiat. 102: 299, l9h5. Turner, Neil, l9h7. W. J., A. A., Brinegar, W. 0.: "Electroencephalographic studies following electric Arch. Neurol. & Psychiat. 57: 719, shock therapy. �286.lﬂ§elation EEG Number Delta of Manuscript re: Activity ..." by Fink and Kahn Dear Doctor Fink: I am very pleased to inform you that your paper has been accepted by the Editorial Board for publica- NEUROLOGY AND PSYCHIATRY. tion in the of issue in an early article It is planned to use your A.M.A. ARCHIVES OF the ARCHIVES. Yours very truly, ROY R. GRINKER, M.D. Editor-in-Chief for Psychiatry P.S. It is necessary for publication that you forward an additional copy of your paper directly to Mr. G.S.Cooper, Managing Editor, A.M.A. Specialty Journals, 535 North Dearborn St., Thank you. Chicago 10, Illinois, as soon as possible. �L___E,, _, WW--. , , , , R. GRIEKEE, . DIRECTOR, P. a BOY MICHAEL REESE". 29th SIREET CHICAGO AND ,. pgmg's 2mg; E 16. ILLIIS|957 in %£;"3 Max Fink, Department M. DEdeEimental °f Hillside HOSPigg; 75 263rd Stfeéi “ ‘ Glen Oak§,3 c‘. NEWTYGRKE . -“ i V. - . I J .' --E EVE I ; . 3 i...' -_ .*-« . n a" Psychiatry l, ‘pja.'ff~xﬁE=b . .4 -' . ', 3‘, . 2“” ﬂ �C ' o Please return to r;’ MD Publications Inc., 30 East 60th St., New York, 22, by Jan. 2 1958. Relation of Electroencephalographic BeltavActiviiy to Behavioral Response in . Electroshock, Quantitative Serial Studies. EAX FENK Ali RDbnﬁT L. AAHN. AMA-Archives of. e rology & Pegcniatry 78: 516-525, November, 1957 - I In a study of the neurophysioloch correlates of convulsive more”, serial electroencephalogram were obtained at weekly intervals in an consecutive patients referred for electrodzock. no records were quantitatively analysed for the degree of delta activity by moments of the per cent. tine delta, latest frequency and highest amplitude delta in the record, and daemon of burst activity. signiﬁcant relationship was found batsmen the degree and duration of induced delta activity and clinical evaluation of behavioral change. The results were conﬁned in a predictive study in m additional 9; patients. A Differences between these results and those obtained by others are ex’ plained in tonne of differences in methodology. A presented. It - adaptive interpretation or convulsive the repy is is concluded that convulsive therapy is the nonspeciﬁc induction neurophysiologic of persistent states of altered cerebral function, providing the physiologic milieu in which changes in sdaptive intezpersonel behavior occur. Ilprosrenen’c steer electrooonvulsive therapy . is seen es :1 special. case of behavioral response under these conditions. the rating is an evalmtion by an observer depending on annex-one teeters, including the type of adaptation, the goal and expectetim of the observer (therapist, family or adainistrstor), and the setting in which the behavior occurs. �In a-study of the neurophysiologic correlates of convulsive therapy, serial electroencephalograms were obtained at weekly intervals in 2h conseCutive patients referred for electroshock. The records were quantita- tively analyzed for the degree of delta activity by measurements of the per cent time delta, lowest frequency and highest amplitude delta in the record, and duration or burst activity. significant relationship was found between the degree and duration of induced delta activity and clinical evaluation of behavioral change. A The results were confirmed in a predictive study in an additional Sh patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A therapy ‘ neurophysiologic - adaptive interprdation of the-ele- convulsive is presented. It is concluded thataai-lil-convulsive therapy is the nonspecific induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after eledtrégggzﬁﬂiz’gfezwzz a special case of behavioral response under these conditions. The rating is factors, including the type of adaptation, the goal expectation of the observer (therapist, family or administrator), and depending on numerous and an evaluation by an observer the setting in which the behavior occurs. �v w a, z. K . .3 2.» w\ A Y; . 369 .36 N = W. ��EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE graphic Studies, J. Nerv. & Ment. Dis. 107 :517—530. 1948. 13. Kennard, M. A., and Willner, M. D.: Signiﬁcance of Changes in Electroencephalogram Which Result from Shock Therapy, Am. J. Psychiat. 105:40—45, 1948. 14. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Electroencephalog. & Clin. Neurophysiol. 2 :157-162, 1950. 15. Chusid, J. G., and Pacella, B. L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116:95-107, 1952. 16. Hoagland, H.; Malamud, W.; Kaufman, I. C., and Pincus, G.: Changes in Electroencephalogram and in the Excretion of 17—Ketosteroids Accompanying Electroshock Therapy of Agitated Depression, Psychosom. Med. 8:246-251, 1946. 17. Strauss, H.: Clinical and Electroencephalo— graphic Studies: Correlations of Mental, Electro— encephalographic and Anatomic Changes in Cases with Organic Brain Disease, Am. J. Psychiat. 101: . 42-50, 1944. 18. Davis, H., and Davis, P. A.: The Electrical Activity of the Brain: Its Relation to Physiological States of Impaired Consciousness, A. Res. Nerv. & Ment. Dis, Proc. (1938) 19:50-80, 1939. 19. Ostow, M., and Strauss, H.: The Signiﬁcance of Bilateral Abnormality in the Electroencephalogram, J. Mt. Sinai Hosp. 20:173-193, 1953. 20. Ostow, M., and Ostow, M.: Bilaterally Synchronous Paroxysmal Slow Activity in the Electroencephalograms of Non-Epileptics, J. Nerv. & Ment. Dis. 103 :346-358, 1946. 21. Jung, R.: Correlations of Bioelectrical and Autonomic Phenomena with Alterations of Con— sciousness and Arousal in Man, in Brain Mecha— nisms and Consciousness, edited by J. F. Delafresnaye, Springﬁeld, 111., Charles C Thomas, Publisher, 1954, pp. 310-344. 22. Strauss, H.; Ostow, M., and Greenstein, L.: Diagnostic Electroencephalography, New York, Grune & Stratton, Inc., 1952. Fink—Kuhn 23. Roth, M.: A Theory of ECT Action and Its Bearing on the Biological Signiﬁcance of Epilepsy, J. Ment. Sc. 98 244—59, 1952. 24. Bornstein, M. B.: Presence and Action of Acetylcholine in Experimental Brain Trauma, J. Neurophysiol. 9:349—366, 1946. 25. Tower,‘ D., and McEachern, D.: The Content and Characterization of Cholinesterases in Human Cerebrospinal Fluids, Canad. J. Research, Sect. E. 27:132-145, 1949. 26. Spiegel—Adolf, M.; Wilcox, P. H., and Spiegel, E. A.: Cerebrospinal Fluid Changes in Electroshock Treatment in Psychosis, Am. J. Psychiat. 104:697—706, 1948. and Spiegel-Adolf, M.: Physiological and Physiochemical Mechanisms in Electroshock Treatment, Conﬁnia neurol. 13:38—63, 27. Spiegel, E. A., 1953. 28. Landolt, H.: Das EEG bei epileptischen Psychosen und schizophrenen Schiiben, Personal communication to the authors. 29. Landolt, H.: Uber Verstimmungen, Dam— merzustande und schizophrene Zustandsbilder bei Epilepsie, Schvveiz. Arch. Neurol. u. Psychiat. 76 1313—321, 1955. 30. Brockman, R. J.; Brockman, J. C.: Jacobsohn, U.; Gleser, G. C., and Ulett, G. A.: Changes in Convulsive Threshold as Related to Type of Treatment, Conﬁnia neurol. 16:97—104, 1956. 31. Fabing, H.: Personal communication to the authors, 1956. 32. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: The Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 109:889—894, 1953. 33. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conﬁnia neurol, to be published. 34. Ulett, G. A.; Smith, K., and Gleser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. J. Psychiat. 112:795-802, 1956. Printed and Published in the United States of America 525 as �/ 4 I Tax A “ﬁn? .A g. _ MW.» .15. __ O \Q « A A" 33 9% ~ ,. \a E , +3? “a . § mm“ ‘ g... .496 = a «a. .«F N . . my 3s \AVUFQV. . a SEN z «Kay pm“ Aw ‘ . ﬁ 0. 3 qu$v g c. . E «7} Vi __ ramﬂjﬂaj~ a = Arsﬁv xaxwrwmﬂu f» r «UN: :15. _ .n A an é it MW: a. N» “.3 M‘\ «R . R.“ A Mi 31.. A} _ “$me _ 3J3 .. mamme . .rrn: = h J H mﬁuMMc «s V 4. NAQV � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation of electroencephalographic delta activity to behavioral response in electroshock; quantitative serial studies. AMA Arch Neurol Psychiatry. 1957 Nov; 78(5):516-25. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-21b-026 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 7 items. 1: Reprint from the A.M.A. Archives of Neurology and Psychiatry November 1957, Vol.78, pp. 516—525. 2: Two final draft copies. 3: Several pages of handwritten notes. 4: Reference list (mix of typed and handwritten). 5: Postcard from Roy R. Grinker to Fink. 6: Copy of same page. 7: Scans of missing pages fromthe items listed above. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/83ab48a2c2deaa99207d2c9a9f5a4a5d.pdf 5d4afa38e2ad19bfcb3084fe8746be25 PDF Text Text 111: 9/55 Egbert I» Kuhn, mm. Hillside Raspiul, Glen Despite ”posted attomptn, wmlatiam am, my Ia‘rk between aim we activity dwed by «hammock and subsequent. therapeutic outcome haw ham Email, mrtain ahock therapy indum alterations in the sleetmncophalogm in all subjects. mamas voltage whim wmmuml. conclusions are wan-entree! Iran previous studies (1).- Electra:- Three pattema we generally dowribad: ‘1) slowing of tha 2) the in- may of mam, symtria awn {remiss} 51w wave activity, generality a: high appear as burnt nativity) and 3) didnu‘him cios in rate and amplitude. mm in din-act. a at beta rm;— relatim human 12m degree or Mg”, and the number and imam a! mama. In my subjoéts ”mum paint at change is daaeribod, which can be maintained by further those a. tmamnt, but which is apparently not increased. Such indueod oloatroenccpmlu ographic ehangaa are ﬂux-aims. to the pretreatment lswls is number, frequency and Another area than type m ate at“ return at the: cem’bml generally 1 to h weeks, dcpending mhﬁmﬁhip between dagraa of manifest and authors is the the ha}: of direct wry loss and aonfusim and the degree of electroencephalogmphie abmmlity. wry changes with few tmamants and without. Cases are demribed of 3mm significant olaetmncaphalogmphic mm without manifest clinical ﬂange; and also a: never: changes in cerebral emmnicn cf inpaimsnt. In these reports, ganic dimam an at tmtnen‘b. a! agreement ”mg the wry patterns it is? stated that Wim also correlates poorly with clinical results. Hammad at tbs Eastern me Society, Bethesda, September 30, 1955» mach or» ��Whﬁla and EEG these twa “mommy, atuéies dananatrute a ralatianship betwaen clininal ralult tho majority 91’ reports fail to do m. It 3.8 mt 11h]: that this diucrupanay is tha mosult a: diifarunt populatiana, but rather; tun dimer-macs in methods of evaluating Swami, than him at Matias; and diffexunaea in ontinnting change: in aarubrul runntian. In in» ﬁgurae at stuﬁias a! alﬁarnd twain tunetian indueed by at elsatma— in SW Yak, further data m the mkﬁiamhip betaaun EEG ahangea aaa clinical atfoeta of aluetrenhoek wars colleetcd. ’lhs genaral reaulta a: pruviaun investigatiena an the alteratienn in tho EEG with shank this 311137149 Hospital taro anniixnnd, but 313a, a ﬁatinite rmlatianahip betwaan.ﬁﬂﬁ effects and has clinical rasult was dnmnnstratod. Throa £661 are preaanted alaetmeshock today: (1) the m pattem mum electroshock and their “hum to in- pwavument. (2) The internorrelatianl at airfarant quantitieatians at ddlta acttvity. (3) m relation of these abaemtiam to a theary at abet whim. :'vzvﬁhgggggga§§§y Ihuntvmfaar aanaegutava patianta ratarrea for aleetre— 3 shock wart studied. Electruanczgu:.m¢~q us ' 5 warn nan: priar ta traatmant, at uaokly intsrvala ﬂaring traatment aha grist treatment. In 8 ehanns1_ﬂhdcra£t instrunsnt, uaodlo eloatrudus, and bipolar racording Hypervnntilaxdan was tha anly was unad. activatian tachnic utilixoé. truatnant, raaarda ware takna tbs day'attor; ganamully 25 to 31 hunts Datum: after traatmnnt. Th3 Baiter and the tmmnta wen administered by the staff paychia‘bris’m, 6 h? electrnatinulator. Treatment scheéulas namber of treatmants variad tram impruvemant, the 9 to 33. warm An thrae wing a. timma a'waek; patianta shaved alinical psychiatrist tended ta give raver treatments, and warn widely ��m5:- are mam of the diffieultiea in evaluating impmvmnm More might have «momma in the estimates of change in those patients. In any me, by E‘o wing this threefold clusifieatiem, the diffemooa between the groups will be distinct. 9E gag EVALUATIOX first and third W! A total. of 160 meow: were obtained in these who Following the suggestion of Strauss (h), the delta mm am determined for three: lead mmbinetiam (frontal—swam, anterior temporal - vertex, and lobe) for 180 ascends of Hoarding for not load. The delta index :13 on the pemont time woupiod by aerate. ”ﬂame mm of '3 ops- or slower. Tho avenge delta-dude: for the thm loads,.’md the highest delta may: in my load were the 1mm: and in the final tabulation. waves Sinateneouoly, the record me mad for the almost frequency 1am» tifiea at least twioe in my load; the highs» voltage of any delta may and the duration of the longest beret. cm the basis of those were placed 160 mores in It rank ﬁn indie” order from the of slow wave activity the meordu ngt abnormality to the lawn. The were then divided into 3 groups! a Met. upper thins? high degree abnormlﬂy, and lmat m were .. 1m demo mbmmlitm mum-*3: 1. 0m- nouns show a Mitim aomlntion human early out dugm m; okxomlity and improvement. Thane relationships are demonstrated 11: Slide 1. By utilising sleetroehock, we of troutmt is quantification of slow wave abnormality induced by conclude that snob EEG abnormality induced in the first 3 theme on “mental response. 2.. clinical mm minimums We, and than m clinical Mama for the short tom favorable mot bathroom met each of the eeeh other? indie”, first with the ‘ ��WWW £611.3ng ehetrashock mum is the mault of the emﬁm in the mtiant functim in winch new panama of adaptaum, part». Mae me “when amnamu 1mm thaw 6! dental, my be. of a inﬂame! brain as? WM. that: an. alts-rad milieu of eon-ohm}. a puma-equate for ~ 30W, :1: mmnt. mum as measured by delta abnormality is Ta @115 extent the first part. at the Mates».- ”WWI: many of quantitative far the duaidatian at ”Wm 51‘ 27mm mans studies paint. to the Em 5mm: �mm. 1.. than 39mm Lu Th0 Eleatmmeplulm in Thempim, J. Raw. 8: Kent. 131»... Egg 95.107, 3.9512. Jemph a. and Panelist, maetrie 311w]: 3., Harland, W... Kaufman, and Pincus, 6.: Changes in the 81qumaﬁmlegm and in the ke-mtion at 17 {shoutemida [teeming Enam- 3. shmk mommy af Agitated Mpmvam, Payuhoaom. Had... Qt mm, mm: own in the me Mr Barbiturau Anesthesia mma by Elw£mcanwlsin Mama’s and mm SiWicanee for the Timmy (31‘ E01 3.. m and Olin. Rummy“, g; 26l—280, 1951. mum, h. 8km“; Km: Clinical - at mm. madmaophalogmphie Studies a eomhtim Elwtmmawralegmphie and Anatomic Ganges in Gases with m: 14260, 191th. Hammin, Eel” and him, Rd": Mastic U“ a! Mbaﬁihl 3mm! (“Mm Sodium“) in Ma Brain 31m”, Am. J. Wat" m: 12, m, 6. Fink, 3., Am. J. Psychnti, ' 1953. m,Rental Bead», ﬂu H; and a! Qrmie 7. and Dimse, Org-mm Brain 5. Wﬁ; 19%. as n Diagnostia Sign Baum, at 246—58, 1952‘ W in now-y and Mauser, 3.: 33mm a: Impmmment in Wmhoak, cant. "euraloguu, 1‘? W6, mm, m, Fink, Lamina to Byndram, ﬁne Farm-Hand East u. and 1956. 8... www, EM” mumps“ Its my “~26, Kuhn, 8.1. and MM, 1.: Paychoais During mew-9mm Bushman he the Them? of 1952. 312302 Therapy, Am. 3» WM, ��MW“: ﬁwzww/Z WW! :: Var/7 . a; /W‘ / / MMﬁw l-I’M) /, VMW 5/ We W / ' - ’ / ri ' L 444:1” /~57:é'(/ *' . ' �/WW WQMW We. WDZM/JMD szd 4 ”Ma/Z7444444944“ M—IWM W43, g; ﬁw/ 444 W544.» MM ﬂWM AM MW ZIMMWQ L SCAMUE‘D % ”M W“ ”774/ W' AWQQ ”W47 ﬂaw/44¢;”jg Mix/«442 �ﬂ , V MW/a/é/WWM Mat/c9245.? M/W7M7Wa. MW/ZWa/d —%¢%7AQWW 2% H M AA/W/Wd4 Mama/21¢ #wdfm?/ WWWWX‘JP ﬂux/(‘5‘ WWW/LWMW/AW W%WW& ,MAW’ZmV/ %/laﬂ6¢r¢£Wﬂu~ WM 30%.... . �@: ’OZQJWWM %W M,:/éw€ £W7WW éwaf‘W Jazz/WW //~JW’{)W W / W,” make—4441M @ace WMA, W mg WWW—jfszd, éﬂfﬁé;e. I wmbéMW ﬂW; WWW MW @yagﬁa / mm V UZW‘ﬂm W4 M ﬂed/2W " �W cam/um aim W ,mmvwr‘MA/ﬂﬂ M Ma ://Z~M~/Z~;/ . .2. ‘ W ﬁWZW/LM/AM WYAMCMMWWM WW M562Qﬂﬁ7~fw W/QWWMW /¢éa¢d/W @ngaiu/é Mh/o/VW /MM*/WwWéAﬂ.—A 74%. MW/%Wé<~v ﬂms M—/k MM ﬂoWW/I ﬁ/ch/M ﬂWM,W/%9%Wﬂ- WK WW %W MMWMWWJ �3WWﬂw/y/QWW7/W /x£¢¢:W/ZW ~ ﬂ Mé/éex WA’8 75WW/iu7sﬁéw/A/AW/o ﬂmwMM éﬂyiw/(Wga ﬁ WQM/yr/x M. inAM. ﬂ/j/W/W/fgl/M ﬁﬁéz)’ aim/ah‘muzt V 4 UM a/“Z A/dxﬁAMMW -‘ ��;WW%AM a/A/W &M MmW%M;/A Adm/M' ”#7 Wet/«.4145 W%WZ;¢M¢MA w! W ﬁﬂéﬂﬁfdeWQMW' WWWW m km,MW7ML L' MM _ WI/Jﬁ W W . ' - �Q . MM W WWW WM‘“ ~AAAM/AAWM4’W AM‘v/Wzy’g A ' $4MM wz/Z’WWW/ AMAWW AWM �WWW “WMMW MM WW MMWMI "WK, MZMMMVMW ML, I'M/”MW W W ﬂbthxWM WWW /A%W/2Wg MM7 MW. V WM gifMMWﬂ/%M%‘7 4 MW MZM WM 7/134 (12%) Mc/Zzw/anéﬂff" Wm/m Mzgf �0%,. MAW/WW wWM Wr/WA/ZnaWk/ WWW—MW //6W7/» f/A/ay/MW/ W 9Z2WWA» ZaWZM' A: 4w/ W/ﬁ UV ngégfiﬂmm ”2% M”; j �“”1“ ”PM“ “was by ehetmeheek end euheequent um correlations batman elm traumatic eenelueiane from previous etudiee ere m «was; We Ge” cut-cone have been unsuccessful. «muted, 1 however. A11 pastime ﬁlth-A ~ seated to eleetroeheek thenpy nutter alteretione in the " electmneemme patterns. Three pltteme ere generally described as 1) the am ”3'“? am of high voltage which pregneeeee to burst activity; the 3) Mutation at but: 3 frequencies in rate and amplitude. There 1e e direct relation between the - of these changes, and the utmtien point of number and frequency ehmge 1e deeeriheé, which meat, but whieh, seemingly, frequeney and the type or is or treatments. In may an be maintained by eebjeeahe further ’6 ‘ treetmt, ship between degree of manifest M0113 memory the cited authors is lees and centueion maneephnlegnphio abnormality. Ceeee ere eited of severe the leek er and mm ‘ the degree of e memory We with significant electroencephalographic (ﬂange; and ﬂeece: aﬁWii..¢m”e in cerebral rhythm without. with“ clinical m Manet memory inpeimnt. In theee zeperte, aphasia in "month" he: on such organic ashram also earmletihg poorly we azmm rem! te , ., not inereeeed. Alec, such electmeneephalegmmw Another area of easement few treatments and without 6:3 7‘ g“3* �PM n2. awn”, homer. Two my be cited which mud n oomlatiem ham clinical improvemnt. Rowland, Halo mud, Kaufman and Peanut: in this 19% study of involutional woman ~( chums in the olectmncophalegm and in the accretion of 17 katostoroida new Electmncaphalognphic oranges wing alien-omen]: ens-251, 19M). and at agitated depreaeion, Paychoum. Hod. Q: a relation bunch changes in their clinical therapy roporbed activity as the disturbed be:havior boom now must, tho 13 cps activity incmaed. So treatment induced bohuviounl immanent, 13 ops activity diminished. with recurrent» of symptm, thorn m.- an increase in the 1 time 13 ops activity. rating scale and the per cent time manly, Mort Pmdnm by Theory of a Bath (changes Eloctroconmlaiw EGT action, we and ”no. of mums in which EEG 13 cps in the ma under Rumbas-ate Amsthaain and Their Significance for the hum cm. Hem-own. 1. 261-280, a relationship hottest: thiepontom manna We: and the recovery process “solicited. to inpmvomant. By that it Both noted that slow irregular in appuranm, could not be ntiatuctorily related mm antivity as new in a routine rcéord and be confirmed the reports 1951) described wan adminlltermg an intravenous aolutian of a barbituuto thmpentone, Roth elicited characteristic changes in the ma titer metroshock in mxy subjcct. Early than waé random irregular claw mu untidty, bilaterally which, with more treatment, increased to a highly We), synchronous, high amplitude delta runs and bursts. The” urn chiefly 2.3 cm, with voltages of 200.350 uv and cantlnuoua durations of 30.80 seconds. Winn the mating mcord cum“: rhythmic: Golta activity, umpontem increased its basic pm» its Imam. voltage and duration, spread Roth believed its urea, and decmuod that than chug" warn rehtod to the a! recovery, although, mo concluded: " Hanover, my development at a typical we cameo does slot ensure memory and 10 a! the 36 pntiontl who am men a mag. rams to me for longer m'tw wreaks. m M "Wu-v- 3‘ ' �~3¢ tmsicnt impmment in album). "lat-d. to tho EEG «mating EEG oondition mom to be pationto. .1: in are correct in W cm in thanmommue aﬂoat it would ammo: with tho seem, 31mg mat. tho of tho patients develop typical changes, that the physiological basis for in- provmnt is acquired by the majority or one»; it. «man in promoting recovery.“ w or' my not pm In the course of studiea of altered brain function induced by electron at this mums. Hospital in New York, further day. on the ”Intimaships betmn EEG chanson and :31ch effects of electroshock were collected. shock The general remain of mum innoMga’oiom on the alterations in the elontmhook mm omﬂmd, but. also, I doﬂnito relationship between on“ attacks and tho clinical remit «immtmted. Throo fooi are presented today: £30 with - m (1) Tho EEG patterns following electroshock and their relation to mpmmt. (2) mo intercormlationl of nativity. mama; qmtifioaumo or down " (3) The rolotion of those obaomtiona to a theory of electroshock I . SUBJECTS ‘ action. w W: prior to treatment. 1 Twentyofour common“ portion“ referred for ehctm» shook were awaited. An 8 and bipolar moording was Elootmnoephalogms channel Madonna instrument , and. Hypomtiution mdlo electrodes, m the only activation technio mod. During ornament. records wore taken on the day treatment, generally 25 to 31 hours after worn don. trauma“ after a. . ��In this group in mt chum amiable or who moan change was transient immanent. 3m amt. impa‘md. of chm ﬂuctuatians in behavior, at tins appearing. appeamd much as they did EV. diffsmd in tha third groups mmm or? 2 - Strauss (Clinical ham. Bruin that by tha and boron. Wu In w of the difficulties in evaluating impinmeﬁ'o. aa’oimataa of w H111 be A in than patients. change cam, by using this thmefald classiﬁmtim, firlt and sown pnuanu shaved only equivocal or But the ammo was not sua’oainod, no tm¢mnt, they We are “are might. have plum ware distinct. total at 160 thus 11001113 differences botmn the mm obtained in than manta. Following the maggostion or Dr. Rana me! mctmmphubgmc Studies Garrolations a! «.- Electmneophalogmphiu and Antonia chanson in Cases with Organic Dim. Al. J. Payout“... 3&1: hz—so. 19%); the delta ind»: :19th for thm lads (twahlupuriem. anterior tampon)... vortex. «comm of renaming for own land. The and puriﬁed-aunt love) for 180 don: mm is deﬁned an the ﬁgment. slmr. 1m m tin maupiod by waves or 7 tsp: daluninéex for the three loads, and the: highest in my 1nd ware ten mm: and in the final tabulntiom The average or c1011» Simultmebunly, tho ruéorci was scanned for the slowest freqmncy m imuﬁod M. lean twice wlta Have; ed, but ivity, m in my load; the highest voltage of my and. the ruration 01’ the longest burst. %er aspect: recordwe! in m final Malawian, worn m mgulamy of ham act.- aim of Alpha activity“ and um degm fraqmciu and amplitude of fast activitiea. “than indie” ‘14 net land study; Qua Inn «mm diam not. by thumb": to statistical meow. Fat amounts." mm identifiablo in all tho the clinical administration of barbiturates. A: thin ' ��07‘! Similar mm» or the relation at nah or the: Macs and minim mm mm mm. be tho group cum than boron. Slide 2 mmmmlaumormauummmmwmt. 1‘1»me result. the much upmd group Jump! to cut-1y lam-wad and unimpmvod group: mm: a by tho 10-12 10—80% A 52:: by tho 7-9 m 1123mm tmtmntz mm gnaw, alum - the #0 tmamm. ‘ similar out or our”: is demonstrated in 511603 for the man um delta 1:: am 1nd. In tho nut. slide the man ﬂaunt Imam in recorded, ma this ahm tho am aigniﬂunt nhﬂomhipl. Whiz. the mania imprond highest too ‘ pox-«em. patients than delta waves dam to 3 61:! or I.” by the «com! we]: or tmtmnt, th- at)»: two groups mm: man h 03:: by my fourth wok cf tutti-oat. and; The S and: improved group tho fourth the much new by show highar mm... by the not the elitism: Madly, slide 6 Vat «minim for tho mean highest amntndu chm the am are ”mam far :11 three groups. manta the mean aunties: of bursts. 111 (nu-ﬂint}. In than ml: of Hot noted long bun-at” treatment. Burnt: m no less ”mg. m. wave neural more than 7 {remnant in W m significantly 9119er hen, the is the fact” or “gummy of hm“. £91m!- rmthntly mm more maul“ in troqmcy “plum!” than in the other We groups; than studio: my be interpmud u demonstrating that manure: of slow and The patient: lbw longer hunts, winging 1W tho third unimprmd and modes-«uh inpmvod groups and and mm: mm: and by activity aria from the «wk 01‘ than am myuological pm”, m «imam in ablation to the diaturbmoos in earn-bun. function induhd by elactmahock. �3. ﬁnally, can these alterations in npoets of «tubal function mid: In tho» undies, the myriad. 1mm: current-d with own:but been altered by olectroshaok? mama af «tubal function were assayed- tut or Weinstoin and m um 01' double stimulation and tom text showed a W test thus EEG. 013110? any m we ho of tan. In than ation of intuvumu memory and mum” sodium until. racing. 0: than threw indies», only correlation with the subject simultaneous is interviewed 1.21th and can and’ qmatiom of orient- mm, the quantum an reputed errors in orientation, mnfabuhuan, dank). at 3.11am: and rsduplicauon are mud n 'poaitiw' myul tut, and are indicatiw of cerebral wilful-mum; Comet roman to than qmstim after and an a ‘mgatiw' W'm “at. In the wt click, #7. the pox-0mm positivc mm tom are 4 , m wanna. botmn tn. cmpund for meat. me much in titanium. of the m1. gmupa, with the number or weeks ovary patient much improm and at trut- m other tam gram . in the and: improved group had u positive mm by the third weak a! mama, m m abnomaiity panama; in tho unimproved swaps only me patimm had a positive as tram-£19m «opus command mam-m. In 311d. high degree 8. the an relation between, 1‘ EEG abnomlity shows a maul? The“ . ’ tinntmaus tactile tom inclines alarm). maxim and tho distinct carnation which in autism tinny signifiemt. Hint of tho an m1 and thin ahmd no won-elation with mama’s, it. can be concluded that tutu of wry and impromt. In an: and the than are axiom! typo. of mmbml dam- m cannot. speak in gm tom 9! g hrk a! comhum batman m m and 00me dyarnncum or organic payment, function tad taut �‘9. this point I should like us muss m findings and mass thoughts as to thsir significance for s theory or electmshoak mm. At. m moss is 11m. doubt that eloctmshwk m. It 3.: all upmsds to almr, symwio, We. induces delta nbnomnty 1:: tbs may frontal, but with Mmamrtmmm, With immune trusmt thaﬁsqmncios beam the smplitudu higher, tho bunt activity longer sad more regular. mile den: sbnomlity is pussnt in every mpord “ﬁr olsctmhock, its Roth‘s mum‘s mammg Manning emu .mmw «gm 9.: with bat-bum“ are Digniﬂmt 1n pmﬁmg the 11m” emu Mum by «wk. furthsr slntroahwk. In sans subjects sanity is not. induced despite atoms.” Our aux-relations of Guam 0!." test, um s meeasary chm-"u fail to wear in the tram. delta ammlity with 13pm srs «:1»th thorium. significant far tbs ”amiss: o: alteration in cox-ohm function as mm War, a high dogma «hits smorAn early, autumn mm by the EEG, and (and in the m1 taut), also by m. ' pmummﬁSiM for improvemt. when such EEG H u sign- nificmt clinical improvement V111 rail to wear in the patient' a hshs'dar. with wry loss, points Tbs rm. that than camlatiws mm not to the poasihiuty that. this is not a significant master in improvement. In conclusion, than studs.“ land uppers to s theory at E8? action moﬁntly unwanted by Gamma sud can at us (Kuhn). Thou “at ‘ authors postulstsd that wwwmt fanning olactroshoek is than malt of tbs amtion 1:: tbs patient 91' a min at altered brain function in much now puttéms or mputim, a-srtioulorly mm a! denial; my be main-- mm. mm m nudist Winn that :5 «land milieu of «avatar-J. museum u assured by mu abnormality is ,s pm~mu1s1u for improvisamt. ‘ro this extent the first. part. of ﬁns unseen-am Wall is ’“PPGTst �% m W, mm «was: m- studs.» punt to ﬂuaiﬁﬂﬁim of m “grammar of quantum" Wm at mum ' �Dr. Joseph S. A. Miller. To: From: Dr. Max Fink May I have your approval to submit this technical paper to the Eastern EEG Society for its October meeting in Bethesda ? ��mmmMmmwmtmmam mm m m mum as? (3) a» in mm. warm “at m m a: m mam a: mm mm: mwvm mmmmymmm mm,mzm �112:? My) Quantitative Studies 2;: Slow Wave I M 9/5"!» Activitz Following Electroshock Max Fink, HOD. Robert L. Kahn, PhoD. Hillside Hospital, Glen Oaks, New York Despite repeated attempts correlations between slow wave activity induced by electroshock and subsequent therapeutic outcasts have been unsuccessful. Howconclusions‘pfrom W; ”avg/a... rewart-m previous studies?“ "W Wm“ Ail—pam- over, certain mduuo are Electroshock therapy suffer alterations in the electroencephalogram«a»‘ﬁz 9%.- . 3m Three pattems are generally describedzu l) b slowing of the alpha frequen- cies; 2) the appearance of random, synmetxic slow wave activity, generally of; activity, and 3) diminution of beta frehigh voltage which Wﬁbwburst quencies in rate and amplitude. There is a direct relation between the degree of these changes, and the number and frequency of treatments. In many subjects a saturation point of change treatment, but the pretreatment levels mnnbe r, described, which can be maintained by further is which” are reversible. Qfﬂdeef Mir. not increased. The ographic changes the is «he, we!“ c,at!” 5mm electroencephal- rate of return of the cerebral patterns to is generally l to b, weeksxgﬂ’ipending directly ugh- on frequency and the type of treatment. cited authors is the lack of direct relationship between degree of manifest memory loss and confusion and the degree Another area of agreement among the of electroencephalographic abnormality. Cases are describedgevere memory changes with few treatments and without significant electroencephalographic change; and also of severe changes in cerebral or memory impairment. In these reports, Weclinical is correlatgug poorly With organicconfusion also Presented at the Eastern E E W rhytlmls without manifest 0 Society, Bethedda) -~-- clinical confusion > Md “HA0? 8 such gM’Y’EJ results. - Septembee 30, ”0...... «.~.—.._._,___...~—-— 4...“ ._.... 195? �Two studies, however, may be cited as noting a correlation between ectro- u: encephalographic changes and clinical improvement. Hoagland, Malamud, Kaufman rt- ﬁdand Pincus in their l9h6 study of involutional L’ women ‘1) - tonnage-MW: reported a =§W19§9+ relation between changes in their clinical rating scale and the per- cent time 4'40 W61 131, ‘ctivity. more than 3.2% activity increased. cw activity diminished. % A time 1301;: a More As treatment induced behaviojral improvement,—-B=eps tivity.C3,) Roth ﬂ" there was an MK, increase in the . Mow-W .--__ , WWW-WBW‘UI relationship msngmmeWeWw5M— the Mby. ~. the disturbed behavior became more manifest, the With recurrence of symptoms, e WA recently, As . 1 described a between thiopentone induced EEG changes and recovery process. Roth noted that slow wave activity as seen in a routine post-shock record was irregular in appearance, and he confirmed the reports that it could not be satisfactorily m , related to improvement. the However, by administering an intravenous thiopeﬁ‘tone, he elicited characteristic changes solution of in the EEG after electroshock in every subject. Early’there was random irregular slow wave act- ivity, whichyéith increased to a highly rhythmic, bilaterally more treatmen synchronous, high amplitude delta runs and M ILKoVol'PS bursts. These were with voltages of 200-350 is and continuous durations of 30-80 seconds. When its the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were m F4» lemma; chiefly 2-3 area, and decreased its basic frequency. related to the process of recovery, and Both v �he concluded: “The development of a typical and 10 of the 36 patients who attained such a than two weeks. But transient improvement related to the ing the EEG EEG change does not ensure recovery failed torsmit for longer in clinical condition seemed tolae change in these patients. changes with the therapeutic effect it EEG change even If we are correct in connect- would seem, since most of the patients develop typical changes, that the physiological basis for improvement is acquired by the majority of cases; it may or may not prove effective in promoting recovery." Whileathesettwoﬁstudiessdemonstrate a relationship between clinical result and EEG abnormality, the majority of reports fail to do so. It is not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course ofestudies of altered brain function induced by electroshock at the Hillside Hespital in further data on the relationship! be~ tween EEG changes and clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with New York, electroshock were confirmed, but also, a definite relationship between effects and the clinical result was demonstrated. Three EEG foci are presented today: (1) The EEG (2) The patterns following electroshock and their relation to improvement. intercorrelations of different quantifications of delta activity. (3) Athe relation of these observations to a theory of electroshock action. SUBJECTS AND METHOD: Twenty~four consecutive patients referred for electroshock were studied. Electroencephalograms were done treatment, at weekly intervals during treatment and after treatment. prior to An 8 channel �.5‘ but the dramatic in the change so evident patient continued to first group was not apparent. Each noticable disturbance such as obsessional think- show some ing, paranoid ideas, or somatic preoccupation. C. whom Minimalyy or Unimproved: In this group were placed seven patients in change was not clearly noticable or who showed only equivocal or improvement. improved. Some showed transient fluctuations in behavior, at times appearing But the changes were not sustained, so that somewhat by the end of treatment, they appeared.much as they did before. we are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, using this threefold classification, the differences between the third groups will be by first and distinct. EVALUATION OF EEG RECORDS: A total of jects. Following the suggestion of LJ.aPsychiatemgggnehZ-Sewwl9hhd, w 160 records were obtained in these subStrauss the delta index was determined for three lead (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined combinations as the perbcent time occupied by waves of 7 cps or slower. The average for the three leads, and the highest delta index in any lead indices used in the final tabulation. index Simultaneously, the record was scanned delta- were the for the slowest frequency identified at least twice in any lead; the highest voltage of any delta wave; and the durb ation of the longest burst. (V) �Ch. Medcrart instrument, needle electrodes, and bipolar recording was used. Hyperb ventilation was the only activation technic utilized. During treatment,:records were taken the day after, generally 25 to 31 hours The treatments were administered by the C h? electrostimulator. number of treatments after treatment. staff psychiatrists, using a Reiter Treatment schedules were three times a week; and the varied from 9 to 33. As patients Showed clinical improve- ment, the There psychiatrist tended to give fewer treatments, and more widelyfspaced. were 15 women and 9 men in the series, and ages ranged from.2h to 68 with a median of h7. EVALUATION QE CLINICAL RESPONSE: All the patients eight were observed for at least after termination of therapy. determined on the basis of the res- weeks patient's reaponse to electroshock was ident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients were The divided into three groups A. Markeglz ggproved: ~ markedly improved, moderately improved and unimproved. The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer showed the which brought them symptoms into the hOSpital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medic- ation, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. six patients in this group showed some improvebut continued to manifest indications of mental illness. These patients B. iModerately ggprove : The ment typically Showed symptomatic relief, i§,, acute depressive features might be gone, �On the basis of these five indices of slow wave activity the records placed in a rank order from the greatestabnormality to the lowest. cords were then divided into 3 groups - g uﬁbr were The 160 third - high degree EEG re- abnorm- ality) and lowest third =£w degree abnormality. RESULTS:1.0ur results show a positive correlation between early high degree EEG abnormality and improvement. These relationships are demonstrated in Slide I. utilizing these quantifications of slow wave abnormality induced by electroshock, we conclude that such EEG abnormality induced in the first 3 weeks of ‘By is treatment an essential pre-requisite for the short term favorable clinical response. 2. What relationships exist between each of the indices, clinical response, and then / amongst each first with the other? Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much im- showed proved group jumps to 52% by the 7-9 treatment; while the moderately improved and unimproved groups show a gradual, slow increase to 10-20% by the 10-12 treatment. A similar set of curves id demonstrated in slide 3 for the mean highest percent time delta in one lead. In the next shows the show delta other two Slide same slide the slowest frequency is recorded, significant relationships. While the and this) tbo/ much improved patients to 3 cps or less by the second week of treatment, groups Sarely reach )4 cps by the fourth week of treatment. waves down 5 shows the same much improved group show week the mean correlations for the mean and- *{e highest amplitude, the higher voltages by the second week and by the fourth differences are persistent for all three groups. �Finally, slide 6 shows the duration of bursts. mean The records of the much Improved patients third treatment. Bursts are less frequent in the unimproved and week of show longer bursts, averaging more than 7 seconds by the mod- erately improved groups and are significantly shorter in duration. not noted here, however, is the factor of regularity of bursts. In the longer bursts, wave forms frequently were more regular in frequency and amplitude, than in the other two groups. These studies may be interpreted as demonstrating of slow wave activity arise from the same that each of these measures physiological process, and assume the significance in relation to the disturbances in cerebral function induced by electroshock. same I 3. Finally, can these alterations in the pects of cerebral function which EEG may have been be correlated with other ap- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal test of Weinstein and Kahg? tests of double simultaneous tactile stim- ulatioaj and tests of amytal test showed a memory and recalfz) Of these three indices, only the positive correlation with improvement and.with the EEG. results were presented recently at the American Psychiatric Association we will forgo a discussion at this time. ‘93 __,wle These and It.;::; suffice demonstrates the correlation berel éF, tween the amytal eating and the high degreerhEG abnormality. n—v_ this iigﬁgLshows ﬁb£ that the next slide, # 7 ' , distinct relationship between the two factors. At this point I should like to summarize our findings and express some thoughts as to their significance for a theory of electroshock action. There is little doubt that electroshock induces delta abnormality in the EEG. It is a symmetric, chiefly frontal, but with increasing treatment, spreads to all leads. With increasing treatment the frequencies became slower, the amplitudes higher, the burst activity longer and more regular. in every record after electroshock, its ‘While degree delta abnormality is present is variable. Roth's experiment's �~8- inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treatment. correlations of degree of delta abnormality with improvement are also significant for the theory of the mechanism of electroshock. An early, SusOur tained alteration in cerebral function as measured by the EEG, and also by the amytal test, appears to be a necessary pre-requisite for improvement. Where *- in the amytal test), the: the patient's behavior. €l%n ificant clinical improvement will fail to occur in fact that the correlations were not evident with memory loss, points to the possibility that this is not a significant factor in improvement. such changes fail to occur in the EEG (and The In conclusion, these studies lend support )to a theory of EST action recently (Kahn)(.r These authors postulated that enumerated by Weinstein and one of us improvement following electroshock is the result of a milieu of altered brain function in which of the creation in the patient new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of tbs Weinstein-Kahn hypothesis is supported. Secondly, these studies point to the validity or quantitative the elucidation of mechanisms of behavior. EEG studies for �1533 m a???" September 21, 1955 MEMORANDUM TO: FROM: Dr. Soseph S. A. Miller Dr. (1) Max Fink entitled "Quantitative Studies of Slow Wave Activity Following Electroshock" will be presented at the Eastem EEG meeting at Our paper Bethesda, Friday September 30th. (2) May I have permission for Dr. Kahn (the co-author) and myself to attend the sessions of the society? �(new? ' £5)“; saw» 21.. 1955 m! m1 Mamaahamr ”gum (1) our W amt-MM *mpmuu saw» a: 3m 1m Mtiviw (a) lily 1: MWMWﬂnbapWMWMMWmM at whim! is!» ma pammaa tear m». ”aim at the am m (m mama!) and W ta 357‘ �III: Quantitative Studies 2; Slow Wave 9/55 Activity Following'Electroshock Fink, Max MOD. Robert L. Kahn, Ph.D. Hillside Hospital, Glen Oaks, New York Despite repeated attempts, correlations between slow wave activity in- duced by electroshock and subsequent therapeutic outcome have been unsuccessful. However, certain conclusions are warranted from previous studies (1). Electro- shock therapy induces alterations in the electroencephalogram in all subjects. Three patterns are generally described: 1) slowing of the alpha frequencies; 2) the appearance of random, symmetric slow'wave voltage which cies in rate may activity, generally of high appear as burst activity; and 3) diminution of beta frequenThere and amplitude. is a direct relation between the degree of these changes, and the number and frequency of treatments. a saturation point of change is described, to the pretreatment levels The 1 to h weeks, depending directly on the treatment. relationship between degree of manifest memory degree of electroencephalographic abnormality. memory impairment. in cerebral loss and confusion of direct and the Cases are described of severe at the Eastern EEG rhythms without manifest In these reports, ganic confusion also correlates poorly with Evesented is the lack with few treatments and without significant electroencephalographic change; and also of severe changes confusion of further Such induced electroencephal- Another area of agreement among the cited authors memory changes subjects rate of return of the cerebral patterns is generally number, frequency and the type of many which can be maintained by treatment, but which is apparently not increaSed. ographic changes are reversible. In it is clinical stated that such or- clinical results. Society, Bethesda, September 30, 1955. �-2studies, however, Two cited as noting a correlation between may be electroencephalographic changes and clinical improvement. Hoagland, Malamud, in their l9h6 study of involutional Kaufman and Pincus women relation between changes in their clinical rating scale time more than 13 cycles per second activity. and the per-cent the disturbed behavior be- As manifest, the fast activity increased. came more (2) reported a treatment induced behavior- As al improvement, such fast activity diminished. With recurrence of there was an More induced increase in the Roth (3) described a recently, EEG time 13 cycles per second % provement. Roth noted it tone, he elicited characteristic changes in the was random irregular and bursts. w act- wave solution of the thicpen- EEG after electroshock in every slow wave activity, which increased bilaterally synchronous, high with mere treatment to a highly rhythmic, litude delta runs 51 was However, by administering an intravenous subject. Early, there that irregular in appearance, and could not be satisfactorily related to imr ivityas seen in a routine post-shock record reports that activity. relationship between thiopentone changes and the recovery process. he confirmed the symptoms, amp- chiefly 2-3 cycles per second, with These were voltages of 200-350 microvolts.and continuous durations of 30-80 seconds. the resting record evinced rhythmic delta activity, thiopentone increased voltage and duration, spread its believed that these changes were patients than But two weeks. related to the ing the patients EEG EEG transient change even improvement change does not ensure recovery failed to remit for longer in clinical condition seemed to be change in these patients. If effect it we are correct in connect- would seem, since most of the typical changes, that the physiological basis for by the majority of cases; moting recove 1y." EEG attained such a changes with the therapeutic deveLOp is acquired who its area, and decreased its basic frequency. Roth related to the process of recovery, and he concluded: "The development of a typical and 10 of the 36 'When it may or may not prove improvement effective in pro- �.3While these two studies demonstrate a relationship between clinical result' and EEG abnormality, the majority of reports fail to do It is so. not likely that this discrepancy is the result of different populations, but rather, the differences in methods of evaluating improvement, the time of evaluation, and differences in estimating changes in cerebral function. In the course of studies of altered brain function induced by electro- at shock the Hillside Hospital in New York, further data on the relationship clinical effects of electroshock were collected. The general results of previous investigations on the alterations in the EEG with between EEG changes and electroshock were confirmed, but also, a definite relationship between effects and the clinical result was EEG demonstrated. Three foci are presented today: (1) (The EEG patterns following electroshock and their relation to imp provement. (2) The (3) The SUBJECTS intercorrelations of different quantifications of delta activity. relation of these observations to a theory of electroshock acticn. AND METHOD: Twenty-four consecutive patients referred for electro- shock were studied. Electroencephalograms were done prior to treatment, at weekly intervals during treatment An 8 and after treatment. channel Medcraft instrument, needle electrodes, and bipolar recording was used. Hyperventilation was the only activation technic utilized. treatment, records were taken the day after, generally 25 to treatment. The Reiter C 31 hours During after treatments were administered by the staff psychiatrists, using a h? electrostimulator. Treatment schedules were three times a week; and the number of treatments varied from 9 to 33. improvement, the As patients psychiatrist tended to give fewer treatments, showed clinical and more widely �.u. There were 15 women and 9 men spaced. to 68 in the series, and ages ranged from 2h with a median of h7. g3 EVALUATION CLINICAL RESPONSE: All the patients were observed for at least eitht weeks after termination of therapy. patient‘s reSponse to electroshock'was determined on the basis of the resident psychiatrist's impression, staff opinion, the nurse's notes and the clinical evaluation of the supervisor in charge of electroshock. The patients The were divided into three groups - markedly improved, moderately improved and unimproved. A. Markedly Improved: The 11 cases in this group showing recovery or marked improvement. These symptoms which brought them into the beepital; patients were regarded as no longer showed the their doctor felt they were better; and the nurses' notes confirmed such aSpects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hospital B. improvement activities. six patients in this group showed some but continued to manifest indications of mental illness. These Moderately,lmproved: patients typically The showed symptomatic relief, i:g;, acute depressive features might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally g£_unimproved: In this group were placed seven patients in whom change was not clearly noticable or who showed only equivocal or transient improvement. Some showed fluctuations in behavior, at times appearing somewhat improved. But the changes were not treatment, they appeared much sustained, so that by the as they did before. end of �.5are aware of the difficulties in evaluating improvement. Others might have differed in the estimates of change in these patients. In any case, by we using this threefold classification, the differences between the groups first and third will be distinct. 93 EVALUATION delta index EEG RECORDS: was A total of 160 records were obtained in these sub- jects. Following the suggestion of Strauss (h), the determined for three lead combinations (frontal-parietal, anterior temporal - vertex, and parietal-ear lobe) for 180 seconds of recording for each lead. The delta index is defined as the per-cent time occupied by waves of 7 ops or slower. delta-index for the three leads, and the highest delta index in any lead were the indices used in the final tabulation. The average for the slowest frequency idenp tified at least twice in any lead; the highest voltage of any delta wave; and the duration of the longest burst. Simultaneously, the record 0n the was scanned basis of these five indices of slow wave activity the records were placed in a rank order from the greatest abnormality to the lowest. 160 records were then divided into groups abnormality, and lowest third = RESULTS: in Slide 3 - i;g=_upper third= The high degree EEG low degree abnormality. l. Our EEG abnormality and improvement. These relationships are demonstrated results show a positive correlation between early high degree I. utilizing these quantifications of slow wave abnormality induced electroshock, we conclude that such EEG abnormality induced in the first 3 By of treatment is an.essential pre-requisite for the short term favorable by weeks clinical response. 2. What relationships exist between each of the indices, clinical response, and then amongst each other? first with the �~6- Similar analyses of the relation of each of the indices and clinical result identical curves to the group curve shown before. Slide 2 shows the relation of the delta index to improvement. The mean index in the much improved showed group jumps to 52% by the 7-9 treatment; while the moderately improved and un- improved groups show a gradual, slow increase to 10720% by similar set of curves is demonstrated in slide A 3 the 10-12 for the mean treatment. highest percent time delta in one lead. In the next slide the shows the same delta show other two groups to the same much improved group show week h cps by the much improved While the much improved fourth correlations for the week of mean all three 6 shows the mean duration of patients this, too, patients treatment. highest amplitude, the higher voltages by the second week and by the fourth the differences are persistent for Finally, slide and cps or less by the second week of treatment, the 3 rarely readh 5 shows is recorded, slowest frequency significant relationships. waves down Slide mean show groups. bursts. The longer bursts, averaging more than records of the 7 seconds by the third week of treatment. Bursts are less frequent in the unimproved and moderately improved groups and are significantly shorter in duration. Not noted here, however, is the factor of regularity of bursts. In the longer bursts, forms frequently were more regular wave in frequency and amplitude, than in the other two groups. These ures of the studies may be interpreted as demonstrating that each of these meas- activity arise from the same physiological process, and assume significance in relation to the disturbances in cerebral function in- 31 w wave same duced by electroshock. 3. Finally, can these alterations in the pects of cerebral function which may have been EEG be correlated with other as- altered by electroshock? In these studies, three other indices of cerebral function were assayed - the amytal �-7- test of Weinstein and Kahn (5), (6), and tests of memory and tal test showed a positive correlation with tests of double simultaneous tactile stimulation recall (7). Of these three indices, only the amyimprovement and with the EEG. These results were presented recently at the American Psychiatric Association and we will forgo a discussion at this time. It may suffice that the next slide, # 7, demonstrates the correlation between the responses on amytal of abnormality. This graph EEG tests and the degree distinct relationship between the shows a two I factors. this point I should like to summarize our findings and express thoughts as to their significance for a theory of electroshock action. At is little doubt that electroshock induces delta abnormality in the symmetric, chiefly There It is EEG. frontal, but with increasing treatment, spreads to all leads. increasing treatment the frequencies With some became slower, the amplitudes the burst activity longer and more regular. While delta abnormality in every record after electroshock, its higher, is present is variable. Roth's experiment's degree inducing increasing delta abnormality with barbiturate are significant in predicting the later changes induced by further electroshock. In some subjects however, a high degree delta abnormality is not induced despite extensive treat- ment. Our correlations of degree of delta abnormality with significant for the theory of the mechanism of electroShock. tained alteration in cerebral function as measured amytal test, such changes clinical improvement are also An early, sus- by the EEG, and also by the appears to be a necessary pre-requisite for improvement. Where fail to occur in the improvement in the amytal test), then significant will fail to occur in the patient's behavior. The fact that EEG the correlations were not ivident with (and memory loss, points to the possibility that this is not a significant factor in improvement. In conclusion, these studies lend support to‘a theory of enumerated by Weinstein and one of us (Kahn) (8). EST These authors action recently postulated.that �-8improvement following electroshock of a milieu of is the result of the creation in the patient altered brain function in which new patterns of adaptation, part- icularly those of denial, may be maintained. These EEG studies demonstrate that an altered milieu of cerebral function as measured by delta abnormality is a pre-requisite for improvement. To this extent the first part of the weinsteinKahn hypothesis is supported. Secondly, these studies point to the . for the elucidation of validity of quantitative mechanisms of behavior. EEG studies �REFERENCES l. Chusid, Joseph G. and Pacella, Bernard L.: the Electric Shock Therapies, J. Nerv. The Electroencephalogram & Dis., 11g: 95-107, 1952. Ment. Hoagland, H., Malamud, W., Kaufman, and Pincus, 6.: encephalogram and in the Excretion of 17 in Changes in the Electro- Ketosteroids Accompanying Electro- shock Therapy of Agitated Depression, Psychosom. Med., §; 2&6-251, 19h6. 3. Roth, Martin: Changes in the EEG Under Barbiturate Anesthesia Produced Electroconvulsive Treatment and Their Significance for the Theory of Action, EEG by ECT and Olin. Neurophys., 2; 261-280, 1951. Strauss, Hans: Clinical and Electroencephalographic Studies ~ Correlations of Mental, Electroencephalographic and Anatomic Changes in Cases with Organic Brain Disease, So Am. J. Psychiat., 191: and Kahn, R.L.: weinstein, E.A., ("Amytal Sodium") Diagnostic hZ-SO, l9hh. Use of Amobarbital Sodium in Organic Brain Disease, Am. J. Psychiat., 192: 12, 889-89h: 1953. 6. Fink, M., Green, M. and Bender, M.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology, 2: h6-58, 1952. 7. Karin, H., Fink, M. and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. “eurologica, 1Q: 88-96, 1956. Weinstein, E.A., Kahn, R.L. and Linn, L.: Peychosis During Electroshock Therapy: 19.9.: Its Relation to the 22-26, 1952. Theony of Shock Therapy, Am. J. Psychiat., �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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 Quantitative studies of slow wave activity following electroshock. Electroencephalogr Clin Neurophysiol. 8:158, 1956. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-21a-025 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; 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 Several [preprint]s, drafts, and handwritten manuscripts of this title. Three short letters from Fink to Joseph S. A. Miller. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/d22bf8e1eaccf5f9a01c426789665f0e.pdf 7c6234b95a1768fbfe1c37f8a9076215 PDF Text Text Reprinted from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Edited by G. J. Sarwer-Foner, M.D. CHARLES C THOMAS ° PUBLISHER 0 Springﬁeld ' Illinois ' U.S.A. W DRUG INDUCED CHANGES IN INTERVIEW PATTERNS: LINGUISTIC AND NEUROPHYSIOLOGIC INDICES By MAX FINK, M.D., JOSEPH JAFFE, M.D., and ROBERT L. KAHN, PHD. In studies of the effects of newer psychopharmacologic agents on behavior, we are inclined to emphasize their effects on the patient. The newer compounds do, indeed, have specific physiologic effects, and we propose to review some of the induced neurophysiologic changes. But psychopharmacologic agents affect more than the patient alone—and it is the interactive effects that are the focus of this conference. I am reminded in this regard of the story told at a similar conference by Dr. David Rioch about a psychopharmacologic his that the On of earlier days an amphetamine. era, agent patients took amphetamine, Dr. Rioch reported, they seemed much better. However, on the day when he took the medication, the patients also were considerably improved! How can such changes in human interaction be measured? Of the many aspects of behavior that are altered by the new agents—and it is clear that all aspects of behavior, as perception, ideation, motor activity, mood and judgment are altered—verbal behavior has numerous attributes that make it suitable for the evaluation of changes in interpersonal relations. Verbal behavior is easily recorded, is readily quantified as it is already in units (words, phrases and sentences) and can be recorded and measured without the introduction of artificial sets, equipment, tests or instructions. Furthermore, speech is the core of psychotherreflect in of and measurement language changes may patterns apy changes in the ongoing relationship. For these reasons, we have Aided by Grants M-927 and MY-2092, National Institute of Mental Health, US. P.H.S., and Grant 56-151 of the Foundations’ Fund for Research in Psychiatry. 29 �The Dynamics of Psychiatric Drug Therapy 30 undertaken studies of language patterns—of the patient and of the therapist—as influenced by the newer psychopharmacologic agents. The groundwork for this report was laid in a study by R. L. Kahn of the language changes following convulsive therapy (1) . Under the conditions of the alteration in brain function induced by repeated convulsions, changes in syntactical aspects of language were observed which were related to the degree of cerebral dysfunction and to clinical ratings of improvement. Prior to treatment patients expressed their problems and their aspirations in the present tense and first person, without denial, evasion or cliche’s. During treatment, however, they increasingly utilized the past or future tense and the third person mode with qualification, evasion, denial, displacement, cliches and cryptic responses. Such language patterns on the part of the patient resulted in an alteration in the language patterns of the thera— pists. They, too, found interpretive statements in the present tense less communicative, and increasing use of the future tense, displacement, and minimization of symptoms as aspects of a reassuring attitude became prominent (2, 3). Syntactic analyses are essentially grammatic content analyses, and are dependent upon interpretations by the observer of the subject’s communication. More recently, the dyadic TTR, another measure of language change, has been applied to this problem by J. Jaffe (4, 5). The two person group, or dyad, comprising the interview is treated as a unitary system. The language measure involves the pooling of the verbal behavior of both participants—the patient and the therapist in psychotherapy. In these studies, the tape recorded interview is transcribed in temporal sequence without regard to the speaker of the words, and then divided into consecutive 25 word units of intereaction. TTR, or type-token-ratio, is an established psychological index of language diversity. The ratio reflects the number of different words (the types) to the total number of words (the tokens) in the sample. The TTR is calculated for each 25 word unit and the pattern of consecutive scores is studied. In patients undergoing convulsive therapy, there was a �The Dynamics of Psychiatric Drug Therapy 3] consistent decrease in the mean TTR and an increase in variability (standard deviation) about the mean. These changes reflect greater stereotypy and repetitiveness in the interaction. In a control group of subjects, without induced brain dysfunction, there was neither a change in mean TTR nor in the degree of variability, although there was a tendency for the variability to decrease (6). When these two language measures—one a grammatic content analysis and the second, a formal diversification score—were compared, a decrease in the mean and an increase in variability of the TTR patterns were observed in the subjects who evinced two or more syntactic language changes. Conversely, in those with less than two syntactic language changes, no significant difference in the mean or standard deviation of TTR was observed. These observations indicate that with increased syntactical language changes, there is also a decrease in language diversity with greater stereotypy and repetitiveness. Furthermore, when analyses of each language measure were made with the degree of induced neurophysiologic change, as reflected in the degree of delta activity in the electroencephalogram, significant differences were shown only by the subjects with high degrees of delta activity. In the earlier studies of convulsive therapy, a neurophysiologic-adaptive hypothesis of the mode of action of this form of therapy was expressed (7). In this hypothesis, the therapeutic process is ascribed to a persistent alteration in cerebral function, which provides the milieu for a change in interaction of the subject with his environment. Recently, this hypothesis has been applied to the newer tranquilizing agents (8) and validating studies are now in progress. The studies of verbal behavior are one part of the investigation. We would like to describe our present experimental techniques, report the data from the neurophysiologic and language studies for a number of compounds, and discuss the significance of language measures as indices of change in the ongoing interpersonal behavior of therapist and patient. �The Dynamics of Psychiatric Drug Therapy 32 METHODS At present, all observations are made in the EEG laboratory. Following a routine EEG recording, an unstructured psychiatric interview, with short periods of structured inquiry, is taperecorded. With EEG running, an intravenous injection is then given at a slow rate. When specific EEG or clinical changes are induced, EEG recording is stopped and the interview repeated. Periods of EEG recording and verbal interaction recording are alternated for the duration of the period of observation. The EEG is measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow wave (9) , alpha or beta frequencies. The tape recordings are transcribed and measured for the diversification of consecutive 25 word samples of dyadic speech (4, 5) and syntactical changes (1). The dyadic analyses have been described. In the syntactic analyses, the response to three standard questions is evaluated as to changes in grammar and content: “What is your main troubleP”; “Why did you come to this place?”; and “What do you wish for more than anything else?” Changes in syntactical use of person, alteration in tense, evasion (as answering a question with a question or “I don’t disof the the subjunctive, use as by know”), qualification, placement or verbal denial of symptoms, increased use of stereotyped expressions or clichés, cryptic responses or withdrawal and silence were scored as changes in the communication pattern. Consecutive patients referred for drug or convulsive therapies in a voluntary psychiatric hospital were seen prior to, and at various intervals during, treatment. To date, the following agents have been studied by these methods: amobarbital, benactyzine, chlorpromazine, diethazine, iproniazid, lysergic-acid diethylamide and Win-2299 (2-diethy1aminoethy1 cyclopentyl—Z-thienyl— glycolate) . �The Dynamics of Psychiatric Drug Therapy 33 OBSERVATIONS l. Electroencephalogram In a previous study (8), it was observed that agents that increase EEG synchronization or induce a shift in EEG frequencies to the slow range generally induce behavioral changes of sedation and tranquilization. Agents that desynchronize the record, however, or induce irregular fast activity, are associated with hallucinatory, excitatory or illusory activity. Of the first group of agents, we have tested amobarbital and chlorpromazine. Amobarbital regularly induces high voltage, well synchronized, fast activity, at 20-24 cps. The regularity of the appearance of this increased synchronized fast activity has become the basis for the “sedation threshold” (10). Chlorpromazine has a variety of effects, depending upon the pre-injection record. In subjects with well defined alpha activity, both alpha voltages and the percent time alpha activity increase (1 l) With poorly modulated, low voltage, fast records, the per cent time alpha increases. In patients with low degrees of slow wave activity, voltages of slow wave activity increase, and the per cent time of both delta and alpha increase. Diethazine, benactyzine, LSD, and Win-2299 are examples of the second group of compounds. In tests of diethazine (12), in subjects with well modulated high per cent time alpha records, there is a decrease in voltage and per cent time of alpha activity and irregular low voltage fast activity appears. In records with high voltage slow wave activity, decrease in voltage and per cent time of slow wave activity is prominent and is associated with irregular fast activity. Similar patterns have been observed for benactyzine, Win-2299 and LSD. . 2. Language Analyses Changes in language occur with these induced changes in brain function (Table I). With chlorpromazine and amobarbital (Class I) there is a decrease in the mean TTR and an increase in variability (standard deviations) of consecutive scores. These changes are similar to the changes noted earlier for elec— tro convulsive therapy (6) . In contrast, diethazine, benactyzine, �34 The Dynamics of Psychiatric Drug Therapy LSD and Win-2299 (Class II) induce an increase in mean and a decrease in variability. TTR TABLE I TTR Class I Class II CHANGE WITH DRUG ADMINISTRATION (N223) (N227) Difference Class Mean Standard Deviation —0.78 +0.44 +1.42* —l.00“ 220‘ 1.44“ I “ Class II Diethazine Benactyzine Amobarbital (l3) Chlorpromazine (10) LSD-25 Win-2299 p > .02 (9) (5) (3) (10) We have not, as yet, applied syntactic methods of analysis to these recordings. Syntactic analyses were done, however, in the earlier studies of the effects of amobarbital and diethazine in patients with varying amounts of slow wave activity after convulsive therapy. Amobarbital amplified, and diethazine reversed, the syntactic patterns produced by convulsive therapy. With amobarbital, denial, displacement, minimization, and use of third person and future and past tense increased significantly (1), while after diethazine, there was a significant decrease (l2) . DISCUSSION We have observed consistent relationships between the neurophysiologic effects of various drugs and changes in two measures of verbal interaction. We have not underscored, although we have consistently observed, that both the behavioral changes and the clinical ratings of improvement are dependent upon the induction of persistent neurophysiologic changes. We have sug— gested, therefore, that the language changes constitute an important segment of the cues upon which the evaluations of “improvement” are based (1) . These language measures provide an operational basis for studies of changes in interpersonal relations without resort to hypothetic energic or topographic constructs. �The Dynamics of Psychiatric Drug Therapy 35 Also important for our discussion is the demonstration that different patterns of verbal behavior may be related to the different neurophysiologic effects of various therapies. Language analyses provide another means of investigating and measuring neurophysiologic effects. Weinstein and Kahn’s (13) demonstrations that language patterns of orientation, confabulation and denial in structured interviews were valuable indices of brain disease, heralded such applications. The demonstration here of consistent changes in dyadic TTR scores suggests that unstructured verbal interviews may also be used successfully in neurophysiologic analyses. The measures described here are crude, and the data preliminary. The consistent nature of the findings as we have investigated each new agent has been striking. Other language measures have been suggested, including changes in rate of speech, tense, and relative amount of verbalization by each participant. Further analyses with other psychopharmacologic agents, and other measures of language analyses are in progress. How can we relate these observations to the problems of this conference? First, generalizations about the psychologic or psychodynamic effects of psychopharmacologic agents are probably untenable unless the varied neurophysiologic and language behavioral effects are encompassed in the hypothesis. While introspective analyses provide some measure of drug effects, more objective data are needed, and these may be provided by language analyses. For example, the successful use of chlorpromazine in the management of hallucinatory and excited states has been well-documented. In such states, high diversification of language, reflective of diffuse associative processes is prominent. This diversity clinically manifest in tangential, incoherent and neologistic speech, with rapidly shifting frames of reference (5) . With chlorpromazine therapy (and the induced alteration in brain function) there is a decrease in the diversification of the verbal interaction, with a decrease in the use of present tense and first person speech. These language patterns may provide the basis for the change in interaction between therapist and patient. Conversely, in apathetic, redundant, blocked or withdrawn pais �36 The Dynamics of Psychiatric Drug Therapy tients, the administration of LSD (14) or mescaline (15) have been suggested. These agents induce an increase in associative is reflecdiversification a increased which of language processes tion. These agents also increase the use of first person and of facilitate thus and tense speech survey may patterns, present the paﬁents premnn:atdtudes and feehngs “ﬁnch the therapbt is interested in exploring. In summary, we have indicated that concurrent neurophysiologic (EEG) and language behavior (syntactic and dyadic diversification) measures are techniques for the operational analyses of the effects of psychopharmacologic agents, in the two-person system of doctor and patient. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of these new therapies. REFERENCES Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Hoch, P. and Zubin, J. eds. New York, Grune 8c Stratton, 1958, pp. 126—139. 2. Esecover, H., Jaffe, J., and Kahn, R. L.: Psychotherapeutic techniques with electroshock patients. J. Hillside Hosp, 7: 17-25, 1958. 3. Jaffe, J., Esecover, H., Kahn, R. L., and Fink, M.: Modification of psychotherapeutic and supervisory relationships by altered brain function. 1. In preparation. 4. Jaffe, J. An Objective Study of communication in psychiatric inter— views. ]. Hillside Hosp, 6:207-215, 1957. 5. Jaffe, J. Language of the Dyad. Psychiatry, 21:249-258, 1958. 6. Jaffe, J., Kahn, R. L., and Fink. M.: Communication patterns with altered brain function. Read at Eastern Psychologic Assoc, April 1958. 7. Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation between altered brain function and denial in electroshock therapy. A.M.A. Arch. Neurol. dy' Psychiat., 76:23-29, 1956. 8. Fink, M.: A unified theory of the action of physiodynamic therapies. ]. Hillside Hosp, 6:197—206, 1957. 9. Fink, M., and Kahn, R. L.: Relation of EEG delta activity to behavioral 63' Arch. A.M.A. Neurol. electroshock. in Psychiat., 78:516response 525, 1957. 10. Shagass, C.: The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 6:221-233, 1954. ��at 3:2» W mu mm. W WWW “a“ M I. 3., and mm mm mm and It 3.1%., April 12, mum, 11.: 8.1:»: at. 1958. mF?“ '1'? , immummdw mama» was: Wm, mmmumwuwam mu: m). 3,: ... 9 w_ gs 191.206. 1991. �Drug Indueod Ghana-l in Imam“ know: man ma Hwophylielogie XII Indiana ’m 11.9., Jawb- JII‘. xi)... ma Rabat In Kuhn PILD. mmm quoal' ﬁnd for Rani-eh in Fayehutry. PM the Ewart-mt a! Puemtry, Wain 3mm, Elan om, Jul. , 3.1. Aided by ﬁrm“ “2? and name, trident]. 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NWuammmmmumM) w‘nmmw3-MNMW' mmmamu _' Mumamwwammu‘ Mum mmmmmmaﬂmwm3 ‘ Mmmmm,mww:mmmam thwawmrwmmwunm MW hm,muwmmmmmm(m) MW¢W(WmmﬂMMWm �tum” for tho apex-gum]. may”: at the «feat: at mcmhac agents, in tho Mm mm a: “Mr a and patient. Further mention Imus: mm“ m :33ng u mum but: far the underﬂmdinc of the whim «that: 0: than an tharnpiu. at �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Drug induced changes in interview patterns: linguistic and neurophysiologic indices. In G.J. Sarwer-Foner (ed.), The Dynamics of Psychiatric Drug Therapy. C.C. Thomas, Springfield, IL, 1960: 29-44. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-45-011 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Jaffe, Joseph; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint, [preprint] and outline. Reprint from THE DYNAMICS OF PSYCHIATRIC DRUG THERAPY Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/945d2769d3cde3d546dfd13ec8bc4c04.pdf 7b68d01261bda3dea9d45000fea060a8 PDF Text Text The F ace—Hand Test as a Diagnostic Sign of Organic Mental Syndrome Max Fin/c, M.D., Martin Green, [M.D. and [Morris B. Bender, M.D. In the course of sensory studies by the method of double simultaneous stimulation, it has been observed that patients with mental changes may show perceptual errors which are not demonstrable by routine single stimulation.1 When stimuli are simultaneously applied to the cheek and the hand (the face-hand testz) , patients frequently report only one of the two stimuli, or when reporting the two stimuli mislocalize one to another part of the body or even into space. These changes in perception are seen on repeated trials of the face-hand test and seem to form a con— sistent part of the syndrome usually labelled “organic mental syndrome” or “organic psychosis.” SUBJECTS Four hundred patients, who manifested cerebral dysfunction in the form of an organic mental syndrome due to a variety of causes, were studied on the wards of the Bellevue Psychiatric Hospital.* Each patient manifested, to some degree, the following mental changes: (1) impairment of memory, for both recent and remote events; (2) confusion and disorien— tation for time, space, situation and body image; (3) errors on calculation and general information tests; (4) distractibility, poor attention span, inability to handle more than one situation at a time, concreteness and *This number represents several series of patients in whom the method of double simultaneous stimulation were applied. It includes all tests of the face and hand by touch, pin prick and combinations of touch and pin prick stimuli, as well as tests of body areas other than the face and the hand. From the department of neurology and psychiatry, New York University College of Medi— cine, and the department of neurology and psychiatry, Bellevue Hospital, New York City. This work was aided in part by a Fellowship from the National Foundation for Infantile Paralysis, and by a research grant from the United States Public Health Service, National Institutes of Health. Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 46 �4'7 ORGANIC MENTAL SYNDROIVIE rigidity in thinking; (5) perseveration of speech and behavior; (6) emo— tional liability and readily elicited “catastrophic” reaction; (7) loss of initiative and interest in the environment and indecent exposure and soiling of the clothing. The clinical diagnoses were varied, including chronic alcoholism, post-traumatic encephalopathy, hypertensive cerebro-vascular disease, diffuse arteriosclerotic softening, syphilis of the central nervous system and degenerative diseases, such as Alzheimer’s disease, Hunting— ton’s chorea or senility. Observations on the face-hand test in patients with organic brain disease were compared with previously obtained results of similar examinations in normal adults and children and in adult patients with schizophrenia”. The normal adults and children, including students, associates and patients in clinics, were without manifest disorder of the nervous system. The schizophrenic adults were patients from the wards of the Bellevue Psychiatric Hospital. No effort was made to group the patients into the various clinical types of schizophrenia. JMETHOD The face—hand test was applied to each of these subjects. During routine physical examination the patient was asked to close his eyes. One cheek and the contralateral hand were simultaneously touched or stroked by the examiner’s ﬁngers. The patient was then asked what he had felt. The usual response was, “You touched me here,” while pointing to the cheek. After this initial application of the face-hand test, the patient was again asked to close his eyes and the contralateral cheek and hand were similarly stimulated. In the many instances when only one percept was reported, the patient was asked if he had felt anything else. Occasionally the second percept was reported after this question, but more often it was not. Thereafter the tests were applied to the face and hand and to other parts of the body. RESULTS In patients with the organic mental syndrome most responses to the initial and subsequent face-hand tests were of four types: (1) a touch on the cheek only, implying no sensation in the hand; (2) a touch on each cheek, implying a mislocalization or displacement of the percept evoked in the hand to the cheek; (3) a touch on the hand only, implying no sensation in the cheek; and (4) correct localization of the percepts evoked in the cheek and hand. Less frequently other responses were noted, as both percepts in the hand, or a percept in the cheek and homolateral hand implying a mislocalization from one hand to the opposite hand. In a few cases the �NE UROLOGY 4-8 percept in the hand was mislocalized to a part of the body upon which the hand was resting, out into space, or onto the examiner’s body. The following case illustrates the various responses of patients with an organic mental syndrome. Case admitted to the psychiatric hospital with a one year history of progressive difﬁculty in concentration, inability to continue work, mood disturbances, episodes of confusion, forgetfulness and occasional lapses into irrelevant speech. Later, following the death of his wife, he became depressed, cried frequently, and spent many hours talking to himself. The neurologic examination showed minimal right facial weakness and some gross tremors of the hands. On psychiatric examination the patient answered questions coherently and relevantly. He was euphoric and friendly. There was disorientation for time and place, his memory for both recent and remote events was poor, and confabulation was frequent. Calculation and general information tests were performed poorly. Judgment was poor and there was no insight into his difﬁculties. When left alone he carried on a conversation with himself, and when presented with a mirror he identiﬁed the image as that of his brother and conversed with the image, listening for replies and reporting them to the examiner. In addition, there were difﬁculties in expression, both verbal and written, with errors in reading, calculation and reporting numbers. He was able to carry out simple commands but made errors in imitating mouth and hand movements. He handled objects clumsily. There was right-left dis— orientation, and he made errors in naming body parts. Psychometric examination revealed a severe organic impairment with defects in memory, concentration, abstraction, and concrete verbalization. His performance on the Kohs block test was severely deﬁcient, exhibiting ability to complete only the ﬁrst two 1:——-A 60 year old man was ﬁgures. , 0n sensory examination by the method of single stimulation he could identify and localize pin prick and touch stimuli, except that stimuli applied to the left hand TABLE Stimulus Right cheek, left hand Left cheek, right hand Right cheek, right hand Left Cheek, left hand Right and left hand Right and left cheek Right cheek, left shoulder Left cheek, right shoulder Left foot, right hand Left hand, right foot Right and left hand Right cheek, right hand Left cheek, left hand Right and left cheek Right cheek, left hand Left cheek, right hand 1 Response Right and left cheek Right and left cheek Right cheek, right shoulder (P) Left cheek only Correct Correct Right and left cheek Left cheek, left shoulder Left foot, left hand Right and left foot Out into space* Two percepts right cheek Left cheek only Correct Right and left cheek Right and left cheek Type of Defect Displacement Displacement Displacement Extinction Displacement Displacement-allesthesia Displacement-allesthesia Displacement Exosomesthesia Displacement Extinction Displacement Displacement *Patient mislocalized these percepts into space, insisting that the stimulation had not been applied to his body. �49 ORG/1N1C .MENTAL SYNDROME were occasionally displaced to the shoulder or the face on the same side. There were no signiﬁcant differences in temperature, Vibration, position sense, and two-point discrimination tests on the two sides of the body. Stereognosis was intact. Examinations by the method of double simultaneous stimulation elicited many defects in cutaneous perception. These were manifest by extinction and displacement of percepts. The errors were persistent despite numerous examinations and over many weeks of study. Table 1 is an extract from the record of the patient’s responses to touch stimula- tion. Similar errors in localization of percepts were found when continuous and repetitive pin prick, tuning fork and temperature tube stimulations were used. 0n simultaneous stimulation of the cheek and any other region of the body, the patient correctly localized the percept in the face but seldom perceived correctly, or at all, the other stimulus. This was particularly evident when the cheek and hand were tested, especially a cheek and contralateral hand. A pneumoencephalogram revealed symmetrically dilated ventricles without displacement. A biopsy of brain tissue removed from the right cerebral hemisphere disclosed a prominence of senile plaques, Alzheimer cells and fatty pigmentation of neurons. COMMENT In this case there was no question as to the clinical diagnosis. The is of in defects not surprising. It is signiﬁcant that perception presence despite the severity of the mental dysfunction the alterations in perception were consistent and patterned. Even though the patient appeared confused he never made errors in perception and localization of stimuli on the face, whereas he frequently erred in the simultaneously stimulated hand. Extinction and displacements from the hand were frequent during many examinations. These perceptual errors were conspicuous by their consistency, orderliness and predictability against a background of apparent mental confusion. These changes can be considered a prominent sign in the organic mental syndrome. DISCUSSION Incidence of errors on the face-hand test: Of 156 patients with organic mental syndrome, 91 per cent made errors on the initial trial of the face-hand test using touch stimuli. Subsequent trials revealed a similar high incidence of errors. These errors were in a deﬁnite pattern, in which the face percepts were correctly localized, and the hand percepts either not perceived or mislocalized. Displacement of percepts from the hand to the cheek was a prominent feature during the initial few trials of the test. Errors were noted on both sides of the body and occurred on tests applied to cheek and hand on the same side of the body, or on opposite sides. In 87 per cent of the patients errors were apparent through the tenth trial of the test and persisted for many more trials. Repeated testing �NE UROLOGY 50 I 100 ~ ‘~_ 60 O RESPONSES 0*.\ Responses of normal children ages 3-6 DOMINANT Responses of schizophrenic patients FACE CENT PER 1 2 3 4 NUMBER FIG. 1. Responses on 5 6 or successnve '7 8 9 TRIALS gm multiple trials of the face—hand test to touch stimuli:. on subsequent days elicited similar errors. It must be emphasized that these patients were able to correctly identify and localize single stimuli applied to the face and hands. In signiﬁcant contrast to these observations on patients with organic mental syndrome are the observations on normal and schizophrenic adults.2 On the initial trial of the face- hand test to touch stimuli, '75 of normal and the adults cent per cent of the schizophrenic adults per failed to report one of the two stimuli. As the test was reapplied, the percentage of error rapidly declined until by the tenth trial of the facehand test less than 0.5 per cent of the normal adults and less than 3 per cent of the schizophrenic adults still showed omissions or mislocaliza— tions of percepts (ﬁgure 1). However, examination of children, age three to six years, with this method again showed a very high incidence of defects on face-hand tests. The curve of responses, as noted in ﬁgure 1, is parallel to the curve of responses of the patients with organic mental syndrome. The errors persisted for many trials and were observed in testing over many days. In older children, the curve of responses ap— proached that of the normal adult. A number of factors were found to inﬂuence these responses. Such elements as the type of stimulus, the conditions of the test, the part of �51 ()RGA N10 i1! ENTAL SYNDROME the body stimulated, “set” and “attention” of the patient, the type and severity of the mental changes, and the effect of drugs were considered. Timing and type of stimulus: In previous studies on normal and schizophrenic adults,2 simultaneity, similarity and equality in strength of stimuli were emphasized as essential for eliciting these responses. In the patients with mental changes, however, these factors were not as prominent since stimuli of unequal intensity or of different modalities still elicited errors in the tests. Dissimilar stimuli, as application of a touch stimulus to the cheek and a pin prick stimulus to the hand, or stimuli of unequal intensity, as a light touch to the cheek and forceful rubbing in the hand, elicited extinction and displacement of percepts. Similarly, errors in localization were elicited even if stimuli were not simultaneous, i.e. followed one another with a lapse of a moment or two. As previously reported, these errors on unequal, or dissimilar stimu— lation were not seen in the normal or schizophrenic controls. Application of the face—hand test using pin prick stimuli elicited the same pattern of responses as with touch stimuli. Eighty per cent of the patients made errors on the initial trial and such errors persisted in 60 of incidence is This defects trials. for than ten lower, cent more per however, than in the series with touch stimulations (table 2). In some of these patients it was possible to alternate touch and pin prick stimuli, and observe extinction and displacement of the touch percepts alternating with correct responses to pin prick stimuli. In a number of the more severely affected patients, extinction and displacement of percepts were also apparent on tests with temperature tubes, tuning forks and repetitive rubbing stimulations. TABLE 2 INITIAL TRIAL Organic Mental Syndrome Normal Adult Schizophrenic Adult Modality Touch Pin Prick Touch Pin Prick Touch Pin Prick Hand or Face Only Face-Face Hand-Hand Total Correct 156 50 160 68 15 10 122 35 7’7 75 15 45 ’72 50 51 24 36 13 14 5 3 3 2 2 1 2 0 1 5 0 This factor of the type of stimulus was more prominent in the normal and schizophrenic subjects. Less than 30 per cent of these made errors on the initial trial with pin prick stimuli, and the number of errors declined rapidly until by the tenth trial none of the normal subjects and only one of the schizophrenic subjects still showed errors. �NEUROLOGY of cutaneous stimuli between various body parts was apparent. lation of dissimilar body areas with the face as one locus, the the cheeks were well localized and identiﬁed, while stimuli were either not perceived or poorly localized. Combinations SQ On stimu— stimuli to elsewhere of stimuli to the face and trunk, face and foot, face and hand, etc., repeatedly showed face dominance. In contrast, in tests with the hand as one locus, the hand percept was always poorly perceived and poorly localized. This was observed in the initial trials in the normal and schizophrenic adults, but was more apparent in multiple trials in patients with organic mental changes. By repeatedly testing various combinations of other body areas, a gradient of the sensory relationships of these areas has been established. Because the face and hand regions represented the extremes in the pattern of responses, these two regions were selected as the basis of most of the tests. Therefore, this method of examination was named the face-hand test. The errors in these examinations were apparent in tests of both sides of the body without any manifest preference. In patients with hemiplegia of recent onset and associated mental changes, extinction and displacement of percepts were apparent bilaterally, but were more prominent and more persistent on the involved side of the body. In patients with long-standing hemiplegia in whom the mental syndrome was no longer apparent, the defects were limited to the involved half side of the body? The factor of mental set: The mental set or attitude often inﬂuenced the perceptual response. Once the normal adult was examined by the method of double simultaneous stimulation, subsequent tests failed to elicit a repetition of the errors which occurred on the initial face—hand test. It was as if these subjects had “learned” the set of “two-ness.” Moreover, when normal subjects were tested with face-face stimuli, the responses were correct, and then all subsequent face-hand tests were also correct. When face-face tests were interposed among trials of the face— hand test in the patients with mental changes, they continued to make errors on tests of face and hand, even though they were correct on the face-face trial. Such errors persisted for days. Evidently mental set and learning did not alter the pattern of response. The factoq' of attention: It is well known that attention can inﬂuence 4 perception.2' In a series of 30 normal adults who were told that two stimuli were to be applied, none made errors on the initial trial of the face-hand test. However, patients with severe mental changes, who were �53 ORGANIC MENTAL SYNDROME told either before the initial trial or on subsequent trials that there would be two stimuli, still showed extinction and displacement of percepts. It was possible to have the patient, with eyes open, observe the application of two stimuli and report them correctly. Then, with eyes closed, and the stimuli applied to the same or homologous areas, the patient would report the stimuli incorrectly. The effect of fatigue on the performance of the patient has already been mentioned. It is possible to increase the errors of the patient by administering the stimuli more frequently, or by making him aware of his errors and thereby increasing his anxiety. With mounting anxiety, errors increase until culminated by a catastrophic reaction and withdrawal from the examination. A similar effect of anxiety on performance was manifest in the normal subjects. The adults with manifest severe anxiety required more trials of the face—hand test to perceive the percepts correctly than adults without manifest anxiety. Degree of mental changes: We found a deﬁnite relationship between the severity of the mental changes and the frequency of errors in perception in the patients with an organic mental syndrome. The patients varied in their mental status from mild memory disturbances and alteration in intellectual ability, to severe psychomotor retardation, amnesia, aphasia and somnolence. The responses to the face-hand test varied from occasional extinction of percepts seen in the mild cases, to con— sistent, bilateral displacement of percepts to other parts of the body, the examiner’s body, or into space in the subjects more severely affected. In a number of patients with severe head trauma or following cerebral in mental functioning was acthe improvement progressive surgery, companied by a change in response to repeated trials of the face-hand test. The responses changed from bilateral displacement and allesthesia when damage was most severe, to extinction in decreasing frequency and ﬁnally consistently correct responses as the subject improved. Perceptual errors were greatest in subjects in whom nervous system dysfunction was acute in its course with rapid onset and short duration. Patients with severe head trauma, infections of the nervous system, vascular accidents and neoplasms were more likely to show extensive changes on double simultaneous stimulation than patients with chronic alcoholism or senility. It was in these last two groups that there were a number of subjects with organic mental changes who consistently per— ceived the two stimuli of the face—hand test correctly on the initial and on multiple trials. Type of mental defect: There was no obvious correlation of the freface—hand with of in of the the single test errors symptom any quency �NEUROLOGY 54 organic mental syndrome as in patterns of thinking, spatial or body orientation, memory or calculation. Errors in perception were most apparent when disturbances in function were most widespread. A good correlation existed, however, between the patient’s alertness and the responses on the face-hand test. In patients who were apathetic or lethargic, errors on double simultaneous stimulation were most promi— nent. This was apparent in many subjects who made errors occasionally during the initial trials of the face-hand test, but in Whom errors became more frequent and changed from extinction to displacement responses as the examination continued. Similarly, in testing patients with ﬂuctuating states of consciousness, there was a good correlation between the degree of alertness and the responses on multiple trials of the face— hand test. Some of the patients were unable to carry out tasks which had two different aspects. But despite this inability to do two things at once they were able to perceive the two stimuli applied to the sides of the face. Therefore, it could not be said that the inability to correctly perceive one of the two stimuli applied to the face and hand was due to a defect in the ability to perform a task with two different components. The factor of aphasia: Aphasia is sometimes considered a defect in mentation. Such a defect, Where severe or associated with mental changes characteristic of the organic mental syndrome, yields a picture of the pa— tient as confused. For instance, a patient with aphasia may also have a loss of memory and an inability to recall or recognize situations even after they are described to him. In order to determine whether aphasia per se will produce errors in the, face-hand test, aphasic patients, with or without such mental changes, were studied. Patients with aphasia but without mental changes did not make errors on the face—hand test, while patients with aphasia and mental changes made repeated and consistent errors on multiple trials of the test (ﬁgure 1) . Organic mental syndrome with normal responses on the face-hand test: As already noted, not all patients with an organic mental syndrome make errors in tests by the method of double simultaneous stimulation. In a series of 271 patients in whom various combinations of these tests were applied, there were 228 patients who made errors and 43 patients who gave correct responses on initial trials. Of these latter, however, there were 22 who made errors after the initial trial. The remaining 21 were correct throughout multiple trials. Of the 228 patients who made errors on the initial trial there were 28 who were subsequently correct and yielded responses similar to the normal as carried out in one series of tests. In of found 49 it the 271 patients with mental changes that was summary, �55 ORGANIC MENTAL SYNDROME yielded normal reactions. All of these 49 patients had an organic mental syndrome but in general the mental changes were not severe. lVIemory loss was spotty and the degree of orientation varied, Apathy was seldom marked. There were fluctuations in performances. At times there were long intervals, minutes to hours, during which the patient showed no apparent mental changes. Examinations during those symptom—free intervals showed the face—hand test to be normal. In several instances it was learned that the defects in memory or indifference in answering questions pertaining to orientation were‘due to an emotional depression or to a phlegmatic premorbid personality. Their organic mental syndrome was only apparent and not real. There were, however, 11 patients with severe mental changes who reported correct responses on repeated face—hand tests. Eﬂect of drugs: From the foregoing studies it is clear that patients with organic mental syndrome make errors in perception in double simul— taneous stimulation tests. Consequently it was thought that the mental changes induced by drugs should yield similar errors. To test this theory, normal adults were subjected to intravenous injections of 7 to 10 ml. of a 5 per cent solution of sodium Amytal administered slowly. This drug produced the usual nystagmus, dysarthric speech and drowsiness. In addi— tion, normal adults, who made no errors on the face—hand test prior to the injection, now made consistent bilateral errors. Within 5 minutes after the injection errors were apparent on many repeated trials of the test and these persisted during the period the drug action was effective. The more drowsy or intoxicated the subject became the greater the tend— ency to make errors in perception. At the onset, displacements of hand percepts were frequent, but as the drug effect diminished, displacements diminished and extinction of hand percepts became prominent—only to disappear as the subject became more alert. Similar effects have been observed in the patients with a mild mental syndrome. Where only extinction of hand percepts was apparent prior to the Amytal injection, displacement of percepts became frequent and persisted for the duration of the examination. The effect of the drug persisted for longer periods in patients with organic mental changes than in normal adults, so that displacement of percepts was manifest hours after the injection in the patient group. Similar observations on the effect of anesthetics on central nervous system function have been made in a study of normal adults subjected to varying periods of anesthesia.5 These subjects with no demonstrable disease of the brain, who made no errors on double simultaneous stimulation tests prior to anesthesia, manifested extinction and displacement of �NEUROLOGY 56 percepts in either hand on multiple trials of the face-hand test during recovery from anesthesia. When these subjects regained consciousness from a general anesthetic, they were disoriented and confused. There was a manifest correlation between the duration of the perceptual errors and the period of confusion, lethargy and apathy that followed the anes— thetic administration. Eﬂeet of convulsions: During post—convulsive states patients frequently show confusion and other symptoms of the organic mental syndrome. Since persistent errors on the face—hand test were found in patients with mental changes due to disease of the brain or due to drug intoxication, it was thought that any one who has an organic mental syndrome, of whatever cause, should show these errors. F or this reason, groups of patients were studied in whom convulsion were induced electrically for treatment of depressions. Patients who were given intravenous barbiturate prelimi— nary to electric stimulation were not included in this group. It was found that if the post-convulsive confusional state was severe, these patients showed a high incidence of errors on the face-hand test. As soon as the confusional state cleared, the incidence of errors in the facehand test decreased. Value of the face—hand test as a diagnostic sign: In order to determine the value of the face-hand test as a diagnostic sign of severe mental changes, a series of patients were examined in the admission ward of Bellevue Psychiatric Hospital. This examination was carried out by simultaneous stimulation of the face and hand. Each patient was given a series of 10 tests. N 0 history was taken nor were other clues used to make a diagnosis. Using this method it was found that in all cases in which the face—hand test showed errors on repeated trials, subsequent psychiatric examinations disclosed the presence of an organic mental syndrome. CONCLUSIONS From the foregoing observations it is apparent that subjects with the organic mental syndrome showed persistent errors on face—hand tests. It is signiﬁcant, however, that the same confused and disoriented patients did not err in a haphazard fashion. An analysis of their responses based on numerous tests showed that the errors were made in a predictable pattern. There were consistent errors in the hand percepts, whereas there were very few errors in response to the simultaneous stimulations applied to the face. Another signiﬁcant point is that this pattern was found not only in patients with cerebral dysfunction, whether it was due to structural or chemical changes in the brain, but also in normal children. This was found in children in whom the brain was not altered in any manner. The latter �57 , ORGANIC MENTAL SYNDROME observation indicates that this pattern is not the result of disease of the brain, and conversely, that it is inherently organized. Moreover, it indicates that this pattern is acquired early in life. N o explanation is offered as to why these patterns are so organized, namely, face dominance and hand “extinction.” The rostral dominance theory proposed by Cohn6 cannot be supported by these observations, inasmuch as it was found that the foot dominates over the hand. This fact automatically precludes the factor of rostral dominance. Moreover, the authors do not wish to agree or disagree with the well known theories proposed by Goldstein.7 Still another point is that reactions of the child are similar to those of the senile individual with mental changes. One might draw an analogy to the Babinski sign, which is considered normal in the developing infant and abnormal in the adult. From this analogy, it might be inferred that the presence of persistent errors on the face-hand test in the adult indicates a regression to the infantile level. However, we do not wish to convey the idea that we concur with such a theory. Finally, it might be concluded that what is seen in patients with dis— ease are normal patterns of function which appear to be grossly exag— gerated. As noted, repeated errors on face-hand tests may be found in the normal adult under certain conditions, particularly when there is altered brain function. Based on this hypothesis it is felt that a good deal of information about normal function can be obtained from patients with dysfunction as a result of altered structure. Aside from the theoretical considerations it must be concluded that the face—hand test has clinical value. It is a diagnostic sign of the organic mental syndrome. The persistence of errors on face-hand tests in an adult strongly suggest an organic mental syndrome. SUMMARY Patients with an organic mental syndrome make persistent errors in tests by double simultaneous stimulation of the face and hand. The errors are usually made in the hand. These errors are made on multiple trials of the face—hand test and on subsequent examinations on repeated days. The normal and the schizophrenic adults, however, do not make persistent errors. This difference in response between these groups is so striking as to have diagnostic value. Errors of extinction and / or displacement on multiple trials of the facehand test by touch stimulation are indicative of the organic mental syndrome. In a series of patients examined in the admitting room of the Bellevue Psychiatric Hospital, these tests were applied to patients as the �NEUROLOGY 58 ﬁrst questions of the interview. The diagnosis of an organic mental syn— drome was conﬁrmed by subsequent interview in every case. The significance of these ﬁndings is discussed. REFERENCES 1. (a) BENDER, M. B., and NATHANSON, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena, Arch. Neural. & Psychiat. 642501, 1950. (b) BENDE‘R, M. B., and WORTIS, S. B.; Patterns in perceptual, motor and intellectual functions in organic brain disease, Tr. Am. Neural. A. 72:31. 1947. (C) BENDER, M. B.; WORTIS, S. B., and CRAMER, J,: Organic mental syndrome with phenomena of extinction and allesthesia. Arch. Neural. & Psychiat. 59:273. 1948. (d) BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disorder of the body scheme, Tr. Am. Neural. A. 73:170, 1948. (e) SHAPIRO, M. F.; TEUBER, H. L., and BENDER. M. B.; Disturbance of body image and allesthesia. J. New. & illent. Dis. 108:253, 1948. (0 BENDER, M. B.; SHAPIRO, M. F., and TEUBER, H. L.: Allesthesia and disturbance of the body scheme, Arch. Neural. 10 . . & Psychiat. 62:222. 1949. BENDER. M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neural. A. 75:250, 1950. (b) BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neural. &: Psychiat, 66:35.5, 1951. BENDER, M. B.; SHAPIRO. M. F., and SCHAPPELL, A. W.: Extinction phenomenon in hemiplegia, Arch. Neural. & Psychiat. 62:717. (a) 1949. The phenomenon of tactile inattention with special reference to parietal lesions, Brain 72:538. 1949. 5. JAFFE. J., and BENDER, M. B.; Perceptual patterns following general anesthesia. J. Neurol.. Neurosurg. & Psychiat.. in press. . COHN, K.: On certain aspects of the sensory organization of the human brain: 11. A study of rostral dominance in children, Neurology 1:119, 1951. GOLDSTEIN, K.: The Organism. New York, American Book Co., 1939. 4. CRITCHLEY, M.: In order to conceive a clear idea of the pathology, we have only to imagine the physiological phenomena, already noticed, assuming a pathological character. Now, the force of these phenomena may be augmented, diminished, or annihilated. In regard to the cerebral functions, we have, in the sentient nerves, pains or insensibility; in the cerebrum itself erroneous perceptions, judgments, and colitions, or delirium; or a total deﬁciency of these faculties, or come; in the motor nerves continual voluntary actions; or paralysis. Hall in Lectures on the Nervous System and Its Dis-eases, published in 1876. -——Marshall �The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome 31am Fink, M .D., 111a7'tin Green», M.D., and NI 0772's B. B ender, M.D. Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY �NEW YORK SOCIETY FOR CLINICAL PSYCHIATRY The 116th Regular Meeting oI the Society WILL BE HELD AT THE BELLEVUE PSYCHIATRIC HOSPITAL LEWIS I. SHARP. M.D.. Direcior 30”! STREET AND FIRST AVENUE THURSDAY, NOVEMBER 9th, 1950 AT 8:30 P.M. PROGRAMME I. TWELVE YEAR FOLLOW-UP STUDY ON METRAZOL TREATED CHILDREN AND ADOLESCENT SCHIZOPHRENICS . LAURETTA BENDER. MD. and S’raff 2. THE FACE-HAND TEST IN ORGANIC MENTAL DISEASE M. FINK, M.D.. MORRIS B. M. GREEN. MD. BENDER. and M.D. NOLAN D. C. LEWIS. M.D. MORRIS HERMAN. M.D. Prosideni Secrefary Staff invited — Dr. Herman �4/,q/, . 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' mm in: normal 0mm (x—é—x) at «W of an. 3.6 (0—0), mm m1:- (0+m0). ”mum“ uncut: (x—h—x) m magne- lulu ”mu name me mm mm (rm-I). * In. mama or W patzlcntl sun emu. ��i/‘l/B I STANDARBIQATION OF THE FACE-HAND TEST Introduction: In previous studies a simple perceptual test, the test, race-hand test was introduced and the responses to the of normal subjects and of patient with psychiatric disorders were described in detail (1~6). sists The test con- of applying touch or pinprick stimuli simultaneously to the face and hand while the subject's eyes are kept closed. The subject is then asked localize the percepts. occur. The two stimuli correctly or the subject and Two felt and to general types of response may be may what was perceived and localized perceive only one stimulus either not perceive the other (phenomena of extinction) or misloceliae the second stimulus (phencmens of displacement) (7). Most often the mislocslisstion or displacement occurs to another part or the subject's body but occasionally there is displacement into extrspersonsl space or onto the examiner (exosomesthesis) (8). Displacement of stimuli �2. across the mldllno of the body (alleatheala) is another form of displaoomont Normal adults initial trials orrots that may show of the among occur (9). errors in perception teat. characteristically of face dominance). all subjects correctly - be those is perceivod correctly As correct (phen- additional tests are tho errors disappear so that by the.tenth to on the oonaiot of extinction of the stimulus on the hnhd wheroao the face stimulus - may done trial noarly porcolvo both stimuli and continue 0o subsoQuent trials. has been tarmod a ”negatlvo faoe~hand This type of response test." lt oocura not only with normal gdulto but also in patients wito nohlzophronla, depression, or oovoro anxiety{ In contrast to the preceding groups, patient tith' an organic mental tyhoromo show extinction‘and diaplaoef want not only during the initial trials or the ‘tost but ’ after 10 total: of testing or as long on testing is continued. Such a rooponse is termed a ”positive taco—hand �3f test.” -by A normal "positite fees-hand test“ is also manifested ohildren, normal aged persons. fectives asvwell as syndrmhe. by patients with and mental de- an organic mental ~ Because of the differentiel_response or these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it hes been noted thst patients with an organic mental syndrone vary ' greatly in the type and frequency of peroeptuel errors. Also, subjects without organic brain disease ‘ occasionally manifest a positive faoefhend test. The questions thieh arose from these observations are: 1) Is it . poeeiole to classify or standardize the different types of errons ooeuring in subjects with e positive race-hand test? 3 2) Gen these different types of response he corb related with the several groups or subjects previously mentioned?; 3) In there e type of response which can be �llld to ooour absolutely only in notiente with eeyere 4 dieeeee of the brain? 'The present study ie an attempt to enerer these questions.‘ ~ “ ‘ . lethod end Resultez. We test reviewed our previous records of the face-hand done in almost syndrome, normal 1000 adulte, patients with organic mental and schizophrenia adults, as well an in lesser numbere~of normal children, normal aged persons, and subjects with mental defioienoy, depression or severe anxiety. Additional groups or some of theee subjects were aleoteeted in different types of stimuli. e systematic manner with The criteria ueed‘to form- ulate a standardization of the race-hand test were: 1) ‘type of perceptual errorx'a) frequency or the variOue type: or error: with different types of stimuli (touch, rubbing, scratching, or pinprick); quency of errors when 3) effect on the fre~ the Subject ere-witnesses the applio' cation of the stimuli (factor of attention). Fifteen to thirty trials ' or the test were usually done for each eubjeet. �5. Based on theoe criteria, it was possible to divide oeticnte showing a poeitive race-hand test into four groups. The oheracterietio reeponeee for each group are V ' in Teble I. summarized Qheee reeponeee with examples are described more fully in the following peregraphe. mm I Features of the Different Type: of Positive Face-Hand Test \ One-glue Extinction only with , a touch stimuli, Two-Blue Three—glue Extinction Extinction ~pinprick placement with touch, rubbing with touch, rubbing, and and deep ~ stimuli die- and pinprick ’stimull Four-Rina Same as three-plus with at least one or the following feeturoe: e) exosomeetheeie b) alleetheeie c) frequent pereervetion d) occurrence of errors while subject eye— witnesses the areas stim- ulated. One~Plue Face-ﬁend show These Test: errors only of extinction The subjecte in this gnoup~ and not of displacement. errors occur only with touch stimuli. When pinprick �6. in need, both stimuli are perceived correctly, although errors will again uppeer when touch stimuli are reintro- duoed. A 6h year old because of a 1% men with mild diabetes was admitted year history or difficulty in walking. For at leeet the same period of time the patient had been depressed, The elept and ate poorly. and wee impotent. only neurological finding was a elow, heeitent, shuffling gait. There vascular dieeaee. payohomotor was The peripheral patient appeared depressed. showed retardation, and cried readily. Senecrium intact. Spinal fluid, eere normal. The was no evidence of The EEG, and X—reya of the spine diagnoeie wee involutional psychosis. gait difficultiea were thought to be secondary to the depression. this patient hand test. A shoeed a onesplue response on the raoe~ sample of his response: rollove: �7. ' com stinging touch: right chcokolort hand' right cheek touch loft chock—right hand touch right check—right hand '“touch loft chockwlcft hand touch right check-loft chock touch right hand-loft hand touch right chock—loft hand touch lelt chock-right hand touch loft check-right hand ' left cheek right cheek left cheek T222 of Error extinction extinction oxtinction extinction correct correct right chock‘ extinction correct correct touch right check-right hand 'right cheek touch left chock—loft hand left cheek extinction extinction pinprick right chock—left hand correct pinprick loft chock-right hand oorncct pinprick right chook-right_hand correct pinprick loft chock-left hand corrcct touch right cheek-loft hand correct touch loft check~right hand loft chock extinction ' adamant: Although this type patients with cerebral disease, it Or response occurs in is not alwaya charac{'5 w (M . [cal/ca toriatic for this group. It is also seen in caciiihf defrlswod’ a; MAJ (as: t/(O‘ﬁli‘d 4"/ Mo, ﬁtter (a! amt/11:5 Skits} .(achizophrcnia, and, occasionalgy, in normal adults. �8. Two-Plus Paoe~ﬁand Test: In this group extinction ' occurs with pinpriok and rubbing stimuli as well as with These errors.may be touch stimuli. just as frequent with both types of etimhli or may be more conspicuous with touch than sith pinpriok is not present, but or rubbing. may ooour on an A.72 year old man had a 5 weeks and Displacement occasional trial. history of mental. behavioral changes. This. consisted of disorientation, confused behavior, and internittent autism. thero was an examination organic mental syndrome characterized by partial disorientation, defects in recent and oiroumlooutions illnoss, On in answering questions, denial of and pain asymbolia. logical disabilities. l-raye were normal. memory, evasione The A There were no other neuro~ spinal fluid, and EEG, pneumoenoephalogram showed skull diffuse ,oerebral atrophy. This patient's responses on the face-hand characterise the two-plus type or response. A test sample �of these responses followc: Stimulﬁs touch touch touch touch touch touch lett cheek~right hand right cheek-left hand left chock-left hand right cheek—right hand right chookéleft cheek right hund~1ert hand touch right cheek~left hand I . Roseanne ngo of Error left extinction extinction extinction extinction cheek right cheek left cheek right cheek correct correct right cheek pinpriok left cheek-right hand left cheek pinpriok right cheek-left hand oorrect’ pinprick loft cheek~lort hand left.choek pinpriok right cheek-right hand right cheek pinprick left cheek-right hand left cheek Gonncnt: extinction. extinction extinction , extinction extinction This roaponco occurs most often in patientcv with cerebral disease although patients with anxiety state, I depression or schizophrenia may also exhibit it. It is not seen in normal adults. Three-Plus Paco—Hand Test: This group is characterised by the Occurrence of displacement as well as with both touch and pinprick stimuli. The extinction frequency of �10; extinction and displaoomont may be aqual or unequal and, likewise, the number of errors with touch and pinprick otimuli will be variable. A 57 year old chronic alcoholic was found in the in a stuporous condition. Hia Itroot. breath had an alcoholic odor and there oas a laceration over his right foroooad. There here no hospitol focal neurological signs. During the doy the patient graduolly Spooch woo rambling and was was and skull had savoro memory defects There were no X~ru§a were ﬁalluoinationsti' nofonl. The diagnosis ocuto and chronic alcoholism with deterioration; A hand fluid And 35‘ expressed taranoid ideas aod was He hoatilo'hnd asaﬁultivo. ISpihal fully oooacioualgii. at timeo almost incoherent! oomplotoly‘diooriontod with confahulation. become first sample of this pationt'a toot, indicative of fallout: responooa on the race- a throe—plgo rooponao. in go ‘ �114‘ szg Rcaponso Stimulus of Error right chcck~left hand right chock-left hand displacement touch loft check~right hand right hand—left hand displacement touch right cheek-right hand right cheek extinction Touch touch touch loft loft cheokﬁloft hand Correct cheekoright hand. left chock extinction touch right chock-loft hand right check—left check diaplacomont touch right hand-left hand .correct pinprick right chock~1c£t hand‘ right-choek-lcft chock displccomcnt pinprikk loft chock-right hand loft chock-right cheek displacement ‘ pinprick right chock—right hand right cheek left check pinprlck left chock-loft hand FourvPlus Facc~Hand Test: extinction cxtincticn This group shows the. sovercat porcoptual errors. In addition to frequent extinction and displaccment ac scan group. one or . all in the threc~pluc of the following phononcna may be sccn' with touch andﬁlr pinprick stimuli: 1) oxoaomcsthesia; 2) allcsthosic; 3) frequent pcrservation of responses; h) the occurrence of perceptual errors even while the subject keeps his apes open and eye witnesses tho arcas' stimulated. �12. A 60 year old man had a oriéntation, torgetfulness, examination he ShOﬁBd a three year history of interest. and loan of On sovare organic mantal syndrome manifested by cemplete digorientation. marked -d6fect3, and inability to calculate. 'oodperativo. d18~ He was mamary alert There were no other neurological Spinal fluid and skull x-raya were normal. EEG and signs.' showed modernta, diffuse biaynohronoua slaving with slow alpha. A diffuse curcbral atrophy. pneumoogoephalograg disclosed A sample of the patient's roaponsee; 1ndlogt1ng a' fqur-plua face-hand tagt, is as fellows: Stimulus touch right cheek~ left hand touch left cheek» hand right aheek sonal spaco~ , v‘ right.oheok oxosomosthaaia extinction , _ oheek— lart left hand 10ft hand extinction , touch touch right hand- ‘ left-hhook-oxtrlporu , touch right cheekhand . , right right ‘, ‘ of Errér Tzﬁo Haazonse right cheek , oorrhot perseveration ' ' �13. touch right ohook- right chook~loft left hand touch left oheok¢ hand right pinpriok right hand loft ohook- loft right hand 'pinpriok right cheek- right right hand pinpriok loft ’lort hand loft chaok— pinpriok (eyes open) right cheek-left adamant: hand cheek—loft hand right ohook-lott left pinpriok loft chaak~ ohook ohook allosthosia displaoomont extinction _ cheek~oxtrnporaonnl apnoo displacement extinction cheek oxoaomeathosia right cheek—extrAporaonal oxosomosthoain space Throo~plua and four-plus responses invariably indicate disoaae of the brain. normal chock They are never found 1o adult: or in patients with psychiatric disorders. In oddition to tho difforont groups of subject: diaounsod above, the responses of normal children above fears 0! ago, normal hove ngod also been studiod. 3 persons, and montal defectives The distribution or the responses, or the children and aged poraooa are related moinly to age. The youngest children and the oldest adults show threo-plus and four—plus reopensoa. With changes in �age away from thine extremes, one-plus and two~plus re- spouses become more frequent. or the subjects with mentel deficiency, those with ﬁho lowest mental age have throe- plua and four—plus responses while one-plus and two-plus in subjects with higher mental 33035 'neoponses predominate Table II summarizes the distribution or the four different tfpes of responsesamong the various groups of subjects. ShOﬂ Only three-plus may be patients with and four-plus roséonses._ Such responses considered diagnostic of an organic mental syndrbme. TABLE ‘ an organic mental syndrome I; Frequency of One-Plus to Four~P1us Positive Pacerﬁend Test in Different Groups of Subjects Negative Ono~ F5H.test Pius organio nental Syndrome 10% 7% 1% Normal Adults (below 60’ 99% year: or age) “yachixophrenio Adults nearly noooae- Two~ Plan Patients with anxiety nearly occae~ states all ionelly Petients with paycho~ neerly genie depression all‘ Four~ Plus Plue_ 25% 335- o o ' 25% o _ ' ' all ionally Three» rare neVer never more never never �15;- Discussion: In answer to the questions raised in the intreduetlon, our results indicate that four general types of positibe Itsce-hsnd test occur and that these different types can be correlated with different groups of subjests (Table Our attentien there was a was ii). focused mainly on the question of whether type sf response which occurred only in pamienss with severe disease of the brain. All cases with a threeplus or foursplus response have organic brain disease. Suoh'responses are never seen in nermel adults or patients- Iith psychoaenic disorders, even theugh these groups occasionally show one~plus may or two-plus responses. Patients with oerehral disease manifesting s four~ plus response invsrihbly show vsneed foam or mental changes. the severest or most adOtherwise there is no correlations between the type.n! positive faoeahand test and the severity of she senserisl defense. Same good istients with severe mental changes may have only a twenplus �» response; In addition, 10% of patieoie with an ofganio mental syndrome hove a negative face~hand ereelized that the use of ‘fov the groups 16. teet.’ It is to four ~plus nomenclature a one implies an increasing degree of cerebral ‘. -dyafunntion. This nomenclature ‘ was used because of con(1 lenience and much an implication is not intended; . We? This classification of a positiieﬁface-haod should ‘ be useful clinically. In feeting neurological patients, the exect type of positive face-hand -corded, was will test should be re- rather than the deeignetion "the taceuhend test positive" as has been make it easier to of politiﬁe faoe«hand done until now; Judge whether the Such a prooeedure particular type test manifested; indieatee definite cerebral disease or whethef‘it may not be a mnnifestatioh of anxiety or depression.‘ The use or such a classification will also make it easier to compare the response of patients at different times during their illnees. In addition. . , it should be valuable in clinical experimental work,'euoh an the reopen-e or patients to drugs. eleetroehock trentmont; ate. �17o Ema 1“,? : .A stanﬁardization of the dittorgnt face-hand responses is prgsented. A ﬁypea of positive one-pins face—hand that consists of gxﬁinotion only with'touoh stimuli. Itwo~plus reapgnsg 1a charactﬁgixéd by A extinction with pinprick and rubbing gtimﬁix,‘gs.wéll as with touéh stim- uli? A three~plu3xfesponés consists cf extinction plus diapﬁacaﬁont with touch, rubbing, #nd pinprick stimuli. A four—plus rggpénso has all tha charactériatics of a ‘ é three-plus rgaponsa and in addition at least one of tbs following features: a) exo§bmeathesia; b)_allesthesia;. c) pérseveration of respongea;'d) occurrenoa of evbn while the errors subject aypeyitneéaas tha Aﬁﬁlication of fha stimuli. ‘Three—plﬁs éﬁdttour«plua responses invaritbly M-rindictte_¢1aeaaé of Fhé braig. One-plus and two~plua rdaponaea ocgur in patient; with brain disease but are alab maniteated by a hmélllﬁumber of normal alulta and . patients with psychogenic disorders. Pationts with a; r �183 four-plus response the Invarest mental changes but show otherwise there is no correlation betwoon-tho aovopgyy' of the montql changes and the . 7- test manifested. - . face-handV.‘ typo-of'politivo (J ’ " . , 'w L �19. REFERENCES 1. BENDER, u.a., PINK; 3. and GREEN, n. - Puttarnn 1n paﬁcegtiun on simultawawus ﬁesta a: face and hand. Arch.Neurol.&Pq1chiat., ﬁg: 355—362, September, 1951. 2. M.B., and PINK, M. ~ Tactile perceptual tests in the differential diagnosis or psychiatric disorders. J.Hillaido 3032., A: 21-31, Jlnunry, 1952. 3. FINK, M., GREEN, M., and BENDER, M.B. BENDER, tastNo.an dia'noatlo 1, ‘g: h'ar8, - The raoa4hand Sign or disease or the Jan~Feb., 1952. brain. Nburolo . FINE, H. and BENDER, M.B. - Dovelopmunt of perception 9f simultaneous tnctile'stimull in normal children. 2 27-3L, January, Neurolo 1953. JAFFE, J. and BENDER, M.B. ~ Barceptual patterns fol— lowing general anesthesia. J.Nouro.Neurosurg.&Psychiat., gg: 316-321, Hovombor, 1951. and BENDER, M.B. ~ Cutaneous perception in the aged. Aroh.Neurol.&ngphint. ﬁg: 577. 1953. g. BENDER, ﬂ.B. - The phenomenon of sensory displacement. GREEN, M.A. ,Armh.Neurol.&Pq;oh1at., 95: 607-621 May. 1951. 8. SHAPIRO,.M.F., PINK, m. and BENDER, v.3. ~ Exosomesthesia or displacement of cutaneous sensation into extruporsonnl space. Aroh.Rouvol.8:Psgchi-.at., 9. gag: 1.81-1.93, Oct. 1952. Patterns in allasthosia body scheme 3:: other g4: 501~515, Arch.Neurol.&Pa;chiat., aensorysphohamena. Oct. 19 2. BENDER, and M.B. and NATHANSON, H. — their relaticu ta disorder or 3 �3?}!DAMIM’1'IM 63‘ m FAW $33!? a, mu: 1. Green, 3. 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Such awn lpaaaoi'nru'nmvur noon in normal aubjﬁotl a: athtontn with payohaainxa altardbru, av.“ though knit. satay: In: augusianally than onnuplns «r tuaapxun ruaponn0!. rntigatt with a¢r¢hrn1 niacin. Innitlnting n {ourwpiuu than the utvutpuﬁ ﬂfwﬂnit natunaaa ran: at unntal shamans. ashtrviau than. a: an anoa aorwnlatian hiﬁno:ﬁ thy try! at ponlttvn tuna-haaa taut uni sho'spvorﬁﬁy of thy concavial dnftett. Sana pntxcnta with Iivumu unntal dhtngtﬂ an; hav. «£17 u tronplua vulva”... In &dd1t£an. 10¢ a: pntlnnhs with an emanate aunts: tynﬂramn hat. a nonstivu _f&oo~hand that. it in thaliﬁda Ihlt tho as. a: I an. to rauv» plus nandnnlnturu tar Eh. stung. zapztal,nn mnumuuuins angst. or curabrul dysfunnt;on. Th1! nannnalatuml was usad'huoaulq or aonslnlduac and Iuﬁh un'inplioitian in not 1ntqn¢nﬁ. wospcnnc invnrznbiy bu thin alacsiriantion af.a paaztivu'fnaamhuhdvtnnt ahaulﬁ unoful clinioally. 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I mI Immu- mu mm a: mmmd‘ «gammy. adult?!» ‘Ia-I um: roux-III �13* ”I’m: slaw in mt. ”van“ yum ohms” ‘bat a» mum um. man 1: ma autumn” Miami: m “writ: the m: to“ Wand» autumn“ of thin that and of mm mm uni t1» tarp". an» 1. Italy at isthmus clinically Match or with. rut-had unnatural“: in magma-u work ��I 3"? ’ ﬂu-h'S-S.%F#M ___________Z;#__~__'——_ ��15 November 50 Dear Dr. Bender, of outline the studies in which Following is an I an participating under your supervision: a. Being prepared for presentation: i. Patterns in perception in simultaneous tests of the face and the hand 2. The Face-Hand test in the Organic Eental Syndrome 3. Patterns in perception in simultaneous tests of parts of the body other than the face and the hand 4. Caee report- Ethel Beckhorn Nos. 1-4 with‘Dr. Green. 5. Dyecheirie (with Dr. Shapiro) i" i‘b. Under study: 1. 08? changes following arteriography 2. Gomplicatione of arteriography; evaluation of the indications for the use of arteriogreﬁhy and the diagnostic value of the technic // Both of these studies with Dr. Stein. c. Proposed for study under grant by Rational Foundation > ~ for Infantile Paralysis: ',// n, , 1. Relation of sdaptation time, D. S. S. and threshold stimuli in hemiplegia 2. Patterns and factors in the responses of children to D.S.S.; comparison with patients with organic mental changes 5. Gen extinction and displacement be observed in normal subjects using threshold etimnli ? ��S.R. 5004-590M-701102(50) . Q.CITY OF 114 NEW YORK—DEPARTMENT OF HOSPITALS ....................................................................................HOSPITAL CaseNo..._....__.._____ PROGRESS RECORD Name...”...................................................................................... Admitted........................................................................ 19 .......... Ward ....................... Observations and Opinions of Visitings, Consultants and House Staﬁ. A Final Discharge Note Must Be Entered on This Sheet. Sign and Date Every Entry. .1 e . @an A ‘ I PM ‘ - "Wx. Ei‘f~ “. is _ \ [and V5“;- R‘- j "” r 4 iLIJJzJOU» SMCJE , A ' ""19“...“ '>. - Binding for Blank Leave _____________________———_———————-———————————— Continue Notes on Other Side �....................................... Division -_ ___.____________.____.______.~________. Name__________._____.____—____________ Admitted_____.______19___ Ward__.______ HISTORY Case No...........-.--..._.......... �Prev /‘ M. ‘ .‘2. ﬁr M/- > mmf‘ég: WW “W $79“me w /W Cm _ " '2) 05/- m [4 W.“ 4.xMWaﬂ- Y.‘ET>:0<I!WI.’:.6-m¢ 3. ‘ , m “V x-‘6 ' /MM 7 5% Wxép (a; £44, ﬂZZp/raa ‘ ' 414w" ' *W V » dpg, fast/aw. . ." ~ , ‘ ‘ ” WW w 44}, W ﬂm J‘ ' %¢ ./ Wugﬁéﬂy‘é {It/*4: ‘7' ' £4cﬂ/r/oﬂ / ‘ (a) c“: M 447‘ 014M; .— . W M¢W7 (a) ﬂﬂ ‘ lg‘ :11 I " 'I Cc) .A ”..th M 71 M 06‘,” f dams. M @5447 {a} )Lgpi ' ‘ CW “(:1 ‘ . I! 927'. / 2/41/57 I I .- . 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M Karo-4L _ ‘4 ...mo �.i M’m a??? MM Mpg mdM gm» 9' %%-Q zf/Zex/L "0 §. ‘ 7. 'C'meioo 0 - ,'. :_ ‘ , V I‘ f 2 w"ww-wrr‘rvmrg'm'rﬂ’wm .‘ ‘ va ~— 4”“) A.“ I —W"%*“W, .M'MJ’ %{d’ #Cnﬁwwﬁu '> -- iT do n- u ,7 ��' a: @729; :x/Ma. 0W Aw, I M» WWW; cm, ”MM” zz Aggy”: —G/2/m a. V'aéém , �Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION SEVENTY-FOURTH ANNUAL MEETING, JUNE 13-15, 1949 OBSERVATIONS ON THE EXTINCTION PHENOMENON IN HEMIPLEGIA MORRIS B. BENDER MORTIMER F. SHAPIRO AND A. W. SCHAPPELL NEW YORK Routine sensory examinations are usually carried out with the method of single stimulation. This method appears to be adequate, but it does not always disclose existing defects in sensibility. For example, in a patient with a right cerebral lesion the left side of the body may be sentient to a single stimulus. However, the sensation evoked at this very point may no longer be apparent as soon as another stimulation is made elsewhere, such as on the opposite side of the body. The same change in sensation may be elicited with the method of double simultaneous stimulation. This disappearance or extinction of a sensation is not always complete. At times the patient reports a dulling or obscuration rather than extinction. Extinction and obscuration have been found in tests of all types of sensation. They may be observed in patients with lesions implicating the sensory pathways of the brain or spinal cord. The object of this study was to determine: (a) the method which is most successful in eliciting the phenomenon of extinction, (b) the pattern in which extinction manifests itself on the paretic side in cases of cerebral hemiplegia and (C) the frequency with which extinction of cutaneous pin prick sensation occurs in patients with hemiplegia. Fifty patients with hemiplegia were selected at random from the medical and psychiatric wards of Bellevue Hospital. Patients with aphasia or psychosis were included in the series only when their responses in sensory tests were consistent in one respect or another. In this study the cutaneous sensory status of patients with hemiplegia were first estimated by the customary method of single stimulation with the prick of a pin. The patient was asked to report whether he felt a sharp or dull sensation. Various regions of the body were thus tested and compared for degree of sensibility. The same patient was then examined with the method of double simultaneous stimulation. Three variations of the method were employed: (A) simultaneous stimulation of points in homologous regions on the two sides of the body, such as the right and left hand, the right and left side of face, etc.; (B) simultaneous stimulation of points in non-homologous regions on the two sides 160 �Bender, et al.—Extinction Phenomenon in Hennplegia 161 of the body, such as the right face and left hand, the right shoulder and left face, etc.; (C) simultaneous stimulation of points in two different regions on the ipsilateral side of the body, such as the right face and right hand, the right hand and right foot. On each test the patient was asked to report the location and quality of sensations. When the patient reported only one sensation, he was asked if he felt another in any other region .of the body. If he felt two sensations evoked by the simultaneous method, he was asked to compare them. RESULTS The most effective technique for eliciting the phenomenon of extinction was found to be Method B, or the simultaneous stimulation of non-homologous regions on the two sides of the body, such as the face on the healthy side and the hand on the hemiplegic side. The next most effective was Method C, or the simultaneous stimulation of two regions on the hemiplegic side, as for example, the face and hand on the affected side. Method A, or the simultaneous stimulation of homologous areas on the two sides of the body, did not reveal sensory defects as frequently as did Methods B or C. Although we have been stressing the phenomenon of extinction or the disappearance or decrease of a sensation, we have not overlooked the other aspect of the situation obtained on double simultaneous stimulation, namely, the retention of a sensation. We shall refer to the sensation which is retained as “dominant” and the one which disappears as “extinct”. Examina— tions with the various methods of double simultaneous stimulation showed existence of gradients of sensibility throughout the body. One sensory region was dominant to another. Further studies showed that these gradients were patterned. The pattern on the hemiplegic side revealed sensory dominance greatest in the face and less in descending order in the following regions— face, thigh, shoulder, foot and hand. In other words, when the face and any other part of the body on the hemiplegic side were simultaneously tested, as a rule the sensation in the face was perceived while sensation in any other one part was reported as diminished or absent (extinct). A phenomenon which appeared directly related to sensory dominance was that of “displacement”. In some instances when non—homologous regions on both sides of the body were tested simultaneously, the patient reported he felt two sensations of equal intensity, there being no extinction. The sensation was localized correctly on the normal side. However, the sensation evoked by the stimulus applied to the affected side was incorrectly localized. There was an ipsilateral displacement of the sensation toward a region homologous to the point of stimulation on the normal side. The displacement was usually toward dominant sensory regions. Thus when the patient was pricked simultaneously on the face on the normal side and the hand on the hemiplegic side, he reported that both sides of the face had �162 Bender, et (LL—Extinction Phenomenon in H emiplegia been stimulated; or if the hand on the normal side and the face on the paretic side were simultaneously tested, he claimed that both hands had been pricked. In some cases of disease of the brain the displacement phe— nomenon was the earliest indication of sensory impairment. As the disease progressed, displacement was replaced by obscuration and eventually by extinction. One of the signiﬁcant ﬁndings of this study was the demonstration of sensory deﬁcits in patients with a severe psychosis or aphasia. Usually such patients are considered incapable of giving coherent or consistent answers in routine sensory examinations. The psychotic or aphasic individual has trouble in expressing comparisons between two successively induced sensa— tions. He has less trouble when the stimuli are applied simultaneously. With this technique the psychotic or aphasic patient usually responds by pointing to the sentient or “dominant” region and he repeatedly ignores the region which is apparently “extinct”. In summary, it was found that a sensation in one region of the body is readily inﬂuenced by a sensation evoked in another area. This inﬂuence is most apparent with the methods of double simultaneous stimulation. Using these methods in patients with hemiplegia it was found that extinction occurred in 44 of the 50 patients, whereas routine single stimulus examination ’disclosed defective sensation in only 29 cases. Furthermore in 28 of the latter 29 cases the sensory defects became more conspicuous with these techniques. ��.ﬂmwéﬂ nMMﬂL—{A‘ay /m4_g. fa/A/uc/WIZMM g/éé,‘M/£¢M ��, .p~.., ��' ‘D’Mwnrw hvﬂﬂ :- f/‘f/f’l a, am» , . MW Wm V“ ‘ “Mm ,¢__,-m..‘ w ngvm’regﬁww .5 w (V) (:3) gﬂ/hﬂﬂﬂh " M 7% rﬁi. ﬂé’i ﬂmw ’2 mm //M I.“ _ ‘ ‘ ‘ . ; . \n ��wifﬁmﬁ’ﬁ; ’ ��51$“ “<4 3 “it wﬁéu'wéi 3‘” van ��. hi illanh. ‘ , ‘ .A $1.1Hnawwlllflsfalz ”436,... 13.36 Tamrgwuau .-1...i1w.uiu.«ni.1> 53.53.», . �7,) 3“, Wu 3. ' * - “aim/ad. 4.54.wa 975‘; ‘au ) «,2; MMM) LC“ 962.7 ‘@ dﬂaﬁcﬁ . *3 SI ��5.9.50 Sensory Studies In a discussion with Dr Bender today he made the following suggestions: 1. That studies of the face— hand, face - penis as carried out in the normal could be extended in the pattern of shoulder - foot, hand - thigh etc. This will give an outline of a homonculus of sensory dominance in the normal-2. The studies of the reaction in the normal on the abnormal in the penis and breast tests two directions: the influence of amytal might on the normal response and the responses to the test in severe the test and initial be extended in anxiety states (hysterias . . .). 3. It would be an error at the present time to describe the testing as a definite aid in the diagnosis of the organic mental syndrome. With such a figure, the physiological implications of the testing would be pushed to the background. But that if the studies can be verified as valid in OMS, then it might later be described in that condition as another test like orientation, patterns be 4. A memory, etc. special study in normal children of these undertaken. 5. 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A and «rind "am. mo na- tartan an intact. him). mad, thotvmmmlom ma xnms at that ‘91:» mm,~pm31. m umu- in imam-v uma panama... damned typo. in» we annulus... an “to tho «ya-alum 69 In this 9131.!“ that«I I out-91m mum» on the {WW Ian." A awn»a! nu 'WOPW“ Yemen: a: , W ‘Wt I ' “wt touch an ' touch tumult tench Chow-loft hm right than! loft ma~n§z was ﬁght hm tough touch tough. ; . may“ Alma-10“. rum 13.31:! i maintain-ﬂ cum: right hum-Mu an Mi: mam: ma «Musician ,. unnatﬁn utimtion mot it“ in.“ 00m." animation ' com“ dwt Bulk-tilt; land ”at; . chm-k - «tintim � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The face-hand test as a diagnostic sign of organic mental syndrome. Neurology. 1952 Jan-Feb; 2(1): 46-58. And, Observations on the Extinction Phenomenon in Hemiplegia Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-3-005 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin; Bender, Morris B.; Schappell, A. W. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 15 items, each with various amounts of pages. 1: Read at the second biennial meeting of the American Academy of Neurology, Virginia Beach, Virginia, April 11, 1951. 2: Reprinted from January—February 1952 (Vol. 2, N0. 1) Issue of NEUROLOGY. 3: New York Society for Clinical Psychiatry: The 116th Regular Meeting of the Society. 4: [Preprint]. 5: list of publications by Fink. 6 and 7: Drafts. 8: handwritten notes. 9: Letter to Dr. Bender from Fink. 10: handwritten note. 11: City of New York - Department of Hospitals/ Progress Record. 12: Handwritten notes. 13: Reprint from Transactions of the American Neurological Association 74th Annual Meeting, June 13-15, 1949; Observations on the Extinction Phenomenon in Hemiplegia (not written by Fink). 14: Handwritten notes. 15: typed pages. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/cda4311bdad6b67d755b69d80816976c.pdf 2b63fbc4853cb463227378ec92424d29 PDF Text Text [Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No. 1, Jan. 1953] PERCEPTION OF SIMULTANEOUS TACTILE STIMULI BY MENTALLY DEFECTIVE SUB]ECTS*1' MAX FINK, M.D.;t MARTIN A. GREEN, M.D.§ AND MORRIS B. BENDER, M.D. In studiesof the perception of two tactile stimuli applied simultaneously, it has been demonstrated that patients with diffuse brain dysfunction make errors. They persist in making errors either in re— porting only one of the stimuli (extinction) or in mislocalizing one or both stimuli (displacement). When errors are made in simultaneous stimulation of face and hand (the face—hand test) (I), the errors are in the recognition of the stimulus applied to the hand. The percept in the cheek is correctly reported. This “face-dominance” is apparent on initial test trials of normal adults. Similar results have been obtained in tests of young children. Children under the age of six years respond to simultaneous tactile tests almost with the same frequency of errors as do patients with dif— use brain dysfunction. With these facts before us, it soon became ap— parent that mental age was a factor in the perceptual response. There— fore, a study of the responses of mentally retarded adults with mental ages of young children was undertaken. Simultaneous tactile tests were applied to a group of mentally defective patients, and three aspects were studied: their responses to the tests; the order of dominance; and the relation, if any, to standard psychometric tests. SUBJECTS AND METHOD Fifty—seven mentally retarded adults from the wards of Letchworth Village, New York were examined. They ranged in chronological age from 13 to 41, and in mental age from two years, six months to nine ‘From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurologic Service of Bellevue and the Mount Sinai Hospital, New York. fRead before the Seventh Annual Convention and Scientiﬁc Program, Society of Biological Psychiatry, Atlantic City, May 11, 1952. IThis work aided in part by a Fellowship from the National Foundation for Infantile Paralysis. §Post—Doctorate Fellowship, United States Public Health Service. Work aided, in part, by a Grand—in—Aid #MH-139 from the United State Public Health Service, National Institutes of Health. [43] �Max Fink, Martin A. Green, and Morris B. Bender 44 years, eight months. The ﬁgures for mental ages were those recorded in hospital records reflecting performance on Stanford—Binet tests; and in each instance, the most recent estimate was used. RESPONSES TO SIMULTANEOUS TACTILE TESTS ON INITIAL AND SUBsEQUENT TRIALS FACE-HAND TEST 100 odul‘l’s wifh orqanic ------------ .. mental sqndrome 0O RESPONSES oO \l O DOMINANT 01 O a! O adult-mentally defective §O FACE PERCENT N0! 00 .. 0 0O 2 3 4 adult-normal 5 6 7 TRIAL NUMBER 8 9 10 showing responses to simultaneous tactile tests on initial and subsequent trials of the face-hand test in adults with organic mental syndrome, normal children of three to six years, mentally defective adults, and normal adults. FIG. I.—-Graph The subject was asked to close his eyes. Following this, he was simultaneously touched on the right cheek and the dorsum of the left hand. The examiner asked: “What did you feel?” If there was no response, the examiner said “Did you feel me touch you” and “Point to the place Where I touched you.” After this test the subject was again asked to close his eyes and the left cheek and left hand were stimu— lated, and the reports recorded. Subsequent tests included stimulation of left cheek and right hand, right cheek and hand, both cheeks, and both hands. This sequence of six trials was then repeated so that a total of 12 tests involving the cheek and hand combinations were carried out. Subsequently, tests of other body parts, as hand—foot, cheek—shoulder, thigh—foot, shoulder—thigh, cheek—foot, and shoulder—hand were intro— duced—four trials of each asymmetric combination and one trial each of the symmetric body parts. The entire sequence of tactile tests was completed with a repetition of trials of the face-hand test. �Perception of Tactile Stimuli by Mental Patient: 45 RESULTS On the initial trial, 98 percent of mentally retarded subjects reported the stimuli incorrectly. Eighty percent reported the face percept only, omitting the percept to the hand, a type of sensory extinctionﬁ“ The remainder localized the face percept correctly, but mislocalized the second percept to the opposite check, a type of sensory displace— ment. No subjects reported the stimulus to the hand alone or mislocalized the cheek stimulus to the hand. These responses are expressions of “face dominance.” Face dominance was also apparent on subsequent trials of the facehand test. Fifty percent of the subjects failed to localize the two stimuli correctly during the ﬁrst ten trials. They repeatedly failed to report the hand stimulus or repeatedly mislocalized it. The phenomenon of extinction was manifest in all subjects; while in 46 percent, displace— ment of percepts were also reported. A smaller number (38 percent) showed perseveration of responses, i.e., reported previous stimuli even though new stimuli had been applied to different parts of the body. The phenomenon of allesthesia (mislocalization of a stimulus across the midline to the opposite side of the body) (2) was occasionally observed. Only one patient demonstrated exosomesthesia (the displacement into extrapersonal space) (3). Half of the subjects succeeded in localizing and identifying the two stimuli during the initial ten trials. Their ability to localize the stimuli in the face—hand tests was carried over in the subsequent testing of other body parts. A few subjects, however, after correctly identifying the stimuli of the face-hand tests, made occasional errors during the testing of other body parts. These errors were almost exclusively in a failure to report one of the stimuli; neither displacement or perservera— tion was manifest. In all subjects simultaneous stimulation of homologous regions, e.g., cheek-cheek, or hand—hand, were interspersed throughout the testing. Errors were infrequent on such tests, even in those subjects who made persistent errors on stimulation of asymmetric regions, e.g., cheekhand. Such errors were observed in 15 subjects (26 percent) but only on occasions were the errors in a pattern as seen in a patient with a hemisensory syndrome due to a focal cerebral lesion. Relation to Mental Age—There was a deﬁnite relation between the incidence of persistent errors and the mental age of the subjects. Table I presents subjects grouped according to mental age (as determined by standard Stanford—Binet testing) and their responses to simultaneous tactile tests. It will be noted that there is a gradual fall *For convenience in writing we will call this type of response under conditions of double simultaneous stimulation extinction. �Max Fink, Martin A. Green, and Morris B. Bender 46 in the incidence of persistent errors on simultaneous tactile tests as mental age increases. TABLE Mental Age Group (year—month) I No. of Subjects Persistent Errors By 10 Trials 10 10 10 12 10 0 2-6 to 3—11 4—0 to 4—11 5—0 to 5—11 6—0 to 6—11 7—0 to 7—11 8—0 to 9-6 Correct 7 3 6 4 5 2 11 4 7 9 3 1 Relation of Body Parts—During the initial ten trials, face dominance was manifest in all subjects. In the subsequent tests of other body parts, additional patterns of “dominance” appeared. This was represented in the subject’s inability to identify and localize one of the stimuli or to mislocalize one percept in the direction of the second stimulus. As already intimated previously, the locus of the stimulus which is correctly reported is said to be “dominant.” In tests of cheek and shoulder, and cheek and foot, face dominance was observed (Table II). In tests of foot and hand, and shoulder and hand, both foot and shoulder are dominant over the hand. In the relationship of thigh and foot, and shoulder and thigh, both foot and shoulder are dominant over the thigh. TABLE II.——RESPONSES ON MULTIPLE SIMULTANEOUS TACTILE 57 MENTALLY DEFECTIVE SUBJECTS Total No. of Tests in All Patients TESTS IN .M Body Combination” FACE—hand FACE—foot 576 163 FACE-Shoulder 184 SHOULDER—thigh 170 SHOULDER-hand 151 FOOT—thigh 170 FOOT—hand 231 Incorrect Responses Correct Responses face or hand face and hand face or foot face and foot 315 36 face 64 9 9 or shoulder 15 252 128 face and shoulder 105 shoulder or thigh shoulder and thigh shoulder or hand shoulder and hand 45 12 63 3 foot 42 foot 58 or thigh 1 7 or hand 33 113 85 foot and thigh 11 1 foot and hand 140 *Capitalized letters (under Body Combination) indicate dominant part as manifest by t—test value of 5 percent or less. The differences in the incidence of errors in diﬂ’erent body combinations are largely due to the order of testing and the factor of learning. �Perception of Tactile Stimuli by Mental Patients 47 DISCUSSION These results when compared with those obtained in previous ex— periments show that there is a striking similarity in the performances of patients with organic mental syndrome due to diffuse cerebral disease or dysfunction (4a), to normal children below the age of seven years and to mental defective adults with a low mental age. The similarity lies in the types of responses, the persistence of errors, and in the order of dominance. Extinction and displacement phenomena are frequent in all three groups. The responses are apparent on the initial and on subsequent trials. In addition, allesthesia and exosomesthesia are occasionally ob; served. The subjects in each group manifest an inability to identify and localize asymmetric stimuli, that is, cheek and hand. Symmetric Stimuli, however, as stimuli applied to both hands, are well localized, even by the most mentally retarded subjects, by patients with severe brain dvsfunction, and by the youngest normal child. In every group the errors of localization persist through many trials of simultaneous tactile tests. The subjects are unable to localize the two Stimuli despite verbal clues offered by the examiner, such as asking whether there had been another Stimulus. The errors are present even when the subjects are tested with eyes open. The persistence of errors on repeated trials in the mentally deﬁcient adult, in the patients with mental changes, and in normal young children is in marked contrast to the ease with which normal adults correctly localize and identify the stimuli. The performances of these subjects are illustrated in the graph (Fig. I) which compares the percentage of errors during the initial ten trials of the face-hand test. It should be noted that the curve for the mentally defective adults includes 15 subjects who have a men— tal age of seven or more years (Table I). This will account for the curve being below that of normal children whose average mental age was rarely above seven years. Furthermore, the order of dominance observed in mentally re— tarded subjects is similar to that reported for patients with organic mental changes (4b). Face dominance is seen in all subjects, while the hand dominance is hardly manifest. The other body parts are between these limits. As in patients with organic mental changes or very young children one may be inclined to explain the inability of the retarded adults to localize the two Stimuli as due to “confusion” or “inattention.” Such an explanation is unwarranted because these subjects can perceive and localize symmetric Stimuli and the errors are not haphazard. The �48 Max Fink, Martin A. Green, and Morris B. Bender errors show in a pattern so that almost all errors are in stimuli to the hand and none in stimuli to the face. Furthermore, this pattern persists in tests of other body areas and is similar to patterns described for other groups of subjects (5). A comparison of the observations in normal young children and in the mentally retarded adults reveals a striking similarity in perform— ances when the mental ages of each group are compared. In both groups, there is a change in performance about the mental age of six years. It may be concluded that the face-hand test reﬂects the same performance ability as the Stanford—Binet test. The face—hand test has validity as a convenient approximation of performance above and below a mental age of seven years. SUMMARY The face—hand test and simultaneous tactile tests of other body parts were applied to 57 mentally defective adults. Their chronologic ages ranged from 13 to 41 years and their mental ages as determined by Stanford—Binet testing ranged from two years, six months to nine years, eight months. On the initial trial 98 percent failed to localize both stimuli and on subsequent trials 50 percent made persistent errors beyond the tenth trial. The errors were made in stimuli to the hand whereas stimuli to the face were correctly reported. Extinction, displacement, allesthesia, and exosomesthesia were observed. These performances of the mentally defective adult to the face-hand test are strikingly similar to the responses of patients with diffuse brain disease and of normal children of six years or less. Furthermore, there is a deﬁnite relation between the persistence of errors and the mental age of the subject. It is concluded that the face—hand test reﬂects the same performance as the Stanford—Binet and has validity as an approximation of performance above and below the mental age of seven years. REFERENCES Bender, M. B., Fink, M. and Green, M.: Patterns in perception on simultaneous tests of face and hand. Arch. Neural. &' P5ycl1iat., 66: 355, Sept. 1951. 2. Bender, M. B. and Nathanson, M.: Patterns in allesthesia and their relation to disorder of body scheme and other sensory phenomena. Arch. Neural. 6' P5yc/zz'at., 64: 501, October, 1950. 3. Shapiro, M. F., Fink, M. and Bender, M. B.: Exosomesthesia or the phenomenon of displacement into extra—personal space. Arc/2. Neural. é‘r Psychiat. (in press). 4. (a) Pink, M., Green, M. and Bender, M. B.: The face—hand test as a diagnostic sign of organic mental syndrome. Neurology, 2: 46, Jan. 1952. 1. �Patients Mental Stimuli by Tactile of Perception 49 in cutaneous dominance of order The B.: M. and Bender, M. M., Fink, (b) Green, perception. Trans. Amer. Neural. Assam, 74: 1952. in Extinction phenomena W.: A. and Schappell, F. M. 5. Bender, M. B., Shapiro, hemiplegia. Arch. Neurol. 6' Psychiat., 62: 717, Dec., 1949. 1150 PARK AVE, NEW YORK 28, N. Y. �~ a!" hfmaulfﬁﬁg PIIOI?IIOI I! 0' SIIULRAIIOUB 3- _ «- $555!”? ‘ “my“, 1.; -A?» if} iﬂcllhl ITIIULI IIIIALEY 931301173 BUBJIB!£.* By In: vink, 3.»... Ina-tin A. Green. _ 8.3..” and ﬂorria B. Bondar, u.n. «mach-r r“ 3'" a” on Collegp or undicina and tho Neurolozze service of null-vac nouns Sinai Hospital, low York city. ‘. . 9*!h1u vnrk aidod a 1' in part for Infantilc Paralyuin. "M"; by a "‘"‘ " J, 73‘; "u f and tho Ftllauuhsp from the latiennl ronnunt1an . aﬁtPott-Dootortte Fellaunhip, Unitcd States Public ﬁbulth surviec. Hark aided, in part. by n Grantuinind #HH~139 from the United 3t&to Public ahalth Servico. National Inatitutas'ot ﬁnnlth. �1. In etudiee or the peroeption of two teetile stimuli applied eieoiteheoueiy, it hee been denohetreted that petiente with diffuee brain dysfunction Ink! errors. Qhey pereilt in liking. errore either in reporting only one or the etinnii (extihetioh) or in nielooeiieihc one or both etiwnii (diepleeeleht). when error: ere eede in ei-aiteneoue stimulation or face and head (the teoe~hend test) (1) the errore ere in the reoocnitidn or the etiluiue eppiied to the head. it. peroept in the cheek it correctly reported. This “reoe—deninanoe” ie eppereht on initial tent triele of aerial edulte. Siniier reeuite have been obteihed in teete or youn‘ children. children under the ene or six yeere reepond to ei-nlteheoue tactile teete eieoet with the eene treeuehoy or errore ee do patients with diffuhe brain dylfunotion. Uith thete flute before’ on, it eoon beoene apperent thet eentei esp wee e rector in the peroeptuei reepohee. Therefore. e study or the reeponeee or mentally retarded eduite with mental egee or young children wee underteken. aieoiteheoue teotiie teete were eppiied to e group or mentally detective petiente. end three eepeote were studied: their reepoheee to the tests; the order or doeinenee: end the reletion, it eny. to standard peyohdletrio teete. am no me neateily on! Pitty~eeven reterded eduite from the werde or Letohworth Viilege, lew York were examined. whey ranged in chronologioei ego from 13 to #1. end in wentei use from two yeereueix nonthe to nine veers-eight nohthe. The figuree tor'uehtei eaee were thoee recorded in hoeoitei record: reflecting pertoreenoe on stenrord~nihet teete; end ih.eeoh instance, themeoet recent eetinete “I “I'd e �its subsoot sss'ssksd to class his oyss. Following this ho sss sinultsnsously touched on tho right ohsok sod tho dorsal of tho loft hsno. rho oxsninor asked: ”tht did you tool?" If thsro uss no response. tho oxssinor sskod "Did you tool as touoh you'.snd-“?oint to the plans shore I touchsd you." Aftsr this tsst the subjsot sss sgsin sokod to class his syss sod tho lsrt ohssk.snd loft hsnd stisulotsd, sud tho rsports rooordsd. subssQusnt tssts inoludsd stmsulstion of lsrt ohssk and right hsno, right ohosk sud hsad, both chooks,snd both bonds. This ssquonoo or six trials sss than rspsstsd so thst a totsl or 12 tssts involving the chuck; Ind hand ounbinstions ssrs carried out. Subsequsntly, tosts or other body ports, on hsod~root, ohssk-shouldsr. thigh-toot, shouldsr-thigh. ohook~£oot, and shouldorvhsnd sore introduced ~ four trials or osoh ssyulstrio oosbinstion sad on: trisl esoh of tho symmetric body parts. tho ontirs musnos or mum tssts omlcm with s rspstition or trisls of the tsoo~hsnd test. m assault: 0n ths'initisl trisl, 98! of nontslly rotsrdod subjects roportsd tho stinuli inoorrsotly. light: psr osnt rsportsd tbs fsos porospt only, omitting the psroopt to ths hand, a typo or ssnsory sxtiuotion.’ so. rssnindor looslissd tbs tsos psrospt oorrsotly, but mislooslisod tho second poroopt to tbs opposits chock, s type of sensory displsosssnt. It subJsots roportsd tbs stimulus to tbs hand olom or nialoosliud musk stimulus to the Fla'Ior doﬁ§3nisnos in writing so will osll this typo or rssponso undsr conditions or double simultaneous stimulation as extinction. RID Pl; �3._ are unprbtnionn or “race dunintnoa." tact dulinnnn- an: also apparent on subuognlat triuln of rib: flacuhnnd tent. titty per cent at eh. handouts failed to lootliue the two stimuli oorrtetly during the firﬂt ten trillu. 1hr! rupoatediy thilod to vaport tn. hand atinulun or repoatedly nialoetlized it. 15h: phenomenan at extinction was manifest in all lubaoatsg while in forty~six per cont, displuocunnt or poroupta I've alto reportad. A smaller number (335) shorad perceverutien or runponlon; i.e.,_ri§;r§od previous stiuuli even though now stimuli had hc¢n~aapli¢d ta different part: of thn hady. The phenomenon of cilanthnniu (miulooalisntian of a stimulus across th. nialinn to the opposite 3140 at tho body) (3) was ooaaaiannlly obnorved. Only out phtiant dauonutrltod oxotaneutheuia (the dinplaooaonz into extra-pornonnl npaeo) (3). all! or the number or nubjoota uncooeaed in localising and identifying the two stimuli Grins the initial ton trinlu. Their nhility to 1033113. the Itimuli in tho thee—hand tents una carried over in thn auhnoquont testing or other body parts. A for Inbaoetn, amour, actor aomctly identifying m5. sen-mu at the hem-hand haiku. made oaacaiennl errata during the testing or other body parts. ihole errors ﬂute tlnmut again-ivoly in a failure to roport one ork‘ the stimuli . mum displacement of ”mat-tum Ion unite“. In all subject. sinultanoaul Itiunlation or hauologoun ii rngienl. 0.5. aher-ohnck, or hand*hnnd. wort intoruporled throughout the touting. 3mm mm infrequent on men tutu, «ms in those subject: who and. periisuont error. on neinulction at hand. Ehunu annponnou asymmetric regions, 0.3. chairman. fifteen subjects (26!) but only Mowers were chums! on occasions ware in thc error: in a �#. pattern as toga in t pttiont with n honiuoanory syndrnna dun ta 3 tonal cornbral Ionian. Relation to at." definite relation betunen thu 1nc1denoo or perintent 0mm and thc maul m or the subarea. run- I mount. .ubjootnerupod acaardins to nantul net (at dateruined by utcndard There wan a Stanfordwauant to:t1ns) and their respanaoa to ainultannaua tactile be noted that there in sauna; in the tutu.” It an insidonon or porozatcnt errors.on Innultnnaou: unul m 1mnnﬁn. mam. m am m; an tactilo test. an th- "$33“ $233.1. 1o 0 14: 7 3 93313:“ f (yrnrdnanthn) to 3-11 Mo to Mn 5-0 to 5~11 10 10 I 5 6.0 ta 6~11 1-0 to 7.41 12 5 7 11 a 9 8-0 to 9-6‘ I 1 3 2-»6 ‘ nolntion of 3352 Pitts! During the initinl ton trials, faae daninnan. was manifest in 311 lubjoata. In the subsequent tent: or ather body parka. ndditionnl pattcrnn of "dominance” appeared. This wt: ruprnutnzod 1n the aubjeot's inability to identity and localize on. of an. utiuuli or to niulooalitn on: poroept in an. dirlotion or thﬁ Ionand Itinulua.' As already intimated previoutly eh: Lyon: 0: the stimulus which in correctly reported 1: natd ta be ”daminanc". In tent: at check and shoulder. and cheek and fact, face dominance was �5’ obcurvod (Elblc II). In toot: both root and thauldcr at tnxgn It. to tho hand. in.tho rulatzonnh39 thigh. both too: and shoulder are dominant and shoulder and root, daninnnt to tho thigh. and or toot and hind. and shoulder and hand. ‘ BL! 11 alsronsna O! NHLEIPLE 81IULEARIGUS 2ACTILI TESTS BBFIGEIVI sunqsces retal £25: 6nnb1nnt10n' lumber of Toot. in Incorrect All Patient: lACI~hnnd 576 'Acl»foot 163 {AGE-shoulder 184 ‘ 8300LDIR~thigh 170 alonlﬂll¢hnnd 151 Factuthigh 170 toetuhnnd 231 I! 57 NBNEALLY Carroct Duo. 315 or Rand Rosaenaou Paco 1nd Band Fan. or loot taco and root Faee or Shouldor Rougonaol 36 252 9 128 9 Face and Shoulder 105 15 shoulder and Thigh shouldcr or ﬁnish Shouldcr or Hand 3 Shouldgg and 33nd #5 63 12 ‘ 113 Font or fhigh root and Thigh Foot ar Hand Foot and 81nd #2 » (under Body cambination) letterI/indtoatc dominant part *g;pltalilod 63‘ 10.3 17 33 111 1&0 as manxregt by t~toae va1ue of differenaei in tho incidence of errors in airfarent body combination: is largely duo to the order of talking and the factor or lcarning. Ema I ../ �6, amacuggxggg inane reunite when compared with thoae attained in previous experiments then that there in e striking similarity in the per- patient: with organic mental tn diffuee cerebral disease or dysfunction (23). normal children below the use of seven yeere end mental defective adults with e low mental age. The similarity lien in.the type: of reapeneee. the pernietenee 5: errors, and in the order of dominance. Extinction end diepleeenent phenanenn are frequent in all three groupe. Ibo responses are apparent on the initial end an Isabeeeuent triele. In addition, allettheeia and exonemeetheeie are formeneee of syndrome due I oeellioneily obeerved.. the eubJeote in each group unifeet an inability to identity Ind leeelile lay-nettle stimuli. thet is, cheek and hand. Symmetrie ntinnii. however, at etinuli applied to both hands, are well the most nanny named subjects. by patients with very severe brain dysfunction and by the younspnt annual child. In every group the errors or localizatien persist through many trial. of simultaneous teetiie tests. The subject: are unable ta lonelise the two Itinuli despite verbal clues uttered by the whether there had mu another etinuiuu. owner. each The errors are present even when the subjects are tented with eyes upon. The pertietenee of error: on repeated trial: in the mentally deficient eéuit, in the patient: with mental chance: and in annual young children it in marked contrast to the ease with which harnei adults correctly iooeiise and identify the stimuli. The per~ tornnneee or these tubaecte are illustrated in the graph which ieeeiised, even by u mam _ �7:. compare. their our cent error: during the initial ton trials of It Ihould be noted that the curve for the nontally deroctivo adult. includes 15-Iub1003! who have a mental age or 7 or more yuart, (see~!able I). rhia will account for, tho curve being below that or honnal children whose average mental tho race-hand tout. age was rarely above-7 yearn. Further-coo, tho order or conihahce observed in aoutally rotardcd subjects ia similar to that reported for pationta with organic nohtal chahuoa (at). Pace dominance in poem in all aubjeota, while thh hind dominance la hardly annifeat. The other body part. are tetuecn theaa linita. A: in patientc with organic tental chancea'or very young children one nay be inclined to explain the inability or the retarded adults to localine the two utiauli aa due to ”confusion” or "inattention." such an explanation in unnarranhcd hecanaa these subject. can perceive and localite Ion-atria Itinnli and the errata are not haphaaard. The errors shoe in a pattern to that clncut all emu are in stimuli to the hand and none in stimuli to the race. rurtheraore, this pattern per-iota in tecta or other body areaa la similar to patterns daaoribod for other group: of athects (2). A comparison of the ohcervaticna in normal young children and in tho mentally retarded adult. reveal: a striking ainilarity in perforntnoet than the mental age: or each group are oomparcd. In both groupa, there in a chahgc in pcrtor-ahcc about tho mental age or six soars. It may be concluded that the race-hand teat reflecta and the same performance ability an the stanrood~nihot tent. tho race~hahd tent has validity ac a convenient approxmuation at per» formance above and below a mental age of seven yearn. �8. tout and tinnitunnnu: tactila tact. or nth-r body part: unto Ipplioa to 57 noatnlly narcotivc adults. Qatar chronological asst runcpd from.13 to #1 start and taut: anntal yourn-é month. 1303 as dotcrldnld by stanrord~nanot touting rangpd Iran a The facauhnnd ,to 9 yearauﬁnonthlp Eris} 9&§.tlilod to 1903118. both act-“11 and an oubuogupne grin}: 50! and. persistent error. hoynnd can 0n tbs 131%151 trial. 1h. errors ﬂit! lid. in Itlluli to en. hind whovotl 'auumu so. the has am ”metal: "parka. ‘xxtmouon, dinpnomnt, touch . allalﬁhosia and oerquIthnuin wort obocrvod. ihnlo parrot-anac0: tbs Inntally detoetivo'aault to an; tacoohand tent at. utrakxngly similar tn the response: of puttcntn with dztruto brain agnonua and of normal children I59 :1: 13:23 or loan. rurthnmnaao, thorn in a dotinihn rclation botuoon tho p02— uittcnno of utter: and tbs anneal as. at tho aubJoot. It 1: con~ gludnd thnt tn. floc-hnnd touﬁ rotloots ch. sane pgttarllnno as tho senatord~31unt and has validity as tumgpprnximntion or performance V above and below tn. acntal an! or seven yours. �mung 9. ‘ 3.3., rm, I. and «am, Ila rue-m 1n nonunion mm. 1n nimltmeouo tent: or race and hand. ArchJomlJnnzohnt. 1. ﬁg, 355-352. 809%... 1951. 14., am, II. and mm, mm: The raeomand tut u an, a. diagnostic up) or organic mental undress. Inna-019g, g; ‘6“58; m, JW ll... um, I. 1952' and cutaneous perception. m, Mn..mx-.lourol.unoou H.3J The - order of in denim 195:. 7k: 11.3. and summon, HA utter-nu 1n alluthuu mm, than relation to diaerdor or body when and 0th» and unset-i 950. gs: 501615, October, SEAPIRO, ILL, 21m, 14. and mum, 14.8.: nouns-thou: or the plum-anon of dilpllomnt into ours—personal snot. phenomena. Atheurothghiut. , Archmoumhhrqrohut. (in m, ILL, .5. December, 1919. ) Vi crib ./ 7 {(12% 3!!“‘130, NJ. {aha-noun. 1:: 11031910311. ' pan) and WRAPPELL, AMA Minot“!!! Arch.murol.&Pazch1at.. ﬁg; 717-3724. �1% 1139:. 1. Graph gnawing runponnou tugs: ta ninultuniaua tantilo on in1t1a1 5nd subocquant trials of tho in adults with organic mental faoe‘hand test ‘ayndrunn. normal children. age 3~6 yonrt. mantally defective adults and normal adults. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli by mentally defective subjects. J Nerv Ment Dis. 1953 Jan; 117(1): 43-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-9-013 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin A.; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE, Vol. 117, No.1, Jan.1953 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/6428428b2e8c8dd8c101b89ff0bcc16f.pdf 0dca1e713671d6e32179b0a6fd1afba3 PDF Text Text Electroencqahalographic Correlates of the Electroshock Process Max Fink MJJ. and Martin A. Green 14.3). ‘ .. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., in part, by grant M—927, National Institutes of Mental Health, National Institutes of Health, U.S. Public Health Service. Aided, Read at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. V:3-l-58 New York, N.Y. �Electroencephalographic Correlates of the Electroshock Process During the past few years, renewed attention has been given to the relation between changes in measures of cerebral function, and the behavioral changes induced by electroshock (l, 2). Alteration in various aspects of the electroencephalogram has been emphasized by various observers (3, h) in cerebral function. In an initial study in this laboratory, a significant relationship between the degree and duration of induced delta activity and clinical evaluation of "improvement" was observed (6). Subsequent studies have focused on as a sensitive index of changes ' various parameters of the EEG changes including frequency of type of current, age of subject and pre-treatment record It is treatment,' characteristics. the purpose of this report to assess the relation of these aSpects of treatment to changes in the EEG and in clinical response; and to describe the role of serial electroencephalograms in the rational management and study of convulsive therapies. �-2- man: One hundred and seventy-three consecutive electroshock referrals have been studied. Electroencephalograms were taken before treatment, after treatment at weekly intervals during and following the course of therapy until the record had achieved its pre-treatment and on a day characteristics. Patients in whom demonstrated slow wave or spike All the EEG delta activity. the pre-treatment electroencephalogram activity were excluded from the series. records were quantitatively measured for the amount of On the basis of the per-cent time, slowest frequency, highest voltage and longest duration of bursts of slow waves, in selected lead combinations, the records were classified into "high," "moderate" and "low" degrees of delta activity, according to criteria previously published (6). Three convulsive techniques were employed: suprathreshold alternating current, threshold alternating current current methods. The and parathreshold unidirectional alternating current suprathreShold (7) and unidirect- ional parathreshold (8) treatments followed established techniques. In the threshold alternating current method, patients without prior sedation received small amounts of current (90 volts for 0.2 second), usually sufficient for a petit mal response. intervals voltage, and if necessary, duration.was increased until a grand mal convulsion was inAt 20 second voltage and duration necessary to induce a grand mal duced. The minimal was the threshold value. In addition, a convulsive-subconvulsive control study was instituted during a period of these observations. Randomly selected patients referred . �.3for electrotherapy received subconvulsive therapy instead of grand mal. In this technique, patients were given pentothal intravenously until asleep, and then either low voltage unidirectional current fbr 60 seconds alternating current of 80 to 120 volts for 0.2 second were administered for one to three applications, for a total of 2h to 36 petit mal (8) or responses. Of the 173 electrotherapy referrals, lh6 received grand threshold alternating current, 57 by current and 63 by 26 by suprathreshold mal therapy - alternating parathreshold unidirectional current methods. Twenty- seven subjects received a course of subconvulsive therapy. All treatments were given three times a week, for 12-20 treannents. failed to develop a significant behavioral or clinical response, or middle or high degrees of delta activity in the EEG, were subsequently Patients Who treated five to ten times per week. Evaluations of clinical reaponse were trist ment and resident therapists on two occasions. At the supervising psychia- the height of the treat- effect, the degree of behavioral change was scored as ”marked," "moderate," "minimal” orfhone." in behavior in interviews These made by after treatment was terminated. and were based on the ratings were estimates of the change and on the ward from the Ratings of "improvement" were also weeks made by pre-treatment patterns. these physicians two to three These ratings were value judgments four-fold classification of "recovered," "improved” and "unimproved or worse" (2, 6). "much improved," �RESULTS: 1. Variability in Delta Activity'with Convulsive Therapy: variability in the degree of induced delta activity reparted in the initial 2h patients {6) is confinned in these series of convulsive therapy referrals (Table I). While the number of high degree The wide records increases with treatment, fourth week, are still rated as 27% ”low" degrees of TABLE Degree of EEG in the third week, and 18% in the delta activity. I Delta Activity with Convulsive Therapy (Per-cent of Group) Treatment Period h 28 h6 60 Moderate Degree 12 21 27 22 Lou'Degree 68 h8 25 18 16 3 2 o High Degree No Delta Activity 2. Role of Convulsion in The EEG Response: significance of the convulsion per gg in the EEG and behavioral response was assessed in the convulsive-subconvulsive study. Of the h? subjects*'who received convulsive therapy in this study, 9 had * These included 28 subjects who received grand mal therapy on a random selection basis, plus 19 subconvulsive subjects referred for a "second course" of therapy. �-5high degree delta records in both second, third and fourth weeks of ment, 12 during two of the three weeks, and 13 during one of the periods. Thirteen of the h? subjects failed to show a treattest high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta activity records during any week of treatment. Low degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. In concurrent behavioral ratings, 25 of initial 28 subjects in the convulsive group showed marked behavioral change; while of the subconvulsive group, Of the 21; of the 27 showed Bdnimal or no behavioral changes (Table latter group, 19 were referred II). for a second course of therapy. In 1h of these, grand mal electroshock induced high degree delta activity all significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroShock, all and showed a showed middle degree records; and change. three of the five Showed a behavioral Thus, of the h? convulsive therapy subjects, h2 showed a behavioral change. significant �—6— II TABLE Ratings of Behavioral Change: Convulsive - Sdbconvulsive Therapies (Fburth-Fifth'weeks of Treatment), Moderate marked Minimal yggg i Convulsive Therapy (A?) 27 15 5 0 O 3 8 16 Subconvulsive Therapy (27) In evaluations of the degree of "improvement" 51% of the convulsive therapy group were rated as "recovered," and evaluated as sustaining the "improved," and only however, but 70% 11% III). as "improved" (Table 32% 7% were rated same weeks after treatment, "much improved" On discharge, degrees of improvement, while were ”unimproved." in the tWo first two were “unimproved," two weeks or 51% were h2% were 0f the subconvulsive group, categories, 19% after treatment. As in the "improved," these were re- ferred for a second course of therapy, hosPital discharge evaluations do not reflect the effects of subconvulsive therapy. TABLE III Ratings of Improvement: CoHVulsive-Subconvulsive Therapies (TWO Weeks After Last Treatment) Recovered Much Improved Improved Unimproved, worse Convulsive Therapy (h?) 9 15 15 8 Sdbconvulsive Therapy (27) 2 l 5 19 �Convulsive therapy induced and more favorable evaluations The significantly greater behavioral change of improvement than did subconvulsive therapy. clinical observations thus parallel the electroencephalographic data. Also, patients who showed.neither an convulsive therapy, EEG Showed both EEG and or a behavioral response to behavioral changes when Sub- placed on convulsive therapy. 3. Role of Type of Convulsive Therapy: In view of the variety of electroshock techniques employed, the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock on EEG delta activity undertaken. The results are graphically presented in Figures first figure relates and 1 and was 2. The the treatment type to the percentage of records demon- strating high degrees of EEG delta activity in each treatment group during the second, third and fburth weeks of treatment. In each period, treatnent with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unidirectional current and with alternating current at threshold strength was less effective than the supra- threshold alternating current technique in each period; the unidirectional current treatment being method only more effective than the threShold alternating current early in the course'of therapy.* Subconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same relationship by measuring the per cent of each treatment group showing no delta activity or only low degrees * The differences between suprathreshold and threShold treatment methods are significant at .05 by chi square in the h-é and 7-9 treatment periods, but not in 10-12 period. Parathreshold treatment methods are not significantly different free the other two methods during any treatment_period. �-8of such activity. Here, the subconvulsive group is 100% for each treatment period. Suprathreshold alternating current techniques the least number of such records in eaoh period, with threShold show and parathreshold techniques in between. h. Freguenqy of Treatment: Another factor is the frequency in the rate of development of delta activity of treatment. While three times a week, a number activity were treated were given more who all patients and In nine such patients, treatments in each instance middle or high degrees of delta activity were induced. Similar previously demonstrated by Pacella 5. Factor of In the initially treated failed to develop high degrees of delta intensively. daily or twice daily, were at 31. (9), correlates were EEG and Callaway (10). V Age: initial series of'patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta activity during the first and second weeks of treatment; while older subjects developed such activity to a significant degree during the third week. By the fourth week of treatment, age no longer between the groups. Combining the data from supports this observation. all differentiated convulsive therapies During the Second week, h3% of records are in patients under the age of no; but only 30% in patients from h0-60, and 18% in patients 61 and over. In the third measured high degree delta and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects have high degree delta records times per week. when treated 3 �.9TABLE Variation in Per IV Cent High Degree Delta EEG Records with Age * 9 Treatment Period Second week Third week Fourth'week in. is. 2:2 nee ho years (28) 15% 61% 69% ’41-50 Years (28) 29% h0% 56% 51-60 years (28) 32% 56% 55% Over 61 years (18) 18% 50% 80% es To ' 6. Pre-Treatnent Record Characteristics: Previous reports, summarized by Chusid and Pacella (3), noted a significant relationship between pre-treatmnt reca» rd character- istics and the degree of induced "abnonnality." Predominant alpha rhythm, “abnormal" (3) or “borderline abnormal" (11) records were more develop alterations in the EEG liable to than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment'record demonstrated diffuse slow wave activity, spike or spike wave activity were not included in the statistical analyses. Eight such subjects were «- difference in incidence of hig1 degree records is significant at .01 level of confidence between the second and fourth weeks and .05 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. The �-10.. treated with convulsive techniques, high degrees of delta activity however; and seven of them developed earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre-treatment alpha . and the degree of induced delta activity was undertaken. Rank order correlations of the preetreatment per cent time alpha in selected leads (anterior temporaldvertex) with the degree of delta activity during the third and fourth weeks of treatment of +.2h and +.3S reapectively. The in h3 patients demonstrated correlations relationship in the fourth week significant at the .05 level of confidence; while that in the third fails of significance, although the trend is indicated. is week �.11.. DISCUSSION: aspects of these studies warrant discussion: the significance of the convulsion in the electroshock process; and the role of serial electroTwo encephalograms in the rational management and’study of convulsive therapies. In the early studies of convulsive therapy numerous authors, including Kalinowsky 23 El. (12) and Pacella and electroencephalographic gt.§£. (9), emphasized both the clinical differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes Similarly, electroencephalograms in grand activity, while in petit mal therapy, no in less than 25% of subjects. mal therapy demonstrate delta delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, and focal convulsive techniques in each, in.turn,,discarded in routine therapy. Bergman §§.§l, (13), for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records at 15 such "seizures;“ while 70-75% had "abnormal” records after have been described, and Ulettgt El, (1h), in a careful convulsive-subconvulsive control study,reported a significant difference in the clinical response of grand mal seizures. patients receiving convulsive therapies convulsive (33%), or controls (38%). reSponse in the He (60-80%) and those noted two groups, and emphasized the for the therapeutic effect. ReCent ﬁne discrepancy in the EEG significance of the seizure additional reports based on a variety of data further emphasize receiving sub- ﬂue by various observers, significance of the convulsion �.12.. in the therapeutic response (h, 15, 16). convulsions per g2 are, or which thus indicates that reflect, the significant physiologic events are the basis for therapeutic efficacy of convulsive therapies. If the convulsion is the essential element both in the the behavioral response, does the any The evidence EEG and in induction of the seizure play mode of role in.this reSponse?. In the studies reported here, small differences in both the degree of EEG delta activity and the rate of its development different methods of induction of grand mal seizure. Ulett gt 3;, (1h) reported an improvement rate of 57% for the alternating current cenvulsive technique, and 76% for the photo-metrazol were observed between technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulsive photoametrazol technique. In a discussion of this report, Kalinowsky noted.that metrazol convulsions have impressed various workers as being more efficacious than induced convulsions. convulsant drug, PM More electrically recently, Edwalds, (17) describing a 1090, ascribed to it new clinical results slightly better than electroconvulsive techniques. further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance~ we have of clonic or tonic phase, apnea, 332. All grand mal seizures are seemingly not equivalent; and a seizure is not an "all or Different seizure patterns occur and these may none" phenomenon. reflect differences in the physiologic effect of different treatment methods. Further studies of this problem are in progress (18). �-13 .- While this variability in clinical results is reported, it is clear that with repeated canvulsions, rates no matter how induced, improvenent per cent are observed. The differences between various types of treatment are small, and, for the most part, may be readily obviated by of 60 to 80 the simple expedient of increasing the frequency or number of treatments. We may conclude way that convulsive therapy is nonpspecific with regard to the the convulsion is induced. The significant element is the brain change subsequent to the convulsion, and not the agent used in bringing about this brain change. In previous reports (6, 19, 20) convulsive therapy we have noted that is also non-Specific with regard to its application in mental illness, and in its clinical effects. and behavioral The present studies, amplify , therefore, the previous conclusion of the non-Specificity of convulsive we have therapies. applied methods of quantitative, serial studies reported here. EEG analyses in the clinical estimates of behavioral While change have yielded similar data, such evaluations are more dependent on the attitudes of the observer (21), and less amenable to quantification than the EEG. Application of EEG analyses to problemsin convulsive therapies provides a rational basis for the comparison of different treatment techniques. “we have previously noted clinical management patients who that EEG analyses may be applied in the of patients receiving convulsive therapy (6). In fail to show a significant behavioral response on treatnent regimens of three times per week, an electroencephalogram may serve as a �guide for further therapy. In those subjects in.whom high degree delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a more effective oonvulsant method, may result in the neurophysiologic changes. If the degree of delta activity is high and sustained for a number of weeks, other factors as personality (22) or environmental (19) may be assumed to preclude a satisfactory behavioral response, even when the neurophysiologic substrate and further convulsive therapy application has been suggested EEG may well be discontinued. by Roth (5) A is assured; similar for thiopental activated records. The successful application of quantitative convulsive therapies, has led to dynamic EEG techniques to their application to other physio- therapies. Recent reports from these laboratories note a similar application for the rational psychopharmacologic agents (20). management and understanding of �.15sunnru AND CONCLUSIONS: Serial quantitative analysis of the degree of induced activity in were made 173 consecutive EEG delta electrotherapy referrals. Patients were treated by three convulsive methods: suprathreShold alternating current, threshold alternating current and parathreshold unidirectional current. Random electrotherapy patients received a course of subcdnvulsive treatment instead of grand mal, in a convulsive-subconvulsive control study. 1. An induced grand mal convulsion is essential both for the electro- encephalographic and the behavioral changes ascribed to ”shock" therapy. 2. The rate (a) two The EEG delta activity of seizure induction: suprathreshold Mode techniques induce techniques. and degree of induced EEG changes earlier and is dependent upon: alternating current to a higher degree than threshold results of unidirectional current methods fall between these techniques. (b) Frequency of treatment: increasing frequency inereases degree of EEG delta activity. (c) Age of subject: Patients under delta activity earlier than older patients, but ment, differences are insignificant. (d) Pre-treatment record hS develop by the greater degrees of fourth week of treat- characteristics: Patients with dysrhythmic records or high per-cent time alpha activity develop greater degrees of delta activityearlier than patients with low per-cent time alpha activity. 3. It is suggested that serial quantitative electroencephalography provides a rational basis for the study and the clinical management of convulsive therapies. �REFERENCES l. Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. 1.92: 22-26, 1952. Psychiat. 2. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobartital Test 3. Chusid, J.G. and Pacella, B.L.: The Electroencephalogram in the Electric Shock Therapies, J. Nerv. & Ment. Dis. 116: 95-107, 1952. h. Roth, 14.: Changes S. Roth, to Clinical Improvenent in Electroshock, AMA. Arch. Neurol. in the under Barbiturate Anaesthesia Produced by Treatment and Their Significance for the Electro-Convulsive ECT EEG Clin. Neurophysiol. 2: 261-280, 1951. Theory of Action, Kay, D.W.K., Shaw, J. and Green, J.: Prognosis and Pentethal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG Clin. Neurophysiol. _9_: 225—237, 1957. 7:41., ’ Fink, EEG M. and Kahn, R.L.: Relation of Electroencephalographic Delta A.M.A. Arch. Activity to Behavioral Beeponse in Electroshock, Neurol. and Psychiat. Z_8_: 516-525, 1957. 7. Kalinowsky, L. and Hoch, P.: ghock Treatments, Psychosurgegy and Other Somatic Treatments in Psychiatry, Grune and Stratton, N.Y. 1992. 8. Alexander, L.: Treatment of Mental Disorder, W.B. Saunders Co., Philadelphia, 1953. 9. Pacella, B.L., Barrera, E5. and Kalinowsky, L.: Variations in the Ele ctroencephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Paychiat. 367-38u, 19u2. g: 10. Callaway, E.: Slow Wave Phenomena in Intensive Electroshock, Neurophysio . a: 157-162, 1950. ll. Kennard, M. and Willner, M.D.: Significance of Changes in the Electro— encephalogram which Results from Shock Therapy, Am. J. Psychiat. 1L2: : 12. 13. Olin. uo-us, 19m. Kalinowsky, L., Barrera, Reaponse l9LL2. EEG ms. in Electric and Horowitz, W.A.: The "Petit-Mal" Shock Therapy, Am.J. Psychiat. 28;: 708-711, " P.5., Impastato, D.J., Berg, S. and Feinstein, R...‘ Electroencephalographic Changes Following Electrically Induced Focal Bergman, Seizures, Conf. Neurol. 12: 271-277, .1953. �W K. and Gleser, 6.0.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, A31: Jo MChiat. 112: 79S~802, 19560 Ulett, GA” Smith, 15. weinstein, E. and Kahn, R.L.: Denial of Illness, 0.0. Thomas, Springfield, 1955. 16. Fleming, “13.0.: An Inquiry into the Mechanism of Action of Electric J. Nerv. & Ment. Dis. 121;: th-hSO, 1956. Shock. Treatments, 17. Edwalds, R.M.: Intravenous Administration of PM 1090: Clinical Elmerience with a New Convulsant Dmg. Read at FLY. Divisional Meeting A.P.A. 1957. 18. Green, M.A.: Significance ‘of Individual Variability in "EEG Respome to Electroshock, J. Hillside Hosp. é: 229-210, 1957. 19. Fink, M., Kahn, R.L. and Green, “.11.: Experimental Studies of the Electroshock Process, Dis. New. 835 . (in press). 20. Fink, M.: 21. Fink, A Unified Theory of the Action of Physiodynamic Therapies, J. Hillside M. and Kahn, 9: 197-206, 1957. R.L.: Behavioral Patterns in Induced States of Hosp. Altered Brain Function. 1957. 22. Read at N.Y. Divisional Meeting A.P.A. Personality Factors in Behavioral Response to Electroshock Therapy, Coni‘. Neurol. (in press). Kahn, R.L. and Fink, 14.: �ELECTROENCEPHALOGRAPHIC CORRELATES OF THE ELECTROSHOCK PROCESS MAX FINK, M.D., and MARTIN A. GREEN, M.D. From the Department of Experimental Psychi: atry, Hillside Hospital, Glen Oaks, .N. Y. Pro blem : In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment; on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varial, including unidirectional and alternating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12-20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, were subsequently treated at 5-10 times per week. The EEG records were classiﬁed for degree of delta activity into “high," “middle” and “low" degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest amplitude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. _ Results .' ~ .4]; 3, 54 I ._ 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subCOnvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional but by the 4th week of treatment, the di' erences were eliminated. '4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. ”ﬁruments, ‘ Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. . 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient 3) Early. and sustained high degree electroencephalographic delta activity is a necessary,, though not sufﬁcient, pre-requisite for improvement in the electroshock process. ’4 ; Avf" �TRQIW m Subuuowluve Conoubwc \\ d, AC. and u“ .. ﬁYc-‘Hol‘b _ Paiszélﬁftfl’l _ A “ \t W: 0 2a 3! 4¢v 93¢ {I to 057:0 7‘ �. t‘, “i. I 3 “fatig- ‘ ﬂcrld;é J 1’ 3547.79 5‘ ”WW 55/ (7.?” Mfl m- a; V Ear ﬂ<.a..ma'" 7”,... 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WM¢L7A WWMZZ/é ffffww/CL/MJZ’LWM'ZW 421W yzzofs‘vwéz OWW/éﬂéuWWay /%WMMM/&aw Mu>4/L-a\ WW 4% )O/M/Mé’ Mr IQM Muwr‘ ﬂay, $4]de Wit/WC! fww ﬁWM My“ wag/WM?" MAW WM M WM WM MWM‘. jWL/éjfm/ﬁfou/W 4»! sd/zw ,e/Ze‘e/MW. ﬂaw-‘7 ��*2 31”ka only; and m wrehnws 1;) obaomd in mbcmvulsive or petﬁ» m1 curmt We! high degree mm. shaman? mam-um). max—mat, but by ﬂu hth ml: of tmtmnt, the 3) Alﬁemﬂng mar than tbs not. me. mm m a. instruments EEG were ' mum mm a» dance at m aimmty and direct relationshiptom. thatmqueneyoftmtmntxmdm L ’ ‘ Gmlusgm'i ‘ 2mm 2.qu mmmmummamgammm‘ 1) mm in a 2-, mm of mm mmw he ‘ m m or the Mes-tint: a! damn abnormliw is rented. to a) the induction of mm m mm. l 2) 10% type or electrical and us Mama mm meme I a) 1m frequency or tnatmt I 6) ago of the 3) ﬁodmmtim patiant 1n olectmahmk therapy as m mamahouk, manuals-1m alwmszmk, ammatmmm therapy .- wnm do not dmlep delta abnonmlity in than Wt, fail M whim tha therapeutic msulta at mud m1 exmam. this plaeabo affect. The limited a arrimy or mass pmduru is probably due to �Electmaephalagnphio many ' ﬂax 1* From ﬂak, 11.9., comma at the Prone“ Robert L. the Department at Experimental M3. 3“ IMO; i Electmhook m and H. Green, 3.9. mummy, Hillside Hospital, 613:: ��.3 I “,— “A May .— - ,. Mu may or ﬂu mam-m M's-3., Mn A. «ma. 3.»... m mm. 2., an. an». hm mammmwuuauuudumbmm mama hm Wumm mm meta-W MM mam; many bun W- mu 411 m; tmmt «www.mtmmmmwmmwm mm m We! pun-Wt Wam- mum www.mmmmwnmmmzw mum-m Was um mama-1 Mum Me for In many mum-ca it Wm as g dry their 33m- mock, ma M W“ 1240 mm“. atmum‘mwwmaamm.umwu mam-m.mnmmmmmammmma mmmmWWtwmamuwwm WHWW'WWNMWMWIWMW: nut-m tho pm mu; mam-*4... mu I“ awn“, amt V‘ IMWWdWhmw.mm-WM,M m'mM§ msmumWMWqu-y,mzomm “mm; M 3-95 1997;: 2 ‘s g 1 1 -§ 5 ��Electroencephalographic Correlates of the Electroshock H Max Fink, 14.13., W Process MW 1. . *- 14‘1” P: Green, H.D./ 1/ 4.. W. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. =,\ �Problem: In the course of an evaluation of the role of altered brain function in the electroshock process, the relation between electroencephalographic change and behavioral reSponse has been re-assessed. Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalogram before on a day after a treatment” mg card» oﬁuntime intervals during, and following IKE/MA retheir pie-treatment characteristics. treatment at weekly . cords had achieved ‘ .“ -~ 7 1-..9- ~. WW . ~~~~~ . mm ' ~ ' ~ . ”will. . Treatment was stituted at three times per week for 12—20 treatments. West-of atients who failed to develop a clinical response, or EEG changes of significant de- WM m gree, were At ated The EEG 9"“ M" /{“" records were classified for degree of delta abnomality ﬁih records/gang the following indices: “high" "middle" and "low" the percent-time delta; highest percent-time delta :1 wave in the record; highest amplitude ivity. ng * 5"“ Results: M 1) A W‘ -Ax/1 74 ' gs «Ede:94‘»!wa by the supervising M M fxwvm/ positive correlation was slowest delta; and duration of burst act- Kiwi” W W WM i/fal law/Mm a: fin oi‘ .0 lead; any M psychiatrist 3f 1‘41. W dan— Mﬂmdgmmzé “ﬁmmmal? A}. established between the development of ram I’lZunfgy ��In)" l- .J, nmmwmmuwuuunmbmm ammmwmmwammmm 7mm mmwmmgmawmaw ummmvmrmmwmummumw mmmmnmmmm; Wt”.- W mum‘mmammmwmmru-mmm mommimmmﬁwmummum mmmumwuamm.umwu mummmmmam ' ”T” . «mﬁwwwumm,mwmm I EMA : I/r/rp ��(“7 ,. ' 9/“ ;\\ KM 4/ 44(ég/7’M4 4% 4%”‘49444.44.44 /4u44.. ﬁod—n—«a— A: 44.4.44. 14 m @ 4 4 4 L?! («I , I er!) ,1 rd 449-64 -wmm.mm.mnu4— Md ‘chZJ‘M- if éw/AMM -4444 (24 [44/2444] 444 743444.444. ~ 4444424444; (4472442444,) 44 444444 4245/44“ maﬁa-,4 ﬁwjj/WJZM 444444 W \WW’W ‘ 44.4 I 44444444444444 44- £441,148 ‘43 44.474444744- 44.4444/‘ WU) Ker-44444.4. 447444.544” MMW //-/v -n $4244 77 rte—“4.44.4 1/ 44444 45/4 4 ’4 (I) @)(3) 4045': ...44. 4..."... ..... ~ £44444 {Que/7 5:7 82444444 44,444 4 K M444 4244 5447 47,424,, 4244444 ,. �1: 2/1/58 EEG Correlates of Electroshock Process During the past few years, incnasing attention has been given to the ic relation between changes in the electroencephalogram and the behavioral change induced by electroshock. The initial application of EEG techniques to the electr0310ck problem in the period l9hO-l950, was summarized in an excellent review of treatments in 1952, that the who noted rather than the degree of induced neurophysiologic (reflected in the peutic by Chusid and Pacella outcome. EEG) These was the primary number change factor related to favorable thera- studies, largely based on descriptive analyses of pre and post-treatment records, were followed by serial quantitative analyses. In 1951 and 1952, Roth analyzed the in patients during a course of was related to the process ECT and of recovery. In 1953, in the laboratories EEG activated by this- He concluded that thiopental delta noted that induced detal activity at Hillside Hospital, we analysis of neurophysiologic bases of electroshock, based " undertook an on a hypothesis expressed by Weinstein and his coaworkere in which they related improvement in electroshock to persistent states of altered cerebral function. Our �-2... first did studies utilized the amobarbital test show a provement. relationShip and these, parenthetically, between changes in language and Our second index was the ratings of delta index of the electroencephalogram. In our original review of patients, recently reported, significant relationship between the degree delta activity It is and im— and we noted a duration of the induced clinical evaluation of behavioral change and "improvement." our purpose tonight to review these findings; to describe subsequent studies in which various aSpects of the treatment process were the degree of EEG delta activity; and to conclude with a related to summary of the present neurophysiologic adaptive view of convulsive therapy. One hundred and have been studied. a day forty-eight consecutive patien electroshock referrals Electroencephalograms were taken before treatment, on after a treatment at weekly intervals during, course of therapy, istics. until the record had achieved and following the its pre-treatment character- Various treatment procedures have been used, including alternating current threshold and suprathreshold electrodhock; parathreshold unidirectional current electroshock; and subconvulsive techniques with pentothal premedication. �-3- alternating current suprathreshold The K ) and unidirectional parathreshold (Reiter) teChniques are well described in the threshold alternating current patients, without prior sedation, received a methods, for 0.1 second, which was usually sufficient for a petit 20 second second. intervals, voltage increased by 10 volts 90 until a grand mal absence. At up to mal convulsion was induced. just necessary to induce a grand 1&0 volts, 0.1 mal was the threshold voltage and The value. In subconvulsive techniques, patients were given pentothal intravenously asleep, volts Voltage was then reduced to 100 volts x 0.2 second, and increased by 10 volt steps time was current, low and then either low voltage . current of or alternating unidirectional current for ”a 80 nvolts x until 60 seconds; . . 0.1 second were administered for one to three applications. All treatments were given three times a week treatments. Patients who failed to develop clinical reSponse, or EEG changes of treated 5-10 times per All EEG a initially, for 12-00 significant behavioral or significant degree, were subsequently week. records were quantitatively measured for the degree of delta activity. This index was determined by measuring the per cent time delta �.uin 180 seconds of each of three lead combinations, and both the average _and the highest index in any one lead were used; the slowest frequency and highest amplitude delta; Records in the and the initial series duration of the longest burst were placed those with the greatest changes in slow Degree Delta Activity." Delta Activity" and "Low Degree week of The specific limits of ratings of Low degree treatment. 3) Evaluations of changes in behavior were and "High were "Moderate Degree following three slides demonstrate a High-Middle and psychiatrist upper third - earlier report. (Figs. 1, 2, weeks thirds Delta Activity." record obtained during the fourth The The activity - were called wave The middle and lower each range are described in the The into sequence. . made by the supervising resident therapist at the height of the treatment effect. "improvement" were made by these physicians two to after treatment was terminated, and were based on the three four fold "much improved," "Improved" and "unimproved classification of "re00vered," or‘worse." In our initial reports ( , ) we noted that patients who developed �-5high degree delta sustained, activity early, and in whom such delta activity was were evaluated as "much improved" or "recovered" with a greater incidence than those patients who failed to demonstrate significantly delta such activity. These observations are portrayed in slide h. (Slide h; These patients had been treated with a unidirectional convulsive therapy. In a subsequent series of 5b ~ in Graph EST #1) which the degree of patients, a predictive study was undertaken delta activity induced during the second weeks of treatment was determined. 0f the subjects in whom and high degrees of delta activity were induced during both weeks, 67% were eventually much improved; while of those either week, only 30% who did rated as not have a high degree record in were so evaluated. treated with a unidiructional current; third and Of these patients, half were half with a suprathreshold alternating current technique. Slide 5 - (Table I, Exp. Studies) Results: 1. Role of Convulsion§:in Therapy. In the most recent series of patients, randomly selected subjects �-5received subconvulsive therapies instead of grand mal; and both alternating current Of and unidirectional current techniques were used. the subjects who received convulsive therapy, ______had high degree delta records in both second, third and fourth weeks of treatment; .____ during periods. two of the three weeks, and ____ during only one of the Only _____ subjects failed to show a single high record test on con- vulsive therapy. Of 27 the/subjects who received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. Low activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. Concurrent analyses of the behavioral ratings showed _____ of the con- vulsive group rated as showing marked behavioral change; while of the suboonvulsive group, 25 showed no behavioral changes. were referred for a second course of therapy. In 1h of electroshock induced high degree delta activity and behavioral change. activity Of the five who all Of these, nineteen these, grand mal showed a significant failed to demonstrate high degree delta on convulsive electroshock, all-showed middle degree records; �-7and two of the five 2. Factor of Type showed a behavioral change. of Therapy: In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock in EEG delta activity was undertaken. The results are graphically presented in Figures 7. The first related the percentage of records in each treatment group during the second, third and fourth weeks of treatment high degrees of EEG current techniques The gave a lower percentage of high degree unidirectional technique was also degree delta delta records. less effective'than the supra- all these periods. Although effective than threshold alternating current course of therapy. who demonstrated delta activity. In each period,threshold alternating threshold alternating current technique, in more 6 and methods early in the Note, that subconvulsive techniques yield no high activity records. In the next figure, the converse is demonstrated. The relationship between type of treatment, treatment period and percentage of treatment group showing no delta activity or only low degrees of such activity. �-3Here, the subconvulsive group is for each treatment period. Supra- 100% threshold alternating current techniques show the least number of Such records in each period. 3. Frequency of Treatment: Another factor on the rate of development of delta frequency treatment. While convulsive therapies were treated given daily or twice daily. activity were initially treated three failed to develop high degrees of delta activity times a week, a number who on all patients activity is the In all more sudh intensively. Treatments were instances high degrees of delta were induced. u. Factors of In the Age and Diagnosis: initial series of patients, it was noted that younger patients, under #5 years of age, developedlgreater degrees of delta the first such activity during and second weeks of treatment; while older subjects developed activity to a significant degree during the third week. week of treatment, age was no longer a By the fourth differentiating aSpect between the groups. With increasing series of patients, utilizing various treatment techniques, the differences between successive groups is largely a matter of treatment technique rather than age. �.9Similarly, conventional discharge diagnoses bear to the rate or degree of delta activity induced. in young schizophrenics, no The relation either delta activity induced older depressed, older schizophrenic paranoid, younger reactive depressed subjects are similar in indidence of high, middle and low degrees not, of itself, a at different stages of therapy. The diagnosis is significant neurophysiologic factor in electroshock. and �combining the data from all convulsive therapies supports this observa— tion. During the second week,h3% of records are high degree delta in patients ho; but only 30% in patients from uo-so, and 18% 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3 of the subjects have high degree when treated 3 delta records times per week. TABLE Variation in % High Degree Delta EEG Records with Age Treatment Pe riod To ho years hl-SO (28) (25) h3% 61% 69% 29% h0% 56% 51-60 (28) 32% 56% 55% 61+ (18) 18% 50% 80% S. Pre-Treatment Record Characteristibs: Previous reports, summarized by Chusid and Pacella; a ( ) rated significant relationship between pre-treatment records characteristics the degree of induced "abnormality? Escords with predominant alpha rhythm or "abnormal" (Chusid and Pacella) or "borderline abnonnal" and �.10- liable to developé alterations in the (Bagchi §£.El) records were more EEG than those with predominantly low voltage fast activity patterns. Rank order correlations of the pre-treahent per cent time alpha in selected leads (anterior temporal - vertex) with the degree of delta activity during the third and fourth patients demonstrated correlations of +.2h The weeks of treatment in h3 and +.35 reSpectively rehationship in the fourth week is significant at the .05 level of confidence; while that in the third week the trend fails of significance, although is apparently indicated. Discussion: Two aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and ﬁne role of electro- encephalography in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the initial studies of convulsive therapy numerous authors, Kalinowsky including Kalmaasky at al,(l9h2), and Pacella gt_§l:(l9h2) emphasized both the clinical and electroencephalographic differences and petit-mal responses. provement in 60 to 80% While grand mal between the grand-mal seizures induced clinical im- of cases, petit mal induced changes in less than �.1125% of subjects. Similarly, the electroencephalographic reSponse to grand mal is one of delta activity, and to petit mal, is delta activity. no In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been described, and each, in turn, discarded in routine therapy. Bergman gt_§l”( ) for example, in describing the electroencquh- eIographic effects of focal seizure techniques noted that patients had normal records "abnormal" records after after 15 such l0% "seizures;" while grand mal seizures. Ulett gt §l° 20 of the - 75% had ), in a ( careful control convulsive-subconvulsive amdy, reported the significant differences in the clinical changes between the convulsive therapies (60-80%) and subconvulsive (33%), and noted the discrepancy response in the two groups, and emphasized the in EEQ significance of the seizure for the therapeutic effect. These studies emphasize the significance of the grand mal convulsion, both for the clinical therapeutic effect and the electroencephalographic reaponse. Recent reports by various observers, and based on a variety of data, support this conclusion. If the convulsion is the essential element in the EEG and �-12behavioral reSponse in electrotherapy, does convulsion is the induced?. In the studies reported here, small differences in both the degree of were observed. it matter in what way EEG delta activity and the rate of the development Clinical evaluation demonstrated concomitant greater degrees of clinical efficacy for the suprathreshold alternating current method to the two other convulsive techniques. 'Other studies have also for various convulsive techniques. shown differences in clinical results Ulett gt_§l. ( ) noted similar differences in clinical results in a study of patients receiving alternating current5'and photic-metrazole convulsive and subconvulsive techniques. He reported improvement rate of Sl%,'76% and concluded, 33% respectively; that the convulsive photoshock technique clinical efficacy. Epstein and Wender (1955) compared unidirectional current techniques, and reported no results but that unidirectional techniques required more had the than alternating current methods. More a new convulsant drug,.Hﬂ 1090, ascribed to greater than electroconvulsive techniques. and greatest alternating and difference in clinical one to two treatments recently, Edwalds, describing it a clinical efficacy slightly �-13while some variability in clinical results is reported, is clear that with repeated convulsions, provement rates of 60 and for the most part, treatment. regard to have noted we may its 80% are induced; may be no matter how induced, imThe differences are small, obviated by increasing the frequency of conclude that convulsive therapy mode of tat - it is non-specific with induction. In previous reports convulsive therapy (EEG is non-specific with Theory) we regard to their application in mental illness, nor is their clinical or behavioral effects. The present studies amplify, therefore, the previous conclusion that convulsive therapies are non-Specific. 2. Role of Electroencephalography in Convulsive Therapy: we have applied methods of quantitative, serial in the studies reported here. change may give similar data, such evaluations are the attitudes of the observer of EEG ( analyses clinical estimates of behavioral While on EEG ) than the EEG. more closely dependent Further application Analyses to other problems in convulsive therapies may provide a rational basis for comparison of different treatment techniques. �We have previously noted in the clinical management of that EEG analyses may be applied patients receiving convulsive therapy. of In our experience, the early and sustained induction of high degreaydelta _ activity provides the physiologic basis for behavioral vulsive therapy. a An electroencephalogram in patients significant behavioral response per week may subjects in change who in fail on treatment regimens of high delta to show three times serve as a rational basis for clinical management. whom con— In those activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a thera- peutically more effective convulsant If the physiologic changes. be maintained may ( ) for a or environmental ( havioral response, even and degree of delta number of weeks, other ) may be assumed to when further convulsive therapy records. result in the neuro- activity is high; and it factors, as personality preclude s satisfactory be- the neurophysiologic substrate is assured; application has been suggested EEG method, may may welllae discontinued. by Roth ( ) A similar for thiopental activated �.1 5.. lhe successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these application for the rational management pharmacologic agents Summary and ( Conclusions: ). laboratories note a similar and understanding of psycho- �to“ Win the Natalya”. Watmﬁmmbun gim nation bum inﬂamed by It: omwgek. _ than olectmnuplaham In 1953. in the and behavioral mum at. dung" mud. Hospital, We“ of ashram-1019a: upon“ at olmtrouhook m mm. swim: ( champs in )1n were band on which may a. Win mm by Romain and his muted imprmmt 1n 01.6mm to tho a» mom” Mom: of paraiamat sum at altered mmbml function. mmmmmmw< Luminanctwnmtmuump how the damn am mum a: ﬁn 1mm den-a activity and mum «alum of huh-mm damp and “W.“ this report to "view than ﬁnding” to describe mum nmrophyuiolom to nuggut aspect: of u. Almanac-1m or maps-oat. of minimum: 3%! On. W bun swans. 3nd It 1. at W at mt Media in mini: m mun-at woo.” In. ”mud; MWmm in mud!“ and and sum). mom“. {Wﬁt acne-anti" «hammock Marni: a". um um baton taunts-ant, and an ammrttmtatmmquadummfmmw-mm �4-2. of therapy meal the noon: Md «mum. 45* M‘ Pntimts- mﬁpn-matnnt or significant . bum its pwtmhmt m dual-tramw- 31w m a; mum activity, mm are «eluded from tho curios. Fm tmww madman «playing 611nm 1) umg/aumam W at. “mm: 3) MW“ mm mpnthnuhold It) mbommlsiva tonhmqwu‘ with pantothnl Wt 813de m tall dumrlhod. 5%: ( 9 ma pmdicttion. Tm ( gunman; ) hummus damning current. method patients, Mind 1w “mats, mu sufficient tor a phi: 3:1 mm”. and, (Maugham); ummmm lawman! In the thrown!!! ﬁtment prior «mum. ~ W of “dam he.“ M915 smug a) nun-mung «mm at. 3* mm“; (90 Volt. M 20 for 0.1 sound), mad Manila, may, it mam-,7, duration: in” 1mm mm a and m]. whim m mama. mmmomd timmcuurytojutincmma gmdmlmtho, thruhold value. In subconvulaiu m, m.( mu )3 and um mu” u {may maimﬁann mt. for co ornamtingmté mungvoltnxOJWurn “31.31th far on. 15mm. mam, puma“ mm 31m mm warmly to three Appnoatim, for a. total. of 21: to 36 ”ﬁt m1 �A11 tmtmubn an arm: thm tints a wok initially, for trauma“. Pantom- Ibo clinkai n‘spenn, or EEG tail“: to duolop a changes of 12-20 macaw behavioral or' signiﬁcant 4.3190, are subsequently mam 5-10 than m wok. m EEG Mord: were quntiutivoly manna for the dogma or délm mm: in. «data: at to mmr ﬂu: Man-mud ”M,“ activity. The "Manta“ or "lav“ 63M er delta activity, mowing to criteria pu- ‘ ‘ awn matched ( The ). mums; three slides (immune a high, maﬁa and 101! «n: Mord: duung tho fourth-ml: at twat-cut; W l (Figs. 1, 2, 3) Ivan-um or W m hamm- an and. by the mmmm Wm“ m6 random. therapist It. the Mia“. of tho treatment at ”mama-Int" Weaken: run and. by then physician:- two tn m tominatod, and were hand on ma “mound," “men In our initial “tact. tbs-0e four tam W,” M “W or mm." Wu ( g ) no The rating: mks utter dasﬁfiéum a! wind that patients me wanna �4‘" 1:131 damn 601%: activity . My, and in when m «1%: activity 1.! wow. wr- mlulud a “lunch Wmm or “uncured" with a grater muaow than than patient: activity. Thu. chomum who such delta m pawn-wed 1n and. h. (811* In Gnﬁ 511* s In the ta damn-tutu “mutant.” '1' M ”J (km. 1, nut wont. «run or puma“. ms Studio.) mm «new plum“ w tame m nmsmmmy mind .mmmvo thmpiu mm or mad Id; Ind both atom-$1M . W WW“ mt Man. RN and mod. at tho 1:? mm at: who mm mm ”mm haunt" than”. 9 hid high dome in both «ems, mm and fourth mks at truth-at] 1.2 wring hearth-thrum, mummly'motthlmtpoﬂm. thin-In “their? lubdwtlnuodto Muuuglchiwaogrudﬂumm convulnu thunpy. at tho 2? aubjootu who mum Wain mum, Wt, m �.5. dam-mud new or high down 4.11.: nativity mom or mutant. in! now of during both ﬂu my and: mu activity m not“ in than “hm new and third min at imam. and during the fourth elm-1n; in 8 ”Mo-ct: not. Conoumnbmlymatmbmmﬂungu mmwotthch'? a the mini” map rum u showing mud behavioral champ; or no bah":m1. of ”320mm" group, 25 at the 2? ma 101:1 mm. at the 1m» amp, 19 m Mum m- a mad um want.- m than ' “than”. Inlhotthou. activity and :11 kind mmmwkmmmmmmu mm a “Mimi Wharton]. W. in damn-at. 01' tho tin Ibo m dom- dolu nativity an convulsive deutmmwk, mam-a M61. diam records; and hoof this ﬂ“ mandahwiml W. mu, «multiv- thanpy Wad simian-um mam:- antics-:1 change! macaw mini-ll with 3m Moral mango, and W with” in km or mum placat- moving than-aw, 11de both it: MYI mm mud 8E0 «an inﬁnity. mum". «1m nativity, wan. auboomuluvo EEO ma rum“ to «mum mum-:3. «hang: m plan“ an mum �In via or ﬂu mow of unwock Mama» .uployod, And the mun-uni}: ham we «1%: activity mum at +4.2. «has a: typo a: 010%ka an max-nun. Th. gun“ The Won}. "upon”, and the mammal mmw m at gummy pmmtéd in man- 5 ma 6. first agar. ulna: in tub mutant this Walnut typo in 8W dating the unsung. EEG an. activity. mutant um: daunting «mat It mmknshald high.” mom: In each period, otnncth and with numung mt at thmshou oft-cu" thin tho lupnﬁhnlhad alumnus mnem- m tho ‘ ' the tau-angst; m 1m mm, in out mar-cum; curl-mt. tmtamt being not: «mm than the tux-«hold 11th Suboomumn #:00QO yield no high dam «in: activity neural. cum-at. uthod only curly 1n the Mum WWW“: treatment the am come of mumpwmng pox-«near wh/mpwoungno «Inactivity such trut- ”may of my: (low mu mom. What with Winch 1m). nun-mt ported; of the «new. third and fourth molt: of mt Whiting mm dam of » a: nativity. Kin, tho «boom!» in map is WW- than ' «01:1:de 1005‘ for «ch tram �.7. ponod. “puma-«hold uunbor of man alumina current handgun chow th- but. rcmd: in «a: period, nth tun-had ma mmm “chum. in how. f Tm 3. ts Author factor on the truancy at tmtmont. tins a cock, u mater on convulsive nu of mama: of delta activity in tho While :11 who patents wore initially treated thm fund to therapnn vor- dculop mu! demo- or :1qu nativity tmud' non mun-may. In aim Inch uncut-,- an 3110:: an); or win any, and in «eh instant» ﬁddle or my: damn of 601%: activity an mm. 8mm- ma comm won prenatally dumtntod by mu. ﬁg... ( ). m1 cumu( mnmuta k. W' In tho )_. mun unit. or patina“, 1%. was mind that. younger patients, Mr 16 your! at ago, dmlepod grater dam of delta nativity during thnrst. and poems! activity to of & tnatnnt, m at “about; 111111. older subjects. donlopod inch signiﬁcant dogma during the third weak. 3: the fourth not m was no 10:15:01- : dittounuatiug ”poet bottom the groups. �~8— Gcnhdnmg “I. data from an. During tho undo:- mom convulsiv- m. h)! a! mm m raw demo dam in mutant: the as. of hot but only patina“ 61 and. thonpuu supports this obumum. mm no longer present. and 305 in ptﬁmto rm 1:040, In the third and fourth ”aka, the and 183 in antenna» an “mantel: 2/3 of the lubjlctl but high degree «It: «and: uhon trotted 3 tin” par wok. mu Yunnan 1n 1 8131. Dog“ mu ma mm with La * m m mm we no M 51+ 0 m be as) has (as) m (as) (13) W 1:2 as M 691 he: saw 32: 5a 95:: 18: 50: M no durum in 1mm of high dome mom 1: significant u .013 andhurthtruaunnd .OSShomthoummtndthird mic: or tun-em in patient: «or 50 your: at nan) but is not uwimny manna“ 61:1on for the“ put-1m in groups and» 50 yum. �.9. mum "pom, mm by Gama and mu“ )mm . IWmt mktimhip batman pmmst. aunt heard Mauritian and m m W “nbmlity.” new nu: mm: at or 'abnoml' (Ohmic! and alpha mm M113) or “bomﬂino ulnar-t3! (Hum 91 9;.) Wanmmummnunmummmmmum may In than 1w may tut activity ”than. «an or imam“, abduct: who“ pm-vbrnmcnt domain-1m um um «hazy apn- or space an activity nah mam.» Eight A manic mimic or the mush pro-Manta“ ﬁnality. talcum ,mﬁk order tin am in «new land: m pro-smut“ ”mutton: of an} mutton. alpha and pu-mamnt (anterior Mignon). worm) with the 601m activity during the third and tour «the cf gaunt: dalmatﬂm man of than and «It: antivity «run, and for more mm «It: activity an mandala-n dam. of or are not nausea in an gunman. Won. that in puma“ without par aunt mm... er mama-ac «any. m tmtod with emu”. taotmiquu dmlopod high amoe- at palm of a more! or +31; and «35 tmﬁmt mpoctinlm in h3 �.10. m mumumrmmmuummtn the 4351.701“ Widen“; thl while that in. tho third ‘at dwiam. although W6 a mum. W: M «poet- at” than the not an. that”... mt dimuon; tho Winn“ of, whim 1n the 01.6%!“th pm“; and the r910 at «an nontra- W! mopbnlomph (1) 1n the In the including mama: and may or convulsive therapies. mud and“: of cumulus." therapy lawman whim-c. hum-kw the clinical Ind «Mom: ‘ ﬁg. (19%), and Plum 5;. (193:2) aphasia! bah 01¢“ch diatom bum the grim n.1, mpoutm “WM mammmm-Wamm 1mm"mntinwtomofmu. ptﬁtnlindwod Weamhlstmaﬁof mycu. mm. ﬂu chem-pulmyhle mm. to m a! mu ”Univ, and {no pout m1, 1: In subsequent. you-I, various no delta grand an in mum. W131“, has! CW, mﬂmtiml “hunting, mopohr unwitting. foul contain" techniquu have been �.11. thd in mum. than”. Barman 33 3;. mum, and nah, in turn, ) tar example, in mung an cloutWaganc «not: or ( focal "inure manna-u Mad that art-r a), 15 inch "maumr' m1- "isms. Matt 93 g. study, repel-Md a halving ( of patients had - 753 had “abnormal" ), in a ammo-at autumn mm mom _ max-d: utter grand «ram comm). «muywmbeomhin 1n «mm-:1 roman "a! panam- amid" that-apt“ (W) ma theta minus abnormal-1v. (331). or control: (381). no tho two 70 70% mp3, and new tho war-may 1n the 3m noon-- in mum the signification at ﬂu loam for tho thanpuutic strict. Mint additional upon-h 17 various ohsarvm, band an a «ﬂaw of (Rain-“1n and an, alpha“ th- awinmaa at tho ”amnion. m, Roth, mung). rpm, the mm. mnem- um minim par a, an a:- mu tho signiﬁcant physiologic mu mm m the has for thirty-nut: If an. convulsion «fancy or 'oamluva than-qua." I both it tho mud chant/1n mu m and in tho behavioral "903380, does m node of inﬂation at the role in um “spam-7. In the chads." ”ported ham. uny “mama Min-mm in both the dam- ot‘ “ism play any Oman Em hut-.2 sun-u- mu activity �.12. the and at» of 11:»: “mu m abut-"d bum Miami mod: of imitation or grind u). m. m an m. pmidu but: far the mama Mm't tint .mpnthxuhold m @0an album-ting current “chum m mt “tutu. m We cmuloiva than”. “the: India ban the sham moms cumulus.“ “Wu”. exam in clinical results for 813% g 51.. ( ) mud 31:11.11- mum. ms; in mm:- mdiu or Mum waiving atom-um mt mmlpin and mumml mvulnm m! mbmvukin tech.- 1i: amen niquu. no "ported Wat. m. at $73. 763 ad 331 yumﬁuln mam ﬂat the Wain Manhunt: Wm bud tho amt.“ clinical «tinny. non may, W, doom-thing n m «walnut: and drug, a: 1090, named to it a clinical mam; unghuy gmur um dawns." wanna“. w studios an have mm mm m «Wm mam-d by Mom Wm» hm! um manna” of latency, duration, prom-mac In of claim: or tonic ammt phi“, am, two. um; not :11 mind In}, From that. Sundial, it has Mm him: at. minimum; and that : �:31)’ W; m mm a not an an or w“ cum and than my unset dim-mt. taut-mt aimed. Dunn-mo mum panama dutannm in Mahala «rout. of tho Mar mm" 01' this probhn an 11: 9'08“”- thn this "unmey in clinical 1:3qu in ”period, it in clear ma, ups-mt. raw or - in chum-d. m dﬂhmu human var-1m W or mutant m 3.311, and, for ma most part, be mm w increasing the 1:qu ﬂnt with rap-wad comma”. no author he! 60 305 may com!” may: in nonwith mum to ﬁlm W tho minim in Mad. The simiﬂmt or amber at mutants. it. any Mic «mm that amt u the bran W Mum. ta the uranium, and not an mat mamas-1mm mama“... Inwim mm (3m, Theory) in we: noted that commits.” map? 1: l1” 1%. application in with mam maul, m: in its clinical and with Wticity of convulsive. ﬂan-pin. to I bender-1 «facts. no pron-at studs.» «3mm winters, the pram» at the ”and comm �U. have appliad ”mode or quantitative, serial me the m1: studies} mporud here. We in clinical estimates at behainnl change ‘ may give of tho xinihr data, obumr ( ' ) than an m. Us lava dependent an tho m a prawn/mum]. buns for Miami tmtmnt technique“ pmionlly noted that mm mm: my be applied in the clinical magnum. or patients receiving oonmlsivo therapy tin I um tad» Wr applicttion at m analyse: to other pmhlm in convulsive thumps.” compariaon of am such evaluations am @mnua ”ported here, the curly and ( )- In sustained induction at high dam,» a! do“: activity provides the phyaiolagic bait for behavioral in cumulative mmpy. «mango fail to thm char 3 mu. increasing a electroencephalogram in patients uwﬂmt Wen]. times per week aunt. In An w when mutant. tummy, Mummiaogic more big: delta activity has withholding effective «walnut. If changes. it my be 31an for tmtmt ”31mm of norm as a rational basis for clinical manage» mbaem in thonpeutiany aspen”. on who o. tho dome of nmbor of not. been induced, pmdimtien, 0r shifting to mum, my resuli in the mm activl ty is 11139 mks, nth» future, and a punctuality �~15— ( ) or mama}. ( behavioral response, and ) my be can when the «me! to panama. a utiatactory Wide-go mbctrato is assured; further eomhivo therapy my will tion has bum suggested by an Ruth ( moons-tn]. application of convulsive therapies, ) be discontinue. m gaunt: similar applica- for buoyant-.1 activated 330 record» quantum." ‘m tachniquu to bu led to their application to nth“ hemp-us. accent reports from than laboratories not. for A as MW“ similar applicatim mum-1 moment and man-Italians of paychephameolom ( ). �416~ gagglnnianus 1.‘ In aerial qynntitativn analysis of aetitity in degroe of induced EEG delta anhjocta receiving variant convnlaivo therapies, a poaitdvu relationship betuoon the digrea o! indueod delta activity and bath tbs dagroe oi'bohavioral ehnngo and ratings of impruvamsnt 2. and induced grand mﬂl convulaian An is reported. 1: elscntinl for both the EEG behlviaral change. 3. Th3 rate a. and dogrcc‘of induced Hbdo dalta activity is dependent upon: at soiturc inductian b. Fruqunncy at treatment a. Ag. 0! lnb3oct d. Pre¢treatmsnt h. It is pmuvidoa a recommended EEG record characteristics that aerial quantitative electroencephalography rational basis both for the study and clinical managenant or variaus paychodynlmie therapies. �II: 2-5-58. 0131/11.!" Correlates of the Electroshock Pincess EEG During the past feW'years, renewed attention has been given to the relation between changes in the electroencephalogram and behavioral changes induced by electroshock. In 1953, an analysis of neurophysiologic aspects of electroshock studies ( in the laboratories at Hillside Hospital, ) in was undertaken. were based on a hypothesis expressed by Weinstein and which they related improvement The his co-workers in.electro$hock to the development of persistent states of altered cerebral function. In thii initial EEG study ( ), we noted a significant relationship between the degree and duration of the induced delta activity evaluations of tIhI=HIIEIEIIEZl=E=IIi§"improvement." It is and clinical the purpose of this report to review these findings; to describe recent studies in which various neurophysiologic aSpects of the treatment process were assessed; and to suggest the application of electroencephalography in.studies and rational management of physiodynamic One hundred and been studied. a day therapies. forty-eight consecutive electroshock referrals have Electroencephalograms were taken before treatment, and on after a treatment at weekly intervals during and following the course �-2- until the record of therapy ﬂag»! Patientsbﬂwyhgug‘pre-treatment IN EEG - . eggpktfd’ef’d .,,.,;‘""ﬂWh . activity, an...“ M"M ﬁignificant asymmetry were MW’O‘Mmmws-‘W pre-treatment characteristics. demonstrated slogwgave or spike . WW its had achieved series. from the { ‘ {V .up-w‘ . Four treatmentt procedures employing g different types of stimuli have ' i V . 1) been used; /alternating current at-threshold strength; 2) alternating current at suprathreshold strength; unidirectional current (parathreshold); 3)- h) subconvulsive techniques with pentothal premedication. The alternating current suprathreshold are well described. ( ) and unidirectional parathreshold ( ) techniques In the threshold alternating current method patients, without prior sedation, received low currents, (90 volts for 0.1 second), usually Sufficient for a and, if petit mal response. At 20 second intervals, voltage ,_ thewmwmm necessary, duration! were increased until a grand mal convulsion was induced. In subconvulsive techniques, patients were given pentothal intravenously until asleep, and then either voltage unidirectional current for ); or alternating current of seconds ( administered treatments . low l 80 (30 to 120 volts x 0.1 second were for one to three applications, for a total of 2).; to 36 petit mal �All treatments were given three'times a week Patients treatments. clinical response, who initially, for 12-20 failed to develop a significant behavioral or or‘EEG changes of significant degree, were subsequently treated 5-10 times per week. All records were quantitatively measured for the degree of delta EEG Ml WM! We! MM‘AWW activity Masada—WW ‘ delta activity, "moderate" or "low" degreet . l‘ . . I i 5 3 . The 30W week of (Figs. 1, treatment. 2,3) Evaluations of changes in behavior were made by the supervising psychiatrist resident therapist at the heigat of the treatment effect. The of "improvement" were made by these physicians tw0 to three weeks treatment "high, " following three slides demonstrate a high, middle and low degree delta record: during the fourth and M was In our after terminated, and were based on the four fold classification of _ "recovered," ratings ”va ”much improved,"nand "unimproved initial reports (' , ') we noted or worse." that patients who developed �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta such activity. These observations are portrayed in slide h. (Slide u: Est #1) Graph Ecsults: The “W etweeni“! relation neurophysiologic 5" . . and behaVioral response W111 be assessed according to five aspects: 1) 0 2) Type of Convulsive Therapy 3) Frequency of Treatment h) Factor of 5) Pre-treatment Record Characteristics ’Of Age the uz’subgacts’WHo”retaived‘ccnvuISive‘tnerapy, 7 nan nigh delta records in both second, third two of the three weeks, of the u? subjects and fourth weeks of treatment; and 13 during only one of the failed to show a UEgIEE" 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �high degree delta activity early, and in sustained, were evaluated as whom such "much improved" or greater incidence than those patients who delta activity was "recovered" with a significantly failed to demonstrate delta sudh activity. These observations are portrayed in slide h. (Slide u: Graph Est #1) WWW Results: 1. convulsive vs Subconvulsive Techniques: In the most recent series eizpahaaaih randomly selected patients re— ferred for electrotherapy received subconvulsive therapies instead of grand mal; and both alternating current and unidirectional current techniques were used. or the h? subjects who received convulsive therapy, delta records in both second, third two of the three weeks, and show a had high degree fourth weeks of treatment; and 13 during only one of the of the h? subjects failed to 9 12 during test periods. Thirteen single high degree delta record on convulsive therapy. Of the 27 subjects who received subconvulsive therapy, however, none �.5demonstrated middle or high degree delta Y3...” of treatment.§ x Low ( / activity records during any week degrees of delta activity were notedhiﬁwthree subjects during both tgexsecond and third weeks of treatment, and I“ .,.,_,_.,.-‘ ”mud,” Y , “W", v V .V,. inAB subjects ,, ’dmﬁgthefourth Week alli'lll=l==I-I behavioral ratings Concurrent subjects in the convulsive group rated as shining showed hZ of the h? marked behavioral change; hat ‘ while of the subconvulsive group, , ioral changes. of therapy. the Of latter 25 of the minimal or no behav- 27 group, 19 were referred for a second course In 1h of these, grand mal electroshock induced high degree delta n...» . 4,7,.“ .;...-....‘..,r,, 9...“; .. n .mm ., 3., ,. .~-wms...mu m-.. _,. ”a”. .. activity "Walnut... all showed a V.-.~...,..,..~..,.u.ma..~m.—.~..._..Mn...._,.m.. m failed all 4 f. ./ ..,,,.A. . .- significant behavioral change.#fgf the five t. ' to demgnstrate high degreewdeita “if I/VFI' My" : ’ activity a” , Thus, convulsive therapy induced showing on five . Mm)“.- . showed a behaVioral ”n,mmwm .,wmlumwﬂun. significantly greater behavioral changes neither an EEG EEG delta activity. Furthermore, or behavioral response to subconvulsive therapy, showed both the-EEG and behavioral changes therapy. convulsive”2lectroshock, delta activity, while subconvulsive therapy induced minimal behavioral change, and minimal patients 51/ Who~~ I” “(my We“ EEG ,4 .2 shdwed middle degreeprecords; and two of the associated with """ ------—--- 5"“ , /,/r ,//'change.; a r and when placed on convulsive r. e r. a 7.“, �-b2. Role of Type of Convulsive Therapy: In view of the variety of electrOShock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analysis of the effect of type of electroshock undertaken. The first The delta activity on EEG results are graphically presented in Figures 5 was and 6. figure relates the treatment type to the percentage of records in each treatment group during the second, third and fourth weeks of treat- delta activity. In each period, ment demonstrating high degrees of EEG treatment with alternating current at suprathreshbld strength gave the highest percentage of high degree delta records. ieeetment'uéth-unidirect- ional current and*lith alternating current at threshold strength was less effective than the suprathreshold alternating current technique, in each period; a the udtﬁiEgﬁgie;;%reurrent treatment being more effective than the threshold alternating current method only early in the course of therapy. Subconvulsive techniques yield no high degree delta The next figure demonstrates the same activity records. relationship by measuring the treatment per cent of each/group showing no delta activity or only low degrees of such activity. Here, the subconvulsive group is 100% for each treatment �-7period. Suprathreshold alternating current techniques number of such records in each period, with threshold show the least and parathreshold techniques in between. 3. Frequency of Treatment: factor Another dn the rate of development of delta activity is the frequency of treatment. While times aweek, a number who on convulsive therapies all patients were initially treated three failed to develop high degrees of delta activity were treated more In nine such patients, intensively. treatments were given daily or_twice daily, and in each instance middle or high degrees of delta activity were induced. previouSly demonstrated by Pacella gt El. h. Factor of In the ( Similar EEG ), and Callaway ( ). Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta first correlates were and second weeks cf activity during the treatnent; while older subjects developed such activity to a significant degree during of treatment, age was no longer a ﬁne third week. By the fourth week differentiating asPect between the groups. . �-8data from all convulsive therapies supports this observation. Combining the During the second week, under'the age of ho; h=t===:;.30% ' patients "www-W” 9,.0. .. 1M 1‘ . at . on.» . , of records are high degree h3% M 61 and over. In the n.-“5.”. m1”- A, “W third in patients from delta in patients WW WM M ‘4 treated 3 ~ ‘ , W. W"; A .W‘ andﬁdpproXimately 2/;xtf the subjects n:/}pﬁger present M” when cue-yaw and fourth weeks, the differences arep ~ «idelta records in hO-CO, and 18% timéé per W99§° ,ffﬂ have wwww‘t4m HM\“ " ”a“ “by" ‘ high degree W“”w" ‘f" Mama.W ”Q h/‘ WWW, Wn.ﬁ,,,,.,-r..m TABLE Variation in % High Degree Delta EEG Records with Age * Treatment Pariod 5g: ' in is. 2:2 are 61% 69% (28) m ul-so (28) 29% m 56% 51-60 (28) 432% 56% 55% 61+ (18) 18% 50% 80% To no years * The difference in incidence of high degree records is significant at .Ol% between the second and fourth weeks and .05% between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. �S. \ Pre-Treatment Record Characteristics: In earlier studies, a relationship between pre-treatment record characteristics, notably degree of abnormality or predominant alpha, the degree of induced "abnormality" was noted ( , ). and g In these series of patients, subjects whose pre-treatment record demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniques and seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertakenjémk order between pre-treatment alpha and correlations of the pre-treatment per cent time alpha ée—Ge-lMed-ﬁeds—éea-teWﬂ—aemﬁ-with the degree of delta 4. patients demonstrated correlation‘ of . 95’ M activity during the third-and four weeks of treatment in M/Wima . 4'“ M +.35’ if ' I43 f5” 4d” �-95. Pie-Treatment Record Characteristics: Previous reports, summarized by Chusid and Pacella,( ) noted a significant relationship between pre-treat ment record characteristics and the degree of induced "abnormality." Records with predominant alpha rhythn or "abnormal" (Chusid and Pacella) or "borderline abnormal" (Bagchi 33 13;.) records were more liable to develop alterations in the EEG than those with fast activity patterns. predominantly low voltage ,1 In these series of patients, subjects whose pre-treatment record~ demonstrated slow wave Spike or Spike wave activity of a diffuse, or dysrhythmic variety, or activity were not included in the statistical analyses. W, Eight such subjects were treated with convulsive techniquesﬂand seven of them developed high degrees of delta activity earlier, and for more sustained periods than in patients without such pre-treatment abnormality. A Specific analysis of the relation delta activity was undertaken'éxk. per cent time alpha degree of delta order activity during the third—and patients demonstrated correlation( of 05’ correlations of the pre-treatment WWWWith a, , between pre-treatment alpha and M/W/mu . M the four weeks of treatment in 4'“ W +35) [a ' 1.13 ”(tyne/l @4’” �gr.“ 3 r% \ -1¢¥“""‘MI‘CWEHi ‘ — n—fJ‘r‘mWﬁ“ is” w? \\\\- r" ”y, wwﬂ:;¢"‘”w {awr rth geeﬁ'is Significant at the IQ§hlével of . the relatidﬁship in The , .10- ,_ PMW’MW v . . . > I? if“? f e . . iﬁcénfidence; while thatﬂin the . ”His" ”419"“ M third . a"? "’1’ if.” . ﬁx ,q/J’WNW lynx-"”61 (”fl ”M" . . ' . the trend rewindicated. ’71" a/«am “Mmmmmwmm“minim“..m“, Discussion: aspects of these studies warrant discussion; the significance of Two the convulsion in the electroshock process; and the role of serial electroencephalogragh in the rational management and study of convulsive therapies. (1) Significance of Convulsions:’ In the initial studies of convulsive therapy numerous authors, including Kalinowsky gt_gl. (19h2), and Pacella gt ﬁl‘ (19h2) emphasized both clinical the and electroencephalographic ‘3' petit and , .. “7:4!“{ "5 “vﬁﬂu.. “2. ‘ ., r , mal responses. ',>~'(:.w ’ i differences idwmaewa‘huwmmmm. I'“.ﬁ:W’"amhma-~vmmm~a While Sa-‘iukw‘ﬂ-‘Ih-m‘yow'wwmmmww“ ‘ anthem," between the grand mal. k» " qut‘w' cal 'mal seizures inducedngﬂmd c 12 prove- gﬁetrﬁ‘w afﬁx), ‘ ducedﬁphaﬁges MW“ in less than 25% 0 4745“ M M one of delta activity:‘and to petit mal, is no delta activity. . WW 7 mm M In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, focal convulsive techniques have been �.11described, and each, in turn, discarded in routine therapy. ( gt al. for example, in describing the electroencephalographic effects of ) focal seizure techniques noted that 70% I after mal Bergman 15 such of patients had normal records 4 "seizures;" while seizures. Ulett 23 El. 70 - 75% after had "abnormal" records grand ), in a careful control convulsive-subconvulsive ( study, reported a significant difference in clinical reSponse of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive w” as; 6L. (33%).{es—eontrele-438%92J He noted the discrepancy in the . . EEG response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. Recent additidnal reports on a by various observers, based variety of data,&emphasize the significance of the convulsion. (Weinstein and Kahn, Roth, Fleming). Thus, the evidence indicates that convulsions per se, are’or reflectlgthe significant physiologic events which are 0 the bases for therapeutic efficacy of "convulsive therapies." . both If the convulsion is the essential element/in the . . behavioral reponse, does the mode EEG and in the of induction of the seizure play role in this reSponse?. In the studies reported here, small but cally significant differences in both the degree of EEG any dLr statisti- delta activity �-12— and the rate of its ' development were observed between different methods of induction of grand mal seizure. Ulett gt al, ( ) reported an improvement rate of current convulsive technidue, but and concluded 76% 57% for alternating for the photic metrazol technique, that the convulsive photo-metrazol technique had a greater clinical efficacy. convulsant drug, PM More recently, Edwalds, describing a 1090, ascribed to it a new clinical efficacy slightly greater than electroconvulsive techniques. "we have further noted that the convulsions induced by various techniques have varying characteristics of latency, duration, preponderance of clonic or tonic phase, apnea, seemingly not equivalent; and a etc. All grand mal seizures are �‘ .13seizure is not an "all or occur and these may none" phenomenon. Different; seizure patterns reflect the differences in physiologic effect of the different treatment method: Further studies of this problem are in progress. While that with repeated convulsions, of 60 - 80% are obServed. The or number of treatments. We Specific with regard to the differences is the brain may way is clear no matter how induced, improvement are small, and, for the most part, element it this variability in clinical results is reported, may be between various types of treatment obviated by increasing the frequency conclude‘that convulsive therapy the convulsion is induced. change subsequent rates to the convulsion, The and is non- significant not the agent ‘ \ . 92;}, \‘> �-1u- 2. Role of Electroencephalography in Convulsive Therapy: have applied methods of quantitative, We serial EEG analyses in the studies reported here. While clinical estimates of behavioral change may give similar data, such evaluations are more dependent on the attitudes Wé‘v M30 Further application of Wt. of the observer ( 3 than the EEG.‘ EEG analyses to a (5M basis rer'ZZ‘ other problems in convulsive therapies'mey providﬁérational \ MM41$;r’.11.~:a"3"‘“é-e?fof we have clinical different treatment techniques. previously noted that management of EEG analyses may be applied patients receiving convulsive therapy ( in the ). In the experiences reported here, the early and sustained induction of high degrees of delta activity provides the physiologic basis for behavioral change fail to in convulsive therapy. show a three times per ment. An electroencephalogram in patients significant behavioral response week may who on treatment regimens of serve as a rational basis for clinical manage- In those subjects in whom high delta activity has not been induced, increasing treatment frequency, withholding premedication, or shifting to a therapeutically more effective convulsant method, neurophysiologic changes. If the it may number of weeks, be maintained for a degree of delta may result in the activity is high; and other factors, as personality �-15( ) or environmental ( behavioral response, even and ) may when further convulsive therapy tion has been suggested by , _. *MM‘ ,nm4.~~-> ....~,..~v~m be assumed to preclude a satisfactory the neurophsyiologic substrate is assured; may well be discontinued. Roth ( ‘) A similar applica- for thiopental activated «AW‘~ EEG records. V . The successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational agents.( ). management and understanding of psychopharmacologic ..,. awuwlw'uuw... �-16Conclusions: 1. In serial quantitative analysis of degree of induced EEG delta activity in subjects receiving various convulsive therapies, a positive relationship between the degree of induced delta activity degree of behavioral change and ratings of improvement 2. An induced grand mal convulsion and both the is reported. is essential for both the EEG and behavioral change. 3. rate The a. and degree of induced Mode of delta activity is dependent upon: seizure induction b. Eiequency of treatment _ c. . 'h. It is Age of subject d. Pre-treatment recommended EEG record characteristics that serial quantitative electroencephalography provides a rational basis both for the study and clinical management of S various pix-Lodynamic therapies. �EASTERN PSYCHIATRIC RESEARCH ASSOCIATIQNHINC. OFFICERS 1957-1958 DR. DAVID J. IMPASTATO. SEC'Y-TREAS. 40 FIFTH AVENU’ETNEW YORK 11. N.Y. DR. LEO ALEXANDER. PRES. ‘33 DR. LAWRENCE H GAHAGAN, ASST. SEC'Y-TREAS. 164 EAST 74TH STREET NEW YORK 21. NHY " MARLBOROUGH ST.. BOSTON. MASS. i DR. THEODORE R. ROBIE. PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. DR. DR . DR. DR. DR DR. WILLIAM L. HOLT. JR. ‘IST VICE‘PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICEsPRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. Y. 0 0.0 COUNCIL JOSEPH EPSTEIN EMERICH FRIEDMAN WILLIAM FURST' "' PASQUALE LgorE‘sA'rA NICHOLAS Locngeio '* EVELYN‘IV'EY ' w O .0 TWELFTH SCIENTIFIC MEETING; THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SgHARP NEW YORK UNIVERSITY MEDICAL SCHOOL ALUMNIHALL-‘HALLH AII 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) o '0. “O o 0‘ PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing Completion Test (An Incisive Interpretation of the Unconscious) Ferruccio (Ii Cori, M. D. Discussant: Dr. David Wechsler 3. Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detail do you use in your examination of patients and the recording of your findings? ��EASTERN PSYCHIATRIC RESEARCH ASSOCIATION. INC. OFFICERS 1957-1958 DR. LEO ALEXANDER. PRES. 433 MARLBOROUGH 5.," BOSTON. _ MAss. DR. DAVID J. IMPASTATO. SEC Y-TREAs. 40 FIFTH AVENUE NEw YORK N. Y .f'W‘" 1“" AssT I-I SEC‘-Y TREAs. DR. LAWRENCE GAHAGAN 154 EAST 74TH STREET NEw YORK 21. N. v. II COUNCIL DR. THEODORE R. ROBIE, PRES. ELECT 676 PARK AVENUE. EAST ORANGE. N.J. DR. JOSEPH EPSTEIN DR.’ EMERICH FRIEDMAN DR. WILLIAM FURST DR. PASQUALE LOTESTA DR. NICHOLAS LOCA'SCIo DR . EVELYN IVEY DR. WILLIAM L. HOLT. JR. IST VICE-PRES. ALBANY HOSPITAL. ALBANY. N. Y. DR. CHARLES BUCKMAN. 2ND VICE-PRES. KINGS PARK STATE HQSPITAL.KINGS PARK. N. V. , 0 0.0 .0. I ' ‘ L I O 0.0 TWELFTH SCIENTIFIC MEETIN‘C THURSDAY, FEBRUARY 6, 1958, 8:00 P. M. SHARP NEW YORK UNIVERSITY MEDICAI_,,SCI:IQOL ALUMNI HALL— HALL "A" 30TH STREET AND FIRST AVE.. (ENTRANCE ON 30TH STREET) (Parking on Grounds) O 0.. M 9 0.. PROGRAM I. Electroencephalographic Correlates in EST. Max Fink, M. D. Martin Green, M. D. 2. A Drawing CompIetion Test (An Incisive Interpretation of the Unconscious) F erruccio di Cori, M. D. Discussant: 3. Dr. David WechsIer Apparatus and Method for the Study of Conditional Reflexes in Man. Leo AIexander, M. D. 4. Free for All Questions (if time aIIows) How much detaiI do you use in your examination of patients and the recording of your ﬁndings? �”mm: W A! W R433. mm, W 8mm. an. «mm W Main ~me7 WMMaotmm mm, mm mw mum at can a, m. mi» mm mm. 3.1. mum-«math-Wwwmnmaumﬂum, Wéym. ��to to m m (as) 29: ms (as) m m am (at) mm M «a (13) W «pork, m M m sea: M W mmwmama mm. ma: (.3) wanton-«arm “Manna mmmmmtm, “W“ (3) or “box-during my (11) mm: m not: 1m 1w to «:1an aluminum in tum than than with mew voltme- M nativity mtma 9”»th rum m nmm mt. «Wm mun WWW mmmmdmtho gamma. mum: mam-m Wﬂthmmutnmmmawoftmmmwm at Mt: «ﬂier, for “W pom, m mama In than not-1» at Fatima, subjects nativity, activity mad mm vim m Wham; Witty. m 01m awe may“. at mam anm mmmwmmmuwtmtymmm. mm A 4!- this a: my: damn words Miami. It mm awmmehonmdmdfmmam .WMMQMW Tha diffemm in 19 mathmmdmamthmmmmrﬁemufmymu mmmwmrmntmrthmmmmmmmm. ��‘ mm Ammqmuutmmmemmwuwm mm ”tamer mm mm W WW. momma 5.» tommmetthaméfwmafmuﬂumm.m 1. mwmmmuummmmm ,3" mtnuwdwatmwmu ”£2,“qu memumm. mm: WWW“ wwamm M Huh b. a. 1300th m1. um Mam” mum“. W:- & both for the. candy and mm Wm at ��Electroencephhlographic Correlates of the Electroshock Process MB): Fink MOD. and Martin A. Green PM). From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, in part, by grant M-927, National Institutes of Mental Health, National Institutes of Health, [1.8. Public Health Service. Aided, at the meeting of the Eastern Psychiatric Research Association, February 6, 1958. Read E: 2- 15- :2 New York, N .Y. �EEG Correlates of the Electroshock Process During the past few years, renewed attention has been given b relation between changes in the electroencephalogram and behavioral changes induced by electroshock ( l-h ). Based on a hypothesis expressed ﬂie by weinstein and his coaworkers (5% in which they related improvement in electroshock to the development of persistent states of altered cerebral function, analysis of the neurophysiologic aSpects of electroshock an was undertaken in the laboratories at the Hillside Hospital in 1953. In fig initial EEG study,” a significant relationship between the degree and duration of the induced delta activity and clinical evaluations of behavioral change and "improvement" was reportedayeThis study was based on convulsions induced by a unidirectional current instrument '(Reiter). Subsequent eXperiences with alternating current techniques demonstrated differences in the rate and degree of development of delta activity. Age of subject and frequency of treatment were also factors in the EEG reSponse to convulsions. It is the purpose of this report to assess the role of treatment method, age of subject, frequency of treatment and pre-treatment EEG record Characteristics in the EEG and clinical re- sponse to convulsive therapy. Method: : hundred and £e££f3i=irt consecutive electroshock One been a day studied. Electroencephalograms after of therapy Patients wave ﬂ a treatment were taken before treatment, and on at weekly intervals during until the record referrals have had achieved its and following the course pre-treatment characteristics. in.whom the pre-treatment electroencephalogram demonstrated slow AsymmeM/ or Spike activity, or significant aaaynetcy; were excluded from the series. �M Wﬂnﬁ rig/L Wm MW W Jam ”WWW- ﬁght/M4 W M WWW W (W) Jam MM WMWWW/ WWWW2AW W; Jaww W ,asJ—u—m 4/— .49 «3'44» :L WWWWW.%II: WWWWWMMW W ﬂéﬁw‘jﬂ. W’ W .WM MAJJA MM Wag/d �-2employing different eatments proceo Four ‘ van-us of stimuli alte .‘. ‘. current at t-- old strengthf" al - ‘ a current at suprathreshold ‘directio: current ngth; 4 w (parathreshold); t) s unvulsive techniques with -ntothal premedication. have been used' , ~. _ _ nat' The ‘ - ‘ alternating current suprathreshold (7) km W ﬁatients, unidirectional parathreshold and MW b‘ currenté’ ., without prior sedation, received for? second), usually sufficient for a petit mal response. odes second 3", (90 volts At 20 W intewals‘voltage, and; if necessary, duration! ale-re increased . . , until a grand to "Nu“ In the threshold alternating current (8) techniQues aae‘ well described. method ‘ mal convulsion was induced. mwmnl- The “voltage and induce a grand mal was the threshold value. be necessary In subconvulsive techniques, patients were given pentothal intravenously gor (>0 until asleep, either seconds (8); or alternating were administered petit and then for one to three low voltage, currentoi' 80 unidirectional current to l20 voltsﬁrézsecond applications, for a total of 2b to 3.6 mal All treatments were given three times a treatments. Patients week initially, for 12-20 failed to develop a significant behavioral or m m 55;, Mew $3 :13; gm W, were subsequently who clinical reSponse, or Jo treats (1% times per week. All activity. EEG ‘ b records were quantitatively measured for the degree of delta The "records were evaluated as to whether they demonstrated "high," "moderate" or "low" degrees of delta activity, according; to criteria pre- viously published (6). Evaluations of changes in behavior were psychiatrist and made by the supervising resident therapist at the height of the treatment effect) �, WWW WM/Jéw A?%MWW%4 /¢(WWW’MW” JKWWM HQWWWi ' ‘ �-3... and were scored as "marked," "moderate,"'hdndmal" or "none.” "improvement" were made by these physicians two ratings of The to three weeks after treatment was terminated, and were based on the four fold classifica— tion of "recovered,” "much improved," and "unimproved or worse.“ (6) Results: 1. Convulsive vs Subconvulsive Techniques: W MW, ' WW therapgrfglhad the h? subjectstwho received convulsive high degree Of delta records in-both second, third two of the three weeks, and of the )4? 13 subjects failed to the 27 subjects who and during Show a convulsive therapy. Of 6";gr one “a Low weeks of treatment; 12 during of the test periods. Thirteen high degree delta record on received subconvulsive therapy, however, none demonstrated middle or high degree delta of treatment. fourth activity records during any week degrees of delta activity were noted in three subjects during both the second and third weeks of treatment, and in 8 subjects during the fourth week. neahJ-l’ 21‘ ln concurrent behavioral ratings, hirof the.ﬁﬂ subjects in the ‘ convulsive group showed marked behavioral change; while of the subcdn- vulsive group, (Table I). therapy. *» Y‘aab éacbndldb ham, ‘ ﬂ Of 2h of the the or 27 showed minimal latter group, 19 were no behavioral changes. referred for a second course of In lb of these, grand mal electroshock induced high degree delta .RE niekagd: uan W‘LWM ,_ AAAAaaeut "W wthwﬁ W ynxuduvuax “Gunrﬂ nta. waT‘5~/::L¢Gﬁe , . I �.uactivity and all showed a significant behavioral change. Of the five who failed to demonstrate high degree delta activity on convulsive electroshock, all WW m Showed middle degree behaﬂoral change. m. L *3 3 hawk»: records; and two of the five 47 I TABIE Showed a W! 4‘ 9““..44 b ' Ratings of Behavioral Change; Convulsive—Subconvulsive Therapies (Tourth-Fifth'weeks of Treatment) Degree of Change Moderate Minimal 27 15 S O O 3 8 16 Marked ConvulSive Therapy (h?) Subconvulsive Therapy (27) None In evaluations two weeks after-treatment of the degree of "improveof the convulsive therapy grongj::ted as "much improved" or "recovered," and 32% as "improved."qag% discharge, 51% were evaluatedileZS ment," 51% sustaining the and only were were 7% same degrees of improvement, while were "unimproved." rated in the first Of "unimproved;"ﬁgﬁgeiggége§:§§:$§%§:red do were "improved," the subconvulsive group, however, two categorie51’19% hOSpital discharge evaluations h2% in the "improved,“ but for a 11% 70% second course of therapy, not reflect the effects of subconvulsive therapy. II TABLE Ratings of Improvement: Convulsive-Subconvulsive Therapies (Two'ﬂeeks After Last Treatment) Recovered Much Improved Improved Unimproved Worse Convulsive Therapy (h?) 9 15 15 8 Subconvulsive Therapy (27) 2 l S 19 �W. .r -5... din=;.€onvulsive therapyinduced signiiicantly greater behavioral MM“ whichchange and eva uations of improvement thangsubconvulsive therapy We The parallel the electroencephalogr . Also, patients -EEG clinical I observations“ ”A“! who showed neither showed both or a behavioral response to subconvulsive therapy, and behavioral changes when placed on convulsive an EEG therapy. 2.- Role of Type of Convulsive Therapy; In view of the variety of electroshock techniques employed, and the relationship between EEG delta activity and the behavioral response, an analgrsis of the was undertaken. 2. The effect The oi‘ type of electroshock on EEG delta actvity results are graphically presented in Figures first figure relates 1 and the treatment type to the percentage of weeks record ‘n each treatment group during the second, third and fourth tre:Egentgggégggggating:high degrees of EEG delta actigggi) In each of period, treatment with alternating current at suprathreshold strength gave the highest percentage of high degree delta records. Treatment with unicurrent and with alternating current at threshold strength was directional less efi'ective than the suprathreshold alternating current techniquef.in each period; the unidirectional current treatment being more effective than the threshold alternating current method only early in the course of therapy.* Vsubconvulsive techniques yielded no high degree delta activity records. The second figure demonstrates the same the per cent of each treatment group showing 7“: relationship no by measuring delta activity or only low ncés ..-»_. :v-n suprathe a‘, ent perins, tre Eur, .l-i-o . an. etho’.'5 - thre o'd reatv t si " Can at .05 by chi 7—9 “-3 ou- in} vDi7”e~' ces b tw-z para --12 0-" 0d“; no ignifican ' dWL- ‘ j . hold met‘ods, and for each method �at Mt“ M74 @WWAEW �-6Here, the subconvulsive group degrees of such activity. is lOO%_for each treatment period. Suprathreshold alternating current techniques show the least number of such records in each period, with threshold and parathreshold techniques in between. 3. Frequengy of Treatment: Another factor in the rate of development of delta activity is the frequency of treatment. While all patients were initially treated three ltimes a week, a number who failed to develop high degrees cf delta activity on convulsive therapies were treated more intensively. In nine daily or twice daily, and in each instance middle or high degrees of delta activity were induced. Similar such patients, treatments were given correlates were previously demonstrated Callaway (10). EEG h. Factor of In the by Pacella gt'gl. (9), Age: initial series of patients, it was noted that younger patients, under hS years of age, developed greater degrees of delta the first such and second weeks of activity during treatment; while older subjects developed activity to a significant degree during the third week. fourth week of treatment, the groups. Combining observation. and By the differentiating aSpect between the data from.all convulsive therapies supports this age was no longer a IMring the second week, h3% of records are high degree delta in patients under the age of no; but only 30% in patients from uo—oo, and 18% in patients 61 and over. In the third and fourth weeks, the differences are no longer present and approximately 2/3rds of the subjects degree delta records when treated 3 times per week. have high �-7TABLE Variation in % High Degree Delta Suwd To DO years (28) Records With Age M ﬁlm k2 29% ' W % Treatment Period $9.213 69% 61% h3% (28) Lil-50 EEG lit-.9. £211 £59. III W W ‘ 31-66 (28) 32% 56% 55% (18) 18% 50% 80% ‘ 61+ 5. Pre-Treatment Record Characteristics: * Previous reports, summarized by Chusid and Pacella, ($3 noted a significant relationship between pre—treatment record characteristics and the degree of induced "abnormality." Predominant alpha rhythm, "abnormal" (3» or "borderline abnormal" (11) records were more liable to develop alterations in the EEG than those with predominantly low voltage fast activity patterns. In these series of patients, subjects whose pre-treatment record demonstrated diffuse slow wave were not included activity, spike or spike wave activity in the statistical analyses. Eight such subjects were saven of them developed high degrees ”treated with convulsive technique? and of delta activity earlier, and for'more sustained periods, than patients without such pre-treatment abnormality. A Specific analysis of the relation between pre—treatment alpha and the degree of induced delta activity was undertaken, Rank order * The difference in incidence of high degree records is significant at .0 between the second and fourth weeks and .051 between the second and third weeks of treatment in patients over 50 years of age; but is not significantly different for these periods in groups under 50 years. WW WM *7 �-8correlations of the pre-treatment per cent time alpha in selected leads (anterior temporalavertex) with the degree of delta activity during the third and fourth weeks of treatment in _tions of +.2u and +.35 reSpectively. week is significant at third'week N£L0 Two h3 The patients demonstrated correlarelationship in the fourth the .05 level of confidence; while fails of significance, although the trend that in the is indicated. aspects of these studies warrant discussion; the significance of the convulsion in the electroshock process; and the role of serial electroencephalograms in the rational management and study of convulsive therapies. (1) Significance of Convulsions: In the éﬁéggél studies of convulsive therapy numerous authors, including Kalinowsky 2:". g. (12), and Pacella §_t_ (9)7 emphasized 3;]: both the clinical and electroenCephalographic'differences between grand mal and petit mal responses. While grand mal seizures induced clinical improvement in 60 to 80% of cases, petit mal induced changes subjects. Similarly, electroencephalograms in grand delta activity, while in petit mal therapy, no in less than 25% of mal therapy demonstate delta activity is seen. In subsequent years, various subconvulsive, brief stimulus, unidirectional stimulating, monopolar stimulating, been described, and and focal convulsive tedhniques have in each, in turn, discarded in routine therapy. Bergman §t_al, (13b for example, in describing the electroencephalographic effects of focal seizure techniques noted that 70% of patients had normal records 70-75% had "abnormal" records after grand after 15 such "seizures;”'while J �-9mal seizures. Ulett gt a;. (1h), in a careful control convulsive-sub- convulsive study, reported a significant difference in the clinical response of patients receiving convulsive therapies (60-80%) and those receiving subconvulsive (33%), or controls (38%). EEG He noted the discrepancy in the response in the two groups, and emphasized the significance of the seizure for the therapeutic effect. W Recent additional reports by various observers, based on a variety of data further emphasize the significance, of the convulsion in the therapeutiC'responSe (1, l5, 16).fﬁeinstein—end thus indicates that convulsions per; are, or reflect, the significant physiologic events which are the basis The evidence se_ fortherapeutic efficacy of convulsive therapies. If the convulsion is the essential the behavioral reSponse, does the any role in this reSponse?. in both the degree of EEG mode element both in the EEG and in of induction of the seizure play In the studies reported here, small differences delta activity and the rate of its development were observed between differentxnethods of induction of grand mal seizure.jh/§ Ulett gt a}: (11;) reportedan improvement rate of 57% for the alternating current convulsive technique, and 70% for the phodio-metrazol technique. While the differences are small, the authors ascribe greater clinical efficacy to the convulSive photo-metrazol technique. this repert, Kalinowsky noted 'various workers as being vulsions. Eh More more that metrazol convulsions have impressed efficacious than electrically induced con- recently, Edualds, (l7) describing a 1090, ascribed to it In a discussion of new convulsant drug, a clinical results slightly better than electro- convulsive techniques. 'We have further noted that the convulsions induced by various tech- niques have varying characteristics of latency, duration, preponderance �.10of clonic or tonic phase, apnea, not equivalent; and etc. "All grand mal seizures are seemingly a seizure is not an "all or none" phenomenon. Different reflect the differences inhphysiologic effect of the different treatment methodfp Further studies of this problem seizure patterns occur and these ‘are in progress. While this variability in clinical results is reported, that with repeated convulsions, 'of 00 may - 80% are observed. The differences element is the brain may way rates between various types of treatment benobv1ated byzincreagang the frequency we may conclude specific with regard to the is clear no matter how induced, improvement are small, and, for the most part, or number of treatments. it that convulsive therapy is the convulsion is induced. The DOD? significant change subsequent to the convulsion, and not the agent in bringing about this brain change. In previous reports (6, 18, 19) we have noted that convulsive therapy is also non-specific with regard to its application in mental illness, and in its clinical and behavioral effects.used The present studies amplify, therefore, the previous conclusion of the non- Specificity of convulsive therapies. 2. Role of Electroencephalography in Oonvulsive Therapy: applied methods of quantitative, serial EEG analyses in the studies reported here. While clinical estimates of behavioral change have we have yielded similar data, such evaluations are more dependent on the attitudes of the observer (20), and less amenable to quantification than the EEG. Further application of EEG-analyses to other problems in convulsive therapies provide a rational basis for the comparison of different treatment techniques. we have clinical previously noted that management of EEG analysis may be applied in the patients receiving convulsive therapy (6). In patients �.11Who fail to significant behavioral response show a on treatment regimens of three times per week, an electroencephalogram may serve as a guide for further therapy. In thise subjects in whom high degree delta activity has not been induced, increasing treatment frequency, withholding pre- medication, or shifting to a more effective convulsant method, may result in the neurophysiologic changes. If the degree of delta‘activity is high and sustained for a or environment#(18) number of weeks, other may be assumed factora',as personality (21) to preclude a satisfactory behavioral reSponse, even when the neurophysiologic substrate convulsive therapy is assured; and further well be discontinued. A similar application has been suggested by Roth (3) for thiopental activated EEG records. The may successful application of quantitative EEG techniques to convulsive therapies, has led to their application to other physiodynamic therapies. Recent reports from these laboratories note a similar application for the rational management and understanding of psychopharmacologic agents (19). ��3;; Zn, ~ 6w WMMWL, _ ~ 4; �(«My REFERENCES 1. Roth, 1.: Changes in the EEG Under Barbiturate Anaesthesia Produced by W.Q Electro-Convulsive Treatment and Their Significance for the . Theory of ECT Action, 3: 251-280, 1951. 33. £5 Clin. Neurophysiol. Roth, M., Kay, D. W.K., Shaw, J. and Green, J.: Prognosis and Pentothal Induced Electroencephalographic Changes in Electroconvulsive Treatment, EEG “a..- Clin. Neurophy61ol. :2, Chusid, J. G. and Pacella, B. L.: Shock Therapies, h. Ulett, G. and ,1 MM Johnson, _ J. Nerv. m M. W.: 225-237, 1957. 2_: The Electroencephalogram in the Electric:;> &:Ment. Dis. 116: 95-107, 1952. m" "' any...MA... mm:-W M and Scopolamine Upon Efiect of Atropine Electroencephalographic Changes Induced w”,// 1. By Electroconvulsive . Therapy, EEG.,Clin. Neurophysiol. 2: 217-22h, 1957. S. ‘Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Its Relation to the Therapy: Psychiat. 6. Fink, M. of Shock Therapy, and Kahn, R.L.: Relation of Electroencephalographic Delta Neurol. & EBSponse in Electroshock, A.M.A. Arch. Psychiat. Z§: 51o5525, 1957. Kalinowsky, L. and Hoch, P.: Shock Treatments, Psychosurgery And Oﬂier Somatic Treatments in_Psyohiatry, Grune 8. éﬂ:_i; 192: 22-26, 1952. Activity to Behavioral 7. Theory & Stratton, N.Y., 1952. Alexander L.: Treatment of Mental Disorder, W.B. Saunders Co. fhiladelphia, 1953. 9. Pacella, B.L., Barrera, E.S. and Kalinowsky, L.: Variations in the Electro- encephalogram Associated with Electric Shock Therapy in Patients with Mental Disorders, Arch. Neurol. & Psychiat. g1: 307-38u, 19h2. �10° 11 . Callaway, 3.: Slow wave Phenomena in Intensive E1ectroshock,«Elootpa. tag; ennaphalggrﬁk'Clin. Neurophysiol. a: 157-162, 1950. t K)~u~uu¢,nk‘04+&.LUéQQNUM’ antm 3‘ v~n£.aax+ueB ox BK 33,; swam: n 3,. H AW“ um “3' W i?! p 12. Kelinowsky, L., Barrera E.S. and Horowitz, WA“ in Electric Shock Therapy, Am. The J. Psychiat. .y. i'c I 4"?“ use... "Petit-Mal" Response 2Q: 708-711, l9h2. 13. Bergman, P.S., Impastato, D.J., Berg, S. and Feinstein, R.: Electroencephalographic Changes Following Electrically Induced Fbcal Seizures, Conf. Neurol. 11: 271-277, 1953. 1h. Ulett, G.A., Smith, K. and Gleser, 0.0.: Evaluation of ConvulSive and Subconvulsive Shock Therapies Utilizing a Control Group, gm;_g, szchiat. 113: 795-802, 1956. 15. Wéinstein, E. and Kahn, R.L.: Denial of Illness, C.C. Thomas, Springfield, i 1955. 16. Fleming, T.C.: An Treatments l7. Edwalds, Inquiry into the Mechanism of Action of Electric Shock 'Jidbnuav'nﬁuatJWor ,WO-ASO , 1950 . K.M.: Intravenous Administration of with a New Convulsant Drug. Read at PM 1090: Clinical Experience N.Y. Divisional Meeting A.P.A. 1957. 18. Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the ElectroShock Process, Dis. Nerv. Sys. 19. Fink, M.: A Unified Theory of the ACtion of Physiod namic Therapies, J. Hillside 20. Fink, M. and Hosp .__(_3_§ 19 7-200, 1957 . Kahn, R.L.: Behavioral Patterns Brain Function. 21. (in press). Read Kahn, R.L. and Fink, M.: at in Induced States of Altered N.Y. Divisional Meeting A.P.A., 1957. Personality Factors in Behavioral Electroshock Therapy, Conf. Neurol. (in press). Response to �mmﬁmu mumm. in M minions: W manta, mm mm am mm mu, 3.1. a: mm mm, mam mm mum mm M Mia mu: m“. &, M. at mutmmmummmmwmumamrmxm. VIM ��m W a: moo nativity «many to: tho uwmmthomw Migration“ (Miamimdmthouoomw the «Mo Wvomwmmuﬁml) Withomotmm room: Woo with Moment, Magenﬂ MWm«on ntod u “MAW of data. muty. yW WW 1 4- .. 11111 . . mammumuwumamuwmw 25mm W» W t mm ”mm Wt? 'W 28 12“ 21 8'! a 66." h“ 35 13 16“ 3 2 a M K 60 t wowmammmmgmmmw stumpWM Wommmmmmmlﬁm at m woman” mind Wm t1»npy*1n this M. m: who 34? 9 .3, ommamae monmmmmmmmmywamm 19 ”loom mu, plat tofu-rod for t «W W“ of thong, ' Win . ﬂ UWJOOM ��m Mm Mm am m 1%- M 61 M 1:: (28) W (38) M M W (28) 311‘ 565 (18) W 30% , thmum mwmmammﬂva thmm Wsmﬂmt Wampum “W" (ﬂw‘W W“ (n)mmmmmw mmnwpum. mmmerpmmmwmmm~mam ‘- _'mmunwmmu%%wapm§uwmw mmmwmmamummwa. thmmm �“Nuthmmw Mgr: than m 3mm of A. ma W,mm,W. mama“mmWWW pom, mu nativity without. such M for mm wan-«mam» Mutiny. WM maym at the man hum put-mm awn mmarwu1ummuymmm. mum mumaunpmmmmmmamnmmm (wwwm)uwmmdmummwmm m gm was « tantalum w a: mum. mm mum m at Nﬂbwhﬁmmunlyo mmumpmm comma mm“ mw3mmsmmmmm Wmum am at mum, among: an m u Mam. . ��Reprinted from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958. Electroencephalographic Correlates of the Electroshock Process and MARTIN A. GREEN, M.D. In the course of an evaluation of the role of a1tered brain function in the electroshock process, the relation between electroencephalographic change and behavioral response has been re—assessed. MAX FINK, M.D., Subjects and Method: Eighty consecutive electroshock patients have been studied. All patients received electroencephalograms before treatment, on a day after a treatment at weekly intervals during, and following the course of therapy until the records had achieved their pre-treatment characteristics. Treatment procedures varied, including unidirectional and alter— nating current electroshock, and subconvulsive technics with Pentothal premedication. Treatment was usually instituted at three times per week for 12 to 20 treatments. Patients who failed to develop a clinical response, or EEG changes of signiﬁcant degree, Were subsequently treated at 5 to 10 times per week. The EEG records were classiﬁed for degree of delta activity into “high,” “middle” and “low” degree delta records using the following indices: the percent-time delta; highest percent-time delta in any lead; slowest wave in the record; highest ampli— tude of delta; and duration of burst activity. (Arch. Neurol. & Psychiat., 78: 516-525, 1957.) Evaluations of change in behavior were made by the supervising psychiatrist at the height of the Read at the meeting of Eastern Psychiatric Research Association, Inc., held Feb. 6, 1958. electroshock effect; and ratings of improvement were made two to three weeks following the termination of therapy. Results: 1) The appearance of a high degree EEG delta activity during the second and third weeks of treatment was signiﬁcantly correlated with change in behavior and ratings of improvement. 3) High EEG delta activity was induced in patients receiving convulsive electroshock only, and was not observed in subconvulsive therapy. 3) Alternating current instruments induced high degree EEG delta activity earlier than unidirectional instruments, but by the 4th week of treatment, the differences were eliminated. 4) There was a direct relation between the degree of EEG delta activity and the frequency of treatment; and an inverse relationship to age. Conclusion: 1) There is a relationship between the degree of EEG delta activity in the EEG and clinical change in behavior. 2) The time of the appearance of EEG delta activity and its persistence is related to: a) induction of grand mal seizures; b) type of current employed; 0) frequency of treatment; and d) age of the patient. 3) Early and sustained high degree electroencephalographic delta activity is a necessary, though not sufﬁcient, pre-requisite for improvement in the electroshock process. - �mmmmm Garnish” at the mammoak Mam Hawaii‘s WWW at Moan rawhiam, 35.11.3169 363331981, men Oaks, m... mamas a: mm mm mums. w grunt 16-927: 33.131th um, in wt, M. ”03¢ M116 English From the Mﬂtﬁﬂﬂ Band at 131-13 Halal, mm at the Eastern mum autumn ”Manama, ﬁat York, Pcbmary 6,. 1953. Whip-$8 Saran. 3.1. �WWMMW.WMMMMﬁmhm Wmmmmmmammmwmmmm WWW.1IW (1.1).. Wﬂﬂmhwma mmmwmamtaﬂ) unmuwmwmamMMIMm. mmmw Want Mummy m an m a mum 1mm muw um mlmum may in this laboratory, a 65 «mu um! at Wﬁ'mmw). mammmmuuam mmmmatmmwmmtmmutmmm, W a: W, mot mbmwm-mms mm mm“. Itismmwadmmwtﬁomummuuondﬂauum MwmumammmwMommmamw WWWduﬂﬂahquowhﬂnuﬁmlm mm am of mm" mm. and ��in mm Wm: GW‘WWW' The wide variability-1n the mm of mm mums»newt-w in the initial 2h gamma» (‘6) is aanfimw in them string a: mmulaiva mmyy ”towns ( table I) . While the number of law v-meamu $.12, mm We Ward: mama“ with treatmenb, 7m in the third min; and 3.8% in than fourth max, urn mu rut-ma a “1M ﬂames at am». nativity. We of EEG Dalia Activity with convulsive Therapy (Emmi; M .122 ,. High MW h - M) 2mmt Pogod ‘ L 1:2 28 1:6 66 2% Mamie Dame 1?. 21 27 32 W 99W 63 W 25 18 16 3 2 a m 2mm mmw Tim behavioral signﬁimm mama was of the amused in emmion $110? m a 1n the: EEG ma muwmbwmlsiva ﬂaw. m the h? mhjaictu" the maniac! taminva therapy in mi: “My; «It m mlmﬁm mu, incluéod 28 summit»: the pins 19 .» . cm“ of therapy. 9 had grand m1 therapy can a rmdm mimd ~ m3aota Mama for a “mound in ��of me netiv-ity. Kara. the mbcomuleive group in for each 100% treatment per-lee. Sumthrenheld alternating current techniques the least member mmmeld enact of such remade in each period, with thmmeld me teehniqma in between. it. leather teeter in the rate is the Mme? at treatment. three time a week, a while number whe a Miami. of delta aeﬂvity all patients were initially treated failed develop high degrees of “be delta activity were treated were intoneively. In em! mh peanuts, mama were given daily or twine daily, and in each instance new» or high degrees? 91’ delta activity were induced.- Similar wimely 5. F- by ' ter of In the ' Mem'gg g. EEG (9),. and con-slates were enemy (3.0). a initial «new of ptiente, it we noted that yemger patients, under 15 yum of age, Malay-ad greater $339“ ex acne nativity during the fix-at. and heme! weeks of treatment; while clear mbjeete developed such nativity he a eigﬁﬂmt degree during the mix-d week. By the fourth ml: at treatment, age no longer differentiated batman the gmups. supports Cambining the this observance. date free all convulsive therapies During the amend week, ha; of weaves are magma mg: eeme dam: in mean-es we.» the age at in pastimes and rm bones. and 18% in pemente mm wake, the difference: 2mm 63. and no; but mr. my 30% In the third are no longer present and 3.15mewa of the eubaeete have high degree eelta meeree when treated 3 time per week. �3353;;an mmgwmwmlaa 5% Ta ha W50 Over has ascoraanaaaﬁw rm‘ Huh ma SE)... 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(1153de. similar applicatim has hm suggest“: m (5) far thiamm ”bland we} mrahar ha A by am mm. m ammm'vl maintain ma uwmqma ta mmhive W121“, but led to their diminution in amt Win-- Me alumina. W mec npplioatim 13$ Mt. “ports firm the” laboratories min a W mum amt! (26) ,; applieatien tar WM aid warming at ��11;. maids, 15‘; 310 3135 . W, 30. Gamay, An 1935.- ,1: am oxidation at mews 1956. a nu. 3m.: um Wan-awn at m 1090. mama. Inquiry into the sex-«mm, 3.3.: ' a: W. mm,Mariammm»: with a m ﬂew 9mg. am at 21:2. minim Hating LﬁPi‘J HA. I 19570 Signifimaa or mmm vmbili‘g in m magma Experimental stud-1W My Edi-m and am; 31*.“ My My; (in mm). 33m. 8 mun-9mm}: Rowan, W ‘ . 6f “13 o the Action or Physiodsmmia Therapies, m, 14,: 1 Unwed Thom a:197%.;195?‘ , 21. LG»: Shook m, 19a K; and “W,springtiad,m Rd“! W a! 16. 1?. 6:13.: Evaluatim at ma Mr, (3th 00mm}. ﬁr. gamma“ m1: Wraps.“ Winning a £34., Smith, 52* 3.1m Bahamian]. mum in Induced sung or M; n. ma Kuhn. Brain mum. Rand at NJ. Biﬁaioml mung MPJ. Ligand 3‘9 7‘. ‘ 22. Kuhn, 3.1:. and Fiat, 14.: ; A,“ Mummy Futon in Behavioral Mama to Mammw}: “therapy, Gama m:1. (in press). ��“x 1%! mmmmmmwwmmmwmsw wuwmmﬁ ‘xmméugunrwar mum's, far w mum,mwmmwormmumum mmwwmwmmmmmwmu muuwmmuumnwhs. WMWmW rwmmmmmmummcymmmm mmmmm. mum-Mt m m ”##1##“, We“ m Mmaummwnmwmmywm,mm want? mam, MW W wmmmummmmmthmm mm mu to, at lama huh activity, me! for my: Wﬁm a! an mmt ma pu- mum. alpha was the We. cream mtﬂtymmmmwmormmmmema ‘tgﬁﬁmafwma “ ' ‘ ' mm u¢mwmm4munmmmwrmw ’ WW. W! z.-m:auumnwmummuuuuwumt mm: man-mm durum m mammmmtmmmmwgmmm (a) W a: am mm. m mm uMmmmmm. 31* mamam am am am �mm: mm; 1W m W mum m mmar-W: Mrwmwmm at (M ‘ we. at Mm“ (a) at «inactivity «mm hf {mm—m. (a) m m mums. warm as inmate-at. but, my the What W «Woman: “new: rm m with vammﬁmdwmuwm W‘ mm- M whim: WW W mu up» mama. WIta» W maﬁa ~1me m Mmammmmmmammm a: (3) «1' 1. Wu W. nativity that aw: 1w WWt ‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Electroencephalographic correlates of the electroshock process. Dis. Nerv.Syst., 19: 227, 1958. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-32-009 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 12 items. 1: [preprint]. 2: Edit page. 3: Hand drawn graphs. 4: Handwritten notes. 5: Drafts. 6: Program for Eastern Psychiatric Research Association, Inc. Twelfth Scientific Meeting, February 6, 1958 (handwritten notes on back). 7: [preprint]. 8: Final copies. 9: Reprint from Diseases of the Nervous System, Vol. XIX, No. 5, May 1958 (one page). 10: [preprint]. 11: Discussion - NY Neurological Society 3-11-58. 12: [preprint]. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/a1c70b872beb13c5b56dba9ecef3099b.pdf de32dee2acdbbfa2e67eb3cd0c31e52d PDF Text Text Simultaneous of Perception Tactile Stimuli in Normal Children Max Fin/z, M.D. and Morris B. Bender, M.D. Normal adults readily identify and localize tactile stimuli applied simultaneously to the face and the hand (the “face-hand test”).1 While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tenth trial of the test. Young children, however, ﬁnd the task of identiﬁcation and localization of two skin stimulations difﬁcult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattern in which stimuli to the face are readily appreciated (“most dominant”) while those to the hand are not (“least dominant”). In order to determine the pattern of “dominance” in children and the age at which such tactile perceptual tasks are correctly performed, a study of normal children was undertaken. The responses of children to the face-hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his confidence and interest. At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of Medicine and the Bellevue Hospital, New York City. This work was aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in—aid from the Coordinating Council for Cerebral Palsy in New York City, Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 �28 NE UROLOGY For the face—hand test, the child was told: “I (examiner) am going to touch you,” and he was to “touch the same place I touch.” He was asked to close his eyes. The examiner, with the ﬁngers, then touched simultaneously a cheek and the dorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated. After this response, the child was asked to close his eyes again, and now the opposite cheek and hand were similarly stimulated and the report recorded. If only one response was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The ﬁfth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimula— tion of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both cheeks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modiﬁcations had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. In such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal focal difﬁculties. with subjects any sensory group The children were asked what they had felt and to point to the places stimulated. Verbal reports of the locus of stimulation were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one cheek. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. RESULTS Incidence of errors: Young children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli �PERCEPTION OF TACTILE STIMULI IN CHILDREN I00 m 2, E ,_ 9 II m p. k no: m at “J ,— uzJ u o: to u. 100 90 (“C9, ‘ 80 85 70 L2 so 2 | 4 5 6 7 8 9 IO I2 ll .‘N‘K ‘ . '\ x. _ __ “t“ c: In a. 3 '_ ‘~~. \._x_x_‘. - \K 3 0 \,\,. -----------.‘ I‘. E 20 ‘ \ LA— 30 ‘. .- 8 so c: 0 4o o 30 40 ‘- 60 o. 50 -------------- 70 Z 60 \ ' 90 r: ~-.. a . ,_\.-___..‘ 29 _ 3 ......... . YEARS 5 YEARS 7 YEA S .----I ~~~~~ o .......... 9 YEARS L345 NUMBER OF TRIAL AGE Graph 1. Graph 2. during the initial ten trials of the face—hand test; many of these even with eyes open. In the older children the number of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the ﬁrst ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct reof this served clue While all the older to in as a some cases. nearly sponses TABLE 1 NUMBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES ( Age 3 4 5 6 7 8 9 10 ll 12 13—15 Total Number of Subjects 39 34 37 36 26 22 23 20 21 24 29 Touch Stimuli) 1 2 — — — — — 2 — —— l 4 2 2 6 8 6 2 6 8 3 7 4 10 Trial Correct 3 4 5 6 7 l l 1 l 6 3 4 5 2 4 6 — —— 3 2 2 — 5 4 l 6 4 l 8 9 — 2 1 — 2 — l — — —- — 2 2 5 4 — — 1 2 2 1 — 2 2 2 — 1 — — — — 1 — — — — l 2 1 — -- — — — l 2 l l — 1 — —— — 2 Errors Beyond 10 Trials 34 28 28 22 10 4 3 2 0 2 0 �30 NE UROLOGY children that two stimuli were being applied, it did not seem to alter the results in the younger children. In these subjects subsequent trials of the face-hand test were incorrectly reported, even though the responses to the symmetric stimuli had been correct. The perception of symmetric stimuli was much better than asymmetric stimuli. Subsequent testing: Of the total group of children studied, face—hand tests were repeated at varying intervals subsequent to the initial testing in 40 children. Of the children under the age of six, subsequent testing elicited the same difficulties with face—hand tests as was evident on the initial examination. In a few children over six years of age, who seemed to have grasped the concept of two stimulations in the initial testing, errors were manifest on subsequent days. It was as if many trials were necessary for successful learning of the task, and then, even though the task was successfully completed, the learning was temporary. These observations are in contrast to those made in normal adults, in whom subsequent testing did not elicit the errors of the initial test.1 Type and pattern of responses: The errors (table 1) made by children on repeated trials of the face-hand test were of six types: (a) a touch on the cheek only, implying no perception in the hand; (b) a touch on each cheek, implying a mislocalization of the stimulus applied to the hand; (0) a touch on the cheek, and a second touch on the shoulder, neck or elbow, implying a partial mislocalization of the stimulus applied to the hand; (d) a touch on the hand only, implying no perception in the cheek; (e) a touch on each hand implying a mislocalization of the cheek stimulus to the hand; and (f) one or two touches on the examiner’s body, implying a mislocalization away from the child’s body. Face dominance (responses (I, b, c) was apparent in all age groups. It was most manifest as extinction“ of the stimulus to the hand (response a), and was seen in 62 per cent of the errors. Mislocalization of the hand stimulus to the cheek (displacement) was observed in 31 per cent of the errors. While most of the displacements were observed in tests involving cheek and hand on opposite sides of the body, 7 per cent of the errors were displacements from the hand to the cheek in the simultaneous stimulation of homolateral body parts, e. g., right cheek and right hand. At such times the child pointed to the cheek once, saying “a touch here,” and then, moving his ﬁngers 2 to 3 centimeters lower on the cheek, saying “and here.” Other types of displacement were infrequent. There were partial displacements from the hand to the shoulder or neck. Mislocalization of a stimulus across the midline of the body, known as allesthesia,3 was occasionally apparent in the stimulus to the hand on heterologous testing. Furthermore, children *The failure to report one of two simultaneous stimulations has been called “extinction” of a stimulus? The mislocalization of a percept to the homologous body part of the second stimulus is called “displacement.” The mislocalization of a percept in the direction of the second stimulus is called “partial displacement.” In each instance, the stimulus which is correctly reported is said to be “dominant.” �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under five years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner’s body or into space (response 7‘). This phenomenon, known as exosomesthesia,4 persisted in some children despite repeated stimulations with the child’s eyes open, and despite the examiner’s insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?”, a number of children hesitatingly pointed to the symmetrical point in the Cheek on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child first reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on a second locus, pointed to the opposite foot, shoulder or side of the face. Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body part were localized correctly. If the examiner then insisted that there had been a second stimulus, the child pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses d and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot-hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. TABLE 2 FOOT-HAND TEST ( Touch Stimulation Bilateral Ipsilateral Stimuli) Total Trials 53 48 Responses Correct 21 23 Foot 17 16 Hand 1 3 F oot— Foot 10 3 Partial F t.—F t. 2 3 HandHand 2 O Other stimuli: A small group of children who made errors in tests repeated at varying intervals were examined with other cutaneous stimuli. Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. While the number of errors with these stimuli were fewer than with touch stimuli, the �32 NE UROLOGY still extinction hand of and dominance face was apparent. pattern DISCUSSION The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops during the ﬁrst decade of life. It is a relatively unstable ability, for many Focal discriminations. such disturb of the the in state can organism changes cerebral disease as in hemiplegia5 or parietal lobe lesions,2 spinal cord lesions,2 and diffuse brain diseases such as toxic states, senility and inﬂammatory conditions6 can so alter tactile discrimination that the phenomena of extinction and displacement become prominent. Errors in simultaneous tactile tests are the of the trials few initial the test—during adults normal in during apparent period of learning.1 Persons subjected to large doses of barbiturates,6 electroshock therapy6 or anesthesia7 also manifest such inability. A prominent feature in all groups is the uniformity of face dominance. When discrimination of simultaneous stimuli is interfered with, for whatever stimuli the in hand and the stimuli not the made to in the are errors reason, to the face. The corollary of “face dominance” is “hand extinction.” It, too, is apparent in all subjects and under the variety of conditions studied. Furthermore, in an “order of dominance” other body parts are between these two limits. Studies in patients with hemiplegia5 and patients with severe mental of dominance order revealed have disease6 of brain result an a as changes of face-shoulder—trunk-thigh-foot and hand. Insofar as these other body parts were studied in these children, a similar order was observed. Since dominance is evident in young children, it appears that the pattern of dominance is an inherent function of the organism. This childlike way of responding to simultaneous tactile stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. these of dominance rostral to explain has Cohn a theory suggested Recently observations.8 Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with of series hand in the two foot and to patients large buttock, thigh penis, diffuse brain dysfunctionfv9 make such an explanation untenable. with in with children normal in ﬁndings patients of ﬁndings Comparison those with children in the On mental ﬁndings comparing syndrome: organic previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face—hand test, errors are made on initial and subdisis the of stimulus most While extinction frequent trials. error, a sequent with a and children both In errors is occur patients, common. placement done be stimuli. of Furthermore, frequently testing cutaneous may variety with eyes open, and in many instances with repeated verbal clues that there is of factor The not prommade. still and learning are stimuli, errors two are inent Since testing on subsequent days will elicit the previous patterned errors. �PERCEPTION OF TACTILE STIMULI IN CHILDREN 83 In Gestalt terms, patients with organic mental defects and children have difﬁ— culty in extracting a complex sensory “ﬁgure” from the “background” of the total sensory “ﬁeld.” Signiﬁcantly in each group there is no difﬁculty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus ﬁgure has a common background in terms of body image, namely the hand.10 Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjects. In allesthesia, the subjects usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow, In exo— somesthesia, the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with organic mental syndrome also manifest another response to simultaneous stimulation ﬁrst noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthermore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure” and “good continuation.” These are usually described for other sensory modalities. When a circle is tachistoscopically exposed in the visual ﬁeld so that half falls on a hemianopic ﬁeld, or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good” ﬁgures. In simultaneous tactile studies, symmetric ﬁgures appear to be the “good” or “strong” ﬁgures. �NE UROLOGY 34 CONCLUSIONS Ability to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the ﬁrst decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalized). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dominance is found at all age levels tested. 8. One can conclude that extinction and displacement of tactile stimuli, as well as face dominance, constitute a normal and consistent pattern of rechilin these addition In children. observe, in to one can responses sponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difficulties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients With focal or diffuse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. 1. REFERENCES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests 0f face and hand, Th Am. Neurol. A- 751 250, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. 5‘ P sychiat. 661355, 195.12. BENDER, M. B.: Extinction and prec1p1tation of cutaneous sensations, Arch. Neurol. 8c Psychiat. 54:1, 1945; KOLB, L.: Observations on the somatic sensory extinction phenomenon and the bOdY sch—eme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A' 75: 1950' 3- BENDER’ M' 3'; WORTH, 5' B" and CRAMER’ J“: Organic mental syndrome w‘th phenomena of extinction and allesthesia, Arch. Neurol. & Psychiat. 59:273, 1948. 4' SHAMRO’ M . F .'’ FINK’ M. ’ and B ENDER ’ M. B.: Exosomesthesra, or the phenomenon 1c e ment of sensation into extra p er o f di spa 8‘ Psychiat. 68:481’ Neurol. Arch. space, $109221 717, 1949. 1. BENDER, _ 5' _ _ M. F and Extinction phenomenon in FELL , A . W, .. hemiplegia, Arch. Neurol. 8c Psychiat. 62: BEND-ER M B . SHAPIRO SCHAP- M. 3,; The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, 6. PINK, M_; GREEN, M" and BENDER, 1952, J” and M. B.: Perceptual patterns during recovery from general anesthesia, J_ Neurol., Neurosurg. & Psychiat. 14:316, 1951_ 8 . COHN, R., and RAJNES, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation Tr Am Neurol A '74'162 1949. COHN, R.: On certain aspects of the human brain: sensory organization of the . . .1 f A Ch‘d‘en’ II Neurolsggljylfllgastlrgsﬁommancem 7_ JAFFE, BENDER, 1 9. GREEN, M., FINK, M., and BENDER, M. B.: . . . Order 0 f dominance in cutaneous perception. Tr. Am. Neurol. A. In press. 10. JAFFE, J., and BENDER, M. B.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176’ 1952’ �All, [:w.,¢fﬂ (f P Aﬂu‘ f 1 \. 3/“5 ”a...” «w 0' V -—« ‘ "1“" ‘3'". :’ I ‘1 - momswammanual I! W swam new m cm h I“ m, I.B.*’ ' and MM! 3. Bind”. Id). mun-11:16:11.0. ’0 «mum»: 11» 3.11m mama, 1m: 1m: mum tar mama. "Aida! w 1 numbin- fro- the national Pauly-1: . than mil: III um. 11: out, by a mat-1114M contact“ for Cerebral any in In tori: easy. In: . m the 0991141th �1. max: 160mm and 1mm mun «mu appliad “minnow” $9 tho that and tho ma (ﬂu ”fleas—hand lam]. adult. taut”) (1). una1o halt aha aubaaota ara inanrract on tha 1n1t1a1 trial. all ara «errata hr Ina tenth trial at tho taut. than: childran, hauavar, find thla tank or teantatyins and laaaliatna can akin “mutton! mums. may mm only ma of til. we atianll, at 1: thaw rapart tho tan. traauautly'ataloaaltaa «no or than (1). 1h» allaazan orjuaalaoaltaattan or actual: 1a not haphaaard but fallaaa a «cantatant pattarn 1n.wh1¢h atmauli to tha taco ara raaa117 appraeiatad (Wand: doaanant') lhilﬂ thaaa ta ta. hand ara not (”laaat duatnant'). In ardar to datawaﬂna aha aca at ahxah anon taetila paraaptual taaka arr carraetxy partamaad and tho pattara or “daainanaa” in ohildran. a atudw at naaaal childran was undareakan. 2h. aaaponaaa or ahildran to tha taaanhand taut, and to ataultanaaua taetila taaha at othar bad: parts, I!!! aaaartalnad. m mm. M aura «mm m:- a M15hmm «mu um aaraa altnaaa at lallavua Hospital. eara cantor. are: ﬁba and and childran a: naishbara and trianna. an»: aura lithmnm aanitaat ataardar of tha aarvaua .1".Im A tau childran at two and a halt yaara or an. aura inclnaad in tha that. win! asp gruup, but ganaraxly, yuanaar children wart not aha. ta culprahann tho taut. Qua childran mama aaaaanad individually. in: that. aura nun: who aura asaainad in a dar~roua in full via! at ethar aubsaata. 1h» ehtla III ansasad 1n play and ahnn toys vara available thaw aura and to sun tho mum «mum. and trauma. at amﬁaa during �2. W “atom to” an intimate“. rer tat rue-Mad «at, the «mu um um: tho 91.7, ”I (Matt) a mains to touch you,” and ho m to "touch the «no plan. I touch.” no m and to 31m hit or». the minor, with an ringers, then $5..“an mm $ «but and tho donu- ot the hand what m “in“. a» «mu m um m tilt. Ind to point 39 HI. um “mama. m” tt“ mpmu, the an: m and to “on M: om mun. lad an the opposite emu-tutor”. at mm. can mun-1: imam, tall tho more an. mpmo no man to ma mu. tn. child m chock and hand 1: only 1: than “W um an bun new «mm: an." that no trial. the shock and hand an tho um 31“ at tho body an “and in 1 3mm mum. m um and not. or "pawn body Mt int 01mm tutu trul“mum a: mm: «mm or both m. vmm up» at ”1le m m. «mum an m - “Mex-01m” «mum of ”M910 316.3, luft Mud; parts body on meat. u 213% chock and 'hmlaum” “mutton or ”mutt-to may put: an the um “do or t!» body, I: right chock and right hand. and madam" “mutton or ”mud. body nuts, I. both checks or both man. 1!: «oh child until at hut «a tuna: war. Such mt- nu mm mad“. Bub-cam: «at. a: at»: W mu, portend in a 11-11” fauna”. mu 5.3::ch mu} at last 20 «mun cm).- were ovum 1:: «oh mun. A mm.- at modiﬁcation: and to tundra. um: an am with ma aloud, but imam men mu tho me: in". mind would not play the hoping m1:- Qm can. In “sacrum. he introduced ta:- yams Aloe. tMomhrotMandtmmem - �3. chum insist“ on pointing to m minor: ms: mm! m. an the mun mm . For than «mm. a ﬂu train a! 31min touch mama. mind to m- tm. «m: a: hand an mm“, W "man. rm. um. with an will km the the «can» of pointing to their own My gm: can-1d out with «you upon. mu emu. am is!» «mu or am» Immanuel twain tutu an «alarm. 31ml. um: In. ”and ta Mm but: mm to mime any ”5.106“ run run imam-y In Monti” m m mm). Th0 the ltro childrun plan “mum. an mt accepted. comet]; ml. the but than pom: to «and u 1: did pointing. m. that that hid {bit ‘ Iaknd Vorhnl ﬁnd to point ta mm: at the km. of ”melon It an «autumn; noted that child!» would MI “mum. 1..., ma. chock and m. chub. a- to We! also” on one «book. It the 1m- yxolm non «amt. mm“ than m m m. mun tutu are muted «was» an, or ’ on tub-mun: after a up» a? a um, «hum tn an or miss 1.11 um «mm. “1-311. other than light touch mm mm to the unsung. Th.“ manned tomb (rubbing), uncle pin puck. and mouth. pan prion. A: not: mum; m: may gunman“ gt; tutu. mun" Young «at cum I“: my mm on m or calm-on and» the or an $31106 to localllo both ntﬂlull during tho initial tﬁn trails of the {mum mt; any of rub 0n- opon. In the older of children. tho I) go that ton amply tutu-hand Mr not MC»: ham: (W �M muormmmmmumtormmeum: «manned to lake emu after the initial ten triﬂe . Aypemtly the ability to identify two Immemly applied mule ennui me directly related to the we of the «and. m- «mu» m the related tn the mm or previous mu of the face—head tent. fun. I, the tr“). 0: the teet after which the alum nee eminently cmeot 1e recorded. The net «Inn of the hue mama» en the etheote who nude emre 1a the nut ten mun; end on may triu- at the teet the tenth. Graph II 11130th thin vellum tar “looted use m etimlettm man; In Wme. em» In theee mute”). Ina heterolesm were carried out at random. Errata were slide by eubJeete at all ese in teete or either type. 95' me Wham teete. mt: ee both chem, or bath heme. maul: intenpereea in the teeting after the fourth mn. elicited can-eat renames in nearly e11 onee. Me true «reed u e clue to em or the older children that two etmn were being applied. it did not “an to alter the reenlte 1n the younger «mum. In the“ eubjeete “ohm teet mm amarmtu Warm, even though the reenmeee to the ”metric etinuu m been amt.perception of mute «m: an moi: better this: “metric “mu. “tenant MM‘ or the totel of ammo“ emu, m I'm-bend teete were «Noemi; tﬂele or the ‘l‘he A ’ . reputed at “mm tntemle eubeeemt to initial touting in to children. or the children under the ace an. mmumt tut-1m engage the em ditﬁaultiee emu teete over 6 um me etmutione the of “cum evident an the mute). examination. In e ten children or «use, who seemed to lave the concept or two in the auntie). tenths, emu were meanest on W �5._ lubiOQnﬂnt mooaum 43):. It III 1mm a; it'unay trials aura nooonuary tar of the tuk. and aim, mm though the tuk Inna-unrully aunplotod, tho laurntnz uni tauparlrw. than: abacrvutxonn are in central: to that: undo in nernnl Odnltl. in lawn tubaoqnant ﬂouting did not ultelt tho error! 0: Ch. initiil cost (1). $223,535,!Itt953lggbggggggggg; by mum, on Muted its arrow: m (Ethic I) and. mu. or m tum-Inna m: am at an typed: (n) u touoh on the chuck only. implying an pcrcoption in an. hand; (b) a touch on ouch chock. tnvlyins I Italoclllsntian of thc stinulna :pplicd to the bind: (a) a touch on thn dutch, and u aecend tuueh on the uh auldnr. neck or elbow, implying u partial tion or the act-ulna upleud to tan hand; (d) a touch on n13100¢11la~ tbs hand only, Ilplring no porodpttoa 1n thn chock; (a) n taucu on cash hand implying a niuloealisattan at the chuck stimulus to thn bind. and (f) on. or tun taught: on tut alaninor's body. implying a um W m- Illlocllillw the «Inw- body. Flea "dalinundo” (rtspanuoo a, £9 3) an: appurvnt 1n I11 as. grdupl. It nun Inst unnzthnt as c:t1nction* or the uttnulun to the hand (response 3). tad II! Icon in 6a! of thc errata. lialocnlizatton or the hand Itilnlut tn ch. chock (dtnplnoqnnnt) wt: obaorvod in 31! or en. 03:93.. ﬂail. Hunt at thy dinplaocnnutl var. obnorvud ‘03:: involving in abnok and hind an appetite class or the body. I! of tho aurora was: ddnpllaclauts tram the hand to tun shack in tho w I rm 1m ‘*vwr‘ Trt“7~ «*~ 1* urn 9 ?“ie' 4L1“ .r‘mr 3 "'1 anon dlzlod “untinatian' at a nut-alum. Iﬂl omnlilatton or x gore t to tho hdualasduu bod? part of thy nueand stdlmnnn tn dulled «up tomcat.” at a wept 1n the “mum of the ltdond act-min. 1:unlmnmum culled "partial In much instinct, tho ntzluznl which 1: corruotly rapewtuddiaplncunnut.” 1: said to be “dominant.“ . m w �6. sinnltunoans ntﬂnnlattua at hannzutavll body parts. 0.3. right ¢hsok and right hand. At auah tilt. the chilc Iould point to the catch once, saying ”a touch hit..” and than. raving his finger: 5-3 can. lint! an the aback, 3&7. ”and hurt.“ 0th.: typcn at «Laplaoa-nat Hurt turraquont. intro wort partial dimplaocnnntl frnn‘thn hand ta the nhauldcr or nook. llllocalisltian or .- anuzmu (3) t stinhlu: mat!!! the uidliuo of tho body, known m ”mama: imam in the «mm. to the touting. rurthoanuro, childrin under {Iva years or as. :rvqulntly'ninlooulssnd ta. Initial utiuulation away tram thair body to part: of tho nan-anor*a boar 9: into space (rampant. r). rhi- pupae-aaan. known a: iﬁoﬂHIOIihllil (u), per-11:06 in OHIO children despit- rupeutad lt1-n1a330an vita tn. child'- are: open. and despite tan ell-Lucr'u tastntcnat that 1: III the child hand an hutcralacoun that had beta tauahnd. A Anothor phannnnnoa III Inna during ho-mlatovnl touting. ihe child uuuld ropnrt only tn. ttxunlun applied to the check. It the uxtntnor askod insistinsly. ‘Bid yuu r001 anothnr touch anywhnro also?" alanine: at nhildrun quld hanttatingly point to the syn-etrlanl point‘ln tan ordor to chock on tho apposito side or the body. detomnxnp uhoﬁhar this vac a unigua or I Iritalntte phenanonon. In tout. or «that bed: parts var. carried out. In henolcternl tests or root and hand. showman: Ind hand. and about and rant. the It.» phanoInnan.ﬂla ohm-twee. in. «E114 txrnt reported only the feat, tho thauldor er ‘a. catch - and thou, whoa tho attains? inaxated a acoand locus. point-d to the appositu fact, guanine» an aids of thy rice. on Furthanlaro, in non. young «aileron, tho phnnulanou appeared on linslc :ttnulatiou. singlu atannli applied in any body part would bi correctly localixac. It tho ‘mlninor adv insisted that "tram , _,_, L¥=§ ‘&:‘-’ �7. churn had bcon a Iguana skinning. the child petntod hnl1tltznaly appease aid. e: um body. uni-ms pm on to m an 0.1mm indium. and 4mm“ (mpmu g and g) an tnnu-hnnd was intrnqunnt. It nus abnothd 1n 7’ of in. crrarl tents. In all tubdcatl 1n wasn't: an: appurunt, uuhuoqucnt a: tan ruao~hnnd tout unairnatnd can pn‘%crn at run. A. trial. dcnlnnnoo. other sun had: aggggggggg£,§ga§,gag;zgg§L, In taut. or part. or ulnar! 10¢It admin-at uhnn tho ran. and hand, tun hand It. loot. salultunooun tent: or 190$ and hand. tn. toot~annd tout. worn introdaaod after the initial ton 8:111! at tn. taco-hand tact 1n Inn: ohildrtn. In 8h. feat-hind tent. feet 11). dauinnnao In: taparont in 5x! at tho rcupanloa (In. that: and th. cup-k tho nanitoat by hand axttnottou; by dinning-nun: a: hand actual: and to uh. tout; and by par£111 displucullut to the this». knot, 1.3. who and. Irruru §§§55;5L,A 3-513 area» or childrou. It was with 0th.: in tents repentod at varrtns tutorVIJu warn nunltnod cutuusoun Itinnli. Izttnotian Qua allpllaulant phone-nan.unro prick prettnt 1n tacoohnad tent. Etta: pin pr1ok. rupotxtivc pin uuaxo tn. gumbo: at and rcpotitivo touoh (rubbing) attlulitionl. tuudh uttunzi.m orrorl with than. stimuli I‘l‘ town: than with of tuna dunialnoc and bind untiuotzon In: ntill laplrcnt. ~ W pattern ability to idontitr tad 100311£0 sepnruhod tron ouch 9th.» at nun» «titans. Th. ntnultanoonn lit-n11 LI 3 culplcx runntion 1: agenda of 1110. It grudullly dcvnlup: during tn. £12.: tho attic of tho a relatichy unltahlo ab1lity. tar Inn: china»: in otrobrnl alt-n:grannimn eta diutnrb tuna disarm-tnntlonn. focal which �8. in heeipiegie (5) er perietei lobe ieeione (a); epinei cord leeiane (23); end difruee brain dieeeeee ee taxie etetee, seniiity end inflammatory aenditiane (6) zen eo alter tactile dieerininetiaa that the phenunene of extinction and diepieeelent became pruninent. lrrere in simultaneoue teetiie teete ere apparent in aerial eduite ﬂaring the initiel tee trieie at the tent -- during the period or “learning” (1). Pereene eubaeotod to ierge doeee or barbituratee (6), electromehook therepy (6) or eneetheeie (7) eieo leniteet such en inability. ' pro-inent feature in all sreupe ie the unifornity of race dominance. when dieerieinetion or eieuiteneeue stimuli in interfered with, for thetever reeeon, the errors are made in the etmluli to the head and not in the etinnii to the tece. The cavalier: or “face delinenee” ie “hand extinction.“ it, too. is apperent in e11 etheete end under the variety or ccnditioue studied. further-ere, in en ”order or daninenee” other body peril ere A tee limite. Bennie: in petieute with helipiegie (5) end petiente with eevere mental chensee ee e reeuit or brain between theee dieeeee (6) here revealed an order at equinenee or teee~ehoui¢er~ trunkathixh-teot and bend. Ineorar ee theee other body parts were etudied in theee children, e eieiler order tee observed. Since dominance ie evident in young children, it eppeere that the pattern or dominenae in en inherent function or the arsenien. This chidiheed new of reeponding to einniueneaue tactile stimuli in expoeed end exaggerated in edulte ander e variety or pathological oonditione. Recently Cohn bee suggested a theory at reetrli dominance to explein theee obeervetione (8). Our oheervetione are not in accord with each a theory. The dominence of the-toot to the hand in �9. children, an wall I. the douinlnco of penis, buttock, that and thigh to the hand in two large aerial of patients with diffuae bruin artfunction (6, 9) Elk. such an explination untenable. a in lethal Childrun with Findiggu‘;g PM oclparins Eh. tinﬁinsu in ohildron with than. prawiounly roportod in patient. with .QVOTC Inuit: chtngos an. to hrnin dylrunetian (6), a clot. nililnriey in pariah-anon in obturvod; In both group: tn. ability to dilcrilihtti Silaltnntoul Itiluli in lilitod. 0n aon—hanolosous tactilu touch. Inah II the rte-«hand hatt, error: it. 0n and: on initial and suhncnunnt triulu. Hhilo astinntioa or a thinning 1! the unit Iroquant error. diaplhoalnnt 1! cannon. In both childvun and viii-nth, errors occur with a vurioty at cutnnoons Iii-n11. lurthnmnmrv. touting In: tritulntly h. done with 01': open, and in sin: ihntcnooa. with ropaatod Vtrhal ulna: that than. tr. ewe atiluli and still arr!!! Ito undo. 1h. {later or learning 1: not pro-inont niuoo touting on tableau-ht any: will olioit tho previous pattctnod errata. In Gottﬂlt tum-n. patient. with organic anneal dctocta and ohildron have dirtiauity in extracting a ao-piua non-cry ”right!” frun thy ”buneroani” of the total Ionlary "field.” Significantly in each group inure in no difficulty in idantitying. linultanoaua Iii-uli if thy stimuli are applied in syn-attic regions at tho body, Inch it each hind or both 3140. ot-thn than. 3390, each Itilnlun figure ha. a cal-an background in turns of body insgo, unholy, en. "mm." (in), In both groups. that dalinlnco it apparcnt. It in InnlfGIt not only on test. of tuna and hund but Illa on teats or that had othcr body part3. Alto, innotlr II it II! tostod, thn order of dunintnec for othcr body part. in lililnr. while extinction and displaculont are the halt frequent typco �10. or error, othcr annualanu are elicitcd in both children ind patinnta. Partial dinplusoamnta. 0.5. tan uislocalisation of thc pochpt tram tho hand to in. nhaulder or neck on the racowhnnd test, It. cool-ioually obnervod. Th. phcaonnnn or ”allouthnsia" Ina ”axe-anesthesia“ are seen in the more severely affictcd patiatn and an. raunxoat childrvn; bath are franunntly unlooiuted in the same subjeeta. In nllcpthoaia, tat uuhjootu usually localine tbs chock ltinmluu correctly but niuloauliuc the hand Itilulus to thc appetitt hand or clbav. In cxosaunathouia, the ttinnli are ninlocslizod either to Iptcc in front of th: subject er to the uxnnincr'i body. This phcuancnon was frequent in the youngest ohildrcn, Ind despit¢ the nan-ingr'a urging the child pdrnilted in web the cum to point to its on niuloellisationn until I trial of the flag-hand toot nus perfornnd m, with eye: open. nation to than phenomena mm- apantaneaualy, patient: with orgtaio umutul syndruno also naniront Iuother respaano In sauna to simultaneous stimulation rirut noted in children. 1.3., an honolnteral rice-hand testing only on. stimulus (the aback) in spontaneously reported; but yuan tho examintr insists. tbs second it ninlocnlixod ta thn apposite chuck. since the pationtl than IO Ian: niuiltritics in their reapoaacs to young children, it was prodiatod that they would ulna ahcu this phnnannnau. In I series a! patient. with tavern nautal chins... hamolateral taut: or the cheek, nine. (out, thouldor and thigh wart avplicd. ”bun uni: ant nth-alum III reported, the aI-inor Inked for the loan. at the scoond ntinulua. Runyon... varb obtained in 20% of thc patientl, and in each one tn. second utiuulus an: uinlcotlixod to thy ayunetric body part. Purthornarv, in none subjects tbs name phenomenan III observed with single utilnlntion. �11. This phone-soon sppssrs to ho sisilsr to tho cosplstiou phone-soon described iu dostslt litersturs ss 'closurs” sud ”good oontinnstion.” fhsss srs—usoslly describsd for othsr ssnsory Iodslitiss. Uhsn s circle is tschistoscopicslly sxpossd in tho visual risld so thst hslr fslls on s hssisnopic risld. or it s cross is exposed so thst tho contor tolls in tho blind spot, ssny subjects rsport s cosplsts circls or cross. This ”cosplsticn' occurs for “good” figurss. In sisnltsnsous tsctilc studios, syn-stric figurss spoosr to to tho "good“ or ”strong" figurss. W ’ l. shility to idshtiry sud locsliss ssyI-stric simultaneous tsctilc stisuli dsvslops grsduslly during ths first docsds of lits, using prsssnt in 80‘ or nornsl childrsn by tho sac of sight yssrs. Syn-stric stﬂ-uli soc smrs oosdily locslissd and this shility is ssll dsvolopsd in non-s1 three your old children. 2. the own on umtric (hilstsrsl sud ipsilstsrdl) sti-nlstion involvs sithor extinction (only cos of the two stisuli is rsportsd). or displscslsnt (cos or both stimuli srs nislocsliscd). Hhsnsvsr sxtihcticn and displscsssnt occur. stimuli to tho tscs tend to to corrsotly rspostsd. this "fscc dcsdnshcs' is found st sll sgs lsvsls tsstsd. 3. ans can concluds thst sstincticn sud displsoslsnt or tsetils stisnli. ss ssll ss rscs dosinshcs, oonstituts s now-s1 sud consistent pottsrn ct rsspohss in childrsn. In sddition to thsss rssponsss ons osn observe, in childrsn under six yssrs or age, tho phsncsons or sllssthssis, sacsosssthssis sad psrtisl displscsssnt ss nonssl resctions to silultsnsous tsctils sttlnlstion. h. rho difficulties in rscosnitioh ct silnltsasons tsctils stimuli, ss shown by young childrsn, rssppssr in tho sons rsshion �12. in adult patient! with focal or dittuuo dyutuaatian or the bwltn. The abilities or taettlc discrimination acquired by the child aura»; growth are lost by tbs adult who develop: Inntal change. an I rniulﬁ of cerebral Gianna. �13. ﬂlFMGE m, 1;; (a) 1. and mm, 11.: Pattern. in pox-owner! l. rm. tut. or no. and hand. Tram.An.umol.Auoc.l ILL, tn 31-111mm: 250-252, June, 1950. ' W, PINK. I. mm. 11.3.,tutu 8:) alumnae“: or no: and hand. §_6_g_ mm, unutionn. a. (3) ._ 309mb“, 1951. 11.: in perception Pattern: mh.nm1.tn Mutt" and pmlpttation of autumn ntmtien ”chasm-111.Iul'lzomnt.l 2.}. 1-9. July, 195. 11.3.; «11m extinction In: Observttionu on tho scuttle of thc unilaton'liinuction utter body and the phone-anon patent: central gym... $311.43.!mol.Auoc., 15}. June. 1950. 11.11.. mm, 3.3. and mm, 1.: tax-mun ”111111 amore“ mm, of extinction and ant-than. Amhgmﬂﬁﬂnhut. with (D) 3. 355.362, and um 1101.3, 9mm 11.3.: humane-u, or the I. or1.,dnpnocunt rm, I. andormm situation into exam-personal men. human 7111 preparation). 1. 31112130, 5. SHAPED. NJ. and SCEM’PILL, 1.3.: ntinntion I.B., mm, phone-anon 1n 11.111103“. mh.£om1.trnzah1ut.l Q. 7174'”, Decanter, 19kg. $3.1 m two-dune tent is tad m, m, stagnant“ sign or organic until Imam. umlm‘ g; It. I!” a 6. FIRE, 7. J. and mm, ILB. Parceptual ptttomu during maven um, IMIthOIiI. J. gurolquhzcmt.‘ .134. moral rm 316—321, 3951. 136.58, x ' (a) com, R. and RAM, 0.3.: 011Aeon-tun "peat. of the unnory organisation or the has»: but!" study in rental «drum. n «teamed by unilateral umltmomn stimulation. mm.m.nm1. """""""""""""'""'"""" 8. ”.00., It! 10. Mo 19%. or the union crewman at certain “poet: A dwinunoc 111 children. or 11. rantml Itudy the bum brain: (11) ' 169, com, Rd On ”union, 3;, 119-122 (nu-ch) 1951. 31., ”It, I. and mm. 11.3.: 0rd» of ammo. 1n tactile mm, perception. (in prepmtion). the are. tint: J. and mm II.B.: m tutor or ulna-ybe1n911111121106)? ””8, (to or two simultaneous 311th “1.1111. Min, �m; mm or May or the now-83M mt aw Comet Rupmurp. (Touch 1‘93- Nahum ' sex-nu) WAGorgoot manure. efﬂuent: 3 39 t 31» 5 37 ,6 36 7 26 8 22 9 23 10 20 11 21 12 an 13-1529 iggggglgg rump-mm all " 1025 ~-1_-11-.2 ~~1.22»1~ .21321--».‘, --125n~2. 1262~122~ £63-21-a- 28‘sal--26515-1--6821-1-21 3746 -3..n106#21~-2 33 ‘28 28 22 -_ 10 x 3 a 0 2 o �W Foot-Band iblt (Touch Stimuli) '8!IIBIITIUR"“TU!I£ IRIALS .0 00 O Foot n , Ft.~lt. Kind talatoral 53 21 17 1 10 2 2 Ipuilaturnl #8 23 16 3 3 3 0 �" FER CENTOF GROUP ,, I: \. 4’ PER CENT ERROR AFTER k O! 39V 8 N O (,J O 43 O U1 O ERRORS MAKTNG IO 63 O K TRIALS \l O 03 O «0 O OOI �THE MOUNT SINAI HOSPITAL NEW YORK CITY MONTHLX NEUROLOGICAL RESEARCH SEMINAR TUESDAY 27, NOVEMBER BOARD ROOM - 2nd 8:30 P. 1951 M. FLOOR ADMINISTRATION BUILDING EQGMM THE PERCEPTION OF MUETIPLE STIMULI Ia II. DR. MEX FINK AND DR. MARTIN GREENE: TACTILE D.D.S. DR. ROBERT L. KAHN AND DR. EDWIN A PATTERNS WEINSTEIN: OF RESPONSES ON (UNTITIED PAPER) DR. W. S. CHAIRMAN BATTERSBY �} r l x } um um. W“; % ﬂu—é“: 145m’ "I 5’44. 1’31“ _ 4L ‘ 3, ,. I Q ~ ‘ _n ‘ﬂu‘ I... A..— "-4 A4— ‘ﬂ‘ N11,, ’ .‘ “ ��Fluid Spinal Findings Following Cerebral Angiography Joseph M. Stein, M.D. and Max Fink, M.D. WITH increasing use of cerebral angiography, the problem arose as to whether the procedure, of itself, produced changes in the cerebrospinal ﬂuid. Fortyeight hours after angiography a spinal ﬂuid examination in a patient suspected of a brain tumor revealed a cloudy ﬂuid with 3,000 white blood cells per cu. mm. Prior to angiography the ﬂuid had been clear, colorless and without any cells. As no information concerning the relationship of pleocytosis to angiography was available, it was decided to study the changes in the spinal ﬂuid by the usual clinical methods. Spinal ﬂuids from 21 patients were examined prior to and following angiography. Lumbar punctures prior to angiography were done at various intervals, but all punctures following angiography were performed between 12 and 24 hours after the procedure. In each instance the spinal ﬂuid was exam— ined for color, cell count and total protein content. All angiograms were percutaneous, using 35 per cent Diodrast as the contrast medium. Maximal Diodrast volume was 70 ml. at one procedure. While the majority of patients were subjected to unilateral carotid punctures, bilateral punctures were done in four, and combined bilateral carotid and vertebral punctures in one patient. Either intravenous Pentothal (14 cases) or local procaine (seven cases) anesthesia was used. RESULTS Of the 21 subjects, signiﬁcant changes in the spinal ﬂuid following angiography were seen in only two cases. In one, a patient with a cerebral angiomatous malformation and multiple aneurysms, 5,000 red blood cells per cu. mm. were seen in a pink spinal ﬂuid. In the second, a patient with a chromophobe adenoma of the pituitary gland, the protein content of the spinal ﬂuid changed from 89 to 151 mg. per cent; also, seven lymphocytes per cu. mm. were recorded when previously there had been none. In all other subjects, changes in color, protein content and cell count were not signiﬁcant. Three subjects showed transient hemiparesis following anFrom the department of neurology and psychiatry, New York University College of Medi— cine and the neurologic service (third division) and psychiatric division, Bellevue Hos— pital, New York City. Reprinted from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 137 �NE UROLOGY 138 giography, and in none of these were there signiﬁcant changes in the spinal ﬂuid. Since Diodrast can cause changes in membrane permeability,1 and the spinal ﬂuid reﬂects such changes, it could be postulated that a relationship between complications following angiography and changes in the spinal ﬂuid might exist. Such changes were not demonstrated in the present cases. F urther investigations with more exacting techniques for protein determination and protein differentiation are indicated. CONCLUSIONS Neither a marked pleocytosis nor a marked increase in protein content of the spinal ﬂuid are usual concomitants of Diodrast angiography. It may be concluded that when such spinal ﬂuid changes are found they are unrelated to the procedure. REFERENCE 0.: Cerebral angiography: Tolerance for contrast media of diodrast type, 1. OLSSON, J. Neurol, Neurosurg., 1949. 6c Psych, 12:312, �afnuéwlc4’43hm 774449711 Min-1. KM spam: main ﬁndings mnmm mum: mug-play Alon/«4J7? 4.5;}2 zlr" 777': 137-? L/r—s g- If...” no 3"}! ”in. l“ Bax ﬂak $.13. inoronuiag II. or norohrul ungiogrlyhr up i!!! toot aoarruncoa with in. )robluu of uhothcr tho proaodurn.?ut itaolr. pruduaad dhnagoo in the earnbrospianl fluid. rawtyunéght hour: utter ungiegrnphg; a spinal fluid unanianttca int: yqtimut In.unme900%“ o: a and; 27mm with blood tall: pow cubic willltcr. ?tlew to unsiegruphy eh. {lama and without any any. ma how infant“ clan containing tan rolgtleaahlp or pluoaytouta to ungtuguuﬁny in. avgllablo. 1% Ian aoasdod to study ﬂu. dhanﬁog 1h tho spinal Wick m mu m. mum . a.“ am. ”mm. llnid by ﬁbe_unus1 01131931 nnﬁhndu. ‘ Spinal fluids tram tuouty-uno pationta wank $munincd print to and running mum-33mg. 1mm: pun-mm Mar to nag!“— phy tor. don. at various ia$¢rvnln._huk :11 pun-tuﬁcs rolluuinu Ina glogruphy uumo partarnma hoﬁuoonyln anﬂ SQ hear: ﬁitor in» procew tying: {tula can «hunlncd for 00109. 0011 gaunt ‘nd total protein ooatnnt. £11 angiogru-I Inn. pnruutaaonua. uniac;aiﬂ aladraut an Eh. «entrant Inﬁlllm Hand-:1 dioarunt doing. via 70'. a! an. atsa Isaac, “anal. Eh. aujoritx at pgticnta wort auh1oato¢ to unilateral anvctid puuttnruug hilnwurnl gunnturua vat. dam. in fan: putluntn darn. In Ogah {uncanno ch» 3 an! canbinoﬁ bilazqrul suretzd and v.:%.hrn1 in «at. Eiﬁhar intravunoun ponaothal (I! an...) a: local nrmuntun (v 0....) uaaaehnain van 3308. 3 �gggultgt or uh. twentybonp‘nnbjootl, signirionnt «nausea in the ”spinnl fluid thlloving-angiogruphy warn anon in only two out... In «an. a pttiunt with n acrobtul nugiountoua malformation and multiplo unnuryunu, 6000 rod blood «.11: pl? cubic millitor won. in a pinkidh colorod spinal fluid. In the uncond. u pationt with n ohrauophobo adonaln or the pituitary gland, thy pictoll content of tho lbinnl fluid oh‘ngod Iran 89 uilligrml por'uone ta 161 3111151.: par cant. Alto. lava: lynphonyton per aubio mils noon lilihor wort I And racowdod whoa prbviaunly thorn bud boon noun. In ‘11 nth.» nubjootu. chanson in 90102. praz-in aunt-n: call count war. no: significant. Ebro. subjects aurforod trsnn- in.noao wcro thnr. significant august. in tun apinul fluid. In two subjectl. ﬁne apinnl fluid romainod an» ohangod. In thy third. far aronntod :04 blood cell: and twa nymphooytoo per eubio nillilitor turn notod, what. non. had boon inacn prior to thy pron-aura. Binao diodrune can onus. ohungon in membran- perusubilsey (1}. ﬁnd tho spinal fluid reflect. august: in cm. manna... u my be paw-ha than a. rel-Mon menu ounplicntiann ﬁnd such change: axintn. audh changun Into not do- iont haniparonil. and nonntrntod hart. vurchsr inyuatigntioaa vith.noro oxnoting tooha bio: for protein dutorninntion and protein ditrurontiation are in» diontod. W . ploooytonin nor a ngrkad inoronno in protoiu content of an. [pinnl fluid urn uuuul oonoanituntu or aiodrn-t angiogruphy. it'nuy ho aonaluaod Shut ihon Inch apin;l fluid chanQOa urn found. thqy uri unrolatod to an: groundnut. llithnr : lurkod �HO! £3523 ' Angiogmphy: relax-ma. {for 01am. 0.: 00113an 01' Contact M1. Diner“: . o J. Roux-o]... Mum-m... a: hymns. 33:313—816. (am. i949. �x- "e" ' " "-’ - 1' ' I?“ .. J- A" J , ~ ~‘,"~’rnr -m. _.—»,-nn,v~..wni~ ~- 1-... . l“. 9,, .w. Presented at the Fourth Annual Meeting - American Academy Louisville of Neurology - April, 24, 1952 Dr. Costello, Members, and Guests of the Academy: In the course of sensory studies by the method of dou- learned that normal adults readily identify and localize the tow stimuli within the ini- ble simultaneous stimulation, we tial Young ten trials of the test. children, however, seemed could not identify both sti- to make persistent errors. They muli, or if identifying the tWO stimuli} they could not localize them. In order to study the responses and their relation to the age of the subjects, face-hand tests-~the prototype of simultaneous tactile tests—~were applied to 300 normal children ranging in ages from 5 to 15 years. The children were all without manifest disorder of the hervous system, and were from child care centers, hospital clinics and children of neighbors and friends. In the course of some nlay with each child, the examiner introduced the ﬁace-hané test. In this test, the child closes his eyes, and the examiner, with his fingers, simultaneously touches the subject's cheek and dorsum of his contralateral hand. The child is asked to point to the places where he per- the child is asked to close his eyes, and the test repeated-~with opposite cheek and hand stimulated. Subsequently cheek and hand on the same side of the body and simultaneous stimulation of both sides of the face, or both hands are included. At least ten consecutive trials of the face-hand test are recorded for ceived each tje child. stmmuli, and the report is recorded. Again �2. Eighty percent of children under six years of age failed to localize both stimuli correctly during the initial ten trials. The number of errors fell off sharply among the older children, so that only 2% of children in the 11-15 year age groups continued to make errors after the tenth trial.\ This is represented in the first graph--.. Apparently the ability to localize two simultaneously applied tactile stimuli is directly related to the ageof the subject. This same relationship is represented in the second graph. The percent of the subjents in each age group making errors on each trial of the test is compared for representative age groups. Ihe older children manifest an ability to learn from previous trials of the test while the younger chil- dren do not. incorrect responses of all children were of two types--failure to identify one dfithe two stimuli, called "extinction", hr, identifying two stimuli but mislocalizing The 'one of them termed "displacement". Extinction of hand stimuli observed in of the errors, while displacement was in 51%. The preponderance of errors were in the perception of the stimulus to the hand. The stimulus to the cheek was almost was 62% correctly reported. This ability to identify the cheek stimulus in preference to the stimulus to the hand was pre— viously observed in normal adults and termed "face dominance." always face dominance was uniformlylapparent in the children of all age groups in theseries. The errors were apparent in tests involving the cheek and hand on Opposite sides of the body as well as cheek and Such ! i �5. I ’ ‘ I" hand on the same side of the body. WhileverrorSawere frequent in tests of face and hand, chillren made no errors in identi- fying symmetric stimuli, as both cheeks. In the younger children, partial displacement from hand to homolateral shoulderder or neck, or displacements from a hand to the oppo- site hand(allesthesia), or even into snace in front of the child(exosomesthesia) were seen. The incidence of these dis-placements was less than 4%. Since these phenomena were so apparent in younger children and became less frequent with increasing age, it was concluded that extinction and the varieties I of displacement are normal phases in the degqlopment of the response to simultaneous tactile stimuli. In normal adults and older children, such phenomena are apparent during the initial trials only. From these studies it was concluded that the phenomena ’of extinction and displacement are normal phases in the dev elopment of the perception of simultaneous tactile stimuli. Face gew A Ar: 4,»- a. v12.w_ at all age level; and is an inherent pattern of organization of function. Ihe perception of simultaneous tactile stimuli is directly related to chronological dominance is observed age, being gradually develOped in the first decade of life, and being well developed in 80% of children by the age of 8 years. e MW. ._ L. �EBRUPHYSIOLUGY “¢ ,_ 4, .4. lAB'RATOT‘Y HILLSIDE HOSPITAL GLEN OAKS. N. Y. é 0......w...y -,..‘u.- ’. ”luau s..»—..._ Perception of Simultaneous Tactile Stimuli *in Normal Children wrvq Ira ‘ r , A» “WV-'1.......;.,...«-_'.... [Wax Kin/L, M.D. and Morris B. Bender, M.D. r 1w l . V» ~4M-I’an‘,‘ . “and” ...-...a_.~.......~.w:..c- Amman...» .. -_. .w Normal adults readily identify and localize tactile stimuli applied simul1 taneously to the face and the hand (the "fface--l1and test”). While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tLIItlI tIi Il oi the I:.est Young children, however, find the task of identiﬁcation and localization of two skin stimulations difficult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattem in which stimuli to the face are readily appreciated (" most dominant" ) while those to the hand are not (' least dominant” ). lII mdeI to determine the pattern of' dominance” in children and the age which such tactile peiceptual tasks are correctly performed, a study of at normal children was undeitaken. The responses of children to the face- hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD . ca...” .‘ﬁrw' -‘-—<-“-~»—« — ' \, Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his conﬁdence and interest. 'At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of \icdicinc and the Bellevue Hospital, New York City. This work wIs aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in-aid from the Coordinating Council for Cerebral Palsy in New York City, 'Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 ,. ’ 4 I» J �’3 NEUROLOGY 28 ._»--.A:::’mwww Nu... .. P... I. . ,u.‘ w» 'm ....-w)»...._»:,..- .. “1'3““- :7 —y’u«~¢_-'”’(, . A a ""‘f-u-mmﬁr »« ...._,......> .I, . ww‘.MF—b—4w‘ For the face- hand test, the child was told: "I (examiner) am going to touch you, and he was to "touch the same place I touch." He Was asked to close his eyes. The examiner, with the fingers, then touched simultaneously a cheek and the (lorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated After this response. the child was asked to close his eyes again, and now the opposite (both and hand were similarly stimulated and the report recorded. If only one Itsponse was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The fifth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimulation of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both checks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modifications had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. III such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series 'of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal group any subjectswith focal sensory difficulties. The children were asked what they had felt and to point to the places stimulated. Verbal Ieports of the locus of stimulatiOn were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one check. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. _ . . . ~‘~- .mh—wwyﬂn NJ,“ e., .va RESULTS .....-..-~_.- «-~ - ' ’ children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli I ncidcnce‘of errors: Young , 2mm, �PERCEPTION OF TACTILE STIMULI IN CHILDREN 29 iooJ 90‘ 3 < 60 E .. 704 9 6° . '1 3 50a S ‘0 :2 i g a: 0: “‘ , _ . ~....._.. 1“ 90 5 \.\ 70‘ 3 5 ‘- 604 ‘ “\ \‘\ \ 10‘ \“ ‘~.‘ /\ . . 304 ’i H.“ . 3 2° ‘~. 5‘56739Dll12046 ‘ U ”M " “~- J vans -- -- s vans ' ‘04 3 x . so g . -\ . no x3 \s 30‘ ' \-\...-. ‘4‘. nuns ..... ' -~-- 9 , ‘K vans n '5J4ST709210MEG names Y CF TRIAL AGE Graph 1. , m~w-~m \‘x‘ ‘ it 6'20 2f IOO l g D- I: ~—«—-~-..‘..__;__....~_ x Graph 2. during the initial ten trials of the face-hand test; many of these even with eyes open: In the older children the number‘of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the first ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of. either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct‘respouses in nearly all cases. While this served as a clue to some of the older .W....m~. TABLE . a . . t (Touch Stimuli) c . m-‘Wn Age ...._.-.m..;. 3 4 Total Number of Subjects 39 S4 37 36 26 5 6 7 8 9 10 WWM..W~«.».-.A_. 1 NULIBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES 11 12 13—15 ‘22 - 23 20 21 24 29 2 1 3 Trial Correct 4 5 6 8 - — 1 2. 4 -- 1 6 6 3 2., 4 2 5 -2 1 — - -2 1 — — 1 — 1 -3 1 8 2 6 6 8 3 7 4 10 2 . 4 5 2 4 6 -— 5 4 I 6 4 1 1 2 2 2 2 - — l 2 1 1 1 1 — 1 — -1 — 2 2 9 2 ,- - — — 2 - - - 2 l - 2 — 1 — - - — Errors Beyond 10 Trials 34 ' 28 28 22 10 4 3 2 0 2 0 �NEUROLOGY p , it did not seem to alter the hildrcn that two stimuli were being applied, trials of the insults in the younger children. In these subjects subsequent the responses to the lee-hand test were incorrectly reported, even though stimuli was of mmetric stimuli had been correct. The perception symmetric ,iuch better than asymmetric stimuli. of children studied, face-hand Subsequent testing: Of the total group to the initial testing in fusts were repeated at varying intervals subsequent of six, subsequent testing elicited it) children. ()f the children under the age on the initial examhe same. difficulties with facc~hand tests as was evident seemed to have grasped who six years of age, ,nation. In a few children over manifest on were errors in the initial testing. ghc concept of two stimulations learnsuccessful for 3ubsequcnt days. It was as if many trials were necessary completed, successfully task was the ‘iig of the task, and then, even though These observations are in contrast to those made ‘gie learning was temporary. elicit the errors of the {i normal adults, in whom subsequent testing did not tidal ".4 I test.1 (table 1) made by children on Type and pattern of responses: The errors six of types: (a) a touch on the i'peated trials of the faCe-hand test were touch on each cheek, heck only, implying no perception in the hand; (b) a the hand; (0) a touch implying a mislocalization of the stimulus applied to neck or elbow, implying in the cheek, and a second touch on the shoulder, the hand; ((1) a touch on to stimulus applied partial mislocalization of the in the check; (6) a touch on each he hand only, implying no perception cheek stimulus to the hand; and (f) of land implying a mislocalization the examiner’s body, implying a mislocalization away pie-or two touches on the grom the child’s body. all age groups. ’It was Face dominance ( respbnses a, b, c) was apparent in hand the (response a), and host manifest as extinction“ of the stimulus to hand stimulus to of the Mislocalization .'as seen in 62 per cent of the errors. of the errors. While cent 31 observed in per he cheek (displacement)i was and hand cheek in tests involving observed {rest of the displacements were displacements of the were errors 7 in opposite sides of the body, per cent of homolateral stimulation simultaneous the in check the hand to tom the child pointed the times such At hand. ody parts, e. g., right cheek and right 2 to 3 his ﬁngers b the cheek once, saying 5‘a touch here,” and then, moving lentimeters lower on the cheek, saying “and here.” Other types of displacel‘nent were infrequent. There were partial displaceshoulder or neck. Mislocalization of a stimulus ;ients from the hand to the occasionally apparfeross the midline of the body, known as allesthesia,3 was children Furthermore, testing. hand heterologous the on to int in the stimulus p , - “ ,, simultaneous stimulations has been called "extinction” :The failure to report one of 'two of of the second a percept to the homologous body part 3i a stimulus.2 The mislocalization of the direction the in of mislocalization a percept iimulus is called "displacement." The the stimulus which is each " instance, In displacement.” artial is called lacond stimulus iorrectly reported is ‘said. to e "dominant." . i . . , l . �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under ﬁve years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner's body or into space (response f). This phenomenon, known as exosomesthcsia,‘ persisted in some children despite repeated stimulations with the child's eyes open, and despite the examiner's insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?", a number of children hesitatingly pointed to the symmetrical point in the check on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child ﬁrst reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on second locus, pointed a to the opposite foot, shoulder or side of the face. ,Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body were localized correctly. part If the examiner then insisted that there had been a-seeond sti‘mulus,'the 'ch'ild— pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses (1 and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot~hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. - _‘ _ _ . .- _-~qu.-. ‘ 7 TABLE 2 FOOT-HAND TEST _W&-u.~.“.~w (Touch Stimuli) 5......“ Stimulation Total Trials .., -_._... is a- Bilateral Ipsilateral 53 48 Correct 21 23 Foot 17 16 Responses FootHand Foot 1 3 10 3 Partial Hand- 2 3 2 0 Ft.-Ft. Hand ”ma—”Ayug. .. . A .. r M»~..-.._—t_.. I Otlzcr stimuli: A small group of children who made errors in tests at varying intervals were examined with other cutaneous stimuli. repeated Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. \Vhile the number of errors with these stimuli were fewer than with touch stimuli, the i , ,_ ' �w“ o a. ‘NHJa-w ' 32 . NEUROLOGY I still apparent. pattern of face dominance and hand extinction was _ ._ f DISCUSSION __ NM... . ~‘ak ,..,~ .... -V~’W~¢-—/“A... -Mww ,rw ‘r f ,. ‘....-._..u-n-. v“\——»\‘ ‘. < r 3 The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops for many during the first decade of life. It is a relatively unstable ability, Focal discriminations. such changes in the stateiof the organism can disturb lesions,2 cord lobe lesions,2 spinal cerebral disease as in hemiplegia" or parietal and diffuse brain diseases such as toxic States, senility and inflammatory conditions" can so alter tactile discrimination that the phenomena of extinction, and displacement become prominent. Errors in simultaneous tactile tests are of the test—«luring the apparent in normal adults during the initial few trials of doses barbiturates," electroperiod of learning.1 TPersons subjected to large such inability. shock therapy“ or anesthesia" also manifest A prominent feature in all groups is the uniformity of face dominance. When discrimination; of simultaneous stimuli is interfered with, for whatever in the stimuli reason, the errors are made in the stimuli to the hand and not It, too, extinction.” is "hand dominance" _to the face. The corollary of "face Furstudied. of conditions 'is apparent in all subjects and under the variety these two between thermore, in an "order of dominance" other body parts are mental with and severe patients limits. Studies in patients with hemiplegia“ of dominance order revealed have disease“ an of brain result a as changes other these body parts of face—shouldcr-trunk-thigh-foot and hand. Insofar as dominance Since observed. order similar was these children, in a studied were of dominance is an is evident in young children, it appears that the pattern inherent function of the organism. This childlike way of responding to simultaneous tactile'stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. has suggested a theory of rostral dominance to explain these Recently observations." Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with penis, buttock, foot and thigh to the hand in two large series of patients untenable. such make explanation an diffuse brain dysfunction,“ Comparison of ﬁndings in normal children with ﬁndings in patients with organic mental syndrome: On comparing the findings in children with these previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to'discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face-hand test, errors are made on initial and subdissequent trials.‘ While extinction of a stimulus is the most frequent error, with a placement is eommon. In both children and patients, errors» occur be done frequently Furthermore, stimuli. cutaneous testing may variety of with eyes open, and in many instances with repeated verbal clues that there of learning is not promare two stimuli, and still errors are made. The factor the elicit will patterned errors. previous days on subsequent inent since testing mgvﬁ . ; ' ' vb...“ .. ,r» ...- -,4‘-.;.,.va‘ . A. w, .. ~’M"|,.I vauy—as , " ' m-.. .... v -.... *qu...‘ {U thn A ' -....;..W" A... .‘- " " "‘W , A AA i. 1 1» 1 1 1 l i ‘ �PERCEPTION OF TACTILE STIMULI IN CHILDREN ‘ 3‘3 In Gestalt terms, patients with organic mental defects and children have difficulty in extracting a complex sensory "figure” from the "background" of the total sensory "field.” Significantly in each group there is no difficulty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus figure has a common background in tenns of body image. namely the hand.” Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. ' While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjeets. In allesthesia, the subjects ,usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow. In exo~somesthesia,—the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with rganie mental syndrome also manifest another response to simultaneous stim. ulation ﬁrst noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthemiore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure" and “good continuation.” These are usually described for other sensory modalities. \Vhen a circle is taehistoscopically exposed in the visual field so that half falls on a hemianopic field. or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good" figures. In simultaneous tactile studies, symmetric figures appear to be the "good” or "strong" figures. R‘f. , » — “A... .......~-........1 ~ — - AI.- jar-rs: x ., r;'34 �l _‘ Amw— 9 , ..»—-w»4 ‘-‘*V—~.. » ._......-.-... Ms- 34 '1 CONCLUSIONS 1. Ability , NE U ROLOCY , to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the first decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalizcd). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dom-’ inance is found at all age levels tested. 3. One can conclude that extinction and displacement of tactile stimuli, well as as face dominance, constitute a normal and consistent pattern of rein children. ,In addition to these responses one can observe, in chilsponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difﬁculties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients with focal or diiluse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. i . f . .. .-.-~vku-»~‘. .. , _ - - - . REF E1112. ’CES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Tr. Am. Neurol. A. 75: 2'50, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. & l’sychiat. 662355, 1951. BENDER, M. B.: Extinction and precipitation of cutaneous. sensations, Arch. Neurol. 61 Psychiat. 54:1, 1945; Kora, L.: Observations on the somatic sensory extinction phenomenon and‘ the body scheme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A. 75: 1950. BISNDER, M. 13.; WOR'I‘IS, S. 8., and CRAMER, 1.: Organic mental syndrome with phenomena of extinction and allesthesia, Arch. Neurol. 8t Psychiat. 59:27}, 1948. SHAPIRO, M. F.; PINK, M., and BENDER, M. 13.: Exosomesthesia, or the phenomenon of displacement of sensation into extra-personal space, Arch. Neurol. 8t Psychiat. 68:481, 1.. BENDER, -<.»»N.-.~,.--~c¢-v--_.a . _ . .. .,.....-._..a..- . .. . . 1952. ’ M. 8.; SHAmno, M. F., and SCHAPPELL, A. W1: Extinction phenomenon in hemiplegia, Arch. Neurol. 61 Psychiat. 62: . BENDER, t l l e I lbs: - 3w 1?, M . Q33. (TFGJN'zX’UwAaQ , i l l 5...”... . . . . 717, 1949. FINK, M.; GREEN, M., and BENDER, M. 13.: The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, . r 1952. JAFFE, J., and BENDER, M. B.: Perceptual patterns during recovery from general anesthesia, J. Neurol., Neurosurg. a Psychiat. 14:316,1951. COHN, R., and Rum-:5, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation. Tr. Am. Neurol. A. 74:162, 1949. COHN, R.: On certain aspects of the sensory organization of the human brain: II. A study of rostral dominance in children, Neurology 1:119, 1951. GREEN, M., FINK, M., and BENDER, M. 3.: Order of dominance in cutaneous perception. Tr. Am. Neurol. A. In press. JAFFB, 1., and BBNDER, M. 8.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176, 1952. , . l .. .- .-—-.... -~..—....- __.. ‘me—M . Mums—can 7—. . �PERCENT OF GROUP ERRORS MAKING 03 U" mo O _ m u ZCmeD A m OT: m ﬁnch? u m o........v..m.o . _i 2% (be; /C1{»c {ram 62' (2» , — x? "55"” 512/ p i M1144}; ZI“:.Y&A‘4 6A., 1M (.4: V7 “"' c / d4 A [7 5‘" r’,'. :e 7§~<1 593%“ 75/075 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Perception of simultaneous tactile stimuli in normal children. Neurology. 1953 Jan; 3(1): 27-34. And, Spinal Fluid Findings Following Cerebral Angiography. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-8-012 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Bender, Morris B. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 8 items. 1: Reprint from NEUROLOGY, Minneapolis, January, 1953, Vol.3, No.1. Read at the fourth annual meeting of the American Academy of Neurology, Louis-ville, Kentucky, April 24. 2: [preprint] and graph. 3: Monthly Neurological Research Seminar, Nov. 27, 1951, Mount Sinai Hospital, New York City. 4: Report of Activities. 5: 2 items - Spinal Fluid Findings Following Cerebral Angiography; Reprint from NEUROLOGY, Minneapolis, February, 1953, Vol. 3, N0. 2 AND [preprint]. 6: Presentation at the Fourth Annual Meeting - American Academy of Neurology - April 24, 1952, Lousiville; presented to Dr. Costello, members, and guests of the Academy. 7: Xerox of Perception of Simultaneous Tactile Stimuli in Normal Children. 8: graph. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/511f4f0361d13255b6a58a7278a6c995.pdf aa5fa93900e4b745f3e573a0963c15cc PDF Text Text May 17, 2017 A Boy from the Bronx: A Recollection Max Fink, M.D. Arline Alda’s “Just Kids from the Bronx” enticed me to recollect the first 20 years of my life.1 The personal stories of her friends and those of her husband Alan Alda of childhoods spent in Bronx apartment houses and public schools described the rich lives of European immigrants first to the city and their spread to the outer borough of the Bronx with their farms and parks and unimproved acres. Her 19-year old brother Adolph came from New York to shepherd us across the Atlantic on the SS George Washington. We joined my mother’s families the Gottliebs and the Lowenthals in a cluster of apartment houses on Fifth Avenue just north of Central Park. The park, bicycle paths, lake and boat pond were our playgrounds. After my father received the New York State license to practice medicine, my parents travelled along the newly developed Pelham Bay Park elevated train line, along the southeast corridor of the Bronx, stopping at one exit after another, walking the streets near each station, seeking an apartment suitable for a doctor’s office. A five story apartment building at 1201 Elder Avenue just 50 yards from the elevated train station offered a six room ground floor apartment. The corner store was a pharmacy and soda fountain and a luncheonette with newspapers and magazines on the other side. 2 The dual track train stood on steel columns along Westchester Avenue, over trolley car tracks that offered a busy and noisy transportation hub. Multi-story brick houses with honey locust trees filled the avenue. PS 77 elementary school3 was two streets to the North and East on 172 Street and Ward Avenue, with the James Monroe High School just one street to the North. My parents joined the reformed synagogue on �Elder Avenue and 172 Street.4 This enclave became a vibrant Jewish community that sustained my father’s practice. Other practitioners settled in the neighboring streets and the need for hospital facilities led community physicians to establish the two-story Hunts Point Hospital and then a few years later a much larger Bronx Hospital, both offering facilities for practitioners to treat their patients.5 My mother’s brother Max Lowenthal established his office and home on Washington Avenue, a few streets from the Bronx Hospital. His home was on a large lot offering a playground for our family visits. His oldest son Charles was a Scoutmaster and both my brother and I were active Boy Scouts. In time my parents rented an apartment (#3) in the same building as our home. Melvin and Ruth Muroff, lifelong friends lived in Apartment #2. (Apartment #4 was the office of our dentist Dr. Heyman.) In 1928, my father’s mother Dvora Grunwerg migrated and was established in Apartment #5. She occupied the first two rooms leaving the large living room with windows facing the elevated railroad as a play area for my brother Sidney and myself. We adapted to the screeching brakes of train halts and noises of the doors and motors every few minutes, day and night. The living room was our playground, with Lionel electric trains on the floor, chemical experiments, chess and marble games on tables. My grandmother adhered to orthodox Jewish practices and tolerated our noises and arguments. My father’s office windows faced the street. Although Elder Avenue was lightly travelled, my friends and I were admonished to keep the noise levels low. My father parked his car in front of the building entrance, a notice that he was in his office. His open “office hours” �were 12 to 1 and 6 to 8 each day. My brother and I were expected to join him for dinner each day at 5:30. The office telephone was monitored at all times so early in my life I learned to answer the ring with ”Dr. Fink’s office” and record the messages. When my father went to a movie house or a play or opera in the city, he sought an aisle seat after notifying the usher that he was available for calls. I had a mutt dog called Pal. He developed seizures, often vomited, and more often whimpered and cried for long periods. My father had various medications in his office and I soon learned that the pink capsule (secobarbital, Seconal) would quiet Pal nicely. One night, when my parents were at a movie house, Pal was very upset. I fed him two capsules and went back to reading and listening to radio music. Not hearing from Pal, I found him under the dining room table, unconscious and not responding. Panicked, I called my father and blurted that he should come home quickly for an emergency. After a hurried drive through the broad streets of Southern Boulevard, over the trolley tracks, he rushed in and when I showed him the “dead” dog, he listened and examined and opined that the dog would soon recover. My chagrin was an early lesson in the need for examination before ringing a panic button. During the financial depression of the 1930s a barter system was in place. I was often sent to the grocer, butcher and fish shops, pharmacy and laundry, bringing home packages after my mother had called. I rarely needed cash money except to use the train or trolley systems. By 1936 the developing Spanish Civil War and the anti-Jewish restrictions in Germany became daily family concerns as my parents sought to bring Jewish relatives and school classmates to America. To obtain a visa the immigrants needed evidence that they would not �become wards of the government. My parents established bank accounts in the names of each of the relatives with a joint owner, often using me as the citizen.6 PS 77 and the James Monroe High School were well regulated. Boys wore white shirts and dark shorts or knickerbocker pants (knickers) clustered just below the knee; girls wore white midi-blouses and dark skirts. While the halls were noisy between classes, hall “monitors” maintained order. Being a “monitor” was an “honor” and despite my small size, I was an active hall monitor. Desks bound to the floor filled classrooms. I was short and usually sat up front and did not realize until I took eye tests for a driver’s license at age 16 that I was near-sighted. My first pair of glasses were a revelation. I surely was a “nerd” and in the practice of the time I skipped grades four times, graduating from elementary school at age 12. I qualified for the prestigious Manhattan high schools, but my parents refused permission saying that the James Monroe High School was just four streets away and required no travel. The school had four program “tracks” and I was soon established as college bound on the academic track. I studied German to meet the language requirement and became an editor of the monthly Plaudermäulchen (“chatterbox”) and wrote each issue’s crossword puzzle. I was favored by Ms. Sweet, teacher of English literature and head of the Arista, the honorary academic society. Tall and lean, always well dressed, she was an enthusiastic reader of murder mysteries, sharing them with students. When she learned that I wanted to go to medical school, she sent me to the coach of the football team, Mr. Wiedman who offered me a position as a “team manager.” I kept records of the games, team equipment, medical supplies, and monitored travel arrangements for off-site games. At the end of the game season I arranged a team dinner, �once at a New York City retaurant on Times Square. At the school graduation I was awarded an athletic letter M, a note in my college application that may have supported my college admission as a “well rounded student.” I graduated high school in January 1939 at age 16 and enrolled in New York University’s College at its Bronx campus for its Feb-Sep program.7 I lived at home and used the trolley line to come to school. By the second year I established myself as a library assistant in the Gould Memorial Library and a research fellow in the biology programs under Carl Sandstrom and Horace W. Stunkard.8 I soon found niches in the Library and Biology Buildings in which I could leave a cot and some clothes and I often remained on campus for days on end. As an editor of the Heights Daily News, the college’s 4 to 8 page newspaper, I spent a night each week at the printshop in Fort Lee, New Jersey, editing page proofs and setting type for headlines. I wrote stories of campus events and visiting lectures. The aroma of print ink settled in my clothes and led me to work from time to time in the art book multi-color print shop of Martin Jahoda. Martin was émigré relative of my father’s medical school classmate Julius Halpern who fled Vienna with his wife Frieda and daughter Eva on March 12, 1938 (the day that Hitler was welcomed into Vienna). The family lived nearby on Elder Avenue as he studied for the New York State medical licensing examinations. I coached him in English and as a gift he gave me a Leica camera that was compact and easily fit my trouser’s pocket. I used it throughout my medical school career. My parents moved their home to Pelham Manor at 528 Manor Ridge Road before WW II. I did not live at that home. My parents had supported the Elder Avenue Synagogue and they led the organization of the Pelham Jewish Center in their village. It took many years of effort to overcome the community’s restrictive covenants against Jews and blacks, the prevailing Nimby �attitude of Westchester County communities at the time. The Center and Synagogue opened on the Esplanade in 1953. My brother Sidney was born in 1927. He followed the same trajectory in the same public schools that I attended. He graduated Columbia College in 1948 and Columbia’s College of Physicians and Surgeons for his medical degree in 1952. His residency training in medicine at Montefiore Hospital was followed by years of research as a Damon Runyon Fellow. He specialized in gastroenterology and by 1959 he left the Bronx for a career in community practice.9 I recall our Victrola, a large mahogany box that played 10- and 12-inch vinyl records. My parents and then I collected records, mostly symphonic and operatic. My parents had been well versed in opera during their education in Vienna. Radio music dominated our living room as we avidly followed the news, hours of symphonic and operatic music, and the stories of Manchu the Magician, the Lone Ranger and Jack Armstrong, the All-American Boy and other “soap operas” for boys. What else do I recall of my experience in the Bronx? During childhood, cars and trucks were few, much if not most traffic was horse-drawn wagons, leaving manure on the streets. White-clothed Sanitation sweepers kept the streets clean; but we were accustomed to playing ball in littered streets. The Bronx River flowed three streets west of Elder Avenue. “The mud flats” of its banks, the Morrisania Farms with milk cows and chickens just to the north. The Bronx Zoological and Botanical Parks a quarter mile north, well within walking distances, were our playgrounds. We played stickball, practiced skills with marbles (immies, steelies, aggies), tossed and collected Goudey Indian and World War I Air Ace Cards, and built carts using 4-wheel �roller skates. On week-end afternoons we took the train to New York City to visit the Museum of Natural History with its dioramas and Saturday afternoon films like Nanook of the North and the conquest of the North and South Poles by Admiral Peary and Roald Amundsen. I learned to swim at the Castle Hill pools and ride horses at Pelham Bay Park. Speaking of Indian cards, in 1990 my daughter Linda was teaching at Middlebury College. She and Martha went on a shopping trip leaving me to wander US Route 7 alone. A bookshop showcase contained Goudey Indian Cards of 1936 vintage. Nostalgia led me to buy three for $5. For the next decade I bought, bartered, and exchanged cards at ephemera shows until I had a full set of 216 cards in good to excellent condition. These have been a prize collection in my library and are now at the Oregon Museum of Science and Industry in Portland. I received my letter of admission to New York University Medical School on December 6, 1941 the day before the Japanese attack on Pearl Harbor. That summer I began my studies at Bellevue Hospital and was inducted into the Army Specialized Training Program (ASTP) for my medical school years. Because Bellevue faculty made up one of the Hospitals sent overseas, we were taught by a very junior faculty. I participated in many research protocols and was encouraged to undertake procedures as obtaining blood and spinal fluid, set fractures, deliver babies, and do minor surgery. On graduation in June 1945 I started an internship at Morrisania City Hospital in the Bronx. In April 1946 I went on active military duty, was trained in neuropsychiatry at the army School of Military Neuropsychiatry in San Antonio and served 20 months stateside. At age 24, I was suddenly discharged in November 1947 with the end of the war and troop demobilization. Having been in school continuously since childhood I elected to spend the next six months as a ship’s Surgeon on the Grace and American Export Lines. On a Grace Line cruise to South �America I met Bertie and Harry Gross of Great Neck, and met their daughter Martha when we returned at the end of the cruise to Pier 57 in NYC. We began our courtship and Martha and I married in September 11, 1949 after her graduation from Barnard College in June.10 Throughout medical school days I lived at Elder Avenue, often taking the subway to the school. My internship at Morrisania City Hospital from July 1945 to June 1946 and my residencies at Montefiore and Bellevue Hospitals kept me within the borough. On January 2, 1952 I joined the staff of Hillside Hospital on the eastern edge of Queens. I had already established a base at Martha’s parents home in Great Neck in 1949 and thereafter my connection to the Bronx was limited to visits to my father’s Elder Avenue office until his death in 1965 at age 67. My mother Bronia was my father’s assistant when he opened his office. After my brother and I spent our days in school my mother took part in community services, especially during the war years. She organized a storefront child care center on Elder Avenue, nurtured it to become an affiliate of the Federation of Jewish Philanthropies. She developed centers at Clason Point and then at Bronx River Housing. During the war years she was chairwoman of the local rationing board. She was a well known community leader. Bronia’s medical education was interrupted by my birth during her fourth year at the University of Vienna. After the war, when Sidney and I were well along in our schooling she sought to enroll in a New York City medical school to continue her medical education, but was refused admission. With her experience as a community leader, she turned to training in social work, graduating from the Columbia University School of Social Work in 1956. Thereafter she worked at the Lenox Hill Hospital until retired by age at 65 (1967); then at the Brandywine Nursing Home where she worked for an additional 12 years, �My uncle Max Lowenthal had three children. His daughter Irma was very close to my mother and after her children were grown, she too was active in Bronx projects. She married a physician Henry Fleck. She was born in Poland in 1919, emigrated in 1921, and died in 2004 at age 84. Her obituary describes her extensive efforts in enhancing Bronx culture.11 Our families were educated and nurtured in the Bronx. It was a happy environment with little to anticipate the riots and burnings and the white flight of the 1970s.12 During the years of the economic depression, a barter economy and volunteer community efforts encouraged child care and welfare for the poor. It was a nurturing community. 1 Alda, Arline. Just Kids from the Bronx. New York: Henry Holt & Co., 2015. 2 The luncheonette was managed by the Muroffs who were lived next door neighbors. Their son Melvin, 2 years older than I, became a lifelong close friend. A graduate of the Menninger Foundation Institute in Topeka, he later practiced clinical psychology in Scarsdale, New York. He and his wife Blanche were loyal friends and supporters of my research as members of the Board of the International Association for Psychiatric Research. 3 4 Now redesignated Public Schools 195 and 196, at the junction of Ward Avenue and 172 Street. My brother and I obtained our Jewish education and celebrated our Bar Mitzvahs at this center. 5 By 2015 neither hospital, nor the Morrisania City Hospital were still to be found. 6 My parents became citizens in 1928, and I was designated as a citizen at the same time. 7 For students who completed high school admission in February an intensive summer program allowed students to join the sophomore class in September. 8 My research problem was to study the impact of light and darkness on the mitosis diurnal cycle in the ependymal layer of the 48 to 72 hour chick. Others had studied th 24 to 48 and 72 to 96 hour cycles. We found no changes in mitosis rates. 9 After a period of research at Montefiore Sidney began a clinical practice in Paterson, New Jersey with a group headed by Irving Selikoff, an eminent researcher in pulmonary diseases,. He moved to an academi position in Chicago, then at the Veterans Hospital in Providence. He married Eleonor Engelman, a student at Barnard College. They had 3 children Michael (now in Chicago working for more than 25 years as an analyst at United Air Lines); Deena on the faculty in Mathematics and Computer Science at New York University’s Courant Institute; and Bert, a publicist for Rogers & Hammerstein Music studios. While in Providence Ellie died; Sidney joined the US Air Force as medical officer, where he met and married nurse Nesta Hignett, moved to the Veterans Hospital in Hampton VA. After her death he retired to Hampton community. �10 Martha died suddenly on March 31, 2016. Her ashes are under a Japanese Cherry tree on our lawn in Nissequogue. We had been happily married for 67 years. We have 3 children born between 1951 and 1958. Jonathan is Professor and VP for Research at Portland State University; Rachel is Professor of Biology at Mount Holyoke College, and Linda is Professor of Ecology at Sweet Briar College. Jon married Nina DeLange in Phoenix and they have a daughter Laurel and a son Andrew. Laurel graduated Arizona State University and obtained the Master’s degree at the University in Brisbane, Australia. Andrew is completing his sophomore year at University of British Columbia in Vancouver, Canada. Rachel married Tom Dennis, a Professor of Astronomy/Physics and has Rose Dennis who graduated Mt Holyoke College on May 15, 2016 and Hieu Dennis who is completing his 2 nd year at Union College. Linda married the Monarch Butterfly scientist Lincoln Brower who taught her during her career at Amherst College. They do not have children. 11 http://www.nytimes.com/2004/02/26/nyregion/irma-fleck-84-who-battled-decay-in-the-bronx-is-dead.html?_r=0; http://timesmachine.nytimes.com/timesmachine/1971/01/12/83198899.html?pageNumber=26; http://www.nytimes.com/1986/09/17/opinion/l-a-way-for-hay-fever-victims-to-fight-back-763486.html; http://www.nytimes.com/1989/06/07/opinion/l-violence-of-old-men-vs-the-idealism-of-youth-what-tocquevillesaid-279689.html 12 Mahler J. Ladies and Gentlemen, the Bronx Is Burning: 1977, Baseball, Politics, and the Battle for the Soul of a City. NY: Farrar, Straus, Giroux,2006. Appendix 2: The Forgotten Merits of Diagnostic Tests � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biographical Files Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Boy from the Bronx: A Recollection Subject The topic of the resource <a title="Memoir" href="http://id.loc.gov/authorities/subjects/sh85010050" target="_blank">Memoir</a> Description An account of the resource A short, unpublished autobiography written by Dr. Max Fink, M.D. Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Date A point or period of time associated with an event in the lifecycle of the resource 2017-05-17 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Relation A related resource The Max Fink Collection Type The nature or genre of the resource text Identifier An unambiguous reference to the resource within a given context mfp_aboyfromthebronx_20170517_dis Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/023fc3470d6cfddf7614342c86456639.pdf b07bb6498b31f3e58fe2ba4d191c8c0f PDF Text Text l+/26/57 To: Dr. Max Fink From: Dr. H. Goldenberg are contemplating a change in our cholinesterase incubation system which would cause significant differences (5-15% increase) in the reported values for true and pseudocholinesterase. This is the primary reason we haven't fOrwarded your spinal fluid values as well as the more recent serum analyses. We cholinesterase method (like all methods) comprises 2 steps: (1) incubation of enzyme with substrate under fixed Our conditions , and (2) analysis of the reaction products, from which enzyme activity is calculated. The second step employs our new and efficient color procedure. Step 1 is essentially that of earlier workers. On reinvestigating step 1 we find objections to the large amount of salt used by others in their system and may eliminate this ingredient. an apparent As salt is inhibitory, this increase in enzyme would cause concentration. All our past analyses can be corrected for this change by using appropriate factors, but the ultimate decision whether we are to shift our medium will be about 10 days in the making. are naturally anxious to get some idea of the relative changes in spinal fluid values following EST, I will forward figures based on the original salt system on Tuesday. However, as you will start running benzoylcholine as well as the butyryl susbstrate to determine whether there are 2 pseudocholinesterases in spinal fluid. This should resolve our uncertainties on this point and just might possibly lead to new findings. Next Friday we �February u , 1966 Dr. Harvey Robinson WW thimsity of The Baltim, Bur Dr. Institute Maryland Maryland 21201 lbbimm: In mid-October. I submitted the muncript ”0101111132310 Marxism in vaulsiw 'mempy" for ymr mitigation for publication in thc Jam 05 Havana and Mental Dame. I Max MP : jmh Fink. NJ). Promoter of Payduatry �L45 SOL.‘NAL OF /" .Nervour and Mental Diyemc ‘ Harvey A. Robinson} Managing Edi'oy' f Psychiatric Instihne u iv r re “’ofM—u‘ Ia d The \ 82mm”, ,, M0250; OCtOber 19, 1965 "’"-”‘\.:;,_. n—~L"""”"W‘m“‘“'°-—ﬂ _ ..._.. of receipt your acknowledge to This is Mechanisms "Cholinergic entitled manuscript " in Convulsive Therapy. �Max Fink, M. D. Department of Psychiatry Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 �Wm' ~ - .m ﬂ 9 .. w w' ‘5w; Hug-«m- - ‘ nun—v- w-pr. W 4mm‘w-q-w—I-sm . . w wwwmvwmm w “a - . m . , , an(rum October 15, 1965 Dr. Harvey Robinam Psychiatric Institute adversity of Huylmd The Baltimn. Maryland 21901 Dear Dr. Robinson: mm Pbdwﬁm in Convulsiw at. publication in the two copios The Joanne 05 of the manuscript " "010111101310 for your midnmtim for mm and W Dame. style of ﬂu citations follow those of this imtitutim, we will aubdt copies following your stylc if the article mots your approval. While the mead Sincumly yours , MIX HF: jun Pink, M.D. Professor of Psychiatry .wW '- 7k "-7“. m."- �THE N JOURNAL 67/92/011 I OF 6111 d M611 ta l lcwrence DifEdje S. Kubie, Editor-in-Chief Harvey A. Robinson, Managing Editor Eugene B. Brody, Consulting Editor The Psychiatric Institute F 0 U N D E D | N 1 University of Maryland Baltimore, Md. 21201 3 7 4 February 10, 1966 Dr. Max Fink Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: I am very sorry to have to tell you that your manuscript is still under editorial consideration. I do hope to be able to be able to write to you about it very soon. Sincerely our 8, 9V 5 W H. A.‘ Robinson HAR/sa »' �’4 THE JOURNAL OF New/0m and Mei/Ital Diieme lawrence S. Kubie, ZZZ:23:3,”;3.327.315?" The Psychiatric F 0 U N D E D | N 1 8 7 4 Editor-in-Chief Institute University of Maryland Baltimore, Md. 21201 February 1 1, 1966 Dr. Max Fink Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: The Editorial Board has carefully considered your manu" Convulsive in entitled Mechanisms "Cholinergic Therapy. script Subject to your willingness to meet a number of minor criticisms and to make some changes that have been suggested by our readers, we should be very pleased to publish this article. This, then, is in the nature of a provisional acceptance. This consideration of brain cholinergic mechanisms and their significance in convulsive therapy represents an interesting and valuable point of view. Of course, other chemical changes have been demonstrated after seizures and have been assigned equally as important roles as acetylcholine. However, this position is clearly dated, developed forcefully, and the argument is pertinently documented. We feel that the manuscript makes a definite contribution. Nonetheless the Editors are of the opinion that the report embodies some weaknesses which if dealt with would significantly improve the quality of the paper. No one doubts that acetylcholine is important in neural function and that changes in acetylcholine and cholinesterase occur with induced seizures. The assumption that the handling of acetylcholine is fundamentally related to the amount A of hypersynchrony of the EEG is, we feel, an oversimplification. Q) in}. The thesis that the results of treatment by induced convulsions is related to the sensitivity to changes in acetylcholine levels (pp. 18—19).] has no information to substantiate it. Although you describe a "rational biochemical theory" for the mode of action of induced con- �Dr. Max Fink February 11, 1966 2. vulsions, you state only what is already known, that acetylcholine decreases in the tissues and increases in the spinal fluid with induced seizure and that the slow waves can be modified by anticholinergic drugs. Although you cite your own work for the effects ”I of atropine in counteracting the acetylcholine effects of induced seizures, you do not give evidence that the use of atropine changes 1 the therapeutic results in any confirmed study. There is no con— w “7 of evidence in for differences the vincing reactivity or sensitivity (3) central nervous system between psychotics and normals to r" acetylcholine or cholinesterase. ‘ recommend that you consider the following ideas for inclusion in the summary: We There is as yet no consistent evidence for differences in anticholinesterase or acetylcholine senstivity or levels between the psychotic and the normal brain. 1) \/" as yet no reproducible evidence that anticholinesterases given before, during or after electroconvulsive therapy change the results of the treatment. 2) There is 3) Cholinesterase and acetylcholine levels change in response to electroconvulsive treatment and in response to trauma may be a result of other biochemical changes resulting in vasodilation and increased cellular permeability which affect the level of consciousness, EEG, and behavior as well as acetylcholine distribution. At a more superficial level, we should also recommend that the manuscript be carefully scrutinized so as to ensure consistency in drug terminology. We would recommend that the generic names be used throughout the manuscript and that the capitalized trade name be included in parentheses, e. g. , methacholine (Mecholyl). We have indicated a few of these changes on p. 7, p. 9, and p. 10. I regret to note that the references do not follow the style we prefer to use. I am enclosing an information sheet, which may be of some help. Please note that the references should be alphabetized, then numbered, and cited by number in parentheses in the y / �Dr. Max Fink February 11, 1966 3. text. Please note, too, that the references should be typed double-spaced. This enormously facilitates preparing copy for the printer. On the hopeful assumption that you will be of a mind to undertake the recommended changes, I am returning one COpy of the manuscript, and will retain the other for purposes of reference. Please let me know how you feel about all of this. Very sincerely, H. A. Robinson HAR/sa Enclosures �February 16, 1966 mwmmwm Mm Manny mm Dmﬂuvoybmum Psychiatric of mm. Maryland 21201 M 3:321th Myoum andingm W"ﬂwmﬂcmin0mwlsiwnunpyﬂ MWWWmmWW Ivdﬁuﬂacmaffwttompem mum-mm. including meanwmmmmmmnwd. ﬁndtatian following tin style: whidnmmmmud. mmmmmmumamymwimmw mks. 11'. Rabin-cm ’nunkyou formant-aim. Stanlyymm, ﬂux Pink. NJ). Professor of Paydﬁatry fokp �Harsh n, 1986 Hr. Haw-y A. Roux-won, Hanging Editor 1?. Journal a! Havana and Hmtal Dim Psychiatric Institute m Lhimdty of Maryland Baltim'e. Manama new it. Robina: 21201 My" "(2le Wthunofgmdcma,mdmdﬂiedmcitatima toftttlnstyloottmjoumu. than Follovdngymmuwsﬂmn,1hvomdmfmdpmdmsuof in Oanvulsiw hernia: apart Mmemmhth meunincludad,udngayomlmm. Ihawdmdﬂntiﬂewdnhmdmmtimaddoh wanemtmdiatm. Ihopethntthiadmft.michI11hnmmttor,m dthyumappzovnl. M you for your mu. Stanly yams, Fink, NJ). Manor of Psychiatry Max 31‘? �‘5: i THE N JiOURNAL or I 67.120“ 5‘ 3' Men ta ﬂyld lawrence 1 D1336“? Harvey A. Robinson, Managing Editor Eugene B. Brody, Consulting Editor The Psychiatric F O U N D E D | N 1 Editor-in-Chief S. Kubie, Institute University of Maryland Baltimore, Md. 21201 3 7 4 March 9, 1966 Dr. Max Fink Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Doctor Fink: revision of your manuscript, for which many thanks. This now looks perfectly fine in all respects, and we shall be pleased to schedule it for publication. We have the best guess is that this material should get to the printer in five weeks' time or so. Galley proof, then, should come to you some time late in April. My When you receive the galley proof, I hope you will be able to correct it and to return it to me promptly. Very sincerely, H. A. HAR/sa Robinson 02,9 8“! �THE JOURNAL OF NERVOUS AND MENTAL DISEASE Copyright © 1965 by The Williams & Wilkins Co. Vol. 140, No. 2 Printed in U.S.A. Information for Authors Manuscripts and correspondence pertaining thereto should be addressed to the Managing Editor: DR. H. A. ROBINSON, The Psychiatric Institute, University of Maryland, Baltimore, Maryland 21201. Manuscripts should be typed double spaced on one side only of 8% x original and one clearly legible carbon copy should be submitted. 11 paper. The It is helpful if the author supplies a short title for use as a running head. This should be typed on a separate sheet and be the ﬁrst page of manuscript. Type the complete title of the article on a second sheet, and the authors’ names and afﬁliations on a third sheet. Type double-spaced on separate sheets: tabular matter, case histories, quotations, formulas, and other subsidiary matter in the text, footnotes, bibliographies, and legends for illustrations. Legends must not be attached to or written on the illustration copy. Positions for tables and ﬁgures in the text should be indicated in the margin of the text page. Manuscripts should be accompanied by two copies of an abstract of 300 words or less. Illustrations should be drawn in India ink on white paper with clear lettering. Photographs should be glossy prints. The title Of the article, name of author, and number of the ﬁgure should be written with a soft pencil on the back of each illustration, and the top designated. References should be designated in the text by number in parentheses, e.g., (7). The list headed REFERENCES at the end of the paper should be arranged in alphabetical order and numbered. Abbreviations should follow the style of the Index Medicus. Examples: Book reference: 3. Critchley, M. The Parietal Lobes, pp. 171—181. Arnold, London, 1953. Journal reference: E., Mirsky, A. F. and Pribram, K. H. Inﬂuence of amygdalectomy on social behavior in monkeys. J. Comp. Physiol. Psychol., 47: 173—178, 1954. 11. Rosvold, H. Costs of author’s alterations of type or cuts, in excess of $1.00 per page, will be charged to the author. Corrections of printer’s errors are not charged to the author. Also the author will be charged with the cost of engravings in excess of $50.00. One invoice will be sent covering cost of reprints, alterations and engravings. The editorial ofﬁce should be notiﬁed promptly of any change of address. Galley proofs are sent to the author, and should be returned with manuscript to the editorial ofﬁce. A table of cost of reprints with an order slip. is sent with galley proof. �runs-“mm” w'u‘. \ q. WJ~F'WWWWMW'W rerI-Iw-um w-mrwmwwz—mr urn—rm—v- mmrﬂrvmuu (HOMO ASPECTS NIX 0? rim, mm W HJ). "mt—amt“: �....‘.;v- I-‘mm ..r.-- .. ... v t . .. .... -- . 71-17”W‘ m .wn -.-»r.-n---» 1'- ~ 1* ~- the Department of Psychiatry, Washingtm University School and the Dapummt of Psychiatry at the of [ﬂasmri Institute of Paydmiatry, University of Missouri Sdhool of Madicino, SHOO Arsenal St., St. Louis, Missouri 63139. mam Aidad, in by usms grants m—sm, m—2715, menus, and PEI-11380; and thc Psychiatric Ibsen-cm medatim of Missouri. Ix: 65-8 part, 2—25-66 Ravisod for the Iowa 05 Nuvoua and Mental Dame. �GiOLIhEIRGIC ASPECTS OF CONVULSIVE 'DiERAPY While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are rﬁquisite to change in behavior (17, 20, 22). A useful index of murophysioloﬁical changes is the appearance of high voltage electroencephalographic slow wave activity (22, 23). While the biochemistry of this activity is poorly understood, damstretims that it may be inhibited by atropine premedicaticn (3k,66) or blocked by anticholiner-gic coepomds (18, 19) suggest that crolinergic system may play an active part. 'lhe EEG patterns and the response to anticholinergic drugs issimilar-inexperdmntalmdclinicalheadtrmmamdtoa lesser extent, in spontaneous seizures to that seen with convulsive trerepy. 'Ihe activity and changes in concentration of cholinesterases in brain and spinal fluid in head trams, spontaneous seizures and convulsive therapy also slow many similarities . This review discusses these observations to provide the basis for a hypothesis of the role of oholinergic changes in the convulsive therapy process . Acetylcholine has been extensively studied as an agent in the trensmissim of nervous impulses since tion by Dale (12) and Load (38). in a bound form, acetylcholine process . It is A its early identifica— constituent of nervous tissue is liberated during the excitaticm rapidly hydrolyzed through the radiation of acetylcholnesterase and is rapidly reconstituted by the cholineacetylase systemMS) . Free acetylcholine has not been measurable �in normal oerebmspinal ﬂuid despite the rapid bound aoetylcholine during periods But breakdown of of activity and excitementms) . tl'e normal cerebrospinal fluid does have mamble oholimstemse activity, principally of the "tune" of mcholyl hydrolyzing type ChoLéuuch Mpew 05 Wombat Tum. Free acetylcholim was fomd in the oerebrospinal fluid of cats (I41) . within a few minutes after experimtal heed trauma and persisted forvaryingperiodsuptouam. 'Ihequantityoffree eostylomline varied between 2.7 and 9.0 game percent, and the mmt was related to the degree of indmed trams (6). Conctmnt electroencephalogram first denmstrated high voltage fest activity, interpreted as evidence of an intense mutualdismarge,whichwassomsumededbyasmmperiod of flattening of all recorded electrical activity. 'Ihese phases were followed by prolonged periods of high mlitude sharp waves in the delta mquencies. 'Ihe behavioral changes related to the degree of induced of manned free aoetylcholine . With to the aunt higher levels of acetylcholine, Bernstein reported greater degrees of EEG abmvrmlity and greater changes in mciousness. trams and Spontaneous post~trmnnetic seizures were also related to the emunt of free acetylcholim appearing in the oerebrospmal ﬂuid. �em the concentration of ccctylcholim Bomstcin applicd acetyloholinc to cortex. When out oercbrul m l gonna porcentcrlcss,hizhmlitudosharpwavosof1wfmqucn¢m appeared in tho doctmmceptulcgrm. was mm in flattened to 2 gm: When tho concontmtim percent, the cloctromcapmlogmm a fashion parallel to the post-mtic records . Investigatiom in neurological patients by Tower and in the free ccctylcholinc com-Wmtod Wm spinal fluid only in patients with meant head trauma, meant seizures or after olectroconvulsivc thwapy (63). Mal Fun acctylcholim varied from 0.2 to 100 gm pcrctmt. In assaying spinal fluid circumstance activity, they noted a rise in the mpccifio oholimstcmsc fructim (bcnzoyloholinc— splitting) and a drop in tin swcific circumstance {motion (unﬁmdnlim-splitting) in patimts with head tram and sharp following convulsive tmmpy. Artur spontmoms seizures, fluid did not exhibit such inversim contained free acctylcholim. They concluded that however. the ccmbmapiml although it with the varied of free directly acotyloholim m1 and that mammal of the oholinestcmse dome of cerebral functions was a more mitivc indicator of ocmbml damage. the W Bloctmencophalom. talent at varying intervals following also indicated a relation betwum the degree of EEG m. abmmlitymdtmappwmocoffmcmtyldnlincintm combmapinal fluid. �-7- 1......» um"... —— u r. mﬁ" 57—..- .. -- 1"...” y-w.-u~m-v»- vows-r r, wlma-«w- ”a: u . ...v - -. mmased aoetylolnlim in net brain after trumatic also reported by Kovach, activity was inhibited in was to the muscle preparation. 9:5}; m ., n '- e . 71‘ —_.... - "MW“, shock (36). This aoetylcholine by the adninistmtion of atropine eleotrogruphic, behavioral and mmrologic signs of head me trauma were blocked by the parenteral administrvatim of O.5-—1.0 tug/kg atmpins, asweresimilar'clinicaldmgesooomringaftertm inhmisterml additim of anetyloholine (6). observations to the mamnt of closed head Ward applied these injtmies (67) . In 20 patients with varying degrees of trauma, he administered atropine subcutamxsly in doses of 0.1 rug/kg, mting clinical inpmvemnt in scan and a reversal of the electrogrephic effects in others. ‘Ihe some oranges in the post-trumtic electroencephalogrm were mporhsdbyJemmerandDednmrinastmyofdieﬂnazim, another mtidmolinergic drug (33). A single intravenous dose in forty patients resulted in normalizing the abtmal electroencephalogram in twenty—two and marksdnpmvementin six others. of post-Wtic shock and Similarly, in Wm oembraledemainminals, Denisenkorepor'tedablodcingofme clinical changes and trunntin by such (13) . Thu, the mount Aptnat (no. mticholinergio ounpomds as mthylbenaltyzim 05 (up. acetytdwune my thymus 4'1: the mum and the amount as 5w (cumming Wombat “Layman, the dzgue and type abnalmauty, and changu in demomcephatoguphtc W mm“ Md behavtm appm pheuauena, which may be udueed by the «Mugs. 05 «A 05 antéchounugtc _, t , �Bmu'n eeetytchoune and Mahounugic dkugA . The effects of the direct application of acetylcmline to the central nervous systemmyalsobeblookedbymtidmlinergic drugs. The aaninietntion of the clmlineeteme hmibitor diuisopmpyl flmrophoaphate (DFP) elicited high amplitude mpid frequency EEG patterns similar to status epileptiws and ecu post-traumatic states (2!, 31, 32, 68). These EEG effects were blocked by small doses of parenteral atropine and sccpolamine. The great increase in acetylcholim after tetmethyl pyrophosphate ('13P?) was measumd and related to the toxic effects and the induced cmwlsions (29, 59). Wield and Denpsey prepared exposed animal cortex with pmstignﬁne and evoked electroencephalographic spike activity. prior ministration of atropine blocked the appeamoe of spiking, or if present. this electrical activity could be 'Ihe eliminated by atropine (9) . In contrast to these findings, Brenner and Merritt applied topical acetyloholirm in concentrations of exposed cortex of cats , and noted no encephalogmphic chmges The 2—1/3 to 10% to the effect an the electro- after intravemm atropine (1 tug/kg) (7). concentrations of coats/lemme in these experimnts, however, were higher than the topical applicatims (1-H gamma percent) and the intmcietemal (0.240 game percent) injections of Bernstein (6). Brenmr and Merritt also noted electroencePMJogr'aplﬁc effects similar to acetyloholine after meﬁuolnline (rbctwlyl) and car‘bmxyldlolim (Daryl) in concentrations mob lower than the acetylcholine cmcentmticns . They asmibed the increased �effectiveness of these choliner-gic drugs to their lack of sensitivity to cerebral cholinasterases . These data are conﬂicting and to qualify this issue. Cmbnaepémc Fluid View Mar study is necessary Amman of aoetyloholine mtsbolism finds and it Su'wuu. One in nervous tissues in an bustive and bomd form. wring periods of activity, sootyloholixnis libemtedattheoellmmbmwl'nmit is rapidly deactivated by dnlinestemses . The mom“: of bound acetyloholine is the resultant of the oontimnous processes of syntl'nsis, liberation and It has been postulated mm. that the level rises during sleep and falls during waking activity (15, 29, #5, 60). Tobias egg};mported increased free and total sootyldmoline after chloroform and nonbutal (ck) anesthesia in net and frog brinui but no changes after strychnine or piorotoxic oawulsims (60). Richter and levels in transient, however, as the msynthesis rate for aoetyloholim in rat brain is high (7 ganm/gm/minute) (as). mass observations were confirmed by Elliot 51:. 514. (15) and Ckossland and Merrick (ll). Giarm and Pepeu found the increase in acetylolwline following various depressants to be rwghtypr'oportimltomedogmeofdopmsimofthe central mus system mad the redaction in motor Rayner-t and Buck, activity (29). however, studying brain acetylcholine levels �during sedation cone-1m that some sedatives were associated with elevated bmin acetylcholine, but that no rigorous mletimships existed (39). In part, this may be related to the earlier observations of and Elliot that acetyldwline synthesis assured in rat brain slices is accelerated by low dosages of mm narcotic drugs, but irhibited by high dosages (140). Free acetyldaoline was reported in the spinal ﬂuid in patients with epilepsy (10, 63). 0f 56 epileptic patients , m; demxsmtod free acetyldlolinc in qumtiﬁes of 0.02 to 5.0 with an average of 1.0:bgannn percent. Acetyldaoline percent gm levels were related to the fmqmncy of seizms, the extent of electroencephalographic abtmmlity, and to the time since the last seizure, but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliot 9}; 114 also noted fme aoetylcholine in the spiral fluid in mundane up to 3 gm percent after pentylene tetremol (Mammal) convulsions (15) . Mechem vimd the increased acetyloholine as a by—pmchct of the seizure, and not came]. (63). Studying the hypothesis that seizures were imhced by the commution of mtyloholine, ’lbrde measured the level of acetylcholine in hm tissue after pontylenetetmzcl convulsions. She noted a Tower and �rise in the acetylcholina content of the conwlsion. failed . to occur. hash before and a fall during certain levels of aoetyldwline, convulsions suggested that the fall in tissue aoetylcholine Below She during a convulsim was due to the inhibitim of acetylcholine syntresie by increased concenmtions of metabolites such as ammonium ions (61, 62). GiummmdPepeualsomeasmdclmges incenmlnewous system acetylcholine following various after mﬂadmlﬂle stimlatts (29) . Only and 3, 5-dimthylbutylethyl-baxbitm'ete was there a significant changein the acetyldmolim level . They noted a decrease in association with induced convulsions . With other drugs which they classified as ipmniazid + stimnam ipmiazid, (LSD, hydrmcytryptophan, and iprcniazid + DOPA) there in acetylcholine level . they concluded that despite intense excitation produced by these conpomda, them were no changes in acetylcholine hols unless these were observations ('lhe in convulsions. differemes by awarded were no changes betwentheseobservemandOomgtglﬁimdlbmrmdeadmem related to the differences in mthods of biochemical masummnts, for the latter measured chmges mflecting free may be acetylcholine only, while Siam and Pepeu measured the total acetylcholim. including forms of These AW“ bound and m acetylcrmlineluol). suggest that spontaneous an induced mm 4;qu in 5m. acetylehoLéne an abound 5m m bound 50m which my be Reﬂected in the enhance and Auzuau Cmbxal acetylchoune (Laid. activity spud deemed“, teaming tum Levels 06 acexyzehoune, whue deep and anesthesia augment Wicca“ plwduduon taming tame Levels . accompanied by an inc/Lease �t ~ .wr, ~ also Two ,7 w“ in... gym. m.“ cm u , . .......w....w,,.,_ .7... , , .7 , ,...,. “ﬂu..." ......._ , ». __‘ -7, N-... .. n"... -..—.. - .u»...——..r.n Wm m -gNuvom 3mm Chounutwuu. m:- and Wm maid spiral fluid momesternae activity (63, types of dumnstemes 614, 65). whioh hydrolyze acetylcholine are mutually found in the spixml fluid: ctnlimstemse~1 ("trm," "amcific," or mom—hydrolyzing) which has a high specificiw for anatyldnlino; and cholinestemse—II ("pseudo," "mnapccific," or bamyldmolimahydmlyzing) . The diffemt rates of hydmlysis for nothao‘noline and benaoyloholim permits qualitative distimtiom . By reporting tho dwlinestemse activity as a ratio of the activity with mtrudloline and huuoyldmlim substrates empamd to an acetyldxolim substrate dnlimstomseJ/aoatylcholﬁxe and armlimstemse—II/ aoetyldnlim ratios are derived. Normal oembxospinal fluid contains estemses in the ratio of 33:17 for dnlixxestemsa-I to dmlimstemse-II . In patients with head mum. 'lbwer and McEac-Mm reported m inwnion of the oholhnstemses with an shamans in the okxolia‘IIstomean fraction of the spinal fluid and a decrease in dxolimstemao-I activity. 11» extent of the oholimstemse malwasmlttadtoﬂmsewrityofmmmdtothedagzu of the elootmumphalomphio abnormality. In patients with elevated spinal fluid aoetyloholim after ratio of dolineatemoes or total oknlixmstemse activity was fomd. spontaneous seizures, mwever, no chmge in the �Following the recent denmstratims that neurol stinmlation produces changes in brain weight and acetylcholinesterase (37, ), Pryor M9, induced swims in and Otis studied the activity effects of repeated Wistar rats ('43). After as little as u weeks, they observed increases in brain weight and in acetylcholinestemse activity, related to decrements in behavioral performance. in cholinestemse activity may be related to which was Changes changes in cell membrane permeability. Qualinesterese-I is found in highest concentration in the central nervous system while cholinestemse—II predominates in other tissues, especially cerebral acetylcholine, vesclilaticn blood serum. With immersed and increased cellular permeability may be predicted, with a vucﬂai‘}uitrgnswatim varying with the extent and duration degree of of the vasodilation (35). Spiegel, Spiegel-Adolf, and their coworkers demtrated such permeability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassimn and phosphate) in the spinal fluid following electrically induced convulsions (Bu-58) . Such non- electrolytes as nucleic—acid splitting enzymes also increased. Changes in cellular permeability may be the basis for the high concentrations of acetylcholine and increased concentrations of cholinesterase-II after induced seizures or head trauma (65). The persistence of acetylcholine in spinal fluid after trams and after seizures despite increased cholinestemse activity may be related to the sensitivity of the acetylcholine— head cholinesterase-l system to concentration relationships (8, #1, 85) . �.At "physiologic" concentrations , hydrolysis of acetylcholine is rapid (34+ microseconds) but at higher. and lower comentrations, the activity falls off quickly. In contrast, the cholinestemse-II acetylchcline relationship is non-specific and the rate of hydrolysis increases with increased concentratim. ' relationships are related to the induction of seizures. the usual concentrations of ecetylchcline at cell membranes These While are destroyed by the specific activity of clmlimsterese-I in a few microseconds, an excessive concentmtim following excitation may exceed the rate of hydrolysis by dualinesterase-I. is seizmre threshold seizure reached and a seizure induced, with the wt scetylcholine affects vascular itself adding to the increased The of free scetylcholine. and The cellular pemeebility, altering the concentrations of various ions, including dialinestemse-II, in tissues and in the derebrospinel fluid. The activity of dwlinestemse-II, though the low efficiency and depending on cmcentmtion kinetics, remces the acetylcholine in the tissues in hours to days to levels for the physiologic action of chcljnestemse-I. Chawutuase theta ins/wade in appeals. in the spinal (ﬂuid as a uéueaon 06 ﬂuids, mulling (Item chaugu in mm sea numb/tans pumeaway occasioned by teamed aeetylehoune. The teamed ehounutuasu Me paint 06 the homeostatic mechanism canWLung the Leveu 6M. nmuoub system 06 acetyzchaune at can mmbmu necessary datum. �-12.. t-!ypeluync/wny and Induced EC?! Canvuuiom. The significance activity for the convulsive therapy process has been repeatedly stated (22, 23, SO, 51). The early appearance of high degree hypersynchrony and its persisof the deVelopment of high voltage slow wave tence throughout a treatment course has been described as pre- requisite to inpmvennnt. Both the electrograﬁiic and the behavioral clunges of inde cmvulsions were transiently reversed by the acute aministmtion of experimntal anticholimx‘gic alnpomds (18, 19). The intmvernus injection of diethazine, benactyzine, the piperidylbenzilatea and WIN-2299 induced These EEG JB—318, JB-336 and JB-329 BBQ (Ditran), deayncruonizatim in psychiatric subjects. changes were associated with behavioral aka: alerting, anxiety, tremors, illusions , and railucinatims. In patients who had recently received electromnvulsive therapy, them was a reduction in slow wave activity and a reversal of euphoria, dnnial and oonfmion. Atropim in low doses was associated with EEG desynolmnizatim accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchrmws slow anes, followed by lower voltage, poorly organized delta activity with activity fusion and diswientatim. superimposed beta was associated with progressive con- effect of anticholinergic drugs on slow wave activity was also assessed in convulsive therapy by the chronic adminis— tration of atropine (5 mam per day) and scapalomine (1 - 3 mg) The of-WW during the weeks of tmatmmt. The �-13.. mm of group who alwing was significantly less than in a cmtrol had not moiived the amine adminietretim (66). EEG The sasnples were too small for clinictl correlation, but the date is maistent with a definite blocking of the clinical effect. Marked improvement was seen of 5 in 2 of '7 atropine treated, none scapolmnine treated and in four of the six waiving mmdified authors may have Ad who ECT. cmtmls this study we not replicated by the suggest that dosage factors or population changes contributed to the different results (34). in mam Mam, the demoguphic changed induced continuum my be modiﬁed by the 06 muchounugic 06 acctywzounz ad anou’ated 9W1. dlmgd, dugguzéng inc/Lead ed that WWO): anemia inc/Lead ed chaunctgic adaptivity the high wattage Mow wave 05 x16 activity. AcetyMaune and Induced Couvwionc. Despite a constant application of mm , however, there is a greet variability in the time of eppeardnce, the duration and the exxent of the electmgrephic slow ween activity as well as the sensitivity of to modification by alerting, hyperventilation and barbiturates in psychiatric populations(30). The differences in the demo. of induced EEG hypersyncmrcny may related to differences in central duelinergic activity. The failure of certain patients to develop hypersynchmny be may be associated with the absence of free acetylcholine and with minimal clmxges in cerebral function, thus precluding a clinical response to induced convulsions. Tower and HcEachem, �-33.. in their study of omniooerebml tram, included observations of six psychiatric patients undergoing convulsive therapy (63). after 3-? treatments they reported free spinal fluid acetylcholine in two patients; and an increase in clnlinestemseull and a decrease in cholinestemse-I with a reversal of the ratio of oholinestemses in five of the six Studying the patients patients. the one patient in the series who failed to show either free aoetyloholine or a oholinestemoe ratio reversal in the spinal fluid was described as: "It is interesting that this patient was tmtmt.“ From the only one of the six to show no response to these observations they omeluded that the spinal fluid changes in induced convulsions were more like those of cmniooerebml trams than those of spontaneous epilepsy. Other evidence of altemtimas in the pemability barrier seen in the damstmtions of an increased cmoentmtim ofoooaineinbmintissues threedays aftersseriesole induced omvulsions (l). The change in concentration of this large molecule, ordinarily absent in briin tissue, was associated may be with the appearance of hypersynohmny (delta btmsts) in the elect'oenoephslogram. Fm thus obsmvauam we would conducts that induced command, Like mucouebmﬁ Mama and spontaneoua balm/ms, an associated with an inc/Laue in ﬁne. acetyzchoune in am, mey enhancing the. «:2qu as chaunutmuu. The Level. 05 ﬁne Macadam sawing «mm and �a hypUuynchlwny a one mama 06 mend Leveu 05 magichouue maintained by upewted induced Aazwlu. acetytchaune and the. melted mey including chewable/(Mu. 05 The momma», changu in Lym, including acetytchoune (that Aubamue 504 the. pwutent EEG and 04‘.th Aubetancu, mmummm elect/w- H movide the behavioml. changu and EEG hypn- the. Maﬁa Aynchhong ﬁauomlng induced convulsions. An 05 application the medic/tan Medication 06 05 05 «than couoquonA 424 (men in the convuuive zhmpy aupome and the paychoeu (21.). Chounuteluuu and the Medication 05 Peychaeu. Funkenetein g_t_ g}: demnstr‘ated a relationship between the blood pressure response to methocholine, an active cholinergic agent, the and the clinical response to omvuleive therapy (25-27). Inmdiately after the injection of methaoholine, blood pressure falls, usually returning to the baseline within 5-20 minutes. A return within 5 minutes places in the patients in Groups I, II or III; while a return after 20 minutes places the patient in Groups VI and VII. Group I and Group II-III have a 9 and a 35% recovery 89% VI VII and while Group Group respectively, motors rate, and 97% recovery rates to induced convulsions (27). Group I to III reactors may be looked upon as patients in whom methecholine is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the �-16.. While (H8). value of limited but discriminating is classificatim, we have no biochemical explanation of the differences metabolism of nethachcline in these psychiatric in the it M8, is possible that the blood and tissue cholinestemse activity levels of Groups I-III is high, while that of Groups VIJII is to genera psychiatric populations. differences in blood oholinestemse levels in normal and low ccnpared The ill subjects have been extensively titled studied. Despite differences in methods ('4, 5) , elevated cholinesterase levels mntally ccupared to normal populations have been reported for depressive subjects (W, #6, H7, 52), schizOphrenic subjects (1“, 28, 53) and a mixed psychiatric population (#2) . Alpem reported lowered cholinestemse levels in schizophrenic subjects (2). mile these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mntally ill. Negative reports include the failure by Bllman and Callaway (16) to confirm Rubin's study; and Altschule's review of the data suggesting no abnormality of cholinesterase Conclusion. levels in the mentally ill (3). This review stunnerizes sane of the available data suggesting that cholinergic mechanism may be central to the convulsive therapy process. Induced convulsions are associated with vasodilation and increased cellular permeability, followed by the pppeamnce of increased amomts of enzymes and electrolytes in �intercellular and cerebrospinal fluids. Amng the changes are immase in intercellular acetylcholine to levels greater than can be destroyed by aoetylcholinestemse activity, and enhanced amounts of butyrylcholinestemse. The increase in an acetylcholine, vasodilation, and increased cellular permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes are associated with increased electrical hypersynohmny which is recorded as EEG slow wave activity in scalp electrodes, and which can be modified by acute and chronic ediﬁnistmtims of many anticholinergic dmgs, including atropine. benactyzine, diethazine, pmcyclidine and various piperidylbenzilatus. In these regards, induced convulsions are more similar to cerebral trauma. than to spontaneous seizures. in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes , including the concentration of acetyloholine, results in failure to produce The changes behavioral change. Thin! is, as yet , no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic medianisms; the differences in the rate of development of cerebral changes to the same number and frequency of induced convulsions and the classification based on the blood pressure response to mthacholim suggest, however, that such differences may be important in the pathogenesis of different psychoses. ��E' U ‘6 :6 _J! U m 3: = g 0 D. YOUR :3 I) Ta. 41: E O ° 8 : z a £3 'u E as. WITH .- g o 5 .— ‘E 3 e “ n:<3 0? DESK £5 :a: “1’" = 0 0)|.um :3? 1:5a o ‘ﬂ :1: III z....a) co n— .I I) o- '. ”-0 c: :3 0 >~ 3: 5 ” 9 '23: :2 a - c: 1.: U an 3.. 0>§ E "E g0 " L D. a; 0w a0 £5 z13 (g i: (U .—l ._ \— 3 13 U! w e 13 U < .g 23 at- 3 0 o - ac il ,~ 3" :2 '3 E PRESENT ea " ‘- 2'5o AT o 5" a»5 °E n.—O mi 1:8 m “ Ex a Illa REGISTRATION “" ”'7 a: c c q, u:3 32:) «n- m '0 C m >‘ 3: Q h” o: a: 0< c E 5‘: h o55 ON Eucu 0 1 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII|IIIIIIIIIIII|IIIIIIIIIIIIIIIIlllllIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 122nd ANNUAL MEETING AMERICAN PSYCHIATRIC ASSOCIATION ATLANTIC CITY, N. J.—MAY 9-13, 1966 HIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIHIL_ IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII First Name City state Last Name �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY Max Read M.D. at the May Now, Fink, l22nd ﬂeeting of the American Psychiatric Association, 12, 1966, Atlantic City. Proféssor of Psychiatry, 5-9-66. New York Medical College, New York City. �The mode of action of induced convulsions is still puzzling. Various theories have been proposed, including those best described as wholly psychological in scope, and those wholly biological or Neither extreme point of view is consistent organic - structural. with the available facts, and the neurophysiological - adaptive models — combining, as they do, both the biological data and the personality historical facts - are the most satisfactory today. One of the neurophysiological - adaptive theories suggests that persistent alterations in brain fUnction are a necessary condition fOr behavioral change and inprovement in the convulsive therapies. While many measures of altered brain function have been studied, similar relationship of change in measure to behavioral change, the appearance of high voltage slow wave and each has shown a activity in the scalp recorded electroencephalogram.has been the The induced delta activity most useful index in these studies. is readily observed, easily quantified and the amount, distribution over the scalp, amplitude and persistence are each directly related the frequency of the induced seizures and are independent of the mode of induction of the seizure. to the number and While the biochemical basis for these EEG changesgii=3 poorly understood, observations that the induced slow wave activity was inhibited by the intravenous administration of anticholinergic that cholinergic mechanisms may play an active part not only in the EEG activity but in the therapeutic compounds, suggested process as well. �patterns and the response to anticholinergic drugs M. in convulsive therapy were—seen to be similar to the EEG and The EEG behavioral changes in experimental and clinical head trauma and to a lesser extent, in spontaneous seizures. This was clearly reflected in measures of the cholinesterases in brain and spinal fluid in these conditions. These observations led to a review of the neurological and biochemical data in induced convulsions, head trauma and spontaneous seizures, to attempt to relate the available observations to the neurophysiological and therapeutic changes observed in the convulsive therapy process. The activity of acetylcholine in the transmission of nervous impulses has been extensively sutdied since the early descriptions by Dale and Loewi.in 1914 and 1921. A constituent of nervous tissue in a bound ﬁorm, acetylcholine is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by cholineacetylase. Free acetylcholine has not been measurable in normal breakdown of bound the fluid despite cerebrospinal rapid acetylcholine during periods of activity and excitement. But the normal cerebrospinal fluid does have measurable cholinesterase activity. �In_exparimenta&—trauma—ie—eaes, free acetylcholine was found in the cerebrospinal fluid within a few minutes after head trauma lk.(4T$ and persisted for varying periods up to #8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 and the amount was gamma percent directly related to the degree of induced trauma - the greater the induced head trauma, the higher the amount of neasured acetylcholine. Concurrent electroencephalograms first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was soon succeeded by short periods of flattening of all recorded electrical activity. were fbllowed by prolonged and These phases persistent periods of high amplitude sharp waves in the delta frequencies. The degree to which the animal's behavior was disorganized related both to the degree of induced trauma and to the amount of measured free acetylcholine. The higher the observed levels- was of acetylcholine, the greater the degree of EEG abnormality and the greater the changes in consciousness. The development and the persistence of spontaneous post—traumatic seizures were also related to the amount of free acetylcholine measured in the cerebrospinal fluid. In a parallel study, acetylcholine was applied directly to the exposed cat cerebral cortex. acetylcholine was 1 gamma When the concentration of percent or less, high amplitude sharp �waves of low frequency appeared in the electroencephalogram. the concentration was increased to 2 gamma When percent, the electro- encephalogram flattened in a fashion parallel to the post-traumatic a relationship between the EEG changes records, thus again showing and the concentration of free acetylcholine. Investigations in neurological patients by in 1948 demonstrated Tower and McEachern free acetylcholine in the cerebrospinal fluid only in patients with recent head trauma and recent grand-mal seizures, but also after electroconvulsive therapy. Free acetylcholine varied fron10.2 to 100 gamma percent. In parallel studies they measured the spinal fluid cholinesterase a sharp rise in the butyrylcholinesterase (non-specific) fraction and a fall in the acetylcholinesterase activity. They noted (specific) fraction both in the patients with head trauma and in those fbllowing convulsive therapy. After spontaneous seizures, however, the cerebrospinal of cholinesterases although fluid did not exhibit such it an inversion did contain free acetylcholine. They that the level of free acetylcholine varied directly with the degree of cerebral damage and that the reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. concluded Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Continuing a review of head trauma, we note behavioral and neurologic signs of head trauma that the may be EEG, blocked by the parenteral administration of atropine. ward applied these observations to the treatment of closed head injuries. In 20 degrees with of trauma, the subcutaneous varying patients administration of atropine in some and was a reversal of the associated with clinical improvement EEG effects in others. The same changes in the post—traumatic electroencephalogram.were reported by Jenkner and Lechner cholinergic drug. A in a study of diethazine, another anti— single intravenous dose in forty patients resulted in normalizing the abnormal electroencephalogram in twenty-two and marked improvement in six others. That, the amount 06 ghee acetylchouhe may the/LeaAe tn the Aptnat ﬁhee Mia/Cd 5031.0th Wicca/Lewd Mama and the amount acetytchotthe, the deg/Lee and abrzolunaLity, ahd‘changeé type 05 etect/Loeneephaﬂog/Laphéc tn euntcat behautot phenomena, whtch may be ILeduced by the 05 appea/L a4 ammmmon 06 ate/mutated anti- ehotéhejtgtc d/mgb. 3W acetytchoune and antéehouhugtc d/LugA. While the data is not as clear, the effects of the direct application of acetylcholine to the central nervous system by anticholinergic drugs. The may also be blocked administration of cholinesterase inhibitor di-isopropyl fluorophysphate (DFP) elicits high amplitude �patterns similar to status epilepticus and posttraumatic states. These EEG effects have been blocked by small rapid frequency EEG doses of parenteral atropine and scopolamine. Chatfield and Dempsey prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. prior adndnistration of atropine blocked the appearance of spiking, or if present, thes electrical activity could be eliminated by atropine. The Bornstein also reported that the parenteral administration of atropine to modify the behavioral and neurological signs observed after the intracisternal addition of acetylcholine. seemed In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2-1/2 to 10% to the exposed cortex of cats and noted no effect on the electro- after intravenous atropine. not deﬁthtte, the obeehvattone éuggebt that atnoptne encephalographic changes White may bzoch the behautotat and EEG eﬁﬁecté 06 ghee tntaoduced acetytchottne tn the Aptnat glutd. CehebhOAptnat Ftutd Acetytchotthe and Setzuheb. to free acetylcholine and spontaneous seizures ship. One view we of acetylcholine metabolism finds tissues in an inactive and bound fornn Turning again note a relation- it in nervous During periods of activity, �acetylcholine is said to be liberated at cell membranes where it is rapidly hydrolyzed The amount and deactivated by cholinesterases. of bound acetylcholine is thus the resultant of the continuous processes of synthesis, liberation and breakdown. It has been postulated falls during waking that the level rises during sleep and activity. Free ace: Icholine was reported in the spinal fluid in patients with epilepsy. Of 56 epileptic patients, HM denonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with an average of 1.0 gamma percent. Acetylcholine levels were related to the frequency of siezures, the extent of electroencephalographic abnormality, and to the time since the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott at aﬁ. also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma percent after pentylenetetrazol (Metrazol) convulsions. the increased acetylcholine as a by-producifof the seizure and not causal. Studying Tower and MCEachern viewed the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda noted a rise in the acetylcholine content of brain before and a fall during pentylenetetrazol convulsions. certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine Below synthesis by increased concentrations of metabolites such as ammonium ions. �that AponianeOuA on induced Aeizunei incneaie in inieiceiiuian ﬁnee aceiyichoiine Theee etudicb AuggeAi ane accompanied by an iibenaied 5iuid. gnom iii Ceaebnai bound 50am which may be neﬁiecied activity in the Apinai and Aeizuneé enhance aceiyichoiine deeinuciion, iowening iiAAue ieueiA 05 aceiyichoiine, whiie bicep and anebihebia augment aceiyichoiine pnoduciion incneaAing iibéue £evw . EEG Hypenbynchnong and Induced ConuuiAionA. of high voltage EEG slow wave The significance activity for the convulsive therapy process has been repeatedly described, with numerous observers indicating that increased slowing is associated with behavioral In the usual course of convulSive therapy, inter- improvement. treatment electroencephalogram record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and is the dominant activity in all leads. These changes eventually are directly related to the number and rate of induced convulsions, and is not specific ﬁor a method ofinduction. While some relationships to type of electrical current has been observed, all _ seizure inducing methods or inhalant —— —- exhibit the electrical, intravenous same type of EEG chemical pattern changes. �early appearance of high degree hypersynchrony and its persistence throughout a tre-tment course has—bean—éeuné4834xr The «Milan... prerequisite to inprovement. Both the electrographic and the betavioral changes ofincuced conVulsions are transiently reversed by the acute administration of experimental anticholinergic compounds. The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB—318,JB—336 and JB- 329 (Ditran), WIN-2299 These EEG induced EEG desynchronization in psychiatric subjects. changes were associated with behavioral alerting, anxiety, tremors, 'llusions and hallucinations. In patients had recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, who denial and constion. Adztpine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, pooly organized delta activity with superimposed beta activity was accompanied by progressive constion and disorientation. effect of anticholinergic dimugs on the slow wave convulsive of activity therLapy was also assessed by the chronic administration of atropine (5 mgm per day) and scopolamine (1-3 The during the weeks of treatment. The amount of EEG slowing was significantly less than in a control group. The samples were too small fora dinical correlation but the data is consistent mg) �-10with blocking of the clinical effects of electroconvulsive therapy. treated, Marked improvement was none of 5 scopolamine-treated and in controls receiving unnodified replicated ECT. of 2 u atropine- 7 of the 6 This study was not that dosage factors have contributed to the different by the authors who suggest or population changes may results in a second study. A6 reported in tn eeaebaat thauma, the eteetnognaphtc changeb 05 thduced convutttont may be modtﬁted by the adhthtbthatton 06 anttchottnehgte dnugt buggeétthg that tncheabed 05 acetytehottne on amountb tncneated chottnehgte necepttvtty t4 abboctated with the htgh wattage atow wave aettuttg. Convutttonb. Aeetytchottne and INduced Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modification by alerting, hyperventilation and barbiturates activity in psychiatric populations. we would suggest that these differences may relate to differences in central cholinergic activity. The failure of of the electrographic 81 w wave certain patients to develop hypersynchrony may be associated with the failure to liberate excessive amounts of free acetylcholine, and with the minimal changes in cerebral fUnction ��-11a clinical response to induced convulsions is precluded. in their study of patients with head trauma, included observations of six psychiatric patients undergoing Tower and MCEachern after to 7 treatments they reported free spinal fluid acetylcholine in two convulsive therapy. Studying the patients 3 patients; and a reversal of the ratio of cholinesterase ratio reversal in the spinal fluid, the authors stated: "It is interesting that this patient was the only one of the six to show no response to treatment." From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Fnom thete obtenvattont we woutd conctude that induced convutétont, tthe chantocenebnat tnauma and Apontaneout tetzuneé, ate attoctated wtth an tncneate tn ﬁnee acetytchottne tn tnten- cettutun gtutdb, attentng cehebnat penmeabttttg and enhanctng the appeanance 05 chottnettenateb. The tevet t4 matntatned by nepeated tnduced tetzunet. tA one ncétectton 05 attened penmeabtttty attened tevett 05 06 06 ghee EEG acetytchottne hypenégnchhony acetytchottne and the etectnotgtet and othen Aubttanceb; tnctudtng ehottnebtehabet. The changeé tn tntencettutan etectno- tyte4,'tnctudtng acetytchottne, ptoutde the btochemtcat Aubttnate ﬂat the penttbtent behautonat changeA and EEG hypeneynchhony ﬂottawtng induced convutetont. ��-12- CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic central to the convulsive have observed that induced convulsions are mechanisms may be therapy process. We associated with cerebral vasodilation and increased cellular perneability, fbllowed of by the appearance of increased amounts electrolytes in intercellular and cerebrospinal increase in acetylcholine, vasodilation and increased enzymes and fluids. The permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be modified by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl- benzilates. In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetleholine, results in failure to produce behavioral change. �-13There is, as yet, no consistent evidence for differences in the sensitivity or dependence of the cerebral mechanisms underlying interpersonal behavior of populations on Cholinergic mechanisms. Differences in the rate of development of cerebral changes to the sane number and frequency of induced convulsions and of the mentally ill classifications based on the blodo pressure response to methacholine suggest, however, that such differences may exist and may be related to the pathogenesis of different types of psychoses, as well as the success or failure of our present varieties of biologiCal treatments . �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY max Read at the Now, Professor of Psychiatry, Fink, M.D. 122nd meeting of the American may 12, 1966, Atlantic City. 5—9~66. New York Psychiatric Association, Medical College, New York City. �of action of induced convulsions is still puzzling. Various theories have been proposed, including those best described The mode - as wholly psychological in scope, and those wholly biological or Neither organic - structural. extreme point of view is consistent with the available facts, and the neurophysiological models — — adaptive combining, as they do, both the biological data and the personality historical facts - are the most satisfactory today. One of the neurophysiological - adaptive theories suggests that persistent alterations in brain fUnction are a necessary condition fbr behavioral change and improvement in the convulsive therapies. While many measures of altered brain fUnction have been studied, and each has shown a similar relationship of change in measure to behavioral change, the appearance of high voltage slow wave activity in the scalp recorded electroencephalogram has been the useful index in these studies. delta activity is readily observed, easily quantified and the amount, distribution most The induced over the scalp, amplitude and persistence are each directly related to the number and the frequency of the induced seizures and are independent of the mode of induction of the seizure. While the biochemical basis for these EEG changes were poorly understood, observations that the induced slow wave activity was inhibited by the intravenous administration of anticholinergic that cholinergic mechanisms may play an active part not only in the EEG activity but in the therapeutic compounds, suggested process as well. �patterns and the response to anticholinergic drugs in convulsive therapy were seen to be similar to the EEG and The EEG behavioral changes in experimental and clinical head trauma and to a lesser extent, in spontaneous seizures. This was clearly reflected in measures of the cholinesterases in brain and spinal fluid in these conditions. These observations led to a review of the neurological and biochemical data in induced convulsions, head trauma and spontaneous seizures, to attempt to relate the available observations to the neurophysiological and therapeutic changes observed in the convulsive therapy process. The activity of acetylcholine in the transmission of nervous impulses has been extensively sutdied since the early descriptions by Dale and Loewi,in 191” and 1921. A constituent of nervous tissue in a bound form, acetylcholine is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by cholineacetylase. Free acetylcholine has not been measurable in normal breakdown fluid the of bound cerebrospinal despite rapid acetylcholine during periods of activity and excitement. But the normal cerebrospinal fluid does have measurable cholinesterase activity. �In experimental trauma in cats, free acetylcholine was found in the cerebrospinal fluid within a few minutes after head trauma persisted for varying periods up to H8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 gamma percent and and the amount was directly related to the degree of induced trauma the greater the induced head trauma, the higher the amount of measured acetylcholine. Concurrent electroencephalograms first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was soon succeeded by short periods of flattening of all recorded electrical activity. These phases were fbllowed by prolonged and persistent periods of high amplitude sharp waves in the delta frequencies. The degree to Which the animal's behavior was disorganized related both to the degree of induced trauma and to the amount of measured free acetylcholine. The higher the observed levels was of acetylcholine, the greater the degree of EEG abnormality and the greater the changes in consciousness. The development and the persistence of spontaneous post-traumatic seizures were also related to the amount of free acetyldholine measured in the cerebrospinal fluid. In a parallel study, acetylcholine was applied directly to the exposed cat cerebral cortex. acetylcholine was 1 gamma When the concentration of percent or less, high amplitude sharp �waves of low frequency appeared in the electroencephalogram. the concentration was increased to 2 gamma When percent, the electro- encephalogram flattened in a fashion records, thus again showing parallel to the post—traumatic a relationship between the EEG changes and the concentration of free acetylcholine. Investigations in neurological patients by in 19H8 Tower and MeEachern demonstrated free acetylcholine in the cerebrospinal fluid only in patients with recent head trauma and recent grand-mal seizures, but also after electroconvulsive therapy. Free acetylcholine varied from.0.2 to 100 gamma percent. In parallel studies they measured the spinal fluid cholinesterase activity. They noted a sharp (non—specific) fraction and a rise in the butyrylcholinesterase fall in the aeetyldholinesterase (specific) fraction both in the patients with head trauma and in those fellowing convulsive therapy. After spontaneous seizures, however, the cerebrospinal of cholinesterases although fluid did not exhibit such it an inversion did contain free acetylcholine. They that the level of free acetylcholine varied directly with the degree of cerebral damage and that the reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. concluded Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Continuing a review of head trauma, we note that the behavioral and neurologic signs of head trauma may be EEG, blocked by the parenteral administration of atropine. ward applied these observations to the treatment of closed head injuries. In 20 patients with varying degrees of trauma, the subcutaneous administration of atropine was associated with clinical improvement in some and a reversal of the EEG effects in others. The sane changes in the post-traumatic electroencephalogram were reported by Jenkner and Lechner cholinergic drug. in a study of diethazine, another anti— single intravenous dose in fbrty patients resulted in normalizing the abnormal electroencephalogram in A twenty-two and marked improvement in six others. That, the amount 06 ﬁnee acetytchottne may tncneabe tn the Aptnat ﬁtutd ﬁottownng enatnoeenebaat thauma and the amount 06 ghee aeetytchottne, the degnee and type 06 eteetaoencephatogaaphte abnoamattty, and changeA tn cttnteat behavton appeah ab tnteanetated phenomena, which may be deduced by the athntAtnatton 06 anti- ehottnengte dnugb. Baatn acetytchottne and antichottnengtc daugA. While the data is not as clear, the effects of the direct application of acetylcholine to the central nervous system by anticholinergic drugs. The may also be blocked administration of cholinesterase inhibitor di-isopropyl fluorophysphate (DFP) elicits high amplitude �patterns similar to status epilepticus and post— traumatic states. These EEG effects have been blocked by small rapid frequency EEG doses of parenteral atropine and scopolamine. Chatfield and Dempsey prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. prior administration of atropine blocked the appearance of spiking, or if present, thes electrical activity could be The eliminated by atropine. Bornstein also reported that the parenteral administration of atropine seemed to modify the behavioral and neurological signs observed after the intracisternal addition of acetylcholine. In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2-1/2 to 10% to the exposed cortex of cats and noted no effect on the electro— after intravenous atropine. not deﬁtntte, the obbchvat£0n4 tuggebt that ataoptne encephalographic changes White may btoch the behautoaat and EEG eﬁﬁeeté 06 ﬁaee tntaodueed aeetytehottne tn the Aptnat ﬁtutd. CeaebaaAptnat Ftuid Aeetytchottne and Setzuaea. Turning to free acetylcholine and spontaneous seizures we again note a relationship. One view of acetylcholine metabolism finds it in nervous tissues in an inactive and bound fbrnn During periods of activity, �acetylcholine is said to be liberated at cell membranes where it is rapidly hydrolyzed The amount and deactivated by cholinesterases. of bound acetylcholine is thus the resultant of the continuous processes of synthesis, liberation and breakdown. It that the level rises during sleep and falls during waking activity. Free acetylcholine was reported in the spinal fluid in has been postulated patients with epilepsy. epileptic patients, denonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with an average of 1.0 gamma percent. Acetylcholine Of 56 HM levels were related to the frequency of siezures, the extent of electroencephalographic abnormality, and to the time since the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott et al. also noted free acetylcholine in the spinal fluid in concentra— tions up to 3 gamma percent after pentylenetetrazol (Metrazol) convulsions. Tower and MCEachern viewed the increased acetylcholine as a by-produce of the seizure and not causal. Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Tbrda noted a rise in the acetylcholine content of brain befbre and a fall during pentylenetetrazol convulsions. certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine Below during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentrations of metabolites such as anmonium ions. �ane accompanied by an tibenated ﬁiuid. that Apontaneoub an induced Aeizuneé incneaAe in intetceiiuian ﬁnee acetyichoiine Atudiei buggeét TheAe iib gnom Cenebnai in the Apinai bound 60km which may be neﬁiected activity and Aeizunei enhance acetyichoiine duuuctéon, tom/ting tame Lewis and aneatnebia augment acetytchome, white deep acetyichoiine pnoduction incneaeing tiibue 06 ieveii. EEG Hypenaynchnony and Induced Convuiiioni. of high voltage EEG slow wave The significance activity for the convulsive therapy process has been repeatedly described, with numerous observers indicating that increased slowing is associated with behavioral In the usual course of convulsive therapy, improvement. inter- treatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and eventually is the dominant activity in all leads. These changes are directly related to the number and rate of induced convulsions, and is not specific fbr a method ofinduction. While some relation— ships to type of electrical current has been observed, seizure inducing methods or inhalant -— -— electrical, intravenous eXhibit the same type of EEG all chemical pattern changes. �early appearance of high degree hypersynchrony and The its persistence throughout a treatment course has been fbund to be prerequisite to inprovement. Both the electrographic and the behavioral changes of hduced convulsions are transiently reversed by the acute administration of experimental anticholinergic compounds. The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB-318, induced WIN—2299 These EEG EEG JB—336 and JB-329 (Ditran), and desynchronization in psychiatric subjects. changes were associated with behavioral anxiety, tremors, illusions and hallucinations. alerting, In patients who recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, had denial and confusion. Atropine, in low doses, with EEG was also associated desynchronization accompanied by tachycardia, nervous- ness and tension. At higher dosages, hypersynchronous slow waves fbllowed by lower voltage, poorly organized delta activity with superimposed beta activity was accompanied by progressive constion The and disorientation. effect of anticholinergic drugs activity of convulsive therapy administration of atropine (5 was mgm on the slow wave also assessed by the chronic per day) and scopolamine during the weeks of treatment. The amount of EEG (1—3 mg) slowing was significantly less than in a control group. The samples were too small fbr a clinical correlation but the data is consistent �-10with blocking of the clinical effects of electroconvulsive therapy. Marked improvement treated, none of 5 was of 2 scopolamine-treated and in controls receiving unmodified replicated reported in of the 6 This study was not ECT. by the authors who suggest or population changes u atropine- 7 that dosage factors contributed to the different may have results in a second study. A4 tn cehebhat thauma, the eteetnoghaphte changeb 06 tnduced eonkutows may be modiﬁed by the achntnatjwtéon 06 anttchottnehgtc 06 acetytchottne dhugA Auggebttng on tnmeazsed that tncneabed amountA choltnetgtc heceptéw’ty t6 aAAoctated with the htgh voltage Atow wave activity. Acetytchotthe and INduced Convutbtoné. Despite a constant application of treatuents, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modification by alerting, hyperventilation of the electrographic slow and barbiturates activity in psydhiatric populations. we would suggest that these differences may relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the failure to liberate excessive amounts of free wave acetyldholine, and with the minimal changes in cerebral function �-11a clinical response to induced convulsions is precluded. in their study of patients with head trauma, included observations of six psychiatric patients undergoing Tower and MCEachern convulsive therapy. Studying the patients after 3 to 7 treat- ments they reported free spinal fluid acetylcholine in two patients; and a reversal of the ratio of cholinesterase ratio reversal in the spinal fluid, the authors stated: "It is interesting that this patient was the only one of the six to show no response to treatnent." From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Fnom theée obAenvationA convuibionc, we wouid tihe cnaniocenebnai ane aAAociated with an inn/Lease eonctude that induced tnauma and Apontaneoui beizuneb, in ﬁnee acetytchotine in inten- cettuian ﬁtuidb, ditching cenebnat penmeubiiity and enhancing the appeanance 06 choiinebtenabei. The tevet 06 ﬁnee acetyichotine i2: maintained by nepeated induced bunt/(.66. i6 one neﬁiection 06 attened penmeabiiity ditched ieveté 05 06 EEG hypeuynchnony acetyichotine and the eiectnoiytea and othen iabAt‘ance/s, inciuding choiineAtenaAeA. The changeA in intencetiuian etectno- iyteb, inciuding acetyichoiine, pnouide the biochemicat bubbtnate 50h the penAiAtent behavionai changeé and EEG hypenaynchnony ﬁattowing induced canvutbionb. �-12- CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic medhanisms may be central to the convulsive that induced convulsions are associated with cerebral vasodilation and increased cellular therapy process. we have observed perneability, followed of by the appearance of increased amounts electrolytes in intercellular and cerebrospinal increase in acetylcholine, vasodilation and increased enzymes and fluids. The permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be modified by the acute and Chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl— benzilates. In these regards, induced convulsions are more sinilar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetylcholine, results in failure to produce behavioral change. �-13‘5 There is, as yet, no consistent evidence for differences in the sensitivity or dependence of the cerebral mechanisms underlying interpersonal behavior of populations on cholinergic mechanisms. Differences in the rate of development of cerebral Changes to the sane number and frequency of induced convulsions and of the mentally ill based on the classifications blodo pressure response to methacholine suggest, however, that such differences may exist and may be related to the pathogenesis of different types of psychoses, as well as the success or failure of our present varieties of biological treatnents. �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY MAX FINK, M.D. DEPARTMENT OF PSYCHIATRY AT THE MISSOURI INSTITUTE OF PSYCHIATRY UNIVERSITY OF MISSOURI SCHOOL OF MEDICINE 54-00 Arsenal Street St. Louis, Missouri 63139 PSYCHIATRIC RESEARCH FOUNDATION OF MISSOURI Pulilicntion No. 65 - 8 �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY Max Fink, M.D. Psychiatric Research Foundation Publication 65—8 September, 1965 �From the Department of Psychiatry, washington University School of Medicine and the Department of Psychiatry at the Missouri Institute of Psychiatry, university of Missouri School of Medicine, 5400 Arsenal Street, St. Louis, Missouri 63139 Aided, in part, by USPHS grants MEI—927, NIH-2715, MH-o72u9, and MH—ll380; and the Psychiatric Research Foundation of Missouri. VIII: 8/21/65 65-8 �CHOLINERGIC MECHANISMS IN CONVULSIVE THERAPY Despite extensive use, the mode of action of the convulsive therapy process remains enigmatic. The neurophysiologicalradaptive theory attempts an assimalation of neurophysiological, psychological, clinical, social aspects of the process (Fink, 1957, 1962)° In this View, the early development*and persistence of signs of altered cerebral function are and requisite to changes in behavior (Pink and Kahn, 1956), with electroc encephalographic slow wave activity as the most significant index of altered brain function, Demonstrations that premedication with atropine inhibited this slow activity (Ulett and Johnson, 1957) and that-anticholinergic compounds reversed clinical as well as electrographic changes (Fink, 1958) suggests that the biochemical basis fbr wave “the convulsive therapy process may be of the central nervous system. The in the cholinergic mechanisms role of acetylcholine and the cholinesterases in the convulsiVe therapy process is discussed in this review, Acetylcholine has been extensively studied as an active agent in the transmission of nervous impulses since the first descriptions by Dale (191%) and Loewi (1921); It is a constituent of nervous tissue. existing in a processa bound form Which It is rapidly is liberated during the excitation hydrolyzed through the specific action of cholinesterase and is rapidly reconstituted by the choline— acetylase system<Richter andessland. 191:9)w In normal. �cerebrospinal fluid, free aoetylcholine is not present despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (Tower and McEachern, 19u9a)° The cerebrospinal fluid does have measurable cholinesterase activity, principally of the "true" or mecholyl hydrolyzing type (Nachmanson In the absence of free acetylcholine and Rothenberg, 19MB), under’resting conditions, electroencephalograms fail to (a) Cholinergic Aspects of Craniocerebral Trauma: acetylcholine was found after experimental up to H8 show and abnormality. Free in the cerebrospinal fluid within a few minutes head trauma in cats and persisted for varying periods hours (Bornstein, 1946)o varied between 2,7 and 9,0 gamma The quantity of free acetylcholine percent, and the amount was related to the degree of induced trauma, Concurrent electroencephalograms demonstrated records first filled with high voltage fast activity, interpreted as evidence of an intense neuronal discharge,which was soon succeeded by a short period of flattening of all recorded electrical activity, by prolonged periods These phases were then fOIlowed of high amplitude sharp waves in the delta frequencies, The behavioral changes were related both to the degree of trauma and to the amount of measured free acetylcholine, With higher of acetylcholine, Bornstein reported greater degrees of EEG levels abnormality greater changes in consciousness, Spontaneous post-traumatic seizures were also related to the amount of free acetylcholine and �appearing in the spinal fluid. Bornstein applied acetylcholine to exposed cat cerebral cortex, the concentration of acetylcholine When was 1 gamma percent or less, high amplitude sharp waves of low frequency appeared in the electroencephalogramo When the concentration increased to 2 gamma was percent, the electroencephalogram flattened in a fashion parallel to the post-traumatic records° Investigations in neurological patients McEachern (19M9a) demonstrated by Tower and free acetylcholine in the cerebro— spinal fluid only in patients with recent head trauma, recent grand—mal seizures or after electroconvulsive therapy° Free acetylcholine varied from 0,2 to 100 gamma percent, In assaying spinal fluid cholinesterase activity, they noted a sharp rise in the nonSpecific cholinesterase fraction (benzoylcholine—splitting) and a drop in the specific cholinesterase fraction (mecholyl—splitting) in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal fluid did not exhibit such inversion although it contained free acetylcholine. that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of the cholinesterase fractions was a more sensitive indicator of cerebral damage. ElectroThey concluded encephalograms, taken at varying intervals following trauma, also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �These observations were recently confirmed by Kovach, Who recorded increased acetylcholine in rat brain inhibition of this activity and an by gt_§l. (1957) after traumatic shock the administration of atropine to the muscle preparationo ThuA the amount 06 ﬁnee acetytchottne may tncneaAe tn the Aptnat ﬁtutd ﬂattening chantacehebnat tnauma and the amount 06 ﬁnee aeetytchottne, the degnee and type changed tn cttnteat behavton appean (b) 06 a4 eteetnaencephatognaphtc abnonmattty, and tntennetated Anticholinergic drugs and trauma: The phenomena° electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of 095-100 mg/kg atropine (Bornstein, 19u6), as were similar clinical changes occurring after the intracisternal addition of acetylcholine. Ward (1950) applied these observations to the treatment of closed head injurieso In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 001 mg/kg, noting clinical improvement in some and a reversal of the electrographic effects in otherso Similar alterations in the post—traumatic electroencephalogram were reported by Jenkner and Lechner (1955) in a study of diethazine, another anticholinergic drugl A single intravenous dose in forty patients resulted in nornalizing the abnormal electroencephalogram in twenty~two and marked improvement in six otherso �Similar observations have been reported with methylbenactyzine and trasentin in animal experiments of post—traumatic shock cerebral The and edema (Denisenko, 1965), effect of atropine was assessed in the convulsive therapy process by Ulett and Johnson (1957), With the administration of to per day during the weeks the patients received electroshock therapy, the amount of slow wave activity atropine was up 5 mgm significantly less than in a control group received the atropine administration. who had not (These authors failed to replicate this study, suggesting that dosage factors or population changes may have contributed to different results [Johnson et_al., 1960])o Both the electrographic and the behavioral changes of induced convulsions were also reversed by the administration of experimental anticholinergic compounds (Fink, 1958, 1960), The intravenous injection of diethazine, benactyzine, the piperidylbenzilates JB-336 and JB-329 (Ditran), and in psychiatric subjects, These WIN—2299 EEG induced EEG JB—3l8, desynchronization changes were associated with behavioral alerting, anxiety, tremors, illusions, and hallucinations. recently received electroconvulsive therapy, a reduction in slow wave activity and a reversal of euphoria, In patients there was who had denial and confusion, Atropine in low doses, was associated with BEG desynchronization accompanied by tachycardia, nervousness and tension. �At higher dosages, hypersynchronous slow waves, followed by lower voltage, poorly organized delta activity with superimposed beta activity was associated with progressive confusion and disorientation, Both in eenebhat eteethoghaphte changeA 06 thauma and induced convutétOhA, the may be modtﬁted by the adhinttthatton anttchottnehgte dnugb, buggebtthg that tncheabed amountb aeetgtehottne on thcaeabed ehottnehgtc heeepttvtty t5 aMoctated with the high wattage stow wave aetéuttg, 06 Brain acetylcholine and anticholinergic drugs: (c) Similar EEG changes and similar blocking by anticholinergic drugs has been observed following the direct application of acetylcholine to the central nervous system, The administration of a cholinesterase inhibitor DFP (di-isopropyl fluorophosphate) elicited high amplitude patterns similar to status epilepticus, as well as changes similar to those of post—traumatic states (Freedman et_al., 19H93 rapid frequency EEG et_alf, EEG effects Himwich Hampson 1950; These were blocked by small doses of scopolamineo The 3:.Els’ 1950; and Wescoe et_al,, 1948). parenteral atropine and great increase in acetylcholine after tetraethyl pyrophosphate (TEPP) was measured and related to the toxic and convulsions induced (Giarman and Pepeu, 1952; Stone, 1957). Chatfield and Dempsey (1942) prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. The prior administration of atropine blocked this spiking, or the abnormality could be eliminated by atropine. if present, �In contrast to these findings, Brenner and Merritt (19u2) applied topical acetylcholine in concentrations of 2-1/2 to to the exposed cortex of cats, and noted no effect 10% on the electroencephalographic changes after intravenous atropine (l mg/kg)o The concentrations of acetylcholine in these experiments, however, were higher than the topical applications percent) and the intracisternal (002—10 gamma (l—M gamma percent) injections of Bornstein (19%)° Brenner and Merritt also made note of electroencephalographic effects similar to acetylcholine from mecholyl Cacetylbetamethylcholine) and doryl (carbamylcholine) in concentrations They much lower than the acetylcholine concentrations. ascribed the increased effectiveness of these cholinergic their lack of sensitivity to cerebral cholinesterases. These data are conflicting and further study is necessary to qualify this issue° drugs to (d) View Cerebrospinal Fluid Acetylcholine and Seizures: of acetylcholine metabolism indicates that nervous tissues in an inactive bound fornn it is One found in During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterasea The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation and breakdown. that the level rises during sleep (Tobias gt_al., 19u6; Richter and It has been postulated falls during activity. Crossland, 19u9; Elliot, Swankt and and Henderson, 1950; Giarman and Pepeu, 1962). Tobias et_al. found �8 increased free and total acetylcholine after chloroform and nembutal anesthesia in rat and frog brain, but no significant changes after strychnine or picrotoxin convulsions. Richter and Crossland measured the level of acetylcholine (micro-gamma per anesthesia and sleep in rat brain to be seizure levels, The brain tissue) during higher than postdifference in tissue levels is transient, however, as the resynthesis high (7 gamma/gm/minute)o Elliot et_§1f mg, 300% rate for acetylcholine in rat brain is These observations were confirmed by (1950) and Crossland and Merrick (195M). Pepeu (1962) found the increase Giarman and in acetylcholine following various depressants to be roughly proportional to the degree of depression of the central nervous system and the reduction in motor activity. Maynert and Buck (196”), however, studying brain acetylcholine and sedation concluded that some levels sedating agents are associated with elevated brain acetylcholine, but that no rigorous relationships existed. In part, this may be related to the earlier observations of Melennan and Elliot (1951) that acetylcholine synthesis measured in rat brain slices is accelerated by low dosages of narcotic drugs, but inhibited by high dosageso Free acetylcholine was reported in the spinal patients with epilepsy (Cone, fluid in Tower and McEachern, 19MB; Tower epileptic patinets, nu demonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma percent with and McEachern, 19u9b), an average of 1,0 gamma Of 56 percent. Acetylcholine levels were related �to the frequency of seizures, the extent of electroencephalographic abnormality, and to the time since the last seizure, but bore no relation to medication, type of epilepsy or level of cholinesterase activityo Elliot §t_al3 (1950) also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma percent after metrazole convulsions, Tower and McEachern (19u9b) viewed the increased acetylcholine as a by—produce of the seizure, and not causal, Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda (1953) measured the level of acetylcholine in brain tissue after metrazole convulsions, She noted a rise in the acetylcholine content of brain befbre a seizure and a fall during the convulsion° Below certain levels of acetylcholine, convulsions failed to occur° that the fall in tissue acetylcholine to inhibition of acetylcholine synthesis She suggested during a convulsion was due by increased concentrations of metabolites such as ammonium ions. Giarnen and Pepeu also measured changes in central nervous system acetylcholine following various stimulants. Only after mecholyl and 3, 5-dimethylbutylethyl-barbiturate was there a significant change in theacetylcholinelevel° They noted a decrease in association with induced convulsions. With other drugs which they iproniazid + classified as stimulants iproniazid, hydroxytryptoghan, and iproniazid + DOPA) there were no changes in acetylcholine level. (LSD, They concluded that �10 despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied differences in observations between these by convulsions, (The workers and Cone gt ale and Tower and McEachern may be related to the differences in methods of biodhemical measurements, for the latter measured changes reflecting free acetylcholine only, while total acetylcholine reflecting bound and free forms of acetylcholine, [McLennan and Elliot, 1951]). TheAe AiudieA Auggebi that Aponianeoui an induced beizuheb ane accompanied by an incheaAe in inienceiiuian ﬁnee aceiyichoiine iibenaied ﬁnom ii» bound 60am which may be neglected in the Apinai ﬁiuido Cehebnai aciiviiy and Aeizuneb enhance aceiyichoiine Giarman and Pepeu measured the debtnuction, iowehing iiAAue ieveii 06 acetyichoiine, whiie Aieep and aneéiheéia may augment aceiyichoiine pnoduciion incneaiing iiiéue ieueiie (e) Central Nervous System Cholinesterases: Tower and McEachern also measured spinal fluid cholinesterase activity. TWO types of cholinesterases are normally found in the spinal fluid: (19H9) cholinesterase—I ("true," "specific," 0r mecholyl-hydrolyzing), which has a high specificity for acetylcholine; and cholinesterase-II ("pseudo," "non—specific," or benzoyldholine—hydrolyzing)o compounds hydrolyze Both acetylcholine but have different rates of hydrolysis for mecholyl and benzoylcholine. This differential rate perndts qualitative distinctions. By reporting the cholinesterase �11 activity as a ratio of the activity with a mecholyl substrate and with a benzoylcholine substrate compared to a substrate of acetylcholine, two ratios are found: cholinesterase—I/acetylcholine and cholinesterase-IIlacetylcholineo In sudh ratios normal cerebrospinal fluid contains esterases in the ratio of 33:17 for cholinesterase-I to eholinesterase—IIo with In patients head trauma, Tower and McEachern reported an inversion of the cholinesterases with a increase in the cholinesterase-II fraction of the spinal fluid and a decrease in cholinesterase-I activity. The extent of the cholinesterase reversal was related to the severity of trauma and to the degree of the electroencephalographic abnormality. In patients with elevated spinal fluid acetylcholine spontaneous seizures, however, no change in the cholinesterases or total cholinesterase activity in cholinesterase activity after ratio of was found. related to changes in cell membrane perneability. Cholinesterase-I is found in highest concentration in the central nervous system while cholinesterase-II predominates in other tissues, especially The change may be blood serumo With an increase in acetylcholine levels in cerebral intercellular fluids, vasodilation cellular permeability may be predicted, with a degree of transudation of vascular fluids into the intercellular spaces varying with the extent and duration and increased of the vasodilation (Kabat et_alo, 19u8). Spiegel, Spiegel—Adolf, �12 and their co-workers (19u1, 19u2, lguu, 19H8, 1953) demonstrated such perneability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal fluid following convulsions° electrically induced Such non—electrolytes as nucleic—acid also increased, Changes in cellular perneability Splitting enzynes may thus provide the basis for the high concentrations of acetylcholine and the increased concentrations of cholinesterase-II in induced seizures or head trauma (Tower and MCEachern, 19H9c)o The persistance of acetylcholine in spinal fluid after head trauma and after seizures despite increased Cholinesterase activity may be related to the sensitivity of the acetylcholinecholinesterase-I system to concentration relationships (Nachmanson and Rothenberg, lQHS; Tower and McEachern, 19u90; Burgen and MacIntosh, 1955)o At "physiologic" is rapid concentrations, hydrolysis of acetylcholine (3-H microseconds) but the activity falls off quicklyc at higher and lower concentrations, In contrast, the cholinesterase—II acetylcholine relationship is non-specific and the rate of hydrolysis increases with increased concentration; These relationships are related to the induction of seizures. at cell membranes are destroyed by the specific activity of cholinesterase-I in a few microseconds, an excessive concentration following excitation While the usual concentrations of acetylcholine may exceed the rate of hydrolysis by cholinesterase-I. The seizure �13 threshold is reached and a seizure induced, with the seizure itself adding to the amount of free acetylcholine. The increased acetylcholine diffuses rapidly, affecting vascular and cellular perneability and increasing the concentrations of various ions, including cholinesterase—II, in tissues and in the cerebrospinal fluid, The activity of cholinesterase-II, though of low efficiency and depending on concentration the acetylcholine in the tissues in hours to days kinetics, reduces to levels fbr the physiologic action of cholinesterase—I. Chounutemu appeal: in the meme Maid Iheih anheaee in Lhzeheeﬂluiah ﬁﬁuidb, hebuﬁting in cell memblume The Una/Leaded a4 a heﬁKeetéon 05 ghom changee pumeabLU/ty oeeaAioned by incheaeed aeetyZehoLéne. emanate/wees connotahg the [evea 50h rte/wow byAtem 05 ahe pant 06 the homeozstauc mechahbsm acetyzehouhe at eeu membhahu heme/54mg activity, (f) Acetylcholine, EEG Hypersynchrony and Induced Convulsions: Alteration in the blood-brain perneability barrier by the continuing action of acetylcholine may be a biochemical substrate for the postelectroshock hypersyndhrony of the electroencephalogram, Such a possi- bility is evident in the demonstration of an increase in the concen- tration of cocaine in brain tissues threeidays after a series of 12 induced convulsions (Aird et_§lo, 1956)o The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony(delta bursts) in the electroencephalogram° �11+ We have confirmed the many previous reports that convulsive thrapy induces electrographic hypersynchrony (Pink and Kahn, 1956; Fink 1951)° Despite a constant application of treatments there is §t_al., a great variability in the time of appearance, the duration and the extent of the electrographic slow wave activity as well as the sensitivity to modification by alerting, hyperventilation and barbiturates in psychiatric populations (Green, 1957). degree hypersynchrony and has been described as (Roth, 1951; Roth its persistence prerequisite to stain, in the degree of induced The early appearance of high throughout a treatment course improvement following electroshock 1957; Pink and Kahn, 1956)o EEG The differences hypersynchrony may be related to differences in central cholinergic activity, The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, thus precluding a clinical response to induced convulsions° Tower and McEachern (19H9a), in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy. Studying the patients after 3—7 treatments they reported free Spinal fluid acetylcholine in two patients; and an increase in cholinesterase—II and a decrease in cholinesterase-I with a reversal of the ratio of cholinesterases in five of the six patients, The one patient in the series Who failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal fluid was described as: "It is interesting that this patient was the only one of the six to show no response to treatment." �15 From these observations they concluded that the spinal fluid changes in induced convulsions were more like those of creniocerebral trauma than those of spontaneous epilepsy° If electrographic hypersynchrony free acetylcholine, subjects whom it disappears rapidly who may be is a reflection of increased maintain hypersynchrony and those in exhibiting differences in the kinetics of the cholinesterase~acetylcholine hydrolysis systems. Persistent hypersynchrony may result from.a decreased rate of hydrolysis of acetylcholine, associated with low concentrations of either cholinesterase—I or cholinesterase—II. (Conversely, in patients with short—lived hypersynchrony, cholinesterase—I and in tissue and spinal fluid may be unusually higho) Fnom —II these obaehvationi uh uuuid conciude that induced convuiiionb ahe accociated with an incheaie in ghee acetyichotine in intehceiiuian ﬁiuidt, aitehing cehebhai pehmeabiiity enhancing the appeahance 05 choiinettehatei. The ieuei and 06 ﬁnee it maintained by nepeated induced beizuneb. EEG hypencynchhony it one heﬁiection 06 aiteaed ieveii 06 acetyichoiine acetyichoiine and attehed penmeabiiity 06 otheh eiectnoiyteb° that theAe changec It i4 phobabie in intenceiiuiah eiectnoigteb phovide the biochemicai Aubcthate ﬂan the penAiAtent behavionai changei ﬁoiiowing induced convuitionia �16 t.‘ Cg) wfi 0. as. oses= studies have application to the problem of autonomic reactivity and the classification of the psychoseso Funkenstein These between 1952) have demonstrated 1951, a relationship E£;,(19”89 g: the blood pressure response to injected methacholine (Mecholyl) and the clinical response of psychiatric patients to convulsive therapy. is a potent cholinergic agent which induces vasodilation, tachycardia9 sweating, and increased peristalsiso It is rapidly Methacholine hydrolyzed by cholinesterasedI and slowly by cholinesterase-IIo falls after injected blood pressure of subjects to the baseline within five to 20 minuteso returns to the baseline within 5 II, or III reactors; and Group have a VI and Group VII (Funkenstein EE.E£;9 1952)o upon as patients in while Groups VI Patients whom 9 and a reactors Group VI 89% 20 or and VII reactorso 35% pressure Group I, more Group I recovery rate, respectively, and 97% recovery rates I to III reactors mecholyl the injected may be looked is rapidly hydrolyzed; and VII have a slow hydrolysis rateo It is possible that the cholinesterase activity levels of Groups I-III is review, see Rose9 19620] whose blood classified as those whose blood pressure takes IIuIII reactors while Group mecholyl and returns minutes have been minutes to return to baseline, as Group The [For a recent blood and tissue high, while that of Groups VI-VII is low compared to general psychiatric populations° The mentally differences in blood cholinesterase levels in normal and ill subjects have been extensively studiedo Despite differences �17 in methods (Augustinsson, 1955, 1957) elevated cholinesterase levels compared to normal populations have been reported for depressive subjects (Richter and Lee, 1942; Rowntree e£_al;, 1950; Ravin and Altshule9 1952)? schizophrenic subjects (Early 33 Gal9 1963) and a mixed iii, psychiatric population (Plum, 1999; Rubin, 1958; 1960)o Alpern (1956) reported lowered cholinesterase levels in schizophrenic subjectso studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater While these and frequently elevated in the mentally illo Negative reports include the failure by Ellman and Callaway (1961) to confirm Rubin's study; and Altschule“s (1953) review of the data suggesting no abnormality of cholinesterase levels in the mentally illo A similar analysis may be made regarding the relation of central nervous system levels of cholinesterase in the development of EEG hyper- fluid levels of acetylcholine, thus providing a congruent hypothesis regarding central nervous system reactivity to induced convulsions and to peripheral cholinergic agents° synchrony and spinal �Dig- CONCLUSION: This review indicates that central cholinergic mechanisms are significant in the convulsive therapy processo Induced convulsions are associated with an increase in intercellular acetylcholine to levels greater than can be destroyed by acetylcholinesterase activityo Vasodilation and increased cellular permeability are followed by the appearance of increased amounts of butyrylcholinesterase and other enzymes and electrolytes in intercellular fluidso These biochemical changes are associated with increased hypersynchrony which is recorded as EEG electrodess and which can be modified by slow wave many electrical activity in scalp anticholinergic drugs, including atropine9 benactyzine, diethazine, procyclidine and piperidylbenzilateso In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures° in cerebral biochemistry alter cellular recovery and firing rates sufficiently to alter the behavior of subjectso Failure to induce high and persistent concentrations of acetylcholine These changes or failure to induce concomitant electrolyte changes.does not alter cerebral cellular activities and results in a failure to produce behavioral changeo Differences in the rate of development of cerebral changes to the same number and frequency of induced convulsions may reflect differences in the dependence of subjects on cholinergic mechanisms or �:19- in.their sensitivity to changes in acetylcholine levelso These differences provide the basis for the classifications of the mentally ill based on neurophysiological responsitivity by Funkenstein and by Pink and Kahno These data on cholinergic mechanisms provide a theory for the mode rational biochemical of action of induced convulsions in altering the behavior of psychotic subjects9 and are consistent with the more general neurophysiologicmadaptive theory of the convulsive therapy process expressed earliero �REFERENCES J W9, Hrenoff, M9 K9 and BowditchLS. 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V] Phwunacoh Exp9 Them, 1911+, 1195/ Denisenko, P P9 Pharmacological blocking of central cholinoreactive systems and the possibilities of its therapeutic applicatiom In G B , Koelle, w W. Douglas and A9 Carlssogffzheereﬁ Phamnacoﬂogy 06 ChoLLneJLgnc V” and Adaeneagxec Mammmwn. Vol 3 o Glen» J J , J _6_: 9 pj’ 9 Paoceed/cngb 05 W Rascovaﬁenm I‘M" ' and Investigations the Second Inxunaﬁonaz’ Pha/unacoﬁogicaf. Meetcngjgjgb New York, 1965/ Macmillan)9% D9 F9 ,Hemphill, Early, 9 R9 E9 ,Reiss, M9 Brummel, E9 2499199 into cholinesterase levels in serum and cerebrospinal fluid of psychotic patients (Biochem. ”Li/V“) / .7 ,Fl—E9, M5: 556 -552- DJ a” , I 9. �Elliott, K ‘A Co, Swank, Ro L and convulsants on acetylcholine content of {@93sz brain JiwﬂhgéLQ£»¢T//’”//JK (AMeagl 1469—44781 _....—_,—.— A . 1 Ellman, G be and Cal.laway,E E1 throcyte cholinesterase—levels in mental patie.nts Natuhe (Land )@961.J192: l2l§)j w'v-xﬂ 8. rI/J>-~/ Effects of anesthetics and Henderson,_Ng -/7 unifiedtheory of the ac.tion of physiodynamic therapies° HstLde 6: 197 (J 206 H08p)(i1967 (116., “37" “m1 F1nk, Mo Effect of anticholinergic agent, diethazine, on EEG and behavior: significance for theory of convulsive therapy (AﬁkM (Neon/L01: PbyWaL—WH‘J’IQFM3803875J F1nk M A W F1nk,M Effect of anticholinergic compounds on post onvulsive electro: encephalogram and behavior of psydhiatric patients Lectaoenceph CLLn.-~~ NeuhuphyéLOL Jl§66;JlEW(2); 359— 369 convulsive The M mode of action of Fink, therapy: the neurophysiologicadaptive View (9: NeuhopAychLato,J1962Jc3: 231—~233)\ \ )J [AK—y... 7! um: 17% A, m "lat/"M1- Fink, Mo and Kahn, Ru L Quantitative studies of slow wave activity following electroshock ELecLLoenceph CLLn NeuaophyALOLO, @ﬁﬁﬁiq:_;;l58?J Fink, Mo, Kahn, Lefkowits, H 1961,u: R0 J 259 266 Le, Karp,E o, Pollack, Mo, Green, M AC, Alan, B and Inhalant-induced convulsions (:Ahch Geno PAychLa§>((3K; . Freedman, A Mo, Bales, P D, Willis, AG production of electrical major convulsive 117— 121% fIgﬁé'Jﬁ—J: “£11-“.V./ FUnkenstein,D and Himwich, Ho Ea J. ,Ameao patterns — Experimental,€$§£;7 PhgoLoLo, ,. , ”kw—.-Wn J Greenblatt, M and Solomon, H C Autonomic nervous Nehvo MenM 0L6 system changes following electric shock treatment :yatt77M Ho, [1988,L108: 1109422, FUnkenstein, DOH a, J Greenblatt, Solomon, M and paralleling psychologic changes in mentally 1 ill H C Autonomic changes patients 5:T Neav Mani.”’ﬁ . 1951. 011%“ 18,.I Funkenstein, DQH o, Greenblatt, Mo and Solomon, Ho Co Autonomic nervous system test of prognostic si ificance in relation to electroshock Made, {Pbychozsomo treatmento 13: 1952, 3u7—3629” {as 1__1___~u Gal, E0 M8 Cholinesterase activity of who blood from healthy and Sohizophrenic individuals° (Natune" 1963. 19821118-1119> WW (M) ) \9=*" , 5 6%-,“ V �and Pepeu, Go Drug-induced changes in brain acetylcholineo Jo Phanmac0£o," [meg/1&1: 226—2311, 5 Qiarman, (But, J M, o Signi ficance of individual variability in Home, :19574 ﬁg, 229-21104; electroshocko NJ, Green, A, MD Hampscn, w Jo wae " Essig, Co 1:1, ((muuw; and McCauley, f luorophosphate Himwich, A0 EEG response to Effects of H9 Ea electroencephalogram and cholinesterase asvivityo_(Ekectaoencepho Ciino Neuhophybio£0,f1950, g; ulgug> / div-isop‘ropyl (DFP) on Hinwich, Ho E0, Essig, Co Po, X-Iampson, Jo Lo, Bales, Po Do and Freedman, AU Mo Effect of trimetnadione (Tridione) and other drugs on convulsions caused by di—isopropyl fluorophosphate (DFP) Amen. J. R\“”” ““1950,‘1062 816-829) o * fM W . ” ”rm Lo and Lechner, Ho The effect of Diparcol on the electroencephalogram Jenkner, and in those with cerebral trauma, E£eot2wenceph. can. in the normal 1E"o ﬂax iwx subject /”Neun0phy4£o£o,{1955,LZE 303-6053 1M, Johnson, Ulett, Co, Lu J “3 '7 - A0, Johnson, Go Smith, MD, K0 and Sines, Jo Electroconvulsive therapy (with and without atropine); effect on electronically analyzed electroencephalogram Allah, Geno Pbychj. 1/ WM"' Kabat, E0 A0, Glusman, 0%., 0/ > and Knaub, V0 Quantitative estimation of the albumin and gamma globulin in normal and atholo ic cerebrospinal fluid by immunochemical methodso Wells 10 Mada, [194845;E 653—66253 ‘ “NW Mo / brain of the content Acetylcholine ’ Hung, if E53,: 13; 1—H >J 1;::11 t I44wéhjié. humorale Ubertragbarkeit der Herznervenwirkungo Fonyo, A0 and Halmagyi' in traumatic shocko (Aota Pkg/31.0 Kovach, A, Ga Bo , Mo ,1 ‘\ ’ ‘ _ , §’ Loewi, Anch, O.) 55 Maynert, Ube ﬁts, E0 W; Ho and Buck, 1319: 239-292, Effects of Eo Go onacetylcholine synthesﬁgofjo Phwumcoz, Nachmansohn, specificity Plum, (cum /. f; I, iﬂw 0‘ depressants on brain . convuls and narcotic drugd/ Expo ThULo, 1951, 103:_ 35,5433 { and Rothenberg, M, A, Studies on cholinesterase: on of enzymes in nerve tissueo (J. Mob Chmo,ffgu5.} _]_._5_8: 653—666“; Do Study of cholinesterase Chemo, 1960; pg: 332-390, Co Mo activity in nervous Serum cholinesterase activity in mental >M195 , } and mental disorders. R Ravin, H, A, and Altschule, Mo Do diseaseo /AItho Newwﬁc Pbychiaxo a CDNIOSO thacolagi£t,, 1961+, g; 191, and Elliott, K A 9C, Effects; "adetylcholineo Mcbennan, Phybiozo, 1921, . §§: 616-650) �1 Richter, D and Cmssland, J Variation in acetylcho ine content of the Phybioio, 19891159: 2887— 255 a, brain with physiological stateo /Ame8)L88 J 0 M Richter, D and Mo leeI 838 £882,188821 than yfI8828188 ,J’ "T“. <72: D and Lee, 1- Rose , MD 835~83gfj The , W. Ment. 306,8“, 0/1,” 0\ Serum choline esterase and depresmon. 13° Mani. Soc.) f“‘p‘. . 7, Punkenstein est-57K review of the &;8§dand P3ym ,j19625138 , o esterase and anxietyc J. Serum choline (,4 128—153, / ”W i literature. Aota ». in the EEG under barbiturate anaesthesia produced by electroa-convulsive treatment and their significance for the theory of Roth, M Changes C228. action fEZectaoenceph ECT Roth, Ma, Kay, D W Ko , Shaw, ) W28” NeuhophyéLOKO,[1951,[__w261—280 J J and Green, Prognosis and ﬁPentothal induced electroencephalographic changes in electroyzonvulsive treatment .. Eﬁemoenceph can NewzophyA/ZOLO, 8f‘1957.;___9: 225- 237 7’ A S [/80 ofd1d1opmpyl——° i and Wilson, A, The effects aﬂcorophosphonate in schizophrenic-1and manic depre sive psychosis. Newwz NQMOAU/tgo Paychiwto, 1950.313: 87-62, Romtree, D J Rubln, ° We, Nev1n, ° ° WW“ Acetylcholine hydrolysis in psychiatric patients Lo So /.1958,,Ll2___8258-25858) 7 7; /1881, ‘~‘ : 8 .x' )1 Spiegel, E A and Spiegel—Adolf, M Physioochemical effects of electrically induced convulsions (cerebrospinal fluid studies) K Titan/.5 Ame/r.° NewwL AM., 81888.70: 130132 @1111): Spiegel, E A and Spiegel-Adolf, M Physiological and physicochemical mechanisms in electroshock treatment Canéin Weuhoz [195’‘13, 38-63/ A changes Go M and Spiegel—Adolf, Spiegel, E Physicochemical Henry, in the brain accompanying electrically induced convulsive discharges W/TW Spiegel-Adolf, Arnuo ,____ Newwz MAM/Tmﬁﬁﬁ: 81783811 ,Wilcox, P H and Spiegel, E changes in electroshock treatment of psychoses 1988, gg_; 697 706); Stwone W E 90] Pkg/8 Amm M A. Cerebrospinal fluid Amen. J Paych/éaio, o role of acetylcholine in brain metabolism and functiom Med ,f19'7'; 3‘6: 222——255>/ The m._._ . ’1qu ,,,,, ~ '~'" - if! Suence, Spiegel, E A and Spiegel—Adolf, M Permeability changes in the brain induced by Metrazol and insulin convulsions (Jo NULU. Manx. 0125:, 83; 750 755 /0 %% . y“ ,2. ' �Lipton, Tobias, J and convulsants on brain acetylcholine contento *, Med“; ’7 (KS Me MW 0 1:. 51—515 and IJepinat, A, A0 A, Effect of anesthetics Phone Soco Expo BLO£./;~“ ' "I" 1 “t” "‘1’ r7 _ and McEachern, Do Acetylcholine and neuronal activity. I. Cholinesterase patterns and acetylcholine in the cerebrospinal fluids of— patients with craniocerebral traumao x/“Ctinado J Ru ea/Lch m cm 5,, Towem 7. {ﬁn/x”, ' CO ‘ Wm. _, Wk Effect of convulsion inducing a ents on the acetylcholine Ame/Lo Jo Pkg/Maze; 1953, ;l73: 179—183, brain; of the content (ACTH) on of Cc corticotropin Effects of single injection Torda, Jo PhyMLoL, braim,gj'ArrIe/Lo of content and ion acetylcholine ammonium 1953, ll}: 175—178j / Torda, - ,3- a Do Bo Q:W105=1195 W Towem Do Ba 191M313o 2],: and McEachern, molinesterases in jettg ) content and characterization of ., human Do The cerebrospinal fluidso (f'fCanado l32=~ll+53j a «QC/t; Ruea/Lch, J. é)' Do and neuronal and activity. II. Acetylcholine McEachem, B Acetylcholme and cholinesterase activity in the cerebrospinal fluids C’a‘nado p] of patients with epilepsy», \_’\ Tower, D; < 120~l3l> IVWL a Ruem&9?%27“m $0 ’5) and Wo M, of Effect scopolamine upon Johnson, atropine Ulett, electroencephalographic changes induced by electro-ccnvulsive therapy. Ezecthoencepm Cum Neu/Lophyaiozo,fI§S’7‘g"ig_: 217-221;} Go A, and ’/wt" 1 WardiAu AU, tropine (1950, E3 3984020) 1 ‘ in the treatment of closed head injuryoﬁJo Co, Green, RC _ V :1: r7?“ , . V___“,_,,_-..._. W0 1 Neu/LOAu/Lg., E0, McNamara, Bo Po and Krop, So The influence J. -7“~Phalmmroi. Exp. (”of atropine and scopolamine on the central effects of DFP°_ "»»».N..r lgu8'5‘_9_‘2;: 63-720 We‘oea ' /’ (“L-9““ The/Lo , �.l mI ,l I II, .I Al. _I ”I .l .I ,l 'l I JI I _l �SET DuPQCAaTE MAY 24 1966 (m (FINAL EG—J 68 HR �(mm (FINAL EG—J 68 EG—J 68 (CL oE-NMD-Mar 5-20-5D (COG 6131 MAX FINK MAX FINK MAX FINK MAX FINK MAX FINK (READ 660 BY PROVE!) MAX FINK THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY CONVULSIVE OF ASPECTS CHOLINERGIC THERAPY CONVULSIVE OF CHOLINERGIC ASPECTS MAX FINK, MD.1 �ﬁUPLECﬁzTE SILT MAY 24 1966 EG—J 71 W Ward-BMW Gal 2 %E-NMD-Mar 5/20-5Gx 6131 P. 15 5/19/66 722(3) 'E]li“l" 1Department of Psychiatry, ... . ’ - H' i I I .o E u - This study was aided, in part, by USPHS grants MH-927, MH—2715, MH-07249 and MH-11380; and by the Psychiatric Research Foundation of Missouri. While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are requisite to changes in behavior (18, 21, 22). A useful index of neurophysiological change is the appearance of high voltage electroencephalographic slow wave activ— ity (22, 23). While the biochemistry of this activity is poorly understood, demonstrations that it is inhibited by anticholinergic compounds (19, 20, 34, 66) suggest that cholinergic systems may play an active part. (m (FINAL The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and, to a lesser extent, spontaneous seizures. Changes in concentration of cholinesterases in brain and spinal ﬂuid also show many similarities in these conditions. This review discusses these observations to provide a hypothesis for the role of cholinergic changes in convulsive therapy. The activity of acetylcholine in the transmission of nervous impulses has been extensively studied since the early descriptions by Dale (12) and Loewi (38). A constituent of nervous tissue in a bound form, acetylcholine, is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by the choline-acetylase system (45). Free ace— tylcholine has not been measurable in normal cerebrospinal ﬂuid despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (63). ///"L.i//>{{ I "'4 1/. ,1/ :J Waéff?.__ �part. mm (FINAL (CL (GOG The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and, to a lesser extent, spontaneous seizures. Changes in concentration of cholinesterases in brain and spinal ﬂuid also show many similarities in these conditions. This review discusses these observations to provide a hypothesis for the role of cholinergic changes in convulsive therapy. The activity of acetylcholine in the transmission of nervous impulses has been extensively studied since the early descriptions by Dale (12) and Loewi (38). A constituent of nervous tissue in a bound form, acetylcholine, is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of acetylcholinesterase and is rapidly reconstituted by the choline-acetylase system (45). Free acetylcholine has not been measurable in normal cerebrospinal ﬂuid despite the rapid breakdown of bound acetylcholine during periods of activity and excitement (63). But the normal cerebrospinal ﬂuid does have measurable cholinesterase activity (41). CHOLINERGIC ASPECTS OF CRANIOCEREBRAL TRAUMA (READ 660 BY PROVE!) Free acetylcholine was found in the cerebrospinal ﬂuid of cats within a few minutes after experimental head trauma and persisted for varying periods up to 48 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 ga /100 cc, and the amount was related to t e degree of induced trauma (6). Concurrent electroencephalograms ﬁrst demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was succeeded by a short period of ﬂattening of all recorded electrical activity. These phases were followed by prolonged periods of �f.’u ”1: $3.: .gsi 1:..n‘1' 24 1955 EG—J 71 %E-NMD-Mar 5/20-5Fx 6131 P. 15 5/19/66 722(1) Gal 3 high amplitude sharp waves in the delta frequencies. The behavioral changes related to the degree of induced trauma and to the amount of measured free acetylcholine. With higher levels of acetylcholine, Bornstein (6) reported greater degrees of EEG abnormality and greater changes in consciousness. Spontaneous post-traumatic seizures were also related to the amount of free acetylcholine measured in the cerebrospinal ﬂuid. Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was one gamma/100 cc or less, high amplitude sharp waves of low frequency appeared in the electroencephalogram. When the concentration was increased to two 100 gamma/ cc, the electroencephalogram ﬂattened in a fashion parallel to the post-traumatic records. by Tower and McEachern (63) demonstrated free acetylcholine in the cerebrospinal ﬂuid only in patients with recent head trauma, recent grand-mal seizures or after electroconvulsive therapy. Free acetylcholine varied from 0.2 to 100 gamma/ 100 cc. In assaying spinal ﬂuid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal ﬂuid did not exhibit such inversion although it contained free acetylcholine. They concluded that the leve 0f free acetVlChnll‘np (FINAL ((1 �Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was one gamma/100 cc or less, high amplitude sharp waves of low frequency appeared in the electroencephalogram. When the concentration was increased to two 100 gamma/ cc, the electroencephalogram ﬂattened in a fashion parallel to the post-traumatic records. Investigations in neurological patients by Tower and McEachern (63) demonstrated free acetylcholine in the cerebrospinal ﬂuid only in patients with recent head trauma, recent grand-mal seizures or after electroconvulsive therapy. Free acetylcholine varied from 0.2 to 100 gamma/ 100 cc. In assaying spinal ﬂuid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. After spontaneous seizures, however, the cerebrospinal ﬂuid did not exhibit such inversion although it contained free acetylcholine. They concluded that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal ﬂuid. Increased acetylcholine in rat brain after traumatic shock was also reported by Kovach et al. (36). This acetylcholine activity was inhibited by the administration of atropine in vitro. The electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of 0.5— 1.0 mg/kg atropine, as were similar clinical changes occurring after the intracisternal addition of acetylcholine (6). Ward applied these observations to the treatment of closed head injuries. In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 0.1 mg/kg, noting clinical improvement in some and a reversal of the electrographic effects in others (67). The same changes in the post-traumatic electroencephalogram were reported by Jenkner and Lechner in a study of diethazine, another anticholinergic drug. A single intravenous dose in 40 patients resulted in normalizing the abnormal electroencephalogram in 22 and marked improvement in six others (33). (READ “660 mom �2' on I'-.-..AY 24 '“ 1965 EG—J 84 OE-NMD-Mar 5/20-5E GAL 4 6131 P. 18 5/19/66 722(1) Similarly, in experiments of post-trauma- tic shock and cerebral edema in animals, Denisenko (13) reported a blocking of the clinical changes by such anticholinergic compounds as methylbenactyzine and adiphenine (Trasentin). Thus, the amount of free acetylcholine ma increase in the spinal ﬂuid following craﬁicerebral trauma and the amount of free acetylcholine, the degree and type of electroencephalographic abnormality, and changes in clinical behavior appear as interrelated phenomena, which may be reduced by the administration of anticholinergic drugs. BRAIN ACETYLCHOLINE AND ANTICHOLINERGIC DRUGS (REV (FINAL (CL (00G (READ 660 BY PIOVID The effects of the direct application of acetylcholine to the central nervous system may also be blocked by anticholinergic drugs. The administration of the cholinesterase inhibitor di-isopropyl ﬂuoroph sphate (DFP) elicited high amplitude rapid frequency EEG patterns similar to status epilepticus and some post-traumatic states (24, 31, 32, 68). These EEG eﬂ'ects were blocked by small doses of parenteral atropine and scopolamine. The great increase in acetylcholine after tetraethyl pyrophosphate (TEPP) was measured and related to the toxic effects and the induced convulsions (29, 59). Chatﬁeld and Dempsey (9) prepared exposed animal cortex with prostigmine and evoked electroencephalographic spike activity. The prior administration of atropine blocked the appearance of spiking, or if present, this electrical activity could be eliminated by atropine. In contrast to these ﬁndings, Brenner and Merritt (7) applied topical acetylcholine in concentrations of two and onehalf to ten per cent to the exposed cortex of cats and noted no effect on the electroencephalographic changes after intravenous atropine (one mg/kg). The concentrations of acetylcholine in these experiments, however, were higher than the topical applications (one to four gamma/100 cc) and the intracisternal (0.2—10 gamma/100 cc) injections of Bornstein (6). Brenner and Merritt (7) also noted electroencephalographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. These data are conﬂicting and further study is necessary to qualify this issue. , 0 �(FINA! (CL (COG (READ 660 BY PROVE!) atropine blocked the appearance of spiking, or if present, this electrical activity could be eliminated by atropine. In contrast to these ﬁndings, Brenner and Merritt (7) applied topical acetylcholine in concentrations of two and onehalf to ten per cent to the exposed cortex of cats and noted no effect on the electroencephalographic changes after intravenous atropine (one mg/kg). The concentrations of acetylcholine in these experiments, however, were higher than the topical applications (one to four gamma/100 cc) and the intracisternal (0.2—10 gamma/100 cc) injections of Bornstein (6). Brenner and Merritt (7) also noted electroenceph— alographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral ch0linesterases. These data are conﬂicting and further study is necessary to qualify this issue. CEREBROSPINAL FLUID ACETYLCHOLINE AND SEIZURES One View of acetylcholine metabolism ﬁnds it in nervous tissues in an inactive and bound form. During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterases. The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation and breakdown (15). It has been postulated that the level rises during sleep and falls during waking activity (16, 29, 45, 60). Tobias et al. (60) reported increased free and total acetylcholine after chloroform and pentobarbital anesthesia in rat and frog brain but no changes after strychnine or pictrotoxin convulsions. Richter and Crossland (45) measured the level of acetylcholine (microgamma per mg brain tis— sue) during anesthesia and sleep in rat brain to be 300 per cent higher than postseizure levels. The difference in tissue levels is transient, however, as the resynthesis rate for acetylcholine in rat brain is high (seven gamma/gm/minute). These observations were conﬁrmed by Elliott et al. (16) and Crossland and Merrick (11). Giarman and Pepeu reported the increase in acetylcholine following various depressants to be roughly proportional to the degree of depression of the central nervous system and the reduction in motor activity (29). Maynert and Buck, however, studying brain acetylcholine levels during sedation concluded that some sedatives were associated with elevated brain acetylcholine but that no rigorous relationships existed (39). In part, this may be related to the earlier observations of McLennan and Elliott (40) that acetylcholine synthesis measured in rat brain slices is accelerated by low dosages of narcotic drugs, but inhibited by high dosages. �£.;__1 -C£HTE rJdJl “‘ . 2-59—11! RAY 24 l966 EG—J 84 OE—NMD-Mar 5/20-5E 6131 P. 21 5/19/66 722(3) A) GAL 5 Free acetylcholine was reported in the spinal ﬂuid in patients with epilepsy (10, 63). Of 56 epileptic patients, 44 demonstrated free acetylcholine in quantities of 0.02 to 5.0 gamma/ 100 cc with an average of 1.0 gamma/ 100 cc. Acetylcholine levels were related to the frequency of seizures, the extent of electoencephalographic abmality, and to the time since the last sféizlmre but bore no relation to medication, type of epilepsy or level of cholinesterase activity Elliott et al. (16) also noted free acetylcholine in the spinal ﬂuid in concentrations up to three gamma/100 cc after pentylenetetrazol (Metrazol) convulsions. Tower and McEachern (63) viewed the increased acetylcholine as a by-product of the seizure and not causal. Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Torda (61, 62) measured the level of acetylcholine in brain tissue after pentylenetetrazol convulsions. She noted a rise in the acetylcholine content of brain before and a fall during the convulsion. Below certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentrations of metabolites such as ammonium ions. Giarman and Pepeu also measured changes in central nervous system acetylcholine following various stimulants (29). Only after methacholine and 3,5dimethylbutylethyl-barbiturate was there a signiﬁcant change in the acetylcholine level. They noted a decrease in association with induced convulsions. With other drugs which they classiﬁed as stimulants (LSD, iproniazid, iproniazid plus hydroxytryptophan, and iproniazid plus DOPA) there were no changes in the acetylcholine level. They concluded that despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The differences in observations between these observers and Gone et al. (10) and Tower and McEachern ( may be related to the differences in methods of biochemical measurements, for the latter measured changes reﬂecting free only, While Giarman and ) measured total acetylcholine Pepeu includin_ bound and free forms of acetyl- K ya .7; Mageline ”ﬁl- These studies suggest that spontaneous or induced seizures are accompanied by an increase in intercellular free acetyl choline liberated from its bound form which may be reﬂected in the spinal ﬂuid. Cerebral activity and seizures enhance acetylcholine destruction, lowering tissue levels of acetylcholine, while sleep and anesthesia augment acetylcholine production increasing tissue levels. (REV (FINAL 206((1 CENTRAL NERVOUS SYSTEM �bllUl‘U l/oi ’/—\, C/ were LlU Guanges 111 we acetylcnoune level. They concluded that despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The differences in observations between these observers and Cone et all. (10) and Tower and McEachern ( may be related to the differences in methods of biochemical measurements, for the latter measured changes reﬂecting free holine only, while Giarman and ce ) measured total acetylcholine includin bound and free forms of acetyl- K m “Tho («3 in). These studies suggest that spontaneous or induced seizures are accompanied by an increase in intercellular free acetyl choline liberated from its bound form which may be reﬂected in the spinal ﬂuid. Cerebral activity and seizures enhance acetylcholine destruction, lowering tissue levels of acetylcholine, while sleep and anesthesia augment acetylcholine production increasing tissue levels. (REV (FINAL (CL CENTRAL NERVOUS SYSTEM CHOLINESTERASES Tower and McEachern (63, 64, 65) also measured spinal ﬂuid cholinesterase activity. By reporting cholinesterase activity as a ratio of the rate of hydrolysis with two substrates compared to an acetylcholine substrate, acetylcholinesterase/acetylcholine and butyrylcholinesterase/acetylcholine ratios are derived. Normal cerebrospinal ﬂuid contains these esterases in the ratio of 33:17. In patients with head trauma, Tower and McEachern reported an inversion of the cholinesterases with an increase in the butyrylcholinesterase of the spinal ﬂuid and a decrease in acetylcholinesterase activity. The extent of the cholinesterase reversal was related to the severity of trauma and to the degree of EEG abnormality. A similar reversal was observed in patients undergoing convulsive therapy. In patients with elevated spinal ﬂuid acetylcholine after spontaneous seizures, however, no change in the ratio of cholinesterases or total cholinesterase activity was found. Changes in cholinesterase activity may be related to changes in cell membrane permeability. Acetylcholinesterase is found in highest concentration in the central nervous system. while butyrylcholinesterase predominates in other tissues, especially blood serum. With increased cerebral acetylcholine, vasodilation and increased cellular permeability may be predicted, with vascular ﬂuid transudation varying with the extent and duration of the vasodilation (35). Spiegel, Spiegel-Adolf and their coworkers (54—58) demonstrated such permeability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal ﬂuid following electrically induced convulsions. Such non-electrolytes as nucleic-acid splitting enzymes also increased. Changes in cellular permeability may be the basis for the high (ooc (nun 660 8! mom �..._.l!_ﬁ$ .0"de " ;CF;TE MAY 24 55-12%”? 1965 That changes in cholinesterases may be large and measurable is suggested by the acetylcholinesterase activity which was related to decrements in be havioral perform- ance. The persistance‘ of acetylcholine in spinal ﬂuid after head trauma and after seizures despite increased cholinesterase activity may be related to the sensitivity of the acetylcholine~acetylcholinesterase ip is non-speciﬁc, and (m the rate of hydrolysis increases with increased concentration. These relationships relate to theories of the induction of seizures. While the usual concentrations of acetylcholine at cell destroyed by the speciﬁc activity of acetylcholinesterase in a few microseconds, an excessive concentration following excitation may exceed its rate of hydrolysis. The seizure threshold may be (FINAL altering the concentr including butyrylcholinesterase in tissues and in the cerebrospinal ﬂuid. Through the activity of this esterase, though of low efﬁciency and depending on concentration kinetics, acetylchol' ' J (CL (GOG ”J (nun 660 BY mom acetylcholinesterase. Cholinesterases appear in the spinal ﬂuid as a reﬂection of their increase in intercellular ﬂuids resulting fr om changes in cell membrane permeabilit y accompanying increased acetylcholine. EEG HYPERSYN CHRON Y AND INDUCED CON VULSIONS onvulsive therapy process has been repeatedly described (22, 23, 50, 51). In the usual course of convulsive therapy, inter-treatment electro~ encephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment �(FINAL (CL (GOG (READ 660 BY PROVE!) Name wscu adding to the amount of free acetylcholine. Increased acetylcholine affects vascular and cellular permeability altering the concentrations of various ions, including butyrylcholinesterase in tissues and in the cerebrospinal ﬂuid. Through the activity of this esterase, though of low efﬁciency and depending on concentration kinetics, acetylcholine is reduced in tis- acetylcholinesterase. "" ”My Cholinesterases appear ﬂuid as a reﬂection of their ' tercellular ﬂuids resulting fr om changes in cell membrane permeabilit y accompanying increased acetylcholine. EEG HYPERSYN CHRON Y AND INDUCED CON VULSIONS onvulsive therapy process has been (22, 23, 50, 51). In the repeatedly described usual course of convulsive therapy, inter-treatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatelta activity appears in methods~electrical, intravenous chemical or inhalant—exhibit the same type of EEG pattern changes (21, 22, 23, 30). The early appearance of high degree hypersynchrony and its persistence throughout a treatment course has been found to be prerequisite to improvement. Both the electrographic and th e behavioral changes of induced convulsio us are transiently reversed by the acute administration of experimental anticholinergic compounds 19 20). The intravenou injec ion 0 diethazine, benactyzine, t e piperidylbenzilates JB—318, JB—336 and JB—329 (Ditran), and WIN—2299 induced EEG desynchronization in psychiatric subjects. These EEG changes were associated with behavioral alerting, anxiety, tremors, illusions and hallucinations. In patients cently received electroconvu lsive therapy there was a reduction in slow and a reversal of ' euphoria, d fusion. Atropine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, poorly organized delta activity with superimposed beta activity companied by progressive confusion and disorientation. The effect of anticholinergic drugs on the slow wave activity of convulsive therapy was also assessed by the chronic administration of atropine (ﬁve mgm per day) and scopolamine (one to three mg) during the Weeks of treatment. The amount of EEG slowing was signiﬁcantly less than S �J anaema WKY ,— 24 ("f “" -' 1965 EG—J 85 OE-NMD-Mar 5—20-5Fx Gal. 7 6131 P. 28 5/19/66 722(3) Marked improvement was reported in two of seven atropine-treated, norx of ﬁve scopolamine-treated and in four of the six controls receiving unmodiﬁed ECT. This study was not replicated by the authors who suggest that dosage factors or population changes may have contributed to the different results in a second study (34). As in cerebral trauma, the electrographic changes of induced convulsions be may modiﬁed by the administration of anticholinergic drugs suggesting that increased amounts of acetylcholine or increased cholinergic receptivity is associated with the high voltage slow wave activity. ACETYLC‘HOLINE AND INDUCED CON VULSIONS Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, amount, and sensitivity to modiﬁcation by alerting, hyperventilation and barbiturates of the electrographic slow wave activity in psychiatric populations (30). These differences relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, thus precluding a clinical response to induced convulsions. Tower and McEachern (63), in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy. Studying the patients after three to seven treatments they reported free spinal ﬂuid acetylcholine in two patients, and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in ﬁve of the six patients. Only one patient in the series failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal ﬂui They concluded that the spinal ﬂuid anges in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Other evidence of alterations in the permeability barrier may be seen in the demonstrations of an increased concentration of cocaine in brain tissues three days after a series of 12 induced convulsions ( 1). The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony (delta bursts) in the electroencephalogram. From these observations we would conclude that induced convulsions, like craniocerebral trauma and spontaneous seizures, are associated with an increase in free acetylcholine in intercellular ﬂuids, altering cerebral permeability and enhancing the ‘ (FINAL 06((1 �”renown; m cm; patients, and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in ﬁve of the six patients. Only one patient in the series failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal ﬂui They concluded that the spinal ﬂuid anges in induced convulsions were more like those of craniocerebral trauma than those of spontaneous epilepsy. Other evidence of alterations in the permeability barrier may be seen in the demonstrations of an increased concentration of cocaine in brain tissues three days after a series of 12 induced convulsions (1). The change in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynchrony (delta bursts) in the electroencephalogram. From these observations we would conclude that induced convulsions, like craniocerebral trauma and spontaneous seizures, are associated with an increase in free acetylcholine in intercellular ﬂuids, altering cerebral permeability and enhancing the appearance of cholinesterases. The level of free acetylcholine is maintained by repeated induced seizures. EEG hypersyn— chrony is one reﬂection of altered levels of acetylcholine and the altered permeability of electrolytes and other substances, including cholinesterases. The changes in intercellular electrolytes, including acetylcholine, provide the biochemical substrate for the persistent behavioral changes and EEG hypersynchrony following induced conv onsM. An application WM““WWWM‘MMMK of these conclusions is seen in the studies of the prediction of the convulsive therapy response and the claspsychoses. I ., / l \\ W CHOLINESTERASES AND THE CLASSIFICATION OF PSYCHOSES 69‘ / Funkenstein et al. (25—27) reported a relationship between the blood pressure response to methacholine and the clinical response to convulsive therapy. Immediately after the injection of methacholine the blood pressure falls, usually returning to the baseline within ﬁve to 20 minutes. A return within ﬁve minutes places the patients in Groups I, II or III; while a return after 20 minutes place the patients in roups VI and VII. Group I and Group II have a nine per cent and a 35 per ent recovery rate, respectively, while Group VI and Group VII subjects have 89 per cent and 97 per cent recovery rates to induced convulsions (27). Group I, II and III reactors may be looked upon as patients in whom methacholine is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the classiﬁcation, but is of limited discriminating value [48].) While we have no biochemical explanation for the differences in the metabolism of methacholine in these psychiatric groups, it is possible that the blood and tissue choline— sterase activity levels of Groups I—III is I/ high while that of Groups VI—VII is low compared to general psychiatric populations. (m (FINAL (CL (COG �1»:er 24 1966 EG—K 5 %E-NMD-(March) 5/20-5FX 6131 P. 31 5/19/66 722(1) a» (mm /’ ' J (run. , (CL (GOG (READ 660 BY PROVE!) Gal. 8 The differences in blood cholinesterase levels in normal and mentally ill subjects have been extensively studied. Despite differences in methods (4, 5), elevated cholinesterase levels compared to normal populations have been reported for depressive subjects (44, 46, 47, 52), schizophrenic subjects (14, 28, 53) and a mixed psychiatric population (42). Alpern reported lowered cholinesterase levels in schizophrenic subjects (2). While these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mentally ill. Negative reports include the failure by Ellman and Callaway (17) to conﬁrm Rubin’s study; and Altchule’s review of the data suggesting no abnormality of cholinesterase levels in the mentally ill (3). -. ..-_-- _ HeSe studies suggest that cholinergic measures may play a signiﬁcant role in the therapeutic response to convulsive therapy and in the pathogenesis of psychoses. ., ' , 7 CONCLUSION This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convulsive therapy process. Induced convulsions are associated with cerebral vasodilation and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal ﬂuids. The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased electrical hypersynchrony which is recorded as EEG slow wave activity in scalp electrodes and which can be modiﬁed by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various DineridVI-hﬂnzilnqu �“lose stuures suggesr, that cholinergic measures may play a signiﬁcant role in / ( (CL ((IJG (READ 660 BY PROVE!) the therapeutic response to convulsive therapy and in the pathogenesis of psy- { choses. , ,- ' ’ CONCLUSION This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convul— sive therapy process. Induced convulsions are associated with cerebral vasodilation and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal ﬂuids. The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with trauma, seizures and induced convulsions. These biochemical changes accompany increased electrical hypersynchrony which is recorded as EEG slow wave activity in scalp electrodes and which can be modiﬁed by the acute and chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl-benzilates. In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. The changes in cerebral biochemistry alter cellular activity sufﬁciently to affect consciousness and the behavior of subjects. Failure to induce persistent biochemical changes, including the concentration of acetylcholine, results in failure to produce behavioral change. There is, as yet, no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic mechanisms. Differences in the rate of develop— ment of cerebral changes to the same number and frequency of induced convulsions and classiﬁcations of the mentally ill based on the blood pressure response to methacholine suggest, however, that such differences may be signiﬁcant in the pathogenesis of different psychoses. 1. REFERENCES Aird, R. B., Strait, L. A., Pace, J. W., HrenoH, M. K. and Bowditch, S. C. Neurophysiological effect of electrically induced A.M.A. Arch. Neurol. Psychiat.,convulsions. 75: 371— 2. 378, 1956. Alpern, D. O. Aktivnost kholinesterasy i kho— linergicheskaya reaktsiya krovi pri shizofrenii. (Cholinesterase activity and choliner— gic reaction of the blood in schizophrenia.) Fiziol. Zh. (Kiev), 4: 87—90, 1956. 3. Altschule, M. D., Bodily Physiology in Mental and Emotional Disorders, pp. 169—172. Grune & Stratton, New York, 1953. 4. Augustinsson, K.-B. The normal variation of human blood cholinesterase activity. Acta Physiol. Scand., 35: 40—52, 1955. 5. Augustinsson, K.—B. Assay methods for cholinesterase. In Glick, D., ed. Methods Bioof Chemical Analysis, vol. 5, 1—63. Interpp. science Publishers, New York, 1957. 6. Bernstein, M. D. Presence and action of acetylcholine in experimental brain trauma. J. neurophysiol., 9: 349—366, 1946. 7. BFe'hner, C. and Merritt, H. H. Effect of certain choline derivatives on electrical of the cortex. A.M.A. Arch. Neurol. activity Psychiat., 48: 382—395, 1942. 8. Burgen, A. S. V. and MacIntosh, F. C. The physiological signiﬁcance of acetylcholine. In Elliot, K. A. C., Page, I. H. and Quastel, J. H., eds. Nem‘ochemistry, pp. 374—375. Thomas, Springﬁeld, Illinois, 1955. l l l | �SET aumscmi-Z MAY 24 1966 EG—K 5 %E-NMD-Mar 5/20-5Fx Gal 6131 p. 7 5-20-66 640 9. Chatﬂeld, P. O. 9 (4) and Dempsey, E. W. Effects of prostigmine and acetylcholine potentials. Amer. J. Physiol., 135:on cortical 633—640, 1942. 10. Cone, W. V., Tower, D. B. and Acetylcholine and neuronal McEachern, D. activity in epilepsy. J.A.M.A., 73: 59—63, 1948. 11. Crossland, J. and Merrick, A. J. The effect of anaesthesia on the acetylcholine content of the brain. J. Physiol. (London), 125: 56—66, 1954. 12. carine. J. Parmacol. Exp. Ther., 6: 147, 1914. Denisenko, P. P. Pharmacological blocking of central cholinoreactive systems and the possibilities of its therapeutic application. In 13. 14. Early, D. F., Hemphill, R. E., Reiss, M. and Brummel, Investigations into cholinesterase levels in serum and cerebrospinal ﬂuid of psychotic patients. Biochem. J 45: 552—556, . ., 1949. 15. Eccles, J. C. The Physiology Academic Press, New York, 1964.of Synapses. 16. Elliott, K. A. C., Swank, R. L. and Henderson, N. Effects of anesthetics and convulsants on acetylcholine content of brain. Amer. J. Physiol., 162: 469—474, 1950. 17. Ellman, G. L. and Callaway, E. Erythrocyte cholinesterase-levels in mental patients. Na- ture (London), 1.92: 1216, 1961. 18. Fink, M. A uniﬁed theory of the action of physiodynamic therapies. J. Hillside Hosp. (Glen Oaks), 6: 197—206, 1957. 19. Fink, M. Eﬁ‘ect of anticholinergic ethazine, on EEG and behavior: agent, diSigniﬁcance for theory of convulsive Arch. Neurol. Psychiat., 80:therapy. A.M.A. 380—387, 1958. 20. Fink, M. Effect of anticholinergic compounds on post convulsive electroencephalogram and behavior of psychiatric patients. Electroenceph. Clin. Neurophysiol., 12: 359—369, 1960. 21. Fink, M. The mode of action of convulsive therapy: The neurophysiologic-adaptive View. J. Neuropsychiat., 3: 231—233, 1962. 22. Fink, M. and Kahn, R. L. Quantitative studies of slow wave activity following electroshock. 23. 1956. ' ' i ’ Fink, M., Kahn, R. L., Karp, E., Pollack, M., Green, M. A., Alan, B. and Lefkowits, H. J. Inhalant-induced convulsions. Arch. Gen. Psychiat. (ChicagO), 4: 259—266, 1961. 24. Freedman, A. M., Bales, P. D., Willis, A. and Himwich, H. E. Experimental production of electrical major convulsive J. Physiol., 156‘: 117—124, 1949.patterns. Amer. 25. Funkenstein, D. H., Greenblatt, M. and Solo26. mon, H. C. Autonomic changes psychologic changes in mentally illparalleling J. Nerv. Ment. Dis, 114: 1—18, 1951. patients. 27. Funkenstein, D. H., Greenblatt, M. and Solomon, H. C. Autonomic nervous system test of prognostic signiﬁcance in relation to electroshock treatment. Psychosom. Med., 14: 347—362, 1952. 28. Gal, E. M. Cholinesterase blood from healthy and activity of whole schizophrenic individuals. Nature (London), 198: 29. 1963. 1118—1119, Giarman, M. J. and Pepeu, G. Drug-induced changes in brain acetylcholine. Brit. J. Pharmacol., 19: 226—234, 1962. 30. Green, M. A. Signiﬁcance of individual variability in EEG response to electroshock. J. Hillside Hosp. (Glen Oaks), 6‘: 229—240, 1957. 31. Hampson, J. L., Essig, C. F., McCauley, A. and Himwich, H. E. Effects of di-isopropyl ﬂuorophosphate (DFP) on electroencephalogram and cholinesterase activity. Electroenceph. Clin. Neurophysiol., 2: 41—48, 1950. 32. Himwich, H. E., Essig, C. F., Hampson, J. L., Bales, P. D. and Freedman, A. M. Effect of trimethadione (Tridinmn) A—--~— (REV (FINAL :OG(CL �“““““““ vuuvululULlS. Arch. Gen. Psychiat. (Chicago), 4: 259—266, 1961. 24. Freedman, A. M., Bales, P. D., Willis, A. and Himwich, H. E. Experimental production of electrical major convulsive J. Physiol., 156': 117—124, 1949.patterns. Amer. 25. Funkenstein, D. H., Greenblatt, M. and Solo— 347—362, 1952. 28. Gal, E. M. Cholinesterase blood from healthy and activity of whole schizophrenic individuals. Nature (London), 198: 29. 1118—1119, 1963. Giarman, M. J. and Pepeu, G. Drug-induced changes in brain acetylcholine. Brit. J. Pharmacol, 19: 226—234, 1962. 30. Green, M. A. Signiﬁcance of individual variability in EEG response to electroshock. J. Hillside Hosp. (Glen Oaks), 6: 229-240, 1957. 31. Hampson, J. L., Essig, C. F., McCauley, A. and Himwich, H. E. Effects of di-isopropyl ﬂuorophosphate (DFP) on electroencephalogram and cholinesterase activity. Electroenceph. Clin. Neurophysiol., 2: 41—48, 1950. 32. Himwich, H. E., Essig, C. F., Hampson, J. L., Bales, P. D. and Freedman, A. M. trimethadione (Tridione) and other Effect of convulsions caused by di-isopropyldrugs on ﬂuorophosphate (DFP). Amer. J. Psychiat, 106: 33. (mm (FINAL (CL (COG 816—820, 1950. Jenkner, F. L. and Lechner, H. The effect of Diparcol on the electroencephalogram in the normal subject and in those with cerebral trauma. Electroenceph. Clin. Neurophysiol., 7: 303—305, 1955. 34. Johnson, L. C., ilett, G. A., Johnson, M., 660 B! 35. 324—336, 1960. i ' ’ Kabat, E. A., Glusman, M. and V. Knaub, Quantitative estimation of the albumin and gamma globulin in normal and pathologic cerebrospinal ﬂuid by immunochemical methods. Amer. J. Med., 4: 653—662, 1948. 36. Kovach, A. G. B., Fonyo, A. and Halmagyi, M. Acetylcholine content of the brain in traumatic shock. Acta Physiol. Acad. Sci. Hung, 13: 1—4, 1957. 37. Krech, D., Rosenzweig, M. R. and Bennett, E. L. Effects of environmental and training on brain chemistry.complexity J. Comp. Physiol. Bsychol., 53: 5093519, 1960. 38. Loewi, O. Uber humorale Ubertragbarkeit der Herznervenwirkung. Pﬂueger Arch. Ges. Physiol., 189: 239—242, 1921. 39. Maynert, E. W. and Buck, E. G. Effects of CNS. depressants on brain acetylcholine. Pharmacologist, 6: 191, 1964. 40. McLennan, H. and Elliott, K. A. C. Effects of convulsant and narcotic drugs choline synthesis. J. Pharmacol. on acetylExp. Ther., 103.- 35—43, 1951. 41. N achmansohn, D. and Rothenberg, M. A. Studies on cholinesterase: On speciﬁcity of in enzymes nerve tissue. J. Biol. Chem., 158: 653—666, 1945. 42. Plum, C. M. Study of cholinesterase activity in nervous and mental disorders. Clin. Chem., 43. 6’: 332—340, 1960. Pryor, G. T. and Otis, L. S. Effects of chronic administration of electroconvulsive shock on behavior, brain weight and brain chemistry. Paper presented at the American Association for the Advancement of Science, Berkeley, 1965. 44. Ravin, H. A. and Altschule, M. D. Serum cholinesterase activity in mental disease. A.M.A. Arch. Neurol. Psychiat., 58: 645—650, 1952. 45. 46. Richter, D. and Crossland, J. Variation in acetylcholine content of the brain with physiological state. Amer. J. Physiol., 159: 247—255, 1949. Richter, D. and Lee, M. Serum choline esterase and anxiety. J. Ment. Sci. (London), 88: 428—434, 1942. PROVE!) �Dupucmr. MAY SET 241966 EG—K 6 EG~K 6 %E-NMD6131 p. 12 5-20-66 640 (4) 47.R h M. ee, Serum choline and depression. esterase J Ment. Sci. 435—439, 1942. (London), 88: extension. J. 429—437, 1962. 50. Roth M. , Changes in the EEG under barbiturate anaesthesia vulsive treatment pro duced by electro-conand their signiﬁcance the theory of ECT for a ction. Electroenceph. Clin. N 51. Roth, M.,europhysiol., 3: 261—280, 1951. K physiol., .9: 225—237, 195 . 52. R owntree, D. W., Nevin, :I‘he eifects 53. Rub' 54. (REV 55. Spiegel. E. (FINAL (CL �J. , .,Kay, ' .W.K SI 52. Rowntree, D. W., The effects of Nevin, S. and Wilson, A. in schizophreniadiisopropylﬂuorophosphonate and manic depressive chosis. J. Neurol. psyNeurosurg. 47—62, 1950. Psychiat., 13: 53. Rubin, . . . .. /W_g3, v logical and . Physio, physiocochemical mechanisms lectroshock treatment. in C . N ' 1953. 57. Spiegel, E. A., Spiegel-Adolf, M. and Henr G. Physicochemical Chan of psychoses. Amer. J. Psychiat., 104: 697—706, 1948. 59. Stone, W. .E' Th brain acetylcholine Biol. Med., 61: 51—54,content. Proc. Soc. Exp. 1946. 61. Torda, C. ' Effect of ' Amer. J. Physiol., 173: ontent of the brain. 179—183, 1953. 62. Torda, C. Effects of single injection of corticotropin (ACTH) on ammonium ion and acetylcholine content of Physiol., 173: 176—178, 1953. brain. Amer. J. 63. Tower, D. B. and McE achern, D. Acetylcholine and neuronal activit y. I. Cholinesterase terns and acetylcholin ' patﬂuid Canad. J. Res. Sect E, 64. Tower, D. B and McEachern, D. The content and characterization human cerebrospinal of cholinesterases in Sect. E, 97: 132—145, ﬂuids. Canad. J. Res. 1949. 65. Tower, D. B. and convulsive thera anges induced by electroNeurophysiol., .9: y. Electroenceph. Clin. 217—224, 1957. 67. Ward, A. A., Jr. Atropine in the treatment of closed head injury. J. Neurosurg., 7: 402, 1950. 398— v h I E a � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 4/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-004 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1969 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/22ce0e2ce2b39aba2aae8d5d1394cc60.pdf 2c9db7ac17279fda4146fb703f39bab1 PDF Text Text ' """ "r ' " WWO WW WW3. IN Max Rink, -*-' '"I’W v“ ”kw "FWHWOMV'.’ v.3. "m qr min...“ .7... W 14.1). mthofPoydmiatry of School Missouri Meir» , of MRI-nit}; Psychiatry, at the Nissan Institute of 63139. Macaw}. St. Innis, Annual Street, and Vii—072w, bin—927, m—zns, usms in part, by gums Missouri. of Formation :3 Iii-11380; ltd the Psychiatri 5WD W. VII: 7—25—65 Ram ��Wm, lQNQe) . The activity md emitement (Tracer and oembmepiml fluid does have measurable cholinestemse activity, however, principally of the ”true” or maholyl hydrolyzing type (Madmen and Rothenberg, 19%). In the absence of free acetyldroline and mder the cmditims described, electmenoephalogrm fail to (e) Show almorulity. mummy: Meta of Crmiooembml Trauma: Free mtylcholim was found in the cembmepiml fluid within a few minutes after experismntel head trauma in cats and persisted for varying periods up to #8 m9 (Bernstein, 19%). The quantity of free mtyldmline varied between 2.7 and 9.0 gamma percent, and the was related to the degree of induced trauma. wt electmemeptulogmm demstmted patterned Carma-rent charges. The records were first filled with high voltage fest activity, interpreted as evidence of an intense neuronal discharge, com to he succeeded by a short period of ﬂattening of all recorded electrical activity. These phases were then followed by prolonged periods of high amplitude sharp waves in the delta . freqmncies. The behavioral changes related both to the degree of trauma wt of mtylcholine, md the of measured free acetyleholim. With higher Bernstein reported greater degrees of abnormality and greater charges in omecioumess. poet-tnunetic seizures were levels EEG Spmtmeoue also related to the ammt of free mtylcholine warring in the spinal fluid. �Bernstein applied amtylcholine to exposed cat cerebral cortex. men the concentration of acetyldroline was or less, high wlitude shup the electromoephalogrm. waves When of 1 gm percent low frequency appeared in the concentration was increased tOngmepemnt, theelectmencephalogmflattmdina fashim parallel to the post—tramtic records. Investigatims in neurological patients by Tower and HcEadrem (1909a) damnatmted free acetylclwline in the cerebmepinal fluid only in patients with recent head recem grind-mu seizures or after electmvulaive Free acetyldxolhe varied from 0.2 to 100 gm tram, therapy. percent. In assaying spinal fluid dnlineetemae activity, they noted a sharp rise in the nonspecific dmlimsterase fraction (bmwyldwlineaplitting) sad a drop in the specific dwlinesteraee fraction (mdmlyl-eplitting) in patients with head trauma and following convulsive therapy. The cerebmapinal fluid did not exhibit such inversion, although it contained free acetylcholine, after spontmeous seizures. They cmcluded that the level of free aoetylcholine varied directly with the degree of cerebral dmage and that reversal of the cholimvterase W was a m sensitive indicator of cerebral (image. Electroencephalogrm, taken at varying intervals following EEG of between the degree relation indicated a tram, also abnormality and the appeamce of free acetylcholine in the cerehmeﬁinal fluid. �. r -; o-Tn- "W wu-rm- V“ 7 ~ MNIWWF‘. «wwwnmw' . ”3-.— :Nr‘ ‘mw— l‘.«nmw~.—WMM v-y »".\—- (max .9 w— , r‘ "murmur 1 Wm" q‘ 4;. These observations were recently oonfimd by Kovaoh, wounded increased aoetjldxoline in o: 1.1;. rat brain after traumatic shock, and an inhibiﬁn of this activity by the ministration of atropine to the muscle preparation. Tim the «want 05 {no aootgtchoune may ammo in tho who Aptaol staid {cunning WWW mum and the. mount 05 (no acugwwune, the dean.“ and typo cg mmmcapmogwuc «bloom/aim and «Maya in clinical bohavion appeal: cu Wound phenomena. (b) Antioholinegﬂo m and tram: oleotmgr'aphic, The bohavioml and neurologio signs of head trauma were blocked by the parenteral achinistmtion of 0.5~1.0 m/kg atropine (Bomtein, 19%), as were similar clinical changes: oomrring after the intmciutornal addition of acetylcrnlino. Ward (1950) applied these observations to tho treatmm: of closed head injuries. In 20 pttiants with varying dogmas of tram, he amtiniotomd atropine subcutanowsly in doses of O .1 mg/kg, noting clinical in soon and a reversal of the oleotmgraphic effects in others. Similar alterations in the poat-trmnnatic electroimprovement encephalogram were reported by Jenkner and Igdmer (1955) in a rtudy of diethaxino; amthor antidxolinergic drug. A single introvomm dose in forty patients maultod in normalizing the ' abnormal electroencephalogram in six othom. in twentyi-tm and marked ingrovemt .mr—‘xv �T-W‘vw 'h'mivu‘ -.-. ~.w—w.y‘~ WVMMW'Wn-uvw‘w—W 1."'"q'( v -— m7 "In“? - "mmwuﬁwuwmw‘vu “m""vw -WW’-xm -~ wr: TW'f..‘-|‘.Yr 1m Sinilar oboewatiam have been reported with mthylbezuctyzine md in minal exporimnts of post-trumutic shock and man 03mm}. Odom: (mm, affect of atropine Thu 1&5). assessed in the convulsive therapy was process by Ulott and Johnson (1957). With the administration of mnpordaydvmtngmwoeksthepatimts moeivnd oleotxoshodc therapy, the of slow wave activity atropinewto mt oigxificmtly lass than in a omtrol grow who had not monivod tho atropine adhinistmtion. (In a later study these was authors failed to replicate this study, suggesting that dosage factors or popllatim ohms-m multo [Johnson 93; &, may haw contributed to diffemnt 1960]). Similar affects mm obacmd with experimental antioholixnrgio was diothaxim, banaotyiim, the pipaddylbenzilates (Pink, 1958, 1960). The intruvonms injection of and JB-329 (Ditm), lid WIN-2299 JB-318. JB~336 111de ES damchrmizatim in psychiatric subjects. Those EEG ohmgos were associated with bahaviml alerting, anxiety, tram, illusions, and hallucina— tions. In patients the than had recently received eloctmomvulsive a reductim in slow wave activity md a manual of euphoria, denial md oonmsim. Atropine in low thumpy, dam, was was associated with tadnvoardia, mass E88 desyndumization acoarpmiod and Maxim. by At higher dosages, hypcnyndum slow wows, followad by lower voltage , poorly omitted delta activity with super-imposed beta activity wm associated with progressive confusion and disorientation. ”I..- —w m hwy”.-- �.erw—spmﬂlwtvnvamnw." w— r..«wwruun-x...—..,«».w..i. in combat Both Wguphtc mm"._., w-uvw-m .7..-7._~.-—v-—wwww..— um ~— ._.‘...,W wan rvw—Hw. ;W.——»—.- w—u w "r - , -— wwv—ku.“ and induced convulsions, the. ehahgu my be modiﬁed by the. WWMOR antichottuugte MA, Auggutbig that tamed manta 96 acetytehaane on. chawvigtc unpuvttg 4'4 undated with the. high vauaga Alon) wave activity. 05 Wed (0) Brain Similar EEG mﬂlcholim and mtfahnlimggzc ahmgaa and similar blocking by my mticblinergic drugs has been obserwd following the direct application of amtyldmoline to the central nervous cystem. The achinistmtim of a cholimtemse inhibitor Df'P (di-isagpmpyl fluoroplvsphate) elicited high unplitudn rapid frequency EEG patterns similar to of poststatus epileptiws, as wall as changes similar to M stma (Madam £314, 19‘69, Samson gt 9;” 1950, mid Hindi-m 333b, 1950, and Weasel 93.31;, 19%). These EEG traumatic effects were blodmd by small. dose: of parenteral atropine and in amtylcholim after awpolmim. The mat tetmthyl pyrophosphate (TEPP) was masumd and related to the toxic misfostatims and cmwlsims induced (Sim and inm Pepcu, 1952; Stone, 1957). Chatfield and W (1M2) prepared exposed miml cortex with pmstiminn and cvdcud oluhmnoephalogmphic spike activity. Thu spiking, or prior mismtim of atmpim blocked this if present, thc «mutuality could be eliminated by atropine. In contrast to that: findings, Bmmor and Merritt (19%) applied tepical acetylduolim in concentrations of 2~1/ 2 to to the exposed cortex of cats, and noted no effect on the 10% w- «ﬂu-xwa—VVlwu- ��“mun-ny- rw-WV‘VKwnZw'w—w "1W:wmwvtwwav 1W”'_<1>vwnv.<_wum,vwwv ]- ‘_ VFW, .. .- w n - ~-....Vr.ﬂ.--“ “W,- ..‘,_.,‘......_,.,.‘ -.v—--Y‘. ,-. -3- Elliot gt. 5}; (1950) md Crosslmd lid Herridc (195“). 61mm and Popou (1962) fomd the increm in aoetyldnlm following various dapmssants to bc proportional to the degree of depmssim of the central nervous system and the mduction in motor md Buck (196:4), turnover, studying 13min activity. My W lavas and sedation omeludod that some ”dating agents are associated with devoted brain aoetylomline, but that no dawns mlatimxshipo existed. In part, this may be mlated acetyld'xolina to the earlier obsorvatims of Wu: Elliott (1951) that acetylcholine synthesis unsound in mt brain slices, is accelerated by low dosages of mootic drugs, but inhibited by and him dosages. Pme autylcholim patimts with epilepsy was mported in the spinal fluid in (Cone, Tower and Wm, 19%; Tower an (7‘3 epileptic patients, Mom, domtmted free aoetylcholine in qumtities of 0.02 to 5.0 percent with an average of 1.0 gm percent. Acetylcholine and 191mb). 0f 56 gm lawla Hem related to the fmquonoﬁ of seizures, the extent of electmmplulogmphio abnomality, and to the time since the lam: soizum, but bore no relation to mdication, type of epilepsy or lawl of cholinesteme activity. Elliott at al. also noted that :1: fm acetyldmoline was dennnstmble in the spinal fluid in cmoentmtims up to 3 gm permnt after mmzoln convulsions. 7 .w .. "urn“... �.7.~w.. V. - V ,, “my",w 1...,"— 4~.vn,w—._._.m~,m raw-w": '— 0.. ”75v.. .— _‘ . ‘wwm‘ ,van... ..__.,.Wry.~.~ m-Zwm-V'I—r‘wn W.W ”-mw-w.w.mwr~m - n—r.~~—. >¢r:'l.irmv --"‘v-w-V‘MVSWVP -9Tower and McEachem (19'4933) viewed mm the increased acetylcholine of the seizure, and not causal. Studying the hypothesis that the acmlatim of acetylcholixm induced seizures, Tom (1953) masumd the level of acetyldxoline in brain tissue after mtmnolc convulsions. She noted a rise in the as a aoetyloholim content of bmin, before a soizum and a fall during the convulsion. Below certain levela of acetylcholine, cotwulsiona failed to occmr. that the fall in tissue aoctyldaolim during a convulsion was due to inhibition She suggested of aoatylcholim synthesis by increased concentmtims of metabolites such as mimn ions. Gianna!) and Pepeu also measured chmges in cantml nervous system acetylcholine follwing various stinmlanta. moholyl and 3, S—dimthylbutylcthylobarbiturate Chly was after them a significant chmgc in the amtylmolim level. may noted a decmase in association with induced convulsions. With other drug: which they classified as stimlmts iprmiazid 1: (LSD, hydroxytmyptophan and iprmiaxid a ipmniazid, DOPA) tum war: no changes in acetylcholine level. may omcluded that despite intense excitatim produced an by these coupomds, them in acetylomline levels unless trace mm by convulsims. (The differences in obscrvatims no changes Wand between these MomdemcgggléandTmranndEaduem muted to the differences in mthoda of biochemical monuments, for the latter measured chmges in spinal fluid my be mflocting the free acetyloholim. while Gimmn and Pepeu «way—.- —-—.\. �T- - w;—----w~~~.~ .7 um . r - xu ‘ r v,m__.mwa,mﬂmuwwr~pw m~'mvv'v—rﬂr vav-u—w. ---—w ~ ,~ .ﬁﬁr'A—HIwmmrrw‘(Wr-1Inr’mwmr"W'mv-w’ total acetyloholim reflecting band and free fame and Elliott, 1951]). of amtyloholim. The“ mom augguz that Apart/tango“ an. induced su'zwtu by moanpmécd in intercom 6n: mag/Maine an m abound 6m La bound {own which my be inﬂected in the (Laid. Cmbm activity and Auzwtu enhance magma” «lawman, awaiting wine Levels 05 Mots/Moan, Mule “up and muthuia my augment acetytchoune paoduotéan inc/away about mm. measured the [mm We W ’ (:3) Central Nervous sttem Cholinostemes: Tower and Worn (19%) also measured spinal fluid molinesterase activity. The typos of cholimatemnos are nomally found in the spinal fluid: mimestemoe-I (“tm,“ "opecifio," or macholyl—hydrolyzing), whim haaaa high specificity for aoetyldaoline; and cholinestemse—II ("psexido," "non-Specific," or banzoyloholine~hydrolyzing) . momds Both hydrolyze aoetyloholim but have different rates of hydrolysis for monolyl and benzoyldzoline . 'mis differential rate permits qualitative distinctions. By reporting the cholinestemsc activity as a ratio of the activity with a moholyl substrate and with a benzoyldioline substrate compared to a substrate of acetylcholim; two mtios are found: crolinestemse-L/aoetyldlolim and clnlimntemoolllaoetyldiolim. In such mtios normal oembmspinal fluid contains astemsea in the ratio of 33:17 for molimstome—I to dialinestcme‘ll . _ In patimts with head trauma, Twer and Mcanhom reported an inversion of tho cholinestemsea with an increase in the VHF-"147 �».———w ~. r... >qu . 'v—vv—W n» “W...“ mm xwwu-w_~ WY— . “-7 mrmm wnwW—u—mr- w...” maum—w—w—y w «W . unv'r“! "31A“ man-.wvvmw "w” w~:- -11.. dtolimtum—II fraction of the spinal fluid and a decrease in cholinesteme-I activity. Tho extent of the dualinssterass reversal was related to the severity of trauma and to the dogma of the electrocnccphalogmphic abnormality. In patients with elevated spinal fluid acetylchclins after $1)th seizures, however, no change in the ckmlimstomscs or total armlinestemse activty woof was found. in cholinestcms activity may be undamtood in relatim to ohmgcs in cell neutron: permsability. C'holixnsteme—I is fmmd in highest cmmntratim in the The charge cmtral mmus system whilc d'xolinsstemse-II pmdaninatss in othcr tissues, especially blood serum. With an incmm in acetylcmnnc levels in cerebral intcmellular fluids, vasodilatim md incmased cellular permeability may be predicted, with a dsgme of tmsudaticn of vascular fluids into the intemsllular spaces varying with the extent and duration of the vasodilatim and their (W g, 31:. 19%). Spiegsl, Spiegel-Adolf, oo-woﬂcem (19“1, 19M, 19““, 19148, 1953) demonstrated and: pemeability changes and inmassd conductivity of the titauos associated with the appearance of various ions (as pctassim and phosphate) in the Spinal fluid following electrically induced convulsims . Such nm~clcctrolytes as nucleic-acid splitting cellular psmability enzymes may also increased. in Changes thus provide the basis for the high concentrations of metylchclim and the increased concentmtims of duclinesteme-II in induced seizures or head trmma (Tcww V 4nd HcEcchem 19n9c). . persistence of acetylcmlim in spinal fluid after head dmlimstencsc dcspdte and trauma «fur seizma The imam . vmr Var" .muw ��rw ~—.r< —-._..'—v-w__ ‘- ,m Am w—w— WW 7- v nan—1"“ w—u-n w v mm mug; '- wmn—uw—v W v mm -- ,mmmm‘u—n w a"... mm -13- «mum m mm 5M nuvocu Mama 0‘ mbmu nmuimy «a WWW at «may. (a) Aceﬂldaolino, EEG 13mmmd‘wmy and Induced Oonvulsims: Alteration in the blood—brain permeability barrier by the cmtinuing action of acatylcholine may be a biochemical substrate for the postwlectmshoa hypemynchrmy of the electroencephalogram Sud: a possibility is evident in the damnation of an inmm in the mmtmtim of cocaine in brain tissues thme days after a series of 12 induced cmwlsims (Aird We g: .1332., 1956). The in emcentmtim of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of syndimny delta bursts) in the electroencephalogm. We hove oonfimd the many hyper— pmvious reports that convulsive therapy induces electrogmphio hypersynchrmy (Pink and Karin, g 53;, 1961) . Despite a constant applicatim of treatments them is a great Variability in the time of appeanmce, 1956:, Pink the duration and the extent of the electrcgraphic slow wave activity as well as the sensitivity to modificatim by alerting, hyperventilation and barbiturates in pcytidaﬂxic populations. The early appearancn of dagroo hypersynchrony and high persistence thmugzout a prerequisite to mamnt cause has its been described as improvement following electmshodc (Roth, 1951; Roth, §£_g£;, 1957; Pink and Kahn, 1958). the differences in the dogma of induced It is EEG possible that hypersyndurmy mlated to differences in central clmlimrgic activity. The failure of certain patients to develop hypersynchrony may be associated with the absmce of fame aoetyldroline being related may be to him). changes in cumbml function and thus producing .a » “V.lvf"——Iw vu.- "a'v �WW. _. 7: .my- "“ .~..v.,W ”" . , . “V WW 7*MW--—- ‘-u :u wr—u ‘V-U-lw‘-um- WWWW‘,”._¢.~K—.wvﬂﬂ m”. ~"m--'~w , e ~ * .7 _,.,. , v ,7, , (lawn), in their study at” cmniocambml tmmna, included observations of six psychiatric patients undergoing cmvulsive trumpy. Studying the patients aftar 3~7 tmatmnts they reported free spinal fluid acetyldmline in two patients; and an increase in cholimstemse-II and a decrease in dwlinestemsesl with a reversal of the ratio of dialinestemses in five of the six patients. hm those obscrvatims they concluded that the spinal fluid changes in induced convulsions were more like those of amniocembml trump. than those of spmtmeous epilepsy. described the one patient in the series failed to show either fme mtylcmline or a dmlixnsterase ratio reversal in the. spinal fluid as: "It is interesting that this patient was the only one of the six to shrew no response to treatment." They If olectrogmphie hypersynchmny who is a mflectim of increased fme mtyldxolim, subjects who maintain hypersynchmny and those in whom it disappears rapidly may be exhibiting diffemnaes in the kinetics of the dwlinestamsawoatyldmoline hydrolysis systcns . Persistent hypemyndumy may result from a decreased rate of hyd‘olysis of wetylcholine , associated with low mntmtims of either- cholinestarase-I or cholinestemse—II . (Conversely, in patients with short-lived hypemymdurony, dmlimstnmse-I md -II in tissue md spinal fluid may be unusually high) . Fm thug chuwacéoM we would conclude demon; m mediated M an Mme in in W, mm enhancing 2th: MW“ that induczd {we acetyichouue Mg Momma. naming mutual 06 The and Lava as ﬁne 1:; . ru- » m. “mmvw-w' - , v- �"w aw-"m, wrrwnw“—5— mmrwmwm._ . mallow 426 Wad m wm—w—w w. "mm-v m-u—v—v— nw—wuw- gwmy"w_mw u- m. -55.. by muted induud autumn. EEG hwynchlwny a one. Reﬂection 05 abtmed {even 05 Managua and muted 05 01h“ momtym. It 11A pubabtz that that chaugu in movide the mam mngw mm“ pwibtwt 4mm: Mochwécaﬁ 50mm 56!: {nomad the bohemian“ changes mm“ . (f) malimstezm md the Classification of Psychoses: mesa studies have application to tho problem of autonomic reactivity and tho classificatim of the psychoses . Manstein, 91:. 31;. (19%, 1951, 1952) have demtmted a relationship betwaon the blood pmaaum maponse to injected mthacmoline (Macholyl) and the clinioal response of spydtiatric patients to convulsive therapy. is a potent cholimrgic agent which induces vasodilation, tamycardia, mating; and increased peristalsis . 11:53 rapidly Phﬂmacholinc hydmlyled by ermlimstemse-I and slowly by duelinesterase-II . mo blood pronouns of subjects falls after injected macholyl and returns to the baseline within five to whose blood pressure 20 Grow VI and VII have a 9 and a am recovery and Group VII mactom 1133;” 1952). patients in 20 89% to nﬁnutes. Patients 5 those whose blood Wine, Group II—III rate, respectively, while and 97% minutes have recovery mtes as reactors Group VI (Wotan GmupItoIII mactommybelohkeduponas whom while Grows v1 I, II, or III reactors; ormm minutes to motors. Group I and 35% than returns to the baseline within how classified as Gmup pronoun takes more the injected mdwlyl is rapidly hydrolyzed; ‘and VII have a slow hydrolysis rate. It is probable, themfom, that the blood and tissue oholimstemse activity levels of Grows I-III is high; while that of Groups - unr �.- n. .— . VI .wr-. .,m-w.w-,,. ..- - VII in low. A mwkwmr “or a mum: mviow, similar analysis systom levels of "'"ww—ﬁi-m may in mud: r—nmﬁm.mn-‘mrmrp.’ "nu—mu“wl'r-_'In. m Rose, 1962.] mgarding central nervous dwlimammo-I in the dcvelqmnt of EEG hypmyndnmy and spinal fluid levels of acetyldxoline, providing the built for a hypoﬂuais mgarding contra}. nervous cyst-m periptnral mt Inactivity to induocd convulsions and to momma agate. Arm �. ”V7“ :vn-r— www- 7.". New“- mu..~ “Av ‘:~vv-'me~'v xwmm~m.__en.sw—_. mm _.m immv—rmc "cw. .ww-‘rwwm-u-ﬁ—Wrw—_ml -17- see significant in the convulsive therapy ptccess. The published data indicates thlt induced convulsions ame.associated with an inczease in intercollulsr scetylcholinc to levels greater than can be destroyed by cholinsstensse—I activity. Vascdilstion and increased cellular permeability are fblloued by increased amounts cf cholineetersse—II electrolytes in inter» and other enzymes and cellular fluids. These changes are hypersynchwcny which reflected in the increased electrical is recorded as EEG slow wave activity in scalp electrodes, and which can be modified by a wide variety of enticholinerzic drugs. In these reasrds, induced convulsions are more similar to cerebral trance, than to spontaneous seizures. The changes in the onrebmel biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent concentrations of ecotylcholine and Illiuwe to induce concomitant fbilume to produce behavioral electrolyte changes results in a ‘ change. Difﬁerences in the rate of development of cerebral changes reflect differences in the dependence of subjects on cholinergic mechanisms or in their sensitivity to changes in acetylcholine 1mm. mm differences provide the basic for the classification of the mentally The the mode ill by Funkenstein and by Pink and Kahn (1961). observations provide a rational biochemical basis for of action of induced convulsions in altering the �m" 'A "VI-v Ww—vv—n—u—m—«rrm mum-mam mm with tho mm «truer mmmmwrmawm -13.. of pomtie subjactn. 'nnu mm view mwopmsiologie—adapﬂm (Fink, 1957, 1962). an mistmt wavy expressed �_.,. m...“ ... .4. .. .ﬁ-a v “3-..."- w..——_ww «av—m... ”VWFI-WquwLH-‘M‘AW‘K' w-v'lw . . "m." Inn—www-Iw‘m v. "uvw -wu v rays-y‘— :—.- me‘n—I'“m 32mm Aird, R. B... Strait, L. A., Pact, J. 91., muncff, H. K. and Witch, 8. C. Neurophysiologic effects of electrically indwed convulsims. M’ch. Newt. rum. scum, 1956, 75: 371-373. Pram and actim cf acatylchclinch experimntal Bomstuin, NJ). trauma. 1. Nuanpkyuatu 19166, 9: sue-355. min Horritt, H. B. Effect of certain choline dcrivatim clactrionl activity of the cortex. Auk. “want. (6%.). on Runner, C. and mm. Human, A. S. V. and NacIntosh, P. C. The physiOIOgical significant of acctylcholim. In K. A. C. Elliot, I. H. Page and J. H. Qustcl C. C. Thoma, Springficld, 111., 1955: 37I4~375. (Editors), uwmmuw. mtfield, on Dewy, cortical potentials. Mu. Cam, W. “Viv P. O. and Tm, in epil’psy. V., Worn, Jo‘oquo. 1&3, 73: D. B. Grassland, J. 1950, 162: “SQ—MW. E. w. Effects of prostimine md acetylcholine J. Pkg/«20L, 19142, 135: 633~6u0. and D. I. Acotylchcline and mammal 59.639 effect of anaesthesia on the matylchclim commit of the brain. J. Phydob, 195%, 125: 56~66. Dale, R. H. Th action of certain «tau and ether: of choline. and their relation to maxim, J. Plummet. Exp. Thu., 1913, 6: 1'47. Elliott, R. A. (3., Swank, R. L. and Henchman, N. Effects of mﬂmtics and cmvuhmts on acctylcholixn content of brain. W. J. Phgual... Pink, H. A and Merrick, A. Tm unified meaty of the cctim of psychodynmic therapies. Pink, H. Effect of anticholimrgic agent, diethazine, cn EEG and behavior: Iimificm for theory of convulsiva therapy. Mch. Newt. (cued, 1958, 80: 380-4587. was “ch. Fink, H. Effect of mticholinomic on pcat—cmvulsiw electromccplaogm md behavior of psychiatric patients. can. Humming 1%0, 12 (2): 359—369. Emeh. ’ Pink, view. m. of action of cmvulaivu therapy: the mm'ophysiolosic-adaptivc J. Nwaoplgcuazu 3: 231-233. M. Pbdo Pink, H. and Kahn, R. L. thtintive studies of slow wave activity following cloctmstnck. Bactuzuccph. can. "wuphyuotn 1956, 8: 158. Pink, 14., mm, R. I... Karp, 2., Pollack, M., Gm, H. A., Alan, B. and Lafkcwita, H. J. Inhalantuinducad convulsions. ma. Gen. mama, 1961, In 259-356. mm, A. PL, Bales, P. D., Willis, md Himwich, H. 8. Experimental pmdwtim of electrical major convulsive patterns. Amen. J. PhyuloL, 1&9, 1H6: 117—1218. Mkenstuin, D. H., Gmmblatt, H. and A. new Mutt. 0.3., 801mm, H. C. Autmmdc chins“ ramming electric shock Mutant. mm 19%, 108: #094122. J. New. �.- “ 'E'mr u-men... Mountain, wumW,mu“... 1~w‘mww.w“~-mmmern“—"~—IJ...- mm, amnesia H., paralleling peyoholoﬁo 1951, 11”: 1‘18. D. qvp- —..,. WW me‘w ”Va-WV“..— mwmmwmvmuww W3 mantally ill paﬂlnts. 1. How. m. 01.6., H. and Solomon, H. C. Autonoiuio Menuhin, D. it, emenbhtt, M. and 301m, H. C. Autammio nervous system out of prognostic simfioanoe in mlation to alactmskndc treatment. P‘ymm. Mo, 1952. 1“: 3“?“3620 Gianna, N. J. and Pepeu, G. Drug-induced charm in bmin aoetylcholim. W. J. Fitment” 1962, 1% W233. A. and Hiwich, H. E. Effects of Mam, J., 33313, C. P., Manley, di-iaopmpyl flmmptmplmto (DEF) on alectmanoephalogm and cholinastarase activity. ,Eumamcph. can. “Mphysutu 1950, 2: Mil—ha. Basis, C. F... C. F. Hampson, J. L. Balsa, P. D. and Effect of trimthadima (Tridima) and other drugs on Madam, oonwlaions caused by di-isqwmpyl flmmplmphata (OFF). Ame-A. J. mum. Himioh, H. 23., A. H. 1950, 106: 816-820. Jonkner, P. 1.. no ladmer, H. The effect of Dipamol on the olectmmoopmlogrm in tho normal subject and in time with canme tmuna. EWmuph. can. ”meto' 1955, 73 303’3050 6., Ulett, G. A., Johnson, H., Sﬂth, K. and Sines, J. 0. Eleotmomwlsive thrapy (with and without atmpim); affect on Johnsm, I... analyzed ahctmanoophalogmm. chemically 2: 32u-336. 1960, Melt. Gan. Paychiot” alum, M. and Knaub, V. Quantitative estimatim of the Kabat, E. A., albmin and gamma globulin in actual and paﬂmlogic oembmspinal fluid by nomads. MM. 1. Mad" 193:8, *3 (5): 653-662. Wm Kovada, A. G. 3., meo, A. and Halmagyi, M. hm Hamid"Wit Aoetyldiolina‘omtmt of the brain in traumatic smdc. Aotc Phyaiozaglca (HungJ, 13: fiber Lou-vi, 0. Meir. £. 4. gas. 14. our Hemmnwﬁkmg. 1921, 189: 239-»2u2. Haymrt, E. W. and Buck, E. 6. Effects of C.N.S. Dapmsmts on Brain Aoatyloholim. 19M, 6: 191. Wtagut, Heisman, H. and Elliott, K. A. C. Effects on omvulsmt and narcotic drug on aootyldxolim aynﬂnus. 1. PM. I Expat. Thump" 19513103: 35. mam. Wm, specificity of We in mm D. and Studies on cholimtama: on tissue. 1. Biol. (than, 191:5, 158: 653—666. M. A. Ridxtor, 1). mad Crossland, J. Variation in acetyloholim’oontmt of the brain with physiological stata. J. Phyatolu 19%, 159: 2h7-255. W. Rosa, J. '1'. 'me We; Menuhin hat in the ~ A mview of the literature. Add mdor barhitmte anaesthesia produced by twain-mt mad their simificmoa for the theory of M clam-awake actim. Enougmuph. can. Managua" 1951, 3: 261480. Roth, )4. EEG �Both, 15., Kay, D. W. K., Show, J. end (keen, J. Prognosis and pentothel induced electmnmplulogmphic changes in electm—omvuleive treatment. summaph. can. Nemphy‘iol” 1951, 9: 225-237. Spiegel, E. A. and Spiegel-Adolf, H. Permebility chmgee in the brain induced by tamed and insulin cannﬂaions. J. Nuv. Max. 91.5., 19‘31, 93: 750—3755. Spiegel, E. A. and Spiegel~AwlL H. mysiooodieuionl effects of electrimlly inclined cmvulsime (mmbmepinal fluid studies). Tum. Mu. mm. 1455., 19%, '70: 130-132. Spieaal, E. A. and Spinal-Adolf, H. Physiological and phyuicodwmicel mechanism in electroshock treatment. Conan. Newt” 1953, 13: 38-53. Spieael, E. A., Spinal-Adolf, H. and Hem'y, G. mysiooodxdical changes in the brain electrically induced convulsive discharges. marina Tm. m. Newt. Au" 19M, 68: 17h. Spinal-Adolf, M., Wilcox. P. H. and Spiegal, E. in electrmhodc treatment of psydxoees. Mae 19.48, 10“: 697-406. Stem, We Tom, H. E. 1. Pk”. The mole Me, A. Cerebmspiml fluid m. J. mama, of acetyldwbline in brain mtebolism and fmctim 1957, 36: 222'255. Effect of omwlsion inducing agents in the amtylcholine content of the brain. J. Phyeutn 1953, 173: 179—183. (2. m. Effects of single injection of corticotmpin (ACTH) on We, ion and emtyldxolim ambmt of bmin. Ana. 1. Miguel” mnim 1953, 173: 1764.78. C. Wm, and patterns wetyldmline in the oemhmspinal fluich 0011th a. Aoetylclmline ma neumml activity. I. ﬂower, D. B. and of patients with maimmbml mm. CW. 1. Quench, Tatar, Wehem, 27 lQuQa, (Seat. E): 105-119. D. B. and dnlimstemes in hm 1949b, 27 (Seat. 13): mutant and characterization of mmbmspiml fluids. Canad. J. Rum, D. 'Ihe 132-1'45. Acetyleholine and neuronal activity. Worn, II . Acetylmolim and dwlima‘hmsa activity in the Tuner, D. B. and D. fluids of patient: with epilepsy. szm'. J. (Sm. E): 120‘1310 Ulett, G. A. and mbmspiml RPAWA’?, 27 1mm, datum, M. W. Effect of atropine and soopolanﬁne upon eleetmenceplulogmphic charges induced by electm-oonvulsive therapy. Euwameph. can. Namaphguot" 1957, I: 2174224. Ward. A. A. Atropine in the treatment of closed head injury. J. Newsag” 1950, '7: 398-402. Ueeeoe, H. C., Green, R. Wm, of atropm md aoopolauim on the 3., B. P... and Kmp, S. central effects of DFP. Wt. The J. inﬂuence �DEPARTMENTAL CORRESPONDENCE DATE Julx 29z I965 SUBJECT Cholinergic Mechanisms in Convulsive Therapy To.“ Max Fink FROM George A, Ulettz MODo A most interesting paper, well put together and documented and with which I MoDo DEP'T DEP'T am in the main in agreemento There is one minor typographical error on page l2. GAUzlz �CFDLINBMC W315 WV!) IN Max W Fink, PM). mmmpmmotpmmnmmsmmmma Paydaiatzy, (immunity of Iii-semi. Sdml of Medicine SHOO Arsenal Street, St. Innis, Missouri. 63139. , Aided, in part, by usms grants ”44.921, 114-2715, ail-mus, md Iii-11380; ad the Psydiiatric March Fomdntion of Missouri. �VI: 7-17-65 WCWHWIVEW Despite mm application and study, the nod: of action ofﬂnccnwhivethmpmmnminsuﬁmic. Matudy mmmdtomumphysiological( paydwlogical( social ). clinical ( ), ( and aspects, elucidating me pmaent nam— ) phyaiological-«laptiw ). View of the process ). ( 'lha amply dnvalcpmnt and persimmon of signs of altered cerebral fmctiun mm mpomd to be requisite to (Pink md Kahn, 1956), with mess in behavior 0100*:ch slow wave activity as the mat significant index of altered brain function. Thu this Mien slow um that pmddcatim with ampina inhibited ‘Jormcn, 1957) and the report activity (Ulett and that antidxolimrgic a mm nursed these clinical ahatmgmphic alarms (Fink, 1958) 311mm that .me biodmnical basis for the convulsive therapy process the clnlimraic m as wall may be in of the central nervous system. This raviaw discusses the available data agarding acatylcholim ﬂ �and the dwlimstemes in the convulsive therapy process. Acetylcmline has been extermively studied m an active agent in the transmission of dowdptiom of Dale mm impulses since the It is (191A) and Loewi (1921). first a comtitmmt of mmm tissue, existing in a bound form which is liberated during the excitation process. It is rapidly hydmlyud thrwgh the specific action of duclinestarase and in rapidly momstituted by the ohcline~aoety1ase system (Rid'ater and Crosslmd, 19W) . In noml cembmspinal fluid, free acotylchclim is not present despite the mpid bound and breakdown of acetylomline during periom of activity and excitement (Tower Wm, 19u9a). The cambmspinal fluid does have measurable dwlinesteme activity, havever, principally of the "two" or mdwlyl hytvlyzing type (Madam and mm, 19%). In the absence of free aoetyldxomle and mdar the conditions described, electroencephalom fail to show abnormality. �(a) Grahame ﬂats of sootylcholim was found Crmiooembml Tram: Prue in the osmbrospinal fluid within a few minim after sxpsrimtsl Mad trauma in cats md persisted for varying periods up to “8 hours (Bomstein, 19%). The quantity of ﬂu the amtyldmlim varied W1: was (:th between 2.7 and 9.0 gm pennant, and related to the degree of induced mum. shotmsnoephalogmms amazes. me mooxds were demtmted pattmd first filled with activity, immuted as svidsnoo of high voltage fast an intense neuronal distant-3e. soon to be sumedsd by a short period of flattening of all recorded electrical activity. These phases wen then followed by pmlongod periods of high mlitude sharp waves- in ttwdcltafmqusnciss. 'msbehaviomlohmgsswsmmlatsdboﬂitothsdsgmsof mmmd to tho want of mmd fme amtyld‘nline. Vth highcr lovels of amtyldlolim, Bomstsin reported greater dogmas of EEG Why and water changes in consciousness. �31>th wt post-traumatic seizures ware also related to the of fme acetyldwlim appearing in the Spinal fluid. Bomstein applied amtylctnline to exposod cat cambml cortex. When the concentration of amtyldxolim percent or lass, higx amplitude slurp waves appomd in the electxmmaphalom. When was W6 t0 2 gm percent. was 1 gm of low frequency the concentration 01.0meth the 1000160 fashion the patetzmnatic flatumed in a parallal to Parallel investigatima in neurological patients by and Wm (mm dumtmtad free Tower acetylcholine in the cerebmspiml fluid only in patients with meant head tmuna, meant wand-ml seizures or after alectmcmvulsiye therapy. M0 amtychlim varied fluid spinal assaying from 0.2 to 0310111103001”: 100 gm peasant. In activity, they noted a sharp rise in the nonspecific dwlinesteme fraction (Mmoylcholim-splitting) and a dmp in the specific cholinesteme fzmtian (mohaiyl—eplitting) in patients with had tmma and sanguine convulsiva therapy. The cambmspinal fluid did not �exhibit such invemion, although after it contained free acetyldxolim, spontaneous seizums . They concluded fr“ mtyldzoline varied directly with the damage and that the level of degree of cerebral that reversal of the dualimeteraae fmetims was a mm sensitive indicator of cerebral dmgc. Electmencephalogrmna, taken at arming intervals fellowing minim between the dagme of tram, also indicated a EEG-Wt); md the appoamm of free amtylcmline in the cerebmspiml fluid. mm Wkwwm Tim «the, 4;me We! mm 0‘ due magma-u. may tame in the (cumming {m autgtchouu, abnombbty, and WW «the. Mg“ W“ W. «tam and the want chalk.“ and type 0‘ 4'.» 05 demomuphalogmpuc dialed mm); «ppm «6 �Antietam} (b) bahavioml and mutual m and trauma: mmlogio signs of mum The m electrogmphic, blocked by tbs awninistmtion of 0.5-1.0 Wkg ntmpim (Bernstein. I 1986). as was similar inmcistml clinical change” mowing after the additim of aestylchcline. Ward (1950) applied injtmida. those oboemtima to tbs tmatmnt of closed head In 20 of patients with varying dean-e3 trauma, ha administamd mopim WW1); immt in some and in doses of 0.1 m/kg, noting clinidal a mml effects in others. In a study of diethnxine. Jonkner and the W at the W forty patients with anticholimgic drug, altemtiaw in (1955) mportad post-mmtic aloctmcmophnlnm. dose in electroencephalographic W A sinﬂe intmvamus electroencepmlogrmm resulted in normalizing in twanty-tm and marked inpromnt in six otham. Similar observations have been Imported by Denisamco (1965) using mthyl‘bamctyzim and poat-atrmmtic mmtin in animal that and 03li em. ewinmta of �Truss obssmtims were assasssd in the convulsive therapy process by Ulstt and Jornsm (1957). These workers administersd dosages of atropine w to the patients waived that the mt: mm slsctmsm of slow wave per day during the weeks therapy. They downstmtsd activity prodmsd in those patisnts ms significantly less than tbs control group who had not received the atropine ministration. (In a 141th study these authors fdlsd to mplicats this study, suggssting that dosage factors or population changes have contributed to different msults [Jormsm These observations provided the basis g}. 31., 1960]). for studies with othsr imam anticholinsrgic mounds (Fink. 1958, 1960). hummus JB—336 arid Wins. the pipsridylbsnxilntss JB-329 (131mm). and WIN-.2299 induced dssmhrmiutim in psychiatric subjscts. These Hum The injection of smrimntally active anticmlinsrgic camels as disthssim. JB-ala, may EEG EEG changes associated with barnvioml darting, anxiety, tramm, illusions and hallucinatima. In patients also had mently - �mind elootmoonvcnsivs the achsinistmtion of throw, these Imomds was associated with a mduotion in slow awn, mm wave and 'eonnnion. activity and reversal of Aunpim was also examined in low doses, and in these administmtims, EEG dosynctumizstion ms obsomd nervousness sod tension. At highnr dosages, hypersynchrmous slow waves, followod by lower activity with menisci by tachycardia. mimosa wings. poorly organized delta bots activity melamine: by pmmssivo confusion and disorientation. Both in oleotrogmphic annual tum and indwed convulsions, the 0W8 may be mdified by the commont (hogs, administratioh of mticholinargio thus suggcoting that immaud smarts of aootylohlim or inorusod oholimrgic receptivity is sssoointod with the high voltage slow wave activity. (a) min and iomlino anticholimm gm m: SimilanEGorangesandtublookingthmmnobumd following the dinct application of mm systm. sootyloholixu to the mm]. �The aministmtim of a omlineeteme inhibitor- DP? (di-isopmpyl fluoroxmospheta) elicited high amplitude rapid frequency We 19mm, EEG patterns similar to status epileptious, as well as similm to those of post—hmtio states (Freeman 33 11., Hanson Egg, effects were blod<ed 1959; and Himioh by small doses 339;, 1950). These EEG of parenteral atropine. 'me great increase in aoetylcmoline after tetmtthyl pyrophosphete was (TBPP) manned and related to the toxic misfestetims and omvulaims induced (mm and u: thfield and Dempsey 1952; Stone, 1957;) (19%) prepared exposed animal cortex with pmstigmim md evoked electroencephalographic spike activity. The prior mistmtion of atropine blocked thio spiking, the almomality oould be eliminated present, by or if atropine. In contrast to those finding, Emma!" and Merritt (19%) applied topical aoetyldxolim in concentrutima of 2-412 to to the exposed cortex of cats, and noted no effect on 10% the electroencephalographic changes after intmwnous atropine (1 mg/kg.) 'lhe concentrations of acetyldtoline in these experiments, �10 however, were higher than the and the gm topical applications (l-‘t intrusistemal (0.2-10 gm percent) percent) injections of Bernstein (19%).. Burner and Merritt also made note of elem- encephalogmphic effects similar to acetylcholine from motion/1 (emtylhetmthylcmline) much lower than the and cloud (oerbanyldlolinﬂin mtyloholim concentrations. They cmoentmtims ascribed the increased effectivems of these diolinergic drugs to their lack of sensitivity to cerebral almlimstemses. These data are conflicting and further study is museum to qualify this issue . (c) Oembxnsgiml fluid Amtxlcholine and Seizures: of aoetyldiolim metabolism indicates that it is One View fomd in nervous tissues in an inactive band fem. hiring periods of activity, amtylcholim is liberated at the cell dsectivated rapidly by mm, dwlinestemse. The where wt it is of bum asetyldmolim is the resultmt of the continuous processes of synthesis, liberation and bredcdmm. It has been postulated that the level rises during sleep and falls during activity. (Richter and Cmssland, 19%; Elliott, Swank and Hendersm, 1950; Giaruun �Pepeu. 1962). By using liquid air quick freezing methods. Richter and Grassland measured the level of acetylcholine (micro- gem per brain tissue) during anaesthesia and sleep to be mg. 300‘ higher than post-“12m levels. The difference in tissue levels is tnansient. however, as the resynthesis rate for acetylcmline in net brain in high (1950) confirmed m1. the” owemtiom, also Pepeu (1962) fomd an increase 3 noting that after gm per cent. Gimmn md in wetylcholine named by a central nervous mum depressants to be roughly reduction in and no mm activity. acetyloholim we reported in the spinal fluid in patients withepllepey (Cone, and PbEeahem. 19149 1)). 0f 55 'Ibwer and mascara, 19%; epileptic patients. demetmted free acetylcholim in quantities of 5.0 M proportiml to the degree of depression of the central nervous system m :3in convulaims free wetylcholine me demustmble in the spinal fluid in concentrations w to 1;! gm/gm/minute). Elliot (7 with 1.0 of an cent average per gem gamma Tower an (77%) 0.02 to per cent. �12 Acetylchclim levels were related to the frequency of seizures, ﬂnextentofelectnnncemelogmphicmmlity,mdtothe the since the lat seizum, but bore no relation to medication, type of epilepsy or level of clnlinestense eotivity. Tower and Maﬁa-hem (1904912) vimd the increased acetyldwlim a by‘prodmt of the seiem, Studying the hypothesis that the and not camel . emetim of ecstylchcline indmed minutes, 'l‘orde (1953) measured the level of ecstylclwline in brain tissue netmmle convulsims. .‘ She noted a rise in the ,_ V V ecetylcholine content of brain, before a seizure and a the cmvuleion. Below fall (bring certain levels of ecstylcholine, convulsims failed to comm. Stu suggested that the fall in tissue acetylmolim during a oonvulsim was due to imibition of ecstylcholine synthesis by increased concentrations of metabolites such as mnium ions. Wmmmmumdohmgesmmmmm system acetyldmolim following various stimulmts . Only after �13 unholy]. and 3, S-dimthylbutylcthyl-barbitmte significant chmge in the acetylcholim level. damn. was They noted a in associatim with induced convulsions. drugs which ﬁrearm as stimlants Md mmmdumainmtyldmlim + other With 133mm, (LSD, hymoxytmyptaphm and iEprmiazid level. there a + DOPA) them WWW daspito inﬂame excitation produced by these commie. them wan no dung» in mtylcholim level unless than were accompanied by convulsions. (The differences in observations botmmmuwerkmmdmggglmdmmrmdﬂcﬁadmm my be in diffemnaas the to related mummnts, for thc latter methods of biochemical wand changes in spinal fluid w 61m and Pepeu mﬂecting the fun acctyldxolim,‘while 12; bound and reflecting acetyldwlim mumdntatal true form of aoetyldzoline.) Thu: Atuau wages: that on: Wed by an sputum Lame. in an. induced 1mm law 5n: awtytchaunc �”mm—“hr“ V» 3- ‘ v w» . m w 1-: “r. 0... ~ W "n , nr-r-w, ..-.p:..u<ﬂv.»rrw-¢.M “av—w. . .,. 4. ....“.,_. w... ,, 'zs-sznr-W"“air‘quvww'ﬁ'qmti'd‘u. w. » ,‘rv —.».‘ wm‘ , w - 1n abound 4m in bound (on which my wind. (Laid. Cmbm nativity Micheline dalmatian, manna. Lemming mum 15qu in #1: enhauu tame (cum 9‘ Me blew and Mama auguwut mallow: madam“ 42mm aunt (d) Comm]. Nervous Wm and be mm . Sgt” ('holinostemes: (19%) also uncured spinal Tower and ﬂuid cholimsturase activity. No types of dnlimstemes are normally found in the spinal fluid: dwolimstemad ”true," "Specific," or Molyl-hydmlyzing) . whim has a high specificity for acetylcholim; and dxolimtemacu-II ("pseudo," or bonmyld'uolim-hydmlyzing) . "mpacificﬂ Both oompomds hydrolyze acetylcholim but have diffmnt rates of hydrolysis for mcholyl and bonzoyloholine . 'mis differmtial mta permits qualitative diatimtiom. By reporting the cholinostemse activity as a ratio of the activity with a mocholyl substrate and with a homoyldmoline substrate compared to a substrate of acetyldmlim, two ratios are fomd: dzolimsteme-I/wetyldzoline . --- v r v , -- ‘ ~- a"; . ��rmw, 16 vasodilation and increased with a degree of cellular permeability may be pmdicted. amudetion of vascular fluids into the inter. the of duration md with extent the varying cellular spaces g: vaaodilxtutim (Rabat mad their comma pomability such 51;, 19%) . Spiegel, Spiegel-Arblf, (19%, 19W, 19%, 19%, 1953) chm demtmted and increased oonchwtivity of the ions (as various of with the associated appearance tissues potassium and phosphate) in the spinal ﬂuid following electrically indwed convulsions . Such non-electrolytes , as nucleic-edit: splitting mama , also increased. Ganges in cellular permeability @6011th may thus provide the basis for the high of aoetyldzoline and the increased concentratiom of aholimstemse-II in induced animus or head and We!“ The head 1989c.) . persistence of acetyldxolim in spinal fluid after tram activity tram (Taver- and may be after seizm'es despite increased cholinesteme related to the sensitivity of the acetyldxoline- dxolimsteme-I system to meantmim relationships (Nadmm W. , ~1— ~- A” .—,.- �17 and Wu, 1935; Tower and Wm, muse; Burger: and McIntosh, 1955) . At "physiologic" comantmticrns, hydrolysis of mtylcmlim is rapid (3-4 lunar com—um, MW) but at higher and the activity falls off quickly . In contrast, the dialinastemaun acutylchclim relatimship is map-cite and the rats of hydrolysis incimma with increased: ammunition. 0m view of these mktimhips suggests that while the usual concentrations of mtyldmolim a cell dostmyod by the specific activity of few Wounds, my «and the seizum are dnlimstomeJ in a m excessive concentration following excitation the mate of hydrolysis by coir-m Mahala mnbms may be itself cholimstcmeJ. m reached and a seizure inclined, with adding to the mum: of free amtylcholim. The immune! acctylcholine diffuses rapidly, affecting vascular and annular pumability and imam; the mntmticns of various iom and dmlinentemmn in the of molimateme-II , though of low 031". The activity efficiency and depending on ��in brain tissue, associated with the appearmoo of hyper- (delta bursts) in tho electroencephalogram. syndmrony We was have oonﬂmd the many pmvim reports that convulsive thumps: induces elootmgmphio hypomyndarony (Pink and Kahn, m 1956; 93. 93;, 1981) . mutants than is mom. slow by m Despite a constmt application of a great variability in the the W103! and the exam of the alcotmgmphio mitivity activity as well as the alerting. hypeantilatim synchrony and in psychiatric dew hyper- its persistence thmmlmt a treatmt has boon described as pmmquiaite to It is to mdifioatim and barbitumtes populations . 'lhe early appearance of high Week tins of (Roth, 1951; Both 93.2%, mm 19531;th possible that the £15.fome in EEG-hypemynduw my be of central oholimrgio following and @,1956) . induood the dogma of muted to differences in the activity ”Wm . patients to develop hypomyndmmy pnoluding a clinical me name me failure of certain may thus be associated to Wood convulsions. Tower �.. 7.7. wrunvx—u— 20 and Will“ (lauea), in ﬂair study of mommbml tram, included obaawations of six paydziatrio patients mdergoing convulsive therapy. Studying the patimts aftor 3.7 momenta aootyldaoline in two patients; may mpootod free spinal fluid and an imam in (momma—II mumstomod with and a demase in a reversal of tho mti-o of mono-stoma: in five of the six patients. hm those observations they minded that the spinal ﬂuid dmges in induced convulsions mmmliketmmofcmimmbmltrmmanﬂmoof spontaneous epilepsy. Boarding the one pttient in the series failed to who show either true wotyldmlim or a duolimoocmse ratio reversal in the spinal fluid, they wrote: patimt was Mt." "It is interesting that this the only one of the six to show no rospouso If electmgmphio hypemyndxrmy is of inommd {me acetylcholim , subjects whammy and those in whom it who to a reﬂection maintain hyperh disappears rapidly may be exhibiting diffemnoes in the kinetics of the d1011nestemse~ wm. w,- Nx‘vrpl .1 �-\ “ --~w an» .7 r'v-vww-‘ 1". -.r Ti'prp"-ﬂ-=Au‘n “-6.“..- ~-‘ ‘31 . W W . , “‘7.dvzw‘". V... mu. metw'w—mwmlv‘lu":.e.vrlvn—“Atm-‘mWW w-xm “m.- Y‘a""' 21 acutylctwlim hydrolysis system. 'Fhmistant hypemyndumy result dsmd {mm a may rate of hydrolysis of acetylemline, associated with low mnemtmtions of either molimatemsea-I with shortin patients '(Oonwmly, dlolimutcmc-II . or lived hypemynduw, dxommteme—I md -II in tissue and spinal fluid PM: be mmually him) . may that: anomalous was 0&0:va «wanted “W‘m, «shaming the We. an: WWW a EEG 51prwa 1.5 a; Lgtu at WWW paovtde We in We mwmum.‘ wumtuuu. Mad one WW W pubable that saw! an that induced Wag embmcpweabuétym and It a on would coucmde aw by The Level. 05 upcmd Mad .5qu . mama of pmabuéty Mud Law 05 exhale. ﬂzuc changes in 05 «anaemia. mm deem- m mama: 4mm (an m pmumx chugu foaming induced 0.0qu . w ..—-.w-w~.-w... �K. i [ ‘ v. ,7 W .. f m .l . V, ». V, ,,,,_V -. .o “:2 ....V ﬂu, ”w...“ - w-wﬂl’m'." ”no”. .7 ..n “w... amp-“mm- "...v'vmm. ._, f.v-w—«-—v~—— v0?" m—v‘ wkumu. , 3‘“ .7 a run ,. . -- 22 (6) Gaolimtemes Thus studies may and the Classifimtim of Paw: also have applicatim to the problem of ‘ automic Inactivity mum and the clansiﬁcatim of the psychoses . and athora ( a «Miami-nip between ) true blood haw ”castrated pmssum response to injected madmlyl an! the clinical mponae of psychiatric patients to ammlsiw whim ﬁlmy. lel is a potent cholimrgio agent mm, mama vasodilation, tadxyoardia, peristalsis. It is rapidly hydrolysed by and W6 diolinesteme-el and :11me by dzolimstemse-II . Tbs blood pronoun of subjects fall: after injected mohalyl within five to more than 20 md mtums to the basolina minutes. Patients whose blood E l I i plum returns to the baseline within classified as Group panama takes 20 Group VI and VII 5 minutes have boon I. II, or III mentors; those whose blood armors minutes to mtum to baseline, as rumors. Group I md Grow; IIoIII motors �23 have a 9 and a 35% recovery rota, respectively, while Group and Group VII reactors 9:92;, 1952). Group patients in whom 89% and 97% recovery rates I to III reactors may be VI (Menorah looked upon as the injected morolyl is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. We may predict, therefore, that the blood cholinestamsa activity levels of Groups I-III would be high; while the activity of Groups VI A - VII would be low. similar analysis may be made mgarding central nervous uysten levels of cholineatemmel in the development of Em hypersynolumy and spinal fluid levels of acetyloholim, providing a basis for a oongment hypothesis mgarding central nervous system reactivity to induced convulsions dmolimngio agents. and to peripheral �. ..— .—\..‘ .. .—Vw-~'. 7...... "any.” “.7 lmr.r"vv,~ .. ...~ y.. . _,_,‘ , ~~,.. m. .WWV mm. rm. ~ v-y ‘ WV W H .wa-ﬂq 2'4 CONCLUSION : Central oholinergic Insomniac: appear nah- W in!» in the convulsive therapy process. ‘ significant The published data [that induced convulsions are indicate associated with an increase: in interoelluler acetyloholme to levels greater thm can be destroyed activity.“ Veeodiletim and increased are followed by increased other enzymes and by cholinestemse-I cellular permeability wants of cholinesterese—II and electrolytes in intercellulsr ﬂuids. These chmges are reflected in the increased hypereynchrmy which can be modified by is electrical recorded in scalp electrodes, and which mticrnlimrgc drugs as atropine, benactyzine, and diethazine. The changes in the cerebral biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent cmcentrttions of acetylcholim and failure to induce concomitant electrolyte changes results in a failure to produce behavioral change. 4'u-L...» 1.x. —~- -- 7 �2S Diffcmnoos in the mates of development of reflect diffemnoea in mbml that ‘0me of subjects on ohangas cholinergic ruthenium or in their sensitivity to changos in aoetyloholixm levels. Then diffemoes provide the basis for the classifica‘ tion of the mntally “most: the mode ill by Pmkonstein and by Fink and Kahn (1961). observations pmvidu a rational biodnmical basis for of action of induced mnvulsicns in altering the buhavior of psychotic subjects. These views are consistent with the mom general neurophysiologio—adaptive theory expressed earlier (Fink , 1957) . �REFERENCES M, R. Bo, Stmit’ L. A0, PM, do We, “muff, Mo K. ma Bowditch, S . C. Nemphysiologic effects of electrically induced ccnvuleicm. Melt. Peyehiet. 1956, 75: 371-378. ”Wt. (cum, Bomstein, M.D. Presence and action of acetylcholine in experimental brain trauma. 1. Nwophyeutn 19%, 9: 3%«366. Bummer, C. md Merritt, H. H. Effect of certain choline derivatives on electrical activity of the cortex. Mch. Munoz. Psychmt. (cum, 19ﬂ2, H8: 382~395. Wu, of ecctylcholine. A. s. V. and Macintosh, 1-“. C. In K. A. C. Elliot, The I. physiological sigiificancc J. H. Springfield, Ill... H. Page and Queetel 1955: 37u-375. (Editors), Numchmmg. C. C Thomas, Omtfield, P. 0. and Way, E. W. Effects of proatigmine md acetylchcline on cortical potentials. Mu. J. P11544201... 1m, 135: 633~6H0. Cone, W. V., Toner, activity in Wm, D. Acetylcholine and neuronal and epilcpey. J.A.M.A., 19%, 73: 59-63. D. B. Dale, H. H. The action of certain esters and others of choline, and their relation to marine. J. thueol. Exp. Thu... lSlu, 6:1»7. Elliott, R. A. C., Snark, R. L. and Hmdemcn, N. Effects of mathetics end ccnvulsmts on acetyldmline content of brain. W. J. "15161.0(" 1950. 162: ass-hm. PM. M. A unified theory of the action of paydzodynmic therapies. J. Hill‘idl H06p., 1957, 6: 197-206. Pink, M. Effect of mtichclinergic agent, diethezine , on behavior: simﬂcance for theory of convulsive therapy. Adah. Mental. Paychiat. {Ch£c.). 1958, 80: 380‘387. EEG and Fink, H. Effect of mticholinergic compom$ on poet—convulsive olectmencephelogxm and berminr of psychiatric patients. Eummuph. cu... Nauphyuot" 1960, 12 (2): 359-369. Pink, H. and Kuhn, R. L. Qumtitati-ve studies of slow wave activity following electroshock. Eucmemph. can. ”canophyaiat” 1956, 8:158. Fisk, M... Kahn, R. 1..., Ken), 2., Pollack, H., Green, M. A.. Alan, and Iefhowits, H. J. Inhalmtoinduc-d convulsions. Mch. Gen. 1961, “:259-266. mm, ' m, Bales, P. p., Willis, A. md Hinwich, H. B. Experimtel production of electrical major convulsive patterns . W. A. J. ”twin-L" 1%9. 1%: 117.12“- B. hymn ��an'V-WI' -3Spicgol, E. A. and Spinal—Adolf, M. Physicochemical effects of electrically inclined convulsims (cambmspinal fluid studias) . Tm. MM. Newt. AAA” 19%, 70: 130-132. Spicgel, E. A. and Spinal-Adolf, H. Physiological and mysicochomical Marxism in tmatmnt. Conga. NewwL, 1953, 13: 38-63. 013::th Spiegol, E. A., Wm Spicgclmlf, changes in the brain H. and Benny, G. Physiococl'xcmical electrically induced convulsive discharges. Tum. ML. Haunt. MA... 19%, 68: 17a. Spinal—Adolf, 14., Wilcox, P. H. and Spiegel, E. A. Cembmspinal fluid menses in electroshock treatmnt of paydzoces. Mu. J. mm” Stone, H. E. The role of acatyldmolim in brain metabolism and “mm. Tom, m. J. M0 M9, Effect of convulsim content of the brain. Man. J. C. 1957, 36: 222“255c inning agents much, on the acetylcholim 1953, 173: 179.183. Tonia, C. Effects of single injection of corticotmpin (ACIH) on manium ion and acetylcholine (intent of bmin. MM. 1 . Myuol" 1953, 173: 176-178. Acctylcmline and murmal activity. I. Warm, Gnumtomso pattcrm and acutyldwlim in the cembmpinal fluids Tower, D. B. and D. of pationts with armiommbml trauma. 27 (seat. E): 105“].190 I cm. 1. Rucauh, 19u9a, cmtent and dmmcteriatim of cambmspiml fluids. Canad. J. Rumch, Tow-r. D. B. and McEachcm, D. The hm 27 (Sect. E): 132-1u5. dwiimatcmes in Rush, w Tower, D. B. and HcEaclnm, D. Amtylcholino and neurmal activity. II . Acetylcholim and cholinestcme activity in the cembmspinal fluids of patients with cpilnpay. Can“. J. Image, 27 (Seat. E): 120~131. Mum. “We Ulott, upon Rum, Effect of atropine md scopolminc changes indumd by electm—conwlsive G. A. and Johnson, H. w. can. MthyAioL., therapy. Ward, A. A. 1957, 9: 217-22u. Atropine in the treatment of closed head injuzy, J. Nwww., 1950, 7: 3984402. �cmLINElEIC WIﬂiS, AND BEHAVIOR CONWLSIVE TIERAPY Max hm tha Pink, M.D. Wt m1 of Psychiatry at the Miami. Institute of Psychiatry, University of Hisawm'. School of Hedicim, suoo Stmet, St. Louis, Missouri. 63139. Aided, in part, by USHiS grunts $1.009”, I‘m-2715, ”ii-07239, and Mil-11380; and thc Psychiatric Recent-h Poundaticn of Missmri. 'mismportispartofﬂnstudypmmminhmctimand Behavior" undertaken New York. Hillside at Hospital in �n -.v-..ww.nmipv~.. NJ, mi V: CHOLINERGIC MECHANISMS, CONVULSIVE THERAPY, AND BEHAVIOR Studies of induced convulsions have m that the early develommt and persistence of aims of altered colonel function are prerequisite to chmgee in behavior (Pink and Kenn, 1956). Electmemptmlogmphic slow new activity was found to be a significant index of altered bmin ftmction, and the dmnonetm- ticn that premdiceticn with atropine inhibited this slow activity (Ulett and Johnem, 195$) suggested a wave relation to cholimmio melamine. In the following review the mle of acetylcl'olixn and the axolineetemeee in convulsive therapy is diamond. Aoetylcholine he: been extensively studied as an active agent in the transmission of nervous iwulses since the descriptions of Dale (1911;) and loud. (1921). It is first a constituent of nervous tissue, existing in a bomd form mich is liberated during the excitation process. It is rapidly hydrolyzed through the specific ectim o rapidly reconstituted by gelimetemee and is the cholimﬂeoetyleee system (Richter s V 6~28~65 , �Croeslmd, 1909). In normal cerebroepinal fluid {me eoetylcholim is not present despite the rapid breekdom of bound ecetylcholine during periods of activity and excitement (Tour and HoEecMm, lease). The cerebrospinal fluid does have neasmble ctnlineetemee activity, beaver, principally of the "true" or mctwlyl hydrolyzing type (New and ibthenberg, m5). In the absence of free acetylcholine and under the conditions described, electroencephalogram fail to show abnormality. (e) Effect of ﬁrmiocerebral was Item: Free eoetylclnline fomd in the cembroepinal fluid within a few minutes after- experimntal heed periods up to '58 tram in cats and persisted for varying hours (Bernstein, 19“). The quantity of free ecetylcholim varied between 2.7 and 9.0 game percent, and the mount me related to the degree of induced Concurrent electmmoephelogrm The records were first filled he followed by e demetreted patterned changes. with high voltage fest interpreted as evidence of an intense to tram. nemel activity, discharge, only short period of flattening of all recorded �alactriaal activity. periods of high 'Iha These phases were than followed by prolonged mlituda sharp wam in the delta fmqmncies. behaviml chmgea wan nlatad both to the dame of amt of masmd trams and higher haul: of acatylcholine, of amornality and EEG to tha addition, spmtmaous to ﬂu matar With Bernstein uportad snatcr degrees (mange: poet-Me aunt of free fm aoatylcholim. in consciomnass. In aaixums «am also ralatad amtyldlolina app-axing in tha spinal ﬂuid. Bomatain also applied acatyld'zolim to exposed oat cambml cortex. ”Mt When 01‘ tho omeantmtion of mtg/lanolin. 1808. fraqmncy in the was inmasad to ht EX: vaporized high amplitude sharp waves electmphalogm. “man ’7 2 was 1 gm pamt, wam by Towar- and HoEaeham of law the oonoantratim the alactmonoaphalogrm flattened in a fashion parallel to the Pamllal studies ' post-Mic ram. can'iad out in mlogioal patients (19%”. Pm: acatylcholina was fomd in 7 1 {wéli 14?”! [6cm �«1—. . ;_.... 7,. rm. . ‘ 4‘1"“.7 .. run-- «m w, raw-"aw ~~.w.:-v-w—.--lam—www—nv-rwww - the cambmopinal fluid only in patients withmoent Mad wv .r'. r tram mount pond-m1 seizures or aftor convulsive trunpy. Free ...;—--°-"“' " aootyldioline varied from 0.2 to 100 gm __ ~ peroent. _,,./ Tour ~ v. m3...» Mom also assayed spinal fluid oholimtome activity, rating a sharp rise in the nonspecific cholinestemse fmctim (benzoylclwlimqmitting) and a drop in the specific oholinestemse the oeubmopiml fluid did not exhibit such invasion, although it “dined fm mtyloholim. of They concluded fm mtylcl'nlim varied directly with the damage huge. taken at varying intervals following Kantian batman the dome of {m EEG was a mo Electmmoephuomm, tram, also indicated a abnormlity and the appeazmoa aootylcholine in the umbmspinal fluid. Thu, ﬂu spinal dogma of oombml andhat reversal of the dwlinesteme fraction sensitive indicator of cerebral of that the level want as 549.: Micheline. my {mug in the (Mdéaltmiugmuocmbwmmmdmmuntaé Wt / W“ _4___._.._..-' follavdng oonvulaivo mommy. Pollovim spontaneous soizums 01W, 4a.: \ and fraction (mohalyl-splitting) in patients with had 12mm and , �.5and the degue acotylchoune, (no Wenuphdogmﬁic «type 06 abnambbty, and changu in clinical bellow»! my be {Wad phenom. (b) antioholm Am1m, o behavioral and neurologic aims of pamtenl m mm and The EEG were blocked by the Mimic»: of 0.5.1.0 lag/kg atropine (Bomtein, as were similar clinical charges counting addition of mtyloholim . to the tram: W1: Ward (1950) after the intmistenul applied these observations of closed head injuries. In varying dogmas of tame, he 20 patients ’with ministered atropine subcutmly indousof0.lnglkg,notingclinioelimrovmntinsommda Md reversal of the eloctxmoephalogmphic effects in others, In a study 09m, mower uﬁtmolinergio Inchner (1955) reported altemticns in the moephalogm. W A p‘tvtremtio electro- single intravenous dose in forty patients with aleotmpmlom resulted in normalizing in twenty- ), �F i H4 ~37». .V v . “WW. awn" V l -.—.p..r \':v';"'r~~ gw~-_.....—m .— ...r 1"" “v: n n‘ , , , m. ,- two and marked , . , .- ,,_ _ , , __.,,_3._.7,,_,._ “,1”, ‘4‘._,V , an- a www-ruymumrm-e ,, ., .F ‘7...arm'Hﬂ ,_ ya,V. a“W. .. ﬁauawﬂl.‘ .w-qﬂw’ uvwwwrvw-1': -r~)\w‘nw . . . I 5.1119th in six others. In subjects following convulsive therapy the (feet of atropine inblockingtheappeamceofelwwaveectbdtywaemported (mm 139 :Iohnsm, and 1956). (In a later study these authors failed replicate this study, suggesting that dosage factors or population changes [Johmcn gel“, “niece may have mntributed to different results 1980]). observations provided the basis for studies with other loom mticmolimrgic canpcunth (Pink, 1968, 1960). The intravenous injection of experimentally potent antidwolimrgic momds as dietlmine. bemctyzine, the piperidylbenzilates JB-Bls, and .— JB—329 (Ditm), Wution. VIN-2299 and pmcyclidine induced The EEG chmgea were alerting, anxiety, trauma. illusions and JB—336 EEG associated with behavioral hallucinaticna in peyduietric subjects . In patients with recent induced conwlsims these «awards resulted in a reduction in 31m useciated with a reversal of euphoria, denial wave and activity cmfmion. .3 “‘11 i a 5161,! . ﬁg?“ �“Rpm, .,,,,..( ,“_.,. ,.. , N" .37.. 7”,. v Atropine was also Md, . ”a“, N mined in y:~.uf..~r\v.“r - o—r- .. n «v low doses, maniac] by todnyouwdia, “any "n www-mur - voltage, poor-1y organized delta activity with activity was Mum.” ._..-t m... who .er ixﬂu’Joitor, I)?!” elicited high anplitude rapid 935;, post-tmmtic states 1950; andHiwidx 5.3;. m as (mm 1950). These 3: 2.1.2. m; offoats won block-d by small doses of parenteral atropine . Qutficld Tho - “law‘vpm-x- superimed beta patterns similar to atatm epileptious, as charges similar to those of with .-- slow waves . followed by lower mumatarau (di—isopmpyl flmmphooptute) Hanson .,.,, associated with pmgnssive confusion and disorientation. mo administmtimoof a 191:9; , nervousness and tension. At hyporsynolm £1qu ...,,.,..;. dosynohmnizatim was BEG higher dosages, BBC V and Dupscy (19“!) pmpamd exposed animal cortex prostim and evoked eleotmenoaphalogmphic spike prior aministmtion of otmpinc Hacked this spiking, or present, the abnormality could be olimiratcd In contrast to those findings, Mr activity. by and if atmpim. Darrin (19%), applied topical aoetylobolino in concentrations of 2~ll2 to to the exposed cortex of oats, and notedno effect on the 10% «- �ehatrmnaphlomxic The damages after intravenous atropine (1 mg/kg) . concantmtims of acetylcholim in those encperimants, however, were higher than the and thc topical gpplioatims (1-4 intraeistemal (0.2-10 gm gm pement) percent) injections of Bomstoin (19%) . Bmmmr and Merritt, also made note of electro- enceplnlognphic affects similar to aoetyldxolim from nacholyl (mtylbetmt‘m‘lmoline) much and doryl (carbmldlolim) in concentrations lower than the amtyldtolim concentrations . may ascribed the increased effectiveness of these dnlimrgic drugs to their lack of sensitivity to cambml dzolincsterases . 11qu nativity Mamie The“. W and war. 0‘ man, mama induced by autgzehaune 46 can be. backed out maﬁa, mama“, of mtyloholim antebellum indicates that an oak“ as Wed a imctiw bound by anti.- etc. (a) Cambrmghnl Fluid Anglcholine and tissue in that!» topical application, M lintuéowm. with chum-Amt activity 49M studio» tuggeat that it is 34513112.: Ono View fomdv in nervous fem. Wing periods of activity, mtyldxolinc is liberated at the cell membrane, where it is �.v. .mTr,--m.,—,w..‘_-w.. ”“51“,”, wwryw , . "a". 7.,“ -\‘-yuv;-vv—n—-,17'zr'~.m"--r mm.-- .ﬂ‘vv—‘r- - MW‘VW'v'bn-‘Imwx‘y ,. ..,,..‘v-_.v..—-u.-~, ,- -10.. rapidly deactivated by molmesteme. acetylcholim is the remnant of oontinm lihemtion and brim. rises dining sleep was amputee! and mmt The and It processes of synthsis, has been postulated that the level falls during activity. This hypothesis in miml experiments Elliott, Sunk of bomd by Richter and Crosslmd (19%) and Hmdemm (1950). By using liquid air quickffnezing methods, Richter and Grassland observed the level of aoetyldmolim during metathesis and sleep (unsound as W per levels. mg. The basin tissue) to be 300$ micro— higher thm post-seizure difference in tissue levels is tmsiont. however, as the msynthssis nuts for aoetyldaoline in net brain is high (7 gum/Walnuts). Elliott 939;, (1950) confirmed these observetims. After utmsole convulsions they also noted that free aoetyldaolim in concentrations m always demnstmble in the spinal fluid up to 3 gm per cent. In spine]. fluid studies in mm, Cme, Tower and (19%) and Tower and HcEsctnm (19am) reported Wm simificant �quantities of free eoetyldwline in patients with epilepsy. or 56 epileptic patients, an (77%) in quantities of 0.02 to 5.0 gm per cent. The gm mmted free acetyldxolixu per cent with at average of 1.0 eeetyldroline level was related to the frequency of seizures, the extent of electroenceplulogephic ehmlity,endtothetiusinoethelutseizm. Itboreno relation to mdioetian, type of epilepsy or level of dmlimstemse activity. Mather tr: ecetylcholine appearing in the spinal ﬂuid is e by~prudmt of the oonvuleim or Mather the increase in acetyl- cholim is e eeuee of the seizure is pmblemeticel. HeEeehem (19%») suggested Tower and that increased acetyleholine liberation ismtdutotheseizureitselfbuttothepmoese causingthe eeimre. In e study of the hypatrueis that the mmlation of mtyldtolim is causal for seizures. in urinals by mmzole m (1953) induced convulsion and determined the level of acetylcholine in brain tissue before and during convulsions. cmwleime are preceded by She noted that a rise in the acetylcholine content of �M- iv“... “.0". ,_ v Hr. “7 a.“ rm . . ~.— ,VT .m", ...,. ‘mr—v-,~7..‘..v.».. . , ..,_ 1mm- ’77.. ., w.‘ .5, 1. .w, 'TVV'WHP-‘ ‘(n'ry Humannnruu .. . ww'" v-vm ‘r‘ ~ , 1-v.‘.r—~-.- r---v um”... mam-awn” -12- tissuc, abut the content fills during the convulsion, below and that curtain Invals of acetylcholinn,‘eonvulsions failed to occur. She sugspstod that the fall in tissun aeotyldholine during a canvulsion was due to inhibition of acutylcholine oonc¥ntration incroaéed synthnsia by the of mutaholitns/ such as ammonium ions. Seizunzb nan aceompanizd by an lacke¢4¢ {act aettytchclluc libeaatld {Ann (:3 in inteacnllutan bound £03m, Amucmybeumuedinmwud (Md; and’liit this Mammal nativity and Atizultb cnhanct acatyteholluc debthuction, lawtning 125£u¢ (cvelt as aettytchalilc; ukilc Attcp W and ancsthetla acaywwm wanton Alumnus tune. mm . (d) Cuntral Nervous SystaEKCholinestcnanas: Oanoamitant with their~obaervarions of changpa in aestylcholine, waor and HhEaahorn (19kg) neasunod Tho spinal fluid cholinnstcraso activity. types of cholinnatexuscs are normally found in the spinal ,, -~a 1 Wm "F-Ir «rm-“r Tau—w �fluid: cholimter-ase-I which has a high Wm," ”specific,” or mdnlyl-hydrolyzing) , specificity for acetyldzolme; and cholinesteme-II ”punch," "um-specific," or bemoyldiolim—hydmlyzing). Bath mama-uh hydrolyze wetylclnlim but have different rates of » hymolysil form‘mdiolyl and hmmyldxolim . This differential rate permits qualitative distimticns . By reporting the cholinestemse activity In a ratio of the activity with a maholyl substrate with two on Walnut» substrate mated and to substrate of wetylcholim, ratios are found: dwlimstemso~1Iacetylcrwlim and oralinesteme-II/metyldaolim (with WM'IOO) . In Inch ratios noml cambmepinel fluid contains estemes in the ratio 33:17 of for dwlimtemee-I to eholimtemedl . In patients with head tram Tower md Wan reported an inversion of the cholimstemee, with an increase in the dxolimstemeI fraction of the spinal fluid and a decrease in cholinesteme-IL. (ctivity. me extent of the duelinestemee reversal was related ��u. wc- 15": w“: w—qggywww—mqw 'vwﬂvw‘r' w'w. ;~m«w usedatcd with the plum“) . we “c- ,‘ rm-“ ,n, mvmr "W_.,“-..‘w .ﬂ. appear-am: of variws isms (as potassium and in the spinal ﬂuid follwing electrically comm. than was electrolytes u cellular an. ._- ~———~> also a significant increase in such nan- music-acid splitting mama . Minty may aluminum-41 in md madam ‘13:. with the and the induced mixtures or hand km may be in cholimstem activity should of true mtyldxoline. be associated The persistence L a“? M man md after commas: relationships 1945; Tamar and Wm, mummtiom, microseconds) but Men (Nadmnsm and ”MA n5 and laser matmﬁms, contmt, the dzolimstemo-II— 5e 5 5744 (K biz k 4% 4: Mute-h, hydrolysis of mtyleholim at higher the activity falls off quidtly. In 19169; . é'dééﬂloéj“(.1 related to the sensitivity of me mtylahomu-v 1955) . At ”physiologic" (3—43 (Tamr- 54’2“” [w mid damnation Murmurs, is rapid than muse). dmlimstcmsed system to and in incmmd concentrations of mtyldaolim in spinal fluid after hand mum‘s Oranges thus provide the basis for th- high cone-stations of matyldxolim of inctuoed �. “N-r —~ n. 7., VFW..-” W _ a. .. vw—w-‘w— 7..- .—-..~,-— :7 tm'w“‘n‘.mm"\ "Va-"er-rwswrwnh‘ Inwr'n'ra'" ., "mu-wmu» m y'WWW—m. w~~vw-'VI"-’wr11‘xn—n‘ ~ .x v . .. ”rip-“73“‘miwl‘wuw1vv'1‘y; NV”; —,—-.-r~.. .nr w "WWW,— «.v “ «mu—v..."- ‘ . .15acctybholino rulaticnship is non-specific and the rate of hydrolysis inexact-a with cone-ntratian. Mi 1‘“ ; Aum£-‘£o’%}4i 4;; ‘T f? dnatrcyud by tho spocific activity of cholinnsteraseol in faw lasso-.aondn, an excessive concentration fallowing excitation may canned tho by cholinesterase-I. The L¢¢1¢4 A¢M4 ‘ acixurn thrushold nay be reached and a noifnnu indueen, with thc stizumi f i rats of hydrolysis Thu itself adding to the amount of free acetyldholine. innrnanod acutylcholins diffnoos rapidly, affecting vascular i and cnllulnr poxlnability and increasing the concentrations of various ions and cholinnstnrusc~11 in CSP. The activity of dholinnstoraao-II, though of law efficiency and depending th- mmmm kinetics, Mass on the mtylcholim in the tissuns in hours to days to lavels for tho physiologic action of cholinnatonuae.1. 422;“ 42351“ �‘vr , wwvw—M. . ‘ «ruuuv <t—V'1vwv “—w—ww wwwmwrwwnw. raw—em: un.mnv:.-.Wm "WW—.1» yrmlmx-N ltd-www'ﬁa'wmw'guw‘I‘v ~ 1.. —_ '~V"(—m'v M.Wr>‘\'m‘ .17- Choumtmu «ppm in nu mind We! as a acumen 05 their. 41mm: in Lu ceu. The mm: gammy ma m swam 6;;th (e) 5mm», muting 5m mentioned by changes 1,2:qu Midtown. momma; m pout of the eybmetéc mechanum awn-(muting the 604 Ante/Lem Me 05 «mama»: at was mainland: mu‘uy WW9. Mainline EEG! and Induced Ccmvulsiam: . Almmtion in the blood~brain pemability barrier by the cmtiming team of amtyldaolim may be the biodwmical substrate for the post-ehetmshod: hypcmyndmmy of the alectxmnmphalogrmn. Such a possibility is avid-at in the report by Aird «mutating an increase W 23; 3141955) in‘the concentration of cocaine in brain . tissues thme days after a series of 12 induced omvulsiom. His data Show the change in mnemtmtion of this large animals, ominarily abaerrgu: inbrain tissue to be mociated with the appeamnoa of hypnrsyndzmy (delta bursts) in the electm~ W. , �. inn-ha -'!SA‘-’-"—'r-.“ viva... ..».-~=v—-nn , wan-.wp» ‘ wn “-1....er ﬂ.” .7,» :w .r x» In studies of induced convuleime, many ﬂaw-u. we WW“ -; ‘v w "M”,Vrmm “ w... -wA.we--wﬁm~mvav" . _ ‘1 dump-.— have confirmed the pmvioue reports that convulsive therapy induces electmgraphic hypersyndxmny (Fiﬁ: and Kahn, 1956) . Despite a constant applica- tion of mutants, the time of appeamsoe, the dlmatim and the extent of the electromphic slow sensitivity to modificatim by wave activity as well as its alerting, hypemntilatim barbiturates vary greatly in paydxiatrk: populations . appear-awe of high degree hypereyndumy and Too and early its persistence through- out the txeatmnt name has been described as prerequisite to iapmvemnt following electmehodc (Fink md Kahn, 1956). The failm of certain patients to develop hypemyndmmny may be related to differences in the activity of central aeetylcholine and dwlineetemeee. with the absence of free acetyld'xolim beingmlatedtoninimalehangesincembmlfmctimmdﬂnm precluding a clinical response to induced convuleime. Tower and HeEaehem (mum, in their study of Madembml trmma, included observations of six peydmiatric patients mdergoing mleive therapy. Studying the patients after 3—7 treatments "- mpg-w“... �.ww pwzwrn . 7 .19... thay reported free two 41lede patients; and an 1mm activity in the spinal fluid in in duelimstemae-II md a dome in dummtomee-I with a mammal of the ratio of dwolixnstemes in five of thn six patients. ms that the spinal fluid like those of From mica-tubal these observations they concluded in induced convulsions m Ragar'dim the mo patient were mom than those found in epilepsy. in the series who failed to show cithcr me mtylaholim or a cholimstomc ratio reversal in the spinal fluid, thcy wmte: "It is interesting that this paticnt an the only can of the six to show no msponse It a pawn that induce! mama» £6 mmuu i/ t:”PM/1AA ﬂy ff-WLL AW by 1.6 3 0‘ JA mm, sums. Law 96 me EEG Fm «commune hypwyueMony mama“ and 1.6 mm on: mm ascenumcngm. uuuueehuguzazmouummm- AMM‘W was that plowidc ﬂu. biochemical. 60.be (on the pmaaut V WW) mamnt." mm mm pmabuuy m Mug the. mam a; mumamu. W W Wilma mm “#19” ( in Wt to bchaviom changes {allowing inland canmuiau. w;- �(f) Choline-tomes moss studies may and th- Classification of chosos: also have spplicatim to the problem of catatonic reactivity and the clmificntim of the psychoses . Mkonstoinsndotlwrs( )havsdsmxstmtedamlatiom ug ship botwun tin blood possum response to injectedﬂm) (dd‘é’ﬂﬂ and the clinical mpomo of psychiatric patients to convulsive W. lbchclyl is a potent molimrgic agont which induces vasoﬁmion, tachycardia, mating, It is and harassed peristalsis. mpidly hydrolyud by mournstoms-I and slowly by clmlinutcmc-II . M, injoctod m m blood pmssum of subjects falls aftor udulyl and 2‘th to the five to m bssclinc than 20 minutes. Patients Mobloodpmsmmtxmtothbaulimwiﬂﬁnsmutos are classificd as Groups blood possum takos 2O I, II, or III auctions; arm aszprIdeIImctims. imprcvomnt mactors a minutes to mum to baseline, mexoupIrssctorshawa9% rats with conwlsivs therapy, 35% those whose and the Group II—III memory mtc. In contrast, the Group VI �_.__.. ”(ya-v —— . h\'~rvhl."ll'F reactoreheveasstm'themupvnasﬂ recoveryme (human-1n 35;. Patients in an patiente in 1952). “main Groups I to III may be looked upon whm the injected maholyl is rapidly hydrolyzed; VI and VII patients heve the a slow hydrolysis rate. 41121311. 65‘ Weny predict, themfoze, that an blood ahalimateme activity levels of I-III would be high; while the activity of WV” y ’ ,-. u... V,._V.......,m--.-n—nw ’0 ﬂy” 6/” W W hypersynchxuny and spinal In studies of EEG fluid levels of acetylcholim. ahengee {uncaring induced omvuleicne subjects were identified in when e few seixme resulted in e greet of elm wave activity; mile other subjects exhibited mat few changes to my and to frequent seizures (Pink and Kuhn, 1956). If electmgrephic hyper-gum in e reflection of incremd (Conversely, in patients with short-lived hypereyndxrmy, dwiineetense-I be unusually and high). -II in tissue Thue and spinal ﬂuid these epeauletime provide may �-22a basis fcr a congruent hypothesis regarding central nervous system reactivity to clactroshock, and to peripheral éholinergic CONCLUSION: Ccntral dholincrzic nadhanismsqmpoar to be a significant flycﬂu«’g factor in the convulsive therapy process. ”Inc published data {unrinriznlmymnandhto indialté;that induced convulsions are associated with an incruasa in intarcallular acetylcholinn tn 4L¢¢4Eygd4£5414¢¢¢délAbiﬂ— lnvels greater than can be dustxoyed by choiéanoturuneéE— nativity. Vascdilatian follouod and and innnuasud callular'permnabilitylin«a4wc. 71L‘5@ﬁ¢.4;«xu> g aibcgérﬁyxapglugu‘542;;wmatvi byﬂincrnascd amounts of~ehoiinnaﬂcuuao~¥l~ other'enzymas clactrolytas in inturunllular fluids. ��n, w~. «v— ‘w—rr‘Y .r uy-nmvv—mwum-mn "vv'. rwzm—r w—uw-v-mw-wztwvm... a ~II'-v-'<w-:'W.\1v;w'rku'svmv‘mv'nvﬂwv wwww CEDLIWC WV}: mm. MD mum Max w;— .n»;_...v W... "on." ,vurw»; M Pink, H.D. W at th- Pﬂnmi Initiate of -Pmthanapmntof Psychiatry, admity of Miami School of Midas, 5800 Annual St. Louis, Missouri. 63139. attest, W, W mm. Wmismofthnwm"hinhnatimm York. Hillside Hospital in Ethnic!” at mm in part, 2:57 aunts iii-00927, iii-2715, W72“, md $11380; and the Paydaiatric- Renard! Fantastic: 0! New - - w—n mu, mung—.w an �CHOLINEMIC W, AND V: CONVUISIVE BHWIIOR 11W, StudiuofinMdmwldmhnwmmmuﬂy dwalopnntmdpmittmofsiguofutomdmwmmm mpnmquiaitetoahmguinbahavinr (Maximum, 1956). Wesleyanwmivitymfommm: aimificmtinduxoflltondbxuinfmctim,andﬂndemmticn that Mention activity (015th album-sic and Jdmm, W. mtylcmum and with atropine inhihimd tho 196’) this slow wave muted a minim to In the following review the dwlimmruas in mole of Waive ﬁnnpy is discussed. Mutyldnlimmwcmivelystudiedummive amtintrnmmuimofmmusimluusimsmﬂm It is a dcnmiptions of Dale (191k) and Load. (1921). mtitxmrtofmtium,uistinginaboundfommida illibnmtcdmmwiutimmm. )J and is action of culimmme specific hydrolyud m Itiarupidly W rapidly matitutcd by the cholimmtylau cystem (Richter 8 sum-55 �wan-r”... Grassland, 19%). In actual autumnal fluid has mtylclnlim Emmanpitemupidmmofmmmm (Town-mm, Magmaoaofactivitymdcmitmt 19%;). The activity. ”Mimi mm, fluid does but Inﬁnmoffm 19%). matylahonm md undnr the conditions than cholimatcraso principally of tho “tan” or medulla wdmlyzing typemmsmwibﬁmbcrg. fail to gamble Whoa, cleatrunmpimhgrm Witty. (a) Effcct of m Mint}: W hm: hm acetylctnlim mun-951151 ﬂuidwiﬁﬁnafwninuua after demmmtsmdpmiuedforvmina periods 2.» m as hours (Win, 1”). The qumtity of fun gm mtmmumdmthdumeofimmtrm. mtylcholim vanhd between 2.? did 9.0 The W accord. chcmewaphalogzu um first filled with percent. and th- mutated patterned W. high voltage fast activity, intorpmtad as alderman of an intern. mm). diam, only tobfoﬂmdbyadmtpexiodofﬂmingofmmcomod ﬂuv - v > .. �-- .vwru V.—.Ym'> electrical activity. Thou phuu wen then followed - 'u-uwuﬂxm n. ww- by pmlmgod mamamummmmmmmmms. mwmsmnmwmthtothedameof mmmmmtafmmdhumtyldnﬂm. highs:- levuln of mtyldnlim. Romania 911‘th "Modulator dew ofmcmntymdmmrctmpsinmcimu. In addiﬂm, apcntmn post-We aim wan also muted totbmmtoffmmtylebomnapparingintmspiml fluid. Wain also :13le acntyldxolim to expound out 03:11me W. Mthommmimofmtyldmlimmlgm pamtorhu,hnpwtodhighm11tudoshupwmoflm fmmncyinthocloctmmmplulogﬁm. mmmnoentmtim mimmdtoZmpcmt,ﬂnchctm-naplulogm Whafuhionpqﬂhlmﬂnpon—tmicm. Parallel studios m wr carried out in analogical patients byrmmunsmnumw. Pmautyldnnmmfmxdin - r-w» ' 'c . ' -' ' �- the Main]. mount grand-ml mtyldwlim 7...» 7w wn>wwv 'v'vcv’ ku- w. VII-"I'M‘WW ﬂuiﬂ mly in patients withncmt head 1""!t-W'J" \‘vv- "ram-V" tram 301nm or afar convulsive trnmpy. Fun vadedmeﬁtolOOgmpcmt. Tomrmd Wm also assayed spinal fluid cholimstcme activity, noting a map rise in the mpocific cholimtcme factim (WW-cpnttim) and a drop in the specific mailman” fmtim (metnlyl-splitting) in paticnts with had mm and following minim W. Followhu sputum calm the cornucopia-l fluid did not exhibit such it comma {no mtyldmlixn. inwaim, Thay cmcluded 11W that the lavel of {no mtylcmnm varied d1mct1y with the dame of comm}. Manama: mnnlofﬂnedlolimctem fmﬂmmam with» indicator of Gambia]. m. madam, talcmatvuyingintorvalsfonowingmm, mimic-med: mhtionbctmcntkmdcmeofﬁmmntymdtheappem of In: mtylcholim Thu. due in the annbmspinal fluid. want 0‘ We autylchounc my (me. in the ‘mmgoummwwmmmmmog ' 'v "F “'4‘“ �, 'V'lvw—‘U‘ w‘ war.- —',~3 nan—- u ,w--y_.n..-. u. ‘ ., .- ww,———w~.wm_w—w-q ‘1‘ wwm “- v-~.-W . a..“.~,~.-u . q. . WW -..' .m “Fwy-Fumwyv,‘ “15;.” .w, , .7 “mm .-.» 7w.v--m»w~uu-——. .3... 51m. “Wotan, abunuty, MW. (2)) «the «glue and type mmmmgupuc a; mmummmmamumw m, WWMO m and m: The EEG aim ofmmnmmodadhyﬂu behaviomlmdmmlogic (Bnmstein, pun-nun). examination of 0.5-1.0 ug/kg atropine mmmmcunimmmmmmmmum addition of mmmu. Ward (1950) applied mmmdmmmm. We m, Wand of varying ho m'obumum In20patiantswith ntmpim 3W1)? hduudOJq/kynothmdhﬁmliqmtinmmda mutual of the 013:!ch effects in om. In a smdw.muﬁamwm¢Jmm Loam (1955) meoph-‘logrn. m1 W am A single 5.an WW in the pit-atrmmatic ghetto— dose in forty patients with resulted in normalizing in twenty- ), was” w, �two and marked Wm: In subjects in 35.): mm. £011ng conwlsive therapy the affect of atropine inbloddmmappemotslmwmuﬁdtymmmd (um and Jdmsm, 1956). (In a Later smdy these mﬁm failed maplicmﬁxiastudy,suggastinsmatdouge facumuw popnlldmdwgauyhmmtdhumdtodiffemntmulta [Jemima $5, 1960]). Moumatimpmvidedtmmformwithm hum “idioms: Wad: (Pink, 1958, 1960). me hummus injection of Wm, and Wm “WW. durum, may, We mamas mum-yum. thn piperldylbmzilnm JB-318, (Dim), JB—329 pan-m: mticholinergic VIN-2299 and an JB-336 3% 1mm mendim MMWmm ammﬂﬁabduvioml truism, illusion whim. and mlminttims in In patients with mount induaad mnvulsium Mqultodinamdueﬁminslwm activity Wuiﬂzamdofmplmia,dmidmdommsim. ��-. _«.w...-.——~.m. w, .u . . r” v ﬂaw-v v "'wA“"‘f'N‘" . wrv-r-P electmncepiulogmphic The concentrations of were higher than Win W arbor _.. w-av. rwa-mvnw—wvm- v-.-~ TWZ'Awyvq-u'n‘Vtvmw‘T“ "Ann—w- 1::th th- topiml appliantims (1-4 (19%). atmpim (1 Myldlolim in these oxpeﬂmts, imiatnml and the , (—7.“ ~;—v—u~.~~.—.u—pv.—.—~nn:,+-ra.-w—u w... (0.2-3.0 gm pennant) gm '-‘a nag/kg) . however, parent) injectim of Exam md thud“, also made note of chat-.m- axmptulngmphic effects similar to amtyldwlim ﬁrm mcholyl mtmtiom (WWW) (mtylhetmﬂxxlmonne) ascribed mmh Mrthm tho amtyldnomn M Wm. in and duty). Wimqffmimwmwmmcmmm lack of mitivity to rumba]. duality-sums . ThuewmmmmmsuggutmuumWWWWWbyMWu/tmua man 9‘ aqua, tam Won, imam on. with WW¢Mmbebum¢ueummdbgma~ WWHMAn-gmnmmdmw «new (c) a mm, mm. etc. Onoviw «mlmuWMwa-smnnfomdiamm Winnimatiwbmfom. Wyﬁnchofactivity, WWhnmmdatthno-ummm.m1tia r umnnmv~wv yr.- -~ �“Hwy-v .7 m. » ._v .W”...w.— —...‘..r,.u...,...._...,-, Hm..."- va,unlum‘w‘hi‘wv'mvmwv;'QX.‘""“ W ~n-- v “w a”... ‘ ,7 ,v W---w mw_.-r—... Wt “‘1': run”... -- - ww» v" ‘7. "‘ ww.-,-_p.w.~.wmw. midlyduwtimdbydwlknmo. mamtofbomd mm is the resultant of continuum 1122mm lad mm. promotes of synthuis, It has bun pastuhtad that the rdmduuingslmmfnummuctivity. level Thishypaﬂmil mwmmwwmrmmammum) mm,mmmm(1asm. Byusing liquidair qumumm.mmmmmmmmm ofamtyldwlimdndngmﬂmiamdalup<mamdumim www.mmm)mhaocthigturthmpoum hurls. nudiffminmmmlaiatmsimt,hmm, uthnmthaismforamtyldacliminmbminism (7 gums/gallium). Elliott 539;, (1950) mnfimd than obsorvntima. Afﬁrm}. mum-ism Malacnated that {no mtyldxolim am always «washable in the spinal fluid mmwmagmparmnt. Insphulﬂuidstuﬁuinm,ﬂam,lbwnrmdmm (use) md fear and Wm (19m) “perm dwicam: ��m.uﬁumtfansmgﬁumnmdm,mdm balmeevuin lawn of mm, convulsions failed to om. Stunumudﬁntﬁnfanintium Winona: Wamwhimmdummiﬂmofmtﬂdmnm m‘md mm byst- anemia“. We! sud: mtabolim, Bummwwnmeumm mmmmwwwmmwm Wmuumam¢mm MW mmm;mmmuuyzmuummmn,zmmg rmumumzmum W MW WW madam» (d) §xg~ an MAMMWthuLa W (new: tutu. Lena. Cmocnitam: wimﬂnirohamtiam ofchmm inuntyldaolim, Wm (1939) Tutor-mt! name! spinal fluid dolimtcrm activity. Mtymofdnumemmmmnyfminﬁmspiml �» ‘am-V ”II-"Iv ."V'a. ~,.1- . u -;— V’V~-¥'U'~‘v‘<~u Tam—xv... mw—uL-ww-"wv Wanna-I ﬂuid: mich .V m ("pocudoﬁ W as nu-mq-wnwh-..“ .,.,ﬂ_. .. Um," sﬁociﬂcity for him "rm-amiﬂc,” ow two .,. ,... .. n. ..~-. - . ..- ’r .,.,_H. .\..v7,..,,..~—V.TM ,wv, .,.,.< V . a a ‘ , , v.“ .w: _v_ ”specific," or manlyl—hydmlyzing) , Micheline; and “museum-II WWHMWIM) . Both for udzolyl and bemoylduolim. This diffomtial me panda qualitatiw dintimtims . with 3 ”a.“ hydmlyu amtylcmmn but have diffmnt arm: of mm activity ,. By I: a ratio of the activity with MW!» ratios an found: sub-mu mind mpovting the dwlimstumsc a maholyl substrate and to mm of amtylcholim, mumm—I/amtyldxolim and Wm-II/mtylcmnm (with Adi/@8100). In much nudes 'mlm‘bmupimlﬂuidmuimuminttumioofﬂzu for Grantham-J to aluminum-II . mpnﬁmwimmmmmﬂcﬁadmmdm invasion of th- daolimumu, with an We in the cholimammac-II fmtim of tho spiral fluid and a dam in circumstance-I. iathity. m mam: of the WW maul was related �we: --r"vr— mr ww- ~r-r—vrm...‘ v .—-1«w‘ms¢—ae.—r ”"7.“ mgr-nus, r, mm, a." 'W nve- “w, -~. w n r...“ mwv “van" e w.— ‘1‘“ m‘r‘nvwvﬂﬁ‘l'v—vV-v ”Wuwx—m‘me - vuvax wmmrityofmmmdmmawofﬁuem- WWOWW. Inpatim with eleveudspimlﬂuid acetyldxolim other WW,Wr,mminmmioof dulimetemesortommlimtem wdvitymfomd. ‘meimmindxsmnetemeactivitymbemdentood mnmmmmmnmpemmmty. mW-Ihfmmhimmtmﬁminﬁn mud nervous system while duelineweme-II pram inwartiam,upooianyb1mdsem. Hiﬂamimas fin atyldnnne m1: in intemelluler mum fluia stimledm, communion: or hm, modiletim oellulmpemeabilitymybepmdiotod, Wﬁm and We! withedewof of wonder flunk into the inter-0011M spaces vuyingwdmthemmddm'etimofthevasodimion g g, 19:0). Spiml pun-Ability following W 1953). may cheer-val no Spinal-Molt in mm (Rabat m mm reports (19%, 19%. 19W, 19%. memo mndactivity of the tissm , ~~y-..‘.--~_~~.m-mm-v, �av“ y."— ww_"v-w.w . w «mum...»- a. 4 W cm van—n: . Wwmwum u wI-ww—t'h wmw—wmew-mw ..-,m.— w --u-- mumps—m mum-PV- Hw'ms a: w :w-n r- "rm usociatadwithﬂaappemofvuiwsm (apotmiummd W) in the spiral fluid follwing chemically inducad mm. Mmdmasimiﬁmthmminsmhm- electrolytes as madam-acid splitting cums. Chang-s in alluhrWilitywthmpmviwﬁabasisformhm demmmmmmmm ofdnumumeIinirmmdmoermmﬂw MWIMQGJ. mmmmmwuwmammm with the mid «instruction of hue mtyldxolim. me punctuation rammummspimnudmwmmm aims any be minted to the dxolixastuaso-J syntax m and Wm, 19%; mitivity of the mtyldzolinc- Widen mummy (um Tm adﬁcﬁadam, 19%; Burger: and martian, is rapid (3-H mama) but at high» and lunar 1955) . At ”physiologic” helm-h, hyckolyais of amtyldxonm the activity falls off quidcly. In contrast, the mm, chainsaw-II- �«.18.. “mum nhtimMpismn—spociﬁcmdﬁumof mmmwiﬁzmmim. mmammmsummmmm WWWOfac-tyldmmnnmnmm We hy the spadfin activity of him, an massiv- WW4 mﬁm in few billowing excitation mmmmdmmlmwmum-I. The uhmuthruhuldmhomadndnﬂamimindxmd,with mmimuwngmﬂnmtoffnomtyldnﬁm. n» and W murmur: durum 'mpidly, cellular pambﬂity and humming tho vmmmdwlimm-Ilmw. alum-II, W affecting vaswlar mmtim of 'nnactivityof of lowcfﬁcisxwy mt! chpcnding m ﬂammﬂgmkhnua.mmm1mmm dominhammdlyatohwhforﬁnphysiohgmmﬁm of <21»me . �“.1. -. _. n "w' .~. -»~ uv- r—r-wu. szﬂ‘”R—vu'w.vw w-W-wt mm- W-w—mwwswwmwwrrwmxmm’mv-mwmmun-m zmwm-Wm “W A. A. V. AW mmmuWuM¢mmuaumm _\_A_._V_-__‘__.__~V.A,__ ‘-_,__,A__________ 05mmc&W.W, Wad “WWWW m put“ ma Wm“ waning smut-Maya by The {named the waywam. Wade. madam-u ammmoguagmumauumw WW ‘MMWMAmMWW. (a) mymm. HE‘S MWintbblmd—bnin mm permeability and Induced 000mm: bmiwbytheconﬁmm actimofmtymnmmybaﬁlebiodmimmtmfwﬁn chphuogm. _m.mmwuommmmmbymgggy(ms} pout-electroshod: hypemymsm of 13m Wmmmmmumormmmm tummaysamrambfnmdmmm. mmmmmmimufthismmhm, ordinarilyabsmtinbnintissmtobemociamdwimm W orhyponyndm (delta bursts) in W. the electro- at: . �- Inmofﬁmmhm,whmcmﬁmdﬂn mpmimnpmﬂthﬂmwhiwwmchcmmuc Imp-W (Maxim, 1956). myimamtmt applica- www.mmaw,mmmm Wtdﬂunhmmdcslmmaadvityuwnuim sensitivity to mdiﬂwtim by muting. tamer-ventilation whim‘ vary my in manta: Wow. The and only memwmmmiupu‘ismmghmumthmmasMupmmmium W 1‘0le «loam-rm (Fink mm, 1955). m «land in diam {dimofamainptdmtodnvolaphymymhmxymybo Nahum. 1n th- activity of annual mtyldxonm withﬁnmoffmemtyldmlim mmmmeWMmmm mamammmemnmmmm. W (19‘8“), inmiz‘ttudyofcz‘iimbml Tmrmd trauma. imlududobumtimofdxpsyctﬂatricpaﬁm underpins mad“ W. Ming the patimts afar 3~7 mam-ms u I'vv: WW7 ~,-- a'ﬁr‘f �mwmmtymummutymmspmunudm mmmsmdmimmmmm-Hmdams in “11:33th with a mammal of the ratio of WW3 infiveofﬂnuixpatm. mmmWaﬂamﬂnyomclmed wmspimlﬂuiddminhumdmhimsmm mmwmmnbmmmmrmmcmy. wmmpatimtinmududnfdhdmm dmmmldnnmwacholimummmmalin thespimlfluid,ﬁuymz“1tisinmtingﬁutﬂﬁa WmmmlymnofﬂuaixtoﬂIwmmpm-emtm." Itammwzmwmuuuzm¢m mamgm,mmmm mmmWoammu. 1%...qu umbyupuudAumu. EEGhyme/uom umo‘mmwumgzmmmmmwxy at Mumwuqm. Radian muammmmmWMWWWWM‘MMMAM 6:!wa Mu 60W Mad «WM. ��-21- WanamaeﬂmtthmaSﬂmmrym 1952). 93a]. (Wain Patimtsinhmuinmltonlmybclmdupm when the in is injected rapidly hydmlyxed; putientl mdmlyl u uhiln ﬁn Groups VI and VII pctimts but a slow hydrolysis rate. V. my pndiat, theni‘on, that tha bleed dulimatem activity huhofWI-lemﬂdbohiﬂu mihﬂnaotivityof WAdlihrunlysiouyboudumaxdingmtnlm VI - VII walla be 1m. mmmhofdwmmm-Iinﬁummtofm Wynclumy and spinal ﬂuid hwls of amtyldnlim. Instadiosofﬁﬁﬂdumgu followingixducudmnvulsim subject-wan idlntifiodinmmafwsoimmultedin a mat mat of now an. activity; while othox- subjacts mind mammmymmMu-Muim (Pinkmdm, 1956). IfWWionntbctimofmd Inbjommuintainhypcnynm in: mm, inwmitdiupp-m them did mpidlynybccadﬁbitingdiffgmnccs in th- kimtim of the dwiimntm-mtylmolim hydrolysis mm. Panhtcnthypcnyndmyuymultfmamd Mcofhydmlysinotmtyldwlim. mociatcdwithlow I mutation of cithcr choline-tumult or mummy-II . (W13, in aheﬁrutcm-I In many paints and «II high). with m—livod hypnmyndmmny. in tissue and spinal fluid any Thus thou mutations provide �. ..‘-.,—r >17 ,...v v“ » , may .1 ~w ~ v....<~u-.~,nz‘y«.r.-~, w‘wrr' ,. ~_»w—-w-y- ash-:1" ~ want »-.1N" vmn www-z-‘w BMW-“‘1‘;- n ~wm~wvv qu-w-m-w- wrumrwS—V-‘a W-xmp‘rvww .22... amumamhmnmmmmm reactivity to W syntax: em, and to poripmm dwlimrgic WON: mmmmmmawmt _1’minﬁn mmiwﬁmupypmu. 1119me whimdmiﬂmomtimdmmmm Wummmmmmnmmmw MhWMmbodntmyodbydmlimmI nativity. Vuodilatimaﬂimuodmllulupmbﬂityis follmdbyimuodmxtsof diam-II, strut-am and electrolytes in int-”114mm ﬂuids. - "r' :1 Wyn-mu wr “unawa- "I“ �mwmminmmdumm mmmnmamswom.mwmm Mmeiduﬁuminbiodmicalnﬂiwwhidz alters cerebral «11.qu activities sufficient to Alter the 1m behavior of subjects. Failure to mountmim electrolyte dim. of acetylebalimi lid W, high md pmismm: {aim to 1m tht results in a failun to produce behavioral ”mummuofdowlmntofmw reflect differences in th- 63ch of subjects «1 dour-remit: admin”, or in their sensitivity to changes in acetylemlinc lawn. tim of M tho diffcmm ﬁnally in W by Mountain These observations provide a the mode the Win for the classificaand by Pink and Kuhn (1960). rational biochemical basis for of action of induced convulsions in altering the behavior of psychotic subjects. These views are consistent with the more general neurophysiologic—adaptive theory expressed earlier (Fink, 1957). �IFn->"'v'—-'—vnu—w— w—r—v-r—u ”ﬁt—W‘- ".9. ‘- -. u » V . WWII-.11“: CI-DUINEIBIC . , nv— rm mw- WIN, WWOR Wmvw—qmvmmpwmw'm x.xm~.;w~ww-ww mum—w". CONWLSIVB AND 13%”, Stalin of cerebral changes accounted with (Pink and Kain, 1956). convulsive trump}! In these studies, electroencephalographic slowing was the most siyzificant index of altered brain function. The dematmticn that premedicetim with prevented the appearmce of slow 1956) suggested a wave high doses of atropine activity (Ulett relatim to ctnlimrgic meﬁiims. and Johnson, The role of acetylcholine and the dmlineatemaes in convulsive therapy is mlified in the following review which summizes the published am. The role of acetylcmline in the tmsmissicn of nervous imulsea has been studied extensively since the first descriptions of Dale (1914) and Loewi (1921). Acetylcholine is a normal which form bamd is in a tissue existing of neurons cmstituent �.,, ~21- ' - "~va ":murmmrnur-v— «m . Ernie-'4 ‘ ,. v “War W'r’W-erd - 4wr‘; Wr' .w-nv 1'5“”uH-I'J. .1m- ,.w;uwv‘.m,w.‘. liberated mixing the excitation process. It is “m ...Y.,_.,. F“. -v-v—.ﬂ, ,. . t .. 7 m" ,..,nvrv.w._,,m_1w V,.w.,‘.,.,.,,v rapidly hydrolyzed thrmgh the specific action of eholinestemee and as rapidly reconstituted by the momﬁiaeetylase system (Richter 19“ 9) . No a Croeslmd, free ac}tylctoline has been reported in normal mmbnospinal fwd despite ﬂu rapid bmakdom of bound acetyl— eholine during perioa of activity and excitement (Tower and McEechem, 19u9e). The oembmpinal fluid normally has measurable cholinesterese activity, however, principally of the "true" or mcholyl hydmlyzing type (Neelmensm and Rothenberg, 19115). In the absence of free acetylcholine and under the conditions described, electroenceprnlogxms fail te show any consistent ehxornality. (a) Effect of Cranioeerebml Them: Free acetyleholine was found in the cambroepinel fluid within a few minutes after experimental head trauma in cats and persisted for varying periods up to #8 hours (Bomstein 19%). The quantity of free aeetylcholine varied between 2.7 and 9.0 gamma related to degree of induced percent, md the ammt was tram. N" ._., , . V.‘ ,.. . �F‘s—“ﬂ 4 w .iv-IJ'n-urr'wlv'i- \I'-w-v|n"r" ».v 21‘.- .IN w— rh- W Th! records were u. . - ~~w~mvww. a?“ : aux-rum W...“ m“- - ‘vv‘ w—a—E.ww~r_~w um... g‘vi- wn-rv-w mun» r: 1- K—‘Irw' «a...» ,. w... w” ‘quw u,- 1,- \w electroencephalogms demonstrated pattern-d changes. first filled with high an voltage fast activity, intense neuronal discharge, only to all short period of flattening of electrical activity. mesa recorded phases were men followed by prolonged periods of high amplitude sharp waves in the delta frequencies. The to the behavioral wt mrﬁzlated 13%:ng of clmges trauma and of seasoned free eoetylcholine. With higher levels of eontyloholine, Bernstein reported greater degrees of abnormality and greater charges in cmscicusmss. spmtanecus . -3- interpreted as evidence of be followed by a -~ post-tmmtic seizms were also EEG In additim. related to the want of free acetylcholine appearing in the spinal fluid. Bernstein $31- applied aoetylcholine to exposed cat cerebral cortex. men the concentration of acetyloholixm was or less, he observed high mlitude sharp the electroencephalogram. When waves 1 gm percent of low frequency in the concentration was increased to �-- <vw'x' >1:- 2 '.‘W',WWV\Wmm/'FP a». an gm . W v- .n ‘n'uv 7 ~m—w-w..». v m... .vvc'wTV-t or v'.‘.wwuwxnn_r'~u—l’v»wy wrv-suw‘ mw~wwn~w~mnpmmm .- »— -nnmmw—rr-muwawu nvre --u w percent, the electmenoephalogm flattened in a fashion parallel to the post-tramtic meant. 11.1% stndies wemWin neurological patients by Tour and Hohdmm (19am). Free aoatyloholine the oumbmspinal fluid only in mam, The 1.: patients was found in with recent head mount grand-ml seizures or after omvulsive therapy. free acetyloholinc varied from 0.2 to Tower and HoEachem of the spinal fluid. 100 gm percent. also assayed the molimsterase activity They noted a sharp rise in the nonspecific cholinesterase fraction (benzoyloholine-splitting) and a drop in the specific cholinesteme fmtim both in patients with head .trmma convulsive therapy. amd 'me oembroSpinal (moholyl—splitting) in those following fluid following spontaneous seizures containing free aoetylcholine did not exhibit such inversion. 3-2:. and-II: concluded that the level of free aoetylcholino varies directly with the dogma of cerebral damage - �that the reversal of the cholinestemse fraction sensitive indicator of cerebral (image. and was a more Electroencephalogrem, taken at varying intervals following mum in most of these subjects, indicated a degree of EEG relation between the abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. ‘hecstmﬁu Watt. an to. mom 0‘ (no. aaetzﬂdwdne m1 incuae in #:24me {Md 4011ng Macadam tum and me a «wad: lactation my mwowa, duomug, (b) «in. degm and dumgo Effect of anathema“ ﬁe and type as in Am mount 05 ﬁne demamcmuagmic dialed bdrawloa. on ﬁb-traunatic EEG and Behavior: Bernstein aministered 0.5-1.0 lag/kg atropine parentually after head tram and denmstmted bloating of the EEG, behavioral and homologies signs of clinical tram. changes occurring Similar EEG and after the experimental addition of intruciaternal aoetylcholine were also blocked by atropine. �w. --r.-~r-v—~--ww- w-Im-vmm 'mm' "-W‘mmv'm" Ward (1980) 'memnmw applied tmse observations to the hum cases of closed dogmas of tram, head injury. In tremnt of patients with varying 20 he aaninistamd atropine subcutmzsly in doses immt in of 0.1 rug/kg. In saw‘oam he noted clinical and others a reversal of the eloctromoephalogmphic effects of the tmma. In a study of .1er and War diethﬁf’ mother mtidmlimrgic drug, (1955) reported sigmificmt alterations in the post-tmmtic elactmmoephalogm. dose in 1&0 patients with in normalizing in The same slow wave 22 A single 1:1th ahmal electroencephalogram subjects land marked «act of atropine in inmt msul’cad in six others. blocking the appearance of activity wm reported in subjects follwing convulsive therapy (Ulett and Johnson, 1956).. (In a later study thé‘authors failed to mplicate this study, suggesting that dosage factors or population mass” may have omtributed to the different results [Jdmm 559;, 19603). M... �8: These obeervatiom provided the basis for a series of studies with other Imam mtidlolinemic ooepomde (Pink, 1958, 1960). The intuvenom injection of experimental patent antidmolinergic «mantis es diethezim. (Dim). Maine, the pipeddylbemiletes, Jana, J8336, and pmoyclidine were shown to induce EEG illusions deeynotmiutim and behavioral alerting, mxiety. J8329 WIN 2299 end md helluoinetiom in nm—ehotmehodc subjects; and e reduction in allow new ectivity associated with e mvemal of the Wm; euphoria, dmiel ma omfmion in these with prior meant induced omvﬂsiom. In these studies, atropine was also emineddn low doses, EEG desynohrmizetion was observed, eoooepmied by considerable peripheral tachycardia, mmaenese and tension. At higher dosages, oonfmion and disorientation min! hypemyndzmm slow a mduction waves and of-hmmiutiea their replacement by lower voltage. poorly organized delta activity with superimposed beta activity. . �~. . a" ~~_,—vn~m«~p.-~W» A q ”We," W. _ ,_. 1..“ ., ,. w." .-—...n-r.. t ,, . u ,t. .( m...w-,V -—..~— _\|=V-\w:w.~a ~FVJH-ﬁ'u—p‘muwt »‘wb‘wﬂ- 7.;r._‘,.,v,wr _ﬁuv;a_n.‘--,,.p‘m .w-wunw... \ .,.—_,.....~ variety of experiments with a potent duolinesteme inhibitor, D}? (di—isopmpyl frequency EEG fluorophosphate) denmstmted high amplitude rapid patterns similar to status epilepticus, as well as lesser degrees of abnormality similar to that noted in post-tnunatic states (Munich 333;, 1950). 1950; Pmdman 3331., 19:49; md Hampson 93.51,. These electroencephalographic doses of effects were blocked pumteml atropine. Chetfield md Dempsey by small (19%) prepared exposed mimal cortex with pmtigmine and evoked electroencephalo- graphic spike activity. 'lha prior blocked this spiking, or ministration of atropine if present, the abnomality could be eliminated by atropine. In contmt to these findings, Brenner md Merritt (19%), applied topical aoatylcholine in cmcmtmtiom of 2-1/2 to to the exposed cortex of cats, and noted no 10% effect after intravenous atropine (1 rig/kg) on the electmmcephelogmphic changes. The montratims of acetylcholine in these experinmts , hmever, was significmtly higher than the topical applicatims (1-4 game percent) new v” rm— ‘7“ .wv-u- �and the intmcisteml (0.2-10 gamma percent) injections of Bernstein (191.6). Bmmer and hmzitt, also made note of electroencephalogmphio effects similar to soatylduoline from macholyl (aoetylbetmthuldsolinefmd Meryl (wbaxyldloline) in oonosntmtims moh lower thm the aoetylcholine cmomtmtims. inmd They ascribed the effectiveness of those oholinergic drug to their lack of sensitivity to oembml dualinsstemses. FM a waist; conduct: that and MAW“ Wencapdz Logaaﬁtic activity Mu a a “nu mu! upwwtaz 06 as deans tome. Manama agent induced by acwjzdwu'm, appuc'mon'og Mam, topical be. backed can it was; a (Lt/topaz, we may on. Magma Wand by humans, as. (c) Carebmsginal Fluid Amylcholine md Seizures: Aostyld'xolino bomd form. is nomally present in mrvous tissues in an inactive wring periods of activity, free acetylcholine is �. ; .m, . .. ..., , m .. .ﬂzwuwﬂurww—w 1.... y ..‘ , v ".4 .4 .. J, vV—I-N‘r W. . . ._... dwlimstorase. The v—- "’W\‘,a(')~\ro" >m»":qnaArv-n3l.!' 'r ~w.'vu.* '4.-:--wr~vr g~u~wr~a~~u~w> www.1-v-u mm it is libemted at the cell madame, by K." w- level of “mum rapidly deactivated bound aoetyloholine is thus the resultant of the prooosses of synthesis, liberation and It breakdom. may be rise during shop and pootulatod, therafom, that the level will fall during activity. lhis hypothesis was support“ in animal emunants and Elliott, by Richter md Cmasland (19%) Swank and Henderson (1950). By using liquid air quick-frosting mthods, Richter and Crosslmd observed the mtl'nsia and sleep gm per levels. mg. The level of aoatylcholim (masumd as brain tissua) to be 300$ higher than poet seizure difference in tissue levels is transient, however, as the “synthesis rate for aootyloholinc in (7 mimo— mulmlﬁnute). Elliott gt 5;, mt brain is high (1950) omfimnd these oheowatims. After- mtmzole oonwlsiom, they also noted that free mtylcholine was always fluid in concentrations up to 3 domtmble in the spinal gm per cent. v -.~~v~ , . .- �- .... nut, v-wwgg—w mauw-Vr‘ u-~0'iv-a—. n... mg. ._, -:Jpag-.'~vw1 4mv..l.‘N'-rv-~Vr‘-\ ﬁrm—um r“ nmww-r w WM- "— w—rw" .“ - -wmv~—-w--m.. -v.‘ F»; "-v-q .~ www-rwt:.v—.m.-v .10In spinal fluid studies in man, Cbne, waer and (lSMB) and waer and McEachern (laugh) reported McEanhern significant quantities of fro. acntyldholine in patients with epilepsy. 0f 56 apilnptic patients, an (77%) dnmnnstrated measurable acetylcholins in quantities of 0.02 to 5.0 «warns» of 1.0 gamma per cunt. The gamma free per cent with an acntylcholine level was directly related to the frequancy of seizures, the extent of olnctronnccphalogruphic abnonunlity, and the relation of the time of sampling to the last seizure. It home no relation to mndicatian, type of epilepsy or level of cholinesteruse activity. Whethcr>tho acutyldholino appearing in the spinal fluid is a byiproduet of the convulsion or whother the increase in acetyldholine is a Wu!!! cause is of the seizure prublamatical. (1939b) suggested Tower and that the increased wetyloholine liberation in not due to the seizura itself but is related to the procnss causing the seizuma. In a study of the hypothesis that �11 the acommlstim of acetylcholine is basic to the seizure process, Tonia (1953) induced convulsions in animals by mtmzolc and dotsmined the level of acatyloholine in brain tissue before and during comulsions. She noted that convulsions are pmcsded a rise in the acetyldmolim contsnt of tissue; Wily falls during the cmvulsion; levels, cmvulsims failed to occur. and an that the content that bolas curtain She suggested in tissue acotylctmline during a omwlsicn by was due that the fall to inhibition of aootyloholins synthesis by increase! concentrations of metabolites such as In. mim Likely ions. #:215de m mmwbg mm {m mam; ohm «:3;qu an wanted (m it inmate in bound tat t3 isms my be inﬂected in sum 5%; ands wanes «wanna: do 5m, and that cumbmt auction, taming and Leap nhuu an to in augment Minoan; tin no. touch as “mum“ pmduoaon imam ing “A as touch . �v......,.,.w.,. ., 7.“..- www. min-w: .~-.Twr-r.~a y: m nvmw-m ...v 'Nwwmu‘agnar' "n T“.1.,1~V;’§mm- ,M m..., . .u..." .“WWFV . m: or..‘m--.w-,.-W,‘_..< WW. m.ﬁwl... .V w‘~...oww»..wm-_v m_w,ﬁ WWW-A“ .12. central nervous slaten Cholineetoraaeez Concomitant with their observations or change: in ooetyioholine, Tower (d) fluid oholinoateraae end noanhern (1949) mnaeured epinel activity. Two types or oholinoetorenoe ere normally found in the epinnl fluid: oholinoetereee—I ('true," "specific,” or neoholyl hydrolysing), whioh has e high specificity for aoetyloholine: til oholineetereee—II ('peeudo.””non~epeoitio,” or bensoylcholineohydrolyging). Both compounds hydrolyze eoetyioholine but have dirforont rate: of hydrolyeie for This meoholyi and tensoyoholine. qualitative dietinotione. activity as a By differential rate permit: reporting the oholinootoraee ratio of the nativity with meohdvl end with bonzoyioholine outstrnten compared to an noetyloholine lubetrete two ratios are round: oholineeteresoai/aoetyicholine and cholineoterooo-II/aootyioholine (with retﬂoa Initials! norMul 08F th/th: 100). In such contains eeteroeeo in the ratio of 53.17 for oholineatoreno-I to oholineotoroee-II. Thus. normal 08? consist: , ,»-.- .- �_.w.W—-« “mu-wow. arr-u- ﬁmwmmm "WW?“ me-‘Ww‘wmvjrimwmmrm )5 s: mainly of "specific" estomes with a small mn~specific ostemse want. In patients with head tram Tower and McEnchem report and inversim of the dualinestsmos with a simificant increase in tbs daolhnsts'mse-II fraction of the spinal ﬂuid dualimstems-I activity. They and a «mass in also observed a relation batman the extant of the momentous” manual with the severity of trans and with the dogma of the olcctmmceprmlompie In patients with 5.an spinal fluid acetyldzoline as a result of spmtmom saizms. howswr. of cholincstsmss or total Why. no change in the ratio duelinsstss-ase activity was found. Certain usunptions my be mad. mgmding changes in cell mm psmability as explaining the humans in duelinsstcmse contamination in found in highest is Gaolinsstcmse-I activity. the antral mm systm mile molinestemse-II in atlas:- tissues, especially blood sewn. pmdminates With an increase in �,7. ,.~.n_..._..‘..,.q—. 7. v . ...,~ “NW... . «g..- Wv-slv'n-nrrh w-rw-muwwwmmmwwvaWmn-mmmmmv‘wvwrvhmv w -w~'r v- acutyloholim levels in interoellular cerebral fluids following stimulation, convulsions or trauma, vaaodilatim md increased cellular pomability may be pmdiotad, with a degree of transudatim of vascular fluids into the inter cellular Spaces dependant on the extent and duration of tha vmodilation (Kabat 33:. 9;, 19%). Spiegal and SpiogebAdolf dummtmted such pamability ohmgas in nmorma "ports 1953). Thay reported inmmd (19141. 19%, 198%, 19148, oomhzctivity of the tissues associated with tho appearance of various ions as potassium and phosphate in the spinal fluid following convulsions. more was also a significant as nucleic-acid nm-clactmlytes cellular pamability mtmims electrically inmoed may imam in such splitting mzyms. Chases in thus provide the basis for the high of acetyldxolino and the managed omoantmtions of dwlinostorasaJIﬂTmr and Hoanhem muse) . '5 �— m‘ w «'7'- M-mrwrvva-mmmw.mw m The increase in ammnstcme activity should be associated with the rapid «stamina of free mtylcholim. Its persistence in spinal fluid afar tram ad 931m related to the sensitivity may be mtmim of the amtyldwlim—dmﬂmstm-I system to ships 5mm (mam md Rathmbarg, and lowar Midtown Mauritius, ad mo mnemtmtims, tha nativity falls off quickly. In contact, of hydrolysis mm minimip «sciatica mm who in few isdestroyedbythe udlliuomds. where bmoentmtim of mtyldwlim in tiasun. tbs mm of hydrolysis by dwlixnstome-I is W. com. m WWW—I to an is nut—specific with concentration. Thus, the mlhwnbfmtyldxonmatmnmbm specific activity of Wm, 19kg; is mpid (3-3 mimeoonds) but at higher th- dnlimanmc—II-m‘tylcholino the m and At "physiologc" and HacIntoah, 1955). hydrolysis of 19445; mktim~ mmmMMMmybemadndmdaseizm me disaoaiatim in ship nouns in a pemiatm amtylmoummﬁneamml relationof mldwline. The seizure may �16 itself in add wt to the of free acetyloholine. 'lhe increased mtylctnlim diffuses rapidly, affecting vascular and cellular permeability and increasing the cmocntmticns of various ions and dmolincstemse—II (SF. activity of cholinsstemsc—II, though of The on the concentration runs to days to efficiency and dependant kinetics, reduces the acetylcholine in the tissues in in! levels mm” 1c»: for the physiologic action of cholinescemse-I. #:1st am Manuela manta 5M, «may 5m «ppm in {Add dowsmaa someway in. «was {on mm 05 ma past a a gestation dzangm “mad Mwouﬂne. Mme. madman; om «toned by (named in 06 «he :1ij (ﬂ 05 in cut 'hc mechanism mun-um at sou moms nausea; system sanctioning. (c) Agglchclinc a EEG WNW and Induced Convulsicns: Altamtion in the blood brain permeability barrier by the continuing action of acotyloholine may be the biochemical substrate for the post- olectmsbock hypemynchrmy of the electroencephalogram. Such a possibility is oviduct in the upon an increase days by Aird 93 9_1_, 1956, W denmstmting in the cmocntmtion of cocaine in brain tissues three afar a series of 12 induood convulsions. His data shows the change in �-17concentration of this large molecule, ordinarily absent in brein tissue to be seeocieted with the eppearence of hypereynchrony (delts'burets) in the electroencephalogren. In studies of induced convulsions. we have confirmed the neny previous reports that convulsive therapy induces electrcgrephic hypersynchrony (Pink and a constant Kuhn, 1956). Despite time the or however, or treetncnts. epplicetion slow the and of extent electrosrsphic duration eppearence. wave activity; its sensitivity to modification by alerting, hyperventilation and barbiturates psychiatric populations. degree hypersynchrcny. end The - s11 vary greatly in early appearsnce of high its persistence throughout the treatment course, hes been described as prerequisite to improvement following electroshock (Pink and Kuhn, 1956). The failure of certain patients to develcp hypersynchrony may be relatedto differences in activity of central seetylehcline and cholineeteraees. may reflect The degree of hypereynchrcny the level of tree ecetylchcline and should follow s decay rate eqael to the rate of ccetylcholine destruction. �vuzvnc—v-w: —. Since previous studies demonstrated thnt ens prerequisite to the it may be EEG hypersynchrony clinical response in convulsive therapy, suggested that the absence of free soetylcholine suggests minimal changes in cerebral function and thus precludes s clinicsl response to induced convulsions.Touer snd their study of creniocerebrsl trauma, hoEedhern (1949s), in included observstions of six psychistric pstients undergoing convulsive therspy. Studying the pstients after 3.7 trestu meats. they reported free soetylcholine activity in the spinal fluid in ten pstients; and en increase in cholinestersse-II and a decrease in cholinestersse~l with a reversal of the ratio or cholinestersses in five of the six patients. From these observations they concluded that the spinsl fluid changes in induced convulsions were more like those of creniooerebral trsume than those found Regsrding the one show in. ilepsyu pstient in the series who thiled to either free ocetylcholine or e cholinesterese ratio reverssl in the spinal fluid, they wrote: that this patient was the only one "It is interesting of the six to show no _.,. �7‘ response to treatment." It is I probably that induced convulsions increase free acetylcholine and enhancing cerebral perniability altering fluids. in intereellular the appearance of cholinesterases. Free acetylcholine by JMAco repeated seizures. EEG hypersynchrony is one is maintained reflection of altered of other electrolytes. and altered permiebility of acetylcholine levels It is these changes in intercellulor electrolytes that provide behavioral changes the for substrate biochemical persistent the following induced convulsions. L/ (f) Cholineatersaes and the Classification of Pezchoses: These studies may also have autonomic reactivity and the Funkenstein and others ( application to the problem of classification of the psychoses. ) have demonstrated a relationship between the blood pressure response of patients -“.:')l\w - w—w - Fry-w M7.“ �rm, w.» v—v-v- ya—_ -7. -. v'*a‘ 1——.r an ad“): , v-u n.7,. y ~. 7' V .. - r—*yx:'\r‘~'7—‘ —..vwr rhw- revues—WWI: a-m-x) v aw. 'IIMIN'.WP1L _,.. wr—Mrn 'w .n-u- u ...- nun-mun—u-wwwsrx— I‘d 'fllr-nr-F-qlf r".:'m~ — - —» ~ to injected meoholyl and their clinical response to convulsive therapy. which induce! Neoholyl is e potent oholinergie agent Vlsodiletion, tachycardia, sweating, and It is inoreesed peristelsis. rapidly hydrolysed by cholinesterese-I and slowly by eholinestsrese-II. blood pressure or subjects tells etter injected The meeholyl end returns to the baseline in a variable length of time, 2‘2;, five to pressure returns to the hgaeline in as Groups Pstients more than an minutes. I. II, or III reactions: 5 whose blood minutes ere olessitied those whose blood pressure takes so or more minutes to return to baseline, as Group and VIII reactions. The Group I reactors here s 9% improvement reactors s rate with convulsive therepy, and the 35% recovery rate. In contrast, the reactors heve s 89% (Punkenstein 35 3;, 1952). petients In whom IInIII Group VI and the Group VII 3 9'71 recovery Patients in Funkenstein Groups I to III upon as Group VI may be rate looked the injected meeholyl 1s rqpidly ~ �. . ”(Inni- rwlv‘v -. v -hr ~r. ‘r Wﬂm‘r;vz.z ~~w~ ‘ vmvrmm-mwvnvmwurr . . . . -.n- . ~v-cv rwwmvrrw-r ’Hm . , . warm-n'ku-w—w-vwvu-r‘mwm ’W'I-W‘WW . , ., . ‘23.. Groups VII v1 and the while hydrolyzed; slow hydrolysis rste. we may patients have a. the therefore. that predict, would 1.1!! Groups of blood oholinestersse nativity levels be high; while the setivity of Groups A VI-u-VII would be low. central odds nervous be rsgsrding similsr analysis msy devsIOpeent of the in system levels or oholinsstersse~l EEG of soetyloholine. levels and fluid spinal hypersyndhrony In studies of EEG changes following indueed eonvulsions resolted in seizures subjects were identified in whom a few a great amount or slow save activity; while other subjects (Pink seizures and to frequent exhibited few changes to many and Kuhn. 1956). If electrogrsphio hypersynehrony is s that probable is refleetion of inoressed tree soetyloholine, it subjeets who rapidly (the usintain hypersynehrony end those in whom it differences be exhibiting hours) disappears nsy hydrolysis oholinestsrsseoseetyloholine the of in the kinetics systems. Persistent hypersynehreny may be seen to result from associated of soetyloholins. s decreased rate of hydrolysis with low or oholinestersse-I either oonomntrstions of z - w mv as ‘— e �nw—w—uurw—u-A ~ «wv-u . "Hp; v-r w: w-ws-u—mxw —» al’im'rw‘imﬂl'wnnmmﬁ.rww-‘wmm' cholinesterasemII. Conversely, in patients with hyperaynchrony. cholinestoruaoul and fluid may be a basin fbr :yutom 1110111 : unusually high). wwwvvnwa >vv'wwa-uww «VII-MWI—w-W short~IIth .1: in tissue and spinal Thus these speculations providn congruent hypothesis rognrdlng central norvnua ruaativity to electroshock, and parephoral ahelinergio 09‘. �‘‘ r— v» -v «'1: -w:. . ~v~wr 1.». —.vn.~n—u nvw .w is w,“ . V m .,._v you-um: v...“ .uw m...” w. i. (“Hwy . , . V . v—wr\wl~;r‘-V‘va"vwg . 7-..,emu.,_,._c w‘,_pwmi,,”.w.'w.ww rtr‘ ., 1”,.“ M y OOHGLUSIONI be to e neehsnisns appear Gentrel eholinergie The convulsive the therspy process. dignifiesnt teeter in induced that to indioste be date interpreted any published Leonvulsione ere ssseeisted with en increase in intereelluler be by destroyed than esn to levels greeter seetyleholine eholinestersseal activity. Vhsodilstion and increased oellulsr pernisbility is relieved by increased amounts of eholineetsreeeoII, other and electrolytes in inter- celluler fluids. It is these changes that ere reflected in the increased electrical hypersynehreny which is recorded in scalp electrodes, and which esn be modified by sntieholinergie drugs. as stropine, beneotysine, dietheeine, proeyelidine, etc. It in these changes. else. thst provide the change in biochemical milieu which to slter alters cellular ectivities eufﬂ.eient the behsvior of subjects. Fhilure to induce high and failure of aoetyicholine, concentrations and persistent ( . . 'W—vnww �- —-——--p~rm- ,v-vln’ .-. ‘w-m-w --v< w u-wv «m ”uru-ewmmw‘ vat—rm,“ W'WV -. - . wwwm mmnmnuw—wm "wrrm,w— "-1. Wm, chengpe, concomitant results in a failure to induce electrolyte to produce behavioral change. Difference: in the rate 0! development of cerebral chengee may on reflect differences in subjects in their reliance cholinergic mechaniene, or in their sensitivity to changes in acetylcholine levele. These differences provide the basic fer the claeeificcticn cf the menilly by my: and Kuhn (1960). 111 by Funkenetein and �.4 w . .._u~mv — \w"wxww ~ wlxmw-mwmmwwrlmmrrw IV: 6-6-65 CI‘DIINEmIC WISE, CWVULSIVE AND BBMVIOR W, Studies of cerebral changes associated with convulsive therapy have indicated that the development of early and persistent signs of altered coronal fmctim are prerequisite to oranges in behavior (Pink and Kern, 1956). In these studies, electroencephalographic slowing was the most sigmificent index of altered brain function. Th demonstratim that premedication with high doses of atropine and Johnson, (Ulett slow of mve the activity prevented appearance 1956) suggested a relation to cholinergio nechnisms. The role of eoetylcholine and ﬂu cholinestemses in convulsive therapy is amplified in the following review which smrizes the published data. The mle of acetylcholine in the tmsmis sion of nervous impulses has been studies extensively since the of Dale (19136) and Loewi (1921). Acetylcholine constituent of nervous tissue existing in a first descriptions is bound .21 normal fans which is �. -~»-.- cwlwx—Wm.m~mn mmmvwvx 'w'w-m‘ w'dnuev—Wn —-'-v.":'-v-yvl~<-wmv -‘-w'-W"’mnrm"u'm’mmp '«ai-lu'vwv'w»; umpnw-so w-wm'n It is liberated driving the excitatim process. W the specific action of ctnlimstemse and as rapidly recmstituted 19:59). mpidly hydrolyzed by the dwlimacetylase system (Richter 8 Welland, free ac etylcmline has been reported in normal No cemhmspinal ﬂuid despite the rapid breakdom of bound acetyl— choline during pariah of activity and excitement (Tower and HcEechem, muse). The cembmspinel fluid normlly has resemble chclinesteme activity, homver, principally of the "true" or mechclyl hydrolyzing type (Nectmensm and Rcthmberg, 19u5). In the absence of free acetyldxoline and under the cmditims described, electroencephalogram fail to shm: any mietent abmmelity. (1:) was fmmd Effect of Wiccambml Mm: Pme acetyldioline in the cerebrmpirml fluid within a experimtel heed tram varied between 2.7 and 9.0 dew after in cats and persisted for varying periods (Bernstein 19%). an hours to m related to few minutes gamma The qumtity of free acetylchclim percent, and the amount was of induced trmrne. -n way-a ---1-m'— «mu-w v;- �v ‘ .v-vuwv—‘uwuwaI—r'm mm ‘lh'une‘ “an”, . - 1W um van-mar ammw— mmmx($—‘Wv~ ~-;Www Ww-v' .wma a..- ‘nv‘w I'u Commitmt electmemephalogme Th records were first filhd with mmted patterned dwxges. high voltage fast activity, interpreted as evidmoe of m intense manual disclmze, mly to befollmdbyasrwrtperiodofﬂettmingofallmcomed electrical activity. 'Ihese planes were then followed by pmlmged periods of high amplitude sharp waves in the delta frequencies. The to the beheviml enemas were mutant of measured fme related to degree of acetylcmlim. tram and With higmer greater of acetylcholine, Bernstein reported degrees of abnormality and greater- changes in moiwmss. levels EEG In addition, spmtaneous poct~tmunatic seizures were also related to the mt of free eontylcholine appearing in the spinal fluid. aoetylcholine Bunstein later applied to expomd out cerebral cortex. mm the cmmtmtim of acetyldaoline was 1 gm pement orless, Mowemdhimmlitude sharpwavesoflwfmquencyin the electmenoephalm. When the concentration was inmd to w... wal‘r-vunu .,.. u ��min-u .41. - v... and :— » -1~—— “Va-x v,m..,».«n—n ww'Al'wr‘w'nx‘xa'r .. ”-p- vwrn 'iwrylvv.-ws“ «ﬁrm-mu». tr'r'r—I‘lumm$1~I'm’w-VWW-Iv‘rn'wwu .~ that the reversal of the dwlinestemse fractim sensitive indicator of cerebral BMW tram Jag-Anny... ”a.“ r‘np‘woyppﬂ" v—y- x w— v—w-1,msw»: v. was a more damage. were takan at varying intervals following in most of these subjects. me authors reported the relation homunmofﬁmahmmntymdtheappeammoffrm mtyldwlim in the w‘bmspinal fluid. Thu: AW my We and that a «the mount 05 (m acdytcholxiuc 5mm summing Weenebmdtﬂawm batman the mount 05 mayuuz Won W Memory, main wind In the Micheline, (1)) M indicate m dcgm and changes Effect of and typc 05 in AM mm on unﬁnisnmd 0.5-1.0 awomuphatogmmc bchawéoa. at-«mmtic nag/kg (an. atropine EEG and Behavior: pmtually after mmummdmmmmdbmmofmeme. behaviomland anatomic aims of tmuna. Atropine also blocked the clinical changes similar to head mum EEG md seen following the experi— mtal additim of intracisterml aoetyldnline. n-w �.r .nwm-nuw v m, 1‘ x—~.wwrv-—um—mw“n-«WW«-Waqm v Ward (1950) . mm dawn c." m xwwuv— m ‘- um ,r—m—xw applied thase observations to the treatment of hmm cases of closed head injury. In of a: patients with varying be administered atropine subcutaneously in doses tram, of 0.1 mg/kg. In 20 some cam he noted clinical immanent and in others a reversal of the electmphalogruphic effects of the tram. In a study of dietlmint. another antidmolimrgic dmg, Janknor and “dancer (1958) reported significant alterations in the post~trmmntic olectmenoephalogzm. dose in #0 slow single intravenom patients with ahmml electroencephalogram resulted in normalizing in The A 22 subjects and marked immvemnt in six others. sum elect of atropine in blocking the appearance of um activity convulsive following in subjects reported was 1956); (In a therapy (Ulett md Johnson, later study then authors failed to mplioate this study, suggesting that or population changes may have [Johnson 93.51., 1960]). dosage factors cmtributed to the different results .u-wmwm �"rm—W .7, . .\.—.~ v‘ u. w wr— w' w --=»—-.--«-v- 'w' nu.- "I 1- nun.“ mm-‘Ivm’lwuu‘twr "uvmq-WIWVWW. “HM-:rv‘lwr." 1— x—A 'i‘w'wwuvuwrwwn uvvmw": «rung-w unmoun- . aw awn:v-v—nnJ—m variety of experimta with a potent dzolinestomo inhibitor, A DI? (di—iaopmpyl ﬂmmophosphatc) fmqumcy EEG mutated hiya mpﬂttxde rapid éimilar pat-hams to status epilepticus. as well as dam status (Md: 5331.. of abnormality similar to that noted in pmt—trmtic looser m 1950). doses of mad 1950; W ﬁg, 19139; aid Won 95%, eleotmonoeptulomphic effects were blocked by small pmteral atropine. Chatﬂald md miml com»: with proatignine Way (19142) pmpamd and evoked electmmoamalo- graphic spike activity. The prior uninistmtion of atmpim blodmd this spiking, 'cuminatod by wif mat, the abnomlity could be mine. what to these findings, Banner md Harri.“ (19152), applied topical mimome in Momma of 2-1/2 to In 10% to tho awed cortex of cats, and noted no effect after intravmous WClm/kg)mﬂne1¢otmumphalommicdmges. 'Iho mtmtims of acetyldnlim in those experimts , mm, was significantly higher than the topical application: (1—1; gm meant) m "nm‘lV‘I-"WPX' mm» �.9— intmiﬁuml and the Bormtdn (19%). (0.2—1.0 W gm percent) injections of and Pbrz'itt, also made mate of elmwuhgrmic effects similar to aoetydxolim from ucholyl 1n (mummyldwline) commenting: dam. '33); m and dozyl (carbmayldloline) later than the acutyldnlim concentrau ”W th- inmmd offeetivomss of these momma. drum to their mitivity to animal lack of durum. FmavWa‘WandWaMu my I mama that Waupiwgwm «may mm by «wane, uau we. on a a mutt 0‘ mm. Magnum: with chaunutume blocked M (:3) We): Waxed bg We. Role mm away applied.- can be ‘ of Oanbmsgg ﬂuid @951me in Saizums: Amtyldzolim is normally present in mrvous tissm in an inactive bound fem. Daring periods of activity, free amtyld'aoline is ��. N...- ~mv nun-7‘ «mamwmw-nrwu-W-ww-m—mmw Yum—U" v2»: 'lwwvv Wx-uwww- vv'r‘wr-I w-ww ‘t‘I—L :\ mean-v1- avast-Lo— nary-row: .10... Inspimlﬂuidstudiesinm, (19%) and Tower md Warn Cone. TmrmndEadnm (mush) reported significant qumtitios of fun mtyldwlim in patients with epilepsy. 0f 56 cpilaptic patients, an (77%) demastmted ﬂammable free Michelin in quantities of 0.02 mm of 1.0 gm to 5.0 gm per cent with m per cunt. The acetylcholine 11.3ch. was dinctlymlaudmﬂmfmqmcyofaeizm, theemntof 0W0 dun-normality, and the minim oflthe It‘bom lagt seizure. tha to angling tingof no mmim to of Ila-dictum. type epilepsy or lewd of dwlimtemse activity. WW a W 61011110 Michelin: appearinginﬁn of the awn. is a (mm of the Madam arlwhetha-r the aim fluid is spinal W is pmblmtical. (mush) suggested that the in acety1~ Tower md' inmd acetyldwline mlat§d liberation is not due to the seizum itself but is to the process casing the seizum. In a study of the hypothesis that v w. �' “W "m’ W“"‘W*P"W‘ TW""-'“'M'rmz‘m-ww' : ~<I w'l-w' uzm-w-wwnw-rmr wrmnsa-mmrw “my; —nwu—n-»mrw—u-—r w-w w n—w- wan-m .mmw- n- -_w.—..——,aw—. mw'hmmrmw m «w -11. the accumulation of acctylcholine is basic to the seizure process, and animals metrazole convulsions induced in (1953) by Tcrda dctcrnined the level of aoetyldmlinc in bmin tissue befom and during convulsions. She noted that convulsions are pmocoded by tissue; of content that the content in the acotylcholinc a rise gradually falls during the convulsion; and that below certain lcvols, convulsions foilod to occur. fall in tissue acctyldholinc She suggested that the during a convulsion was due to inhibition of acctylcholinc synthesis by increased concentrations of notabolitcs such as alumniumicns. Tho passagp of electric current through brain substances induces a change in callular activity with an increase in free aoatylcholinc to lnvcls sufficient to induce a grand mal soizumc. Tho prosenco of free aoctylcholinc in the interocllular fluids is associated with electrical hyperoynchrcny, reflected the EEG as dolta slowing. (d) Effcct of Electroahock on Acctxlcholinc and Cholin~ saturates: Tower and McEachern (lShQa), in their study of cnanioocrcbnnl trauma, includcd obscrvations of six psychiatrin �, .— “7 hin""'-"""""’n w—xwwr‘W'wv-Wsmuwvw ”‘1.meer!. ., . A a .m "Jaw-«v 7 wmr- mm- vmm:wwwq~mw‘m¢7~w 1"‘3-0! w ~12-- patients attu- 3-7 Linda-going mmrulsive therapy} Studying the patients mam-atmﬂay upwind fm Micheline activity an.incseaae .ad rxuia in.two in in th. Spinal patients; dwlimsteWII rawnrsal a: a damase in and mum-I with a the ratio of cholinesteruses in five of the six obsewatims time has paints. W they concluded that'the spinal new; convuisions were 11kg those tunic ahansps in induced mm a! than those found in epilepsy. Ragarding the ma patimt in‘the series who failed to show 01th» I’m mtylolnline or a dwlirastemao ratio reversal in this intsmsting the spinal fluid, thoy smote: "It is that pstimtmﬂamlyaaoftrasistosmwnompameto mamt." WM than. a show: in «1mm, cons/Lamb“ augment about ﬂu. note 1,: 1.6 05 “chaste that 7W!- acaytchaune mwmgaammwmmuwsm <1“ch 4:.qu and Adm/Lu enhance. autyb Ls that «sorghum damnation, �“mu-w. v— vaw >W—Wrﬁww.vwam—.m .‘w'wwrr Mr“!!! wrwwumm'm WV - W9 augment wmm 1WW"WYI3"W'FVI'W‘VW wwmmww-zw (”wan-vim -13- Lawn. tww 05 “Midtown whiz: “up and auuthau wetytchauu puduocéou inc/mum about. (was. (2) Central Nervous Sygtem Cholinesterases: Cbneumitant with their observatims of W (1939) muasumnd spinal in acetycholine, Towor md Hcﬁadxem fluid cholinesterase activity. The types of'dholinostoruscs art normally found in the spinal fluid: momentum—I ("trm,” "specific," which has a <92" mdmolyl hydrolyzing) . big: specificity for amtylcholim; and duolinestemseoﬂ ("peeudo,” "um-specific,” or bonnoyldwlinc-hydmlyzing) . wands hydrolyze mtylmolim but have different Both rates of hydrolysis {bu-ulcholyl and banzaylcholine. This diffcrantial rate permits gamma distinctions. By ram-ting the cholimsternse activity as a ratio of the activity with macholyl bonaoyidaonm substrates two mama and with acetyldmbline an to- substrate ratios am fomd: momentum-Ilacetyldnlim md alwlimstcmeII/amtylmolim (with ratios normal CS? Ach/Aeh a 100) . omtains ostemses in the. ratio of cholimstcme—I to dmlincsteme-II. Thus, normal In such 33: 17 CS? for consist. �-.v rmvs 'mm l-F'W'WW wmmmm .mpr—w— rm . . may of "specific" caucuses with a small now-spedfic estemae coupon-mt. In pathmts with hand inmim of tho cm the fluid fraction of the spinal activity. dam the and 'mey also observed a of tha dwlhmstomse with ad mm Wm report and daclizmtomes with a simifioant increase in the “Wm-II Wanna-I mm Tower and of the W a decrease in relation batman with the severity of cummpmlogmpic mun. In patients with increased spinal fluid amtyldxolim as a multofspmm of Wm warm seizmu.‘hdnvor. or total dwlinestcmo activity in the made was found. metimmybomﬂomgamﬂngdmgeainmn mm activity. tha pemability as explaining the WWW-I m1 mm: syatcm is fomd 1n imam Wt in dulimstemse mnomtmtim in mile dwlixmtemesﬂ pmdmimtes in 0th:- tissuaa. especially blood scrum. With an increase in �,- xw- m-mmwm m anatylmolina lawla in intercollular cambml fluids following atimlatim, convulaima or tram, vasodilaticn md cellular pamability my be ﬁlmed pndictod, with a dogma of mmudaﬁm of vascular fluid: into the inter gallular spams mtmmmtmdamimofmvmodimm(mt g; g, 19%). Spiagal and Spiegal~Adolf mutated such pamabmty W 1953). marred inmaaad omchctivity of the tissues Thay associated with W than in mm reports (19%; 19u2, 1m, 19%. appaarmca of various ions as potassim and in the spinal fluid following electrically indumd commie». Thom was also a simificmt-imm in such nm-aloctrolytaa as manic-acid splitting anzymas. (images in of circumstance-11 (Tower and Wm lSth). _ �wwlv mun-am.- V‘r‘ww.\\.sm uwrvvu‘x' ..- me—wwmvmvwn .q-zwuwm pawn-w ., cannwmuw v-Mr-ru-m‘ovr WWWWW «um—a. -.--< www.mm -15.. The increase in dwlinsstsms activity should be associated Its persistence with the rapid dostmctim of free asstyldxolins. ' in spinal fluid after trauma and seizure of the amtyldxolins—dxolixnstsmsvl may be system related to the sensitivity to concentration relation- ships (Nsdmsnsm and Bothsnbsrg, 19%; Tower and 3mm and MscIntosh. 1955). At “physiologic" Wm, 19%; oonosntmtims, hydrolysis of aostyloholins is rapid (3-H mimosaoonds) but at higher and mosntmtims, the activity falls off quickly. In lomr W, the cl'nolimstsms-II-sestylohomm relationship is naiospscific and the rats of hydrolysis increases with concentration. usual levels of sootyldxolim stosll sambmms is specific activity of cimlinsstemss-I in Thus, the destroyed by the few milliseconds. Wm omosntmtion of soatyldioline in emsssivs excitation leads to an mm tissue, the mm of hydrolysis sxosedsd. com. The ssizm threshold may by cholinsstemss—I is be roamed and a seizure me dissociation in mstylduolinwdxolinestemseul relation- ship results in s psrsistsnos of aostyldaolﬁne. The seizure may �mm “a." "W.— .mﬂmpw txm mm Wm-mmwmm—mwm m "m . amtyldiolixn diffunes rapidly, affecting vascular md cellular pamability and and Wins catamaran-II W of in the concentrations of various ions CSP. The nativity of dwlinostamse—II, cfficimw md depuuhnt low on the oonomtmtim kinetics, mmmldnwninmetissmsinhwmtodaystolewls for the physiologic action of dwlinostemse-I. (I) mo md Classificatim of mmm, gmmm . mamas: Altemtion in the blood brain pemability barrier by the continuing actim of mtyldmolim may be the biomenﬁcal sub- strata for the post-3W hypemyndumy of the electro- mmpmom. Such mag, 1956 is possibility o mom in the report by Wmtingm 5.11m intha concentration of‘ miminbmintissmsmmdaysafteraserieaofuinduoed Gambian. this His dun 1m mlccmln, aim the change in momtmion of mutually absent in brain tissue to be ��mm. WV wwwm'wmmww’rr‘v m (memwmw“'m'ww .19- my be mama“ in the. mum nub/mug ad the. dwuuuthu— hypmymmuy Awwu. my mama Whom 1’th be. oﬁ acetyl— dummzd hyd/wtyau to as a mt: {m mm an Law ma mammom wowed mun, u Cthénutcmc-II. Comma (Ly, in and Wmmv! WW, my be muddy 06, mm ~11 ewwc with 5h0u~uv¢d in Mac, to the Wainwmmk Mammy. WW and spinal (laid high) . stat-ﬂea ’meae may also have application 3 chaunutmvr MM}: between the blood problem of )have pmsum mponse of patients to initiated médblyl and their (minim). response to I convulsive mm tram. which is cholinorgic a potent hamlyl amt vaodilatim. tachycardia, mating, axomestemeq hydrolyzed by is It midly astemo—II. "me blood and hemmed peristalsis. and slowly by moun- pmssm of subjects’fans after injgcted manlylmdmtmmtoﬁnbmeuminavariablplmgﬁmofﬁm, �-m. “...u. “v ,,.. ‘mw you ,,, d . ”are". ‘V‘ -- m, mus-www- I vm‘ five to W rm www.- w. m 1 ”3.... v- .-r'l w - way-vr—v- .m-MWWWW. “gnaw-why , Patients more than 20 minutos. Mums to the baseline in 5 an minutes ,,.mu(._“‘,_,m,“ . whose blood classified as present. Groups I, II,’ arm mmmmbaaoline, amHdeIImactions. MW]: or III mactima; ﬁnes mean blood rams hm a 9i Wt the aroup II~III reactors a 35% rate pmsm takes minutes 20 and convulsiva'thompy. with. unwary rate. In umtmst, the MHmmmmmaast'mddnGmupsvnath-wverymu (main 5; g, 1952). Patimtsinmﬂcmaminmltolnmaybelmdm as patimts in whiu the We may the injactgd mdaolyl is rapidly hydrolyzed; Group Hand VII predict, hvels of W when: Won, W H~Vii a slaw hydrolysis rate. that tha blood Esolimstemo activity -I~III would be him; whim the activity of ma be low. regarding the data for eatcmenl, in patina hm We recall hem a similarpmdictim mntmlm which the domiopumt syntax: levels of cholin— of early and sustaimd EEG lypamynclumy and elevated spinal fluid levels of aoetyldlolirm was minted to a low level of dwiineaterase activity. mus, w-n —. wu- �,-.n I ‘ -21- the data of paripiuml stimulation by dwlimrgic agents is wt to the hypothesis regarding mutual “activity to electroshodc. mm system m1? m'.mrrw-uww gum �CIDLINBMIC PECHANISIS IN WV}: m m M, NJ). From PM the Departunt of at the Missouri Institute of Paydziatry. Lhimity of ransom School of Medicine, 5WD Arsenal Stunt, St. Louis, Missouri 63139. Aided, in part, by usms grunts 1914-927, 11-1—2715, mmzus, and Iii-11380; and the Psychiatric Renard: Fomdation of Missouri . �VI: 7-17-65 GIOLINERGIC MICHANISI‘B IN CONVULSIVE W Despite extensive application and study, the mode of the oonwlaive therapy process “mains enigmatic. has been devoted to neurophysiological social ) aspects , ( Much study l, ( ), clinical psychologice1( . of action ), ( elucidating the present neuro- ). physiologioal-edeptive View of the process ( 'me wly development and persistence of signs of {motions were reported to be (Pink and m, activity es the The this and muisite to changes altered cerebral in behavior 1956), with electroencephalogramic slow wave most significant index of altered brain function. demtmtion that pmdicetim with atropine inhibited slow wave activity (Ulett and Johnson, 1957) and the report that mtidaolinergic «wounds reversed these clinical as well as electrogrephic menses (Fink, 1958) suggests that the biochemical basis for the mvulaive therapy process may be in the cholinergic mdmmisms of the central nervous system. This review discusses the available data mending acetyldxoline and �and the dualineetemsw in the convulsive therapy process . Acetylcmlim has been extensively studied w an active agent in the transmissim of nervous impulses since the deecziptiom of Dale (191») and Ioewi (1921). It is first a constituent of nervous tissue, existing in a bound form which is liberated during the excitation pmoess . It is rapidly hydrolyzed through the specific action of molimaterase and is rapidly reconstituted by the choline-acetylase system (Ricmer and Crosslend, 19%). In normal cerebmspinal fluid, free acetylcholine is not present despite the rapid breakdown of bcmd acetylmolim during periow of activity and excitement (Tower and Hailed-tern, wheel). The cerebmepinel dwiimnteme activity, however, medxclyl hylmlyzing type fluid does have maurnble principally of the "true" or (Madman md Rothenberg, 19%) . In the absence of free acetyldmline and under the conditions described, electmenceplumgm fail to show elmozmlity. �(a) Cholinemc Aspects of (kmiooembml Trams: Free eontylcholine was found in the oerebmspinsl fluid within a few minutes after experimental head tmuma in cats and persisted for varying periods up to “8 hours (Bernstein, 191:6). The quantity of gm free acetyldloline varied between 2.7 and 9.0 the wt was Wt related to the degree of induced electroencephalogram menses. The records were percent, and tram. demtmted pet-rm first filled with high voltage fast activity, interpreted as evidence of an intense neuronal disdurge, soon to short period of ﬂattening of all recorded he succeeded by e electrical activity. These phases were then followed by prolonged periods of high saplitude sharp waves in the delta frequencies . Ihe behavioral changes were related both to the degree of tum and to the want of measured free aoetyldwline. 9th higher- levels of aoetylcholine. Bernstein imported greater- degrees of EEG abnormality and greater damages in consciousness . �Spmtanccm post-traumatic seizures mm also related to the mmt of free acetylcholine appearing in the spinal fluid. Bernstein applied ccatylcholine to exposed cat cerebral cortex. M the cmccntmtim of acutyldrolinc WM 1 gm low frequency of waves unplitudc sharp high percent or loss, appeared in the electroencephalogram. men the cmcantmticn was Wed to 2 gm percent, the electroencephalogram: flattened in a fashim parallel to the pcatétmumatic records. Pmllel investigations in neurological patients by and Madam (191ml) Tower dammtmted free acctyldrcline in the ccmbmspiml fluid only in patients with meant head trauma, recent grmdoml seizures or after clactmconvulsivc therapy. Free acetylchclim varied from assaying spinal fluid 0 .2 to 100 gm percent. In drclimstemc activity, they noted a sharp rise in the nonopecific cholincsterasc fraction (benzoylcholimnsplitting) and a drop in the specific cholinestemse fraction (maholyl-splitting) in patients with head trauma and ﬁll-owing convulsive therapy. The cerebrcspinal fluid did not �exhibit such inversion, althougz lit command free acetyldxolim. after Spontaneous seams . that the lavel of They comluded two watylcholim varied directly with the dame of cerebral damage and that reversal of the dzolimsteme fructims a more sensitive indicator of mmbral dmaga. taken at varying intervals following mlntim batman the W EEG 935;, Ehcﬂmmaphalom, also indicated a abnormality and the of fme mtg/10mm in [Add 1 Kovach Thu dogma of mm. was ﬁne cerebmspiﬁal fluid. 1957] mmummmuummcam maumuuam WWWMdﬂwmo‘ (an Widow, the ham and. type. 0‘ WWch abmmutg, mmuummuuaappmu Mandated pm. �Fwy-.. W, .,- V l .7..— (wt‘ mm- M 1-... WWW“ 'mw .. :‘w ,v- a. , , m1. vv vv-uw-u-,o-vw-w.w.w ‘V'I-V-t.mNrIV-WI AntiohoMc (b) wry-urn "I“ wv-mvww—w-wuam—run-mnw—uu—wxw m and tram: ”myr—w—vm—wwwq wrivlwmwwr-wﬂw v: ,«w- me electmmphic, beluvioml md nemlogic Sign of trauma were blocked by the mutual ministration of 0. 5~1.0 ag/kg atropine (Bomatein, 19%). as were similar olinmel oranges occurring after the inmatemel additim of acetylcmline. Word (1950) applied these observations to the Moment of closed head injuries. In 20 patients with varying degrees of amine tram, ministered subcutaneously in done: of 0.1 ng/kg, mating clinical improvamt in some and a reversal of the electmenoepmlogmphic effeots in others. In a study of dictum, mm mticmlinergic drug, Jenkner and warmer (1955) mpwted electmmphalogxm. the postnmtmtic done he in forty patimts with A altemtims in single intmvemua em}. electroenceprulogrmne resulted in normalizing in twenty—m and muted imminent in six others. Similar observations have been reported by Denisenko (1965) using methylbmectyzim and ‘ meantin in poet-trumatic ﬂock and cerebral edem. animal experimts of ‘ . u—v. . .mmrrmm �- .v -'4In v'nvwr»vr Anew—Wt nv -V “war w rr v. I1wurwuu‘wv gm" w'twv‘z' 'or‘ Ila-3 », ~.,r-.mwm-w-—~ v.“ ,1,“ .‘ .v-y m twinw-vp "Ivy" .m.‘ war. .r my rnm ~; . "mam—q .74- ..w w. .... , Thee duet-mums wen eeueeed in the omwleive therapy process by Ulett and Jornem (1957). Then workers eduiniotemd doeegeaofatmpineupto the patients received that the was mt: mper'daydm‘ingthemeke «mm of slow wave therapy. They Wed activity produced in these patients significantly has then the omtrol m who had not mind the atropine ministration. (In a. later study these eutm failed to replicate this etuiy, suggesting that douse factors or populatim changes have Wed may to different results [Jomem 3:311; 1960]). These observations provided the basis otlur 1cm mtieMlinergic W for studies with (Fink. 1958, 1960). The intmmue injection of emerimentally active antiomlimrgid comma es diethedm, benectyzine. the piperidylbenziletes JB-318, JB-336 and JB—329 (Dim). and wan-2299 induced deemmmiution in psychiatric eubjects. These were associated with bernvioml ﬂirting, anxiety. EEG EEG clmges tram, illusions and hallminetima. In patients um had recently �,__.,,__,,.. . V... 7)... W- w -— ....,... . .V-r—w, .wx-7'Uwiwt ~s| '1‘ u u a...” ,.. w‘mmjwlm‘vwnmu‘m . "0...an ”mi—W- .thwuww. ‘ m.,.m-.-.,,, M_ "H". H," ., ,.. .w-.m.1, , a“, r .neqy..-mw—-; - .r» vr'." received eleotmoonwnoive therapy. the eduinietmtim of theseoomomdemeeaooietedwithemdmtioninslowmve activity and meme]. of euphoria, denial Atropine was also EEG emined in desmlumiutim WI m and tension. and confusion. low doses. and obeemd in these administratims, mind At higher superimposed beta tachycardia, We, hyper-8mm slow waves, followed by lower voltage, poorly activity with by activity mined delta “mind by progressive confueim and disorimtatim. Both in oenbral mm and indumd omvulsime, the ehotmﬁmphio clauses my be modified by the comm-rent administmtim of micmmemic drugs, thus Weed mt: of aoetyloholine or- mating that incmeeed cholimrgic receptivity is eeeooieted with the high voltage slou’ wave activity. (o) 13min mmnm and m! mmm : SimilarEBGohmgeemdthblookingthmfheshenobmmd following the direct application: of aoetyloholim to the centre). mam. - .rml... ww—wu-uuwy w— “WY—r! �'lho anninismticn of a chainsaw. inhibitor DP? (di-isopmpyl fluomphocptute) elicited high maplitudo rapid frequency W EEG patterns similar to status cpilcptiws, as well as similar to those of post~tzmmtic states amen 23%, 19%, 1950; and ma: gag, (W We 1950). effocts'wom blodcad by small doses of pmntaral atropine. mat was 91; 5}; EEG The inmaso in acetyldaoline after tetmrdxyl pymphosphate named indumd and routed to the toxic mmisfostatims (Wand 3m, PM: 1952; ('11???) and convulsims 1957;) Chatfiold and Dummy (19h?) pmpamd exposed animal cortex with Tho pmtimim and ma chmmlomic spike activity. prior administmtim of atmpino blodcod this spiking, or pment, the mutuality could he oliminatcd by if atropine. In contrast to those findings, Bram” and Merritt (19%) applied topics-.1 acctyloholim in to the expound cortex mania-ts of 2~1l2 to 10$ of cats. md mted no effect on the electroencephalographic changes after intravenous atmpim (1 Wits.) 'me concanmtims of acatyldnlim in ﬁxes: cxperimanta, �10 harem, wan higher than the topical applications and the inmoistomal (0.2-4.0 Bernstein (19%). Exam» and gm (1-14 gamma percent) pennant) injections of hwitt also made note of electro- m unholy]. onooplulogmphio effects similar to Midtown (nostylhotmﬁayloholine) and doryl (Wlmlinoﬁn mantmtims moh lowor than the acutyloholim oonoonmtiom. 'Ihoy ascribed tho imaged effoctivomos of look of sensitivity duolingio those drugs to thoir to oembml olnlimstemes. Thou data one conflicting and furthr study is masonry to qualify this issue . Gummyiml Fluid mglmlinc (o) of aoetyloholim mtabolism and inﬂates that it is Selma: found in One View mm tissuns in an inactivo band form, wring periods of activity, mtyloholim is liberated at the call midly mum, Mum it is deactiva‘ood by dzolimstomso. 'Iho mount of bomd mtyloboline is the resultant of tho oontinumas pmoosses of synthesis, liberation and broakcbm. It the level has been postulated that rim timing sleep and falls during activity. and Czomland, 19%; Elliott, (Richter Sam): and Hmdorson, 1950; Gianna: �,7... ,r‘ w .w..,» "gun-w WW, _ w w" Rpm. 1962). .1,‘ A. 4w- By ....- a. m brain mg. higher than 3005 tissue levels is mw. 1...,” wr'w".‘— wan mama basin .v—w tho love]. of during :- "w m:a..»=-v~<wmu «we» u-m—v .fr'um-g v.~'mrw-"n—u'w .r‘xm is high mtylcmlim (micro- munch and sleep to b- mm, mini-It. \‘w‘ , air quick freezing Minds. post-ulna! levels. (7 Thu diffm in as the msyntlnais mm for gm/m/ndnuta). Elliot $3; omfimd these observations. also toting that after nan-uncle aonwlaims spinal "Wu-1 tim) wotylcmm in rat (1950) , using liquid Richter and Cmoclmd per ‘v-‘w‘m fm acetylcmlim m «ﬂammable ﬂuidinmncmtmtimamtoagampermm. Pepeu (1962) fomd an qt central mm 11mm in mtylclnlim Wan depressants to in the mm caused by a group be roughly proportional totindamoofdepmasimoftheemmlmmusmummm‘ mdmtim in Prue mm activity. mtylcrolim m 'fluid in mportad in‘tha spinal patients with epilepsy (Cone, Tum“ md and mum. mmud 5.0 m 19149 b). or 56 fm amtylcmlim percent with McEncMm, 19%; epileptic patients, an (77%) in quantities of 0.02 to an average of 1.0 TM:- mm cont. �v— v w. «...v..v,v .-A—W. ,_.1,._,...V,. -v-.»-m—wv —-.~ ammm‘ «wwwm 'y'vvx'v u—wu.uw,n-w.-w.~:.wmw.1». mu '1 “a“. - .vwruw—Nv- l2 Maryldnlim levels wan related to the froqmncy of seizures, mmdcmmmhmiomlﬂy,mdtoﬁm 1b zinc. the lat column, but bore no mlation to medication, type of cpilopsy or level of Tadcr and Wm ($0th (Hugh) Vimd tbs increased acetyldmclim a lay-product of the Stwying the hypothuis that the inducod aim. m activity. (1953) 301m, and not causal. mum We! of acotylcholine the level of acatyldiolim inbmintissucmotmaoh convulsion. Stumtcdarisoinﬂae acetyldaolim content of brain, baton a sebum and a fall during tho convulsion. Below curtain levels of acetyldmolino, convulsion hind-to comm. She smeared that the fall in tissue can due acetylcholim during a cmvulsim acetylcmlim synthesis sue): on by Wed to inhibition of concentrations of natabolites amnim 10m. Wendhpoualsommdclmgosincenmlmm systcn acetylcholim follauins “rims stinulmts . Only after �13 SMDutyhthyIMimte was there a mcholyl and 3, W significant dam in the acutylcholim level. they noted a in association with inmost! omvulsions. drugs which may qumtifiad as atiwlmts 1:me maninaoetyldwlim impmniazid 4» and no W mind + 1309A) comma, them in mtyleholim lava]. muss these by convulsions. (The than WWW duspite int-mo excitation produced by those mu imam. (LSD. mpmma level. other With were diffemnms in observations mmmmmggmrmrmdmm may be related mutants. to the differences in fm‘ methods th: Lunar unwind of biochemical changes in spinal fluid nflcatingttnfmeaoetylmolim,whilnsiamamandhpeu‘ manna tatal Myldwlim in tissue uncaring bound fm form Thu: an and of acetyldmlim.) AW W Auggut ﬂux Apontaum by an u induced We 1mm in law (no. acotyzchouue �-, .4.‘ . rum- .1:.--—.-. -. ‘T r. .l ~,w ':.»"-rx\~\I--«-~-v~’ ‘mw"‘ m~.r...v.w—.m...~»-. . .«m-n vyr -. . 1-.“ , —;..- r...» ,.r;« “a v.—~ 1n tummy-1 La 5pc“: (mid. mmwe bound (on which my Wag dalmatian, “up and mduaﬁon immune mane (d) Oantml Nervous activity. (19%) also ‘mo Austen/ted 6mm «cavity and Aazuu mm:., m Wm be. tum . Sgt” mama enhance Mae. Lama masthead in the W 06 acetytdtoum (holimstomaa: Tour and spinal fluid diolimstema typas of duolimstarms we normally fund in thc spinal fluid: dmlimstume-I ("tr-m," “specific," or Molyl—hydmlyzing) , which has a high specificity for acetyldiolim; and daonmstemo-II <"imudo," "mspadfic," com or benzeyldxolim-hydmlyzing) . Both mtyloholim but rates of hydrolysis for have diffamnt hydrolym diffcmtial rate Molyl and bomoyldmolim . This qualitatiw distinctions. reporting the duolimstemse By permits activity as a ratio of the activity with a maholyl substrate with a bemoyldxolim aubstmtc mud and to a substrate of mtyldmolim, ten mtios are found: dualﬁnatemeJ/mtyldmlim �-- ~ :4: 7r>m\‘-Vrmwu~<hvuwrr. n >--'rw. aw, ww H'VJ’IW'W‘VCu-‘rm'"‘l ~w:wa-w-._,.rm unr— w .vumma .w. "- urﬁ ,. .... 0-» ‘wV.M-a>vﬁ “Tr-aw -r-.-~,:-. 1m.” ~ m 15 and Mm-II/mtyldmlim. comm fluid :30an censuses for “must-men! to In such ratios mall in tho ratio of 33:17 dawn . Inpatimtswithhadtmm.mrmmmmmd mimmimofﬂndnﬂmtmwiﬁ'minmeinm W41 Mum-I fraction of th- spinal fluid and a activity. ‘11:. W in what of tho cholimtomso Wmmuudmtmmtyofmmmdmm m at the In :13qu WW. mints with owned spinal fluid acetyldxolino m:mm,mvar,mm1nﬁnmioof dwlimtm or total mun-statue activity was fomd._ mmmannmmmymmmamm mumimmminanmpombiuty. WWW-Ii: antral mm system while Manama-II pmdminms 1’ththth in other tissue. specially blood scum. in mtyldmlim hula With an inmue in mnbml intcmauular fluids, up“ .7. 7" .- » -~ ..,_, , u �A , . ,_ =...V........ w...” ..l.._, nv'rvxw w." .7 "Myw-IlI-Irwwaur- ‘7 ""Fvwmm“ v raw-4‘7“-” ”Val n”,_~ -17 . "A «rum—u ﬂ,” "mum—.1,“ NW... , 16 vasodilation and Wei with a degree of umudatim of vascular fluids into the inter» cellular permeability cellular spaces varying with the extent vaaodﬂataticn (Kabat and their Wm 35. _a_1_, 19%). and may be pmdicted, dmtion of the 81313301, Spiegel—Adolf, (1981. 19%, 19%, 1938, 1953) WWed sud: permeability changes md maimed mndmtivity of the tissue associated with the appearance of various ions (as potassium and prosphate) in the epiml fluid {alluring electrically induoud convulsions . Such nucleicaoid splitting cellular permeability WWW of aims, may nm-elactmlytes, as also ixmaaed. Changes thus pmvida the basis for the high acetylde and the inmased mntratims of cholimsteme-II in induced animus or head tmuma and Wm 'Ihe in ' (Tamar- 1939c) . persistm of mtyldwlim in spinal fluid after head trauma and after aims daspita increased dwlinastemse activity related to the sensitivity of the aoetyldiolin'e- may be dwlimstarmd system to Wmtim relationships (Nadmansm �,wn‘ww’ ,.. i . ..-.. _‘ “a... n”. “ ‘,,_ .3», .1. m, .Vq‘r‘. am-rw , ~,--‘V~rwtrm—Ww ..~.-—-~—..-w wr".v\-4I"\9-rr"x““w-myrvwrmmwn'v .(-,.‘v.,..._..-..‘_w,,,,rn.—.y~.—_-.r~,- 3“ .~.-. 17 and Withers, 19'65; Towcr and Wm, HacIntosh, 1955) . At ”physiologic” 1909c; Burger: and comtmticns, hydrolysis of acatylcholinc is rapid (34 micxmocondn) but at higher and lower concentratims, the activity what, falls off quickly. In the dmlincatnmo-II acctyldmolim mlatimship is ad ﬁn mn-cpociic m 01’ hydrolysis cmccntmtioc. W witl': increased. anvimcfﬁnscmlatimhipc suggestsﬂmtwhilem usual commtrwticns of acetyldmoline t cell m: are dcstmyud by tbs specific activity of cholimsteme-J. in a fut micro-cm, an emaive concentration following cxcitaticn may exceed the rate of hydrolysis by cholimstemso-I. seizure mmmm the uixum may be mmd and a seizure itself adding to the mm: The induced, with of free amtylcmline. 1110 increased acetylcholinc diffuses rapidly, affacting vascular and cellular minty and increasing the various ism and circumstance-II in the of dialimtcmc-II , mums CSF. The of activity thaugh of low efficiency and depending on �the mien kimtics, mamas tho watyldxolim in the tissuns in hours to days to levols for the physiologic actim of dwlimstame-I... Chaumtemu «ppm is ﬂu. camamemmmm In The. am 5M cu a. gamma gum, mating 5m a“ when pmabuug “mined by imucd changu mm. Wed mm“ me put “the hmmtéc Wm “mucus the ants (n ma agate»: 05 Wu manually «mum. (a) Amgzleholine, Alumina in MW at cm EEG the. blood-brain Mum and Indumd Oomvulsiaw: pemnbility barrier winning action of mtyldwlim may be the by the biodmmioal substrate for tha poatwlectmahock hypemyndmy of the eloctmanmpinlom. 3% a possibility is evident in the Mommim of an immense in the concentration of cocaine in brain tissms thme a series of 12 induced convulsions (Aird army in concentration of this days after 5331., 1956). The 1m mlecmle, ordinarily absent �mnpr- rug—m.» r m «7 r.~L,-»---.--,V-...Ww.‘n - v v '.>T4wmw‘m .mw—z , ru71.,‘ mu mr‘m—D'J.lr>aw' yawn-vanquas,‘ ‘w. - p". yr. -., “wharf” . WV. ”us-apt..." 1.. .19- in brain tissue, was asaociatad with the appoarunoe of hyper» synchrony (delta bursts) We hIVD in the electroencephalogram. confirmed tbs many pruvious reports thut convulsive thaxapy induces olectnngnlphic hyporuynchrcny (Pink and Kahn. 1956; Pink 33.3;, 1961). Duspite a constant application of mmmmuammmty'mmtmo: appoarunnn, the duration and tho cxmnnx of the electrogruphic slow Haws by activity as wall as the sensitivity to modification alnrting, hyporvuntilatian and barbiturates in psychiatric (papulntians. Tho early appoarnnnn of high degxan hyper~ syndhmuny and its puraistnncn throughout a truatmant course has been dnscribod an pmuruqnisite M (Roth, 1951; Roth It is possible that EEG to £11., impruwument ﬁollcwing 1933; Pink md M111, 1956). the diffirnnces in tho degree of indncod hyporuynchrcnv may bc related to differances in the activity or auntrul cholinnrgic mechanisms. patients to davalop hyporsynahruny The may failure of certain thus be associatad precluding a clinical rlsponse to induced convulsions. Tbuer .. l . V , ”.17 v ,, n �w, ._‘_,._..._‘,|,,, r. Wm. ;.,,,,.__ m. ,. ~ "v.0... . (T W . r r, -_ "u . rw.par.-‘W-.~ .erz. .7.” , .1 . _ y . ., 4.1-. . -- n v-uvnwwwv-wm‘uv “wave-«W.www—ur-p—, w-n—w—w M-ru- "n" .,-v , . _ _ , ‘ v—av-um . . woun- 7 -w v-_. .- m 20 and Wm (19%.), in ﬂair study of W231 tmm, hcludcd observaﬁm of six psydtiatric patients mder'going omwlsive mampy. Studying the patients after 3-7 tiny upon“! {me spinal fluid and an inmm mutants Minimum in two patients; in mournstcmvn and a dam in .mvemal pith of the ratio of dxonmatorms a dwiimstame-I in five of the six patients. From mludad that the spinal fluid these obscwations ﬂwy We: in ma commlsiom mmﬁmmoofmioambmltmﬁmmof sputum epilepsy. WWMpntientinﬂwmﬂaawhofanedtom oither {no acetylomnm or a dmlimsteme ratio reversal in iﬁtemsting that this the spinal ﬂuid, tiny. wrote: "It is patimtwaaﬂnonlymafﬂnsixmshwmmsmoto Wt." ‘ at If alectmgraptdc hyporsyndmrmy increased free acetyldmolim, subjects who is a mﬂectim maintain hyper- syndmymdttmeinﬁmitdisappemmidlymybc waiting diffemnoas in the kinetim of the dmolimstemsw » , _ v—-— w . 7 v vamp-omen“ W . p ,. . V... , ‘ �22 “I (21011th 'mooo studios and the Classificatim of a : malochm applioatimtotmpmblanof atomic mootivity and the classification of the Mountain Po mm and ( ) mlatimhip boom the psychoses. how dumstmted blood possum response to injected ndxolyl and the clinical mpomo of psychiatric patients to convulsive ﬁxaapy. Homolyl which W is a percent cholinorgio agent vaoodilation, taduyoudia, sweating, and peristalsis. It is rapidly hydrolyzed dxonmotorm-II . slowly by The blood falls after injoctod Immolyl within five to more than 9mm and takes Group 20 Group VI and VII oholimstemeel md pussum of subjects mtums to the baseline minutes. Patients whose blood {within baseline the returns to classiﬁed as prawn 20 by W 5 ndnutes have been I, II, or III reactors; those whose blood ormminums tomtumto baseline, reactors. M I and thp III—III as mam �.. pr 7: . -r WW..." . . .r. . n .. 7.. .- -. mm». . 1 unw- u . “val ~ « - ....._. v .. wiv'r—z-v .?-'a‘.v~'uV.—T{=n‘)("\ﬁlr- - ,r., "saw-- wry-WW...» N. mv—ﬁ m—m ‘»-y-_I-sﬁ-vvvvx , 23 have a 9 and a 35% recovery and Grow VII mentors 91; gl__. 1952). patients in Group whom while Groups VI 89% rate, mspectivuly, while and 97‘ recovery I to III mactom the injected mornlyl Group VI rates (Funkeastein may he looked upon as is rapidly hydrolymd; md VII have a slow hydrolysis rate. We may pmdiot, thcmfore, that the blood dxolinesteme activity levels of Grow): I-III would Groups VI A uystcm - bu high; while the activity of VII would be low. similar analysis may be mad: regarding central nervous levels of dwlinectemse—I in the duvelownnt of EEG hypersynchrmy and spinal fluid levels of aoetylcholim, providing a basis for a omgment hypothesis regarding centml nervous syntax: reactivity to induced oonvulsims cholinergic agents. and to peripheral �- ~—-~vw=rr'u. . ~ . “,_ w-vvww (“vwxx mu, .- v*'ul""‘v‘“""w“1-c-»w‘mlh-rtr"'4<-Ia‘.—-vuz‘ --— (—1 m-wry_._ 7...," .V, 7 ,_, . ‘ my — . w". ,.c_..,.. .. u... w. Flaw—w. v3. ‘~.,..,,‘w,-." 2‘4 CONCUISION: Central cholinergic mechanism appear to be a significmt factor in the convulsive therapy process. may The published data interpreted to indicate that induced convulsion: are be associated with on increased- in intercellular acetylcholine to levels greater than can be destroyed activity. Vaeodilatim and increased by dmlimsterese—I cellular pemability are followed by increased ammte of clnlinestemee—II and other enzymes and electrolytes in intercellular fluids. These chmgea are hypemynclu'my which can be mdified by reflected in the increased electrical is recorded in scalp electrodes, and which mticholinergic drugs as atropine, benactyzine, and ydieﬁuazine. The changes in the cerebral biochemical milieu alter cellular activities sufficiently to be associated with altered behavior of subjects. Failure to induce high and persistent cmoentrttions of aoetylcmline and failure to induce concomitmt electrolyte changes results in a failure to produce behavioml change. n: M ...1,.“‘..w. “,4 _. ...... ._ �25 Differences in the rates of development of mm reflect differences in their lependance of cubjects mechanism- changes on chom'cergic or in their sensitivity to chmges in acetylcholine levels. mean differences provide the basis for the classification of the mentally ill by kaenstein and by Pink md Kuhn These observations provide the mode a Miami (1961). Mechanical basis for of action of indmed nmvcﬂsims in altering the behavior of psychotic subjects. These views are consistent with the more earlier general neurophysiclcgic-«iaptive theory expressed (Rink, 1957) . �" -v~1r'-W4'VY—,‘V.'Z"V‘."-‘ w "- ---'~-' REFERENCES Aim, R. 8., Strait, I... 1‘... Pace, J. W., Hmnofi', M. K. md S . C. Nemphysiclogic effects of electrically loaned deitch, convulsions. Aach. ucuxoz. Izyahtat. (catc.). 1956, 75: 37l~378. Pmmoe and actim of coetyldwline in oxporinnntal Box-cumin, M.D. brain trauma. 1. Nounaphga£o£., 1986, 9: 3%9-366. Brannon, C. and Merritt, H. H. Effect of certain choline derivatives on electrical activity of the cortex. Moh. Newt. Pageant. (ChicJ. 19H2, M8: 382-395. W, of amtylcholim. S. A. (Editors), V. and Hoolntcsh, F. C. ‘lhc physiological Biglificmoe In I. K. A. C. Elliot, C. C limos, ummag. H. Page and J. H. Quutcl Springfield, 111., 1955: 378-375. Omtfiald, P. O. and Dagny, E. W. Effects of proatigmine and acetylcholim on cortical potentials. Mn. 3. Phyaialu 1982, 135: 633-630. Wm, D. Acetylchclino and murmal Corn, w. V.,-'l'cwcr, D. B. and activity in cpilcpsy. J.A.M.A., lane. 73: 59-63. Dab, H. H. thoiz- The action of certain caters md others of choline, and nlctim to maxim. J. Hamel. Elliott, Exp. The)!" 19114, 6:187. C., Swank, R. L. and Henderson, N. Effects of mostlutico and cmvulamts on acetylcholine content of brain. MM. 1. Phytiol... 1950, 162: 888-1371;. Pink, H. R. A. A mified theory of the cation of psychodynmic therapies. Pink, H. Effect of mticholimrgic agent, dietmzinc, on behavior: simificmcc for theory of convulsiw ﬂxcmpy. Melt. Pogohiat. (Chic). 1858, 88: 380487. BBQ and mm. Effect of mtichclimrgic compomdc on pat-mullahs cloctmcnocphalom and bobcvior of pcydaiatric patimts. Eltethoenctph. Cliu. Neukophg6£a£., 1960, 12 (2): 359-369. Firm, M. Fink, H. and Kahn, R. L. Quantitative studies of slow wave activity following electroshodc. Electuuceph. can. Newman!” 1958, 8:158. Pink, 14., Kuhn, R. L., Karp, 3., Pallcck, M., Green, M. A., Alma, B. and Infkowits, H. J. haunt—induced convulsions. Molt. Gen. Paychiatn 1961, “:259-266. W, m. ' 8 A. 14., Bales, P. 1)., Willie, Hiwich, H. E. Exporimtcl production of electrical major omwlsivc patterns. 1. MM” 19kg, 1.35: 117’12“. A. and �'"WW.'I<-.~;—-- -, -‘—-'-a . .. r! _‘,',.."_'__m, ,- . ‘1).m. u ‘P. - ..~—.—.-a..nuu.~.~ . ‘~»~..ww*m‘m—. - v w W .-w-rvu.wm.m .w, ”mu “.3 w-w WW..."— xw-mv-vrv at K Ib‘mwv": “nun-ms?” u mmic mutt, of in mlation pmgnoatic system sigxifiomoa to test mm Maintain, D. H., 013011031106: truatmant. Payclwaom. “ad” 1952, lb: 3u7~362. .Giaman, N. J. wtyld‘tolim. H. and Solomon, R. C. ML, F., Md Pepau, G. W. 1. Drug—inclined changes in brain 1962, 19: 226-23“. A. and Hiwich, H. E. Macaulay, J., amen, Effects of diwinopmpyl flmmplmsm (DE?) on ahatmenoepbalognm and dwlimtama activity. methamph. can. ”Mphgunl., 1950, 2: “1-48. Basis, C. Wm, W,mm" H. 3.. Basia, C. In, J. I... Bales, P. D. and A. H. Effect of trimathadiono (Tridimo) and other drugs on mvulsims named by di~ioopmpyl fluorophosph'ata (DFP). 1950, 106: 816-820. mu. 1. Pﬁwidl, Jamar-r. F. L. and bachnar, H. The effect of Dipamol on the ehatmwmphalogminmmmlaubjcctminﬁmewith Gambia]. 7: um. 303‘3050 Ehctaouuph. can. Namephgalatu 1955, Jansen, L. C., Ulatt, G. A.. Johnson, 24., Smith, K. 31:! Sims, J. 0. thanpy (with md wiﬂmt atmpim); affact on alantrmioany Julyzad electroencephalogram. Malt. Gan. WWW! mm" 1960, 2: 323—336. 61mm, M. and Knaub, V. Quantitative estimation ofﬁnalbminandgmglnbulininnomlmdpaﬁmlogic cembmspinal fluid by imxmehamiml methods. Mu. J. Meet, Kabat, E. A... 1938, k (5): 653-862. Loud, 0. Fiber hwmrale {Ibertmgbarkait den Hennammiﬂnmg. Mali. 5. d. an. ”quiet" 1921, 189: 239~2u2. Wm, mm, spadficity mm in new on D. and Studies on dualinestame: tissue. J. Biol. (than, H. A. of 19%, 158: 653-666. Richter. D. and unwind. J. Vaziatim in acetyleholim content of the brain with physiological state. MM. 1 . Phyaiatu 19139, 189: 2157-455. W in the EEG mdar bubimmte Mmesia pmdwad by alactm-omvulsiva tumult and thair significance ECT of the action. Manuphguol.” can. Eumuuph. may to? 19 1, 3: 261-280. Roth, H. ‘ W mt. WW. Ruth. 14.. Kay, D. Pmtothal omwlsiva 1957, 9: 225-437. J. md amen, J. Prognosis and ahetmphalogmphic changes in electroW. K... Shae, can. Memphyauln Spiagel, E. A. and Spiagal-Adolf, H. Permability changes in the brain induced by mm). and insulin convulsions. J. New. Matt. v.3... 19M, 93: 750-755. �F ” rum" , ,7“... T9,“ wm.~n..wr.”“.,.,r,.w ..;._‘.,..,_,Vk,»,mqr,..r. 14."... _.-..,.4,. r...“ ‘. ”um-um..." :w-"CRIWJEFIMI-‘wf‘t . .,»;r-,W—;.—‘m'w"Ir-E'WAn-‘n-vu-I 1”“7(IAHV«——l ._ - n -.--~ 7»-v—-———~r-—-n~—w-v-—. -3Spicgol, E. A. and Spinal-Adolf, H. Physioochemiml effects of ohctrically 1mm oonvulsiam (oembxospinal fluid studies) . Tm. Mu. Haunt. AM” 19%, 70: 130-132. Spiogel, E. A. and Spinal-Molt, M. Physiological and physioochemioal mohanim in electroshock tmatmnt. Conga. Newt” 1953, 13: 38-63. Wm Spiegol, E. A., Spinal—Adolf, We dinning“. in the brain Tm. Mu. and Kenny, G. Haysiooodmﬁoal electrically indumd omvulsiw Nunez. AM" 19342, 68: M. m. Wt Spiegcl-Adolf. 21., Wilcox. P. H. and Spiegel, B. A. Oambmpinal fluid in elnctmehodc of psychoses. J. 19%, 10”: 697-706. chm W. 3ch” Stem, W. E. The min of acetyldxolim in bmin metabolism and ﬁmction. Man. J. ”13‘. “£41., 1957, 36: 222-455. Torda. C. Effect of omwlaion ﬂaming agents on the acetyldmlim content of the brain. J. Phyaiol., Amen. 1953, 173: 179—183. Tom, C. Effects of single injection of oortiootrvpin (ACE!) ion and acetyloholim content of brain. on I. “watch, 1953, 173: 175-178. mum W. and nauronal mtyldmline activity. I. Mr. Wm. Cholimterm patterns ma motyldwolim in the oambmspiml fluids of patients with Canad. J. Hum, 19mm, tram. 27 (Seat. E): 105-419. D. a. and Wm the omtmt md WMim of W323, in human cerebmcpinal fluids. Cam. 1. Tower, D. B. and cholimatcmes 191.9», 27 D. D. mm, (Seat. E): 132-435. Tower, D. B. and unis-clam, D. Mutyldxolima md mama]. activity. Motylcholine md daclimteme activity in the In”! osmbmspinal II. fluids of patients with epilepsy. Canal. J. 3.914%, 27 (Scat. E): 120-131. mm, Ulett, G. A. and Johnsm, H. w. Effect of atropine and soopolaminc upm chotmonoeptnhgmphic changes induced by electm—oonwlsive therapy. Eamomuph. can. Monophyunzn 1957, 9: 217—22u. Hard, A. A. Atropine in the tmatmnt of closed hand injury, J. Meano.ung., 1950,‘7: ass-noz. .V. .- - �(July 2, 1965) Jan. 3, 1958 EDIE 0!" ACTION OF TheCNS BIWCAL ms IN EHAVIOR indopendcntupmanmrofenzyne for systems proper mtabolism and functim, including cholimstemae- aoctylcholine, glucose-phosphatase, etc. The bahavior variety of is large, in either direction wt: that affect CNS ﬁmcticn and, thereby, since processes in equilibriun by increasing may be shifted or damaging the available quantity of a metabolite. A. For drug action, thanfom, tho following are cmsideraticns in potency: ‘ (a)mescdrngaffectmmzymsyste1nina reliable my? it (1:) Can (c) What get to CNS to affect the system? defenses does organism process to block or limit drug's actim mac in CNS? metabolism the affect directly amt of a specific system, to that extmt is the CNS dependent upon the system? Is the dafoct thm induced sigiificmt for the metabolism B. of CNS Secondly, while an may mderlying behavior? Rut Menace can body call into play when system has, is affected to substitute other may system? the variatim in drug effects in behavior depend upon: (a) Beluvior at onset; and pmdispositim (personality) to response; (b) mug dosage - availability to has on m mzym system; CNS and the effect it �W'wv‘mw n—m—.n-u.r:~wvmr .v 4-:- \I.’—:r~"!lwwmi‘ mama v; M'er‘ui'v-V-‘P 1‘2'.~vr1v-'wv— (c) Depmdence of war "-3;*..)I(7'4<~<'I‘R,IWT~’:~.~HV~’V~W ~, - an.» :uru.r-owr:< , .. mm? a. mum cvw V:""\ 1 < =- 1 w - -—-v. again on specific enzyme ommimic defenses (Le. substitutim for affected system). (d) Whether effect was gradual (allowing for system -— defenses, and ,r'ia Le. , enema metabolic system) or acute (not allowing defense). Individual differemes in meme may be due, thus, to differences in: (a) Dosage, ratio 8 mute of mainiatmtim (b) dependence on the affected system (c) adaptive ability to biochemical changes. To these changes, EEG is a me approximation and indicator, reflecting the homeostatic balance in various the CNS. enzyme systems of ��21 mtylcholim hydrolysis system. Persistent malt from a damned rate of hydrolysis of aoetylomlme. associated with low mmantmtim of either or Grantham-11 . livcd W, hypemyndmany my (immunised (Oonvamly. in patients with shortcircumstance—I md «II in tissue and spinal fluid my be mustang! high). Fmthuc obawa‘ioumwouldcsuaudetmmduud MW ”mam m «wanted We. and in cmbut pmabuoty 5m. Wag MW mm (at. EEG «the hypwymmny Wow nu 06 wumwmu. Mad a WW and 426 in 6m with as on. attend by amazon 9‘ WM W behauiuat dung“ the blockade“ 50M um 06 muted Mud bum. pubabLgtMtuu the“. dungu Lgtu that The We! men 06 ethyl. 05 campus“. ammummamm- mm 60!: the. attuned wavubiana. mam � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 3/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-003 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1968 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/9528d68ea90232ebce57ade28fbef74f.pdf 93461c25c5f8ae971bd4c1aadc2a1278 PDF Text Text I; I Mnémc . ' Recent studies changes in the 7&4 ’demonstrated that a necessary change in behaviort was the development of early mg sistent signs of altered cerebral function of slomgga ”a was a “f7 in these laboratories re-evaluating the role of cerebral mechanism of electroshock pie-requisite for ?. [ours Wt (Fm/IL indeay and per- which electroencep/alographic and/(ah , r:f.:'6) any. mes may of this observation remained unclear until the recent reports of Ulett describing the ability of premedication with high doses of atropine to pre- We wt}; (WMI‘Collowing 5 vent the appearance of the EEG suggestion of this report, we delta abnormality a . nth the investigated the roles of acetylcholine and cholinesterase in electroshock therapy. The data amply demonstrates a close relationship between the degree? and persistence of the ele ctroencephalographt‘cr abnomality and the appearance of measurable quantities of free acetylcholine in the m ‘ mm“ as“ as well {:5mm of. to ﬁcholyl-cholinesterase, The I q ”'2 ('7’de } Loewi u W? normal ratios of” cholinesterase WW of the ‘ p $.00» . 1 f .— p. role of acetylcholine in the transmission of nervous impulses has been a subject Edi} W x 072/) Q). for study since the first description of The arguments as «If theWeﬁ‘ects 4 (ﬁes r’ to whether actylcholine is the main or only �agent in the transmission of the nervous impulse are not of primary concern It is sufficient to here. of nervous tissue; that note that acetylcholine it excitation process; that exists in a it is bound form and a normal constituent is librated during the a is rapidly hydrﬁlyzed through the specific action S of cholinesterase; and as rapidly reconstituted by the choline-acetyléueg fluid iﬁ: Richter Crossland - 1916). Furthemore, normal cerebrospinal I‘M? Mariam ”‘?¢‘94) 4.94mi m‘t‘uﬁv contains no free acetylcholine deSpite the rapid breakdown of system ( & a, bound acetylcholine during periods of activity and excitement. The cerebra- spinal fluid normally has a definite level of cholinesterase activity, which is principally of the "true" or mecholyl hydrolyzing type{ IVMﬂM/“V 4“} "Romsuetkg. any). .111 the absence of free acetylcholineﬁand under the ”normal" conditions described! ﬁe electroencephalograms fail to (a) Effect of Cranlocerebral Trauma: variables was lationship of described by show any . The consistent abnormality. earliest changes in these 0 glmstein (l9h6) in a classical study of the re- changes, degree of experimental head trauma, and levels of cad/w»?!grew oft! cats free acetylcholine in the 09!. stu subjected to varying degrees EEG 0 a of head trauma, B/mstein first showed that free acetylcholine appeared in {Yaszwm the CSF ‘ céE. within a few minutes; and persisted for varying periods up to M hours. There was a positive relation between the degree of 17am and the quantity �-3gamma 9 per cent. cu- electroencephalograms demonstrated patterned changes. Initially, the of free acet’lcholtne which w Eg-rwﬁﬁal varied-khan 2.7 and 9.0 Ocn Com-raw records were filled with high voltage .fast activity, 516 int'preted as an intense neuronal discharge; only to be followed by a short period of flattening of all #01 recorded electrical activity. These periods were "followed by prolonged periods of high amplitude sharp waves in the delta frequencies. Mt 0 Ulth thes/e'zlectroencephalographic changes, Bﬁrnstein fur- ther noted that behavioral manifestations w{ he werencorrelated with degree of the of as as free level well acetylcholine traumal/ ”in; highest levels of acetyleholine; he noted the greatest degree of abnormality as well as the greater severity ””77? M u/ the of WW t'anges a the appearance ofAseizures. _ W, diva EEG alteration in consciousness, 7393!. rnnumnrm further substantiate these observations, B/grnstein applied acetylE Y 105553 choline to the cat cerebral cortex. When the concentration of acetylTo and choline was 1 gamma per cent or less, he observed high amplitude \sharp waves of low frequency in the electroencephalogram. creased to .7lmaém WAC/c! the concentration was in- he ~Wana Mada per-cent, the electroencephalogram we. fad-w 2 gamma 74: When Tower and McEachern (1919 a) flattened,‘ m repeated thﬁe studies in human cases: w �cere‘rospinal in the fluid only in patients following head trauma, recent grandmal seizures and electroshock therapy. to 100 gamma In cent. addition, per terase activity of the. ific cholinesterase spinal fluid. (benzoylcholine Specific cholinesterase ( mecholyl The free acetylcholine varied from 0.2 Tower and Mc Eachem assayed the choles- They noted a sharp - splitting)fraction rise in the nonspecand a drop in the - splitting) fraction in the patients head trauma and those following electroshock therapy. No with such inversion was demonstrated in the fluids containing free acetylcholine following spontaneous seizures. These authors also conclude that the level of free acety- lcholine varies directly with the degree of cerebral damage; adding, however, that the degree of reversal of the cholinesterase fraction is an even sensitive indicatbr of cerebral more damage. In most of these subjects electroencepéhlograms were taken at varying intervals following trauma. Here, too, as in Bernstein's experimental study, there Was a direct correlation of the extent of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal Thus, we may conclude that craniocerebral fluid. trauma results in the appear» �-5. in the spinal fluid; and that a ance of increased amounts of acetylcholine direct {KN rJ relation “between the amount of acetylcholine, the degree and type of electroencep‘llographic abnomality and clinical behavior. (b) Effect of Atropine on post-tramuatic EEG and Behavior: In his studies, Bernstein, administering 0.5 0 atropine, demonstrated a reversal or a blféking of the EEG - 1.0 mg/kg. effects of trauma, depending on the relation of the dose to the trauma. Atropine also modified W the behavioral and neurologic signs of trauma. In the experimental condition of [Mrﬁﬁc/UEPNM acetylcholine, which induced EEG and clinical ﬂanges similar +1.14 to head trauma, Bornstein also demonstrated the blocking and reversing effect of atropine. Ward ( 1950) applied these ideas to the treatment of human cases of closed head injury. In 20 patients with varying degree‘ of trauma, he admin- istered atropine subcutaneously in doses of 0.1 mg/kg.. In selected cases he noted dramatic clinical improvement which action. He \ .traum.we. also noted, alographic effects of IA) lg. m M ATTRI Ben-5;} to he atropine selected instances, reversal of the electroenceph. In the study of another anti- �To“) f \DIW I cholinergé' drug, "DIPARCOL" ‘6' (diethazine), Jelkner and Lechner( 1955) re- port significant alterations in the post-traumatic electroencepbdogramio A single intravenous dose in no instances of abnormal electroencephalogram re- sulted in nomalizing in More 22 instances and marked improvement in six others, recently, Ulett and Johnson (1956) demonstrated the of peripheral atropine IL’ .0 to block the same effect occurrence of slow wave activity follow- ing electroshock therapy. This study suggests the possibility that the same biochemical condition underlies the electroencephalographic abnormalities in head trauma and One in electroshock. report stands out in contrast to these findings. the§5 In ex- periments Brenner and Merritt (19h2), applying topical acetylcholine in con- centrations of to 232‘ intravenous atropine to the exposed cortex of cats, noted no effect of 10% ng/kg) on the electroencepahalographic changes. It is important to note however, that the concentrations of acetylcholine in these experiments was significantly higher than the topical applications “a, 0.: ML andnmtra-steruc (0.2 Merritt, however, make - 10 gamma) (1-34 g7ama%) injections of Bomstein (19h6). Brenner aha-4.1L note of electroencephalographic effects similar to ace- 0 tycholine from mecholyl (acetylbetamethylcholine) and d’iryl (carbamylcholine) , ‘ each in concentrations much lower than the acetylcholine concentrations. �-7. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. A - variety of experiments utilizing DFP (di-isopropyl fluorophosphate) a compound with irreversible anti-cholinesterase effects - demonstrate‘ the developnent of high amplitude rapid frequency waves similar to status epileptic“;s as well as lesser degrees of abnormality noted in post-tramnatic states _ wich et a1, 1950; Frefdman _e_t_ a}, 1929; and Hampson gt a}, 1950.) A! .. (Hit In these studies, too, the electroencepahalographic effects were blocked by small doses of atropine. In another laboratory study, Qhatfield and posed animal cortex with activity. The Me PR0 ST! Dempsey (l9h2) prepared ex- NW and evoked electroencephalographic Spike admestratgﬁof prior atropine blocked this spiking, or if present, the alnormality could be eliminated by atropine. Thus, from a clude variety of experimental and clinical studies, that electroencephalographic activity as a result of trauma, To PM; AL ‘5“ we may con- induced by acetylcholine, either application or interference with normal cerebral metabolism, can be blocked or eliminated by atropine. �-8(c) Role of CembraSpinal Fluid Acetylcholine in Seizures Acetylcholine is normally present in nervous tissue in a bound, in- active form. During periods of activity, the free acetylcholine is liberated at the cell ”I; The membrane, where it is rapidly deactivated by cholinesterasmﬁ- level of central nervous system a acetylcholine is this ant of the processes of synthesis, liberation and breakdown. It the result- may be post- ulated, there/jars, that the level will rise during sleep and fall during act- ivity. this hypothesis is tge That (1949) and Elliott, , was demonstrated by Swank and Henderson (1950) liquid air quick-freezing methods, Etc.“ ter ANIM in “8.1 experments. was 300% higher than ' micrograxmna the post seizure level. tissue levels is transoi'ent, however, as the 7 in rat brain is high (1 gr: . and Crossland demonstrated anesthesia and sleep level of acetylcholine (measured as brain tissue) Richter and Grassland ’R’tSW ”thesis The By using that the per mg ' difference in rate for acetylcholine J Elliott 33 a; confirmed thez'e (I950) gaxmna/gm/minute). observations. In addition, they noted that after metrﬂzole convulsions Jﬁi FK’EE acetylcholine was always demonstrable in the spinal fluid in concentrations up to 3 gamma per cent. In spinal fluid studies in Tower and Me man, Cone, Tower and Me Eachern (19h8) and Eachern (19h9 B) also demonstrated significant quantities of free �.9acetylcholine in patients with epilepsy. 0f 56 epileptic patients, meaSurable demonstrated/free acetylcholine in quantities of 0.92 to 5.0 with an average of 1.0 gamma per cent. gamma “¢¢ ‘7.) ()7 per cent, acetylcholine level was directly The related to the frequency of seizuresf/ the extent of electroencephalographic abnormality, and the relation of time of / n01 ., M sampling l 14¢, tonlast seiZure. It bore I relation to medication, type of epilepsy or level of cholinesterase act- ivity. As to whether the acetylcholine appeared in the spinal fluid is a by- product of the a M V“ ' s I o n / conclusion; or whether C the increase in acetylocholine was a is problematical. a, increased cause of the seizure, lieve that the Tower and [{cetylcholine liberation itself but related Me Eachem (19h9 B) be- is not due to the seizure to the basic process causing the seizure. I In a study of thfhypothesis that the accmuulation of acetylcholine is basic to the seizure process, Torda (1953), induced convulsions in animals by met zole. She determined the level of acetylcholine in brain fore and during convulsions. She W tissue be1' ' . noted that convulsions are preceded by a rise in the acetylcholine content of tissue; that the content gradually $118 during the convulsion; and that * 5423..) occur. Furthermore, she postulated convulsions u WAS 8. certain levels, convulsions failed to can?» send 3 factor} which in physostigmine probably acetylcholine, but in electroshock seizures was not. �Shendllu concluded was due that the fall in tissue acetylcholine during a convulsion to inhibition of acetylcholine synthesis by increased concentration?- Sec” of metabolitesnas ammonium ions. While considerable argﬁihent waxes about the significance of acety- lécholine in the mechanism of seizures, it is apparent that free acetylcholine appears in the Spinal fluid following seizures; that activity and seizures enhanceﬁiacetylcholine; dfstruction/lowering tissue levels of acetylcholine; while sleep and anesthesia Aﬁgment acetylcholine production increasing tissue levels. �W!"— " WM—w-"ﬁ ' TNT <- Mm; E Aest‘ I. / I w- . , » urr u ' , M 0' - ,,._ -m—~ I 4,4 " 6Z7 v - ,1 5 M 1,;“414, m. -w—.‘ —V<.._—. .Avv»/— up ~~r .-———:v mm” M: . ~ . w.,-- ”v7 /’ W“, .. -v. .. . . . wﬂnm .,,_.V,r, _.._ .<‘._,._r_.__.=_,,m,_qw ' -. ‘ EE < ,. ’ I I: l -7' ['4imzzm4m-‘ean-,g-gﬁc ‘ ~ — ‘ , / -~—...:.;_.-f.._ Mg; ((244.4'4/pv A , , ,.. / /' l . ’ / 3 ‘ j Z e" . ��-« ”tum-35$: 434.. \2 as: {525% mthhw ‘3‘ M . {3%. «3%. Ma g. 7 \i‘xw _. , n ﬁwkﬁkxﬁhﬁ \.m§\. 5n Q“ W; ‘53 h}. 41“; 7 53.3% _ x w x ”‘1; (“VM , «$ka ��the level of free acetylcholine and should follow a decay rate equal to the EEG WWI-£6 rate of in desthtion. Since previous studies demonstrated that Ron hypersynchuy was a necessary pre-requisite to clinical response to electroshock therapy, it may be stated that the absence of free acetyl- choline precludes changes in cerebral function and thus precludes a ical response to electroshock. Certain assumptions 61M (1/ .WQS in \mﬁxam em . may be made regarding M‘ W£%,ML 4W; Cholinesterase I is found in clin- WM“; all 4 {a ;ﬁb€,¢.¢£ £0»£u64* ' ' highest concentration in the central W, W nervous system; while cholinesterase II is predominant inAblood serum. With the increase W! M/mx.dv£[7 in acetylcholine levels, in the intercellular fluids M Wftoaow M 6i mm ‘5‘”; vs odilation and increased cellular permeability degree of transudation of vascular fluids may be I: into the dependent on the extent and duration of the / predicted, with a intercellular spaces tasodilation, (Kabat gt 3;.) 19118); ration changesggﬁztlt high ncentrations of 15?; , enzymet, th 4/ rate of hydrolysis idndecreased, ' achnﬁnson and Rothenberg, �@ Tit/4M ﬁgﬂﬂﬁ W05! M. r ' ”1“." I (m0 4» w- ar A » W M L’ M.%u 7 . WW1 ’53), do W MW; - ’ . - W I44"! %_ /o¢ /ZM"‘ �2% Mwaﬂ.‘ éﬁ 7M/Cc 42 d a >/~7‘$[ 6a 56) iwwwh‘ 4M 444W ' 'wZ/zé 9“. ﬂ A—ﬁr7:9%__~_ ��__ _%j%i%% __M __~__ Meg/Eran!» , , M W/ 8&9- afﬂt ‘9 _4€§./_""f. ' 1% ﬁﬂwjg; W M; ___-#__ ��F:+r§¥¥33~%¢;*‘ '77 , "“37 ' \. *Q W~~ -~’ vM—w7ﬂx-«7A 77.7.«7-«7 . .ﬁW-M 1'} f MW~ §' \»M ‘ \ ﬂ r \- j "39% \~§\-&3~ .uxawk , 7 - 7 «.77; 7 777 , 77.7—7— ...-< w... 7- W - 7 7 7 7 77 77.3, 777 a Q7 M353; --:-..___7—a.7..7 ' 77.7.7 1377-3 ~&\ 71;;7.}7c§?§37\7:s7 sw C\ hﬂa§»3~§~3~ 77-.. 7.7.77 ‘ 7- 7., 7 x 77 5g .v‘wz\ if»; ~ \ f ��I: she/ﬂ ammunummmmmmmmemw at our.Mating um 'mmsmmmmaozmmmmmmumu Meat 11: than Inherited“ ﬂu 1-01. mmpn—mquuiuformmhmurnammtot mhwpmtsim ddﬁndocobulmuondmam Wcummawmmm(mmmv$6h topmtmawotthamdalhtmutw(mttmdm 1956). rationing the Inseam at this report, In investigated the , of acetylcholm Ind cholinoatome in diam-tutu n clone of w’ My. «f ﬁfe? ":9- ‘ therapy. as. data amply the dean. and persistm of the ham 1".th 010W 113109 mm 75:, role: “humility math- I'm acetﬂdwlim in :ppm of measurable quat- the cerebmpinal fluid as wall as an in- moralenrucetvlchdjnohthotmumornemmpnmm Mamamrormsmmtmtmumotmwxm affects by Dale M1 (1911s) Ind/(1921). ' rho W: n to another «1th 4 ' �“wwwmmmtu‘mdmammmm of M 0mm hon. It in affluent to who that mtyldmnm 1| nmmlmtitmtofmmmmy mtnmmmabmtmaaa is liberated as. an mum normal cut-Ironing]. 1.913%) than“ th- or activity and that m ﬂuid contains an hm saga-mt. no true of bdund 1?. iallnpidly mtylchoum (faster and McEachorn new periods The comma-121ml dummy; nomliy has ﬂuid lenl of Munster-nae activity, Men is principally of the mM W was; a: Manning and .- mam mmtitutod mun (mm-a 6mm - 19M). Funk-awn, «citation W through by during thy W (W n “two" deﬁnitm- and Rothanborg: 1935). hmmdfmmtylchonmmdwwrthc'mml"condium (a) fact. :10 mmbrd Tm: th- mliast chug» in than Wmaomumwaommmwmuauummdm vngaumpdEmm,mdoxpommhudtm,mdm otrmumymwminthoembmpamnm. human-numbMtedtonqingdogmluthomtrm,homu1nnruahamdthattm �v r A—w— WWW—«WW. W-_-m_w..__quw$ mtmmmwnmcsruuunarummmmm per-1m for varying poriodl up to Mm. that m a. pain» mum ‘mmmmammmmwnttnomwmma mamaandsammmh human; mum, W was rm activity{ inmlytohtoﬁmdbyawm tbs records won filled with high voltam urpntodalunmﬁeuo neuranldiachatgoy period of mtumd We. {humus of :11 room-dud Glacial-191 activity. Thou period: ~mwwwmm—n -M." mthntoﬂmndbypnlowmothighwnwbshammmh fw. summogmmc . tbs delta. than With that behavioral as wen u . i changel, - Barnum 11mm:- new Nautical! an duo 00th with dogma of tum, with the 15931 of tree mtylclmline. with highest levels a: mmmmwmmuudagmotmmnmwumuum the in alteratim in seventy gm‘bar ma the 1'0 Wmu.» o: apontanam farms:- ahounotothnupoud mam, change! Wanna: animus. those chain-mum, in m. Bantam applied acetyl- «teen-balsam. Unauthomntntimot amylmmlgmporom.arm,hooblemdhighmpntudu �Mmsdloufnqumyintheauctmmoplhlom. manommutation an increased to 2 gun pen-cont, the ﬂattened; in a tnhiun pal-Inn}. to the Tatar,“ kaW mammpmlogm pout-twat“ a) repeated mm. § rum. mm mum-um otnxwingtmofwmandoﬂm»wm¢nsordem. 13112 mmmmmmmrmmmmmnmwm mummmwzm,mmiummmm therapy. murmmtyloholimuxﬁsdhuOJwMgmmrmt. In muQMrmm-aemmdmmmmmiuwatmm ﬂuid. Mm:MmmmmpMcmmmM(m wmmntm) - (tn-chem fondling dug: in the lpociric chainsaw emitting) fraction in the pntiantl with head trams mm W. tho fluids outlining mean faction m a lo s'ugh hint-310nm and We Wadi: rm antyloholim tanning mutations mum. more also conclude ﬂat the Laval a: nu agctymm uric. Wummmotumbmmgm,mr. than: Mmdnﬁmldmmnmmmtnmummmw sitiw indiutor of mm m. �Inn-tatuaumjomwmrmunmnmh— iamla tanning. m. Hun, too, an in Bernstein's W cm, Mmammwmumamumtdmmwwum adenwmmmaﬁWMd. mmmmmludnmtmmnmmnmunthaw ”ammuarmmmmmmnudgmum adfmtrahﬁondmhomﬂnmtofmwlm,ﬂum mmdwogmowwmmhémmﬁ Banners gm Am 9&th of (12) In u.- on BEG and mms, Barnum, maturing 0.5 - 1.0 lag/kg. um, mumudamdor&umdmm¢hm¢tmb Mam'unumorunmmmm; Atmpimdsomdm tho Word and usablogic aim of tum. In tho maximum eon-.- .wmgm mmmwmm,mmaumnwmm dmm of mmcistam induced Km and clinical m: rmrsing arrest. or «3mm. m<m>mmmmmmmathmm¢ WWW. mmpumummmotmhmintend atropin- aubomunly in data «(0.1 W0. In about! an! �.__.. _“_«, _._.__,,....<.,.___,. W7. w _. mmwmmummmmmmnmwam actim. ”waww", .. __._ 7 bmmnmmma,mrmafﬂualectw 'exmpmpmpmo effaahl .w M” wwwmmwv—WWWWWV.W_ 0239113301110 «um. hmsmammu- am, Inn-mm (mm). mwmuﬁﬂ mmamwmmwmmnm.” AWWMHMMWOIWW mmmmmmammwwmmomn: IMW,Mtandemm(1956)Wthume£fm -A——.~-T.v _ ofpoﬁpheglatnﬁminﬂocﬂngthemmotdmmwacﬁuw following unattached: the sm Wen]. mm. 00:811th mm saw mggom tbs Minty any mm. the mmmmmmum WWW mu- MWMdsmmnmmnmmgﬂndi-nga. Inmates- 3m: W mmmm in Wmmdzimloﬂwtmmedmnaotmu,wbudmdfm parjnants and Hewitt (1913); topical .ofinWatnﬂmﬂM/kﬂmthooloatmmmm xtumrwmmmhmr, thatthecmnmumofmamwm mmmnmamswmwmmmmmmappuuuéu (Mm$)mmmmmm(o.2emm)mmatnom �thin (W). 3m: and ”.11“. of hm“, mar, WW]:- ognplun affects 81:11” to noetycholino (WW), chonu) and duty]. than th- mmm mmm. 1mm at that. cholinorgic drugs mums. IA - n van-Low ma at expert-ants nah in commutation! Inch lover my mum ﬂu 1mm attach thou-lack.“ to um with incur-11:10 2m mmm (awwmﬂ- DFP muutytomhnl (div-1W}. Imam“) cumin-stoma. strum - mum- thadaubmtnthighmpnmdonmdfuqmymvelmumm mnpueusuuuumm dugmoxabmmutymmnmt-W mm 919;. (Es-non. museum, too, 1950; mag, 192m and Ema-ca mmmmmnphicoftoctImnWby Inn dot» at am. In W as. 1950). mama-y mm, tantrum and 3-way (191:!) pm mud dwtmmphdomplﬁc m1 mmuw. ﬁnpriarWtimotnmpimelm, expand cox-u: with procugdno md ovum, mmmntyoomuonmmmbyatm. m.rmanneworupommae1mmam.mmm and. tint datum-MW activity induced by mtyldzoune, um �tuna, uI combs-alum unbeblocbdoralmmmbyatmm. topical tpplmuen or interference with mum. of am run. may. mummpnmtmnemuamuam, mmmotacuuty.mrmmmunhenuumw maxi-,1Ihonit1lnpiﬂym1nudbycholmmnu. thunder Wmmauwlm ilyﬁnnﬂaruulhntd’ﬁbpmm at manna, ulnar-1510:: and mmmuuuu - this mm is true um It N ha mm, Wm. dudngnlupmdhﬂdnﬂngmiﬂw. nut m Maud by aches:- and 02-083de (1919) NW§.mmﬂdeM'(19SO)mmupemu. 11mm: on quash-trauma methods, Riches: and cm wining dam-mad um (many-dam mwmmmxamwm prn.mmm)ulwmmmmtmm an wmmmmnmymnummm rats. for Micheline 1n nth-11:1 18 high (1 gulp/mu). Elliott ggmmjmmunu'obsemum. 111mm, thqmtndthat snot-mm mmmrmmwmmmmmn �_...—_——___w wv—wwrvnvr—ﬁwwv—wvw th‘smmnmmmtmﬂmuptoJEtmmm Intpdmlﬂuidotﬂiuinnn,“m,Tmrundﬂon(19hﬂ)md mwhmmm alumnae-ad mimt managed rmmmmupumuumomm. 0t56wihpthpt1mﬂ.hh (1919 B) (Wmmmnmmmwmnm'mmuuudoawa mmoem,umqmndeJMWM. magnetism:- mmmnmpdmmmotmymmot WWw,wmnuumor‘motmm¢ “Whitman“. Itbonmnhﬂmtomdicgﬁm,typadepﬂsply armaehammnuacuuv. hummumtymwmmmamuam mammumrmmmmamwmma _munofthaac1mn,1apobmm rmrlhdmmm (19193)» mmmwmmnumumtmuwm iwmmnudhthohsdcmumth-mum. ht’ahwdmlwmmmdmdmw lib-intact): «13m process, rm (1953).1ndnoodoauvu1d.min mwmtruoh. Sheatoxudmdtholmlofmtyldxolim 13an - �”memcm. mmmtommmmm,addbytmommmmmmmmtdusmj anthem” Mfmsdumgwmmgwdmtmmmmh,m Wmn,mmudtmtm, .MhWWumpmmyaummm,bﬂh mmmmtmrmnmm WWWM. maimhiladtoopw. Wmammmmmummumotmtymmm that: by increased mam-cums ﬂ ”tam“. such a min in. M13 mm nrgunent mm the significance of newb- ‘Wmﬂnmcmdms, niaappumtﬂmttmmwh mwmmmmdrmmm; thitmvityuﬂ mummammamum, «mm; mm sloop mug-mm, M W mammal-19701.net tum @tyldzonm product“ mm with than muse: 80m omimumdchmgummmm,2mrmdncm(mwhw (a) , Walnut! ”1:413:de «shun-ammo activity. «Wmaammmrmmmmmm Twin.- Minster». �"w ——_<__~___..——ww—m_mw—.wrw “—vwr , wwwv I (”ta-m“, .. ”apedtic',: for Mahlﬂgdw mid: he a ma: Spain-o{r 21w for WW; and «shaman-a II ('psendo", ﬁes-Specific,“ a!" WW Warsaw-MW). m have 6133mm ram «Wrormmawmmmoum. differential a..—vnv—_——-_ nu cholimteme activity an mm he» 083 Bach/Ann and mm 1133a, This qualitative dintlnctim. W Rpm-ting the 138111158 substratu’to mtylchonnc, but a ratio of the activity mtylcholm mum-nu, an Wm (mu Wm - me). autumnal m the zonal as: consist: a; mm necholyl and haul- m nuns are found: In mch ntiol non-1 of 33:17 for lack/10h to sub/Ash. manor “pawn" amt-Suez- with a mi]. ‘ non-speciﬁc eaten“ emporium. In patients with hand .‘IZ chainsaw” activity. tram, I'm and kitchen report a sweat may, manu- mum. the county of mammmm eorrdnﬁm between ﬂu extent at tho th- dagm of Wu. tuna and usert. that. there in a definit- mend both with �r,_._W__,__.___._... Inpuumvith mmmmammuvmru: unatotopmmuiznm,hmr,mm1nthonuodobd139mm or total audits-Item activity“: round. Imrandlhmm (191:? g), in than study érudounbnl at tram, n- W‘mmmtmmtmmmw. 3m» &pm WW, zuwnzmmmnmmmgmmmmmw ﬁmw decram c‘Wmﬂthnmerulofth Wotan“, amr 3-? am Mupomd rm mtylchanm m..1? ratio at abolition-M7411 ﬁve pt tho :1: patient.“ Fro-than ohm» nmmwmmtmmtmwmmmmm nor: 1113 than. of crunooerehnl um than that: found in opium. kmtmmpmmmmmmmmmwum Momtmwaweamna ratio reversal,- fb-ymwﬂn ummmmtmnpcmntmaaamlymotmmumwm to want." W �mrmmyaahmmmu. Alia, fmmcwdmrmﬂ pungent m ot’l'mrmdgcﬁcehcémb), mtthctcguths fwdtoMspimlncid WWW thalamus tomcat-ant, penuts us to considor the yummy basic to the anaemia of the um:- that such hm 9:.th pmceu. Ghana‘s: .g. . ocmlusians Certain further deauctiom and agaafalectric m mmmgmmma mum. The pmscuce intcmnnhr ﬂuids Mean alcctmcn Maximum; The pen-- mduccaachangeinccn— ﬂax-activitywith‘anmmu when acetylcholina induce; to gradual pastime. tom: “trim ofﬁo mtylchaum inﬁll WW, nﬂwted in tb nudomeofhwanmmncmtelymﬂm �»;y- mmarmmwmmmwwrmamnuoqmmw an at new destruction. 31m. pm” IMO? Mutated tint lmonnnnmmmnmausaxnmumuypnhunmxuwintnhumnxmqmmnijhmbmahock thonpy, it my be stated that the absence a! {mo acetylchcnne pm- cludu chmgu 1n eczema]. {motion and thus pracludu n clinical aspen-e to electroshock. ‘hﬁhhnummmummsnybomwbrqpnnmgdumpainaﬂluuwmmepmb usability at! explaining the increald 1n Ghanaian-Ame activiw. I is round in highaat cannuntrttian in the central narvoun estemse Quintet-rue aystaum while n is pram in other games, especially blood serum. choline- With the increase in mtylchoum levels in the inter-cellular ﬂuid: as a result. of stimulation and convulsion, “sodium and increased cellular pemeability may bawm¢mum,muhacbgmouttnmmmmmaaatwumnurﬂmuh1Mmibuhﬂmm celluhr spaces dependent on the extent and duration of the ﬂuctuation, (but �r_"__. m,_m into tbs spin-1 fluid; and that thus the electrolytes increased, than siwmsnt increase in changes . mm in permsbmty of calls may ﬂms such u nusledc‘soid Splitting was s amps“. pmids the basis for the sppomncs of high concentrations of scstylchouns and for increase concentrations of Cholinutsrus II, (Tatar sad With the increase HcEschom 19h? in cholinss’oerssa activity, should not the free sooty. lchouns be rapidly destroysd? ﬂuid after trams a). To what melanin cam it's persistence and seizure be «embed? An explanation is available in the for this discrepancy observations 0: Hush-am and Rothsabsrg (191:5). continue! by Tower and Ks ﬁschsm (191396) and Burgaa and the Intosh (1955), tylchouas - shonnsstersse I system “humanips. At ”physiologic” extremely rapid (3-4.1 1vity in spinal is cmcsntrations, mdrolysis microseconds) but falls of! very ﬂuidly extremely sensitive to (Haldane at higher and lower of, ill-t the sea- montrstion acetylchonne is consentmtims, set.- tbs Cholinesusrass II cum). In contrast, acetylchonns uhtionship 1s non-specific, and the rats at hy€re1ysis incmsss with concentrsum. 0011 mums, insstarase this I, in the 11:53 acetyai‘shonm functional with nouns]. st. 1m_ls o: soatylsholins is dsstmysd by the specific. oMsr 0! milliseconds. Where wvity of chol- the excitaﬂea is such as to - �1nd. to an of “casein mm by concentration of sootyloholino in nervous tissue, the rots momma. ‘aooodoo. choline mounts, the ssisuro threshold dissociation in sootyloholino - unt vaaouur ad As is ruched the oonoontntion o: oootyiand c soisuro occurs. 1h. _ cholinostorsse I motionﬂzip vaults in s per- sistonoe of acetylcholine. rho «ism-o, In. acotylchouns. ‘ itself, perhaps adds to the Ian]. at inc'mmd mtylaholino airing.” rapidly. with result- 1'1» permeability connineffects and the appearance of increased names») mmoimnuooohomonom II. Itumoouvuyorwo onlym, though of lot sfﬂciomy, roduoos tho sootyicholins ~«mum of cholinostonso and 69th on concentration aworim, 1on1, InAhours to kinetics that - to levels for the plvsiologic I. Altontionintlnbloodbnin pewbmty humorbyths cantimingsutim omo observed in pout-electroshock oioctmooophnogrm. 1: evident in the mount apart no Aird 33 g (1956) Such s possibility- «annotating a significant increase in tho concentration or odd-inc in bmin tissuo 3-day: utter s ashes of 12 elects-om. an on. shows #olooulo, ordinarily obsent in brain tho clung. tism, in omcantntion of this mg. to b. con-eluted with the spposmoo �, w— _, N‘erm—. #179 WW ducal unu, however, the 1:: mt subjects. the ma 1tuntoa 311 com awumum of trout- «‘WW AM» 7 ms extent; miuuw to «- Despite a Maﬁa: nry may in the of high dogs-ea hypersymhmy, m: by Alerting, mule the duratiamdﬁ' hypnrvmtmum populating. me and wly appearance m persist-mo Wont the tmtamt cont-u, has been described In a neceﬁnry pu-requinita for imprwmmt following shook( nuke: Kuhn. 1956). Batman certain patients to dovdop 137”“an aholine Ind Manama: Assuming my be um mechanism Perhaps and gloom- of.macs-mug the failure them staring of acetyl- nﬁud. is. that a gnnd m1 leisure indicative of the developmnt of tissue 1min or free acetylchonm in mass at the I; hub- at. at hydrolysis by Mae-unl- that the electroencephalographic Wrenchrany in a reflection of tbs persistence of this almond. concentration of acatylcholineg than tho diffemnco in paint: who maintain hypermchrm and those in when it rapidly (tumour-O Ida] disappem, 15 a nﬂactim of the theta.“ of the wonmatemmcetyldmum hydrolysi- Byataa. Persistent. Mommy "cults non decreased "to of �rw‘“. a“ + V ‘. , “m---“vmw hydrolysis of acetylcholim. .Ismbmmmmmdm'oomct, dWrmorbothof the following postulates m opantin an patient: with persist-mt hyper”:— chm. 1) Western” spread batman the the tiam. opt“ ammunition, so that than in a great Imam.- substrate concentration and those present in with high gootylchaline) Ind/[Y 2) Gunmetal-nu m I~1a in 108 1113.1”, lo that the cmntntian kenotion a: this mm opemtim, thong) at a slow decay rate. Conversely, in patients with short ed lampemymhm, cholineatomaelandnintismandspimlﬂuidm Anthem, at” the appunnce of high oomentratiom of acetylcholine stuns!» the production or tissue cholinestemse I in the central Frau tho lucid studies of ”am-noun (195$), a stated in depnasive psych” induced mtylchonne my pncnorbid m1. (1 nervous system. dim rahtionahip batman cm— Mutton of tum cholinestcmse‘ I and level . /) luv-750.. of nervous nativity can be mmpnuul depression) , than the choc:4 . g.» alumni“ I to production a maul. Waters” amt. m �g; hmmmmmwmmumummm _atummuv1ty. Wuﬂaweiwtnmwmmmd WWNWPGW. Itilmww mmmxmmbymmmxx. rhpbhodpmmnotnb mrmcmwmohdmmumbéomuam matm.g.g.nntommzomm. hummus-Wm” mmumuimmsmwmmmducmx,n,mmm Mgmwmmsmuﬁamwmm tomato: Wumumdmmum. mmxnﬁmmaﬁw mtnuuummmmmamnumw;sssmnm �4t). awn-mwmm. the l «tutor cautnlnorvm ”Input Immuoimumm” 1, human tn: of our): and sustained ma levels of :cotylnhouno m Khan, the Wencﬂlhareaaidhrpndicumnm data Wmnohm and 910nm spinal ﬂuid mum to a slow 1nd of chainsaw” activiw. at peripheral “mat-.1431 w chained: neat: 1| thn hypotheti- roaming central nervous syntax nictivity to “rte elect—reducer. �thmmphmdem, 1) mammmamnmmmnud. It'snhuato 3) Whmdduudbwhmcuaoﬂurmmﬂmﬁxm ﬁn" memm—Wrww. «swim 1nd... W tht ‘3) a) shamans activity and patterns ethical norm all at up blame mm a m” a) ‘) 1’) at. of W at M “1 frequency at emu-mu (patina-1) mung; Momummy. mm 1 .7 �NEW» J? I i . , \J Danae ReleefAeetylchenne / bu]. ' E ”Km m Mm at i E Wvulsulﬂ 45% (”<— thenpyﬁdmtnted thet/ Gen-change in behevie 6 wee the development or slowing up he"? as f Wheat oheervetion W - we. index (Finkw and ﬁlm, mined unclear until the «out report! J’ the than; at Mention with high deeee of atropine s f1. E «‘1 E {E ""1? ijmtmg Week WWM”) ﬁcdw- View. describing "‘" hum-tomemﬁemmenw E)W” “M" “ W131- '7: the role of care- Wrelrequeite , ?:- Conan/.hve in the melanin o: WW0 E F amazes - 7'3""‘ early and persistent eight of altered cerebral Mention 2 E 15:7 umrmwwww22". 'W‘m~" "M" m-dbe’prevent the appeennce of the EEG delta abnormality (meet um John-on, name“) 1d; 1956). Following the mggomm at this report, we role/ Convu' | £09 of eeetylchame and cholineetereee in therepy. The data up]:- m E W ”‘35“: e m clue relationship ehetreeneephalogrephic S‘ounvxﬁ ities of free eeetylchonne 1n Wane ~> between the degree and persistence of the led the appeuenee of measurable quant- the eerebreepinel fluid as wall as an inn. vereim of the annual ratios of bensoycholmemlinemme to monomehenmetereee . W he role. of ecetylehenne 1n the bum tea! study since the Loud tnnuﬁdan first eﬂeﬁe—by m1. (1911:) and/(1921). the 3 description of We. W of nervous impel-ea he: as to whether gmmm "’ �lawmanaalyﬁgentmthomaiuionofmuwmmmmmt cf pm", man: here. It in mnmnt a normal constituent of nervous is liberated m it mm in n baund torn and tiuuo; that during the excitation process; that through the specific notion of that mtyldzonm 1: Minute” 11'. in rapidly hydrolysed aid as rapidly raconttitutod by tho Wtyhu‘ Bysm (Righter h mainland - new]. «3&0;me ﬂuid 191m) damn W W contain- no 1910).. in» mtylcholim (Tower and 1493116th mo rapid breakdown o: bound acetylcholine during periods of activiﬁy and excitement. cerebroapiml fluid manually has The chain-stance activity, principauy ”ohm hydrolysing typo (Warm and of the ducribed, eloobmemelﬁdlogma Effect. :3 crab fail to 'tm‘ or w condition- Wm Show Tram: W Bothenborg. 1915). In tbs shame of fmo «Mammalia- and under the (3.) Fummm, any conailtant abnormality. 506-) ﬁﬁMU Jeotad to varying degree: of had tram, Bomtainﬂﬁut abated that (I 4 In. �‘1'. acetylchmne uppeu'ed in the 08? within a _ few aw” minutee etterhtnme and Wm up“: Wﬂoeitiwhnktm persisted for verying periods up to he hams. hw_¢,_e./ ”MK“ at tame/:1 ﬁe quantity of tree W... W”-~Nu '{L versed heaven 2.? and 9.0 pm per cent, Mi 'Wgne 7__ ‘ , “MM . Wu} Mm amount-m. electroencepﬂlogrm 1111:1113, the Vracorde were mud filled with all patterned changes. high voltage recorded electrical fut Witty. 1n:1 short mm in immune. my!» mum F. - activity. mane periods then Inﬂated by prolonged perloﬁe a! high amplitude sharp the delta “V, z.- terpreted as an intense neuron-J. discharge; only to he followed by m “I. were 0.190 correlated with degree of tame, WW mtylcmhemthegmteetdegneotmmmntylmthe M seventy-M WM. as well all with the level of tree mtylcholine. with highest levels W MA. 5(- in containment-change- in greatef and '20 J gamma“-/' ‘ period of ﬂattening of Iﬁ‘J‘ eponteneoue of. name, poet~tremt1c eeimree/ 0/1/24. Wow furtmr substantiate these abstention, Bemetein applied ecet choline to the apoeed cat oerehrel cortex. acetylcholine use 1 gm When the concentration of per cent or lose, he observed high mutude �W“ sharp ms at low frequency castration m immune! to mum . m (£2, patimto therapy. gm pan-09111.; Eu mount "(19349 a.) :1me mpeutud was found Wham the can. the electmcaphalogm in a fashion pummel to the poototnmtic Tower and @ 2 in the electroencepmom. ”com. by}; WI W ”arm. thou studios in in up «rebroapiml ﬂuid only 13' '7 adtmm,moentgmm«1uuure3}nd’m that :m neotylchguna varied IMOA to .100 gm per ant. In ”1 addition. Inner and Mencken-n assayed the cholkutenu activity at the spinal “Maternal M (W ﬂatwf/ m. W W fluid. They noted a sharp rise in the mamaiﬂc oholinesterase (berm. Molina-splitting) .WW” with”. taunting thanpy._ Ho such inversion m dmmstrated 1n the fluids containing tree acatylohonm following Spontaneous seizures. than: authors oL ‘ do. concludcﬁt the m1 of tree acetyloholm varies directly with the degree of cerebral W P. .._ ‘ 3% dam; Mr, rover-:1 of tho ohalinenterue slum inﬂate:- nt con-bra dunno. adding, tau a, that the traction/tram non m �W -5- want-)Ww an m at (g m of those i P 5 tervala tanning MA mm, direct cox-“hum of the _of Em Mommy m appearance of true uoo‘ylgaolmo in the nnbmspzlml Tf (-l [I m. I' that. eminent-b211, traum- WM ﬂ” W/ m I 1" m?! mes-d a in- the ﬂuid. . min-11mm- ofﬂaoctyldmnno in tho Imus]. ﬂuid; and, that the” bemoan mum the dim: degree pthmtylcholiﬁ, aim wt at and type ()3) {“49— . ‘ varying 1 . lA~ mammognphic nbnomlity/ an!" clinical War. am Am g. mtg-swan at EEG and Behaiorz ﬁw‘x mu Mud- W u“ /w mama-d {munching at mam attests/Mb— . W j—h‘ “1.31m °£ 3th. 6‘“ W ”ﬁshnet-n1 a and neurolcgic {.1336 of W *h tum. trams. 4;; W ”1.574; Mn“ 2 “:86 awn/9 Men of 'mtncistorml acetylchoune, which induaod Em and clinical . W effect of utmpdm. closed head In 20 clung” 11:11:: to had Ward (1950) tum, Bgmatoin applied axons 1331117. 1m: 06 31.10414. _ Water! ibis—W to the trentmt of 0... human pttienuuith varying agree of iatarad atropine subcutaneously in dam o: 0.1 when In cues 9f m, , be achin- M can! �r WWWmmmm—W’mmww E aux. mmmmmmlmm'mmm rmml at tho electro- ,_ .W. . A E. enceprmlognphclc effects . W ~vm1Wv—wr E m. cholinergic drug, a! alterations in the report 31mm Inﬁm study of author anuJaguar and Loom (1955) 915::th We Ammumtmnmmhommammmmm E E «(At a_ 833”“me r A-..“ ‘ m . __V W tu: 9.11.4447 M W mudmmmnmgmzzmmmmmdwmmcmm of atropino in blocking the following the 010% and Johnna (1956) WW w W and I in m Wm of that wave activiw therapy. this study suggest; an biodmictl in head mm.- Mutated the smith“ ﬂat uﬁdeﬂ; th- chctmnoepkﬂommic \ I \\ E I ‘ _ manpoz'tstandaoutinconmsttothuennmngarlnﬁwhm_ ' \ pennants Brenner and Merritt. (19M), applying topical aoéﬁyldzoline 1n concentratiomctﬁtomitoWWcomdmu,Wmdfm i or intmenma atropin- (1 E E It is important to not. the r ‘ 1r E nag/lag) on hmr, oloctraomphnlom that the concentrations of “Mabel!” in thésa expemnta ma signiﬂmﬂy higher than the topim¥ upplioationl . r E . L E «hang». (1-1; game. S) and than intncistamn1(o.2 . - 10 N , Born.of gum)1njecti%a 1 .:/\_ .\ �mm Banner and (19115). ognphic affect: 01101130) and than tbs imu hunt, annu- to doryl hunter, m not. of 0100th :cetyuholina from mecholyl (nootylhetmthylo (Micheline), not: in mneontrations 193$).de concentration. mh 1m:- Thq ascribed the manned effect- at those abolinergic drug: to their lack of maitivity to cerebral mums. mm high «11 u n epileptic”, mm In (W, ﬂan at 913;, am. In author 1950; degrees a! abnomlity noted in mhtmmtie boom 339,, 1919; and Emma 23$.19So). m1 if present, ﬂu», mentor} The tho in: warn W by ‘ study, Ghntﬂald and aorta with prosuwm 39m activity. or 1075531; studios, too, the olectmneoﬂnlognphie effects .1111 date! exposed W «puma. npid fnquencykw similar, to status Dempsey (19152) and «oh-d pnpmd eloctmemoptnlomma prior aduiniatntim of ntropinn blocked this spiking, Ibnomlity could be 15leth by atropine. a variety of upexdmntul and clinical elude that eloctroenuphnlogmphic nativity induced by studiu, u- my con- uctyldmuno, nth»! �w .—-——\W- W.. 'WM as e result at Btu-Lug tram, topical application or interference with nee-all period! of aetiviﬁy, 3% free acetylcholhe in liberated W, mm, when it in rapidly Mum by 01103111081283”. {mu—ML WAammchmne 115M101: at ma We, hm. that the than the Th9 10701 mint, of remnant of the processes It may be postulated. therefore, m1 mm rise during aleep and run mmiﬂw. this methane is true and is at the cell That we: denountrehd by Richter and Cree-land (19h?) Swank and Render-eon (1950) in animal uporlmntn. m using liquid air quick-freezing methods, Edema: and Greenland denomtrated that. mm the anesthesia and sleep 1M1 at wetylehonne (manned ea per a. brain tissue) was 300% difference in ﬂame level: rate for acetyleholme in 21g f” (1950) Maw, “ _ Vﬂ ' *~-~r-—.._ (ﬁtter mtmole camﬂei brain is however, an the meynﬂxeeia high (7 W‘“ observation» The game/alum“). Elliott W‘mey H“ , 0,94» A noted that ”W «J'N'n‘ﬁ' a free mtylohnline was always demmatrabh WW”, x. is tme’imt, at 6611th these higher than the poet eeiaure level. in - �-7 w» mmmwmm_—-— '“ " ' - : qumm unmadﬂﬁdmmcmquptoBmwmt. m, In ’lpin-J. ﬂuid audio. in fear and Kahuna!!! (191:9 B) Illa Geno, Tan:- and He Enohem (191:8) and mmm woman!) in patients with opuspay. free (77%) mud lignuieant quantum: at Of 56 OpilOPtic W mammal.- rm miyloholine directly ranted to the momma to the last minute. W ‘in quantities of 0.02 to 5.0 at cultures, the extent It hon no mention to mansion, cm emulsion, orwhetharthe «nun, that. the 3pm ﬂuidisabyb mummammoamumd-s is prom-untied. Tm: and When: hem-ad mtylchoum liberation in not itself m‘mntod to the mic is buie to the scum process due mung ﬂu ”inure.” process, Torch (1953)/ induced» animals by metruole. She dctomined mm; type of epilepsy mm.“ line ot‘ I “ﬂammumymmmauzymm or the mo-ammm af-f;m abnormality, ml the mung»: of or lavai of choljnaatemne activiw. product of the M; J gum per cent, with In may at 1.0 gum per cent. 16791 ﬂuent“, tin level 01' (191:9- B) to up be. “ism § mm Won: 1:: mammalian in bran �Mam berm nadduring W Wm. mm¢me convulsions rise in mintymmum Mutant of tissue; that tho by a my» mum Mfﬂndudngﬂwcmnlﬁm3umﬂutbomcemm15,m whim failed to occur, )hrﬁzem/de a - \\\_~_,_.H_. than” K.’ as during u convulsion We»; H111» duo V‘; to inhibition at aoetylchenno mama; martial. argument” about. the MWWM’ZMMM choline the W Mum mﬁummum Inch 3: ram-m; ' mtylchaum; while sleep and W . mtautivity tum 1m].- nf and - 15min. WW magma: mem- mum 0.th mtylchoum produnﬁan abut-ration: of change: in mtylchonm, armor and of of W»! Gmtlnt War/wed...“ 03m. Mun 1m. W Mb... in clam ﬂuid Jan-L, dostmcum, lowering mowing J.» —_‘_..~... . ,‘_‘ manned concentration- at by tum, /" prob-Lb acatylohouna, but in m msm"ﬁot¢&nmumtthofmmmmw in mm poetuhud /,:v’ . ‘ whim: z” with When: (1916),..— min-1 fluid cholinemmu activity. are normally fwd 1n the spinal fluid: than Two W Minuteman-I �\ } 0m”, - ~apec1nc',§ or ity for wetylcholine; and hm mxéming)mm Bath W W Wyn for Mom and differential rite pend” qualitative distinction... cholirmstame activity a, memo. has a high cholimtarwo 'II (.“psaﬁdo', 'nm—apecitio,' or Mam-manning). dittemnt. rates a! madam—1 1 .éetymxoam, but Mandamus. By Thin ‘ ”porting the M ratio of the activity ”errand and prf W(mﬂ1M/Aah Wk”: bent. oylcholiué swam—ates to an aoetylcholim substrate, m_ meio- are round: WMw-‘C/WLW M osr contains antenna in an _ Thus, normal 68! consists ntio - /1,u?l’zjdua.2 mo)‘ In such 0133:17 for n“ non-specific ester-nae component. In institute with hand tram, Tour and Warn report ‘5 dwinzfTr W the dog-reset mmtyg ﬁzz-J2 65.x; tram and‘tho “Av-o: ”” mu it" ,g 3 nAsimﬂmt correlation batman the extent of the chalkenamc reversal “in with ' 1 WW a)”; M minly of imposing" octane“ with a . no I , the oWncomalogmphin 33 3 Jr”? �In patients with 130de mu ﬂuid hétylcholm activity a I result of Ipcntenoouc seizures, hammer, no change in the ratio of chol- inestemea or total cholineeternae activity an Wm Manx:- Tower and a their study of creaioocrehral (19w 3), in ‘:A six portede psychiatric phtienta mapping in: * ﬁle rm. W); W patients utter 3.7 troatmntc, theymported {1; m M decrease cholimntame, a “I. tram, re- therapy. ﬁtm- rm ioetylohonne act- a: cholinectemco with a revered of the 5 W We: W ratio of chcnneetoru? in five of the six patiente. Fro: tho/e oblont “time more (V they concludejthnt the apinﬂ. ﬂuid Wax: are- “Du—4 ' in lib those of cmniooemhrel tum than then found in opucpcy. haul-ding the one patient in the series who {tiled to show either 1“ﬁeyW“ tat "It {mnwetylcholim or a cholincaterace ntio reversal, 0 u mum-ting that this patient was the only om o: the six to chow no recponce to treatment .' �Ducunm m , but than variant obnomtiom, In my comma that therapy induces spinal ﬂuid changes mm otrmrandwchem (191:9 rum to maps»). ﬂuid b), ﬂu W 111m cerebral tram amt. that onlytho gamma, railed ta show a response to peanuts us to consider the pwnibmty that such biochemical “t, basic to the machinist o: the W at alas-uric current through brain ular activity with an .inemaae to inﬂuee a grand mal'acisun. in m. Thu tmtnant, We m process. cnmlusiom certain further deduction: and ‘ago than than. an mamas poasibla. the pun-- manna: a change in cell- mtylnhnuno to level: uranium. presence at! free :1lech in tho �enema—II in Mt in other tam, W blood anew man. With a. 1mm in acetylcholino levels in the inter-canning fluids an a result of . mum amm'umnmdtmundmmmmmmmm annular ms dupendantm ma ottoman duration or themuon, (mm. ngm)vltmwpmwmwmbmmsmmmmw 81:6.me in mm mom (19M. "s2. W» M. '53). Thu I!!! convulsion, 3111:9301 and modihﬁna and nomad annular pemahility my �throws mumm;mmtmbmehmmud, luxuriant mmmmmmumw-m splitting m. 4 mummramtydmmmmmﬁomtormtw _ wwmumamwmmwtermmmtma ﬂmmm ’n. (rmr w mm 1916 B). mammmincholmMmae activity. mummfmmwb 1mm replay be ﬂuid nth-r m doatroyud? and re whet We. ”ism I» «edited? :1: can . . it’- pal-datum in in amplmtim for this (1180mm ammuntheobumtmormmmmm.mm" tyrower and He Enchun (1919c) and Bax-gen me monoun- At ”physiologic“ mantmtione, m «2% (m rapid (3-15 dam) mtnﬂm. mm: but at. higher and fans acetylnhoum nation-hip 1: with (195$). thet the 33.6w sensitive - chonmteme-I cyst. is mtienehipe. 1v1ty he Intonh cm). Wu, mg. with hem-1 ne- to concentrationor. acetymhenne 1s Mr concentmtiona, set- In contrast. the [hasten-e411 and the mm rd: of hydrants 11mm levels of acetylohnnna et eettutyoreheaamteytheepune «name-nu, theseemohenne inseam-I, 1n the order or nimucom. . more 3% annotation W - �loaf» In main menu-luau or mwlaxolm in mm tissue, at hydrolysis Mascara-2‘1: by ehouneumtn, my As tha rah an mutation at acetyl- thaimnthrydzouu mammalian”. occurs. In. dissociation inpootylcboum - Ghanaian-a I whammy results in a par-- mm,1tu1f,par}upalddstothtlmlof unﬁt-#61:. with munnu mom-ea untmoeofaoetylchonne. nu ﬁtym. mm gym: pemmuw grim .W 1mm muesnmnummmmnmumﬂ.'1t1umauuwottua ant. vascular and 0mm, aid the or mummcm,mmmmnmmmmmt, ypuulbi uduoeathnm‘ylcholmm, action at ' mmudm,umrermmo1agu muons-I mm,muhasentumm,ubccomnmummw �all?» . ! I W dwwm{mubm)nmmmmm hmumnamwaotmmmmmmuu Wuhnecmﬂmdmmpnvmmmmtmmm due” mu, )2pr m, extent) its in lost abducts. Ila-pelt. n m up at uppunnoa mum: m vuy greatly in of mg: dogma WW. nut.- daumua: m 2171 to modiﬁcation by ﬂex-ting, ituntosa- has bean W applicatiu: of b mmmﬁan and hub-- w psyuhntzic popﬁhtion. me and 1t! any appearance courts, trait“: Want yum the 63mm u n uncanny pn-mquuiu for Mt following 01.0m— m( ampmumwmm'z Pcmmiomudwm. M&Km,1956). ButmtutbcmhmiumucﬂnngtheMnno! dialing and Mentor-Ion m be nut-d. Assuming that a grand Ill is. seizure indicative of the MW of tism le'nlloffmo mmmnm-«mnudwwwmm-I/ ’md ehctmphdognmc hyperqnchmil a reflection at u: um. the per-31m of thin abnoml commutation a! Micheline; than the difference upmummnmmmmmmmman W(Mhouni Wm, 13 a nﬂactian of tho mm m W «we. d tho dammsuwtymm Persimt types-3mm units m- M nt- of �.vp—v—vW—yw—qw—nw « W ‘13mzmmmmmmm.dummorwd WWW. of ! ﬁn {ma-mg postulates are opontiiu k £3 menu with pom-tons E chm; l E W . Westerns-i 18 in low cWﬁﬁ;u tint 12W in a great 1) . spread tho hm tho amigo]. mum- aubatmh Mutation and at Wanna-II 131m. no that tho concentration 135mm. of chum on oporatiw, [and hi. W1: a lion docq nu. Camel-loin in patients with short hypersy'mhm, Whoomrnae-I and-II in tissue mm and spinal a. ”7 fluid am we produotion of tissua cholimsteaé-a-ao-I 1n the oentml nervous syntax. W mm WW ame-I my“ aim-rm tho lucid studio! o: (1955’), mutation of Mam? cholimateroao-J ﬂ ‘ 35 4‘— high. \Purmemon, the appeal-once or nigh concentration of acetyldxouno am in I new with high mummy 2) and those pmsent and a direct mum}: between on» level of aetiuty can deMa’o be ‘ do... 91»th 1M Manon» my stunts chainsaw-1 pmduotion to o m zoom. stated 1:: Massive psycho-3 (fungus-.1 60pm). than tho Wu! mu. Eﬁofji 1 �‘ .53.- In moth-r cutout, those studies of outcome reactivity. “Eadie: _ In have opplioation imp-W by to the woman Watch an! other: havo damn-tram a mhtiomhip between the blood pressure reopen-o of patients to inject“! mohohl and ahock. Namely]. Ward“, is ﬂair mama). naponaivity to alcoho- a potent oholinugio agent which induces sweating; and vuadﬂation, momod peristalsis. It is rapidly cholimutoma-I and slowly by cholinostam-ﬂ. Tho W 15'de w pressure of sub- mu an: arm- mused menoml and Muml to the baguun. 1n n variablo length of tin, 3.3. the to natal-unto ' 20.119112“. more than Patients whoa- blood pressure “mummswmmomieduaroupl, II, QMIII no notions; those whose blood pressure “has 20 or more 11mm to rotum to o MWImotonhwooﬁm WM M”! mt ntouitthdthonupII-vmructomaﬁimute. hmmmmnmtonmoMmmmwpﬂIn9ﬁmmxy buoﬂmueroupvlmdmmcum. , g" Wilt-v rats. (momma at, 1952.) ' hmmmzummuummupumumm-mmA Wmédmlylio a lion npiﬂyhydmlyudy than the W81. nu. V. may Gmumm potiontahan m» predict. Hanson, that tho tholinoutenu ‘ uuuwmnmdwxammuldbohighyuhuoﬂmmuvﬁy \va x �a. dwnamwum. Homnhnrcaamrpnmnm mmurwmmmmdemM4,mumuu mammmmwmmmnmmmm mammmmﬁarhmammmmmum mmaudpwmmwmmmumpmu mwnmmuammmmuwumm. �Wmmamnﬁanummotmm-oraammmm W emmwmuummamyummtmwmm l quire #11: veriﬂmtim. 1mm For this purpose mutionahipo ho WM Wash-at 1) it in anaemia. ' murmumaammmmmnm. typo, OllQWﬂogrlI patterns. m and magnum at suggest-d that an mam. 1‘4an A1», the “mum 2)Rohumdmchmty1choumuvohtothomnicalmd patina“. 3) mung» 1:: indie” or mama brain nmcuon othorthnn mama: such mtylrhmao 10701:. h) mums; of cholinoatenae actimy and patterns or blood spinal ﬂuid to: 41)le b) We!“ a) ram otdwoloznant of 3m , d) amber and frequency of tmtnentl a) antennae (perimnl) mativity f) 60mm]. meti‘rityo 14 .& 7’ 5. Wm n... WWWM? éIJMW~ 4* , um and �111: 7-3-6A (I: on rue ROLE or AcsrrtCHOLrue ' ' 'vh .d) AND CHOLINESTERASE 'IN'OONVULSIVE THERAPY -« IStudies evaluating the role of cerebral changes in the mechanism of cenvulsive therapy have demonstrsted that the develogpent of early and persistent signs of altered cerebral. function are prerequisite to changes in behavior (Pink and » t A ~A. . at ': n . ' .c. ‘ I: ‘c .' V A s ', <:-~t ‘ Kahn,‘l956), In these studies, electroencephalographic slowing was the nest significant.index This ohzrvation remained un-v clear until the reports of Ulett describing the effects of pre- medication with high doses of appearance in the atropine preventing of the EEG delta abnonnslity (Ulett and Johnson, 1956). Following reniewed the suggestion of the we report. role dt acetylthis cholinestersse in-‘convulsiva' therapy. ‘he data suggests a close relationship between the degree and persis of the electroencephalographic slowing end the appea ence of and choline measurable quantities of free acetylchnline in theygnrebrnspinal / influid as well as an inVersian of the aerial ratios of benenycholine. . 'cholinesterase to lecholylcholinesterase. that: The role of acetylcholine in transmission of nervous the impulses has been studied since the first descriptions of Dale (1915) ..snd Loewi (1921). The srgunenta as to whether actylcholine' is the main or only agent in the trans-ﬁssion of the nervous, impulse are not of primary concern here. .It is sufficient that acetylcholine is a normal constituent of nervous tissue; that it exists in a bound torn and is liberated during the excitation is that process; it rapidly hydrolyzed through the specific'action~ - A ‘ " . A .1 F .v «an ‘ -< _- : .V. l antes-.3 var-I‘m.- ,, . “be”: wMYJ/I'" 44:: gauges-5mm �. .1 of cholineeteraae and as rapidly reconstituted by the choline- I ' acetylaee system (Richter &.Crossland, 1969). Furthermore, normal cerebrospinal fluid containe _ free acetylcholine despite the rapid breakdown of (Tower and HcEechern, l9b9a) bound no acetylcholine during periods of activity and excitement. 'The cerebrospinal fluid normally has measureeble cholin- esterase activity, principally of the "true" or mecholyl ’ hydrolyzin3 type (Nachmeneon and Rothenberg, 1965); ' In the absence of free acetylcholine and under the conditions described, electroencephalograme_fail to consistent show any ‘ I abnormality; .. ‘ i (a) Effect of gregiggerghggl . 3 Exagggz .1n n study of cats subjected to varying degrees of head trauma, Borenetein (1946) reported that free ecetyltholine appeared in the CSF within a few udnutes after experimental head trauma and persisted for varying houret acetylcholine quantity of periods up to £8 free _The varied between 2.7 and.9.0 gamma percent, and-the amount weeV poeitively related to degree of trauma...‘ Conconntant electroencephalo3raes demonatrated patterned chan3ee. Initially, the records were high , filled with n fast activity, interpreted as voltage intenee neuronal discharge; only to be followed by a short period of flattenin3 of ell recorded dectrical activity. These periods were then followed by prolonged periods of. hi3h amplitude sharp waves in the delta frequencies. The . behavioral chan3es were also correlated with degree of trauma, as well as with the level of tree acetylcholine, with ,higheet levels of-acetylcholine. Bernstein reported the greatest _‘-_... �_, ‘ 1 , _ ,. .3 w. a yawn-mun?” lift!“ .1»? . .. my vmr in?! 0...“, yr,“ y». my -1,“ 'V'W'FM' cream-ls“. . _ . .~ > I -3degree of m abhor-slit” the greatest. and thence; in consumes ' furthermre. spontaneous post-Ftrat-oticseisures livers also related to the of tree aco'tylcholino- appearing iii the apical fluid. 1 “t l..,‘_.‘.__.. l... V A t ‘ ’ further substation ,theae‘ohsarvations, Bonstsin applied .acetylcholine to the eiposed cat cerebral cortex.' "h. the concentration of sutylcholine use percent or less. he To , ‘ . . ' EI - . line ‘ observed high amlituda sharp waves of low froqmncy in tho electroencephalogram. When/the concentration ‘ves increased to 2 3—: perceot,’ the electroencephalogr- flattened in. afashion parallel l to the post-trematic records. ‘ . Tower and HcIIchem(l9lo9a)'-Iropa_ated neurological pstients. thssa studies in Irse acotylcholins ass 112 foond in the cerebrospinal fluid only in the patients with. rocoot hood trams, ~recent grand-ml seizures or convulsive therapy.- The free acetylcholine varied from 0.2 to lOO' 3‘s perceot. lnladdition, Tower end lichchern assayed the cholinesterasa activity of the spinal fluid; They noted ashsrp rite in the “nonspecific cholinesters'se ‘ fraction '(hensc'ﬁiholine-splittiog) and a drug in the specific choliioesterasefractiou (escholyl-splittioc); in the patients ‘ with head trams and those'follwiu in Mlsive thereby. no ~ - such inversion was ’d-oustrstod it: the fluids containing tree acetylcholins fondling spontuooos soisores; These authors concluded that the level of tree acetyleholino varies directly} the degree of cerebral dance; «nesting, haever. that with. the reversal of the oholinostersse' frantic: cos ‘a sore sensitive indicator ot-esrshral donate-V ,' I. ' _ ' ’ �7-1-2 intorvalo following varying at cm in loot of theoe anhjeeto. .‘lhe nthore reported a direct Electroencephalocrnooere trano - m and the appearnce of the of ahnorn'lity degree correlation oerobroopinal fluid. in the of free acetylcholine _ two Theoe ' increeoe the etudiea indicate. that crnioeerehral tron-a nay nomt of free acetylcholino in the opinal fluid; ’wt of froo that a direct relation eniota between tho acetylcholine, the degree and type of eioctroondphalouraphic and abnormality. and changeo in clinical behavior. ' Bornotein adainiot'ered O.5-l.0 tog/its atropine after hood traumawae tho induced anddennatrated blocking of mifeot no effecto. Following the experitrana.~ induced intreciotornal which ecotyldlouno. addition of jof and neurologi'c eigno behavioral nntal 2 clinical change. oililar to head trouno.'lornatoinohoerved 1 blocking effect or atropino. zoo and , Vardf1950) applied theoe idoaa to tho treatnont caeeo. .. of hulah ' of closed head injury. .In 20 patiento with varying degree of trau'oa.‘ he adminioterod atropine outmoly dooea of in 0.1 tog/kg. In one eaoao'henot'ed'clini'éel ignorant. and in tho of electroencephalographic of the 1 othero, revoroal effocto am: ntioholinargic of 'otndy a another dm. tragna. In Lechnar (1955) reported oinificant altoretiona in the poet- and » tranatic electroencephalogrn. inota‘nceo ' in 22 of A. oingle iatrovonooo dooe in abnornal electroenoeph'aloorno reoulted in inatoncea and unto-a iaprovooont 1. eix othoro. ‘ 1.0 nor-dieing ! o , �. 3 Iv. . . p 5 u ' .. ' ‘ , . V“ U - 'F ‘ ‘ ' r ‘‘ Ulctt and Johnson (1956) donoootntd tho I... ’oﬂoct'ot Antroptno 1n blocung tho oppnronco of no: 111601” couwlo1n. oct1v1ty vi. than". an' mood: tho study oouuto tho that 0.- Motbdcal .chauo. oloctMuphoch on... 13 hood ; m... cod 1: ,.- i . “owl-1o...1:: oootrut t6 thou 11.11:. In an: out undo noon 0. mod-onto Broom: .d Hordtt _(1m).__m1y1og top1c‘11'ocoty1f161111.11 ,' - 1 ’ thou. of tom! 1o concoctrouooo o1-2-1l2 «to; noted no offoct of clocttooocoohologuohu that tho mtntw. no “unfunny atom an... 11: to tho otrop1. of oootylohou. 1o than tho tinted lad-or tho .rooot) ,m :5 ~ ' I m2. W at onoophalogtophic otfocto won Modal by . ‘_- A #ﬁ.1w-_ ‘ moot“. . -V . in ﬁ...___‘..-% 1.,mr-4gmv4._.ﬂ 41V W to 6.1;.an about:- ‘Wq 1950) 11.. 1950).. Inothou 3 . 1 «duty of 1.011qu nth choumtoruo' 1nh1b1tor on (614.9:ny (Imam-photo) Mutton 1113b qutodo 1‘.“ (Money pot... “-11“ to out. 1n opuoptmoo. u -11 u 1.3.: «lop-o. of no.6 .' 1969; and v _ tho potont post-truth: . _' . ototuﬂlltnttcmuot 11., - on tho h w ‘ motion. to. thutlod o1 logo1t1v1ty A . _ . tut1oom1hoyucﬂbold01Wdfott1Mﬂthou- at"... ‘ 1"...“ § (mutants). I _. '34; (oatylutuothylcho1bl a“ by: -chol'yl 111 commutati.oh 1.» ti.” on. .otylobu. concou“ch ennui-31c. drugs to w...h- hM-—mbvwmmr wWe... am (OJ-IQ ‘ A quuuuu'u (1-1 3-1 oloctroooooohologrqluc oflocto 011111: to 4 ﬁlls) to ooto. '- ‘ (1 1-..... earth: Mt tho. Wu 1; atria-tuna 'o’z Wain (1946). mm: .11 smut. potent) at] ow w. m new”. at .1... too, tho “cotto- 0.11 dam of otrop1oo. �- 6.In another_laboretpry study, Chetfleld and Dempsey (1942) 'ptepered exposed animal cortex with proatlgnlne and evoked electroedcephalographic spike actlvlty. The prier.edu1nlstratlon of V . _ ‘ 'atroplne blqcked’thls spiking, er if present, the abnormality could be elimlnated-by ettopineuv Thus. from a _ variety of experimental end cllnlcnl studles; __ we A may conclude that.eletttoencephaldgtaphic aetlvlty_1nduced by ‘ acetylchallne. either as a result of trauma, topical applleation qr [ntefitxcnce with cerebral metabolism, can be blocked gr ellmﬁnated 5y atrnpxne (a) ‘Role of Cerebtnaplnal Fluid W...‘ " Acetyicholtne normally appears to be present-1n nervbus tissue in bound. inactive farm. 'chollne 15 activated thus the During periods of liberated at the cell by Ac cholinesterese. activity, free acetyl- membrane, where The it is rapidly de- level of-bqund acetylchcllne ls resultant of the processes of sinthesis. liberation breekdpunw It may be and postulated, therefore, that-the level wlll rise during sleep and fall daring ectlvity. ‘That this hypothesis '15 true was demonstrated by thhtet and Crosslend (19a9) and Elllatt. Swank-and Henderson (1950) in anlmal experiments. By using ltquld-alr‘qule-freezlug methods. Rlcﬁter_and‘Croaslapd demonstteted that the anesthesia and sleep level of acetylchollne {measuted as microgtemﬁe per mg: brain tiesue) was JCCZ higher- poet thaﬁ the seizure level“ ‘The d1£fetence_1n tissee levels is trapslent. however. as the tesyntheels rete for acetylchollhe 1p rat brain is high (7 gimme/gm/mlnute). lﬁlllett‘et a1. (19$0l; a �- 7 _ AIter metrezole convulsions, confirmed these observations [they also noted that free acetyl~ was choline ttatione always demonstrable in the spinal fluid in concen. up to 3 V . l genus per cent.> ln spinsl.£luid studies in and and Tower (1948) Cone, Tower and Menschern men, Mcéechern.(l949h)-slso denonstrsted significsnt of free eoetylcholine in pstients with quantititCe 56 enileptic patients. 49 epilepsyl"0f (77X)'demonstrsted’messursble free acetyl— chuline in Quantities of 0;02'to 5;O genus oer cent. with an average per.cent. lhe acetylcholine level was directly reletedl extent eelzures; of electraencephslogrephic the to the frequency of ebnormslity..snd the telation.of the time of coupling to the last of.l.0 gamma seizure. It hare no relation'to indication, type of epilepsy or“ .Ievel of cholinestetese sctivity.ll ' . , Whether the acetylcholine appesttng in the ~ '. A 3 g. spinal fluid is a by-broduct of the convulsion, or whether the incress} in acetyl- I]choline is'n cause of the seisure, is problematitel. McEachern (l949b) Tower and believe that the increased scetylcholine libetstion' ls not due to the seizure itself but related to the basic procees' causing the seizure; In a s“dy of the hypothesih that the accumulation of scetylcholine is basic to the seizure process, Terds'(1§53) induced Canvaeions'in animals by nettezoles She_determined the level of scetylcholine in brsin tissue before and during convulsions. .She noted that convulsions ere preceded by s " rise in the scetylcholine content of tissue; that the coucanc‘grueuaiiy fells'durins the convulsion; and that below certain levels, convulsions failed to ‘occur.v She suggesteﬂ that the fell in tissue scetylcholine during convulsion use due to inhibition of see.tyleholine synthesis by concentrstious of metabolites such so smunnium ions. increased a ' �While ebout erguneut the role of acetylthere.ls considerable choline in the mechanism of seizures. it is probable the: free acetylcholine ie increased during seizure. and appears in the cerebral spinal fluid; that activity and eeizures enhance acetylcholine destruction; lowering tissue level. of acetylcholine;‘ WW while sleep and enestheeie.eugmeot acetylcholine production, . increasing tissoe levels. 7 l. . rd) Concomitant with their observations of changes in acetycﬁbline. Toqer and Mczechern (1949) oeaeured spinal fluid cholineetereee activity. ‘rwb types of cholinii lesteresea are normally found in too ebinel fluid: .cholioeeteraee-I ("c-me". "specific" or-necholy'l hydrolyzinﬁ), which has a high: ' nod specificity far eeetylcholioe; cholineeterdIo-II ("peeudo"." epecific". or beozoylcholine-hydrolyzine). -Both coupounds hydrolyze' - ‘ ecetylchollne, but have different rates of hydrolyeie ftr mecholyl "and beoZOylcholine. -Thioldifferehtiel rate permit! duelitetive' distinctionse of the .By repertins the cholioeetereoe ectivityJee e ratio. activity with uncholyl and benroylcholine substrates to on retidio ere found: cholinesterene-l/ choline-tereue-II[acetylchbline.(with Ash/Ash - 100). acetylcholioe substrate, acetylcholine and ln-such ratios normal CS? two contain: eatereeee in the ratio of 33:17 ‘ior choliuentereee-I to cholioeetereee-II. Thus; noruel CS? consistedllllllli with of "epe¢i£ic” utterance a euell non~apecific eetereoe component. mainly ' i In patients udth heed tron-I. Toner end Holechern reportm m inverting of the eniupte of dbollniptirg‘le with d lignIIiCInt meg. mime unionist-nan meme decreaue in choline-cerebe-I ectivity.- betweenthe current or the cltolihbotereee of mm fluid and e They eleogreQOrted a Mﬂel correlation with the severity �of cm... W the of electroencepheloirmhic and with the degree I II I abnormality; '- . ,I" In patients with increeeed result of spanteneoue eeieurne. of. 1 e 395-1221: r" , eoihel'tluid ,ecetylchoiine howewet. no cerebral ad Tower tum, ee e thmge'ingthe ratio. cholineste'raseslor total" cholineetereee ectivity‘ w _ wee found. nonethern (194090. in their etudy of crazie- reported obeervetione in eix peythietrit petiente undergoing convulsive there", \Studyiegthe patients otter 3-? treatments; they. reported tree ecetylcholtne activity in the Iepinel fluid in two petiente; end en increeee in cholineetereee-II and e decreeee' in aoli‘neeteree'e-I with e revel-eel of the retio of cholineetereeee in five 6! the eie petiente. In: the,” Nobeervetione, they - like thoee of ctmiooen‘hrel tron-e epilepe'y. petient in the Veeriee who foiled to ehow. free eoetyltholine or e cholineetereee retio either Mani-in _ Regarding the one the eoihel fluid. they Petient wee wtou:_"1t.ieinteteetlnsthet thie no" one-of. theeie tee-me. to only. to a... the tree'tneut". .. . I 1 ' I DISCU§§ION . Fran theee verioue met-yetioneQwe hey contlode thet canvuleive therepy iodueee epiunl fluid like cerebrel sore ehmgee emtw thn than of maintained. we chpredtet trans” , epilehey. If the perhllel ie‘ ot the degree ehhtitn new electroencephalogrmhic ebnouelity, the acetylcholine, end e— , thaaee the thetfluid epinel in cootlmd induced céwuleione were sure thihkthoee found in . “arena of free revered of cholineetereee ectivity retioe �-.10 _ the splnal field and the nunber and frequency of lnduced cone vtlslons., Also, item the observntlans of Tower end McEachern 1n (1949b), the cemment thst ohly the patient who failed to shew. -§pinal fluid changes-talled'to show a response to treatment, ptrmits us tu consider the possibility that such biochemical bas1c therapy of the the chmges are to ccnvulelve medical“ process. cpnClualonsiare pnsslhls'. ad The hasssge of electric current: through breln sw‘stencesilnduces in change sctlvlcy with an increase 121 free a deductions Certain further mm“ . acetyl-. choline to levela'suffictenti‘to1nduce a grand nsl seizure. The . presence of ' ' free acetylchollne 1n the intercellulsr fluids electrical hyperaynchronyr‘renscted lathe .386 as delta? slwlng-r The degree of hyperaynchrow sc'mrate-ly reflect} the, decay acetylchollne of should fonds! free a ad rate equal level S1nce studiesthe purines of deatrhctlon. acetylchollne rate to demonstrated. that EEG hypersﬁchtony use: a, necessary ﬁrvrequlsite induces. ' . ' ' to the cllnlcsl respome 1n central‘slvsthﬁapy. it my be stated .mu'mm chances that the dunes of free aestylchollne in cerebral fulcrum ad thus prilud'es s clinical rem the 1ndueed convulsions. tn Certain eat-muons nay be ends regardles changes In cell embrace permeability as emlal’nlng the incresse in theme-:- .estetasd activity; Chollnesterase-l ls feud m htgheat concen- ' tratlran . 15 ~- 1n the centre} nervms system; predominant in other tlesues. especihlly the increase in eoetylchollne ‘ anus chounfcsmrsse-II Innis blid serum With 1h the 1ntercel§lulsr cerebral fluids as a result of stlmletlon and cmwlslhn, vasodilation and increased cellular permshillty be Pradicted’;’ my ' D E .MLr-JM: 4‘ . ‘ . M. -. . t a ‘- . �~11} thﬁ inch:vasculdglfluids'tnto with a degree of ggancudatian of dnrittan of thg'. and ch. on dlpcndcnt spaces nxtcnt cellulnr vnddtlptlio-n _do occur numétous wag (um 0:11., 19m, anpiy.dcnonstrstcd ‘Ihnt ouch ”manna chm ' SﬁlejiIFAdolf 8910331 1n and by répofti (1961; '62, 'bb,"£§;.'53)é - . . denunstrat§d They cdnductivity cbhvulsldnn e1.c:r1c.11y_iuaucgd tacguased.che that Idikqgo pot-saint as ﬁargous of ions. 1n n cf the clouue; resultud thh lldid§ el§ctgolyths the while phbiphatQ, that and ipingl into and nan-cltcirolytés nngsnittcant 1n .tncraalcd. incrpaso 1h Gunﬁght prﬁibiliﬁy nucleic-acid abutting 'enzyus. of £011; may'thtu prﬁvida thé basil for-thudappoarahco of high ‘w-u 'contgntrati§u§ of a¢§tylch611ns and for lqcrcnand cancantgattons' of cholineaterasefll (Tower 1nd1HcBIéhern.19b9c)." _ . within. 1n;glil%;1n‘ch011héytct‘ne‘acglgitz; free act-tylﬁtoiiné _rnp1d1y> b0 dutioyoih? T.“ wit ohoﬁﬂd not tﬂe $phdnsn can ind uéttbed? agitate-ht. sbtml' fluid. arm: ugh; m panache-e. in. 1‘ qbuertitiann. EB. thin‘diactcpcdcf nvnillbla in An éxplanattqn.for ' Sy :kuurgxl (19.005). Nachuntoh of Mun-ad and__loth¢nber3 . McEdchcm (1969c) .ind poison and HuprtoIh (1955),.{thaf the acetylcholinc-cholthél'brabe-I'uyatﬁu is vary aanptttvi~co:¢on¢aq4 itdtibn relpttonshlpq; At "physiqlogic" éoncentrdtlons, hydtolysis , - and, buc'd: 1i higher of ncntylcholigi tdpid‘(3—6’nucranecoudn) qu1c¥1§itiL}dqno off cutv,). activity £111: lower cqngcptrgtionl. rtiatiénﬁhip to chbltneutaraac-Il-acutylchollno In conraac. the rafd with egocenttaiian. hydrolyita-tncfgases of the and non-specific. i . 'um. nor-.1 um. {mama mu- n: «manna. a cell ' Qéttvity' chi geocylchbltnn ipqctftc by thidgntioﬁjd npnbr-neny tho f ;_1 ‘jt �.i. V-“ wry...” m.“ r'rr'l r . v: _, r“'\7ﬁ"x.:r'7m¢rm., _ ’0"; 3 Of cholineaterase4l ithhe order of niliiseconds. . _Where - . . 'l excitation 3 A a , lead% to an'excesaive‘concentration of acetylcholine in nervous tissua the :nté othydtnlysia I by cholinesterase-I is F 4A A 'A’Q": exec-eded. thu con:enrration of acetylcholine mounts, the seizure threshold is reached and a seirure cccurs. The dissociation in ncetyichoiine- A3 m}! 1 “+4—ow cholinestern5u—Z zclationahip chnlinn The neiznrej liree acetylcholineul itself, The results in a perniatcnce of acetyl— pernapa adds to the level of “gt“..i. increased acetylcholine diffuses rapidly,» with resultant vascular-and cellular_permeability effects and the iPPEﬁvahcé cf inzréaaed ions in CéF; ﬁnd also etficiencf, increased cholin- r LAM; astsrawemii. 4 Aﬂnmnmm. It 15 the activity of this enzyme}.th0ugh'cf lqw- 3 and dependent on concentration kinetics that rdduceﬁ’ the acetylcholine leval;yaperiod I . j ' , of houra to days. tb levels - .__\._-xw-:‘.mz...' for the p‘Eaiologic action of cholinesterase-I 1“ Alteratian in the blood brain permeability barrier by the f ~continuing action of acety-lchoiin e may be the biochemical aub'5trntc {or the hvpcrsynchrony so often obServed in past~electro~ «nu—“\me'mut maﬁw—«A .hnck-electraencephalogramst Such a possibility is evident in the' I 'i ' ' report by.Aird et all (1956) demondtrating a significant increasn in the concentration of cocaine in brain tissue 3 days after a' 'seriea'of 12 induced convulsions. ‘ g of concentration tiisued to he His data about the change in i, . 1M . ' - ' In ..—.u..‘,~«.r.n.v.— 9-1.4.L — .1. “F... thi a large molecule, ordinarily absent in brain torrelatcd with the appearance of bypersynchrony ’ I (delta.bursta) in the elecnroencapnalogran. In our studiea of thc appearanca cf clactroencepnalographic he, have confirmed tire many changes with acmvulaimi .previous reports tnat convulsive thctapy induces hyparsynchrony in most subjectst Despite a constant application of treatments, ‘ a �«.13-‘ electro- however. the time-of'appeatancé. duration and extent of the graphic slow ' 1' A . 'ventiiation it; its sensitivity barbiturates - all QAV$f and populations. and - The to wodification by aierting,'hypervary greatly in psychiatric appearance degree of hypersynchrony, high early beeﬁ has the course; tieatmeﬁt persistencv throughoﬁt described as a necessagy prerequisite for improvement following Electroshock(Pink and Kahﬁ..1956). But what is thé~mec§anism" "undcrlying the failure of certain patients_to deielcb hyperaynahrony?_ Perhaps-thgse studies of aceryléhollne and cholinEstﬁraﬁes may be rélated. ‘Assumiug that a grand mal seizure is indicative of the at‘ttssue levels 9f free acetylchnline In eicess of "' ﬁhu fate of ﬁydzoiysis by cholinesterase~I;-and_thét the electroencephalographiC.hypatéyuchrony.13 a reflection of the'peraiatenCe, development ' of this.abncrmél concentration of acetylcholihe; than the differencé 1h pugzehts who maintain.hyperaynchrony"ind those lh'vhom it ‘rnpidly (fgv hears) disappears. is a reflection 0f the kinetics of the ch01tngsterase-acegylnhollne h§dtofysis systeﬁg Persistént.. hypersynchrbnj Insult; from dccteiqéd rate of hydrdlyeﬁs of ’cboline.v ¢ ‘arahstn-nﬂ acttyl- ,. _If the hypothclla~prevtouely'deducgd are cattact; nithér-ane» ‘ . . V ' . , f u-ww-xa..yrmwméw.w}v-JH‘ or both bf the felLowlng postﬁlateg‘are operative in patients with 99 tslsteﬁnt hypersy nebr‘ony: (1) is a ‘ . Chaitaeﬁteraseél is in low great.spread betweén the apt! thosé preéent '_and 1n cancentratton, an that théte' trace concentration the ttésue with high acctyicﬁolxne;vandlor' '(2) Chalinesregage-Ii is a1 enzym¢~aub low, so that the concentration Ltwetzks cf chis‘system are opcratxve, though at a slow decay .. .13...- ...,.__..J rate“ �‘ _ fonversoiy. :u patientc with short-lived hyper:yuchruny. Cholin- cetetaee-I and -II in tissue and spinal fiuid may be unusually - Furthermore, the‘appeatﬁnce at high concentrations of acetyl-~ Ichcline stimulates the production of tissue chclinesterdse-i in the(antral nerVDus.system.- From the lucid studies of Nechmanaon (1955). a direct relatzonship bétwéen concentration of“tiesue cholin-- estethee~1 and level of nervous activity can be deduced. It 109' ievels of cholinestereaeél can be dull- demonstrated in depressive 'psythoseé (? menonaueal deptession), then the electrcshock_induced _acetylcholine may stimulate cholineetetaee-I production to a mare normal. pre~morbid leverm , cantext, these studies 1n_enqrher problem of autonomic reactivity. may have application to the. ‘Rncent qtndies by Funkenltein and others have demonstrated a relationship between the blood presents of patients .respbhsefto injected mecholyl and their event-n1 reopensiyity to ' :i' ” ' - 'Hecholyl which a induces“ cholinetgic potent is agent electsaShack. ' “ ~2i: tachycatdia, ic?‘ perietaISist sweating. incteaeed and vagadilation. chnlin~e hy hydraitzed cholinestetaseél and slowly by ls rapidly estetaee—II. 5;.. atter injected fails vatinb'le length of time, blood pressure of subjects return. to the baseline in a five to more than 20ninutee. Patients rthalyi i The and presiﬁre'l whose blood 5 the minutes are classified as Group I. baseline in to returns those whose blood pressure takes 20 or more '21! ':an reactions; minutes II to return to‘a baselineg‘es Group The Gtoup 1 reactors have a 92 improvement ' VI and VII reactions. 'IlllI-I-I - rate with canvuisive {1- - H; i ~ therapy. and the Group II, II-III reectorl : 352 rueovery rate In a i contrast, the Gto up VI reactors have a 892 and the Group US;da~9§1~agent-uzeaauuzyq:ate.£runktntto&n-otqe3~y¥$953-- I ; 1 �“ VII a 97! recovery as patients in 2W4"??-:'£€i§:?fjw*ja 15 _ Groupu_ I to may llI may be looked ubon the injedted mecholyl is hydrolyzed; rapidly while the Group V! and VII patients have We a slow hydrolysis rate. predict, therefore, that the blood cholinestereee ectivlty.-' levels of Grouce l-III would be high; while the activity of Groups Vl-Vll would be low we recall here a similar prediction cholinthe date central for of nervous levels item Iy regarding esterese~l, in which the develovuent df early and sustained EEG hypersyhchrony and elevated epinel fluid levels of acetylchdline related to low level of cholineeterase activity. _Thus, the date of peripherelystlmulatiou by cholinergic agents is A ,was congruent to the hypothesiq regerding central nervous‘system‘reP activity to electrcahock. cammsmus: This survey of the literature of the roles of acetylchollne of cholinesterase in convulsive therapy hue led to a number speculetione which require yeriflcetlan. 'For this purboee, it and 3 is ‘ suggested that en-investigetion of the following relationships, 'be undertaken. (1) Level of free_ecetylchollne iu the epiqal fluid. 1‘3. type; cbnvulalye frequeucy. to number and therapy relation Also. the essociated electroencephalogram'patterns; Reletidn of such ecctylcholine levels to the clinicel (2) behavior of patients. (3) than z‘ 3;“:Ww’gwwm‘us rate (Funkenetein $5321" 1952); ;Patients in Funkeaetein whom .24; EEG in indicec of altered brein function other with such ecetylcholine levels. Changes ’ , .7 ., _ �{4); Reiéttoh chalineate'fﬁe gétivify of blpbd scrim andpspinu fluid to: (I) ﬁattémﬁ of and ‘ age, , (b) alméta (c) rate bf deveiwopt'zent of‘ EEG (d). numbg: ,md fréqqencyof . f ‘ treamhts . (e) ,aﬁtbn'omc (heriphgnli reactivity -(.f)',cerébu1 reacthﬂty‘ ‘ ‘ , 3 . gpexfsonauty Run: ofatroptne“. physos‘tiglnlne'admini‘attatian on (’8‘) (5) hypersyhchrony ‘qliﬁical behavtdr. , _- ‘ ~‘ E36,“, j 4 �III: 7-3-6A ‘r (1:, ﬂab-(i) ‘ ON THE ROLE OF ACETYLCHOLINE AND CHOLINESTERASE IN CONVULSIVE THERAPY Studies evaluating the role of cerebral changes in the mechanism of convulsive therapy have demonstrated that the development of early and tunct persistent signs of altered cerebral are prerequisite to changes in behavior (Pink and on Kain, 1956) - was the most In these studies, electroencephalographic slowing s significant index. This obhrvation remained un- clear until the reports of Ulett describing the effects of pre~ meo11ation with high doses of atropine in preventing the appearance of the EEC delta abnormalitv (Ulect and Johnson, 1956). ’Followlng the suggestion of this report. - we Eg 5: reniewed the role of acetyl— choline and cholinesterase in convulsive therapy” {é to data The lg; ve x close relationship between the degree and persistence? of the electroencephalographic slowing and the appearance of Suggests a T: .¥ measurable quantities of free acetylcholine in the cerebrospinal {g fluid E; as well as an inversion of the normal ratios of benzoycholine- cholinesterase to mncholylcholinestersse. I h:§ . . Ihe role of acetylcholine in the transudssion of nervous impulses has been studied since the (1914) and Loevi (1921). first descriptions The arguments as d of Dale to whether actylcholine is the main or only agent in the transmission of the nervous impulse are not of primary concern here. .It is sufficient that acetylcholine is a normal constituent of nervous tissue; thst exists in a bound form and is liberated during the excitation process; that it is rapidly it hydrolyzed through the specific action g) �oi cholinesterase and as rapidly reconstituted by the choline— acetylase system (Richter normal cerebrospinal a Crossland, 1949). Furthermore, fluid contains (Tower and McEachern, 1949a) no free acetylcholine despite the rapid breakdown of bound The acetylcholine during periods of activity and excitement, cerebrcspinal fluid normally has measureable cholin- esterase activity, principally of the "true" or mecholyl hydrolyzing type (Nachmanson and Rothenberg, 1945); In the absence of free acetylcholine and the conditions under described, electroencephalograms fail to show any consistent . abnormality. Effect of Craniocerebral Trauma: .In a study of cats subjected to varying degrees of head trauma, Borenatein (1946) (al reported that free acetlehcline appeared in the CSF within a few minutes after experimental head trauma and persisted for varying periods up to 48 hours. The quantity of free acetylcholine varied between 2.7 and.9.0 gamma and the amount wasl percent, positively related to degree of trauma. Concommtant changes. electroencephalograms demonstrated patterned Initially, the records were filled with high voltage fast activity, interpreted as an intense neuronal discharge; only to be followed by a short period of flattening of all recordedeaectrical activity. These periods were then followed delta frequencies. behavioral changes were also correlated with degree of‘ trauma, as well as with the level of free acetylcholine. with highest levels of acetylcholine, Bornstein reported the greatest The m �consciousness in change the greatest degree of EEG abnormality, also seizures uere and furthermore, spontaneous post-traunatic the in appearing related to the amount of free acatylcholine spinal fluid. applied' Bernstein observations. these To further substantiate when the cortex. cerebral exposed cat scetylcholine to the he gamma 1 less. or acetylcholine percent was concentration of waves of low frequency in the electrosharp observed high amplitude encephalogram. When the concentration'vas increased to 2 gamma parallel fashion in-a flattened percent, the electroencephalogram to the post-traumatic records. A 112 in studies these Tower and McEachern(l969a) repeated the found in was Free acetylcholine patients. pneurological head trauma, with recent the in patients only cerebrospinal fluid The free acetyltherapy. convulsive ‘recent grand--nal seizures or from 0.2 to varied choline lGO gamma percent. In addition, Tower spinal the of and HcEachern assayed the cholinesterase activity cholinesterase the nonspecific in rise fluid; They noted a sharp fraction (benzcyhholine-splitting) and a drop in the specific the in patients (mecholyl-splitting), fraction cholinesterase therapy. No those convulsive following with head trauma and in free containing the in demonstrated fluids such inversion was acetylcholine follouing spontaneous seizures. These authors directly acetylcholine varies concluded that the level of free that however, damage; cerebral of with the degree suggesting, sensitive more a was fraction cholinesterase of the the reversal indicator of cerebral damage._ -' �- 4-following intervals varying taken at were Electroencephalograma direct a reported The authors most of these subjects. trauma in of the of degree correlation EEG abnormality and the appearance cerebrospinal fluid. the in of free acetylcholine trauma craniocerebral indicate that These two studies may fluid; spinal in acatylcholine the of free amount the increase free of the between amount and that a direct relation exists electroencephalographic of type and acetylcholine, the degree behavior. and changes in clinical abnormality, (b) Effect of Atropine on Bernstein administered 0.5-1.0 pggt-grggggtig mg/kg EEG 5&4 thgviog; atropine after head trauma- EEG effects, manifest of the blocking demonstrated and induced was the experiFollowing of trauma. behavioral and neurologic signs mental addition of intracisternal induced which acetylcholine, trauma,“Bornstein' head to similar EEG and clinical changes observed a blocking effect of atropine. human of treatment the Wardflgﬁo) applied these ideas to degree with varying 20 In patients head injury. closed of cases of doses in subcutaneously of trauma, he administered atropine and in improvement, clinical noted he some cases In mg/kg. 0.1 the of effects electroencephalographic the of others, a reversal Jenkner anticholinergic drug, trauma. In a study of another the in putreported.simificantl'alterations (1955) Lechner and 40 in dose intravenous traumatic electroencephalogram. Asingle normalizing‘ in instances of abnormal electroencephalograms resulted others. in 22 instances and marked improvement in six _ �- 5 - atropine effectwof Ulett and Johnson (1956) demonstrated the sane conVulsive‘v illoﬁing slow wave of activity the in blocking appearance biochemical‘nechanisnl same the therapy. This_stndy suggests that ’ . V ' under£:5the electroencephalographic changes in head cranes and in . *-',._—s Mov ~...,_..-—~ in contrast to these findings}: In their i _. M. . experiments Brenner and.Herritt (1962), applying topical scetyle in concentrations of 2-1/2 to choline 102 ‘ to the exposed cortex of cats, noted no effect of intravenous atropine (l nglkg) on the electroencephalographic changes. lt_is iaportant to note, however, that the concentrations of acetylcholine in these experiments than significantly the topical applicetions (1-4. was higher 3“. I percent) and the intracistsrnal (0.2-10 galls percent) injections Bornsteind(1946). Brenner and Merritt. houever5'slks_note of of electroencephalographic effects similar to acetycholine free mecholyl (acstylbetanethylcholine) and doryl (carbanylcholine), each in concentrations Inch lover than the acetylcholine concen- effectiveness of these incteessd the ascribed trstions. lack drugs cholincerebral of to sensitivity to cholinergic their They ‘ estereses. A I variety of experiments with the potent cholinestarsse' inhibitor DFP . .31. induced convulsions. due report stands out a.m- fluorophosphate) demonstrated high (di-isopropyl amplitude rapid frequency 885 patterns similar to status epilepticus, as well as lesser degrees of abnormality noted in post-traumatic stete!!(ainnich, et el., 1950) Freedman et a1., electrohempson the 1949; and et al.. 1950). In these studies, too, encephalogrephic effects were blocked by snail doses of atropine. -——.‘ Cs- �In rustle? labcratbry study. Chétfield and Dempsey (1942) evoked and anxmai prestigmlne :ortcx expasud ytch prepared r9103hdlU.YJDF1C Spiﬂe autlwtzy. electro- prior.admznzs:ration of The 'uzrcane biotk\d this 5:1 1:5. a: if present, the abnormality v?u.d be viim‘:1th by atrepir~ 7C 1 trtn 'hu.. a variety of experimental clznlcal scudzcs, and 'har eie-ttnuvcethIographic acti;1cr ._:ti;:hrr;:¢. irhc: -T;t'!‘!". ‘th as 3 wﬁ tnd¢¢¢d bv reswlt of trauma. topical appl;astict or :rrvzral m;:a‘clzﬁn, can be blscked ur elzmztated ltz'tln|k‘ -. (r) ‘3}.: 'x '.;re:.cwg:n31 ~ a:e:yL.n;1;1¢ ﬁcrtully appnars :; “Jqu, ;v¢;ttae iczm. It trcaxd;un {L58 Ln 4 The level of spund acetyichclinc is v c: the pro: I! 3325 cf synLEcsig. liberation an; may be Lcscuiat is true :45 npmanstratpd 1W: -. nex.{;3;. pr-Sen: 1: vezvous 11554t a I u . therefore, that the level bill during «lead and fall duslng activity {111352. 9v'xn a“ ‘T ac:1;i:;, r:ce acatvicell membrane. where it is rapidl; de- Activated ty challnestarase. c::.:an; bv . Du::n3 pazxud$ of :hu;in# is liberated at the ;h;. the .,‘.‘.:l Au€£.luld.;‘£- "‘ r.u.J 2 by thhte: Pyzdur$;n (1950? and La That this hypothesis Crosaiand {19u9b and aagzyz uxanrimun;s Sy Richter and Grassland qu1ck-freézing methods. asxrg liquid air deﬁoﬂSLYdtzd that the anesthesia ard sleep level of acetylchoiin‘ .Lgustcd mi:ragra:13 per 25 :Fdn fn» Ln»? uvi;urc lcvc; Itdnxieﬁt .. ?. .5 (D N mg. The brain fiSbUd} was 3092 hich? difteteECe in tinauc levels 13 .5 the resynthesis rate for azetyluhclihe in m rat braxn is high (7 gammaigm/clnute). 'Elliott er a1. (1930} :. par-- �After metraeole convulsions, free noted that also XIhey acetylobservaticne, these “K ;3r?ic~‘i n ; chul;ne :ws always demunstzable in the spinal fluid in concen- tratians to up In spinal 3 gamma per cent. man, Cone, Tower and HtEechern fleid studies in ahd Thuer and McEathern (1949b) ‘1348) ti quantititls 86 also demonstrated significant free acetylcholine in patients with epilepsy‘ 'Of patiehts. epileptic Lhuiine in quanti'iea 49 (7723 demonstrated 0:02 tc of SP0 gamma naeeurable free acetyl- per cent. ith an average was related level directly acetylcholine pu:.cent. Ih: (L the frequeﬁcy cf seizures; the extent of electroencephalzgraphic t6 the last of relation of time the sampling and the abnormality, cf 2 O gamma It bore seizure. no relation ta medication. type of epilepsy or level at cholinestetase activity. Whether the ', a . a the in fluid is spinal appearing acetylcholihe ty—prcdcct of the canvulsion. or whether the increase in 9 - catae of the Seizure, is prshlenlticela acetyl- Tower and chachern (1949b) believ that the increased e;e:ylchcline liberation (T; itself but related is not due to the seizure caaeing the seizure. A“ In a to the basic preceee s“dy ef the hypOthesls that the accumulation acetyleheline is basic to the seizure process. Torda (1953? indured convdsxcrs in animals by metzazcle She determined the level of acetylcholine in brain tissee before and during convulsions.» convulsichs byla She noted that preceded are rise in the acetyicholine content of t:ssue; the: the content gradually falls during the convulsion; and that below certain levels, convulsions failed to occur. 3 She ccnvulsioc suggesteﬂ that the was due fell in tissue acetylcholine during to inhibitien of acetylcholine synthesis by incrcdeed reagentratiacs of mezabclites such as ammonium ions. �While there is considerable orgumcnt about the role of the machanism of seizures. choline in it is acetyl- probable thot free atetyltholice is increased during seizures and appears in the spinal fluid; that cerebral activity and seizures enhance acetyl:hcline destruction. lowering tissue levels of_acetylcholine;while sleep and anesthesia augment acetylcholine production, V inLrGaSXSg (d) tissue levels. Svstoo Nervous Centrai Cholinestegase: Concomitant with their observations of changes in acetycholine, measured spinal fluid choliuesteraee activity. Tower and Hcﬁachern Two (l9é9) types of cholinii esterases are normally found in the spinal fluid: cholihesteraso-I i"true". "specific". or metholyl hydrolyzing), - which has a high specificity for acetylcholioe; and cholinesteraBe-II ("pseudo","nonspecific”, or beozoylaholine—hydrclyzine). Both compounds hydrolyze acetylchcline. but have different ratio of hydrolysis for mecholyl and beozoylcholite. distinctions of the .By This diffexehtial rate permits qualitative reporting the cholioesteraso activity as 5 ratio activaty with mecholyl acetyicholine substrate, two and benioyloholine rati$ are found: substtates to an cholinesterasevl/ acetylcholine and cholinesteraoe-II/acetylcholine (with Ash/Ash - 100). in such ratios manual CSF contains esterasea in tho ratio of 33:17 for cholinasterase-I to cholineateraee-Il. Thus, normal ‘ CSF consists- inly of "specific" eaterases with a small nonhSpeciiic esterane component. traoma, with head Toner and Kcﬁachotn report an patients inversion of the amounts of cholineoteraies with a significant In increoae in the cholinei‘trase-II fractiOn of spinal fluid and a decrease in cholineatorase-l activity. They also reported a correlation between [la extent of the cholinesterasc rcvérsal with the senority �the electroencephalographic of trauma and with the degree of ‘ abnormality. scetylcholine a as patients With spinal‘fluid increesed .In however, the ratio in change no sponteneous of seizures, result found. actitity was cf :holinesterases or total cholinestereee (e) Effect of ﬁle trnehock on at A Tower and McEachern’(l9493), esterases: it oline and Ch in- in their study of cranio- psychiatric trauma. in patients six reported observations cerebral Studying 3-7 after the patients convulsive therapy. undergoing the they.reported in activity free acetylcholine treatments, . ’spinsl fluid in increase in cholinsstersse-II patients; and a decreaee in cholinestarase-I vith a reversal of the rstio llron'thess Of the six patients. of cholinestersees in five and an two in changes fluid the concluded spinal that they observations, cdnvuleions trauma craniocerebral those like more were at induced than those found in * epilepsy. Regarding the one patient in the series who failed to show cholinestsraee in ratio reversal or s free scetylcholine either the spinal fluid, they wrote: "It is interesting that this response shun to no of to the six one the was only patient treataen.." . DISCUSSION From these various observations, vnlsive therapy induces spinal fluid we may conclude changes more that con- like cerebral is. 'trauma than those of spontaneous epilepsy. If the parhllel of. the degree maintained. we can predict a relation between of abnormality, the appearance free electroencephalographic qcetylcholi1e. 3nd ; ra"97331 of cholinestcrane activity ratios ' �‘“ the L-L Fpl'd: fizid and the number and frequency of induced-con; xtisisrs. Alsu. irsm the Observatians of raver (1959b), 1hr ccmnent that cnly the patient suing? ELUiJ ;hangua us in ptrmits :hnngcs are filled who and McEacharn failed to Show to show a response to treatment, cozsider the pcssibility that such biochemical basi: to the :cchanism of the achuleive therapy process. Certain further deductions and conclusions are possible. rhé brnin subrtances of induces through electric current passage change a in cellular activity with an increase in free acetylchclinc to levels sufficient‘to induce a grand mal seizure.i The preaence 3f free acetyltholinc_in the intercellhlnr fluids electrical hypersynchrony.ref1ecced in the induces , slaving The degree of hyperaynchroqracturately reflecth the level of free acetylcholine and should follow to the rate of acctylcholine destruction. demonstrated that 1c the as delta EEG a decay rate equal Since previous studies hypersynchtony was n_neccssary pre-requisitc EEG clinical responsc in coavulsive thcrapy, it may be stated that the absence of free acetylcholine suggests minimal changes in cerebral function and thus pracludes a clinical reapanse to the induced convulsions, bc made regarding changes in Certain assumption: may membrane cell permeability as explaining the increase in cholinf esterasd activity“ Cholinesterase-I is found'in highest concen- trarian in the :entral nerQOus system; while cholinﬂesteruse-li is predominant in other tissues, especially bloba sdrum. ~With the increase in acctylcholine levels in the intercellulur terebral ilwids as a ‘ xesult'of stimulation .-J.-;'..L ..i ;w::tjs;; and convnleibn,‘ :uliuau: gartelhllzty may be predicted, �.. 11.. interthe fluids into of vascular with a degree of transudstion of and the duration the on extent dependent cellular spaces vssodilstisn (Rabat et all. 1948). 'Ihst _do such permeability changes in and Spiegel-Adolf by Spiegal demonstrated amply occur was ; . demonstrated They '53). 'é8, '6h, '42, (lQél, numercus reports cenductivity the increased that electrically induced convulsions cf the tissue; resulted in a leakage of various ions, as potassium and phosphate, into the spinal fluid; md that while the electrolytes iignificsnt increase in non-electrolytes permeebility in Charges nucleic-acid splitting enzymes. i .creased. there was a Wes of cells may this provide the basis for the appearance of high :ﬁccentrations of acetylchdline and for increased concentrations - oi chalinesterase-Il wt ch~he (T owe: and Mczachern l9h9c) incevihy in cholinesterase activity, shculd not the free acetylcholine be rapidly destroyed? To what Mechanism can seizure be ascribed} its persistenze in spinal fluid after An explanaticn for this descrepancy is available id the ebsersetidns trauma and cf Nachmsnson and Rothenberg (l9é5), hy confirmed McEachetn (1949c) end Bergen and Macintosh lever and ' (l955),lthet the scary!:hcline-chclineglerssc-I system is very sensitive to concen- tration relaticnships. of acetylcholine At is rapid "physiologic" concentrations, hydrolysis (3~4 microseconds) but at higher and quichly_(hsldene off curve). lower concentrations, activity falls relationship is In conrast. the chdlinesterase-Il-acetylcholine nGt'EpCCllli, and the rate of hydrolysis increases with csncentration. Thus, with normal functional levels of scetylcholine membranes, the scetylcholine is destroyed by the at cell specific activity �where'exzxtJZLcn -:41 in the Urdu: of "111;3dC9ﬂdi '!;U&uLVc '1..‘q;. :rL:.:1"-"wf cchaevtratton of acatylcholisu in “Bfiohs is Hytirwﬁxw ‘; ‘b: ‘*::e:tr3:icn f :lr311rﬁ:ster.19a—I t.s ex;cc:J¢d_ Ev: {Htéskrld the seizure uf acatvlzholivc mount:, The :2 I tree acetylahoiine t"r‘1"; -~'.' *1 I: ~~II .r‘;c1nn;y. The “erhaps adds to the level of rapkdly,« diffuses ucstylcholtne increased a; the actlvtzi cf thia enzyae. Jun LCgﬁﬁduﬁt ad Lu CUCLUDCYaCXCn A ‘Lc acetylcholice level’ f): fke shwcx persistence of azwtyl- a the and pctmrubility effects vaatulax-ind cellular £53; cholxn~ Inzteased 413: and .v‘retued inn. 1n 1" t.~':t"’ '¢ ’.vnshiv rzeults in nex:;ra. itself. The Etna 'W' disscnlation in acet/isholtné~ a tﬁOugh c1 low klnolizs that lchls period of heurs to days. to p cholineatetaRP-I. of action /w;alcgic (lottrtcnvcphgiagraMs Suuh a posstblllty xs ev.5c:t in the' I Tcpﬂ$2 by Axrd e: 1n 1n-.e;ae a democdttating (1936) sxgniticact 1;. erin gdcszte in of cuvuent::;103 the ‘ 12 L9LC€RTT¢L10a itisund Cedutuw ’v‘ tiesue is data induced convulsionq. 3 da,; af e' shows the change in brain in absent tﬁis ordinarily nnlecule. large ct of wﬁtﬁ hypersynchrvnv the ;nTT91aLcJ Appearance ta be eleCtroancephaiogram‘ the in (deitu bursts} electroencephalographi: of of the appearance In 0d: stLdica nuwbuni' the many confirmed have we changes nuth hypersynchtony induces therapy convulsive previoug reparas that of treataents. application constant a Deepitc in maqt Suh‘c~(w ' #cmwnlsiozs, _ �FLHCLICof the Jnd 54r3:1cn extra: ILmv of Appearance, (it “VlﬁVﬁf, ‘rT'XXATXOH 315 *"ri‘::w“" . ‘ {v hyperaler21u1. c;d1‘i:1L1‘" tc senaazxvzty its Qaca graph;; 5ch I herb:tgrates all cgrly appearrnce TLQ vary greatly in géyzhiatric of?.igh degree hvpe: vnchrany. bwaa has tzcatmunt the ::.r:‘~‘ 1:* ::§ 33:1IHEE'CV (Lfvgghiji 31¢;Yihﬁﬂ as a nuccaaary E'sctrgﬁﬁ”( t-tr': 'quh:iwlrr 2H: and Kihn. 1956). Bu: what 1: ch; meghanism' imitate of caftain pﬂttents_zo deveiop n3persy1.Lrauy be and acccyléhriine may chottneqterases of <tgiiee - L%ewﬁ 9:;L4y3 greraqgtsira to: inprrvcmeu: folluwing \s-uﬂ.' .la "Z¢piwﬁx seizuze ls :ndznattnc o: thy *EA: 4 armnd m;. ; {13:uc KQIHL; 2f {tee a»:'{2.chv'LHv in ‘HH and ghnlznugcaraae-i; by ," -«;c *nd~a;;z‘s n. erlag'-.5;; hypetsyncnrcnv La 1 iKSQ$E a! that the alertrc— ref\r\::LLn cf the pvrstazunce the ditfctence then 3f acetylcholinu; c~rven‘:¢;2cn Phﬁ”':d1 ‘32: 9‘ u. :rﬂ-tr:: -in ra:a;¢1r ry;c:e,n :n:;r.v in- at in whom it Persistent .frizzc=2-r3we-QLPn;l;bol{we hydrolysln system. {La 3 Lh of ace:"Lhvnral of atu I decreased fr3a rate I h5“a7annchtnn", resulcs K . . V s-prrvlousiy deduced are correct, ezther one 'J 9" 0' LI V 1 rv- in .A 0‘ t r9 n ’ I‘ ‘1 ,— P" patients with (a as are operatlva pcstula: suing .cr'xst.uz hyﬁvrzy nebrbny: (" 1% :‘i attrast-I IS in law s: rte er: in LF: tisSue t2) h‘ Yh<‘ 2 Cb'litugrpzata—II is :oﬁc=n£r3££nu , «12L h1gh Kev, so %: that thc:e a;¢:ylchclzne; and/3r that the noncancraziou at though are 02e241122. g; 5. suqtyt 'h:..- 1 slaw decay rash o �I ‘, f)‘:W-‘rvrs. t“: " st: gfztzl Ira in» ‘.-* “2:- 1" 2 ~ 3 :: "ca proqz tlcn <th .L . Fran Chv a:v:yl- nzgh cgnawnLratiors or :"l':us:eraae—I stuchn suuid . attivit" cad be (;Q55!. . of Wacnmunsan ill-n If can be deduzcd“ 13w demorstracad in dapre:?£ve yzr~xe5 g‘ acnopausal depr¢sszct), then the electroshock induced ' $:L:V1-‘QIIUL 1¢v-:rimula:2 ;%;l;ne {grasp-I graduation to a more usn“ku: Eu ,4 -\ \ v 1‘! :g: - - cgﬁu"'crac#3 c r .t “.CE Ha4.3: xu“ « chhriy. 2 z: ‘“"gi;ia:: r, tzarv122d;3, an r31): l éﬁn y‘;rra L) txue to more than -;‘.c;- upnli:ation cm Rucent szudius by Funkeaatein and. rglarlcsshlp Fatwaer the blond p:e>3ure a "aren* L!(11FP:51~ ‘gegt whicb iﬂduces swancpag, and in;:¢n.cd peristalris. 20 minutes. 5 minutés are :lauSLfied as Gtaup 1. .1, 20 or were c ‘JYI .3. 'daczsrs have h.'..~¢‘ax:u.-, ax a 92 Improvemant C’W‘Tiht, the Group ‘,~.. , .._..- V1 sir-.1 GK'C‘J-P charapv, and the Group II—III reactors a 'IIIII-III I: Patients whcsa bleed preséﬁre 'na.r1:#e: zhcsa vF‘ue blaod presecrc zukej 92:13:: 2:. (ha :1: b43313: in.a varlnc;e {ength of time. t;ﬁh.ﬁ$ to [J3 baseline in xrd .L‘ :1J11e3_may hive untrrgvi: [EdQLIUity ‘Ezm 01 '\ Iiﬁ.~it. tigsc 4 if tiaaué ;nclltester85&—E in the ogzuac‘ ctaLentrat on 0‘ chxuu 'hcixn— aid snvgi cf rer"ccs 3t _ _‘ c..". x‘ _ "\c_r..e— ‘ ’P?‘ é ratu with Louvulsive 35% recovery rate reactor: have MW. -......»n.a.cac textzmw a 892 and the Group I‘*'Hal-*mHO‘vw-Iy9ﬁ-’ ' In ,- �ﬁll a: 31., 1952). :e:c"crﬂ rate (Funkensteln 9—“ -Pa7;ean in Fuzkensteln Grcups l to Ill may be looked 972 a ;: Ew;l;ui- :1 "him ET n 'J' m C‘. '1 de Ch: 1716 and VI; V1 upon tad weuhalyl is r2p;dly hYJrolyzed; patients have a-slow hydrolysis rate. predict, therefore, that the blood cholinesterase activity. levels of Grorps I~III w0uld be high; while the activity of Je may Grazps Vl-Vll would be low We recall here a siuular prediction rega:ding the ds:a fur central nervous system levels of cholin-A 11 which u‘rergse~l, the development of early and sustained EEC hyperaynchran) and elevated spinal fluid levels of acetylchclinc relatvd to was a law level of cholinestarase activity, 1. 43"¢ cf 9:11pﬁnral ‘u: V \ u \ . azngtuast 0y 8 cbslincrgic agcntz is the hypotheeib'regarding central nervous sysrvm re? :5 aztivitv :2 :zzm‘;atl>n Thus. a ., ”w“ “a ~c:r.shuix. a A,~‘ ,.-."..( 'c-~ :AJ'L H—-—.- as... ThLG survey of the litarature of the rJlos acetylzholin (f "V .o. :hclinestarase in ccnvﬁlslve therapy has led to a aﬁd speculations which require verification. For number of this purbose. ‘t L Rdgglilhd that an-investlgarion of the ftlivwing relationships :elztlon :c :3Evulslve therapy - type, ,0 J I v o 9 L." I in 14" number and fttquency. .ociated oleczrcencephalogram'partarns. h Relsclcn of such a;eryl:hollne levels to the clinical behavior oi patients. (2) (3) Llaé BE“ Changes in lndices of altered braih function other with Such acetylchcline levels �(L) 'Relaciou of :holinesherase accivity 1:03 serum and splnal and patterns of fluid to: (a) age (b) diagncsis (c) rate at development cf (d) number and frequency of EEG hypersynzhrocy t:eatmehts reactivity (e) autcacmlc (peripheral) reactiﬁity [csrebral (i) if») «g; _pe:sona11ty Rut at" :nLrIL Eshxvic: atropine. 'physcgstigmine adrainistmticn on ’ EC,“ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 2/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/18207735ad5546b08aac89618232e7bc.pdf 66f756c9dd21d0500a4b4e9773773d3e PDF Text Text ��Wm « . . ”1%! W3 l/W W "79"! - duh [cow ~ 4444...; n— wlamaZu-ﬂ nag ‘3 073 /3 W _———_—_é¢%0u_LL__p_J_ 1w... mug: . j” / 3 H4 Ito :98 ��'VfJii MMud‘vue I7M¢2+ ? la Mal. .max Q ,4”; . 9:19 M00 4/73 ,“ K We; /a¢/If ,, (14.2...e‘23m,“ L DF/Wdﬁ ﬂan" 714 - “7‘ 44.4.5 44W r M , %W(“ W77 27/56:.) xéa/av-p 2/3“; 413»; Ma... 7w,» #1W 1‘ I; a.“ me: ‘M‘M w 4‘ 7‘ WWW/3,1:I/7 w»! AWL—«awe; CK’S") mm) M �7 7 4%? % ,4» 014/.- a‘,‘” __n ”ViV W ,, (A. 2‘ MW "5 11M; r W ��‘ WMA (“Av/Jaw AJa—lnw.m.5¢nﬁ¢ ��M Wf - I7 ‘70 [Lav/2.». 5’52 31 ,9: d3: ��ﬁbrw Dr? ' D.- £44415" Iv ~43 VP-’YV MED-thaw Masha“. -6” 'DFP- m 51am JV 1 ‘ ��\ \-_' <f/ e4 AM (3 ��73/4 r 4/»! / 4? ��" ,; . “A; 7 m 7V ��Ph. i74800 MECHOIYI® CHLORIDE (METHACHOLINE CHLORIDE U.S.P., MERCK) a SHARP DOHME MECHOLYL* Chloride produces the same physiologic response as does acetylcholine, which, when released at nerve endings, produces parasympathetic stimulation. In therapeutic doses, MECHOLYL slows the heart rate, lowers blood pressure, constricts the bronchioles, dilates the peripheral blood vessels, constricts the pupils, Increases intestinal tone and peristalsis, causes salivation and ﬂushing, and stimulates the detrusor muscle of the bladder. In general its eﬁects are the opposite of those produced by epinephrine. Its action is much more prolonged than that of acetylcholine and it is, moreover, devoid of the nicotine-like effect of that substance. METHODS OF ADMINISTRATION MECHOLYL Chloride is a potent substance and careful consideration should be given to Its dosage and method of administration. For *MECHOLYL is the registered trade-mark of MERCK & CO., Inc., for its brand of methacholine. [i] stopping an attack of paroxysmal auricular tachycardia it should be given by subcutaneous iniection (never by intravenous or intramuscular injection), and the same method of administration may be used in treating scleroderma, chronic ulcers, Raynaud's disease and other vasospastic states, although in the latter conditions better and more prolonged eﬁects are obtained when it is administered by the method of ion transfer For administration by mouth (iontophoresis). the less hygroscopic MECHOLYL Bromide is supplied in tablet form. Atropine intravenously immediately terminates the action of MECHOLYL. A syringe containing a suitable dose of atropine sulfate [0.6 milligram (l/iOO grainI] should be available for immediate intravenous iniection if the dose of MECHOLYL Chloride causes undesirable symp- MECHOLYL Chloride is supplied in ampuls Since MECHOLYL constricts the bronchioles containing 25 milligrams (0.025 gram) of the powder. Solutions for subcutaneous iniection are prepared by dissolving the drug in sufﬁcient sterile distilled water to make it possible to measure accurately and administer easily the dosage desired. WARNING Injections of MECHOLYL Chloride should be given subcutaneously only. lniections should never be given in- travenously or intramuscularly. PRECAUTIONS The patient should be lying down during the administration of MECHOLYL Chloride to minimize the effects of lowered blood pressure. [2] toms. Overdosage of MECHOLYL may produce momentary cardiac arrest. The Trendelenburg position, to give the cardiac center the beneﬁt of any circulation present, is sometimes beneﬁcial in such an emergency. and may produce an asthmatic attack in those subiect to this condition, it should be used with extreme caution, if at all, in cases where there is a history of asthma or hypersensitivity. Substernal pain following the administration of MECHOLYL is said to be rare. However, the use of this drug in patients subiect to angina pectoris is not recommended. USE IN PAROXYSMAL AURICULAR TACHYCARDIA One of the most efﬁcacious uses of MECHOLYL Chloride is in terminating attacks of paroxysmal auricular tachycardia. It is, however, not effective for prophylaxis or for continued treatment in cases of frequent recurrence of the arrhythmia. [3] �not recommended for the treatment of auricular fibrillation, auricular ﬂutter, or paroxysmal ventricular tachycardia. It is DOSAGE The initial subcutaneous dose of MECHOLYL Chloride should be limited to IO milligrams (0.01 gram) to test the patient's tolerance. Careful preliminary testing of the patient with a small dose will not nullify the effect of a subsequent dose, and is advisable if there is any doubt of the patient's ability to tolerate the drug. treating paroxysmal auricular tachycardia in patients under twenty years of age, IO milligrams given subcutaneously usually terminates an attack. In older patients, 20 to 40 milligrams may be required; obese patients sometimes require more. In Slow absorption of the drug due to inadequate local circulation may interfere with the therapeutic response. If the attack is not terminated in two minutes, compression of the vagi, together with gentle massage at the site of iniection to promote absorption, is suggested. Conversely, if absorption is found to be too rapid, further absorption may be retarded by applying a tourniquet above the site of iniection. The eﬁects of MECHOLYL may be terminated immediately by atropine. [4] and larger dose (if that given ﬁrst fails to interrupt the attack) may be given 20 to 30 minutes later, providing no severe reaction has occurred following the ﬁrst dose. Quinidine in moderate doses (not more than 0.2 gram four times a day) usually does not impair the MECHOLYL effect. Larger doses tend to inhibit its action, although MECHOLYL has been known to “break through" the depresr slon of quinidine. 174800 For oral administration or administration by the method of ion transfer (iontophoresls)—Ph. A second I Gm. bottles. 10 Gm. bottles. MECHOLYL BROMIDE (for oral administration only) is supplied in Boxes of 24—200 mg. (0.2 Gm.) tablets Bottles of 500—200 mg. (0.2 Gm.) tablets OTHER USES OF MECHOLYL CHLORIDE been used (by suba number of other condi- MECHOLYL Chloride has cutaneous iniection) in tions, particularly in certain vasospastic diseases, such as Raynaud’s disease, in chronic ulcers, and in scleroderma. If a test dose of IO milligrams of MECHOLYL Chloride has been well tolerated, the subsequent dose may be increased cautiously up to 25 milligrams (0.025 gram). In these conditions, however, the much more prolonged eﬁect produced by MECHOLYL Chloride administration by the method of Iontophoresis (ion transfer) or by the oral administration of MECHOLYL Bromide Tablets is preferred. MECHOLYL CHLORIDE is supplied ,snm DOHME SHARP 8: DOHME as follows: Philadelphia, U. S. A. For subcutaneous iniection— DIVISION OF MERCK a: CO. Inc. Boxes of 6 ampuls each containing 25 mg. (0.025 Gm.) of the dry powder. I 5 I P- IB-413 [6] Printed in U.S.A. �For the Medical Profession only ‘ANECTINE’® CHLO RIDE BRAND SUCCINYLCHOLINE CHLORIDE INJECTION 20 mg. in each cc. Multiple-dose vials of IO cc. (for intravenous use) ; n’l ' ix, use 'v 6’ ‘ " ' e .,'alysis. While respiratory depression is usually a r single dose of the drug, or following ’M‘uV-r-mtous administration, cessamore prolonged respiratory there may on occasion be depresoion requiring adequate respiratory exgen by the administration of supplemental or controlled . - -. . ‘ANECTIN E’ Chloride brand Succinylcholine Chloride Injection is an ultra-shortactmg skeletal muscle relaxant; that is, following intravenous injection of small procedures. The quick return of spontaneous respiration is a deﬁnite For more prolonged relaxation advantage. ‘ANECTINE’ may be given by continuous intravenous drip; tachyphylaxis does occur and cumulative action is not seen. The degree of relaxation not be ordinarily may controlled by the solution. Upon stopping the intravenous drip, adjusting the rate of ﬂow of narily resumes within a minute and spontaneous respiration ordirecovery is complete within 5 minutes. CHEMICAL PROPERTIES Succinylcholine chloride, also to as diacetylcholine chloride, is odorless, crystalline substance referred a white, which'is readily soluble in succmic acid bis (ﬂ-dimethyl—aminoe‘thyl) water. Chemically it is ester dimethochloride, and its formula is as follows: i ' ' ’ Cl CH2COOCH2CH2iV(CHa)3 CH2COOCH2€H2N(CH3)3 :I'he ester linkage is rapidly hydrolyzed in alkaline solutions but is in acrd solutions. In order to relatively stable promote stability, solutions should be refrigeration. It appears that succinylcholme is rapidly hydrolyzed kept-under followmg its PHARMACOLOGICAL ACTION ‘ANECTINE’ causes muscular transmission at the myoneural paralysis by producing a blockage of nervous junction.This action was ﬁrst reported et al.1 Independent studies by Bovet The at Wellcome Research Laboratories have been conducted on the synthesis2 and pharmacology“7 of the drug. de Beer and his associates3-7 have found that doses as low as 0.05 mg./Kg. given cats are effective in producing intravenously to muscular relaxation, and that intravenous doses of 0.1 mg./Kg. or more produce and complete muscular characterized by short durationprompt paralysis which is of and action extremely rapid recovery. Repeated injections produce reproducible and phylaxls nor signiﬁcant cumulative predictable muscular paralysis, neither tachyeffects being seen. When given by intravenous drip, a predetermined degree (scratic of relaxation in a cat nerve-gastrocnemius muscle) could be closely approxrmated by adjusting �The administration of doses of ‘ANECTINE’ sufﬁcient to produce complete neuromuscular blockade has not caused any signiﬁcant. ghange in blood pressure (except for the typical asphyxial pressor response in the absence of adequate respiration). No,evidence of any histamine-like depressor action has been found, thus differing from observations with d-tubocurarine. The ECG of the caﬁ was unchanged during a 2-hour infusion maintaining complete paralysis. ' ‘ ‘ Acute toxicity studies in albino mice showed the intravenous L.D.5o to be 0.55 to 0.59 mg./Kg. Complete paralysis resulted, with marked dySpnea and anoxia; death was apparently due to respiratory failure. Those mice which survived the initial symptoms exhibited disappearance of anoxia and dyspnea in 2 minutes and had completely recovered within 30. minutes. Chronic toxicity studies on albino rats showed that the intraperitoneal injection of -1' mg./Kg. or less, twice daily over a period of 4 weeks, produced no evidence of toxicity. important.diﬂ‘erence‘between ‘ANECTINE” and d-tubocurarine is that the former is not antagonized by anticholineste'rases. On the comrhlti’, 5.14.911 drugs as physostigmine, lThis rostigmine (neostigmine) and procaineaapnoli‘asgmthg 5;th 1:8 :11 would support the theory that syuccinylcholine'is hydrogze succinylcholine. by cholinesterases and that interference with this enzyme actiOn results in per- -. sistence of activity of the drug. Edrophonium (Tensilon) also prolongs the action of succinylchohne. An- ' ,. ' CLINICAL INDICATIONSUKNI) DOSAGE ‘ 1 Short Duration: ‘ANECTINE' Chloride brand Succinylcholine Chloride Injection is indicated for the production of muscle relaxation during surgical procedures, 3,9,13il5-17 and in conjunction with electroshock therapy.13,14,16 In view of its very short duration of action (usually about 3 minutes following a single intravenous injection) succinylcholine is ideally suited for procedures ;requiring 'only brief relaxation, .such as endotracheal intubation, endoscopic examinations, orthopedic manipulations, short surgicalvprocedures such as tonsillectomies, and electroshock therapy. As described previously, intravenous administration of the drug produces relaxation within a minute, which lasts about 3 minutes and is quickly followed by recovery of spontaneous respiration in those cases where apnea hasoccurred. Dosage for. Short Procedures: The average dose for’relaxation of short duration is 20 mg. (1"cc.) ‘ANECTI‘NE’ Injection given intravenously (Foldess)... The optimum'doSe will vary among individuals and may vary from =10 to 30 mg." for adults (0.5 to 1.5 cc.). Following administration of doses in this range, relaxation develops in about 1 minute; maximum muscular paralysis may persist for about 2 minutes, after which recovery rapidly takes place within the next few minutes. However, very large doses may result in more prolonged apnea. ”-21 Obviously, facilities for supplemental or controlled respiration with ,adequate exchangeoi oXygen should be available at all times. In order. to'avoid carbon dioxide accumulation and hypoxia, supplemental or controlled respirationgshould b? provided during respiratory depression without waiting for the development 0 apnea.. , Prolonged Relaxation: Although ‘ANECTINE’ isfshort—acting, prolonged relaxation may be obtained by repeated injections or, preferably, by maintaininga continuous intravenous drip.8,3o By adjusting. the rate of ﬂow, the desired degree of relaxation may be obtained and maint‘air‘ie'd‘, and the degree of relaxation can be changed within 30 seconds by changing the rate of ﬂow. Upon stopping the ﬂow of the intravenous drip solution, relaxation. quickly disappears. In those cases where respiration has been depressed it usually returns to normal_within a. few minutes upon stopping the intravenous drip, V. Dosage for Long Procedures: The-'aVerage dose for continuous intravenous infui‘ sion is 2.5 mg. per minute for adult patients. For convenience'in preparingsolutions for intravenous drip there are available ‘Anectine’ Chloride Solution, 50 mg. per cc., 10 cc. ampuls and 100 mg. per cc., 10 cc. ampuls. The, contents of one 500 in mg. 10 cc. ampul may be added to SOD-ecstetileiisotonic saline solution to an prepare (1 0.1% mg. per cc.) ‘Anectine’ Chloride Solution; the contents of one 1 Gm. in ’0 cc. ainpul‘maybe added to 1,000 cc. to prepare an 0.1% ‘Anectine" Chloride Solution. This concentration is suitable for continuous intravenous infusion, See literature accompanying ‘A‘u‘ectine' Chloride Solution,’5_0fn‘1g./cc., 10 cc. ampuls, and 100 mg:‘]cc.,«10 c‘c‘. animals for details regarding use of'r'this‘product for obtaining ' ' r‘elaxatiOn. Solutions for prolonged intravenous drip jay also be‘ prepared. for a dilution of‘An‘e’ctine’ Injection, 20 mg./cc. in appioprrate proportions. ‘ NOTE: Succinylcholine is rapidly hydrolyzed by alkaline'solutions and therefore loses potency rapidly. it mixed with thiopental sodium (pentot‘hal sddium). Such mixtures, if used at all, must be used within a few minutes ofvprepatationq however, separate injection of ‘ANECTINE’ is preferable. Succinylcholine chloride is quite stable when storedqunder refrigeration. 0n long standing at room temperature potency gradually decreases; however; solutions may be kept as long as 3 months at room, temperature without signiﬁcant loss of potency as determined by biological assay. , , ' !~- ‘ �.m . . CONTRAINDICATIONS AND PRECAUTIONS The drug should be used only by those skilled in‘ the administration of sppplemental *oecontrolled. respiration and facilities for this procedure, including adequate respiratory exchange with oxygen, should always be immediately .. available. “'V ' 'ANECTINE’lis not an anesthetic agent and should not be regarded as a substitute for anesthesia; 'its‘Ause“ does not take the place of givmg an adequate amount of anesthetic agent. Some anesthesiologists believe that rapid injection is responsible for the muscular twitching that is seen just prior to relaxation. These fascrculations may be due to the‘rate’of injection of the drug, and may be minimized or avoided ‘by giving the injection more slowly/,8,”8 While respiratory depression is usually of very short duration following a 'single dose of the drug, d" following cessation of continuous intravenous administration, ‘LiiCl‘C may‘e..-.§ribcc{i.iongespeaially with excessive doses, more prolonged respiratory depression 1.9-2]- requiririg controlled respiration and the administration of oxygen. The duration of the effect of ‘ANECTINE’ may depend on plasma-cholinesterase activity.94,2°,27 Patients’with severe'liver disease, severe anemia, severe malnutrition, and possibly those suffering from' polyphosphate insecticide poisoning may have a decreased plasma-cholinesterase activity which may intensify and prolong the action of ‘ANECTINE’, especially if large'doses are used.23,29 In such cases, in addition to the usual measures of controlled respiration and administration of oxygen, it may be desirable to administer plasma or whole blood for the purpose of restoring cholinesterase activity,” Neostigmine and other anticholine’sterases, as well as edrophonium (Tensilon), do not antagonize the action ,of~‘ANECTINE’, but on the prolong its contrary eﬁ'ect. They are therefore contraindicated as antidotes for ‘ANECTINE’. Intravenous injections of proCaiiie likewise may prolong and intensify the action of ‘ANECTINE’. There is evidence that intraocular pressure is increased slightly following injection of ‘Anectineflﬂ “This effect is seen immediately after the injection and during the fasciculatory phase; it' subsides as complete paralysis supervenes; it appears to be the result of brief contraction of the extraocular muscles. This suggests that ‘Anectine’ should ’be usedl‘with caution, if at all, in intraocular surgery. The opinion is expressed that the effect is probably not sufﬁcient to contraindicate the drug in general, surgery or electroshock therapy for patients with "' glaucoma. ‘ r‘ .- .KBIBIZIOGRAPHY 1. 2. Bovet, D., Bovet—Nittl, F., Guarino, 3., Longo, V.G., and Marotta, M.: Pharmacodynamical property of certain derivatives of suc’cin'ylcholine with curate-like action: esters of trialkylethanolamine of dicarboxylie aliphatic acids. Rendieonti Istituto Superiore di Sanita 12:106, 1949. Phillips, A.P.: Synthetic curate substitutes from aliphatic dicarboxylic acid aminoethyl esters. J. Am. Chem. Soc. 71:3264, 1949. Castillo, J.C., and de Beer, E.J.: Poteii‘tiationbl' curarizing action of diacetylcholine (succin lcholine) by aliphatic dicarboxylic acid aminoethyl amides. Federation Proceedings 9:262, 19 0. Castillo, J.C. and de Beer, E.J.:_The neuromuscular blocking action of succinylcholine (diacetylcholine). J. Pharmacol. 6: Exper. Therap. 99:458, 1950; de Beer, E.J., Castillo, J.C.,1.Phillips, A.P.,3Fanelli, R.V., Wnuck, A.L., and Norton, S.: Synthetic drugs inﬂuencing neuromuscular activity. Ann. New York Acad. Sci. 541362, 1951. Wnuck, A.L., Norton, 5., Ellis, C.H;, and- de Beer, E.J.: Production of controlled neuromuscular block by infusion of diacetylcholine. Federation Proceedings 11:403, 1952. Ellis, C.H., Norton, 3., and Morgan, W.V.: Central depression by drugs which block neuromuscular transmission. Federation Proceedings “11:42, 1952. Foldes, F.F., and McNall, P.G.: Succinylchélinei A new’a‘ppréach to muscular relaxation in anesthesiology. New England J. Med. 247596, 1952. Brucke, H., Ginzel, K.H., Klupp, H., Piaffenschlager, F., andWerner, 6.: Muscle relaxing effect: of bis'echoline e'sterof dicarboxylic‘acid in narcosis. Wien. klin. Wchnschi‘. 63 :464, 1951. Ginaiel, K.H., .Klupp,.H.,; and Werner, G.: Pharmacology of ”bis—quaternary Yammonium a, compounds. Comparative tests withisome aliphatic dicarboxylic acid esters. Arch. int. Pharmacodyn. and Therapy. 87:79, 1951. 7Gi'7nzzei,9§(l‘.H, Klupp, H., and Werner, G.: A‘dicholine ester with greater curare effect. Experentia . a. Arnold,‘0.H., Bock-Greissau, W., and Ginzel, K.H.: Wien. med. Wchnschr. 101:492, 1951. Thesleﬁ‘, S.; Pharmacological and clinical tests with LT 1. (0.0—succinylcholine iodide). Nordiak ’ Med. 46:1045, 1951. Holmberg, G., and Thesleff, S.: Succinylcholine iodide as a muscle relaxant in electro—shock treatment. Nordisk Med. 4621567, 19SL‘Abst. in J.A.M.A. 14821064, 1952. Dardel, 0.37., and Thesleﬁ, 8.: Clinical results with succinylcholine iodide, a new muscle relaxant. Nordisk Med.‘46:1308. 1951. Thesleﬁ‘, 5., and Dardel, O.V.:'Clinical report on succinylcholine iodide. Presented at 26th International Congress of Anaesthetists, London, September 3—7, 1951. Abstracted in J. Am. MJWom. Assn. 7:58, 1952. " 3. 4. 5. 6. 7. 8. 9.' 10. 11. : 12. 13. . - , ‘ 14. 15. ‘ 16. ~ ' �I7. Mayrhofer, 0., and Hassfurter, M.: Surgical risks in patients with cardiac and vascular disorder. Wien. klin. Wchnschr. 63:88.5, 1951. 18. Holzer, 1-1.: Wien. med. Wchnschr. 102:112, 1952. 19. {IggerfgIséKd Prolonged respiratory paralysis after succinylcholine. Correspondence. Brit. MJ. 20. Love, S.H.S.: Prolonged apnea following scoline. Correspondence. Anesthesia (London) 7:113, 1952. 21. Gould, R.B.: Succinylcholine. Correspondence. Brit. MJ. 1:440, 1952. 22. Bovet, D., Bovet—Nitti, E, Guarino, S., Longo, V.G., and Fusco, R.: Investigations on synthetic 23. 24. 25. 26. 27. 28. 29. 30. 31. curarizing drugs. III. Succinylcholine and its aliphatic derivatives. Arch. int. Pharmacodyn. and Therapy 88:1, 1951. Poulsen, H. and Hougs, W.: Letters to the Editor, Lancet 2:199, 1952. Foldes, F.F.: Letters to the Editor, Lancet 2:245, 1952. Kay, H.T.: Letters to the Editor, Lancet 2:200, 1952. Evans, F.T., Gray, P.W.S., Lehmann, 1-1., and Silk, E.: Sensitivity to Succinylcholine in Relation to Serum-cholinesterase, Lancet 1:17.29, 1952. Bourne, J.G., Collier, H.O.J., and Somers, G.E-:ASuccinyIchoIine (Succinoylcholine)—MuscIe »S[« Relaxant of Short Action, Lancet 1'§2.£5, 1952. Lehmann, 1-1.: Letters to the Editor, Lancet 2:199, 1952. Hampton, L.J.: Personal communication. .L . ,r .:l Diacétiyilchdlihe I" and Little. M., Jr , Hampton, L.]., Grosskreutz, D.C.'. (Succin’yIcIroIine): A Controllable Mu'scIe Rel’axant. Presented before the Twenty-seventh Annual Cpnzress of Anes‘ ” ‘h thetistSyVirginia Beach, Virginia, Septemher 22-15,..1952. " " ‘1 ' Lincoff, H.A., Ellis, C.H., DeVoe, A.G., de Beer, E.J., Impastato, D._I., Berg, 5., Orkin, L., and Magda, 1-1.: The EEect of Succinylcholine on Intraocular Pressure. Am. J. Opth. 40:501,1955. — PREPARATION FOR IMMEDIATE INJECTION OF SINGLE DOSES FOR SHORT PROCEDURES ‘ANECTINE’ CH LORIDE mo SUCCINYLCHOLINE CHLORIDE INJECTION 20 mg. in each cc. multiple-dose vial: of IO cc. For intravenous i'nieetion V Also available: FOR PREPARATION OF INTRAVENOUS DRIP SOLUTIONS ONLY ‘ANE CTINE ’ C H LO R I D E m SUCCINYLCHOLINE CHLORIDE STERILE SOLUTION 50 mg. in each cc. IO cc. ampuls (Total contents 500 mg. Succinylcholine Chlorlde) To be diluted before using FOR PREPARATION OF INTRAVENOUS DRIP SOLUTIONS ONLY HIGH POTENCY ‘A N E C T I N E ’0 CHLORIDE SUCCINYLCHOLINE CHLORIDE STERILE SOLUTION 100 mg. in each cc. 10 cc. ampuls (Total contents I Gm. SuccinyIchoIine Chloride) To be diluted before using ‘Aneetine’ Injection is supplied in the form of a sterile isotonic aqueous .rolution. ImtoniCity 15' achieved by the addition of a :uitable quantity of sodium chloride. \\ .” p,“ BURROUGHS WELLCOME & CO. (U.S.A.) INC.,TUCKAHOE, N.Y. Associated Houses: LONDON BOMBAY by 731 MONTREAL BUENOS AIRES Printed in u.s.A. SYDNEY CAIRO JOHANNESBURG DUBLIN AUCKLAND 41 I o o 6 �Poloni, A.: L'Acetilcolina nel liquor dei malati di mente. Hancenze di effetto curarosimile del liquor di echizophrenici sul mnecolo acetilcolina e en dorsale dell: saga, I1 Gervello g1: 81-1oh, 1951. Translation of EEEEEEE‘ author, using the method of Tower for the conservation of acetylcholine in spinal fluid, and the dorsal muscle of the leech for the test, has made the fol» lowing observations in several trials, making use of the spinal fluid of 10 normal subjects and 110 mental patients, of whom 50 were schizophrenics, 10 progressive paralytica and 50 subjects with other forms of mental disease: The (1) That the spinal fluid of normalaubjects cistains acetylcholine in a to 1:1G' concentration varying from 1:1 (2) That the spinal fluid or schiaophrenice in 9h$ of the case: does not contain ecetyloholine bet a substance which produces an action antagoMstic to acetglgholine, 7; weble to that of ”curare", in a concentration of 1:1 to 1:1' .... (3) In the spinal fluid‘of the progressive paralytic: one encounters the some curare-like subetance nut in a lower concentration than in that of schizophrenics. (h) The spinal fluid of persons affected with other forms of mental sick— ness, as well as that of normal subjects, did not contain the curerelike substance in a discernible quantity, but only acetylchcline, which was found in greater concentration in the hystericale and epileptice, in lower concentration in senile psychotics and alcoholics. This emphasizes the pathologic vale of the report obtained from the spinal fluid of schizophrenics and progressive parelytics and suggests the hypothesis that the curare-like substance is trimethylamine, product of the excessive catabol~ ion of choline, of which the author has found an abnormal urinary excretion in schizophrenics; (In the some paper, in a footnote, the author eliminates trimethylamine, since does not have aurora-like properties.) it �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY Max Fink, M'.D. �\ From ‘ the Department of Psychiatry, Washington University School of Medicine and the Department of Psychiatry at the Missouri Institute of Psychiatry, University of Missouri School of Medicine, SUOO Arsenal St., St. Louis, Missouri 63139. MH-072u9 and MH—2715, MH—927, grants part, IVE-11380; and the Psychiatric Research Fomdation of Missouri. Aided, in IX: 65-8 2-25-66 by USPHS Revised for the Jowmal. 06 vaouA and Manta! Disease. �CHOLINERGIC ASPECTS OF CONVULSIVE THERAPY While the mode of action of convulsive therapies remains enigmatic, one theory holds that the early development and persistence of changes in brain function are requisite to changes in behavior.“3’21,22 useful index of neurophysiological change is the appearance of high voltage electroencephalographic slow wave activity.22 '23 While the biochemistry of this activity is A poorly understood, demonstrations that it is inhibited by anticholinergic corrxpoundsl9920’3""56 suggest that cholinergic systems may play an active part. The EEG patterns and the response to anticholinergic drugs in convulsive therapy are similar to experimental and clinical head trauma and to a lesser extent, to spontaneous seizures. impulses has been extensively studied since the early descriptions by Dale12 and Loewi.38 A constituent of nervous tissue in a acetylcroline is liberated during the excitation process. It is rapidly hydrolyzed through the mediation of aoetylcholinesterase and is rapidly reconstituted by the bound form, �choline—acetylase system.‘+5 Free acetylcholine has not been measurable in normal cerebrospinal fluid despite the rapid breakdom of bound acetylcholine during periods of activity and excitement.63 But the normal have measurable cholinesterase cerebrospinal fluid does activity.“1 ChoLéneILgic Mme/ta 06 CILanLoce/Lebm mena. Free acetylcholine was found in the cerebrospinal fluid of cats within a few minutes after experimental head trauma and persisted for varying periods up to 1+8 hours. The quantity of free acetylcholine varied between 2.7 and 9.0 gamma/ 100cc and the amount was related to the degree of induced trauma.6 Concurrent electroencephalogram first demonstrated high voltage fast activity, interpreted as evidence of an intense neuronal discharge, which was succeeded by-a short period of flattening of all recorded electrical activity. These phases were followed by prolonged periods of high amplitude sharp waves in the delta frequencies. The behavioral changes related to the degree of induced trauma and to the amount of measured free acetylcholine. With higher levels of acetylcholine, Bornstein reported greater degrees of EEG abnormality and greater changes in consciousness. Spontaneous post-traumatic seizures were also amount related to the of free acetylcholine measured in the cerebrospinal fluid. �Bornstein applied acetylcholine to exposed cat cerebral cortex. When the concentration of acetylcholine was or less, high amplitude sharp the electroencephalogram. to 2 waves When of low frequency appeared in the concentration gamma/100cc, the electroencephalogram parallel to the post-traumatic records. Investigations in neurological patients McEachern demonstrated 1 gamma/10000 was increased flattened in a fashion by Tower and free acetylcholine in the cerebro- spinal fluid only in patients with recent head trauma, recent grand—Hal seizures or after electroconvulsive therapy.63 Free acetylcholine varied from 0.2 to 100 gamma/ 100cc. In assaying spinal fluid cholinesterase activity, they noted a sharp rise in the butyrylcholinesterase fraction and a fall in the acetylcholinesterase fraction in patients with head trauma and following convulsive therapy. however, the cerebrospinal although it ' After spontaneous seizures, fluid did not exhibit such inversion contained free acetylcholine. They concluded that the level of free acetylcholine varied directly with the degree of cerebral damage and that reversal of cholinesterase fractions was a more sensitive indicator of cerebral damage. Electroencephalograms taken at varying intervals following trauma also indicated a relation between the degree of EEG abnormality and the appearance of free acetylcholine in the cerebrospinal fluid. �Increased acetylcholine in rat brain after traumatic shock was also reported by Kbvach, at a£.35 This acetylcholine activity vitae. was inhibited by the administration of atropine tn electrographic, behavioral and neurologic signs of head trauma were blocked by the parenteral administration of The atropine, as were similar clinical changes occurring after the intracisternal addition of acetylcholine.6 0.5—1.0 mg/kg applied these observations to the treatnent of closed head injuries. In 20 patients with varying degrees of trauma, he administered atropine subcutaneously in doses of 0 .1 mg/kg, Ward noting clinical improvement in some and electrographic effects in others.67 a reversal of the The same changes in the' .*-‘_ post-traumatic electroencephalogram were reported by Jenkner and Lechner in a study of diethazine, another anticholinergic single intravenous dose in forty patients resulted in nornalizing the abnormal electroencephalogram in twenty—two drug. A and marked improvement in six others.33 Similarly, in experiments of post—traumatic shock and cerebral edema in animals, Denisenko reported a blocking of the clinical changes by such anticholinergic compounds as methylbenactyzine and adiphenine (Trasentin).13 ThuA, the amount 06 Mae acetytchloune may tamed/52 éptnat ﬂuid 60110“)th cmtnocuebaat mama and the tn the, amount 06 - ‘ -A,‘r �ghee acety£cho£ine, the degnee and type 05 e£ecthoencepha£nghaphie in carded/C behavion abnolzmablty, and changed phenomena, which may be deduced by appear/L aA the adminibtnation Lute/mutated anti- 06 chounugie daugb. Bluuln acetylchoﬂéne and antéehounugic dhugb. The effects of the direct application of acetylcholine to the central nervous system may also be blocked by anticholinergic drugs. The administration of the cholinesterase inhibitor di—isopropyl fluorophysphate (DFP) elicited high amplitude rapid frequency patterns similar to status epilepticus and some posttraumatic states.2'*’31a32a68 These EEG effects were blocked by small doses of parenteral atropine and scopolamine. The' EEG geat increase in acetylcholine after tetraethyl (TEPP) was measured and pyrophosphate related to the toxic effects and the induced convulsions .29 ’59 Chatfield and Dempsey prepared exposed animal cortex with prestigmine and evoked electroencephalographic spike activity. prior administration of atropine blocked the appearance of spiking, or if present, this electrical activity could be The eliminated by atropine.9 In contrast to these findings, Brenner and Merritt applied topical acetylcholine in concentrations of 2—1/2 to 1096 to the exposed cortex of cats and noted no effect. on the electro— encephalographic changes after intravenous atropine (1 mg/kg) .7 �The concentrations of acetylcholine in these experdnents, however, were higher than the topical applications (1-H gamma/1000c) and the intracisternal (0.2-10 gamma/10000) injections of Bornstein.6 Brenner and Merritt also noted electroencephalographic effects similar to acetylcholine after methacholine (Mecholyl) and carbamylcholine (Doryl) in concentrations much lower than the acetylcholine concentrations. They ascribed the increased effectiveness of these cholinergic drugs to their lack of sensitivity to cerebral cholinesterases. 6mm Atady a necuAa/Lg Ceaebao¢pina£ Fluid Acetyﬁchoﬁine and Seizuneb. One view Thug data M9, conﬁuwxg and to quaiiﬁy thié iAAue. of acetylcholine metabolism finds it in nervous tissues in an inactive and bound form. During periods of activity, acetylcholine is liberated at the cell membrane where it is rapidly deactivated by cholinesterases. The amount of bound acetylcholine is the resultant of the continuous processes of synthesis, liberation 'u and breakdown.15 It has been postulated that the level rises falls during waking activity.15’29’“5’6° at al. reported increased free and total acetylcholine during sleep and Tbbias after chlorofornland pentobarbital anesthesia in rat and frog brain but no changes after strychnine or picrotoxin convulsions.5° �(microacetylcholine of level the neasured Richter and Crossland in and rat sleep anesthesia during tissue) brain gamma per mg. brain to be 300% The difference levels. post—seizure than higher rate resynthesis the as however, transient, in tissue levels is gamma/gm/minute).“5 (7 high is brain in rat for acetylcholine Crossland a£.16 and at Elliott confirmed by These observations were and Merrick.11 Giarman and Pepeu reported the increase in be roughly to various depressants following acetylcholine nervous central the of of depression the degree proportional to Buck, and Maynert activity.29 motor in system and the reduction sedation during levels acetylcholine brain however, studying elevated with associated were sedatives concluded that some existed.39 relationships rigorous brain acetylcholine but that no of. observations In part, this may be related to the earlier in measured synthesis acetylcholine McLennan and Elliott that narcotic of low dosages by accelerated rat brain slices is dosages.”° by-high inhibited but drugs, in fluid the in spinal Free acetylcholine was reported an patients, epileptic patients with epilepsy.1°’63 5.0 0.02 to of in quantities demonstrated free acetylcholine Of 56 Acetylcholine gamma/100cc. 1.0 of with an average gamma/100cc extent the seizures, of the frequency to related levels were since time the and to abnormality, of electroencephalographic �the last seizure but bore no relation to medication, type of epilepsy or level of cholinesterase activity. Elliott at al. also noted free acetylcholine in the spinal fluid in concentrations up to 3 gamma/100cc after pentylenetetrazol (Metrazol) convulsions.16 Tower and McEachern viewed the increased acetylcholine as a by—product of the seizure and not causal.63 Studying the hypothesis that seizures were induced by the accumulation of acetylcholine, Tbrda neasured the level of acetylcholine in brain tissue after pentylenetetrazol convulsions. She noted a rise in the acetylcholine content of brain before and a fall during the convulsion. Below certain levels of acetylcholine, convulsions failed to occur. She suggested that the fall in . tissue acetylcholine during a convulsion was due to the inhibition of acetylcholine synthesis by increased concentra-’ tions of metabolites such as annenium ions.51:62 Giarnen and Pepeu also measured changes in central nervous system acetylcholine following various stimulants.29 Only after nethacholine and 3, 5—dimethylbutylethyl-barbiturate was there a significant change in the acetylcholine level. They noted a decrease in association with induced convulsions. With other drugs which they classified as stimulants (LSD, iproniazid, iproniazid + hydroxytryptophan, and iproniazid were no changes in the acetylcholine level. + DOPA) there They concluded that �despite intense excitation produced by these compounds, there were no changes in acetylcholine levels unless these were accompanied by convulsions. (The between these observers and Cone may be differences in observations at at. related to the differences in measurenents, fOr the latter and Tower and McEachern methods measured changes of biochemical reflecting free acetylcholine only, while Giarman and Pepeu measured total acetylcholine including bound and free forns of acetylcholine.“°). Thane btudieb Auggebt that aae accompanied by an tncteaee tibeaated 6aom tté Apontaneoub on tnduced 4etzune¢ tn tnteaeettutaa ﬁnee aeetytchottne bound ﬁonm whtch may be aeﬁteeted tn the Aptnat staid. Ceaebnat activity and eetzuneé enhance aeetytehottne deatAuction, toweatng txnbue teveZA 06 aeetytehottne, white eteep and anebthebta augment aeetytehatine paoduetion ineaeaetng ttbbue tavetb. ' Centaat Menuoue SyAtem Cholineeteaaeee. Tower and McBachern also measured spinal fluid cholinesterase activity.63’5“’65 By reporting cholinesterase activity as a ratio of the rate of hydrolysis with two substrates compared to an acetylcholine substrate, acetylcholinesterase/acetylcholine and butyrylcholinesterase/ acetylcholine ratios are derived. Normal cerebrospinal fluid contains these esterases in the ratio of 33:17. �-10In patients with head trauma, Tower and MCEachern reported an inversion of the cholinesterases with an increase in the butyrylcholinesterase of the spinal fluid and a decrease in acetylcholinesterase activity. The extent of the cholinesterase related to the severity of trauma and to the degree abnormality. A similar reversal was observed in patients reversal of EEG was undergoing convulsive therapy. In patients with elevated spinal fluid acetylcholine spontaneous seizures, however, no change in the after ratio of cholinesterases or total cholinesterase activity was found. Changes in cholinesterase activity may be related to changes in cell membrane permeability. Acetylcholinesterase is found in highest concentration in the central nervous system while butyrylcholinesterase predominates in other tissues, especially blood serum. With increased cerebral acetylcholine, vasodilation predicted, with vascular fluid transudation varying with the extent and duration of the vasodilation.35 Spiegel, Spiegel—Adolf, and their and increased cellular perneability may be co-workers demonstrated such perneability changes and increased conductivity of the tissues associated with the appearance of various ions (as potassium and phosphate) in the spinal fluid following electrically induced convulsions.5"'58 electrolytes as nucleic-acid splitting enzymes Such non- also increased. �-11- Changes in cellular permeability may be the basis for the high concentrations of acetylcholine and increased concentrations of butyrylcholinesterase after induced seizures or head trauma.65 That changes in cholinesterases may be large and measurable is suggested tte recent demonstrations that neural stimulation by and learning produces changes in brain weight and acetylcholinesterase reports, Pryor and Otis studied the effects of repeated induced seizures in Wistar rats.“3 After Following these activity.37’“9 as little as u weeks they observed increases in brain weight and in acetylcholinesterase activity which was related to decrements in behavioral perfornance. persistance of acetylcholine in spinal fluid after head trauma and after seizures despite increased cholinesterase The activity may be acetylcholine— the of the related to sensitivity acetylcholinesterase system to concentration relationships.8’“1’55 At "physiologic" concentrations, hydrolysis of acetylcholine is rapid (3—H ndcmoseconds) but at higher and lower concentrations, the activity falls off quickly. In contrast, the butyryldholinesterase~acetylcholine relationship is non—specific rate of hydrolysis increases with increased concentration. These relationships relate to theories of the induction of seizures. While the usual concentrations of acetylcholine at and the cell membranes are destroyed by the specific activity of acetylcholinesterase in a few microseconds, an excessive concentration following excitation may exceed its rate of �-12- hydrolysis. The seizure threshold induced, with the seizure itself may be reached and a seizure adding to the amount of free acetylcholine. Increased acetylcholine affects vascular and cellular perneability altering the concentrations of various ions, including butyrylcholinesterase in tissues and in the cerebrospinal fluid. Through the activity of this esterase, though of low efficiency and depending on concentration acetylcholine is reduced in tissues to levels for the action of acetylcholinesterase. ChoZanAzcnaAeA appcanb in the Apina£ 6£uid kinetics. more direct a4 a ncﬁﬂcction 06 theta incncaAc in inzcnchZuzan gluidb ac6u£xing diam changcb in cc££ mcmbnanc pcnmcabizity accompanying incncabcd EEG Hypcnbynchnony and Induced Convu£5ion4. of high voltage EEG slow wave The acctchhoanc. significance activity for the convulsive therapy process has been repeatedly described."’?-’23’50,51 In the usual course of convulsive therapy, interhtreatment electroencephalograms record progressive increases in amplitude and in theta activity and a reduction in beta activity. As treatment continues, delta activity appears in bursts and eventually is the dominant activity in all leads. These changes are directly related to the number and rate of induced convulsions, and is not specific for a method of induction. While some relationships to type of electrical current has been observed, all seizure inducing methods —- electrical, intravenous chemical or inhalant -— exhibit the same type of EEG pattern changes.21’22a23:3° �-13The early appearance of high degree hypersynchrony and its persistence throughout a treatment course has been found to be prerequisite to improvement. Both the electrographic and the behavioral changes of induced convulsions are transiently reversed by the acute administration of experimental anticholinergic compounds.19’2° The intravenoue injection of diethazine, bonactvzine, the piperidylbenzilates JB—318, JB—336 and JB—329 (Ditren), and subjects. WIN-2299 induced EEG These EEG desynchronization in psychiatric changes were associated with behavioral alerting, anxiety, tremors, illusions and hallucinations. In patients who had recently received electroconvulsive therapy there was a reduction in slow wave activity and a reversal of euphoria, denial and confusion. Atropine, in low doses, was also associated with EEG desynchronization accompanied by tachycardia, nervousness and tension. At higher dosages, hypersynchronous slow waves followed by lower voltage, poorly organized delta activity with superimposed beta activity was accompanied by progressive confusion and disorientation. effect of anticholinergic drugs on the slow wave activity of convulsive therapy was also assessed by the chronic administration of atropine (5 mgm per day) and scopolamine (1-3 The during the weeks of treatment. The amount of EEG slowing was significantly less than in a control group.66 The samples were too small for a clinical correlation but the data is consistent mg) �-1uwith blocking of the clinical effects of electroconvulsive therapy. Marked improvement was reported in treated, none of scopolamine-treated and in 5 controls receiving unmodified replicated ECT. of 2 1+ 7 atropine— of the 6 This study was not by the authors who suggest or population changes may have results in a second study.“ that dosage factors contributed to the different - AA tn cueblcat tJLauma, the demographic changes induced convuutoms may be modiﬁed by the 06 antichounugtc dlLugb Auggebting 06 Want/cation that tncneeued amounts acetytchoune on tncneated chounugtc aecepttvity ts amounted with the htgh voltage Atow wave activity. 06 Acetytchoune and Induced Convutbtont . Despite a constant application of treatments, however, there is great variability in the time of appearance, the duration, anount, and sensitivity to modification by alerting, hyperventilation and barbiturates of the electrographic slow activity in psychiatric populations.30 These differences relate to differences in central cholinergic activity. The failure of certain patients to develop hypersynchrony may be associated with the absence of free acetylcholine and with minimal changes in cerebral function, wave �-15thus precluding a clinical response to induced convulsions. Tower and McEachern in their study of craniocerebral trauma, included observations of six psychiatric patients undergoing convulsive therapy.63 Studying the patients ments they reported free spinal after 3-7 fluid acetylcholine in treattwo patients; and an increase in butyrylcholinesterase and a decrease in acetylcholinesterase with a reversal of the ratio of cholinesterases in five of the six patients. Concerning the one patient in the series who failed to show either free acetylcholine or a cholinesterase ratio reversal in the spinal fluid, the authors stated; "It is interesting that this patient was the only one of the six to show no response to treatment." From these observations they concluded that the spinal fluid' <3; changes in induced convulsions were more like those of 4 ‘4‘ craniocerebral trauma than those of spontaneous epilepsy. «3-.3‘ Other evidence of alterations in the perneability barrier may be seen in the demonstrations of an increaSed concentration of cocaine in brain tissues three days after a series of induced convulsions.1 The change 12 in concentration of this large molecule, ordinarily absent in brain tissue, was associated with the appearance of hypersynclu'ony (delta bursts) in the electroencephalogram, �1 -.,,-_..._. -15Fhom theae oboehvationb we would conclude that induced convuibioni, like chaniocehebhai thauma and Apontaneoui Aeizuheb, ane aAAociated with an incheaie in ghee acetyichoiine in inten- cebtuiah 6iuidA, attuing cuebhai pumeabifity and enhancing the appeahance is maintained Lb . one 05 cholinebteJLaAeA. The Level 06 ghee by hepeated induced Aeizunei . heﬁiection ieveu 06 aLCULed aitehed pehmeabiiity 06 06 EEG acetyichoiine hypmynchlwny acetyichoiine and the eiecthoiyteb and otheh Aubitanceé, inciuding choiineAtULaAeAs. The changeé in intuceuuiah elect/w- .oi.m_m_._._.. _ ..l.__a u.- iyteé, inciuding aeetuichoiine phovide the biochendcai AubAthate 601:. the pelwibtent behaviouai changed and EEG hypwynchnony ﬁoaowing induced convuibianb. An ww...-._.~__.-m~ 06 application the phedietion o6 06 these conciuiioni is been in the btudieb the convuiAive thehapy heéponbe and the ctaiiisication as psychoaei. ~--....-_ Choiineétehabei and the Ciaibiﬂicatian 06 PAychOAeb. ._‘ 4» .. V Punkenstein at at. reported a relationship between the blood pressure response to methacholine and the clinical response to convulsive therepy.25'27 Immediately after the injection the blood pressure falls, usually returning to the baseline within 5-20 minutes. A return within 5 minutes Of methacholine places the patients in Groups after- 20 minutes \‘ \e I, II or III; places'the patient in while a return Groups VI and VII. �-17Group I and Group II-III respectively, while and 97% have a 9% and a 35% Gkoup VI and Group VII recovery rate, subjects have 89% recovery rates to induced convulsions.27 Group I to III reactors may be looked upon as patients in whom is rapidly hydrolyzed; while Groups VI and VII have a slow hydrolysis rate. (The response to injected epinephrine was suggested as a second criteria in the classification, but is of limited discriminating value.”8) methacholine While we have no biochemical explanation fbr the differences in the metabolism of methacholine in these psychiatric groups, it is possible that the blood and tissue cholinesterase activity levels of Groups I—III is high while that of Groups VI-VII is The low compared to general psychiatric populations. differences in blood cholinesterase levels in normal and mentally ill subjects have been extensively studied. Despite differences in nethods,“’5 elevated cholinesterase levels compared to normal populations have been reported for depressive subjects,"""’5"‘7952 schizophrenic subjectslh’28’53 and a mixed psychiatric populations .“2 Alpern reported lowered cholinesterase levels in schizophrenic subjects.2 While these studies appear inconclusive, they provide data that the variations in blood cholinesterase levels are generally greater and frequently elevated in the mentally ill. Negative reports include the failure by Ellman and Callaway” to confirm Rubin's study; and Altschule's review of the data suggesting �-13no abnornality ' of cholinesterase levels in the mentally ill.3 that cholineAth play These Atudteb AuggeAt meaAuAeA may a signiﬁcant note. in the thuapeutéc aupome to canvutatve the/mpg and in the pathoggnebta 06 paychobu. �-19; CONCLUSIONS This review summarizes some of the available data suggesting that cholinergic mechanisms may be central to the convulsive therapy process. Induced convulsions are associated with cerebral vasodilaticn and increased cellular permeability, followed by the appearance of increased amounts of enzymes and electrolytes in intercellular and cerebrospinal fluids . The increase in acetylcholine, vasodilation and increased permeability appear as interrelated phenomena associated with ' trauma, seizures and induced convulsions. These biochemical changes acconpany increased hypersynchrony which is recorded as EEG slow wave electrical activity in scalp electrodes and which can be nodified by the acute and ' chronic administration of anticholinergic drugs as atropine, benactyzine, diethazine, procyclidine and various piperidyl— benzilates . In these regards, induced convulsions are more similar to cerebral trauma than to spontaneous seizures. in cerebral biochemistry alter cellular activity sufficiently to affect consciousness and the behavior of subjects . Failure to induce persistent biochemical changes, including the The changes concentration of acetylcholine, results in failure to produce behavioral change. �-20There is, as yet, no consistent evidence for differences in the sensitivity or dependence of populations on cholinergic mechanisms. Differences in the rate of development of cerebral changes to the sane number and frequency of induced convulsions classifications of the nentally ill based on the blood pressure response to methacholine suggest, however, that such differences may be significant in the pathogenesis of different and .._..__...V ___,‘~,‘....____... ' «uAW—‘wﬂﬂw ,1“ psychoses . �REFERENCES 1. Aim, B., Strait, R. L. A., Pace, J. W., Hnenoff, M. K. and Neumphysiological effects of electrically Bowditch, S. C. indnced convulsions. Arch. Neurol. Psychiat., 75: 371-378, 1956. 2. Alpern, D. O. i kholinergicheskaya Aktivnost kholinesterasy reaktsiya kmvi pri shizofrenii. 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D. and Effect of trimethadione (Tridione) and other drugs on convulsions caused by di-isopropyl fluorophosphate (DFPj . Amer. 33. J. Psychiat., 106: 816-820, 1950. effect of Diparool on the electroencephalogram in the normal subject and in those with Jenkner, F. L. and Lechner, H. The cerebral trauma. Eleotroenoeph. Clin. Neurophysiol., 7: 303-305, 1955. 3M. Johnson, L. c., Ulett, A., Johnson, M., Smith, G. K. and Sines, J. o. ElectroconvulsiVe therapy (with and without atropine); effect on electronically analyzed electroencephalogram. Arch. (Chicago), 2: 35. Gen. Psychiat. 32u—336, 1960. Kabat, E. A. , Glusman, of the albumin and and Knaub, V. M. ganma Quantitative estimation globulin in normal and pathologic cerebmspinal fluid by inmunochemioal methods. Amer. J. Med. , 4: 653—662, 1948. 36. Kovach, A. G. 3., Fonyo, A. and Halmagyi, M. Acetylcholine content of the brain in tratmatic shock. Acta Physiol. Acad. SCio Hung., 37. '3: 1-“, 1957. Krech, D., Rosenzweig, M. R. and Bennett, E. L. Effects of envirormental complexity and training on brain chemistry. J. 38. Carp. Physiol. Psychol., 53: 509-519, 1960. Loewi, 0. ﬁber hmmrale Ubertragbarkeit der Hemmemdirkxmg. Arch. Ges. Physiol., 1898 239-2‘J2, 1921. �39. Maynert, E. on H0. W. Effects of C.N.S. depressants and Buck, E. G. brain acetylcholine. Phamtacologist, 6: 191, McLennan, H. and Elliott, 196M. Effects of convulsant and K. A. C. narcotic drugs on acetylcholine synthesis. J. Pharmacol. Exp. “1. Ther., 103: 35-u3, 1951. Nachmansohn, D. and Rothenberg, on Specificity of enzymes M. A. Studies on cholinesterase: in nerve tissue. J. Biol. Chem., 158: 653-666, lSHS. M2. Plum, C. M. Study of cholinesterase mental disorders. #3. Pryor, T. and G. nervous and in activity Clin. Chem” 6: 332-3H0, 1960. Otis, Effects of chronic administration L. S. of electroconvulsive shock on behavior, brain weight and brain Presented chemistry. at the American Association for the Advanoenent of Science, Berkeley, 1965. an. Ravin, H. A. and Altschule, M. D. Serum cholinesterase activity in mental disease. Arch. Neurol. Psychiat., M5. Richter, D. and 58: 6‘45-650, 1952. Grassland, J. Variation in acetylcholine content of the brain with physiological state. Amer. J. Physiol., M6. 159: 2u7-255, 19u9. Richter, D. J. Sci... 88: I‘28-‘43“, Ment. and Lee, M. Serum choline esterase and anxiety. 19M2. �H7. “8. #9. Richter, D. J. Sci., Ment. and Lee, M. Serum 88: 1135-439, 19H2. Rose, J. Acta Psychiat. Scand., 38: T. Rosenzweig, The Funkenstein M. choline esterase and depression. test - a review of the literature. 12H—153, 1962. R., Krech, D., Bennett, E. L. and Diamond, M. C. Effects of environmental complexity and training on brain chemistry and anatomy: a replication and extension. J. Comp. Physiol. Psychol., 55: l4294437, 1962. 50. Roth, M. Changes in the EEG under barbiturate anaesthesia produced by electro-convulsive treatment and for the theory of ECI‘ their significance action. Electroenceph. Clin. Neurophysiol. , 3: 261—280, 1951. 51. Roth, M., Kay, D. W. K., Shaw, J. and Green, J. Prognosis and Pentothal induced electroencephalographic changes in electro-convulsive treatment. Electroenceph. Clin. Neurophysiol. , 9: 225—237, 1957. 52. Rowntree, D. W., Nevin, S. and Wilson, A. The effects of diisopropylflmrophosphonate in schizophrenia and manic depressive psychosis. J. Neurol. Neurosurg. Psychiat., 13: 53. 167-62, 1950. Rubin, L. S. Acetylcholine hydrolysis in psychiatric patients. Science, 128: 2510-255, 1958. . -1 �5Q. Spiegel, E. A. and Spiegel-Adolf, Permeability changes in M. the brain induced by Metrazol and insulin convulsions. J. New. Ment. 55. Dis., 93: 750-755, Spiegel, E. A. 191*1. and Spiegel—Adolf, Physicochemical effects M. of electrically induced convulsions (cerebrospinal fluid studies). W5. 56. A880, 70: 130-132, 19“”. AHEI‘. NeUI‘Ol. Spiegel, E. A. and SpiegeléAdolf, Physiological and M. physicochemical mechanisms in electroshock treatment. COnfin. Neum1., 13: 38-63, 1953. 57. 58. Spiegel, A., Spiegel—Adolf, E. and Henry, G. .M. Physicochemical changes in the brain accompanying electrically induced convulsive discharges. Trans. Ass., 68: Amer. Neurol. Spiegel-Adolf, M., Wilcox, P. H. and 171+, 19'42. Spiegel, E. A. Cerebrospinal ﬂuid changes in electroshock treatment of 59. psychoses. Amer. J. Psychiat., Stone, role of acetylcholine in brain metabolism W. E. The and function. 60. Amer. J. 'IbbiaS, Jo Ml. Lipton, 104: 697-705, 19%. Phys. Med., 36: 222-255, 1957. Mo A. and Iepinat, A. A. Effect Of anesthetics and convulsants on brain acetylcholine content. Proc- $Co Exp. 61. Torda, C. B11010 Mdo, 6': 51'5“, 19145. Effect of convulsion inducing agents on the acetylcholine content of the brain. 173: 179-183, 1953. Amer. J. Physiol. , �62. Torda, Effects of single injection of corticotropin C. on ammonium ion and acetylcholine content 63. Tower, D. B. and McEachern, D. of brain. (ACTH) Amer. J. Acetylcholine and neuronal activity. I. Cholinesterase patterns and acetylcholine in the cerebrcspinal fluids of patients with craniocerebral tram. 616. Canad. Jo Researdl, Sect. E, 27: 105-119, lgugo \ Tower, D. B. and McBachern, D. of cholinesterases in human The content and characterization cerebrospinal fluids. Canad. J. Research, Sect. E, 27: 132-145. 1949. 65. Tower, D. B. and McEachern, D. II. Acetylcholine and neuronal activity. Acetylcholine and cholinesterase activity in the cerebmspinal fluids of patients with epilepsy. Canad. J. Research, Sect. 66. Ulett, G. A. E, 27: 120—131, 19u9. and Johnson, M. W. Effect of atropine and sc0polamine upon electroencephalographic changes induced by electro—convulsive therapy. Electmenceph. Clin. Neurophysiol., 9: 217-22u, 1957. 67. Ward, A. A... Jr. Atropine in the treatment of closed head injury. J. Neurosurg., 68. Wescoe, w. The 0., 7: 398-402, 1950. Green, R. E., McNamara, B. P. and Krop, S. influence of atropine and scopolamine on the central effects of DFP. J. Pharmacol. Exp. Then, 92: 63-72, 191.8. �for Ihe Bio Sciences Informgﬁon Exchange. . . . . NoI' for publlgnhon pubhcahon or Prepared j DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE ——1 m”: PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH "one: or ; . s SUBMITTED TO! ‘Public Hoalth Service. NeIionaI lnr+i+u+es of 'n-r OF Paganini “mmame ‘ and Give names. department. and ofﬁcial Win ‘l'ifles RESEARCH Hulfh. ' ‘ ' rnoJEcIr;”.-\ Div. of Research Grants. Bofhesda l4. Md. ' , in Spinal Fluid § 7 a—sm. (022 , ' , PROJECT NO. (Do no? use this space) and. U lemme} l Read" Injuries“ ' , I of PRINCIPAL INVESTIGATORS and ALL OTHER PROFESSIONAL PERSONNEL engaged on the proiecf. 11.9., Rmsurgem, mums: Gluing Instructor in NeuroIn. surgery. Dartmouth Radical School Smutﬁadgs. i. . John P. Wilson, Ph.D., Assistant meensor 1n the Physiological Sciences, Dartmouth Medical School I NAME AND ADDRESS OF APPLICANT INSTITUTION: ' Hitchcock Fomdation Hanover , New Hampshire SUMMARY OF PROPOSED WORK — (200 words or less —- Omlf Conﬁdential data.) In In Bio Sciences lnforrnaﬁon Exchange summer!“ of work In progrcss are exchanged wlﬂn qovernmonf and privan agencies supporﬁng research In modiul and rant-d ﬁelds and an forward“ to invosﬂqaton such informnﬁon. Your summary Is to be usod for rhese purposes. vbnqm study of in. neq'tylnholine MW: of spinal fluid mama“ in hudinjxaﬁu, utilizing the biéh'nsa'y author! am! Young; Mariana, has A, bun Wt“ tale .mn. In! study Indiana the presence put of «cannon», smtonin.‘ and one. unidentified in the period following head injury. mezpmponod “any: is an extension of this Mainly ml: u.m1n tissue as will as tpifail fluid. and ~11; aging. in addition chain: 'analysis for these one 3mm” (spectrephntnnuomter). during tha We“ f.‘ Silbmitted beginning SIGNATURE OF PRINCIPA INVESTIGATOR for periOd I. September 1956 A , ldenfify fhe Professional SchooI (medical, dental; public healfh. graduafe. or ofher) wifh which this proiecf should b idenfiﬁed: mm, INVESTIGATOR —— mm Romanian .. Do NOT um:- Ti—u: :nnn'n- I 11 ed. �12/17/56 smmc comm wanes WW3 rwml :5an or ~ may mam Acrmr! IN BLOOD ml mm... m) mma: )5.“th for the at mum of t papa-1m mutation mod for): Gil-13:1 mm th Mien, in Matt“, Mm mum Samar, Brooklyn, «.2... Pom-my 15, 1957. A with. m mom-mm nth-ad in ”portal for tho «5mm; a! W My W m W tar um» 91' m «mu-cm» Minty. Though of W31. “14 «mm-nan (2.39) and on m thalliutan» in min-.1 fluid. the mum. in nanny applaud. to the may.“ of and and «11:, um mm, m. on» biological num. Only 0.3 um, :1. of 13311:]. fluid at 0.001 I1. at m mu «um: knyltuooblno 10 why-d a lmdng incubation, m um is nquirod for a in dnmtion. W but”, pa 8. 1! “Situated by am“ 51 tol- trickle”— mm into a calorimeter tube. notummm¢1smwwnmmrm~wmmm «.1331. uotio acid, cum-1mm, ind daunting m thus Whom. Thu than that map mu :m an: m mt: with ”Miami” to product Absorption mm a. 510 tho a. ma to format ton, color with an New”. want, m m M. or new in. y. an be both may.» mum the cam in not by Adding *Mn 1397" u in spin]. ﬂuid, um sham-mu 1: n «1mm Wu: mum-m), (lawnmmmwmmm dot-ruin“ 0! W “machinist-mu. mm of mm in various Mansion. fluids at. amounts-nod and coup-rd to tho ﬁndings in pun-nu with mm dim». Th. nor-:1 W “01ka Yb Ind!!! W10»). alto mu .ployd to “My «batman. that action, no): u LSD, which is a mum inhibitar of 10 �WW. Wham” mtahmtortothnmnmwwwcm hr this mu the awyummm - hm“: - WOJn1¢romoerquythu¢ummmmmtof tm»mmlibcatdhyumc lauwrkmwamwmawmmmnmm mum at m mm, 9.3. mm mu m... 3 601m, 3., m4 Gold-abut, m, a. 3mm. My», 1, 21.6 (1956). �we «mwmman. m: 31.3mm, wmmmc cmmms, m 1'3ch W W, W W. 'm .m no Magnum - Lon; Inland for of a n.‘., 3661“,, 1) m ”may, not M1» on an. ”WW- mm» harm), and for tho Illa; than 111:“ mu u spam. mum mum“ of and and ”both“!— mum.» 1mm in fan madman. a: aninitiou 1: Mm a. "mm m mm and tin-Sr to u» » W in mu W. W]! ma ‘ wat u Wtimﬂu York Mm, 11.0%ch cm 15, 19,7! “W nautical mm: m mm. mu that: m s: muons; mm; (nmalm, mom. mm of atypical alkaloid- m- mm», mthmuumbounafmuc mp: mkummcut 1n thiamine, and Wow. I'm: sum in : Mia «fat mm, 2) awn-s in ”WM 111le 20mm rm- the 91‘ m from macros! M Marina. municidanﬂmdtmmdwmﬁkh wish alkaloid! W I” be much. duration at diam-ranting nut-win 1:: tbs who «Wu. to We 03:10:13.1" I couple“ uh“ for henna; m6. mutating than and hack «mm ma mum-1a, «man. um, mad tmtm into a. null value at cthylm mum“. Tho aim a truncated m M Wu to dryness, thin upon-d out on mt» pupa. Separates: of tho 1: want either by handing cur-anaemia an; Mme).- 1anmmppmu1n mmmnarmmuostmtmamm mum. at mun, ms. mu. am.» 3min. m �“ cam mum «an an a! mt thomh with H» (521:1), or by in 1n 1:: m3. m- petition :5me“ W (m bola). At oommdm mum m «a «a: 1m puma). um ﬂax-1p: , the. club“ with 1106M, tht «ma by mpontm in «11ﬁlth ﬂaking. mud tub», than mm. arms. and Wm mama. m this point than W WI m MinnaﬁyotwlwtomdbthnMaunm«maintain-momma mummuawxomumqmmutmmmu W. M Mal-Inﬂux com-mm; 1m «mum at out amen my be gland mm, thmhthMmWw5uw, mat. mad ”imam, mmtmu, WWI» W mama. W W bah structural {mm at th- '13., and to! 16 drug: tar in pasture m dam-trusting the with ml: w. metric Rub dag mhmtmthmmmoﬁhmcamwath WWIMtMO. Amioutm of tin mm to ﬂu arm. a! “Mum“ prior to m {allowing 4mg than” will I» mean“. �(Effect a! In a Was Mona an 3% Theory of convulsion for amriigmﬂme report to this society we noted the relational” between the degree of induced delta eetidw during the course or therapy and the behavioral response to electroshock. Thane patients, in when big: éegreee of delta nativity were induced early, and were sustained, miteeted the greatest. degree: at helmvieral change, as well as a significantly greater percentage of inprovemrt. and recovery than these patients in when only law degree: a: delta activity were We (Fm: m: m. 1957). In the past few years, a variety of reports relating changes in £me( 1‘) leetylchoum and oholineeternae in the spiral fluids of patients (Subs, Herd) 1rd minis 0 (Bernstein, Teller and HeEnohern) following head the obsem’cime that cholixm'wbic agents may by trauma (32mm, Bard, Jemmr) alter the EEG m; putterne induced and by electreeheck (Inuit), led us to investigate the role of autylcholine-eholinestemee metabolism in acctroeheck therapy. In 1956 Ulett reported that atropine or schpclmne, when administered row! the clock schedule blocked the appurme of the delta activity on a. we hm com to mandate with electroshock therapy. meet. noted, however, �that his patients nurtured numerous madcaiubla aide effecta during these mutations. (19%) had Previously, mm (1950 ramming the suggestion of Bernstein new that atmpine mama bath the EEG patterns and the mumlogm signs induced in an by head trauma. Here, too, the side effects wen marked. In 1953. W:- md Lechmr ropertad that mum-a1 effects similar to atropine mm intend in patients with 610W 11-. in tram, head on also reported the effect at normal subjects. the EEG hypothesis of the we of nation lanthanum is a soluble We: Wr “was: dry with. at“ comlaiva mama» aethnsm the bmdyoardia, «11m: moment neumplvuiolagicnqdapﬂva than”. coupow with Wologic to atropine. In maximum animals. hymns 335; Media 1.1m. and 111mm: of patients ﬂaring electroshock Warsaw; and to relate than them findings to the ham and whim by Maine min- we purpose of this repwt to describe the effects of is dicthuine um; Thcy EEG blocks slowing of the heart; Wasp-m, «ﬂatten. induced by ucatylcholme, main ugal uni hypotenaion. m ma fasciculation e and pilocarpmﬁ and induces �~3- m: shock ﬁreﬂy-two paymttric patients, in-vurioua stages of electron- treatmnt in an studied. the EEG these 351 upon-ward. voltm’ury purchiatric hospital have been WW Follow laboratory. Wtemd intmmny at a routino amtration, 4mm” both the were 25 mm the habtwioral m per minute, for a total errata. Prior and a to the W Mahatma, period were upeonaordad. Running 'dmg record again tested in recording, diamante unstmtured historical intervicw regarding, and meordeﬁ EEG EEG an BEG at the rate or 290 to 250 nan, depending upcn drug maximum, aubjoots Imam periods were mntinued until mummm Wanna patterns on visual \. inspe ction. m m: (a) Neal: follwed by n fooling of Q. 11!. subject; manifested spontaneous gouging initially; dryness of the mouth and, a thickmsa of speech. They nohd heaimde and makneu of the increased mathsmou and difficulty in W were Psychiatnc/cleaﬂy mnifoctad in between 13 and 30 mm attaining mm am noon rammed by eyelid closure. subjects. In the not. pound titer drug mutation, ax subjects spontan- �.3. 0011333” med fouling: of «mm mums mm amnion illusions, about than" 111mm, the setting of the «auras or our icientity. by the um: and Myrtle Such and m: pm- patterns were transient and had diaappuamd‘ of the expat-meat, usually vitiun three hours. In um subjects, mesing august-loan and panic led to, a «mum at an wrung. amt Hero, too, mummm at minimisation War was mum: tune hours. (b) In previous studies, we had noted the intimate rolaﬁommP hem ehangan in syntactic language 1:3th with mmm induced by allotmm. changes diothaaino inﬂamed In In subjects alteration in mm prior to abatmshook, in syntactic pattern at an “lurking” musty. 3&3er with tielta activity, We}: clinical amnesia {anthems of an ”alteration in cerebral function, diathaninu induced a appearance or animation of amt: languaga ambnl patterns. indicative tmient. dis- The pct-5.06 01' ohms” in language in mum-rent with 63mm in eloetmmephalom. (a) Patterns: In all words, than dosymhmiaaum or fmqmneics. Them m. M 15 in 3. MW in wltage and a decrease in pruinamo at In patients without. delta activity (magmas), �.5. me «mum ‘ppannoa or small by the T123543 5.- W8 of 198 voltage 6-? cps uctivity. are Monstmtcé in Slidoa 1, not. appear slower to be alterad. 0131.2. The basic alpha rate does Mishap in voltags and appaamnoe of The fmuweies with mwmtmtion in blockad. In patients with vu'ying ”thaw waiting voltages: W 1m voltage m and burst «halite. in 3 is a decrease ntdxitw diuppoun; and 31m and am Wotan hem This change It wants times {bits or Maud high voltage dean from convulsive urea-am, them are now: in Sudan ham. «W «mm Manny and voltage 1m, 15mm. mm Ghana's Ind h. mm: is West in all 6100mm imam. during drag mumum, and persists far one Concurrent with electroencephalogram changes, uillon}. and language patterns at the pm-dnjoatioa language in 313% m putter”, Nauru: awn uppured. ciascxﬁbed. With the to three as the ho- mum the para-injection behavioral and �as w: ﬁtness obaorntions confirm the report of Jeanne: and Manner of tho affects af diethaaim altars moot-d: subjects. in’*uonm1" we also note that diam II‘ with mammal: induced delta activity in a fuhion dearth“ similar ta atropine and ocopolnmine, l5 ty- Ulett. Memo". Shea patterns are similar to the affect of these anti-showman conpaw-ads in records 1'0le head tram. In the» subjects, intmvma ammo caused immediate changes bath in the we and in behavior. It is appsrmt, Wafers, and that. it; its: duration of activity is most mum). for the @0an mm. mutual: aim audits by mmus obumra at new man attracts of head ﬁrm point to an inﬂate of muralagie dyst‘motion, the :2» mwlohonm 1n the the madly affects the centre). nervous when, basis fer the owned EEG alteration; and the 1m). at spinal fluid. the effmt at ttmpine both an mm a» continuum tin-tho: support to ﬂu chm: of relationship batman the dome an mm» m wbjoets with heaé mm mm Wim Em putt-rams. of mmm. In those studies of Wain. and u the patterns and has nutylcholmo chatmahook, the intimate relationship 13¢qu EEG bonnie: �.7. m trauma... m ﬂuid m mama. beam On We the bases note the parallel to we observations» in head of, these observatim, as wall as studies at spinal chanmmmu lavela, would magi-st that [the (Tower and mwem, Mammal substrate in similar to that. of head tram. Fink and W22), of the electmshack promos: Electroshock my be Ionized upon as a continua-d mothod of inducing cerebral dysfwc’oian for its bazaviaml “Tact. Purim pmidas 13m atudiaa have (1th that. alteration in cerebral mm: pbyuiologic basis for the behavioral changes in electmahock (Fink and Kahn, 1957). Such altamtion in embm mum pmidol m milieu for a change in the eat-mum's adaptation to his environment. aspects a? behavior, in pemaptim, mum lama, mood, recall, memory, m affect, the basis for the therapist's ovalmtim ate. Margo mange, and of immanent. studies of ﬁiathudm amplify this neumplvnolegia mm“ The hypothesis of electroshock by suggesting the type of Minute mat. Marlins both the Wuhan biennium and the beluvioral chm. �m: Dicbhaam, a patent mﬁwohcainergic unwound, 1:1th was upemmntnny intuwnmsly in wyuhiatric subjects in various sages at commlaive thanpy. mectmmcephalogma minimum theme in voltggs, a. and observatmm or éeaynchronixatim of fmquencioa, hyperventilation Manson in mean}: mmmt print dnlta activity. accords with delta activity sham! ammu- changes with mama‘s-anus of delta burst activity. Gmmt pat-amass with the ahetrogmﬁxic effects, behavioral and language indicative of a reversal of the electroshock affoct. were charred. It is maelndod that: (a) Disthuine is a patent anti—cholimrgia amount! that readily enters the antral not—mus system upon intmmm ministration. (b) The Modalities}. butts ras- Fm changes in electroshock is to this of head trams; and (s) therapy The may biocheniml lie in buis of the mode of action or m cmﬂsive the acetylchounoocholmatemu system. ��(glum‘ﬁrzr Wﬂ «/¢V7/‘ “W“W WMWW— #MZ ; _WMQ!4¢W MM ‘ é; 7% WM/ 64331” .461 ha— @fﬁ/If/y EEQaQ/JW gag/M1114. ﬂ 64x7 ��14.3.,“ , / -4I/ . .. M... �é“; sessé c W ﬁg? ngz/ & W‘Za- MWX m ’55 2 “a! gégil Mara. 461/ 4. .4“) ¢ MM: Wu W Jeni #M“ K/m 1» 14:44::____ ��/Z¢, Aﬁfﬁgg L££A4AIZI~ mWMmQ ("43 2% 2 . @a M 3" ��/ / 'v-—-9:' wpw'.” v -' MIG/’4 4trsmg+¢zi9 - ._ ~‘ ~ . " . Dr ��10/ M‘ £77. ~———-—-—-————-——__ / 1 w W? WW M tr M WM mu 5 m; Mar fir WM ltra in x1“! EEQ. 32 ' #2 Cf; .- .20 _ Wa MAX—«l 4.4.!” . #34“... 4'“ ‘7 AIM xcreq cwé‘.’ :4. ('3) M44. Min-A- ��“0011/ /;4a+ a” ._—————-9 ,4¢,,‘“‘“':_:=, l/aw M #u/t. 410/ ﬁ’é‘fu’” S“ v MM ��[f7 x, W/ r{ /¢C// A"! wax / (31) I) 2 %%l -———-> MIL. ”cw / ) ��ﬂew- �O EST —_WU. ”WXW IK. Bag 11“» “~ f ‘ 4W Iy .NQ W .CW ‘e’ Iaéas/uue' ‘ MM? c) jivfeaﬂﬁuﬁp 041.. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Files: Acetylcholine and Cholinesterase, 1956-1966 (folder title 1/4). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-003-0-001 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/547dda87f02e63e10815bbd8bd8b58a3.pdf 2de3623b012b67ce51e9e637220d0b84 PDF Text Text Role of EEG Frequency Shift in Behavioral Effects of Drugs mmmm.* During the past few years we have been interested in the interrelation- ship of changes in various measures of brain function and the behavioral response of psychiatric patients to somatic therapies. were devoted Our initial studies to the changes in tactile perceptual tasks in patients with organic psychoses. This study, carried out at Bellevue Psychiatric Hospital, demonstrated that patients with active organic psychotic reactions made repeated errors in the simple task of reporting two simultaneously applied cutaneous stimuli. The persistence of such‘errors was interpreted as an index to the presence of an "organic mental syndrome." In the initial studies at Hillside Heepital in 1952, the same patterns of errors were observed in patients receiving convulsive therapy. we then became interested in the role of altered brain function in the "improvement" induced by convulsive therapy. we In our first group of patients followed consecutive electroshock referrals with weekly measures of changes in brain function of brain function: and memory clinical interviews. tests, simultaneous we used four indices tactile tests, the amobarbital test for organic brain disease described by Weinstein and Kahn, and the degree of induced delta activity in the EEG. It was soon apparent that neither the memory scales nor the tactile tests were sufficiently sensitive indicators of alteration in brain function to be satisfactory for our purposes. The amobarbital test, however, was a sensitive indicator. In this test, the subject is asked a series of questions regarding his illness the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Island, N.Y. Read at the Section of Neurology and Psychiatry, Queens County Medical Society, June 3, 1958. Frcm Long ‘ �.2and orientation for place, date, time and person. Following the administration of intravenous amobarbital until the patient has nystagmns, the questions are repeated. Errors of confabulation and disorientation are scored as "positive" tests, and have been found almost exclusively in subjects with active cerebral dysfunction. In the patients in the electroshock series, a significant relationship was observed between changes in this test and impmvement ratings in convulsive therapy. Amobarbitﬂ Test EST - Improvement #1 “----‘--- u..---.--—----—--——-we in the also measured the changes in EEG. ﬁne degree of induced delta activity Examination of a series of preliminary records, as well as the description in the literature, demonstrated the early development and ‘persistence of Slow wave activity in the EEG during convulsive therapy. this preliminary information, we obtained weekly records during and ‘We measured of treatment. a after course specified leads for the per-cent time delta, the slowest frequency, highest voltage of delta and the duration With of burst activity. Using these quantitative indices 180 records activity. in The we ranked the initial patients according to the extent of the induced delta upper third were classed as ”high degree delta records," 2h the middle third as "middle or'moderate degree delta" and the lowest third as "low degree delta activity." High, Middle and Low Delta - EST #1 �.3 When we related the development of high degree delta activity to improvement rating, a signiﬁicant relationship Fig. EEE was again demonstrated. 5 Delta - Improvement - EST #1 ---—-—------ -—------ yo--— --—‘-..- ~- In subsequent months development of high degrees of third to EEG delta activity during the second and ratings. In the next table, these observations in the next Sh patients. weeks of treatment have summarized a predictive study, relating the we embarked on improvement F1 . we 6 Table: Patients High Delta 2nd, 3rd weeks of Treatment EST 2’ 3’ ’4 -_------- ----—----‘u-n-—---------_-----m-‘-----—----By this time we believed that EEG delta activity was related to the behavioral changes in convulsive therapy, and its significance in a control convulsive-subconvulsive study. Of was tested consecutive convulsive therapy referrals, randomly selected patients were subjected to a course of subconvulsive therapy instead of the convulsive therapy. This to the patients or their therapists. 0f the substitution was unknown subjects received convulsive therapy in this series, high degree delta who activity records were observed in of treatment. Of the 27 Subjects 3h during the second who to the fourth h? weeks received subconvulsive therapy, however, none demonstrated either-high or middle degree delta activity �.u. EEG . records during any week of treatment. In concurrent behavioral evaluations, of the h? subjects in the convulsive group h2 behavioral change, while only showed such 3 showed marked of the 27 in the subconvulsive group a change. In clinical improvement ratings, 2h of h? were rated "recovered" and "much improved;" 15 "unimproved or worse." But as "improved" and 8 as of the subconvulsive group,only 3 were "recovered" and "much improved," 5 as "improved" and 19 rated as "unimproved cr'worse." we were now convinced that high degree of EEG delta activity reflected the physiologic changes essential to the behavioral change in convulsive therapy. An alteration in brain function, sufficient induce considerable - and of the kind to activity appeared to be the prerequisite, not sufficient factor - in the convulsive therapy EEG a necessary, ﬂaough slow wave process. Perhaps a similar relationship was observable in other somatic therapies? we next examined insulin activity is induced, hours after gavage. receiving deep or prolonged which Not coma therapy. During each coma, EEG delta usually persists for a few minutes to a few infrequently - in approximately 1/3 of patients insulin therapy in our hospital, seizures, aphasia result. After such events, EEG changes of delta activity coma coma persist for days, The relation ' and in cases of prolonged between prolonged coma, coma, for weeks and months. altered brain function and behavioral response has been discussed by numerous authors. Revitch reported eight cases and concluded that improvement was related to the induction of organic brain damage, similar to lobotomy. Yaeger et a1 �-5. noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of of prolonged coma. EEG In reviewing our insulin abnormality in 12 cases coma experiences, noted we that our best clinical results have been observed in prolonged coma cases. As a result, it has been the intention of our staff to induce such a state. Persistent coma EEG delta activity has been observed in a small subjects, and only in those with prolonged neurologic signs. Thus, in insulin coma number of our or persistent also, a relation between delta change and behavioral response is indicated. Concurrent with these investigations, We had begun clinical EEG coma investigations with the newer tranquilhers. Initial study of Raudixin in 1953 He were failed to indicate any clinical efficacy. able to administer large doses - up to 10 With mgm. reserpine, however, At these levels, behavioral change become prominent but so also did neurologic complications. Parkinsonism was readily induced, and seizure induction and increased clinical depression became prominent. The EEG changes on chronic administration were small. With our doses, desynchronization was apparent, but at higher dosage hyperSynchrony was also noted. With chlorpromazine, however, we were more fortunate. we had undertaken a control insulin coma-chlorpromazine study, in'which the experimental dosage called for levels sufficient to induce clinical parkinsonism. In three of the thirty patients grand mal seizures were induced. In all patients significant changes were observed in serial EEGs. These consisted of increased modulation, increase in per-cent time alpha, and in twenty patients lOW'voltage theta and delta activity. On hyperventilation, delta �burst activity was observed. In reviewing the experiences of others, noted numerous reports of chlorpremazine inducing seizures; exaggerating seizure activity in epileptics; and activating seizure available for reserpine. EEG we records. Similar reports are review of the electroencephalographic effects of various phreno- A tropics demonstrated that not all newer agents induced Meprobamate, in clinical doses, induces an increase in activity. slow wave EEG fast activity, with increased voltage and Spindling. The records are most similar to barbiturate records. Benactyzine (or suavitil) induced neither slow nor fast activity but desynchronized the record, with flattening of voltages and loss of wave whatever rhythmicity was present. clinical experience we were impressed that chlorprcmazine and reserpine were the most effective modifiers of psychotic behavior, with benactyzine and meprobamate as relatively inefficient agents. It From our seemed appropriate therefore to extend the neurophysiologic adaptive hypothesis of the it was mode of action of convulsive and insulin EEG frequencies to the delta range would active in modifying psychotic behavior; while those that induce a shift to the beta range, or As a corollary it was desynchronize the record would be less effective. suggested that agents that induce no change in brain function or changes so small as not to be reflected in serial have therapies; suggested therefore, that agents that induce a change in brain function reflected by a shift in be most coma little EEGs would behavioral effect. Thus, a classification of newer phrenotropic �-7drugs based on their EEG effects was suggested: (3) Increased slow wave activity with hypersynchrony (b) Desynchronization with voltage and frequency irregularity, .and (0) irregular theta Increased high voltage fast activity In reviewing the available literature reports of promazine and perphenazine would indicate delta range. that these agents induce a shift in the Mepazine has minimal EEG effects, EEG spectrum to the and these are largely desynchronization. Information regarding other newer agents was not available. we EEG have undertaken two studies based on changes to behavior. One is serial EEG this hypothesis relating studies of patients receiving chronic tranquilizer medication at the hospital. a study of the relation acute administration: between the EEG and A now second is the behavioral effects on the data of our chronic administration studies are not yet available, but the acute studies have progressed sufficiently to danonstrate the applicability of the hypothesis. Fbllowing the observations by Denber derivatives, diethazine, elicit some EEG when that one of the phenothiazine administered with chlorpromazine, would activity similar to convulsive therapy, we undertook explorations of this compound. In the EEG laboratory with continuous 31 w wave recording, varying amounts of diethazine from 100 to 250 mg. were administered intravenously over a 10 minute period in psychiatric patients at various stages of the convulsive therapy process. Instead of hyperynchrony, patients who were pretreatment and without EEG delta activity, demonstrated significant desynchronization of the record. �-8Fig. 7, EEG - Diethazine - Pretreatment interesting, however, Most 8 was the effect of diethasine in patients with increased slow wave activity during convulsive therapy. Here, too, desynchronization became manifest, and there was a decrease in the voltage and per-cent time of the induced delta activity. EEG - Diethazine - Delta Activity effects, we observed distinctive behavioral changes. Patients became more irritable and restless; they Concurrent with these complained of sensations of extremities. In some, EEG unreality, visual illusory and of dysesthesias of the phenomena and delusional thoughts their illness, the setting of the test procedures or our identity. There were changes in their language patterns opposite to that previously about described for amobarbital, so that denial, minimization, cliches, third person mode and past tense were less prominent. The duration of these behavioral and language changes was from one to five hours. changes were of similar duration administration and disappearing The EEG - appearing during the period of when drug the behavior had apparently reverted to the pretreatment state. The ability of diethazine to activity led to an evaluation of induce other illusory known and hallucinatory hallucinogens. In checking �-9the literature we noted that that mescaline reversed the Denber and Merlis had previously described EEG changes induced by electroshock, in a fashion identical with diethazine. Pennes had observed hallucinogenic activity for another experimental compound Win 2299. We obtained some of this material, and repeated our diethazine studies. Here, too, Win 2299 induced EEG desynchronization associated with clinical patterns of restlessness, excitement, hallucinatory and illusory activity. Fig. 11, Win 2299 We repeated these studies with was a - 12 EEG LSD, and again the same patterns. There difference in the time constant, but concurrent with the behavioral effects we observed EEG changes. Recalling the ability of benactyzine to desynchronize records, this compound intravenously, and again, we observed the same we EEG administered pattern of desynchronization, associated with restlessness and excitement. While not observe the illusory and hallucinatory patterns, kinds of language changes in these patients that we we did note the we did same observed with diethazine. �Fig. 16, 17 Benactyzine The chemistry of these compounds Thus, from each of these agents, - EEG is noted in the next figure: EEG desynchronization was induced, and hallucinogenic or excitatory activity was observed. we can.now amplify our initial hypothesis to encompass hallucinogens. like to refer first to conclusions described in l9Sh by Wikler in a study of the effects of mescaline, n-allylnormorphine In-this regard, I and morphine in would man, in which he stated: ".... regardless of the drug administered, shifts in the pattern of electroencephalogram in the direction of desynchronization occurred in association with anxiety, hallucinations, fantasies, illusions or tremors, and in the direction of synchronbation.with euphoria, relaxation or drowsiness." ‘We would now generalize our observations of EEG changes and behavior to note shift to the delta behavior. Agents that and that agents that induce EEG synchronization range are potent agents in the control of psychotic induce synchronization in the beta range are relaxant, euphoriant and sedative, while agents that desynohronize the record tend to be hallucinogenic. This hypothesis lends itself to a variety of applications. It provides a bases for the understanding of the mode of action of various organic �-11- therapies in psychiatry. EEG analysis may also provide a basis for the assay of new drugs and therapy procedures. Finally, these observations permit a more rational management of the somatic therapies. to explore each application in summary I would like fashion. application of the neurophysiologic adaptive hypothesis - for that is the rubric under which we subsume the relationship between the The in brain function, reflected by the EEG, and the changes in behavior - to insulin coma therapy has already been described. we have changes applied this concept to our studies of phrenotropic agents, and have been able, both It is predictively and retrospectively, to assess new agents. possible to understand lobotomy therapy, and sleep therapy, within this framework. As is for the assay of drugs, our explorations into hallucinogens that each of the potent hallucinogens a biochemical similarity in a common tertiary amine radical connected one example. have new we have recently noted by an ethyl linkage to a large nucleus. compounds with this linkage. One On this basis, we sought for group are known anti-parkinson agents with anti-cholinergic properties as parsidol, artane, kemadrin, panparnit and benadryl. we have not yet tested these compounds for their EEG or clinical effects. Recently, Pfeiffer reported at the Academy of Neurology that these compounds, in trained subjects, were identified most with LSD. In 1956, Gottlieb reported that benadryl desynchronized the patients, much as we saw this evening. available in the literature. shock EEG of electro- Thus, some confinnation is �.12With regard to the third therapies - this hypothesis ammﬂication may - the management of somatic be of considerable help. In convulsive therapy and in drug therapies, the patient'who responds in a favorable fashion is‘no problem. But what of the patients who responds poorly, or not at all? Could the failure of response be related to inadequate dosage? In electroshock, when a patient manifests paranoid or withdrawal behavior, or no significant change, an If the record we may assume fails to EEG provides a guide to management. demonstrate high voltage slow wave that treatment has been inadequate, activity, then and continue the treatnent course or increase the frequency or alter the convulsant method. If EEG changes are present, then we would assume that other factors - personality, sociologic or interpersonal - are not conducive to "improvement" by electroshock, and other remedies sought. Similar applications are possible for phrenotropic agents. In summary, we believe that somatic therapies in psychiatry exert their effects primarily by altering brain function. Changes in the EEG Spectrum are one reflection of sudatalteration and are useful as a guide to the mode of action, effectiveness and application of somatic therapies. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Role of EEG Frequency Shift in Behavioral Effects of Drugs, 1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-12-011 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/371617534179d54e66d61621a46020c8.pdf 6e55d00563bbed3481f9a9906c445b08 PDF Text Text therapy, we hue ahead-red at individul wide response. Subjects duomtrete sue to equivalent number: or induced veriebﬂjkgy 1n digress of minim. EEG the EEG delta ee’dvity In the observations observed the to teeters of to be reported, the reletien webologic variability is amend. mam Ed Hethod: referred patients consecutive heapi’oelized malty-dive slammed.“ M with wire tested Subjects studied. therapy were ‘ im’TA‘MVvV «Ov1 M W the tor Bottleneck end ~ ~ within a week prior to treatment. ﬂeetreemphllo— wmdompriortotreemnt,endetweek1yintemledunng treatment. The records were wt! for the degree of induced deeoribed< previously indieee £5} activity using quentitetive Bad; petienh wee or imml’bbq Medea-eff. 5? Gem flaw. Reﬂexeither using week, times a three trotted instruments. I «M—-W-nuzwm: .4- HH' an. -\'. [UK/W Clo.) f‘ru’f a?) �heults: 1. Subjects with 1! and FC human moment (H), fem-color Rorschach responses showed induced delta (PC) signiﬁcantly lesser activity than subjects who had no such or bath amounts of responses. 2. Subjects with fewer Rorschach responses (R) and fewer total moment (Home) teaponses of delta activity. m 3. . The .. higher the malted simificantly greater degmee Wmmt «L test, the greater the «rot-beers on the degree of induced delta activity. gnawing: These studies describe a consistent tram perceptual responses and 041v w relationship between pre— obeemd degree of phtsiologic alteration following repeated induced cerebral trams. While factors of current, skull resistance, inherent responsivity of brain, 239. may affect the manifest physiologic alteration, that the subject's usual test eeores) affect the the EEG nodes of adaptation (reflected in his pemptnal physiologic response to cannot be viewed as it is also probable tram. In this context, in isolated physiologic index but is seen �Conclusion: Individual differences in the ma activity are related to have Insurer as latter the” differences in perceptual petteme. been shown to reflect pereomlity differencee, we would the individual'e node of adaptation ('persomliW') ﬂ“ Wﬁest chengef mtg; Physiologic ‘76 5359:: (me). suggest thet Wed—be We EFFE‘ ’1 \ would conclude that those aspects of experience and edaptetion that effect perceptual trauma. me the to at affect also responsivity tests �It't'f7 7-..“. Psychologic Factors in EEG Reactivity to Induced Cerebral Dysfunction In the course of an investigation of the role of alteration in cerebral function in the changes in behavior induced by convulsive therapy, we have observed a wide individual variability in the wide denonstrate degrees of Subjects response. EEG EEG delta activity to equivalent numbers of induced convu1310ns. In the observations to be reported, the relation of pSychologic factors to the Observed variability is assessed. Subjects and Method: Eightyafive consecutive hospitalized patients referred for electroconvulsive therapy were studied. Subjects wire tested with the Rorschach and the Gottschaldt embedded figure Sinai Modification) within a week test (Battersby — prior to treatment. Electroencephaloat weekly intervals during grams were done prior to treatment, treatment. records were measured for the degree of induced delta The and activity using quantitative indices previously described. Each patient was treated three times a or Medcraft instruments. week, using either Reiter �Results: 1. Subjects with H and FC human movement (M), Rorschach responses showed induced delta form-color (F0) or both significantly lesser activity than subjects who amounts of had no such responses. 2. Subjects with fewer Rorschach responses (R) and fewer total movement (MWFM+m) responses Showed significantly greater degrees of delta activity. 3. The higher the nambeehefepre-treatment error.score on the Gottschaldt test, the greater the degree of induced delta activity. Discussion: These studies describe a consistent relationship between pre- trauma perceptual responses and the observed degree of phisiologic alteration folloWing repeated induced cerebral trauma. While of current, skull resistance, inherent responsivity of brain, may affect the manifest physiologic alteration, that the subject's usual modes EEG etc. also probable of adaptation (reflected in his perceptual test scores) affect the physiologic the it is factors reSponse to trauma. In this context, cannot be viewed as an isolated physiologic index but is seen �activity interpersonal in the setting by influenced as one that is of the test situation. Conclusion: to related are EEezeactivity the Individual differences in have these latter as Insofar differences in perceptual patterns. been shown to reflect personality differences, the individual's mode we would of adaptation ("perSOnality") is related to (EEG). index the physiologic in manifest changes that those aspects of experience and adaptation tests suggest that also affect responsivity of the EEG ‘We would conclude that affect perceptual to trauma. ��_..,,, WWw-w ,, .w ”m.“ "Wm“. ‘WW..‘M_ . ,, ’w m—w"'1"‘mr-' W'sw-m-v-ni w ar— w..,._r..._.c ‘11ij ��EE 4» mm 0%; MW I'quw. ”a Mme-(W “,de '. d2. M + F6. Eneu. MwFt 0“ 2° (FMm) 2o " H. M ‘37) H’ (1.9.) e (:42) 6’40. 3 (I57. ($71 “-— .1 E4“ O'C) H I§ «2.) I2 Suﬁ.) (4°74 lo (“74) ‘— oS' - Esr' 0-4 .154; -3": �W M l4. 2 ,2, mm“ ' ”W 3‘!!- 4.6 ”M -?.I 2-! c. 2. 3 .0! non-I- ”*Fm-Ihs (a: EJfI-‘Il .(«y-h ��// 7%2.4“; M»! é 4,4...» r9 x‘W W. 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II 4+"I II III \' ' u {I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological Factors in EEG Reactivity to Induced Cerebral Dysfunction (research), 1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-9-008 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/866335cd8b6a0e848ec4f05bda1e57d7.pdf 610411ecffe18c07ab2ae5b0c8adcc8c PDF Text Text ZJ’W 4r 9, I; /y’7'.rf [E Wsﬁ%w‘> In a series of investigations of the role of neurophysiologic factors in the changes in behavior induced by convulsive therapy, that an alteration in brain function prerequisite, for behavioral it was concluded necessary, though not a sufficient was a change and "improvement" ( ). Changes in brain function were measured by a variety of indices, of which alteration in the waking was EEG induces a the most satisfactory shift in the EEG ( ). convulsive therapy consistently Spectrum to slower frequencies, with the development of runs and bursts of high voltage delta activity. m frequencyI? per-cent ‘ The degree and rate of development frequ However, there is'uide variability in the I‘ A voltageandr‘degree ,t/ ~e£-~h2rstr time treatment process [lay activity different subjects. With-equal—numbers—and developed ’7 at various stages of delta activity have been related to the age of the subject of treatment 1 Yet, when 1’ ), and mode ), frequency of induction (electrical, chemical, photo-chemical). the degree of delta these factors are held constant, variability in activity is it” ( ( of the still manifest (. ). Previous experience has danonstrated that both the behavioral reSponse Y and ratings of improvement to convulsive therapy a perceptualm processes as may be related to various " . number and type of Rorschach responses ( ), �score on the California F scale ( , ( ), and errors on figure-ground tasks dud. ); and to such sociologic factors as age, education level, place of fail.‘ W‘ M treatment m to explain the degree of the EEG the variability, this W W“? their perceptual-psychologic aﬁﬁability wt mm “a“ pie-treatment ofA W subjects, Ma ‘ ‘ EEG M“ characteristics WWWWMWW» Was“ can—ad. this M. It is the purpose of j study m~--~m to elate pre-treatment. SUBJECTS AND METHOD : W Gonsecutive patients referred for convulsive therapy in a voluntary psychiatric hospital were studied. 22 to so with a median of 149 c and depressive, schizophreniﬁ The patients ranged in age from years; and were diagnosed as suffering from psychotic cyclothymic reactions. While the range of conventionally applied diagnostic categories was ML 5" broad, the population exhibit} the cannon characteristics. MAI. (7414:444aA4;€7 a single ethnic f“ �OBSERVATIONS: l. Quaint. Variability of Induced-Beita—Activityt In the patients receiving convulsive treatment and investigated Mimi Mm , a} 1 M/b/ by the methods outlined, the variability in the Wed-Wotivity is considerable. We have summarized the observations in 1146 patients in Table I0 While the per-cent of records in the high degree category increases with successive treatment given at three tines a week, half the population has Aral“, a; Z:/£ not achieved..:the’ degree of—éelta activit}; in the third week, and in the fourth week. in all subjects. By the fourth week, however, 5% m ‘ y 140%“ is apparent �TABLE I £24 4314/4. Degree of Inducedﬁsihe Activity With Gonvalsive Therapy gPerﬁzem of Groug, Name) Treatment Period W ~lHts-Aetjjri’ox Mao—k ## First Rx High Degree Moderate Degree Low None Degree # Week Second Week ‘l‘hird Week Fourth Week 1-3 h-b 7-9 10-12 ‘ 14% 28% he?! 60% 12% 21% 27% 2275 68% h8% 25% 18% 16% 3% 2% 0% HH 3/58 �-72. BA «MM Relation of Pre-Treatment Rorschach to 3.4.3 *4 Variabili ”“2" In the analyses of parable-meat 21:3... Rorschach 7%). the number of responses andAqualitative aspects *ann—Iimaw.._ .. i’movement Mbﬁuywa/‘iée' related to the degree of induced tel-ta activity. Wm—uummuw z.»_..mM.m.w.w—m:"g:od Me “mum—.9... h re were signiﬁcantly fewer cup-us t W EEG and color were WWW ‘nv mu» magnum-u “a...“ m.» .own-ru‘m-v-u-m: ”4/. ML. m mm.mm wulmw‘w.m mm,,. ‘ that With gh "‘ were observed. WW We activity \ manifesting moderate and low degrees of such activity. degrees of Be W 133121911135 m deem-96") in patients with highNRgrees of -.._-----_---_:.§ w on those activity t , 3* - van.” w rv: .-mm—Nw-w,.bv,W M. In patients who were observed) avid; taéeported signii‘'ican significant differences in Mw‘m.mmq_,m.m-.~=m~ failed to report 44». M ”iv! movement WK ﬂy fewer EEG Low reactivity "égher degrees of 7 ”WW’ / , �... -_’.. .ymrw—W‘w~——-- -w'r“"" ~- v-vwam- / W- --»—',.w erw w �W-num z 19*; III ff ; “¢“-'—-h nqh-II-uylL-" '51? A expressed y‘TAIB'I-E ------ similar relationship is noted for color responses. Patients form-color“ in the Rorschach developed lower degrees of delta activity with treatment than those l or a , greater degrees of human movement who W4. expressed color, coior-forxnll . olor responses. Combining both 1W My who & movement and b color) 4“, Wobserved in patients w who gave nor form-color reSponses, than in those patients who neither expressed either or both these responses. Analyses for number of whole responses (W), per-cent of good form responses (F‘s-$5), significanttx 444% populago) and per-cent oi responses, failed to demonstrate Sawwuﬂ—v M relationships 1; the degree of induced an» activity. �II TABLE Relation of Number of Rorschach ReSponses to Induced wide-«4L EEG 9* Mean Activity $.13. Diff. Number High Degree Moderate, am Low Degree 3m 114.2 7.2 20.8 15.0 High Degree Moderate, b... Law Degree h. of Resgonses 6.6 Number 2.9 3J4 5.0 5.]. ’0 2.8 4L SR2 (.01 of Movement Reagonse 2.1 2.3 wE305 gM+Fm+m2 �TABIE Relation of Movement and To A/ Induced III Rorschach Responses golor EEG M» Activity Ht High Degr_ee .— 9* Moderatesz Degree h Sign; . Human Movement (M) 3? 20 (53%) 18 (147%) Other Movement (FM-m) 2f 20 (71%) 8 (29%) I? 16 (814%) 3 (15%) 33 17 (52%) 16 (h8%) x2== 39 (75%) 13 (25%) P 93 11 (148%) 12 (52%) x2= 7.60 25‘ 15 (60%) 10 (140%) p L .05 37 3o (81%) 7 (19%) No - Movement Form Color (FC) Other Color (C, or None Both mm Either M Neither M or FC nor FC CF 0-0) 52‘- X2= p 6.19 4 .05 3.88 4 .05 �.11.. 3. Relation of Pro-Treatment Errors §g§§gglo"1Variabilit In a previous study ( ) related to changes in the degree of on drug: is scored bveo Smx to q errors on the hidden-figures test were EEG ,1, $.4va eel-be activity and positive reaponses the amobarbital test for cerebral dysfunction physiologic responses into a to on Hidden—Figures Test % ). ( Combining the index, a range of changes from zero (Table Did)- The larger the pre-treatment error score, the greater the degree of physiologic change with treatment. The triserial ILL correlation is +0.3h, significant atA .05 level. TABLE IV In a similar analysis of the pre-treatment errors to /\ the difference just fails of significance Relation of Pre-Treatment 1;. Considering the Spectrum made. An initial some EEG Pattern to amongst EEG ( Variability. ) or these and frequency the subjects, an analysis of the of these characteristics and the study variabilityﬁlm./ (Table Nb). variability in modulation, voltage, in the pro-treatment relation between EEG EEG patients EEG nesponsivity was whose pre—treatment EEG �TABLE IV Relation of Pre-Treatment Errors in Hidden-Figures Test to Physiologic Variabili 132 (a) Combined EEG - Amobarbital Index: Miologic Changes Mean # Errors 6+ (8) 13.3 3+, u+ (19) 11.2 0 (lb) 7.9 5+ ) , 1+, 2+ ~= p +0.31; 4.05 34.» Mark (b) EEG Ma Activity nghﬂai‘ha No Highiﬁ: 5.13. Diff. 3,2, (31) 11.1; 7,7, (13) 8.2 4.? t p M, ms. �.13... manifested slow wave activity had demonstrated that high degrees of delta activity appeared earlier such activity, As was as per-cent M confirming earlier report} of Kennard and W'illner 1" Jawwnw correlated with the degree of induced dean activity, time/)del-ta- activity.* MIX; / in patients without ( ). 13h; pre—treatment per-cent time alpha one approach to the problem, activity h and were sustained longer than measured In 44 subjects, a correlation of +0.35) ‘05‘ week (10-12 treatment). treatment the observed fourth during level/was DISCUSSION : In these studies, the degreeof induced EEG delta activity during convulsive therapy has beer- related to pre-treatment perceptual and dwwations ure, patterns. “i limited and are scope in \\ 2' / concluszwgarding I these\ and d bservati theor data with clini of s th\consistencz \\ explomtiglng; ,2; 1,7 further warrants constructs "”” ‘"‘ ”” "W“ ‘ EEG [While {a 1m.“ reports the behavioral patterns of euphoria, hypcmania and denial were shown to be consistently inter- preted by the psychiatric observer or family as "improvement," While somatization, ).Improvement "unimproved,"( and in excitement rated were as paranoia panic, convulsive therapy has been related to such lire-treatment variables as high * Previously demonstrated as a correlation of +0.81; with degree of delta activity ( ). �scores on denial personality indices anal-eerie the California F scale )t , ( W M ); absence of ( cam-W color, human movement, form-color responses, low number of responses, or high number of whole and tests good form responses on Rorschach and foreign birth ( most highly esteemed, educational ( ) ). Thus, ( ); and low educational attainment in an environment where verbal therapy is patients least like the therapist in social Mattributes W are referred for somatic (or non-verbal) therapy. Under the conditions of induced altered brain WM function, those subjects with least ability Wm hypomania, '\ WW ‘ " , she I; reapond with non-verbal behavioral mode; of euphoria, denial, displacement and minimization, and are rated as M "W ” "“76"“! while Subjects with greater perceptual and linguistic discrimination respond with the more verbal patterns of paranoid, panic, somatization and anxiety, and are I/ rated unimproved. II In the observations reported here, the pre-treatment perceptual also related to the degree of physiologic response. 4 discrimmtion and verbal discrﬁptive ability degree of induced gum» The greater the mode is M“! on the Rorschach, the lower the delta activity; the fewer the Rorschach responses, the less ., �.15discriminating and the less the ability to separate figure from ground, W the greater the physiologic responsivity to induced convulsions. difficult to formulate a causal relationship fer—the—eepeetc—e£ It is clinical behavior,(both pre and post-treatment) perceptual patterns and physiologic response. But M M behaviors it ’L“’Z° is operationally meaningful to interpret these various W of the subject tainteraction with the environment, with each measure of behavior representing an abstract or sample of subjectexaminer relationship. In this framework the problem of the relationdhip between personality and physiologic measures is transformed "whether" to one of "how" and ”under What ccnditions." from one or In these series—aﬂ- subjects, heightened perceptual discrimination appears related to low degrees My» W25 MW Wluf / of alpha activity in routine, suite recording and decreased delta-activity- f06ﬂ””‘$ responssnity to convulsive therapy. In clinical behavior sudn subjects are prone to A tutu: introspection, anxiety and ideastional disturbances; and show poor improvement ratings to convulsive therapy. These observations are and EEG consistent with previous studies relating personality a5pects by Kennard, Ulett and Shagass. Kennard and Schwartzman related resting EEG spectra of low alpha index ( to schizophrenic personality, ) �~16- psychotics , non-mm, while high alpha index to Ulett gt_ a_l_. ( ) psychopaths and young individuals. indicated anxiety prone7ness was ﬂying: correlated with v M poor alpha activity, slow and fast activity in the resting record, and poor response to photic stimulation the sedation threshold amplitude of beta ( ), ), ( activity and with poor in the alpha range. In Shagass' studies of low was responsivity to barbiturate as measured by positively correlated with anxiety clinical response to convulsive therapy ( ' ). and tension Thus, behavioral reaponsivity and interaction, reflected in personalitytheoay ltheenyand psychiatric nosology by EEG may be m related to neurophysiologic reactivity as reflected patterns, within the limits of the sensitivity of our measurements or methods of experimentally altering (activating) both behavior Inherent in neurophysiologic responsivity are all and EG. the aspects of the internal milieu, as reflected in individual differences in biochemistry, and in the pre-treatment continuum as EEG record characteristics; the individual environment reflected in perception, motor patterns, mood’ and verbalization; but also the sociologic aspects of the individual's experience. In the series of patients studied here, an ardysis of educational level with degree of . responsivity demonstrated a I.‘ 24.,q me $45 a: D . 3 EEG V] ( - p< .02) relationvship. Subjects �years of formal education had a lower percentage of high 6&b’tgd7’a" 56w! degree records than subjects with less than eight years or education. \ with nine or m more /CONCLUSI ON: The variability in the degree of induced 5am) mm deb: activity manifest during convulsive therapy has been related to technical factors of the treatment. Yet, when these are held constant, (regs-365%; ' ' y has studies, been patterns. Patients with fewer variability is still manifest. In these related to pretreatment perceptual and EG number of responses, fewer movement responses, and absence of human movement, color and form-color responses on the Rorschach; greater errors on figure-ground discrimination alpha activity 026m) 00'“ ' had higher degrees or induced eel-te- activity. Physiologic reactivity, measured in EEG tasks; and higher per-cent time interpersonabv patterns; behavior, manifest personality measures and d scriptions of clinical or m different verbal behavior aspects of the interaction of subjects If environment. In mks framework, EEG and and personality variables are related within the limits of the sensitivity of the measures used' ��#3:» Mummmammmmtmmmmmmo Mumthanmwmhmwuwuw ). pmmummmtmaﬂommm( mmthCAMomhi‘ﬂmh'f ( . handmmmnwmu )yaaatomahmmctutountm,mumm,m plau.a£b1rth( ). mtmmmmumotuutmtmt imammnmmmummmmmmwamo and thud:in pmptu-luwyuholoﬂo prim, Wow 13mm m WWW. m mam... �swam: 3w m mm mm m cumm- ”that: studio‘s. for W110 3210 than” in a Wham patients runs“! in ago I'm 22 mwumandunorwmsaMnr-dhwumfm psychotic: Wain, mhiaophmic and W110 tho mum mtm‘. from mm minim range of uppnod mm sitcom: m baud, m mm (mum-mm:Maamcm(mhmmm «and common Wmmmum. - m: emu), mugmt and ﬁrst Wm. 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In eerlier reperte the behevierel patterns at euphoria, hype-enie end deniel were eheen he be ceneietently interpreted by the peyehietrie tenily eheerver e! ee 'ieprevenent', while eenetieetion, penis, pereneie end excite-eat were reted ee Inniepreved( ). leprevenent in eenvuleive therepy hee been releted te each pre-treeteent veriehlee ee high eeeree deniel pereeneiitw indicee (e )3 eheence Beele ( ) end an the Geiiternie r or been: eeveeent, color, toreoeolor whole or anther high nether 1e! e! er reeveneee, reepeneee, end seed for: reepeneee on lerecheeh teete )3 end ( lee edecetienel etteineent end tereign birth ( ). Thus, in en environment where verhel therepy ie eeet highly eetee-ed, petiente 1eeet like the therapist in eoeiel end edncetienel ( ) ettrihutee are referred for eeeetie (er nonuverbel) therepy. Under the aenditiene of induced �altered hrein reaction, thoee eanecte with leeet diearieineo ve tiee ehility reepend with non—verbal hehevierel Iedee o: enphorie, hype-enie, deniel, diepleceeent end linieieetien, end ere reted ee 'eueh improved”, while enhjecte with greeter peroepteel end linguietie dieerininetien reepend with the mere verhel petterne or pereneid, penic, eoeetiee~ tiou end enxiety, end ere reted 'uniepreved.“ In the ebeervetione reparted here, the prentheeteent perceptuel node ie elea releted to the degree of physiologic reeponee. the xreeter the perceptnel diecrieinetion end verhel dieeriptive ehility on the Boreahech, the lower the degree of induced elew were activity, the fever the hereeheeh reepeneee, the ieee dieerieiheting end the 1eee the ehiiity to eeperete figure In: ground, the greeter the phyeielosic reepeueivity te induaed aonvuleiene. It ie difficult to rereelete e eeeeel reletiehehip between clinical hehevior (both pre end peetetre%teent) pereeptuel �pottorno and phyoiologic rooponlo. But it in oporotionolly looningtul to intorprot thou. various tasks to rolotod behaviors of tho oubjoot in hit intorootion with tho onvironnont, with ouch nonsuro or bohovior roprouoating on obstruct or Io-plo or oubaootuoxoninor rolotiouohip. In thio tronowork the problon of tho rolotionship botvoon poroonolity and physiologic noosuroo 1| transfornon tron on. or 'whothor' to can of 'hov' and 'ondor what conditions." In than. Jobs-eta, hoizhtouod porooptuol disoriuinotion dogrooo of alpha oppooro rolotod to low activity in routino, waking rooordo and docroosod amount: of inducod slowing in such bohovior In oonvuloivo clinical to thoropy. coupons. ond idootionol to anxiety introopootiou, oro subject: pron. dioturhouooo: and shot poop inprovolont voting: to oonvnloivo thoropy. an... 1/ oboorvotioao oro conoiotont with proviouo studio: toloting personality and EEG oopooto by Konnord, Ulott and �shagaae. Kannard and subvertaaan EEG ( ) related reating apectra of low alpha index to aehinophrenic pereouality, while high alpha index to non-paycbetice, payebopatha and young indiviﬂuale. Ulett g§_5;, anxiety ereneneea and elow and wee ( indicated ) correlated with peer alpha activity, feet aetivity in the reating record, and poor reapenea to phetie atiaulatien in the alpha range. abaxaae' atadiee at the aedatien threshold ( In ), lav reepenaivity to barbiturate aa aaaaurad by amplitude of beta activity teneien wee peaitively correlated with anxiety and ), ( aonvulaire therapy and and with peer clinical reepenee te ). Thee, behavioral reapenaivity ( interaction, retleeted in personality concepta psychiatric neaolexy nay reactivity ae tetlected be by and in related to neurophysiolocio BEG patterna, within the liaita at the aeneitivity at our aeaaureaente er aethoda at experiaentally altering (activating) both behavior and mac. �Ink-rent in nonrophyliologic rcapensivity uro .11 the tnpccta of tho inturuni lilicu, a: rotlnotod in individual prootrostn§nt and 336 ditterouccu in biochonistry, in tho rtcord entrnotorictiolg the individual onvirounont continuum I! rctloetcd in porccption, notor patterns, need lad varbdiiaation; but also tho oeeiologio 33poctn of th- iudividnal'a .xparionec. In the scrioi at pati¢utc otudiud hnro, an anulyuiu of cduentional lovol with dear-o of rooponuivity danonatratud a aiguiricuut ( - p EEG (.02) relationship. Subjects with nine or sore yunra of tarsal cducttion had a lover parcentago at high degree slow unto oleotronruphie rccords than aabjcct- with yuurn or education. lot. thin eight �- 19 . COICLUSIOII The veriebility in the degree of induced aloe eotivity eeniteet during convuleive therepy to technieel feature at the treeteent. held cenetent, etudiee, BEG fit, were hee been when releted theee ee veriehility is still eeniteet. In theee slowing hee been releted to pretreeteent pereeptuel end EEG petterne. Petieute with fewer number of reepeneee, fever reverent reepeneee, end ebeence of hneen eaveeent, color end Rorecheohg greeter errore for-acoler responses on on the figure-ground diecriniwetiou teeke; end higher percent tine elphe edtivity hed higher decreee e: induced elee were eetivity. 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Inc... m mm 1mm. . �February 21, 1957 Individual Differences in EEG Responsivity Fink, MJD. to present observations Nbx 1) Problem tonight is in the laboratory of Ex- made perimental Psychiatry at the Hillside Hospital and then try to discuss their significance. we have no the clarification The problem explanation but wish to present this material for it may bring. is to account for the variability in EEG re3ponse to electroshock. The Observations: 1) Repeated EST induces EEG changes. These are of many kinds includ- ing disorganization of frequency; decrease in beta frequency, amplitude; increase in delta % % time and amplitude; delta bursts; spike charges; increased sensitivity to hyperventilation, amobarbital, There 2) is a direct relation in group data of (a) with degree of induced EEG time and dis- - # of treatments changes (b) frequency of treatment (c) type of ' treatment Note (gm or pm). that our analyses are devoted to one aspect of the EEG response - i.e., delta. quantitative measurements The and myself and included were bursts; slowest frequency 3) % and were described here time delta, highest 1955 by Dr. Kahn time delta, duration of highest amplitude of delta. But analysis of our records, so classified as high, middle and demonstrated a definite relation between the ment" % in EEG response and the "improve- in the behavioral\response. Presented at the Metropolitan EEG low Society, February 21, 1957. �In the first 2h table the was obtained: following patients, % High Abnormality 1-3 h—o 7-9 10-12 25 80 91 88 Moderately improved (6) o 16 so ho Unimproved (7) 0 0 O 20 (ll) Much improved first we were struck by this correlation, and, devoted the subsequent year to demonstrating the significance of this relationship. our conclusion - that, improvement You may know of in electroshock therapy requires the induction of a state of altered brain fUnction, of which the EEG-delta index is a cardinal sign. recently, More notes that 3 we at the part of our table which of 2h patients had high records within 1-3 treatments, and that after 10-12 treatments 5 ord! Why Let took a second look patients still had not achieved a single high rec- this difference? me demonstrate some of our records to show the difference in EEG responsivity to electroshock. It is first series all treatments were given in the in the latest by Medcraft - three important to note here that by Reiter instrument; and times a week. That extraneous ulus was eliminated, all factors as threshold or suprathreshold stim- recent treatments have been given at threshold stimulation, achieved by Dr. Green by repeated PM a seizure resulted. 1) . High EEG 2) Moderate 3) Low EEG response. EEG - Lesnick response. - response. Baum - Silverwater in increasing dosage until �To what can we ascribe the difference in response? immediately come to mind, and I will discuss each one A number of factors briefly: (a) .553: is a factor in this varying responsivity, but not the sigIt is true that some younger patients achieve high EEG abnormal- Age nificant one. ity early; as first two patients over 60; but an analysis of the data of our electroshock studies, for which I am indebted to Dr. Green, indicates do some age to play a small role. Analyzing the records of h9 patients, Dr. Green divided the results in- to those above and below hS; above and below 50 - as significant cut-off points. There was a tendency for the older group to have lower EEG ratings in the h-é period; but by the 7-9 period, the differenCe was gone. ' (b) ‘ §_egc_: Clearly not a factor. (c) Clinical diagnosis: is difficult to assess. As you know, clinical diagnoses have no independent reliability. They are approximate descriptions of experience, clinical states and depend largely‘on the examiner's‘bias, setting This factor [of the examination, purpose,etc; also on the patient's age; and only incident- ally on any operationally defined observable pattern in the patient. For these reasons, this analysis is deferred. However, gross more inspection shows that patients with low reactivity have often been called schizophrenic and paranoid, than involutional depress- ives and manic depressive- and that patients with high reactivity have more often been called involutional depressives and manic depressives than schizophrenia-paranora. -_-——-————————-——— of treatment: �-h- significant factors, and since we are describing the results of individuals treated in groups in whom these factors were constant, we are Both are not going to explain this further than to say that stances, to convert a low a high EEG it is possible, in some in- response to three times per week electroshock to response by going from Reiter to Medcraft; or by going from three EEG times per week to five times per week or twice a day. But these factors only amplify further the variation in response. Egg. DeFede We have assumed abnormality We is have looked appear that the development of cerebral changes, of which delta a prototype, for is the logical outcome of repeated electroshock. an explanation, therefore, of the after adequate courses of It may be may reSpond by failure of delta to shock. that not all patients respond to brain trauma by delta, but other changes (as increased beta voltages and frequency; or increased disorganization; or increased responsivity to hyperventilation). Regardless of the construction, a difference in responsivity exists, and is manifested in our series. we have The factors conceptualized the problem as one of "cerebral reactixdty." we have already outlined are important in such reactivity, as have described, but we believe that more is involved. Out studies are we new in the progress along the following lines: 1) 222 Factor of Personality: In the course of our study of factors which bare on the type of behavioral response euphoria, paranoia, withdrawal define personality -), we to electroshock (i.e., denial, undertook a study of personality. To is extremely difficult. But Dr. Kahn in our laboratory has done so by the use of a variety of indices. The Rorschach; an interview with relatives designed to elicit premorbid behavior, eSpecially denial; figure-ground perception; tachistoscopic recognition of words, 32g. �To our surprise, significant correlations between the degree of delta abnormality and two Rorschach factors I score were achieved. 63 and the patients, EEG have listed the table of in the h-6 score reflects a low or middle The IS as well as the denial interview M & C initial in scores our responsivity. The EEG's were done CHART (M & C) EEG and 7-9 treatment period. The negative response; the plus, a high reSponse. THEN REFERRED TO significance of this chart is in the "apparent" diverse phenomena that it purports to relate. If borne out by future observations, it states, that patients who'have no movement responses and either no color or color-form responses have hh% chance of high EEG delta reSponse in the 2nd and 3rd week of treatment; while patients with Form-color reSponses have only a for such a 16% chance result. it be that one's perception of the world is directly related to one's cerebral respOnsivity? Or, do the conditions which permit delta to appear, that is, those that require an ability to withdraw and assume a passive Could ree Ostow described attitude as by for alpha index, also midify the patient's sponse to the Rorschach? we have become increasingly interested in this problem of passive choose to describe attit- it - in the problem of "vigilance" - "alertness.“ In our laboratory, Drs. Pollack and Kahn are engaged in developing psychophysical ude, or, as we measures of such "vigilanceg" while we have become increasingly aware of the influence of the observer's activity on the ongoing 2) A second factor which EEG. interests us with regard to the problem of in- dividual responsivity is the concept of physiologic reactivity. Electroshock �EEG (17) ResRonsiviﬁz to ECT or R (58) GM 00 2 OM czyc h (33) h (33) 7 M CE/C 3 (30) u (no) M 00 1 (25) 2 (50) OM M m FC 5% level of conf. S (71) 9 (50) h (22) 12 10 �is a way of inducing certain diffuse chemical changes in the nervous system. So is metrazol - barbiturate - activation technics it is show - hyperventilation. significant variation in responsivity. hypoglycemia Each of these For example, that hyperventilation induced delta readily in some patients - eSpecially children - but in others, no such response is noted. Dr. commonly known Green of our laboratory has hypothesized, and is now studying, the possibility that a degree of physiologic responsivity - which is measurable - is an inherent characteristic'of organisms. To this end, he is carrying out pretreatment activation records in all our subjects; as well as measuring their threshold for in EEG depend. electrically induced convulsions. I am confident that there are other "factors" on which responsivity to electroshock - and perhaps to all activation - we the variation may the ones described, namely personality, vigilance, are excited by and physiologic responsivity. tonight, not the common characteristic of the EEG response to activation, but the individual variability and the factors on we have emphasized which this depends. 'We have tried to exemplify our problem by our data of the variation in delta response to electroshock. Further study of each act- ivation technic to relate the role of personality, vigilance and physiologic reactivity to the variation in EEG responsivity. �-3and middle (lower socio-economic upper lower (Jewish)! ' j , ~ first The generation, group. and _ ideation‘ mood , responses. W; in the first hospitalisation, of Psychiatric . psychiatric bellman” «read-tune class), immigrant and were ' patterns we 114' W. They use voluntaﬂeﬁon‘ar predominantly 1, with a short period (few months to few years) illnesjzlectroconvulsive treatment was administered three «W “M'- _ times a week using 1hr % WM mthods. rﬂ L3 r . suprathreshold unidirectional or alternating current A“n*”"t ”WA a Jayne/1nd“! 11’ ﬂat man !0 ti 3.: Wig Ml’" {M-dtun ﬂit/“23‘ Within a week prior to treatment subjects were tested with Rorschach and figure-ground discrimination for presence or absence of j ,x’”‘\_, [I 2 responses and total (H + EM+ tasks. The Rorschach human movement protocol was scored responses (M), total m), type and number of color responses (0, movement CF and F0) In the figure-ground discrimination task, a, () modification of Gottschaldt's hidden figures, the subject number of responses (R). L niacin-mam is presented with and below it a page containing two forms a cmnplex figure in which the - a simple geometric figure, simple figure is embedded. The task is to outline the embedded figure in the complex figure. I' ”A4€ "- ad‘ Electroencephalograms were obtained prior to treatment, andweekly“ on a day following a Mamie, treatment. Patients whose pre-treatment records contained �measurable delta activity were excluded from the study. slow wave activity frequencies of and 7 W MW was measured 04, wave actiﬁty, Based on these activity in the record. of induced by determining the per-cent time of and—less three selected in cps, highest amplitude of slow The amount and leads; the slavest frequency / longest duration of burst indices, records were classified as pan/40M "low," "moderate" or "high" degree delta- W previously described of high degreesdeébba ( activity, according to criteria ). In the observations reported here, the activity in the second and third development weeks of treatment treatment intervals) was used in the tabulation. Patients who M. (We, developed high WWactivity during either or both these periods were classed in 3 of delta degree the high degree group. Those whose records did not demonstrate activity in either ,week were classed in the moderate-low class. 7-9 tt%gree or" �watt—baa WI? “H.“HQ mammmuormmmummmwm "mu alum, that «warm ant m1: of “Mom (W m). In Guide“ the “mummy in mum, vellum, m rmwmmwmmmmmtm mm,“ Wsamunugmmwmmmmmumum mﬂWNudl. MMM3M( )orthmputmtlm mmzmwmnmcmutmwmammwmtw mama in aetiﬁirapmﬁ muormdmmmalmthm such with“ «mum mm mmm< mm an «mu- apart at W )., «mapmwmmmmpmmmm ”mtg-lam muey m “rant-d nth tho W W ma of as pass-mm was at such wuvﬂyw In mum «1' ”3.“, +0.35, " m1: {'“4‘. ..., am “tax”; 44”.. a l1" an activity. tom-rm autism, tho .05, w a WW 2.3.2.1.“ Wmudu‘mumormduummwmu � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Individual Differences in EEG Responsivity Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-6-006 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence. Drafts, one with Martin A. Green and Robert L. Kahn Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/d01fea06dd83b521f86d15c567b14a69.pdf 5db07271542a5e11cdde7c401a2c6afa PDF Text Text ��s [.9 227mb, ‘5)04 ..: L M ~17!ou ' m ,1 Z 0 is ,« , 042454 “11“., m «:4 ’ ‘ ,J‘vmw& —!—.‘W_ ��W ﬁfw_“______‘______Wr r M l)CZ¢/vw€u M“ @WLE; $54: W gm . KW C Z’W ‘TN’M 2r 3) am! Vn. Fr‘e—L WW’ Am); Maﬂuﬂ/EW/ �INDEX TO ADVERTISERS _ PAGE AAAS ........................................................ 5, 394, 396, Inside Back Cover American Tobacco Company _____________________________________________________ Back Cover Columbia University Press _____________________________________________________________________ 6 Ford Instrument Company ______________________________________________________________________ 391 International Equipment Company _____________________________________________________ 398 Johnson Research Corporation..--__________--_.____-________________-_.-____; ______________ 5 Macmillan Company _________________________________________________________________________________ 8 Measurements Corporation _____________________________________________________________________ 6 Microcard Foundation _____________________________________________________________________________ 392 Oxford University Press, Inc ________________________________________________________________ 391 Rinehart & Company, Inc ________________________________________________________________________ 394 Ronald Press Company ___________________________________________________________________________ 2 Schwarz Laboratories, Inc ______________________________________________________________________ 4 Ivan Sorvall, Inc ______________________________________________________________________________________ 7 Taconic Farms, Inc __________________________________________________________________________________ 394 University of California Press _______________________________________________________________ 393 University of Chicago Press ___________________________________________________________________ 3 D. Van Nostrand Company, Inc _____________________________________________________________ 395 John Wiley & Sons, Inc .......................................................................... 397 399 ��£32 » . x : ‘ . . . , V ( - 4 ‘ V ‘ ‘ ' . , \ . , - '1' ”:5. .9. ,2; «E a‘ ,7;- 7- \77 ‘- . _ mtg if} m: 34ifv; 5:32;: ;. ‘ , er?” is VF» ‘ﬂh‘flaz: ”r: 91‘;._;.;..,.::_:.»’~~:_V ;‘;,».+~:-.éé ,5». ifp. ,, ..~- .393, - ,_-_».;,-,-« r .- - ' - 2 . . �DEW? 17; 1956 Gamept of Gamma]. Localisaﬁm to Hana Action Effects 1) Certain functionnascribod to CNS are "localiaable", as motor power, motor aphasia; while others, an memory. Judgment, Mm, insight, m1- culation, figure-ground, m nmlocaliuble. The first. greup am aortical (mom pariphemi than antral); damage is generally permanent; will lenient! have maimed exam; and EEG is usually not pathological. lam-vloodiubla lesions are generally deep or basal; mowezy at m:ctim is possible; null lesions have no effect (1w. at mass wtian 1am in The effects are pmﬁnmt. 2) m results in a nonuloealiuble lesion .. with diffuse Mfmcﬁwa is the teahnic gxgalleneo to study such mass whim lesiom‘ applieabla) and It 3) EEG a; Psychological tests ’of ”OW” am positive to the dogma that they measure mass action affect»: ram” than focal - exaept it focal interferes with pexfbmnoe as in lesions meating 75.31011, actor power and mum speech» 1;) Concept of Active vs sum Lesions! In studies of head insulin, lobotom and post. apex-nun me! of an or more mths duration, the atudiaa reflsct 100311111313 (cortical) Meats mainly: for the deeper activities am no lager active“ Any defects in hm» cticm am expresaima of speciﬁc certioal laculinbla W» mtmst, studiee of brain tumors, immediate post-tnmtie statues, post-v 19mm, and EM (early) are stud-m or active dysfunction - a. cambinntim of the focal and the diffuse defeats. m degmo of: dysmnction depends on the ma In offset, plus the localised defect. �J.A.M.A., Dec. 13, 1958 PNEUMOTHORAX—MAURER ET AL. 2014 ination revealed adherence of the fundus and nodules throughout the adnexa. A diagnosis of pelvic endometriosis was made, and on Aug. 18, 1955, total hysterectomy with bilateral salpingo-oophorectomy was performed. The patient’s postoperative recovery was again uneventful. In the four and one-half years after the thoracotomy, the patient has had no recurrent chest symptoms or pneumothorax. Comment Aberrant endometrial islands have been reported in many locations, including the ovaries, uterine ligaments, rectovaginal septum, sigmoid colon, urihernia umbilicus, bladder, laparotomy scars, nary sacs, appendix, vagina, vulva, cervix, lymph glands, and small intestine, and in bizarre locations, such as the upper and lower extremities, lungs, and pleura.l Sampson’s2 original theory of transtubal regurgitation of menstrual blood and endometrial particles, published in his original paper in 1921, could certainly explain the method of implantation of endometrial growths on the pelvic and intraabdominal viscera, as well as on the inferior aspects of either leaf of the diaphragm. The lymphatic and hematogenous dissemination theory of Halban would be necessary to explain distant endometrial implants in the thigh, lung, and pleura.1a Distant spread without passing through the pulmonary capillaries could occur only by way of the vertebral veins or “lung shunts” which have apparently been demonstrated between the pulmonary arteries and veins bypassing the lung capillaries. In view of the concomitant ﬁnding of pelvic endometriosis and the involvement of all layers of the right leaf of the diaphragm, with perforation and supradiaphragmatic seeding demonstrated by thoracotomy, in the present case report, it would seem logical to conclude that the endometrial involvement of the diaphragm must of necessity have occurred as the result of transtubal regurgitation and transperitoneal dissemination. Exact explanation of the method of development of the pneumothorax on the right side is more difficult. However, the clinical observation that all episodes of pneumothorax occurred only during the time of menstruation, and the inability to demonstrate any source of lung leak or primary disorder in the lung which could explain any possible leakage of air into the pleural cavity, would suggest that the recurrent pneumothoraces in the case reported here were the result of erosion and perforation of the right diaphragmatic leaf by endometrial implant and the fa]of the from the of air by uterus way passage lopian tubes into the peritoneal cavity and then by way of the opening in the diaphragm into the pleural cavity, with consequent pneumothorax. Although we are unable to ﬁnd any reports of spontaneous pneumoperitoneum occurring during the menstrual cycle, the practical possibility of this is suggested by the free anatomic communication between the cavity of the uterus with the peritoneal space by way of the fallopian tubes. Practical application of this knowledge is regularly used in the so-called Rubin test for patency of the tubes. During this procedure, carbon dioxide is passed into the uterus and then by way of the tubes into the peritoneal cavity. During the test, patients may experience shoulder pain and present roentgenographic evidence of pneumoperitoneum. Summary Chronic recurring pneumothoraces resulting from erosion of the diaphragm by endometrial implants during periods of menstruation occurred in a young woman. This was surgically corrected by excision of the involved portion of the diaphragm. The un— anticipated ﬁndings encountered at operation in this patient present an additional indication for exploratory thoracotomy in all cases of unexplained, constantly recurring, spontaneous pneumothorax. 827 Union Central Bldg. (Dr. Maurer). References 1. (a) Novak, E., and Novak, E. R.: Textbook of Gyne- cology, ed. 5, Baltimore, Williams & Wilkins Co., 1956, p. 546. (b) Nunn, L. L.: Endometrioma of Thigh, Northwest Med. 48:474—475 (July) 1949. (c) Hartz, P. H.: Occurrence of Decidua-Like Tissue in Lung: Report of Case, Am. J. Clin. Path. 26:48-51 (Jan.) 1956. (d) Hobbs, J. E., and Bortnick, A. H.: Endometriosis of Lungs: Experimental and Clinical Study, Am. J. Obst. & Gynec. 4:832-843 (Nov.) 1940. (e) Nicholson, H.: Endometriosis of Pleura, Thorax 6:75-81 (March) 1951. 2. Sampson, J. A.: Perforating Hemorrhagic (Chocolate) Cysts of Ovary, Arch. Surg. 3:245—323 (Sept) 1921. FUNCTION OF THE BRAIN.-—Any biological view of the function of the brain leads us to an unavoidable conclusion: consciousness is not unique to man, to the primates, or to the mammals: it goes back to the roots of vertebrate history and has been progressively elaborated in content, coloring and complexity roughly in proportion to the evolution of the neuromuscular system. It cannot even be argued that consciousness is a unique vertebrate invention—the crab, the octopus, the butterﬂy, the ant, all possess sensory devices imparting to them the awareness of their world; all demonstrably engage in integrated time-binding, self-serving action, and it must be presumed that all participate in some proportional measures in conscious awareness of themselves and their environment—H. W. Smith, The Philosophic Limitations of Physiology, Perspectives in Physiology, Washington, D. 0, American THE Physiological Society, 1954. �2013 Vol. 168, No. 15 TO DUE PNEUMOTHORAX SPONTANEOUS RECURRING CHRONIC ENDOMETRIOSIS OF THE DIAPHRAGM Elmer R. Maurer, M.D., James A. Schaal, MD. and F. L. Mendez Jr., M.D., Cincinnati Chronic recurring spontaneous pneumothorax is results which disorder usually common relatively a from rupture of subpleural blebs. Endometriosis of the diaphragm, on the other hand, is an exceedingly has be determined, lesion as and, nearly can as rare never been reported in association with, or as a cause of, unilateral recurring pneumothorax. The following case report is presented because of the extreme rarity of the lesion involved and the unusual association of pneumothorax with the menstrual cycle. It is the ﬁrst recorded instance of successful surgical treatment of chronic recurring pneumothorax by excision of a defect in the diaphragm that has resulted from endometriosis. communicated This diameter. in 2 cm. was an aperture freely with the peritoneal cavity. The area of disease in the diaphragm, along with the defect, was widely and completely excised. The consequent diaphragmatic opening was 0. size of cotton, sutures mattress with interrupted repaired Examination of the specimen showed that the disease had involved the complete thickness of the diaphragm. Final inspection of the superior surface of the diaphragm revealed which 1 in diameter, nodule, cm. purplish-red a solitary obviously represented a supradiaphragmatic endometrial implant. This also was completely excised. Following reexpansion of the lung and the placement of an intrapleural catheter for water seal drainage, the chest wall was closed of endometriosis diagnosis was The postoperative in layers. the right leaf of the diaphragm resulting in perforation and Report of a Case A 35-year-old woman was ﬁrst seen in consultation on March 13, 1953, because of pain and dyspnea resulting from a spontaneous pneumothorax on the right side. The patient had had two previous spontaneous pneumothoraces 1952. Nov. 14, occurred ﬁrst on the having the right, on Findings on the general physical examination were negative except for distant breath sounds over the upper right part of the chest and hyperresonance of the percussion note due revealed chest of the Roentgenograms pneumothorax. to a a very minimal pneumothorax (15%) over the extreme apex and the base of the right lung. No emphysematous blebs were apparent in any portion of either lung. Because of the small quantity of air in the chest and the absence of serious thoratube thoracentesis or of air the by removal symptoms, costomy was not thOught to be indicated. The patient was discharged from the hospital for follow-up care by her attending physician. She was again seen in consultation on March 20, 1954, approximately one year after the original examination, because of 12 new episodes of recurrent pneumothorax on the right side. All pneumothoraces were associated with pain and mild dyspnea and had been veriﬁed ﬁrst the chest. For of the examination by roentgenographic 15 all that information the volunteered the patient time, episodes of spontaneous pneumothorax had come during the period of menstruation. The important clinical signiﬁ— time. the at appreciated not observation this of was cance Because of the chronicity of the lesion, open thoracotomy with possible talc poudrage and excision of any blebs that examinaroentgenographic been on have apparent not may tion was recommended. Right thoracotomy on March 31, 1954, revealed a persistent moderate pneumothorax on the right side. Careful examination of all lobes of the right lung revealed no evidence of blebs. Testing of the lung with positive pressure, while saline solution was dripped over the surface, disclosed no points of air-leak. The lung parenchyma grossly presented a normal appearance and consistency. The most re— markable ﬁnding involved the right diaphragm. Near the point of emergence of the inferior vena cava and extending radially and laterally in the central portion of the right leaf of the diaphragm was a circumscribed, oval-shaped area of attenuation which measured 4 by 3 cm. in diameter. Numersurface. this modulations on apparent were purplish-red ous In the central portion of the diseased area in the diaphragm Photomicrograph of excised lesion, showing, endometrial stroma and glands extending through ﬁbromuscular structure of diaphragm. implant of endometrial nodules on the intrathoracic surface of the diaphragm. Microscopic examination of the surgical specimen showed extensive involvement of the ﬁbromuscular stroma of the diaphragm by nests of endometrial stroma and glands (see ﬁgure). The single nodule on the supradiaphragmatic surface was composed of endometrial tissue. The postoperative course of the patient was entirely uneventful, and she was discharged from the hospital on her ninth postoperative day, being afebrile and ambulant, and with her right lung completely expanded. Because of pain in the pelvis and dysmenorrhea, the patient was seen by a gynecologic consultant. Bimanual exam- � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Consciousness studies (notes), 1956-1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-5-005 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: notes: consciousness studies Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/4e44a5022aa24b8167f7810c1ba666eb.pdf 6c8bb654be03cc6faa66ea6f3e6b84ab PDF Text Text ��mm“mh«f.~«»-MM ��Patients with High Delta Activitv during Second, Third Weeks of ﬁeatmnt. Clinical Katina EEG Delta Both High High One None [ﬁramwr - high Moderatelz Imgroved Unimproved Much ImEroved (18) 12 (67%) h (22%) 2 (11%) (16) h (25%) 8 (50%) h (25%) ('20) 6 (30%) 7 (35%) 7 7mm] - (35¢ ��Clinical Ratings Cogpared to EEG and Amobarbital Test Results much Improved High Delta and Positive Amobarbital (29) Either High Delta or Amobarbital (26) Positive Neither High Delta nor Positive Amobarbital (36) [arm - x7414] Moderately Improved Uhimproved 25 3 1 10 ll 5 5 10 21 �and Ruth. Mt: M (29) man: or mum Mu ('16) mm may am: at num- Etc: man Mm mg: (36) �mm. (29) min: mm: W mu a:- mum - Mus m! “WW“! (3% �EEG Delta - Amobarbital Test Delta Activity; Records Middle Low High EEG Amobarbital Test Positive Negative [ﬁﬂ'ﬁ/ - Ifxg' (15) (346) 29 8 8 10 16 20 �(cast rbi Positive (’35) , (M) negative ,.. ! i ,‘ [I \ . I A ’ H' -,‘ I x ‘\\| x\.‘. \ x K i r ‘ 1 (j. ‘\ ; 1 I z E 10 16 20 ��A.m..‘+l__-.A_MA;.“__ A... < �; a M ��uhL—JCICHXU m I Prepared by “MS WEEK IN CHICAGG {DE—JD C) {SINH “ﬁg“ “UL—:X‘Cl A W «LE .00 N ��MURRAY 11an 8-2077 S. F. KURZER VICE-PRESIDENT IN CHARGE OF SALES GRUNE 8: STRATTON MEDICAL PUBLISHERS 381 FOURTH AVENUE NEW YORK 16. N. Y. ��M Merri/ébﬂ M HOTEL WILLIAM HENNING RUBIN PRESIDENT FAMOUS FOR THE "5"" OZMMMC ' — CHICAGO JOHN B. GRANDE GENERAL MANAGER WHERE FAMOUS PEOPLE EAT ��ESRA No. 37 1957 Program -1- ELECTROSHOCK RESEARCH ASSOCIATION SCIENTIFIC SESSION- Thirteenth Annual Meeting Sunday, May 12, 1957 Hotel Morrison Chicago, Illinois Chairman: Ernest B. Parsons, M.D., Pres. Cotillion Room A.MJﬁ: 9:00 Registration \v 9:30 A.M.' 1. 9:45 10:00 2. 3. rNeurophysiology Studies of EEG change with EST with or without Atropine in Man and Rat. Tetsuo Fukuda, M.D., John A. Stern, Ph.D., George A. Ulett, Ph.D., M.D. Discussion opened by: Bernard L. Pacella, M.D. . A.M. A.M. . 15A X/ MIL u 10: Mm" “2?? 30 W1? A. M. Psychological Aspects Personality Factors affecting Clinical Responses to Electroshock Therapy. Robert L. Kahn, Ph.D., Max Fink, M. D. An Evaluation of the Peculiar Selective Quality of Pos Electrotherapy Amnesia. Aloysius S. Church, M.D., 5}t Psychopathology of Electroshock Therapy. W“ ,,. 10:h5 A.M. Bernard L. Pacella, Discussion of 2, 3, 5. 11:15 A.M. Technigues Current Patterns in Cerebral Electro-Therapy. 6. 11:30 A.M. l1:45 A.M. M.D. & 4 opened by: Leo Alexander, M.D. Gerhard Hirschfeld, M.D. Further Studies on the Analeptic Action of Peripheral Electrical Stimulation in Hypoglycemic Coma. Charles H. Jones, M.D. Discussion of 5 and 6 opened by: William L. Holt, M.D. R. Embassy Room P 12:30 to 2: 30 PM 105/” Annual Luncheon and Business Meeting. �' -1- EJJ .. » .u ..., 111'. .j,. . . 4 . ,.‘... ,, - . v 7. ‘ 6‘ r: . . -. - ....£x~ ~ . .“- . .." ' ‘ . -. ‘ ;-‘ . ' . ,.. ... ' -. : I , .-. ..‘ d.I ’ "x - s 1' .- ., L «i=2» '_ " . . f‘: .1)- 1'! 1 ~ I \ WOV'.J“%£M{1A .. ‘ t 4. '- .' . :- .- .- \‘J.'\ .r. . ‘ :' ..:.'.-.3 .~... .. .. ”-0.“.-. : . ' . n}. I . . -,-.L z .‘ ' . 1‘ ' . ‘ ‘ . 5“ma...— ’ ‘I ‘ - -- ‘ ' " ' . . �ESRA No. 37 Cotillion 1957 Program -2- Room 7. 2:30 P.M. 8. 2:45 P.M. 9. 3:00 P.M. 3:30 P.M. 3:#5 P.M. 10. 4:00 P.M. ll #:15 P.M. #:30 P.M. Clinical Aspects Clinical Applicationscﬁ'Nonconvulsive Electro-Cerebral Stimulation. John D. Moriarty, M.D. Indications for Electroconvulsive Treatment in Office Psychiatric Practice. Paul H. Wilcox, M.D. Discussion of 7 and 8 opened by: David J. Impastato, M.D. The Use of Electra-Cerebral Stimulation in Mentally Defective Patients. Harold H. Berman,M.D., Milton ’ Jacobs, M.D., and Joseph Spielman, M.D. Discussion opened by: Charles Buckman, M.D. Drugs and ECT A Comparative Evaluation of the Safety of the Use of Chlorpromazine and Reserpine in Conjunction with Electroshock Therapy: A Review of the Literature and a Clinical Report. David J. Impastato, M.D., Seymour Berg, M.D., Anthony R. Gabriel, M.D. Electroconvulsive Therapy Combined with Chlorpromazine and Reserpine. Frank J. Ayd, Jr., M.D. Discussion of 10 and 11 opened by: Herman C. B. Denber,M.D. ��___.._——.————~—————-————-—————— _m, —-———~———_.———..——————-————-——-——— �mm“. Wm -_ w— _———~——————————_— ! —-——-————-—————__—____.__.._.— p.4— ““—.— __.._._____.. ————————————___——-——____—._— _____ ‘ . __ __ ~ ___.___ .____ ._..._ _ ...___.__._. .— ��w v«w 1. w VW. . ,_ . . wv ﬂ . 9 «x; M“ a? s. ks \ x\ W”. x ‘ \ tn .\n. as .9: ��l L. . x, 93‘1“” nerT/‘wr'y . ‘ V. t i Mm,» ,‘(Z R �rwﬂ‘mrﬂ~“w~&uwwé_é< Wn:~'5~‘~".m . l _ __-. A—e ,...r‘_;..,1... , �PUBLISHED BY INFORMATION SERVICE VOL. 9, NO. 10 OFFICE OF THE MEDICAL DIRECTOR Available to non-members at 35.00 per year. JUNE-AUGUST 1957 (SUMMER EDITION) Dr. Alan Gregg Dies APA Honorary Fellow Dr. Alan Gregg died at his home in Big Sur, California on June 19 at the age of 67. He served as Vice-President, Division of Medical Sciences, Rockefeller Foundation for two decades and in this position of national leadership made psychiatry one of his major interests. Few men have had so profound an effect on the advancement of medical sciences as he. He will be sorely missed by physicians the world over and by psychiatrists most particularly. NINTH MENTAL HOSPITAL INSTITUTE For the ninth year over 400 staff people from all types of mental hospital installations in Canada and the U. S. will come together at the Hotel Cleveland, Cleveland, Ohio, Sept. 30 Oct. 3 to consider common problems and directions of progress. Major topics at this year’s Institute will deal with the problems of the open hospital, revision of commitment laws, management principles, role of private hospitals, mental deficiency as a psychiatric problem and many others. Prof. James L. Hayes, Department of Business Administration, St. Bonaventure University, will deliver the Academic Lecture. The enrollment fee is $50. See program and registration form in Mail Pouch. - All who plan to present papers at the 1958 Annual Meeting in San Francisco please note Form for submitting proposals to the Program Committee in the Mail Pouch this month. NOTICES 1. THE ANNUAL APA DESK APPOINTMENT BOOK FOR 1958 WILL BE OFF THE PRESS THIS SUMMER. USE ORDER BLANK IN THE MAIL POUCH. DEMAND EXCEEDED SUPPLY LAST YEAR. SUGGEST ORDERING PROMPTLY. ($3.00 PER COPY). 2. WE HAVE A FEW HUNDRED COPIES LEFT OF THE BOOK OF SUMMARIES OF SCIENTIFIC PAPERS OF 1957 ANNUAL MEETING, BUT THEY ARE GOING FAST. ($1.00 PER COPY). THE AMERICAN — GRADUATE TRAINING IN PSYCHIATRIC HOSPITAL ADMINISTRATION Two outstanding courses in psychiatric hospital administration are now available and merit the attention of all psychiatrists concerned with advancing professional standards in this area. One is at Columbia University and the other at the Menninger School in Topeka. The Columbia University Course This course, which leads to a Master of Science Degree, is under the auspices of the School of Public Health and Administrative Medicine and the Department of Psychiatry of the Faculty of Medicine. It encompasses basic courses in administration, specialty courses in the Department of Psychiatry, and supervised field work. Recognizing that mental hospitals are hard put to let a staff doctor leave for prolonged periods, Columbia has made every effort to tailor the course to meet candidates’ needs. It extends over 20 months, but ei ht of these are in academic residence broken into four quarters of 2 months each. The preferred plan is for the candidate to spend four months in academic residence, followed by 12 months in a supervised administrative residency or in a position already occupied by the candidate during which time he may carry out a special project. This is followed by a final four months in residence. For candidates who already occupy key administrative posts and who cannot be away for more than one quarter at a time, special arrangements can be made. As for costs, each candidate’s need is likewise evaluated individually. The total tuition for the 8 months of academic residence is $900.00 and Public Health Service stipends are available which will pay this plus ordinary living costs. Frequently, state funds in the state where the candidate works, are available to pay travel costs. There are some openings for the year starting in Sept. Write for details to: Exec. Officer, School of Public Health, Columbia University, 600 W. 168 St., M PSYCHIATRIC . ASSOCIATION Office of Medical Director, I785 Mass. Ave., N.W., Washington 6, D.C. Canada Office, 2I6 W. St. Clair Ave., Toronto 5, Ontario Office of Executive Assistant, I270 Avenue of the Americas, New York 20, N. Y. PLEASE ADDRESS ALL NEWSLETTER COMMUNICATIONS TO OFFICE OF MEDICAL DIRECTOR �The Menninger School of Psychiatric Hospital Administration This School offers a one-year integrated course, leading to a Certificate, which draws on the resources of the Menninger Foundation, Winter V.A. Hosp., and Topeka State Hosp., supplemented by other Kansas state hosps. and schools, an industrial concern, a general hospital, two universities, and several state government agencies. The curriculum consists of didactic instruction in basic administration while clinical experience is provided by systematic rotation in the departments of participating institutions accompanied by seminars with department heads and special projects. With regard to costs, applicants may apply with state sponsorship. The sponsoring state may pay the stipend with the understanding that the applicant will remain in the employ of the state after he completes training. A limited number of stipends at $625 a month are available to unsponsored applicants. The next course starts in September. For full information write to the School, Menninger Foundation, Topeka, necessary. (work on the new home is expected to start this month. Hope is to have it finished by January 1). . Approved setting up separate fund for receiving miscellaneous gifts (such as royalties from publication of lecture series of North Shore Hospital) with proceeds to . be used to add to APA library. . . . Authorized and appointed Committee to work with planning group for the Jamestown Festival this fall which will celebrate Williamsburg State Hospital, the oldest in US. Drs. Zigmond Lebensohn, David Wilson, David Young, and R. Finley Gayle, Jr. are on the Com. with Robert L. Robinson of this office as advisor. . . . Approved contribution of $50 to the National Society for Medical Research. . . . Continued APA membership in the World Congress of Psy- chiatry. . . . Designated Francis J. Braceland as official delegate to the General Assembly of the International Society for the Organization of World Congresses of Psychiatry. . . . Approved in principle proposed constitutional amendment prepared by the District Branch Assembly regarding election to membership in APA through the Branches; and also another proposed amendment incorporating present practices regarding creation and operation of District Branches. . . . Approved recommendation Kansas. of Medical Director to consolidate all central office APA Position services for mental hospitals and to explore ways to Our Association has always insisted that Supts. and finance increased services in this area. . . . Suggested Med. Dirs. of institutions for the mentally ill should be appointments of APA representatives as follows: Dr. Frank J. Curran to World Federation of Mental Health psychiatrists. In doing so, however, it rec0gnizes the need for special training in administration for those who meeting in Copenhagen; Herman C. B. Denber to Congres de Medecins Alienistes et Neurologistes de France et wish to qualify for these positions. des Pays de Langue Francaise at Lyon, France; Rudolph The courses described above have been established with the encouragement and support of the Committee on C. Novick to Advisory Com. of National Congress of Certification of Mental Hospital Administrators. Only a Parents and Teachers. (These appointments were made handful of psychiatrists have completed them thus far. by President Solomon). . . . Recommended to Council The courses are expensive for the sponsoring agencies to reappointment of Dr. Henry Brosin to the American Board of Psychiatry and Neurology. . . . Directed that problem offer and experienced persons have put great effort into of improving dental care in mental hospitals be explored at curriculum development. Commissioners, superintendents, and others in admin- next Mental Hospital Institute. . . . Received announceistrative positions, as well as those who aspire to these ment of retirement of Dr. Frederick L. McDaniel as CIB positions, would do well to give serious thought to sign- inspector and expressed appreciation for his services over five years. . . . Changed dates for fall Council meeting to ing up for these courses. Available financial support should be an encouraging factor. November 23-24 (Sat.-Sun.) in Boston, Massachusetts. . . . Selected Saturday, October 26, as date for next meeting of NIMH GETS $4 MILLION INCREASE: The US ConngS}. has voted $39,217,000 for the Nat. Inst. of M. H. under/h" Robert Felix’ direction. This is $4 million more than/ last year—remarkable in view of general economy dri e. Testimony of Dr. Braceland for the APA and Mike Go of National Committee Against Mental Illness played i portant part in explaining need for additional monies in these areas to the Senate and House Committees. Senator Lister Hill and Representative John F ogarty, always strong supporters of mental health, spearheaded the effort to get the appropriations through Congress. EXECUTIVE COMMITTEE ACTIONS them \ O A pilot training and research program stressing the interrelations of biological and physical sciences as key to better understanding of the nervous system and human behavior has been set up at Albert Einstein Coll. of Medicine, Yeshiva Univ., (Eastchester Rd. and Morris Park Ave., N.Y.C. 61) with a $1,700,000 grant from the Nat. Inst. of M.H. There is provision for 36 pre- and st-doctoral fellowships. The grant covers a six-year d. Write to Labe Scheinberg, M.D., Dept of Mediher details. ° FALL COMMITTEE MEETINGS: Woodner Hotel, WashThe Exec. Com. met at the APA Central Offices June ington, D. C. The following Committees will meet all 29. (Unusual and pleasant feature was that most of the day on Friday and Saturday, Oct. 25-26: Standing Coms. APA staff members attended to become better acquainted on Technical and Community Aspects and Professional with the Com. members and general affairs of the AssoStandards. Also Standing Coms. on Budget, Ethics, ciation.) Among other things, the Com.: With regard to Program and Nominations. Ad Hoc Coms. will meet only financing remodeling of new home, delayed taking out any on request of the Chairmen and with clearance of the mortgage unless and until expenditures appear to make it Coordinating Com. Chairman to whom they are assigned. . �~\ The Council this year will not meet to receive Committee reports until November 23-24, but the Executive Com. will meet with the other Coms. on Sat., Oct. 26. Canadian Mental Hospital Institute Plans for the first Canadian Institute are shaping up nicely. It will be held at the King Edward-Sheraton Hotel in Toronto, Jan. 20-24, under joint auspices of APA and the Canadian Psychiatric Assn. This Institute will be patterned after the U.S. meetings. Major theme will be “The Mental Hospital and the Changing Community," Dr. Mary Jackson is Chm. of the Program Com. with Drs. C. Buck, W. Boothroyd, J. Griffin, J. Hagan, A. Miller, D. Lewis, and Drs. C. Roberts and J.Gilbert of the M.H. Section, Dept. Nat. Health and Welfare as advisors. Since it will have a clinical orientation, this first Canadian Institute is planned for psychiatrists in senior posts in all types of Canadian mental hospitals and for the administrators of Federal and Provincial mental hospital systems. More details in the fall. New Printing of Glossary With the first printing of 30,000 copies of A Psychi- ASSEMBLY OF D,B, NOTES . . . .Met May 13-14 during Annual Meeting. . . . Installed following officers for 1957-58: David C. Wilson, Speaker; Walter H. Obenauf, Deputy Speaker; John R. Saunders, Recorder; Policy Com., (Area I) Albert M. Biele, Frank P. Pignataro (Alt.); (II) Lester E. Shapiro, Ulysses SchutZer (Alt.); (III) J.G.N. Cushing, Edward H. Williams (Alt.); (IV) James L. Sagebiel, G. Wilse Robinson (Alt.); (V) Alfred Auerback, Edward G. Billings (Alt.). . . . Volunteered to assist Med. Dir. in obtaining accurate information to publish obituary notices in Newsletter. . . . Revised Procedural Code. . . . Suggested Council action to seek extension of MEDICARE program. . . . Commended Dr. Wilson for Assembly exhibit at Annual Mtg. . . . Decided to study inspection of psychiatric facilities and depts. of psychiatry in gen. hosps., and facilities of public mental hosps. . . . Submitted two proposed Constitutional amendments for consideration by Council. . . . Will investigate planning of Divisional Meetings. . . . Scheduled next mtg. for May 12-13, 1958 at St. Francis Hotel, San Francisco. PERSONALS. . . S. Spafford Ackerly was honored by a atric Glossary exhausted, a new printing of 22,000 copies Testimonial Dinner on June 19 in recognition of his 25is now available. A limited number of copies have been year contribution to psychiatric education and community health in Louisville and Kentucky. . . . Paul V. Lemkau made up with a hard-cover library binding for libraries has returned to Johns Hopkins Univ. as Prof. of and others who would like it in more durable format. The Public Health Admin. (mental health) at School of Hyhard-cover copies have no cover design—merely the 8: Public Health following a 2-year leave of giene of title the book. They sell for $2 per copy. The paperbound edition remains at $1 per copy. Order from Mental absence. . . . Baruch Silverman was presented a Canadian Mental Health Award on Apr. 17 in recognition of “his Health Materials Center, 1790 Broadway, N.Y. 19, N.Y. outstanding contribution to the mental health of the CaDid you know that the following Isaac Ray Award nadian people,” . . . Alan D. Miller, Dir. of MH Study Lectures had been published and are available through Center of Nat'l Institute of Mental Health, was transferred to England on June 18 for advanced study and reany bookstore? The Psychiatrist and the Law, byL Overholser, 1953; Psychology of the Criminal Act and search. Stanley F. Yolles has succeeded Dr.Miller as Punishment, G. Zilboorg, 1954; The Guilty Mind: PsyDir. of the Center. . . . Major admin. appointments in N.Y. chiatry and the Law of Homicide, by judge John Biggs State on July 1 were: Arthur G. Rodgers (LF) as Dir. of Syracuse State School; Ulysses SchutZer as Dir. of Jr., 1955 (all these by Harcourt Brace 8: Co.); and The Urge to Punish, H. Weihofen, 1956 by Farrar-Straus and Binghamton 8. Hosp.; Charles Greenberg as Senior Dir. Cudahy. The latter publisher will also publish the of Rome State School; and William C. lohnston as Dir. lectures by Dr. Philip 9. Roche given at the Univ. of of Craig Colony. . . . Franz j. Kallmann received an Michigan this year. honorary medical degree as one of 6 scientists in differfields honored ent Third so Int'l Congress of Medical at The General Practitioner Education Project now operQ Arts, Turin, Italy during 1-9. June program, . . .17; from the Office Central E. ating (Charles Goshen, Projand Gantt Harold Horsley Rosen were Visiting Professors would information about psychi- for ect Director) appreciate 2 weeks this spring at Univ. of Arkansas Dept. of atric courses for GPs now in planning stage. It is sugDon D. Psychiatry. . . . Jackson appointed Asst. Clin. gested that when a course is being planned effort should Prof. of Stanford Univ. Med. School and Psychiatry at be made to have it approved for credit by the Amer. elected of Pres. Mid-Peninsula Psychiatric Soc. . . . of Acad. General Practice (through its local or state William H. Kelly has accepted position of Asst. Dir. of branches) as inducement to attendance. Dr. Goshen of Mental Health and Head of Mental Hygiene Div. Dept. will be glad to assist in publicizing such courses. for State of Michigan. 0 The Smith, Kline and French Foundation Fellowship NEW PRESIDENTS 8: SECRETARIES . . . Ark. D. 8.: Committee awarded 19 new Fellowships in May. 13 of Robert G. Carnahan & Leroy D. Lamm. . . . Cent. Calif. them will enable medical students to participate in reWilliam S. Fife & Arnold Sheuerman, Jr. . . . N_o. D.B.: search and training programs this summer. Among other Calif. P. Soc.: Thomas A. Gonda 8: Maleta Jo Boatman. Fellowships announced, one doctor will study research . . . .Kings County (N.Y.) D.B.: Morton H. Hand 8: organization at Boston Psychopathic Hosp., another will Abbott Lippman. . . . Hawaii P. Soc.: Robert A. Kimtake a Master’s degree in public health, and two lecture- mich 8; Robert S. Spencer. . . . Md. D.B.: Leo Kanner & ship programs will be established. Applications for Charles Ward. . . . No. Pacific D.B.: Herman A. Dickel consideration in October this year should be submitted 8r D.E. Alcom. . . . Quebec D.B.: Graham 8; Taylor 16. and Information forms by September application may Henry Kravitz. . . NP Soc. of Va.: Thomas F. Coates, . be obtained from the Fellowship Committee, Box 7929, & W.D. Buxton. . . . Washington P. Soc.: Seymour Jr. J. Philadelphia, Pa. Rosenberg & Marvin L. Adland. . . . Del. P. Soc.: George I �DeCherney 81 Walter Davis. . . . East Bay P. Assn.: Louis B. Boyer & Marion E. Roudebush. . . . Long Island P. Soc.: Edgar D. Congdon 8: Harry H. Gonda. . Milwaukee NP Soc.: David Cleveland 8: Edward C. Schmidt. . . . No. Pacific Soc. of N&P: D.E. Alcorn & Robert M. Rankin. of P. at the Univ. of Miss. under Floyd Moore and Oscar Hubbard. Also visited State Hosp. at Whitfield where . Wm. L. Jaquith and John Head have built up a fine program since 1949. They have a high patient turnover now and a new building for maximum security patients especially worth seeing. Also renewed acquaintance with Beverly Smith and Willard Waldron in Jackson. . . . On BRIEFS. . . . All who attend the World Congress in Sept. June 21 went to NY to speak to Bd. of Directors of will be glad to hear that Nat’l Committee Against N.A.M.H. APA members present were Hon. Fellow Mrs. Mental Illness, Inc. has (through APA) made funds availHenry Ittleson, Walter Baer, G.S. Stevenson, Jules able for simultaneous translation of papers. . . . Herman Coleman, Marion Kenworthy and Paul Lemkau. Was B. Snow, Supt. of St. Lawrence State Hosp. in NYS, pleased by much support from the floor for closer ties writes that 90% of his patients are in open wards exand strong Support for APA’s programs. . . . On June 28 cept at night. . . . Iago Galdston, Chm. of Com. on Int. joined Ewen Cameron’s Com. in Boston on future planRels., has sent over 100 copies of the Summaries of ning for the CIB in Pres. Solomon’s office. Drs. BarteAnnual Meeting Papers to colleagues abroad. . . . I have meier, Ewalt, Braceland, and Yerbury also there. . . . prepared a little pamphlet about my favorite vacation Flew back to Washington to meet with Joseph Barrett on haunt called ”Day Sailing and Cruising in Mahone Bay, planning for celebration of opening of Williamsburg N.S.” and I’ll send you a copy if you write. . . . Chas. State Hosp. (1773) in conjunction with Jamestown FestiBush and David Gaede are inspecting hosps. in Mich., val this October. . . . After the Exec. Com. mtg. Pres. having just finished up in Mo. Hope to start in NYS in Solomon and I flew to Nashville to participate in dedicaa few weeks. . . . Warren Johnson, my asst., recently tion of magnificent new admission and treatment building conferred with Cyril Ruilmann, F. Williams, and O. S. at Central State Hospital named after the Supt. O. S. Hauk in Nashville on psychology legislation in Tenn. . . Hauk. Wm. S. McCullagh, Pres. of the So. Psychiatric Smith, Kline & French Labs. have just granted $10,000 Assn. and Frank Luton also were among the speakers. to the Nat. Acad. of Relig. and Psychiatry for fellowAsst. Supt. White presided and Cyril Ruilmann introships for clergymen who want to become mental hospital duced the speakers. Gov. Clement gave the main chaplains (there are over 300,000 clergymen in the address. The Tenn. program has improved remarkably in country). . . . Sorry to hear of the death in June of Miss the past two years. . . . Forgot to mention last month that Dorothy Clark who rendered such valuable service as in course of Mental Health Week speaking tour I particiAPA Nursing Consultant from 1949-1951. . . . Write to pated in inspiring award ceremony for employees at St. Dr. Leo Alexander for details about the fifth Annual Louis State Hosp. where over 700 have served for 10-25 Institute of Psychiatric Treatment to be held in Philaof Nurses Dirs. his Kohler, Supt. Congratulated years. delphia Oct. 17-19. . . . A lady reporter at the Ann.Mtg. and Volunteers who organized the program. . . . Mike in Chicago was overheard to say, "Next to the White Gorman and I had stimulating talk with Robert Felix and House crowd this is the nicest group I’ve met.” . . . . Seymour Vestermark recently concerning NIMH programs Chas. Goshen and I attended meeting of APA Liaison in coming year which will be expanded with increased Com. with Amer. Acad. of General Practice in NYC to appropriations. . . . Also attended meeting of Wyoming discuss Gen. Practitioner Educ. Project. (R.Matthews, Valley M.H. Soc. in Scranton, Pa. where I met APA Chm., Frank Luton, Phineas Sparer, and Merritt Foster members Robert C. Murphy and Emlyn T. Davies. . . . were there for APA)....On June 6 spoke at Ann. Mtg. of Received notice this month that NIMH Advisory Council the M.H. Soc. in N.J. and on the 10th at the opening had turned down our application for renewing M. H. session of the M.H. Institute at Lansing, Mich. where Architecture Study grant; but funds are available to V. A. Stehman had brought in representatives of all Mich. continue it to end of and in meantime effort will be year hospitals. It was an outstanding meeting well attended. made to find other ways of keeping it going. . . . Expect . . . Went from Lansing to Battle Creek with E.F. Jones, to be off to Mahone Bay, Nova Scotia by end of month for Mgr. of VA Hosp. there, and showed his staff pictures of a few weeks of sailing and loitering. . . . Happy vacationforeign hospitals. . . . Did same thing for residents at ing to you all. . . . The next Newsletter will be in Sept.... Ray Waggoner’s Institute in Ann Arbor a few days later where also talked with Moses F rohlich who (as Chm. of Com. on Nomenclature) is hard at work on system for recording case data on IBM cards. . . .With Robert L. Robinson met in Toronto with Program Com. for Canadian Mental Hosp. Institute to finalize details on June 21 and was also able to visit Homewood Sanitarium at Director Medical Guelph (A.L. MacKinnon, Dir.) where the Ontario Psychiatric Soc. was meeting on the 22nd. . . . Also recently spent several days in Conn. with Chas. Bush where we consulted with the Governor on the mental health prohas Blasko that reJohn there. to Sorry report gram signed the Conn. Commissionership for another job; but P.S. Don’t forget to order of the Desk 1958 copies your his efforts to have the law changed to give the Commisand Book of Summaries the the (33) Appointment have been successsioner more administrative authority Scientific before the (81) Papers supply runs out. the 19 On Dept. visited expanding rapidly ful. . . . June ��WV-..— -»——————. ———_,—_a—.__.._—_,-__ ._________, __._ —_________.___._. _ __ .__- .__.__._. _____... —*_ ��October, 1956 vs Age EST # 1 & 2 - h Below 115 us yrs. over Changes - Reiter - £9 pts. 6 7 H L M 5 S 8 (id—ﬂ) 7 3 10 (50%) 13 5 10 (35%) 6 h 19 (65%) L yrs 50 over yrs 8: Distribution Age — H M 8 h 16 (57%) 12 3 6 (28%) 5 3 13 (61%) - EST 1 & 2 patients h9 5 3 31 - [10 yrs. 1 3 I41 - SOyI‘S. ll yrs. over - 6 5 10 2 3 Reiter vs Medcraft - .ii:;.L_ Reiter (EST # 2) H 12 (h8%) yrs. yrs M 7 30 & L 6 - 61 H 7-2 20 51 " 60 9 M h-6 Below 50 - L yrs. & EEG 25 Medcraft (EST # 3) 16 ptS. pts. LWC - h all ages 6 _Z_:_2_ L M H L M H 11 5 9 7 3 15 2 5 9 1 6 9 �Beiter vs Medcraft h Reiter (EST # 2) ‘17 Medcraft (EST # 3) CONCLUSION: 9 M pts. 8 3 Pts. 2 1 all ages and at h—é and at 7-9, xrs. from left to right. - over - 7 9 L M H 6 h 2 11 6 1 3 5 H older group only) whereas with Reiter Medcraft produces maximal change early in treatment and in changes & 6 L Both groups ( same - MS % it H records with.Medcraft increases. Therefore later changes consist only ��95 (I M hWé/Mv/ém W W/f 44’me Wm" PHI/M41; be M 52/15 ’4 gal/ﬁe): MM) 686cm; Mwwﬁﬁw ��\. \ Séwrﬁ‘sax «wk? '».,_ *Mﬁw'yr-Ea ”138:3? ‘ ��4‘ .' .ﬂu/W aw ' , . b; Izaak?“ wumad, W ’ 147? Xv 520’? ��Ti? V 1‘ s: I. 7:. V Z 1 - \_ rm . 111374;? : 7'“: _ ‘ " - . > v, ‘ y; ’ * Winn-n35 "W" ______ r - “22:! ‘ - -——~‘——‘ . ‘ ~ ' . ‘ ’ ' ‘ ‘ ( ‘ ‘ . I J ‘ 7 ‘ I v ' - ' V n I l ' ¥ ‘ ‘- ��', ’03. Alll‘llll �. ,7 — v Q ,.. r. ‘ _ T TrK. u _ ,.., . V, 9.. 1 , . ., a ‘ ,_. ‘ w, w . n 5 . . , . . i .A . :i.» ,. ...L. I, ( :4 . , ,. . < 5,: _. . . . . z .,. "“ ; .; 'n’hr ' ‘ 1 V 13—, ., awh'A_ “,1 “1.“..«2 , ‘ n .‘ r r 1 . . .a . _ _ ‘ ._ u... , a, h J _, N ‘ '5 _, ‘ v F :. , 'v h, .7 . ‘ 4‘;- _‘ , . x; x , .31.. , u . . . , .. ,2 .. _ "1 , A . ..a h .u '. A ... . i , , . N m. u . 1 , J 1-: I :. r. , , ‘ r ._ ; . . . . .ﬁ . . , rJ . :., I ‘ V, sv,._______-_._..:_:>..7;_.;_T t.« n—' n a. r r , :J: I. I; » .n .= . . II\ ' ' J any. ‘_.‘ , 2 Mr .7 . _ . .3 ‘l ,_ g» ..‘ I .a‘ . ,~ L, m .H _ J ,V , --.,-_.' r, 7 , n .T» . 1 H . — , . ”37:-.." \.L. \I Z" W“ ‘ K A [“97 '. .1:..." , .u: ._, Nu L x; ' ,- , . .. a w H _ H _ _. .,. . . .> . 7 wm _, . . . ., l , ,.. ., ,. . m "W”. 5,2 , , ' .3 1 ., . j A . g ‘ ., i. .. . ‘ V.,, Hutu” ﬂ A, 1 ��.g.W- an}, , 3 ‘ \——r —- --m I-L I I I I ' Mr n/f r? l' 2, 7 6 1 ‘. é ' / ./ o -’ I ' _» ’ //,,../ ’ ‘ , * Q 3 5* �W INDIVIDUAL PSYCHIATRIC TREATMENT INDICATIONS Paul H. Wilcox, M.D. Revised Nov. 21, 1953 Li PREDOMINANTLY NEUROTIC if and Org., B.P., F, otherwise IF start Nm, Ag, 3, 0-0, G, HqA, with Sequence Ir, Un, Of, or Par, start with Sequence I III PREDOMINANTLY SCHIZOPHRENIC if and D or Ag, otherwise I5 (Psychosomatic symptOms, anxiety or reactive depression) start start with with Sequence Sequence I PREDOMINANTLY ENDOGENOUS DEPRESSION start with Sequence Sequence Sequence I Sequence E.S.nc. II III Sequence IV E.C.T. COznc. 002 II \/, \ \ ___, 4______e 93 MANIC _, COznc. ___, E.C.T. ___, ___, low E.C.T. 1: Eu if Tr ______+ 602 \ifD ._____, II ifC 1:0 if c __, if t _____, if 'r _, ___, (III) (for termination of trance) 002m. (II) \<: (III) high E.C.T. C02 (IV) E.S.nc. (I) E.S.nc. (I) ifT if t plus 0...? terminate D if _____, E.C.T. (II) Note: Appropriate psychotherapy should accompany all phases of treatment wherever indicated. The goal of therapy is for the patient to have a mild 002 reaction (t) and be essentially symptom-free (O) for an observation period of at least two months. £21 - anxiety increasing Ag - agitation B.P. - systolic B.P. over 170 mm. Hg., systolic c - brief confusion (e.g. only 5 min.) C - prolonged confusion (e.g. more than AS min.) Cf - clinical confusion coznc. - non-coma 002 (whiffs) C02 - coma 002 D - persisting or increasing depression E.S.nc. - non—convulsive electrostimulation E.C.T. - electroconvulsive therapy Eu - euphoria F - marked fear and anxiety A H-A G Ir - Nm 0 — - severe guilt feelings - marked hate and aggressive tendencies marked irritability severe nightmares symptompfree - for 2 mos. or more obsessive-compulsive features Org. - organic changes Par. - paranoid trends O-C s - sleepless tT - mild tension - mounting tension Tr - prolonged trance state Un - unreality feelings ��52 m - �MAX F'INK. M. D. 275 MIDDLE NECK ROAD GREAT NECK. N. Y. HUNTER 7-4542 \; . :\ \ \ . w . .\\\ a h {zitgiisézirié \ ,5:11:15rfie1 v, flhhugavwx.§.1 at»; J. 3.11.. , _ if NDD‘ $5.. . J 3.25.1.5 4.51 1. $313 £511:er “V :2 1! ��a M.“ .7 �-7 r. v my .‘__r,\~. ‘_,_ an" .7 ”amt , 0, .7.— ..w . x 7 , ,...r,_ ‘_— v-4 . . ,_ w “K- mﬂ.w~..—-~_‘nr—._;_i , _ 7 _ 7V -_.-N,...~ . 1,-.. ~..~._.V..,.v .,_‘,.r_._h., V . if"? ��mw "">‘- aw ﬁn ’4_l4 I; Ant“ . ��4...»... ”Mu-L" ��Ft: £13 3"! HM (M) ��i 3 i E .1 i ��. _ a-‘v—{WWG’W’W‘tVF‘r‘Fw—ugfva , WNW—“W “WW. _ , . , . , ‘ W. . , _. ,' , ‘ A,.V,.. 3m, .zwu -..m~w~ W «RM-4mm "F v :i‘\ @ﬁ - A» \\\ 'l ‘3“ l." ..,. ‘ “ \.§;‘.§g was. wig-33;; __ ‘ ' _ ‘ A Em ' axis: .3, ��(L ALLA 4 4T ��;; i ��For creative activity, as possibly, for problem solving, the hyperh alert state must be avoided. In the alerted individual, discrimination is more focused, acute, and differences are sharply maintained. Under such conditions, old pathways are clearly maintained and the possibility of new associations is less. For creative work, pathways must be connected ected before. This can only be accomplished were not con; discrimination is diminished. reverie; by fatigue (creativity late at night); by isolation; by alcohol; etc. Perhaps in the EST situation, the cerebral state induced This ? is if that done by is similar to drowsiness (Surely the EEG - perceptual effects are similar) patient is able to use ("create") available before. and thus the new defenses which were not Also, in the tachistoscopic situation, the presentation is a hyperalerting situation - but, the reverie state (or dream) afterwards, permits of greater elaboration of the memories (greater range of imagery - greater creativity,). I/e3ﬂd �January 7, 1957 Role of Altered Cerebral Motion in Behavioral Change Following Induced convulsions m m, 14.9., Babe” In M; 31.3. m Hm Karin, 31.1). role of altered consciousness in the clinical behavior of epileptioe, patients with mental disorders, and in the diagnosis: of dis-orders of the central nervous system is unclear. Recent studies of the electroshook therapy process amonamtcd the crucial nature of persist.ent alteration in brain fxmction for the behavioral changes induced. In the course of theee studies, an appreoietion was obtained of the types of alteration in behevior induced 120' diffuse cerebral dysfunction; the role of the pmoz‘bid personality in the behavioral pattern; and the smith. 1w of various tests on indiooe of altered brain function. To define and measure the effeotc of alteration in consciousness Pmblem """"‘""'"" (manning rm diffuse control dysfunction) on clinical be. havior patter-no. The Kethod: Subjects on a voluntary paychiatric hospital referred for electro— shock therapy were studied concurrently by psychiatric, psychologic and neuroplwciologic techniol. Alteration in brain function (the demo of organic mental I; sycamo- was measured by four indicee: (a) Eleotroenoophalogm, moored for per cent time delta under nesting and activated conditions; (1:) Diaoriontetion, confabulatm-y responses one language changes following intravenous mobarbital. (c) Dininution in perceptual discrimination of simultaneous tactile threshold stimulation touts. (d) Interference with recall of 3 letter words after interpolated looming of nonsense syllables (”retroactive inhibition of recall") . mound by repeated psychiatric intent and reports of therapists and hospital personnel timing 2) Behavioral ohengec were views with subjects; and after the period of therapy. pmorbid percoaolity was eotimted by Cstructured interviews with relatives and by Rorschach tests (scored for H o reopens”). ROM“! 1) Modification of twavior is related to the dogma and persistence of alteration in hrm function, as measured by the electroencephalogram, amobarbital teats and perceptual discrimination teats. 3) The �in! 0' J c‘u pattern at the induced behavioral change, manifested by ahnnges in lmguags, mood, attitudes and symptom, is related to the preamorbid personality structure. Such behavioral patterns as euphoria, donisl, withdrawal, severe wry loss and disorientation, paranoia, WMrzitability and installed musty, have been obsemd. 3) Various indicss or altered cembrsl function have different sensitivities to modification depending upon the extent and activity (recent or old) at the dysfunction, and the personality of the subject. 2) The ’ leusiem 1) Behaviors]. nodii‘icstian in canditims inducing altered brain fanatics is ths adaptive response of tbs argmism under the conditian of an aims-stint: in the state of camcioumss. 2) has type of adaptive response is dependant upon tbs premorbid pemomiity of tbs subject and the milieu in which the behavior occurs. altered brain function mt be interpreted in tons of thsir sensitivity; their time of application in the ongoing process; and the pmrbid persmlity “the subject. This significance of them observations in tha understanding of epilepsy; the treatment. or mental illness; and in medsfinition 5f altered states of consciousness will be dissusssd. 3) Tests 01‘ Iron tbs Heumplwsiolom‘r Laboratory, Department of Fotperimental Psychiatry, Hillside Hospital, Gian Oaks, New Iork, U.8.A. �January 7, 1957 Therapy of Schizophrenia: Effect of Alteration of Brain Function on Behavior In the course of experimental studies of the mechanism of actidn of electroShock therapy in patients with psychiatric disorders, a hypothesis was elaborated regarding the mode of action of other therapies in patients with schizophrenia. 1t has been demonstrated that the essenp a electroshock is in therapy behavioral change to pre-requisite tial EEG defined by function as of brain delta, loss altered sustained degree of discriminatory ability on perceptual tests, and disorientation followThe behavioral response sodium. amobarbital of administration the ing under the conditions of an altered state of nervous system activity is an adaptive response of the subject, dependent on the premorbid person, ality . who and the environment. Similar factors have been demonstrated as operating in patients Show sustained improvement following insulin coma therapy. studies of drug therapies in schizophrenia demonstrate that the therapeutic efficacy of the newer psychopharmacologic agents demonmechanisms which brain are to the degree to related is directly strably altered. Conclusion: The mode of action of the various physiodynamic therapies (ICT, EST, Drug) is directly related to the degree of sustained alteration in brain function induced; such alteration being defined by changes in the resting and activated electroencephalogram, disorientation tests, and perceptual discrimination tests. , Ongoing ��can ﬁrsthand for the pemeption 01‘ words momma anti aubjem were unable to Mantify m wows with increasing degrees at cerebral 3-) Wmotim, We: in percoptim were highly sex-minted with other boo Moral chug”, inﬂiaaﬁve of an alumni interaction with the omirmmt. Minimum 1) Diffuse alter-nuns: in brain mum, as measured by elactrmcaphalomﬁzm 631%: mad emanation tests after mammal, results in altemtiw at pamytm pat-toms by an increase in threshold, impaired Metamucil: of stimuli, of which the ability to diacriminato a rignre from a. comply: backgromxd in a 5min h) ' ma We! ' 2) Alteration in pemepbim mpmanu sweet an m rather than a speciﬁc as? altered behavioral interaction with the envirmnt, Maialogieal defect, This factor sham be considered in peroeptnal 112.20.00.21. brain lemma as will. nudist {51% Ion-k, ”.34: m W; mar”?! �December 17, 1956 Concept of Cerebral Localization vs Mass Action Effects Certain functions ascribed to 1) CNS are "localizable", as vision, motor power, motor aphasia; While others, as memory, judgment, insight, cal- culation, figure—ground, are non-localizable. (more peripheral than central); have marked effects; and EEG damage The is generally first group are cortical permanent; small lesions is usually not pathological. lesions are generally deep or basal; recovery of function is possible; small lesions have no effect (i.e. a mass action law is applicable) and EEG effects are prominent. The non—localizable It results in a non-localizable lesion - with diffuse dysfunction. is the technic par excellence to study such mass action lesions. 2) EST 3) Psychological measure mass tests of "OMS” are positive to the degree that they action effects rather than focal - except if focal dysfunction interferes with performance as in lesions affecting vision, motor power and speech. h) Concept of Active vs Static Lesions: In studies of head injuries, lobotomy and post operative cases of six or more months duration, the studies reflect localizable (cortical) defects mainly: for the deeper activities nd are longer active. Any defects in fun- ction are expressions of specific cortical localizable damage. In contrast, studies of brain tumors, immediate post-traumatic states, post- (early) are studies of active dysfunction - a combination of the focal and the diffuse defects. The degree of dysfunction depends on the mass lobotomy, and EST effect, plus the localized defect. m away. ”cw-u W7»: 6% 2.2 .-W M- ��«M m a» mum at :1“er bum mum the dun» Mariam mum sum and chm a! me: aluminum; m vat-um a! the mmw‘mpu and tho «the submit ammmmm mammmmﬁg mumammnwmmm. Mmumafmw mun Winemwnuwm at them mm“). mm 1»th mm mu with annWtupmhupmrbm uwamwmmwwmm, the Mine of at a act-Latin Wm m by th"W”, WV. the an dwaﬁmt mm mm»: Mum Mow, m W: m that mum and. at my m Mum; torﬁumohanin WWMemlmm meettheu MWMWMWMNW¢ » �(July 2, 1965) Jan. 3, 1958 HOLE OF ACTION OF BIOCHEMICAL AGENTS The CNS is IN BEHAVIOR dependent upon a umber of enzyme systems for cholinestemseand including fmction, mtabolisn proper acetylcholine, gluoose-pkwsphetase, etc. CNS function and, thereby, affect of that agents variety behavior- is large, since processes in equilibrim may be shifted The in either direction by increasing or decreasing the available quantity of a metabolite . A. For drug action, therefore, the following are considerations in potency: (a) Does a drug affect an enzyme system in a reliable it way? to affect the system? (c) What defenses does organism process to block CNS? in action once limit drug's or (b) Can B. Secondly, get to mile (NS an agent may directly affect the metabolism CNS the dependent upon the is extent that to of a specific system, system? Is the defect thw induced simificant for the netsbolism of CNS underlying behavior? that defenses can body cell into play when system is affected to substitute other energy system? Thus, the variation in drug effects in behavior depend upon: (a) Behavior at onset; and predisposition (personality) to response; (b) Drug dosage - availability to has on an enzyme system; CNS and the effect it �(c) Dependence of organism on specific enzyme - and organismic defenses (i.e.,-~ substitution for affected system) . Whether effect was gmdual (allowing for system ((1) defenses, i.-e . , alternate mtabolic system) or acute (not allowing defense). Imividual diffemnma in response may be due, thus, to differences in: (a) Dosage, mtio S mute of Ministmtim (b) dependence on the affected system (c) adaptive ability to biochemical changes. To these clauses, EEG is a gross approximation and indicator, reflecting the homeostatic balmce in various enzym systems of the CNS. ��Personality-O.M.S. Tests of O.M.S. 2-5-57 The All our tests of changes in cerebral function tapas continuum. degree of cerebral dysfunction at the time of examination will determine which tests will The degree of “ show changes in patterns. cerebral dysfunction is dependent on numerous variables including; Rate of develogment of dysfunction Premorbid state of functioning on the tests employed Stress of the examination- needs and motivation of the subject Localization of the cause of the dysfunction (local vs. diffuse) ' factor, the premorbid state of functioning, as characterized the present evaluations of personality organization by the Rorschach One by test and by interviels, graphic fashion; can be pictured as operating in the following ‘ ��V E F E E F E ;‘ ﬁs‘;’*;)¢¢2\ _ a '“ﬁ‘ �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource EEG (notes), 1955-1957 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-3-003 Date A point or period of time associated with an event in the lifecycle of the resource 1955-1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: EEG notes Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/d7a08df9cf0427fc8180966376064147.pdf df0afef232047bc6a8f732705fc32387 PDF Text Text USPHS M—927 Final Report ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK (Perceptual Changes Induced by Drugs and Electroshock) the Department of Experimental Psychiatry Hillside Hospital From Glen Oaks, L.I., N.Y. September 1, 1959 �September 1, 1959 FINAL REPORT weal Department of Experimental Psychiatry HILLSIDE HOSPETAL 1., Glen Oaks, L. N. Y. 235$! 1 1. Acknowledgment 2. Summary 3. Summary,Five Years, 195k - 1959 27 h. Publications, 195k 32 5. Presentations 195k - 1959 1959 37 195h #h, 6. Summary #1, September 1, 7. Summary 3,52, January 1, 1956 #3, April 8. Summary - February 1, 1958 1, 1957 September 1, 1959 - 2 January 1, 1956 hZA - April 1, 1957 55A - February 1, 1958 70A Fink, M.D. Principal Investigator max Research Associates (Experimental Psychology) Robert L. Kahn, Ph.D. Research Associates (Neurophysiology) EEG Technician Secretary Hyman Karin, Ph.D. Eric Karp, M.A. Martin A. Green,M.D. 195k 195h-1958 1958 1956 - George Krauthamer,Ph.D.1959 Hanna Mosquera Janet Bowie ' Associates, supported through other grants: Research Research Research Research Associate Associate Associate Associate (Experimental Psychol.) (Psychiatry) (Psychiatry) (Sociology) 1956—1959 Joseph Jeffe, M.D. Donald F. Klein, M.D. 1959 Nathaniel Siegel, Ph.D.l958 - Max Pollack, Ph.D. 1957 �Acknowledgment These studies would not have been possible without the of Founder of Hillside Hospital, and the support interest faith, Dr. Israel Strauss, the Board of Directors, and the Administrator, Mr. Maurice Bachrach, who sustained this program during its early vicissitudes. are also indebted to the Henry Kaufmann and the Dazian Foundations of New York, the Foundations' Fund for Research in and the Nassau Board County of Health Mental the Psychiatry, following pharmaceutical firms: Smith, Kline and French and Laboratories Bristol Geigy Pharmaceuticals, Laboratories, We Wyeth Laboratories, whose support is gratefully acknowledged. �September 1, 1959. M-927 Altered Brain Function Following Electroshock Progress Report #h Max Fink, M.D., February 1, 1958 - September 1, 1959 Director, Department of Experimental Psychiatry Hillside Hospital, Glen Oaks, L.I., N.Y. Associates: Robert L. Kahn, Ph.D.-Research Associate (Experimental Psychology. y) Psycholo Eric Karp, M.A.-Research Assistant (Experimental (Neurophysiology% Martin A. Green, M.D.-Research Associate Hanna Mosquera - Technician Janet Bowie - Secretary �-3ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK SUMMARY: In the past eighteen months, the various studies of the convulsive therapy process were completed and extended, and The begun. agents of psychopharmacologic an investigation framework for these investigations has been the neurophysiologicand 1955; Kahn, (Weinstein view convulsive of therapy adaptive Fink and Kahn, 1957) extended to insulin coma and drug therapies in psychiatry (Fink, 1957). The following aspects of the convulsive therapy process were studied: A Convulsion: comparative study the of 1. gignificance of the neurophysIoIogic, psychologic and behavioral effects of electrical and inhalant (Indoklon) induced convulsions. 2. S Eﬁe a tic Basis of Neuro h siologic Change: Further effects of acute administration of experimental studies of "normal" the both on and agents sympathomimetic anticholinergic and post—convulsive EEG. s There As Convulsive of ects ic 3. Sociopszcholo of the of factors Relation age, education, a. F Scale) the California by (measured and stereotypy nativity to the selection of therapy, duration of hospitalization, diagnosis and discharge ratings. b. Changes of F score with treatment, and relation of these changes to EEG indices. Thera : In supervisory chothera and Convulsive h. PsaIteratIons psychotherapeuggc in the relationship sessions, with convulsive therapy were observed. 5. Perception: Both patterns of change and individual differences on ac stoscopic figure-ground discrimination tasks and perception of the upright with induced convulsions. These studies were extended to drug therapies and the following studies undertaken: 1. Neurophysiologic: EEG of change on acute and chronic Relation a. administration of various psychopharmaceuticals to clinical behavioral change. III: 8/59 �potency. actiVityo b. EEG as a screening device for psychopharmacologic c. Relation of EEG changes to hallucinogenic effects of megimide. 2. Communication Patterns: Relation of induced neurophysiologic change to dyadic diversification and syntactic d. EEG language measures. 3. §pciopsychologic Studies: Aspects of the doctorpatient relationship affecting choice of somatic therapy. studies have supported and expanded the neurophysiologic-adaptive view of convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the mode of action of psychopharmacologic agents. These �~5- ‘mm PROGRESS REPORT A. THE CONVULSIVE THERAPY PROCESS; 1. Significance of the Convulsion: An earlier convulsive-subconvulsive control study had demonstrated that significant behavioral changes occurred almost exclusively in patients receiving grand mal convulsive therapy. The present report is an assessment of the neurophysiologic,behavioml, and clinical effects of two different methods of inducing convulsions - electrical and inhalant. Twenty-five consecutive patients referred for convulsive therapy were randomly classified into two groups with seizures induced in thirteen patients by the standard Medcraft alternating current instrument, and in twelve by the inhalation of hexafluorodiethyl-ether (Indoklon). In both groups treatment was administered three times a week for a total of 10 to 2b applications, determined by clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following the 10-12th treatment, and two weeks following the last treatment. In addition to evaluations of behavioral change, tests included measures of intellectual function (five subtests from the Wechsler-Bellevue Intelligence Scale), perception (figure-ground discrimination using embedded geometric figures, the perception of pseudoisochromatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levinson revision of the California F Scale). An electro- �-6encephalogram was obtained during each of the testing periods, and measured for the per cent time slow wave (6 cps or slower) activity from a continuous 66 second sample. The results failed to show any significant intergroup test differences between the electroshock and Indoklon groups at each of the three test periods. Intragroup analysis, however, showed that during treatment both groups made increased errors on the intellectual and perceptual tests, and had higher scores on the F scale. By two weeks after the termination of treatment both groups returned to near pretreatment levels for most tests. Both groups were comparable for the degree of induced EEG slow wave activity after 10-12 treatments.v The per cent time slow wave activity for the Indoklon group was 51% and for the electroshock group h7.5%. Within each group individual differences in behavioral change were related to the degree of neurophysiologic change - those with the highest degree of EEG change showing the greatest behavioral change. Rank order correlations between changes in test performance and the degree of slow wave activity with treatment were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue, and reached a level of statistical significance for digit span (+ .61, p < .01), object assembly (+ .h6, pr< .05), F scale (+ .38, p (' .05), tachistoscopic perception (+ .67: P <: .01) and perception of embedded figures (+ .h3, p < .05). �-7Two different convulsant agents thus produced similar neurophysiologic and perceptual behavioral changes; and it was concluded that the behavioral change in convulsive therapy is related to the degree of altered brain function, and is non-specific for the type of agent used to induce the convulsion. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April, 1959). 2. Biochemical“nu—On.“— Aspects of the Convulsive«non-mu...Therapy Process: The significance of high voltage EEG slow wave activity in the convulsive therapy process (Roth §t_al, 1951, 1957; Fink and Kahn, 19S?) and the report that this activity was blocked by the administration of such anticholinergic agents as atropine and scopolamine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant systemic effects with the administration of these agents, reports describing diethazine as an anticholinergic compound with potent neurologic but minimal systemic effects (Jenkner and Lechner, 1955; Lechner, 1956) led to studies similar to those of Ulett and Johnson using this compound (Fink, 1958). These observations with diethazine further led to the investigation of other experimental anticholinergic agents. Clinical and electroencephalographic responses to the intravenous administration of diethazine, Win-2299, benactyzine, JB-318, JB-336 and atropine in psychiatric patients at various �-8. stages of convulsive therapy were studied. Each is a potent anticholinergic agent in vitro. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with a A of diagnoses. total of 107 observations were made, variety as some subjects were studied with more than one compound. The observations were made in the EEG laboratory using a standard 8 channel instrument and needle electrodes. In each trial, the compound under study was administevhd intravenously at a set rate per minute until clinical behavioral or electrographic changes were observed. It was observed that administration of these anticholinergic agents was associated with a) desynchronisation of EEG rhythms with a blocking of post-convulsive delta activity; b) alerting, excitatory behavioral response with illusory, delusional and hallucinatory ideation, and c) systemic effects of muscular weakness, dryness of the mouth, dry skin and tachycardia. The electrographic, behavioral and systemic effects were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, mescaline and diphen- hydramine - sympathomimetic and antihistaminic agents - also induced EEG desynchronization, blocking of post convulsive delta �-9- activity and clinical excitatory activity support the suggestion that the behavioral and electrographic patterns of these compounds are also based on an alteration in synaptic activity. Increased synaptic activity (cholinergic, sympatholytic effects) is associated with EEG hypersynchronization, and clinical sedation and euphoria; while decreased synaptic activity (anticholinergic, sympathomimetic) is associated with EEG desynchronization and clinical excitatory and.ha11ucinogenic states, thus supporting a hypothesis initially described by Wikler (195h). It was also suggested in these studies that the discrepant observations of EEG slow wave activity after the administration of atropine was related to significant differences in dosage and to species specificity. (Presented, in part, at the Society of Biological Psychiatry, San Francisco, 1958 and awarded the first A.E. Bennett Psychiatric Research Award of that Society; and, in part, at American EEG Society, Atlantic City, 1958. Published, in part, A.M.A. Arch. Neurol. & 80: and 380-387, 1957; Psychiat. accepted for puﬁlication, EEG Clin. Neuropﬁisiol.) 3. Sociopsychologic Aspects of Psychiatric Treatmen : a. Duration of Hospitalization, Diagnosis and Discharge Evaluation. In an earlier study of the Hillside Hospital population (Kahn, Pollack and Fink, 1957), it was noted that age, education, place of birth and social attitudes as measured by the California F scale, were related to the selection of therapy. Those patients who were older, had less education, were foreign-born and with high stereotypy scores on the F Scale �likely to receive convulsive therapy. In contrast, who and who native-born better were educated, younger, patients were more obtained low scores on the F Scale, received psychotherapy as their sole form of treatment. This study was extended to determine the relations of these sociopsychologic factors to l) the duration of hospitalization, 2) the clinical evaluations at time of discharge, and was final diagnosis. The entire in-patient adult population on March studied. This consisted of 171 patients, 57 men 3) the 7, 1957 and 11h 68 16 from to in women, ranging age years, with a median of 35 years. Patients hospitalized for the shortest period (1-5 months) were noted to be the oldest, have the least education, were most likely to be foreign-born, and have the highest scores on the F Scale. Younger, native-born, more educated, lower F score patients were hospitalized the longest (10 or more months). The same relationship of these factors to length of hospitalization was found when separate analyses were made according to diagnosis and type of treatment (convulsive therapy or psychotherapy). Discharge evaluations of improvement were significantly related to age - the older patients having the most favorable ratings. Analysis of the data by type of treatment, however, demonstrated that among the convulsive therapy patients ratings of recovered or much improved were given to those patients with �the highest born. F scores, least education and who were foreign- Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education native birth. older, less educated, foreign-born, high F score patients were more frequently classified as involutional or manic-depressive psychosis. It was postulated that these relationships reflect the influence of social background and psychological processes, such as the behavioral patterns of communication and mode of expression; and that these relationships contribute not only to the pattern of mental illness, but affect all aspects of the patient—therapist interaction. (Presented at the Eastern Psychological Association, Atlantic City, and the Academy of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatry.) b. Changes in Social Attitude with Convulsive and The Treatment. earlier observations that the California F Scale is useful in understanding the reason for referral for convulsive therapy and the evaluation of clinical response Following following such treatment, further studies were undertaken with this scale in regard to the following questions: 1) What does the F Scale measure in a psychiatric population? 2) Do F scores change with convulsive therqay? 3) Are these changes related to the degree of altered brain function? �-12- entire in-patient population of the hospital was given the F Scale, and one month later, was retested with The a "reverse" F Scale, in which each statement was changed to the opposite of the original. The "reverse" scale was scored in the same manner as the conventional scale, with high scores reflecting greater agreement. It was noted that those patients who made low scores initially, indicating a predominant disagreement with the statements, showed an increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients who made high scores initially showed little change on retesting, agreeing with the statements to the same extent even though the meaning was reversed. It is evident that low F score patients are more critical and discriminating persons, while those with high F scores are more undifferentiating and stereotyped in their reactions. This observation is related to the process of selection of patients for convulsive therapy. A high degree of stereotypy of thinking and communication is incompatible with the establishment of a conventional psychotherapeutic relationship, thus inhibiting the psychoanalytically-oriented psychotherapy stressed at this hospital. It follows that the high F score patients will be unsuccessful in psychotherapy and most likely referred for convulsive therapy. In another study, sixty-nine patients were given the F Scale before, during (at 10-12 treatment period) and after �-13convulsive therapy. Ten patients, selected at random, constituted a control group and received subconvulsive electroF in score of +5.7 mean There increase was a stimulation. during treatment in the convulsive group - a difference 5% the level. In contrast, the control group at significant showed an insignificant change during the same period (+0.5). The extent of increase in the convulsive patients was related to the degree of cerebral dysfunction as determined by slow (more The with EEG. delta high the on patients wave activity +8.6. of had mean increase a record) h0$ of the sample than Those patients with low delta indices, however, showed an F the treatment scores were Following +3.h. of increase comparable to the pretreatment levels. These findings support and elaborate previous observations on the effects of convulsive therapy. Greater agreement with show conventional treatment during statements Scale the F in Changes discrimination. and in difficulty stereotypy of changes language the characteristic thus score parallel cliche; and of use increased denial, evasion, qualification, and stereotyped expressions (Kahn and Fink, 1958). It is also comparable to the increased difficulty in complex visual F and 1957) figureKorin, tactile ground discrimination (Kahn and Fink, 1957). (Presented at the Eastern Psychological Association, 1958; and accepted for presentation at the Divisional Meeting of the American Psychiatric Association, New York, November 1959). and perception (Fink, Kahn and �-1hh. Psychotherapy and Physiodynamic Therapy: Previous studies indicated that patients referred for electroshock in this hospital are of two types. The larger older age who have limited education and are foreign born. They tend to be non-introspective persons, stereotyped in their language and thinking, and verbally uncommunicative. Symptoms of depression, agitation, withdrawal and somatization are prominent. The second, and smaller, group of patients are younger,native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of somatization and depression. Four patients, two from each group described above were studied to determine 1) reasons for referral, 2) whether different attitudes were required in psychotherapeutic 3) the relation of the psychotherapeutic management, and approach to the patient's clinical response to convulsive therapy. It was concluded that these patients were referred for convulsive therapy because of difficulty in communication in the psychotherapeutic relationship. In two cases this was a reflection of the patient's limited verbal and introspective capacity related to educational and social factors. In two instances, however, the impaired communication was reflected in acting-out behavior. group are patients of an �-15Following treatment, the older, less educated patients were able to sustain the behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization ‘In the better and denial developed during electroshock. educated patients, the decreased acting-out behavior was associated with increased interpretive psychotherapy. It was suggested that the relationship of psychotherapy to convulsive therapy various with the communication pattern and adaptation shown by the individual patient. Published in the Journal of Hillside Hospital, 1: 17-25, 19 58 ). 5. Perception: have of procedures test perceptual-cognitive variety been studied in patients receiving somatic therapies. a. The Tachistoscopic Perception of Embedded Colored Figures: This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control“ groups of 20 patients treated with phenothiaains medication (thorazine and promazine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, and after four weeks; the convulsive weeks two time a following the third were tested patients A . cessation of treatment. �-15There was a statistically significant increase in mean errors with convulsive therapy, and a significant decrease from the pretreatment scores following treatment. "Control" subjects made significantly fewer errors at each succeeding period. There was a significant difference in EEG low between showing changes as classified errors patients (per cent time delta) when compared with high EEG changes. There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with no unions Even in those to cerebral dysfunction. attributed patterns EEG with high changes, the "style” of his response patients pattern was maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at number of which completion was shown might change. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April 1959). b. Rod and Frame Test (Withinz: This task was administered to h? patients consecutively referred for somatic therapy. Marked individual differences in performance were correlated with age, education and score on the California F Scale. Patients whose judgment of the vertical was strongly influenced by the surrounding frame (field dependent) were more frequently �referred for convulsive therapy than drug therapy. No significant change was found with drug or convulsive treatment. For both drug and convulsive groups retest correlations were high (+.86 and +.88). It is considered that individual differences on the Rod and Frame test reflect personality factors that are of importance in psychiatric treatment. �-18B. PSIGHOPHARMACOLOGIC STUDIES; 1. Neurophysiologic Asgects: According to the neurophysiologic~adaptive view of the convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central nervous function, providing a milieu for changes in the subject's interaction with the examiner and the environment. In these studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Fink and Kahn, 1957). The efficacy of newer psychopharmaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the mode of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharmaceuticals tested in acute experiments an increase in synchrony with or without an increase in slow wave activity has been observed for chlorpromazine, promazine and triflupromazine. Behaviorally, these drugs were associated with a) increasing sedation, drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimization and displacement of symptoms. Barbiturates regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. �-19Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with alerting, hypomania, excitement and increased motor activity. Decrease in voltage and per cent time of slow wave activity in subjects with post-convulsive delta activity with LSD-25, benactyzine, Win-2299, JB-318, JB-336 and diethazine. Of these drugs, benaotyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. was seen electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronization of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpromazine and barbiturates, augmented the per cent time delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethazine, LSD-25 and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. The �-20. Various experimental psychopharmaceuticals were tested. In addition to extensive studies of b-b methy].ethylg1utarimide hexaflnarodiethylether (Indoklon) the following agents were studied; phenyltoloxanine(PRN-Bristol), methonalide (ELM-188, Bristol), tropin-h-chlorbenzhydryl ether (WY-21h9, (Megimide) and Wyeth), dimethylaminoethanel and varieties, Riker), its congeners (Deaner and JB-318, 329 and 336 (various piperidyl- benzilates, Lakeside) and imipramine (Tofranil, Geigy). Because significant behavioral and electrographic changes were observed, a more intensive investigation of imipramine (TofrEnil) was undertaken. In 28 acute experiments, consecutive patients referred for physiodynamic therapies were tested in the EEG laboratory at various stages of treatment. TofrEnil solution (10 mg/cc) was administered intravenously at a set rate (1 cc/ho sec) until electrographic or behavioral changes became prominezit, for a total of h0-125 mg (0.5-2.5 Behavioral observation and electrographic recording continued for one to three hours. In patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral TofrEnil of 75-350 mg was administered. In the acute studies there was initial restlessness, associated with dizziness, dry mouth, "faintness," nausea, mg/kg). and on four occasions, vomiting. These symptoms persisted for lassitude, heaviness eventual drowsiness. Heart rate was 10-20 minutes, and were accompanied by of the extremities and unchanged or slowed. Blood pressure dropped by 20-h0% in �-21.. older (age > 60) patients. Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographoc patterns accompanying these behavioral changes were initiated by a gradual decrease in voltages during the injection. By ten minutes, the per cent time alpha had been halved. In patients with moderate amounts of beta activity, such activity occasionally increased in voltage and per cent time. By twenty minutes, in association with behavioral lassitude, low voltage (to 50 microvolts) random theta frequencies (5-? cps) appeared. In records with post-convulsive delta activity, there was a marked decrease in voltage and per cent time of slow wave activity. These % to two hours. for electrographic patterns persisted There was considerable individual variability in this acute EEG response. In patients who received 100 mg or more of TofrEnil, EEG and behavioral changes were observed in all but three. In six patients, dosage of TofrEnil less than 50 mg were associated neither with EEG nor with behavioral changes. In chronic Tofrénil studies, behavioral changes generally appeared during the second, and were maximal during the third, week of treatment. The most prominent behavioral adaptation was euphoric denial. Patients complained less of somatic displaced their illness became increasingly difficult to discuss symptoms, and denied, minimized or on inquiry. It �-22In six patients them. with significant life relationships and depressive increased and restlessness somatization agitation, restlessness, affect persisted. of cessation the to excitement, insomnia and vomiting, les five patients in noted were symptoms No in change therapy. In three, therapy. showed administration chronic on studies Electrographic Low modulation. record a decrease in voltages with poorer Well 10% appeared. to up cps) activity (5-7 theta voltage few. a in prominent more became defined fast activity after four weeks of NeuroInternationale (Presented at the Collegium the 1958; at September, Psychopharmacologicum, Rome, March, Montreal, Conference on Depression and Allied States, in Published, 1959. EEG Society, June, 1959; and American harmacolo chc Ps of s C.I.N.P.; Proceedin the in gamed. part, Ps Ass. cﬁiat. 1959; 32§~332, N. Kline, ed. 19E8. Frontiers, 682-685, and Neurology __3. _E: 1653117159959; _8_: Relationship Therapist-Patient of the 2. Aspects Affecting Choice of Therapy. than other aspects involves The selection of therapy the In the of patient. the manifest behavioral patterns been have problem this further efforts to clarify past year therapist-patient and frustration that We have hypothesized relationship. and implicit relationship hostility in the therapist-patient have a significant environmental pressures or explicit the in factors emphasizing undertaken, influence in referral for somatic therapy. residents with interviews 76 structured In a pilot study somatofor requests and supervisors were initiated following �-23- therapy. These interviews were designed to elicit the basis of the referral. It was found that in only relatively few cases was there a change in the patient's clinical status which directly led to the referral. In most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure from the patient's family or ward personnel. .It was also noted that patients with similar behavior patterns were treated differently, some given somatotherapy and others none. The reasons for this ranged from "whim" to quantitative differences in symptomatology and individual preferences for type of treatment. It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These same extraneous factors also influenced the timing of the referrals. As a result of these findings a "Somatic Treatment Referral Sheet" was developed (see Appendix) to be completed by the therapist whenever somatic therapy is requested. This study is continuing. �-2h. 3. Language Patterns as Measures of Behavioral and Neurophysiologic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that two language measures, a syntactic content analysis (Kahn and Fink, 1958) and dyadic diversifica‘ tion scores of unstructured interviews (Jaffe, Kahn and Fink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interviews on acute administration of various psychopharmacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: amobarbital, benactyzine, chlorpromazine, diethazine, lysergic-acid diethylamide, and Win-2299. Following a routine electrographic recording, an unstructured psychiatric interview, with short periods of structured inquiry, was tape recorded. With EEG running, an intravenous injection was then given at a slow rate. When specific electrographic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow waves (delta) and beta frequencies. �.25tape recordings were transcribed and measured for the diversification of consecutive 25 word samples of speech of The both participants (dyadic) and for syntactic changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, for each sample the ratio of the number of different words to the total number of words (a diversification score) was calculated. The syntactic language analyses were based on the response to standardized questions using a method previously described (Kahn and Fink, 1958), scoring such changes as syntactic use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophysiologic and behavioral effects of the drugs applied. Amberbital and chlorpromazine are neurophysiologic synchronizing agents. Amobarbital regularly induces high voltage well synchronized fast activity at 20-2h cps, while chlorpromazine administration is followed by increased synchronization of the EEG record and a shift to slower frequencies including occasional slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilization. On the language measures there was an increase in stereotypy and �-26~ repetitiveness associated with increasing use of alterations in tense, displacement and evasion. and / cliches, Diethazine, benactyzine, LSD-25 and Win-2299 are neurophysiologic desynchronizing compounds. These drugs are characteristically associated with decreased voltage and per cent time of alpha activity and increased irregular low voltage fast activity. Behaviorally hallucinatory, excitatory or illusory activity are observed. 0n the language measures there was decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Psychodynamic, Psychoanalytic and Sociamgic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, 1958, and at the American Psychiatric Association, Philadelphia, April, 1959). �-27. SUMMARY lgsh - 1959 out-“n” laboratories of the Department of Experimental Psychiatry were established at Hillside Hospital in September, 19Sh. During this five year period neurophysiologic, and and perceptual), linguistic (personality psychologic sociologic aspects of "somatic" psychiatric therapies have been the principal foci. The Convulsive Therapy: The view of the convulsive therapy process as the induction of a non—specific state of altered brain function, similar to craniocerebral trauma was supported and amplified 1. cerebral Within subjects altered milieu, this 21). ll, were seen to respond in various ways (26), of which the most "successful" was explicit verbal denial (7, 31). This latter (10, adaptation was most prominent in characterologically disposed individuals (36). An alteration in brain function was pre-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were essential to this process (26) but electrical induction was not (B-h2). The alterations in brain function were measured in various ways including electroencephalography (6, ll, 12, 2h, 39), language patterns (b, 7, 1h, 31, h3; B-2h), perceptual tasks (2, 16, 17, 3?, h6; B-26, hl, h2) and tests of Reference numbers are to publications or presentations (Blisted in the appendix. ) �recall (8). It suggested that the neurophysiologic basis of convulsive therapy may lie in an alteration in central synaptic cholinergic - adrenergic relationships, with a predominant shift to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the was relationship of high voltage EEG slow wave activity to behavioral change (6, ll, 26) and the blocking of post-convulsive electrographic and behavioral changes by central anticholinergic agents (21, 3h, 35, bl, h2) and central sympathomimetic agents (h2). A variety of behavioral changes were seen during convulsive therapy (26; B-l7). Such patterns were viewed as adaptations to altered brain function, and were believed dependent upon characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value judgments by the observer of behavioral change in the subject (26). Adaptations characterized by denial mechanisms, both in behavior (B-17) and in language (7, 31) were seen as most favorably rated by the psychiatric staff. Such adaptations were related to habitual modes of conduct (character, personality} (36; B-ll, 32). The persistence of the altered behavioral nodes was noted as dependent upon the degree and duration of altered brain function, the environmental expectations, and the type and �+29- degree of family and medical support (26). Different varying types of behavioral patterns were best supported by psychotherapy (19). Measures of linguistic behavior in structured (7, 31) and unstructured (1h, 29; B-2h) interviews showed characteristic alterations towards increased denial, minimization, displacement, stereotypy and repetitiveness related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21,h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), embedded (Gottschaldt) figures (37; 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years of education, nativity and degree of stereotypy and conventionality (measured by California F Scale) were related to selection of therapy, duration of hospitalization, diagnosis and treatment response in hospitalized patients (15, 36, ho, hS). 2. Neurophysiologic-Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis concerning the mode of action of other therapies such as insulin coma, leucotomy and psychotropic drugs, was expressed (10, 33, 38). This view holds that the efficacy of these therapies depends upon the induction of states of altered brain function, in which �varying adaptive patterns may become prominent. The adaptive pattern is related to the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of drug therapies MY—2092 3. is this hypothesis as applied to psychotropic now in progress, supported by USPHS grants and MY-2715. Insulin Coma Therapy. initial case study showed the significance of denial patterns and of persistent altered brain function for the An behavioral changes in insulin In an insulin coma therapy (3). - chlorpromazine control study, no coma differences in hospital improvement ratings were observed in the two treatment groups (27). Chlorpromazine was safer, easier to administer, permitted continued administration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin some by psychotropic drugs in this institution. h. Pharmacotherapy. The ongoing program in evaluating various psychopharma- ceuticals is derived from these hypotheses. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various new compounds are in progress. EEG patterns, along such continua as synchronization-desynchronization and frequency shift, and various perceptual, perceptual-motor and personality �-31.. and h2) 3h, (21, behavioral bl, to related being tasks, are linguistic changes (21, h3). The neurophysiologic basis of experimentally induced hallucinogenic states has been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis (21, h2) is now being expanded. �.132-" PUBLICATIONS AND PRESENTATIONS 195k - 1959 A. Publications. 195h Patterns of Perceptual Organization with Simultaneous Stimuli. Arch. Neurol. & Psychiat., 72: 233- 255. Bender, M.B ., Green, E. andFFinE, M. 2. Standardization of the Face-Hand Test. “”""§z Neurolo , h: 1. 211-217. Fink, M. and Green, 1955. M. ' Delusional Reduplication of Parts of Body after Insulin Coma Therapy. J. Hillside Hos ital h: 13h-1h7. Kahn, R. L., Fin , . an rau er , h. The Amytal Test in Patients with Mental Illness. J. Hillside Hospital, h: 3-13. Kahn, R.L., Fink,'M. and Weinstein, .A. 3. 1956 Denial of Blindness Following Cerebral Angiography. J. Hillside Hos ital, S: 238-2h5. Fink, M. 6. Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophzsiol. Q: 158 (Abst) Fink, M. and Ka n, R.L. 7. Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. & Ps chiat. 76: 23- 29. E. A. Kahn, R. L., Fink, M. and Weinstein, 8. Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol. 16: 88- 96. Karin, H., Fink, M. and Kwalwasser, §. 5. 9. Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety. Wachspress, Hillside Hospital killer, . 67- 77. J. S .A. M., Blumberg,'I'WG Fin E, ﬂ. and �~33:. PUBLICATIONS AND PRESENTATIONS 1957 Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hos ital, 6: 197-206. Fink, M. 11. Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. & Pszchiat..- 78: 516-525. Fink, M. and 10. A w Itajin, ROE. 12. Significance of Individual Variability in the to Electroshock. J. Hillside Green, M.A. 13. EEG An and Response Hospital, 6: 229-2h0. EEG Clinical Response to Megimide. EEG. Clin. Green, M. and Fink, M. Neurophysiol. 2: 180. Objective Study of Communication in Psychiatric Interviews. J. Hillside Hospital, 6: 207-215. J. Jaffe. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hos ital, 6: 216-228. Kahn, R.L., Pollack, M. and Fink, M. 16. Perception of Embedded Figures After Induced Altered Brain Function. Amer. Psychol. 13: 361. Kahn, R.L. and Fink, M. 17. Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli. J. Hillside Hospital, 6: 2hl-2SO. Karin, H. and Fink, M. 18. Perception Experiments in a Study of Ambivalence. Arch. Neurol. & Psychiat. lg: 167-176. Karin, H., Tarachow, S. and Friedman, S. 1958 with Electroshock 19. Psychotherapeutic Techniques Patients. " ‘J. Hillside Hospital, 1: 17-25. Esecover, 3., JaTTe, 3. and Kahn, R.L. 20. Lateral the Sedation Clin. Neurophysiol. l2: 162-163. Gaze Nystagmus as an Index of Threshold. Fink, Mo EEG. �PUBLICATIONS AND PRESENTATIONS 1958 21. Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. A.M.A. Arch. Neurol. & Psychiat. ﬁg: 380.387. Fink, no 22. Effect of Diethazine on EEG and Significance for Theory of Convulsive Therapy. EEG. Clin. Neurophysiol. l2: 207-208. Fink, M. 23. Effect of Anticholinergic Compounds on Post-Convuhive EEG 776 and Behavior. (abst). Fink, EEG. E. Clin. & Neuroph siol. $2: Electroencephalographic Correlates of the Electroshock Process. Dis. Nerv. Sy . $2: 227. Fink, M. and Green, EXperimental Studies of Convulsive and Drug Therapies in Theoretical Implications. A.M.A. Arch. Psychiatry: Neurol. & Psychiat. ﬁg: 733-73h (abet). Fink, M., a n, . . an reen, M.A. 26. Experimental Studies of the Electroshock Process. Dis. Nerv. Sys. l2: 113-118. Fink, M., Kahn, R.L. and reen’ 0 M. 27. Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Amer. Med. Assoc., 166: 18h6-1850. Fink, M., Shaw, R., Gross, G. and Coleman, F.S. 28. ' Clinical and Electroencephalographic Effects of Megimide in Patients without Cerebral Disease. Neurology, 8: ‘ 682-685. Green, M. and Fink, M. Psychiatry, 3;: 2h9-258. Jaffe, J. 30. Communication Networks in Freud's Interview Technique. 29. Language of the Dyad. Psych. Quart. 2g: hS6-h73. Jaffe, J. 31. Changes in Language During Electroshock Therapy. and Ed. P. of Hoch, Communication, Psychopathology Eratton. Kahn, R.Lo and Fink, u n, ., rune M. �-35PUBLICATIONS AND PRESENTATIONS 1959 32. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biol. Psychiatry ed. Massrnan, J., Grune & Stratton, N.Y. pp. 1 -l9 33. Alteration in Brain Function in Therapy. N. ed. Kline harmacology Frontiers, E Co., Boaton, pp. 325-332. Fink, M. 3h. Significance of EEG . Fink, Psycho- Eittle, M. Brown ‘ Pattern Changes in Psychopharmacology. Clin. Neurophysiol. g: 398 (abst). Fink, M. 35. Electroencephalographic and Behavioral Effects of TofrEnil. Canad. Psych. Assoc. J. A: 1665-1718. Fink, M. 36. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. JoNoMoDo 128: 2h3‘2h8- Fink, Mo, Kahn, Roll. and EEG. PoIIacE, HT" 37. Effects of Diffuse Altered Brain Function on Perception. Proc. XV . Int. Con . Psychol. Publ. North-Holland, Amsterdam, pp. 238-239. Fink, M., Kahn, R.L. & Karin, H. 38. Therapy of Schizophrenia: Role of Alteration of Brain Function on Behavior. Congress Re orts II Int. Cong. Psychiatry, I}: E9?-E§3 Kahn, R.L. and Korin, H. labstS. Fink, M., 39. Relationship of Threshold and Duration of Seizures to Degree of EEG Delta Activity Induced During Electroshock. EEG Clin. Neurophysiol. —2: 399 (abst). Green, M. ho. Prognostic Application of Psychological Techniques in Convulsive Therapy. Dis. Nerv. Syg. 32: 180-18h. Kahn, R.L. and Pollack, H. In Press bl. Effects of Psychopharmacologic Agents. szchotropic Drugs, 2: Ed. Bradley P. Fink, b2. Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients. EEG Clin. EEG and Behavioral Neurophysiol. Fink, M. M. �PUBLICATIONS AND PRESENTATIONS In Press (contd) Interview Patterns. The D amics of Psvchiatric Drug There , ed.-3T arwer-Foner, C.C. nomas, Springfield, Ill. Fink, M., Jaffe, J. and Kahn, R.L. hh. Formal Language Patterns as Character Defenses: Implications for Psychoanalytic Technique. Pszchologz of Speech and Hearing Disorders, ed. Barbara, D. ., Grune & Stratton. Jeffe, 3. h3- Drug Induced Changes in Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. A.M.A. Arch. Gen. Pszchiat. Kahn, R.L., Pollack, H. an h6. n, o Set in the Perception of Simultaneous Tactile Stimuli. Am. Jour. Psychol.Korin, H. and Fink, M. The Role of �3. Presentations. 1. Relationship Between Altered Brain Function and Denial in Electroshock Therapy. American Psychiatric Association, Atlantic City. Delusional Reduplication of Parts of the Body after Insulin Coma Therapy. New York Neurological Society, and the New York Society for Clinical Psychiatry, New York. Relation of Changes in Memory and Learning to Improvement in Electroshock. Electroshock Research Association, Atlantic City. h. Quantitative Study of Slow Wave Activity Following Electroshock. Eastern Association of Electroencephalographers, Bethesda. Newer Drugs in Psychiatry. Nassau Neuropsychiatric Society, Long Island. 3. 1956 Changes in Language During Electroshock Therapy. American Psychopathological Association, New York. Electroencephalographic and Clinical Effects of Megimide. Eastern Association of Electroencephalographers, New York. 1957 8. Perception Experiments in a Study of Ambivalence. Section of Neurology and Psychiatry of the New York Academy of Medicine and the New York Neurological Society, New York. Individual Differences in EEG Responsivity. Metropolitan EEG Society, New York. 10. Criteria in Evaluation of Clinical Behavioral Change. Round Table Discussion, American Psychiatric Association, Chicago. 11. Personality Factors in Behavioral Response to Electroshock Therapy. Electroshock Research.Association, Chicago. �938PRESENTATIONS 1957 12. EXperimental Studies of the Electroshock Process. Society of Biological Psychiatry, Atlantic City. Effects of Diffuse Altered Brain Function on Perception. XV International Congress of Psychology, Brussels. Therapy of Schizophrenia: Role of Alteration in Brain Function in Behavior. International Congress of Psychiatry, Zurich. The Relation of Ambivalence to Aggression and Authority in Psychoneurotic Patients. American Psychological Association, New York. 16. Perception of Embedded Figures After Induced Altered Brain Function. American Psychological Association, New 13. York. 17. Behavioral Patterns in Induced States of Altered Brain Function. New York Divisional Meeting, American Psychiatric Association, New York. Objective Study of Communication in Psychiatric Interviews. New York Divisional Meeting, American Psychiatric Association, New York. Significance of EEG Frequency Shift for Psychiatry. Metropolitan EEG Society, New York. Effect of Diethazine on EEG and Significance for Theory of Process of Convulsive Therapy. Eastern Association of Electroencephalographers, New York. An 1958 Correlates of the Electroshock Process. Eastern Psychiatric Research Association, New York. 22. Significance of Individual Variability in EEG Changes During Electroshock Therapy. Eastern Association of Electroencephalographers, Montreal. 23. Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications. New York Neurological Society and the New York Society of Clinical Psychiatry, New York. 21. EEG �-39. PRESENTATIONS 1958 Patterns with Altered Brain Function. Eastern Psychological Association, Philadelphia. The Relation of F Score to Behavioral and Psychological Response with Altered Brain Function. Eastern Psychological Association, Philadelphia. 26. Intensity of Stimulation and Perception of Simultaneous Stimuli in Cerebral Dysfunction. Eastern Psychological Association, Philadelphia. Communication 27. 28. 29. 30. 31. 32. 33. 3h. 35. SociOoPsychological Aspects of Diagnosis and Treatment: Theoretical Implications (Symposium). Eastern Psychological Association, Philadelphia. Drug Induced Changes in Interview Patterns. Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (Tranquilizing) Drugs in Psychiatry, Montreal. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. American Psychiatric Association, San Francisco. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. American Psychiatric Association, San Francisco. A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon". American Psychiatric Association, San Francisco. Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Electroshock Research Association, San Francisco. Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Society of Biological Psychiatry, San Francisco. Role of EEG Frequency Shift in Behavioral Effects of Drugs. Section of Neurology and Psychiatry, Queens County Medical Society, New York. Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior. American EEG Society, Atlantic City. �shoPRESENTATIONS 1958 Prognostic Application of Psychological Techniques in Convulsive Therapy. Eastern Psychiatric Research Association, New York. 37. EEG and Behavioral Effects of Psychopharmacologic Agents. Collegium Internationale Neuro-Psycho Pharmacologicum, Rome; and Eastern Association of Electroencephalographers, New York. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock. Eastern Association of Electroencephalographers, New York. 1959 Effects of Tofranil. International Conference on Depression and Allied States, Montreal. Sociopsychologic Factors Affecting Therapist-Patient Relationships. American Academy of Psychoanalysis, Philadelphia. Effect of Induced Cerebral Dysfunction in Man and on Tachistoscopic Perception of Embedded Color Figures. Eastern Psychological Association, Atlantic City. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction. Eastern Psychological Association, Atlantic City. h3. Sociopsychologic Aspects of Psychiatric Treatment. Eastern Psychological Association, Atlantic City. hh. Language Patterns as Measures of Behavioral and Neurophysiologic Change. American Psychiatric Association, Philadelphia. EEG and Behavioral �C. Reports in preparation: 1. 2. 3. Experimental Studies of Convulsive Therapy - a monographic review. EEG Patterns and Synaptic Events in Experimental Hallucinogenic States. Comparative Study of Indoklon and Electrically Induced Convulsive Therapies. Studies of the Sedation Threshold. Effect of Induced Cerebral Trauma in Man on the Tachistoscopic Perception of Embedded Colored Figures. Individual Differences in the Perception of the Upright in Hospitalized Psychiatric Patients. Social Attitude (California F Scale) and Convulsive Therapy. Sociopsychologic Factors in Drug Therapy. Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function. �’os. Relation Between Altered Brain Function and Denial in Electroshock Therapy Robert L. Kahn, Ph. D. Max Fink, M.D. Edwin A. Read , at the Weinstein, M.D. Annual Meeting American Psychiatric Association, May 1955. the Research Service of the Hillside Hospital, and the Department of Neurology of the Mount Sinai Hospital, New York. From This investigation was supported in part by the Medical Research and Development Board, office of the Surgeon General, Department of the Army under Contract No. DA-h9-OO7 MD-3763 and grant M-927 from the National Institute of Mental Health of the National Institutes of Health, Public Health Service. �Although many theories concerning the mode of action of electroshock and psycholphysiological among the relationships been have offered, therapy (3,h,5,6) studies In previous understood (1,2). remain poor v ogical factors certain function, that was suggested of brain it of patients with alterations of effects the to therapeutic related of the observed patterns of behavior were electroshock. dis(3,6), anosognosia of or illness denial included patterns in and language, (8) changes time and (7), reduplication orientation for place that indicated was It (9). paraphasia misnaming or particularly nonaphasic These than rather of illness the stress to these phenomena were fonns of adaptation neural of milieu the In judgment. Specific defects in memonv, perception or motivations his the expresses damage, patient brain reorganization provided by the with modes of interaction changed of in new s,rmbolic patterns indicative of forms insuch denies the delusion patient In anosoynosic the environment. of an the and operation, fact blindness, of a limb, loss capacity as hemiplegia, as well as other problems in livinﬁ. In disorientation for place, the way in the symbolic as serves hospital which the patieit be need to the often traumatic situation, representation of some aspect of the the locates or of familiar place a name the he uses well and go home. Thus, misnames and mislocates the the outside hospital. a confabulates journey his to or close hospital academy" skating "roller a as the to hospital 'When a paraplegic patient refers names Mount the (Mount Cyanide, Sinai) hos the ital or a paranoid patient calls home symbolize the patient's feelings in dramatic fashion. In paraphasia, the ob- a to personal related usually are patient jects the Thus, patient and of hospitalization. illness that problem, particularly and and objects the of places body, selects aspects of the environment, parts which are misnamed by the in of his a feelings the exnression for them language his in uses n interaction. new mode of �.3. could be brought out by the administration of amytal sodium ("positive amytal test"). 'With a return of the complaints of pain these changes in behavior were no longer apparent either clinically or under amytal. This sequence of events were repeated during two Subsequent courses of electroshock. While this report supported the hypothesis regarding the therapeutic action of electro- test" in investigating the probdid not represent the usual condition for shock and showed the usefulness of the "amytal lem, it concerned only one case and is given. The theory is further tested in the present study in which a group of potients receiving electroshock for mental illness were given repeated amytal tests before, during and after the course of treatment. The purpose of the study was to determine the relationship between the clinical response to the which electroshock treatment and changes in behavior produced by the drug. theses tested were that those patients more likely to show: (1) evidence The particular hypo- improved with electroshock would be who of brain dysfunction on the amytal test and (2) behavior patterns indicative of denial. METHGD series of amytal tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the patient Each awareness of was given a illness. The drug ution at a rate of .05 grams (1 is then administered intravenously in a cc) per minute until nystagmus, slurred drowsiness and errors in counting backward are noted. now repeated. The The same 5% sol- speech, questions are following changes, when persistent, are called "positive" and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness. 2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness. 3. Misnaming the hospital, either euphemism as "rest home." its proper name, or in terms of a �ah. Displacement of the location of the hospital, such as to another city. 5. Confabulated journeyt 6. Reduplication of the hospital, as stating that he is in another hos~ pital of the same or similar name. 7. Disorientation for time of day with confusion of day and night. misidentification of the examiner such as calling or an "entertainer". 8._ Gross him a "lawyer" 9. Disorientation for year. The patient was given his first test prior to treatment, and re-tested at weekly intervals. All patients in the series had negative amytal tests prior to the initiation of therapy. Treatments were administered three times a week, so that the patients were generally tested after every third treatment. A test after a treatment. Testing was continued after the termination of therapy until the result had become negative. of and records standard tests memory and learnElectroencephalographic ing ability were also given, but will not be considered in detail in this paper, was always given two days POPULATION Twentyufour patients at Hillside Hospital receiving electroshock with the Reiter Electrostimulator were studied. There authors. The patients were taken on the was no basis of consecutive referrals, and the determination of the necessity for treatment was Some patients were selection of cases by the made by the clinical necessarily excluded because their treatment staff. was terminated or interrupted before they were adequateLy studied. Another was omitted because he had manifestations of brain disease and a positive amytal to electroconvulsive therapy. thirtyvthree. Patients treatments. Some The number who showed test prior of treatments varied from nine to clinical improvement tended to receive fewer of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. �~5One patient decided for himself that he had enough treatment and eloped. gnostically, the patients consisted of 1h with depressive schizophrenia and one manic reaction. There were 15 and the ages ranged from 2h series, to 68 reactions, women and 9 men 9 Dia- with in the with a median of h7. of response to E.S.T. Evaluation.Wa— M~~ All the patients were observed for at least eight weeks after completion of treatment. on Determination of the patient's response to electroshock was made staff opinion, the the basis of the resident psychiatrist‘s impression, nurses' notes and the clinical evaluation of one of us (M.F.) who supervised the treatments but was not aware of the amytaltest results. In this way the pat- ients were classified into three groups. gﬁwwyarkedlv Improved; The 11 cases in this group were regarded as show- ing recovery or marked improvement. These patients no longer showed the ptoms which brought them symp into the hospital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. B. Moderatelv Improvegz_ The six patients in this group showed some improvement but continued to manifest indications of mental illness. These patients typically relief, i;§:, acute depressive features showed symptomatic might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticeable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation, C. Minimally or Unimnroved. In this group were placed seven patients in whom change was not ient improvement. somewhat improved. clearly noticable or Some showed But who showed only equivocal or trans- fluctuations in behavior, at times appearing the change was not sustained, so that by the end of �9-6- much did before. as they appeared treatment, they are aware of the difficulties in evaluating improvement. Others might In by these any case, of in patients. change estimates the have differed in and the between first the differences using this threefold classification, We third groups will be distincto OBSERVATIONS l. ﬂggjggL Test Results of The number tests given amytal Reactions. of A. Distribution Positive -um-W from to three thirteen, ranged electroshock of the course each during to patient shown the data Table is In maintained. I, depending on how long treatment was . for the number of and number and percent posthe treatment tests given during The improved patients markedly each in the group. patients itive for all moderthe with unimproved the group, showed many more positive reactions than between these groups. Every markedly improved ately improved patients in On other the treatment. reaction during ient had at least one positive amytal cases unimproved of the and five hand, one of the moderately improved patients the of incaach A the results of comparison showed result. a positive never the than better at significant groups, using chi-square, is statistically level of confidence. TABLE I pat—_ 1% WWW DISTRIBUTION OF POSITIVE ANITAL TESTS DURING TREATMENT ” No. of tests given durinc treatment Markedly improved (ll) Moderately improved (6) Unimproved (7) Number positive % Positive 50 38 76% 39 15 38% hS 6 13% the In groups of Fig. treatment. each l stase at B. Positive reactions who had positive each in of group the patients percentage for are compared » �treatment. of each stage at results after reactions had positive Almost half the markedly improved patients nine to seven after reactions had positive and.all treatments, three only treatments. In the unimproved cases, on of number positive the hand, other the of the course during increase consistent no was and there small reactions was other the between to tends fall improved group moderately the Again, treatment. two. Although some than more received patients 15 treatments the data is not small too became each number in group the because presented beyond this point than more received unimproved patients of the Four of comparison. for purposes mode One the of with consistently negative amytal test results. 20 treatments occasionally an with only treatments 30 received over improved patients erately positive reaction. There were variations in the per- reactions. positive a .e-u' two consecleast at Using week. week to from sistence of positive reactions improved, markedly the of nine of persistence, criterion the as utive positives showed perunimproved group the of one and only two of the moderately improved C. Duration_3§ “-5 one but patients treatment all of termination the ,After sistent positives. The reconvulsion.. the last after nine days had negative amytal reactions treatment. week after second the by test negative a developed maining patient improved group markedly the in D. Factor of awe. Since the patients conceivis reactions, it from depressive suffering be older tended to persons to age be scley related might results test able that the difference in amytal assum— the is this Underlying improvement. clinical to coincidentally and only funbrain altered show of signs to more s likely i older the person that ption | shown. each is 2 for group mean the Table age In electroshock. when given ction �-8. TABLE 2 RELATIONSHIP OF CLIEICAL_IMPROVEMENT TO AGE Than Age Markedly Improved (ll) h7.6h 0' Moderately Improved (6) 50.00 Unimproved (7) 35-29 It is apparent that the first patients. two groups were older than the unimproved Yet, while the mean age of the moderately improved cases higher than the markedly improved group, theSe patients still show is slightly significantly fewer positive reactions. In Table 3 the number of positive reactions during treatment is shown of he over to age. limited years patients the analysis is for In this table the relationship of positive reactions in the different groups remains unchanged from that when the groups are considered as a whole. each group when TABLE 3 OVER hO PATIENTS IN AMITAL'TESTS DISTRIBUTION OF.EQ§EE;VE a... No. of tests given durine treatment_ Number positive % fpsitizg Markcdly Improved (1m) h6 35 76 Mederately Improved (5) 3h 15 hS Unimproved (3) 17 O O 2. Other Aspects of Behavior. were there and disorientation of denial illness explicit and the of drug influence the under both occurred changes in behavior that fashion progressive treatment is of significantly the course clinically during Apart from in those patients who improved. These aspects may be divided into verbal and non-verbal communication. A. can: Channes in Verbal Language. These consisted of denial expressed in �-99.. evasion and in the use of a syntactical pattern involving the third and second When person. asked about their symptoms patients gave such answers as "it's hard to say" or “I forgot" or "I don't know; I‘ve been waiting for the doctors tell as "it's to me." The change what they in syntactical person is illustrated by such remarks call a depression," "I‘m afraid answering the question "what trouble." Sometimes In patients patients is talk of a relative would there One to the start of treatment what will get hurt" or your main trouble" with "what who improved in the non-drug interviews. somebody was a who was is 3223 main sick. notable development of such patterns patient, for example, whenzisked prior his main trouble, said "I'm depressed." such was After two treatments he answered the question with "I don't get along well with my mother-in-law." After five treatments he said "I don't get what you he said know." After ten I that‘s "I all sick; get after eight, what 11 "in and said way after don't my see wife," "right now, it‘s that I do you mean" and "I don't know how to explain it." At the termination of given home" an followed by "I to want main get was as trouble his tr atment, mean," and account of how "good" his wife was. of these group, increased the use the other hand, on In the unimproved language patterns did not occur. They were not present in some, minimally or inconsistently noted in others. In some of the unimproved patients there was than the of drug the under effects of these language patterns actually less use there had been in the pre-amytal interview. ..B. clinical in Changes in Non-Verbal Behavior. and drug interviews most frequently the moderately improved and improved. Euphoric reactions occurred both in in the markedly improved, less least in the group which were considered un- In the unimproved patient classed as manic, euphoric behavior was present in his clinical behavior and was not changed by amytal. �-10—‘ of of four interviews the amytal in apneared Changes in sexual behavior other the of each in one in only but patient the markedly improved patients makthe examiner, caress hug to form of or This took the trying categories. ing remarks with sexual content or engaging in masturbatory ient in the unimproved group showed activity. this behavior both during are-drug A pat- inter— views and under the influence of amytal. Withdrawal or "selective inattention" was shown by nine of the eleven the amytal of the phase drug during markedly improved patients particularly about the questions answer to of failure consisted interview. This behavior fashion. and cryptic in dysarthric responding and hospitalization or illness the other each of groups. in once occurred only the drug under This reaction who appeared the category unimproved two in of that patients It was interest withdrawn before the test became more responsive under the influence of the drug. ravage: there is that indicate these in patients tests the of anwial results damage or brain of and the production improvement between clinical a relation method of determined this by particular an altered state of brain function as The examination. In patients who improve, the amytal test becomes consistently treatment. of the course in early positive In moderately improved or unimproved does not increase and frequency their reactions patients there are fewer positive such function brain methods of evaluating with more treatments. With other the in showed abnormalities All not patients present. close correlation was found frequently as was and * learning impaired record electroencephalographic damage The brain of effects who did not. those who improved as in in patients are not unitary and different methods of study show varying results. more analyzed_in being are these data in patients a The electroencephalographic the show that The findings preliminary be reported elsewhere. detail, and.will amytal the to comparable EEG improvement, to related abnormality is Wegree of test findings. �.11 - in to changes function brain of altered In relating the various aspects behavior after electroshock therapy defects in the formation of In the of language. first symbol it has been helpful to distinguish between patterns and defects in the adaptive uses category one may include such clinical phenomena as loss. of memory and certain types acalculia aphasia, apraxia, finger agnosia, cannot select he but wants he "know" to what say In aphasia, the patient may and movements and sounds of the appropriate elements from the entire category of elements excannot select the defects With patient memory integrate them. them temporal pata in and units arrange significant perience, class solving of problem manifested in tests commonly also tern. Such defects are fre— Such are patients scale. and in certain subtests of the Wechsler-Bellevue them into quently concerned with their and of marked anxiety degrees and exhibit defects frustration. Adaptive changes in language, on the other hand, relate to interaction They behavior. of motivational aspects the with the environment and concern The besame and disorientation. denial of are exemplified in the phenomena and other in defect a conditions as havioral element may appear under certain cases as a part of an be may example, for form of adaptation. Left~ri9ht disorientation, impaired and is of right which the left concept aphasic defect in a paralyzed able to identify seem not may Other however, patients, or lost. or and ear left arm their (non-paralyzed) Show right their left arm, but can relate not does and as long as it of right knowledge left similarly indicate a the not in electroshock of prois action therapeutic to their illness. milieu neural the in providing rather but formation duction of defects in symbol The in which altered forms of adaptation may be maintained. outcome of electroshock treatment by the psychiatrists predict the Other point treatments. the initial amount of "confusion" that occurs after The test amytal Leprovement. to not related was "confusion" where to cases Many �-12.. should be useful as a prognostic guide by defining the nature of these changes. In cases "confusion" some patients the amytal test mainly a matter of memory defect and in these may be negative. On the other hand, some patients imp such Clinical In of evidenae few without treatments "confusion." a after prove instances the amytal procedure may show an alteration in brain function. In may be this study almost half of the markedly improved patients had positive reactions In another case, treated privately by one of us (E.A.W.), within three treatments. after only two result prior to treat- marked improvement of a severe depressed condition was noted convulsions. Yet this patient, who had a negative amytal ment, showed a markedly positive reaction one day These results do not than patients brain damage ectly measure brain damage, but rem that mean who do improved not improve. rather after the second treatment. patients have a The amytal one deduces test greater degree of does not dir- the presence of braincianage the nature of the adaptive changes in communication. Thus patients with brain damaje who do not show such changes are considered to show a negative re- im~ methods of behavioral demonstrating other that sult. It is for this reason paired brain function may not distinguish between improved and unimproved patpositive do and not others amytal a Why some develop test, patients ients. despite many more convulsions is unclear, but factors and to the patient's habitual mode may be related to personality of adaptation to stress. It is be so function brain of altered state treated a that nevertheless, necessary, that these forms of adaptation or denial can be maintained. It is for these which electroshock methods of administering believed that reasons that it is be not seizures will generally unilateral as function brain minimally alter efficacious. Also it affords some explanation as to why electroshock often has a beneficial short term effect while evaluation of long ternleffects little difference between treated and untreated cases. show �-13In considering what constitutes "improvement," it is likely that such evaluations are dependent in considerable degree on the types of verbal and patient denies that imp he rated and is and uncomplaining, affable he has any problems, appears he has developed he that has or does mean not acquired insight that It proved. non-verbal adaptation that the patient uses. a more realistic understanding Thus, when a of his interpersonal relations. exemplified by the patient previously cited who said he This is well was "depressed" in third person when asked about his illness. While his behavior is rated as improved, actual analysis of his language shows that he is using different forms of symbolic the pre-treatment interview, but later used evasion and use of the adaptation. Recent mechanisms of studies have supported the findings concerning the development of denial in the improved patients. Carter (12) confirmed Janis’ (13) findings of consistent evidence of circumscribed amnesias in patients lowing electroshock. He that general memory impairment did not occur, "selectivity" in forgetting of unpleasant material concluded but rather, that there was a from the fol- patient's past life. Komgold (11;) likewise reports selective and "mechanisms of observes (15) Teicher similarly, sensitized forgetting. highly repression" for "emotional" stimuli after electroshock. Another aSpect of the difference between the improved and unimproved groups which may bear a relation to the therapeutic proved patients there were more changes in all not only in verbal patterns. Thus, a patient mechanism was that in in, types of symbolic adaptation, who appeared withdrawn both in the pre-drug and drug interviews had a poorer prognosis than the patient became withdrawn only under the who showed who effects of the drug, Similarly, the patient altered sexual behavior under the effects of the drug had exhibited this behavior during the prenamytal questioning as well, and did not improve with treatment, while the four patients manifesting sexual behavior only under �ﬁll!" the effects of the drug, did improve. The importance of the change in symbolic pattern is also illustrated by the fact that the unimproved manic patient showed no changes in this aspect of his behavior during the amytal test. It is thus likely that the facility of changing symbolic patterns in a situation of added stress is an important one in determining response in all somatic therapies. �SUMMARY AND CONCLUSIONS ment treatelectroshock for consecutively referred (l) Twenty-four patients the during intervals and at regular during were given amytal tests before, courSe of treatment. (2) There proved to be a close relationship between the shorteterm tests. of the anwtal results treatment and.the to sponse patients showed early, persistent re- The much improved positive reactions during patients showed no positive reactions or and increasingly the course of treatment. Unimproved intermediate group who showed infrequently and inconsistently. unimproved the than reactions showed more positive moderate clinical improvement of reincidence positive the much in improved the of short group but fell far An showed them actions. (3) Changes in behavior forms of non-verbal and language were most consistent and pronounced related to denial in the improved group, even in interviews not employing drugs. (h) The improvement clinical that the hypothesis support observations function in of altered.brain milieu of a in electroshockzmequires the creation mainbe may of those denial, Which new patterns of adaptation, particularly tained. �mmmmggzg 1.) Gordon, Fifty H. L. : 2.) Kalinowsky, L. Shock Therapy Theories, Mil. Surg. $92: 397, l9h8. B. and Hoch, P. H. Shock Treatment, PBychosurgery and : Other Somatic Treatment in Psychiatry, (2nd ed.) 3.) ’Neinstein E. & 1..) Psggrchiat. A. and Kahn, R. L. _6}_1_: Syndrome : Ybrk, 1952. of Anosocnosia, Arch. Neurol. 772-791, 1950. 'E‘Jcinstein, E. A., Kann, R. L., Sugannan, L. A., and Linn, L. Use of Amobarbital Sodium in Organic Brain Disease, 889-8911., Am. : Diagnostic J. Psych., llg: 1953. S.) weinstein, E. A., Kahn, L., and Malitz, S. R. Its the "Amytal Test" for Brain Disease: A. M. A. Arch of 6) New weinstein, E. Serial Administration of : Diagnostic and Prognostic Value, “enrol. and Psychiatu 11: 217-226, A. and Kahn, R. L. : 1951.. Denial of Illness: Symbolic and Physiol- ogical Aspects, Springfield, 111., Charles C. Thomas, in press. 7.) Weinstein, E. A. and Kahn, R. L. Brain Disease, J. Neuropath. 8.) & : Patterns of Disorientation in Organic Clin. Neurol. l; 21h-226, 1951. and R. A. L. E. L. A.: Kahn, Sugarman, weinstein, , A. M. A. Arch. Neurol. uplication, 9,) 'weinstein, E. 0rg-tanic Brain Psychiat. M. A. Arch. Neurol. 10.) weinstein, E. A., Linn, L. and Kahn, R. L.: Its Relation to the Therapy: {31: 808-8111, 1952. L.: Non-aphasic Misnaming (paraphasia) in A. and Kahn R. Disease, A. & Phenomenon of Red- & Psychiat.,‘éz: 72-79,l952. Psychosis during ﬁlectroshock Theory of Shock Therapy, Am. J. Psych., $925 22-26, 1952. 11.) Mcinstein, E. A. and Kahn, A. M. A. Arch. Neurol. ness, 12.) Carter J. T.: Type convulsive Therapy, 13.) Janis, I. L. : R. & L.: Personality Factors in Denial of Psychiat. Ill- Q2; 355-367, 1953. of Personal Life Hemories Forgotten Following ElectroAm. Psychologist §; 330, 1953. Psychologic Effects of Electric convulsive Treatments Post-treatment Amnesias.) J. Nerv. & Ment. Dis. ill; 359, 1950. (I. �REFERENCESz 1h.) Korngold, M.: An Shock Treatment, 15.) Teicher, A.: Investigation of Am. The continued Psychologist Q; Some Psychological Effects of Electric 381-382, 1953. Effect of Electroconvulsive Therapy actions of Schizophrenic patients, Am. on the Visual Re- Psychologist, g, hhS, 1953. �] ONS I REACT. 90 ._” much Improved (11) '*~ Mod. Improved ‘ 80 ” Unimproved (6) /// (7) / t// ‘\\\\\\_ //////////’ “~. * AMYTAL POSITIVE 3o PERCENTAGE 20 / / / (“” \ " , ,/ . " / x,” I f 10 O ' h-é ,__.._..7..___.-_....-_,_....__.-..;}..-.__ 7-9 10.12 13.15 NUMBER OF TREATMENTS occurring reactions test amytal of positive Fig. I.-—- Percentage treatment. of stages different each at in group �{fw g; ,{1/,m»‘-‘ JUN 26 ”12!. :c. .M Altered Brain Function Following Electroshock H—927 Progress Report - February 1 1958 - September 1 1959 Summary: In the past eighteen months various studies of the convulsive therapy process were completed, a program for the investigation of psychopharnacologic agents consistent with the general hypothesis concerning the node of action of physiodynamic therapies was developed. The physiologic effects of nany interrelationship of the neuro- new compounds with the psychodynanic, perceptual, personality and sociologic aspects of patients' behavior provided the framework for tnse investigations. following areas of study were explained: l) of psychotherapy with physiodynanic therapy; The the interrelation 2) the elucidation of the synaptic chemical events which are the basis of the convulsive therapy process by the acute administration or experimental anticholinergic compounds at various stages of convulsive therapy; and behavioral 3) studies of the acute and clinical effects of a EEG variety of psychopharnacologic agents; h) the use or language indices, such as syntactic and dyadic~ 1959 �-2- diversification analyses, as measures of behavioral neurophysiologic changes with drugs; and 5) a comparative study of indoklon and electrically-induced convulsions in psychiatric therapy; duration of 6) sociopsychologic aspects related to hospitalization, discharge ratings and diagnosis in a voluntary mental hospital; 7) the relation of social attitude to the effects of convulsive therapy; 8) aspects of the therapist- patient relationship affecting aha: choice of therapy; 9) studies of individual differences in the selection of, and behavioral change with, convulsive therapy by perceptual aethods. These studies have supported and expanded the neuro~ physiologic-adapative view or convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the node of action of psychepharnacologic agents. �Progress Report: A; Psychotherapy and Physiodyganic Therapy. Previous observations have shown that two types of patients are referred for electroshock in this hospital. largest number are patients in the older limited education and are foreign born, age groups who have They tend to introspective persons, stereotyped in their thinking language and verbally unconmunicative. symptoms The The be non- and Their predominant are depression, agitation, withdrawal and sonatisaticn. second, and smaller, group of patients are younger, native- born, better educated, and verbally ccnnunicativo with a capacity for intropection. They characteristically exhibit thinking disorders and overactive behavior states, with sonatisation and depression occurring An to a lesser extent. oratory explanatory study was undertaken of four patients, two for each group described above, for the purpose of determining 1) reasons for referral for convulsive therapy, 2) whether the differences in patients required different attitudes in psychotherapeutic nanagenent with electroshock, and 3) the �-1... relation of the psychotherapsutic approach to the patient'e clinical response to electroshock. It was found that all of the patients studied were electroshock because of a failure of connunication referred for in the psychotherapeutic relationship. In a reflection of the limited verbal and cases this was two introspective capacity social factors. In the of the patientdue to educational and other two cases, however,-the inpaired communication primarily due wee to unmanageable acting out. Following treatnent, the older, less educated patients were able to naintain this improvement with a reassuring and to nininication the tendencies denial toohniqne,-supporting during developed electroshock. electroshock eeened to make In the better educated patients, the patients nore’anenable to an psychotherapy. torn of interpretive It or psychotherapy was concluded that the relationship to electroshock varies with the particular_type of communication pattern and adaptation shown by the individual patient. This �-5. the and been Journal written up published in material has or Hillside Hospital, 7: 17-25, 1958. B; Biochemical Aspects of the Convulsive Iherapz Process. The significance or high voltage the convulsive therapy process (Roth and Kahn, 1957) and the EEG 22.;l! delta activity in 1951, 1957; Pink report that this delta activity was 'blocked hy the adninistration of ahtioholinergic'compounds; atropine and scopolanine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant, 'systenio effects with the administration of these agents, .reports describing diethasine as an anticholinergio'conpound' (Jenknerwith potent neurologic but minimal systemic effects l956) Lechner, studies 19553 to.undertake led Lechner, us and sinilar to those of Ulett (Fink, 1958). and Johnson neing this'conpound These observations with diethasine led to the agents. of other antioholinergic experimental investigation Clinical and electroencephalographic responses to the intravenous administration of various anticholinergic agents �-6in psychiatric patients at various stages of convulsive therapy were studied. These observations were related to hypothesis covering the node of action of convulsive therapy and of hallucinogens. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age tron Ivariety of diagnoses. since some The total or 18 to 67, with a 107 observations were made, subjects were studied with more than one compound. A drugs were administered at various stages of the treatment process. The observations were laboratory using a standard electrodes. In each intravenously at a trial, 8 made in the EEG channel instrument and needle the compound under star was adninistered until set rate per minute with clinical behavior or electrographic changes were observed. The compounds studied have been diethasine, Win-2299, benactyaine, JB~318, JB~336, and atropine. Each is a potent anticholinergic agent in vitro. It was observed that diethasine, Win-2299, benactysine, �-7; JB-318 or JB-336 administration therapy were associated with at various stages-of convulsive a) desynchronisatien of rhythms with a blocking of post-convulsive b) EEG delta activity; alerting, excitatory behavioral response with illusory, de- lusional and hallucinhtory ideation, and c)_systenic effects ‘drynessof muscular veakness, degrees of the mouth, dry skin and tachycardia. . The electrographic. behavioral and systemic effects were concurrent. These observations are regarded as consistent with the. suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, nescaline and diphenhydranine- synpathoninetic and antihistaminic agents also induce EEG ~ convulsive of desynchronisation, blocking post delta activity and clinical excitatory activity support the suggestion that both the behavioral and electrographic patterns are based on alteration in synaptic activity. Increased synaptic activity (cholinergio, synpatholytic effects) is �-8. associated with 336 hypersynchronisation, and clinical eedation and euphoria; while decreased synaptic synpathominetxic) is associated with clinical excitatery activity (anticholinergic, EEG and hallucinogenic desynchronisation and states. Discrepant observations with the anticholinergic agents, atropine, are considered to be related to significant differences in dongs and structural chemistry. This material was presented EEG at a meeting of Society in Atlantic City, June 1h, 1958. the American �-90. Acute and Chronic EEG and Behavioral Psychophersscologic Agents. Iffects of According to our neurophysiologic~adaptive view of the clinical the convulsive therapy process, efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central function, providing a nilieu for changes in the subject's interaction with the exaniner. In our studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Pink and Kahn, 1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the node of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharnaceuticals tested in acute experiments an in increase in synchrony with or without activity has an increase in slow been observed for chlorpronazine, pronazine and triflupronasine. Behaviorslly, these drugs were associated wave �-10with a) increasing sedation, drowsiness, denial and eqhoria; b) decreasing agitation, panic, excitement hallucinatory activity; of synptons. and and delusional and c) minimization and displacement Barbituratee regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony; behaviorally they resulted in behavioral alerting, hypcnania, excitement activity. and increased motor Decrease in voltage and per cent time of slow wave subjects with pcst~convulsive delta activity activity in was seen with Lsnazs, benactysine, Win~2299, JB-BlB, JB-336 and diethasine. Of these drugs, benactysine produced increased alerting, excitenent, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional The and paranoid ideation. electrographic patterns were consistenthﬁltered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, �.11sedation and minimisation of symptoms were conversely associated with increased EEG the delta range. and hallucinations synchronisation and shift of frequencies to Agitation, tension, panic, excitement, illusions were associated with desynchronisation of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpronasine and delta activity barbiturates, and enhanced augmented the per cent clinical pattern; agents that chronised frequencies, as diethasine, minimised the LSD-25 and tine desyno benactysine, clinical effects typically ascribed to repeated. convulsions. Following these preliminary observations more intensive undertaken. was of an (Totranil), agent, inipranine investigation In 28 can3:§:::: acute experiments, patients referred for physio- dynamic therapies were stages of treatment. tested in the EEG laboratory at various Tofranil solution (10 ng/cc) was adninistered intravenously at a set rate(l'cc/h0 sec) until electroencephalographic �total of or behavioral changes became prominent, for a mg (.05«2.5 ng/kg). hO-125 Behavioral observation and electrographic recording continued for one to three hours. A second group of ve, withdrawn 16 patients nanifesting depressienl or retarded bdnvior and were whp referred for pharmacotherapy, received daily oral Torranil of 75-250 mg for four weeks or longer. In the acute studies there was initial restlessness, associated with dissiness, dry mouth, 'faintness," nausea, and on tour occasions, vomiting. These symptoms 10-20 minutes, and were accompanied by lassitude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. persisted for Heart rate was Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographic pattern accompanying these behavioral changes were initiated the injection. halved. such In {our By by a gradual decrease in voltages during minutes, the per cent tine alpha had been ten patients with noderateonnouniiof beta activity, activity increased in voltage and per cent time. By twenty �-13minutes, in association with behavioral lassitude, low voltage 6 to 50 nicrovolts) randon theta frequencies (5-7 cps) appeared. In six records with poet-convulsive delta a marked decrease activity. two in voltage and per cent time of slow patterns persisted for These electrographic was wave 5 to hours. variability in the There was considerable individual acute of activity, there EEG response. In patients totranil, but three. who received 100 mg or more angptehavioral changes were observed in all In six patients, dosage of Tofranil less than 50 EEG associatedéwith were either EEG mg or behavioral changes. In the chronic Tofranil studies behavioral changes generally appeared during-the second, and were maximal during the third, week of treatment. The most adaptation was euphoric denial which They conplained or displaced prominent behaioral noted in eight patients. was less of somatic synptois, their illness on inquiry. It and ed ed denial. mininisetien became increasingly difficult to discuss significant lire relationships with then. �' ~1h- in three patients sonatiaation and restlessness increased and depressive affect persisted. In two of these, restlessness, insomnia and vomiting led to cessation of therapy. symptoms were noted change in in five patients after four weeks of therapy. Electrographic studies minimal changes. No on chronic administration shoved Voltages became lower and record modulation poorer. Well defined fast activity became more prominent, and in four subjects, low voltage theta (5-7 cps) activity noted. was Details of these studies were presented at the Collegiun Internationale Neuro«Psychopharmacologicum, at the Conference 1958, and Rone, September 12, on Depression and Allied States, Montreal, March l9~2l, 1959. D. Patterns as Measures of Behavioral and Language Neurophsziolegic Change with Drugs. In previous studies of the convulsive therapy process, was demonstrated analysis ( ) that two language measures, and dyadic syntactic content diversification in interviews ( ) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further it‘ �-15- test of language measures as indicea of behavioral and neurophysiologic change, they were next applied to recordings or interviews on acute administration of various psychopharnacologic agents. At the present time 72 interviews with patients at various stages of drug therapy have been analysed, using the following agents: anobarbital, benactysine, chibrpronazine, diethasine, lysergic~acid diethylanide, and Vin-2299. Following a routine electrographic recording, an psychiatric unstructured physiologic interview, with slow periods of structured inquiry, was tape recorded. With EEG running, an intaavenous injection was then given at a slow rate. specific electrographic or clinical changes interview was repeated. When were induced, the Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was shirts in (delta measureg'tor changes in synchronisation, dominant frequencies, and per cent and beta frequencies. tins of slow waves �-16The rthe tape recordings were transcribed and measured for diversification of consecutive 25 word speech and for syntactical changes.‘ samples of dyadic In the dyadid analysis, participants both of behavior verbal the pooled divided into total i;g., the ratio of the number of different number of words. . . The transcribed, samples, and for each sample a diversification 25 word score was calculated, words to the was syntactic language . analysis were based on response to standardised questions using the nothod previously described ( ), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial or symptoms, use of stereotyped expression or clichzs, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophpiologic and behavioral effects of the drugs applied. Anobarbital and chlorpronasinc are neurophysiologic synchronising agents; anobmrbital regularly induced high voltage �-17. well synchronised administration fast activity, at was followed by 20-2h cps, while chlorpronasine increased synchronisiation of the record and a shirt to ﬂower frequencies including occasional EEG slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilisetion, there was an On the language measures increase in stereotypy and repetitiveness associated with increasing use or cliches, alterations in tense, displacement and evasion. Diethasine, benactysine, LSD~25 and Win-2299 of the neurophysiologic deaynchronising.compounds. characteristically induce decreased voltage of alpha activity and increased irregular are examples These drugs and per cent low voltage tine fast activity. Behaviorally they are associated with hallucinatory, excitatory or illusory activity. On the language neasures they induced ' decreasing repditiveness, wider diversity o: words, lesevariability of diversification scores, and decreased use or cliches and alterations in tense. neasures Further exploration of language are suggested as a rational basis for the understanding or the psychologic �-13- effects of the new therepies. Details of these studies have been presented at the Conference on Paychodynenic, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April 11—13, 1958, end Aeeocietion, American the Psychiatric et Philadelphia, April 27, 1959. E. Coupereble study or Indoklon and Electrica11y~ Induced Convaleiona in Pczchietric Therepz. A In our investigation or the-node of action of convulsive therapy we have previouslymnnducted a convulsive-subconvnlsive control study. This study demonstrated that e significant behavioral change occurred almost exclusively in patients receiving grand nel electroconvulsive therapy. The present report in an assessment of the relative neurophysiological behavioral and clinical effects of two different methods of and convulsions current) (alternating electrical inducing inhalent (indcklon). �Twenty—five consecutive patients referred for convulsive therapywere studied. They were randomly divided into two groups, 13 patients receiving grand nal therapy induced by the standard while convulsions were Medcratt alternating current instrument, induced in the renaining 12 by the inhalation of hexafluorodiethyl- ether (indoklon). In both groups treatment time a week for a on the total of 10 to 2h wee administered three applications, determined basis of clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following 10-12 treatnents, and following the of lest treainent. The two weeks tests given included intellectual functioning (rive subtests measures ' from the Wechsler- perception (figure—ground Bellevue Intelligence Scale), figures, the perception discrimination using embedded.geonetric of peeuoisochronatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levincon revision of the California I Scale). An EEG was given during each of the testing periods. �-2066 from continuum slow wave cent a tine activity the per second sanple was used as the index of neurophysiologic change. results failed to The test differences show any between the electroshock and indcklon groups at each of the three test periods. showed significant intergroup Intragroup analysis, however, that during treatment both groups on the intellectual and peripheral on the F scale. By two weeks tests, made increased errors and had high scores after the termination of treatment both groups returned to near pretreatnent levels for most Both groups were comparable slow wave activity in the mean EEG after tests. for the degree of induced 10-12 treatnents. The s user per cent tine delta for the indoklon group was 51%, and for the_electroshock group h7.5%. Within each group individual the of behavioral were to related degree change in differences physiologic change, those with the highest per cent tine delta showing the greatest behavioral change. Bath between change in test activity with treatment and correlation performance and degree of slow wave were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue)and reached a level of statistical significance for Digit Span (e .61, p <-.Ol), �p( object Assembly (+.h6, .05), tachistoscopic perception (+.67, embedded figures (*.h3, p 4< F scale (+.38, p < p < .05), .01) and perception of .05). This study has denonstrated that two very different convulsant agents may produce similar neurophysiologic behavioral change. and It is concluded that behavioral changes in convulsive therapy are related to the degree of altered brain function, and are non-specific for the type of agent used to induce the convulsion. Details of this study were presented at the Eastern Psychological Association in Atlantic City, April, 1959. Sociopszchological Aspects of Psychiatric Treatment. F. In a previous study of the Hillside Hospital population, it was shown tht the factors or age, education, place of birth and social attitudes as measured by the California I scale, were related to the selection of therapy. ‘Those patients were older, had less education, were foreign-born and with high stereotpy scores on the F scales were more whp likely to receive �-22- convulsive therapy. 'In contrast, patients who were younger, the on low and obtained scores native-born educated, better as psychotherapy received scale, their sole F form of treatment. study the relation determine to was Further undertaken of duration hospitalto factors of eociopsychological 1)_th° 2) the isation, The Hospital 171 16 final diagnosis. 3) the and inspatient of Hillside population adult entire on March 7, 1957 was patients. to 68 57 nan and llh studied. This consisted of from in age ranging wonen, median of 35-years. with a years, It period clinical discharge, of time evaluations at was (1—5 shortest the for hospitalized that patients found the least education, were months) were oldest, had foreign-born, the scores andlad highest been have to most likely on the 1 scale. Iounger,native-born, more educated, lower r '(10 more or the longest score patients were hospitalised months). The sane hospitalisation factors of of length to these rdationship made were when analyses found separate was �-23according to diagnosis and type of treatnent (convulsive therapy or psychotherapy). Discharge evaluations of improvement in the population studied were total related to age, the significantly older patients having the nest favorable ratings. Analysis of the data by type of treatnent, however, demonstrated that the convulsive therapy patients ratings of recovered or among much improved were F given to those patients with the highsst scores, least education and who were foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower and high native birth. F The F scores, younger ages, more education older, less educated, foreign-born, score patients were more frequently classified as involutional or nanic-depressive psychosis. It is postulated that these relationships reflect the ingluence of social background on psychological processes, such as the behavioral patterns of communication, nodes or expression and symbolic values. These not only contribute to the pattern or mental illness, but affect all aspects of �~2h- the patient-therapist interaction. Details of this study have been presented at the Eastern Psychological Association in Atlantic City, Avril, '1959, and at the Academy of Psychoanalysis in Philadelphia, April 26, 1959, and has been accepted for publication in the Archives of General Psychiatry. 0. The Relation of Social Attitude to the Effects of Convuleive Therapz. As F indicated in the previous section, the California scale has been found ueeful in understanding factors related to the referral for convulsive therapy and the evaluation of clinical response following have been undertaken with questions: population? a treatnent. Further studies such this scale in regard to the following 1) What does the F scale neasure in our psychiatric 2) What are the behavioral changes induced with convulsive therapy? 3) How are theee changes related to the degree of altered brain function? �-25answer the To first question, in part, the entire in-patient population of the hospital was given the later One month they were retested with a "reverse" in which each statement original. The was changed "reverse" scale was F scale. F scale, to the opposite of the scuzred in the same manner as the conventional scale, with high scores this procedure reflecting greater to determine agreement. The purpose of whether the to the contents related patients' responses were was of the statements, or were a manifestation of a more general personality aspect, such as acquiescence. It was found that those patients who made low scores originally, indicating predoninant disagreement with the statenents, indicating who made showed a large increase the "reverse" scale, on In contrast, patients a high degree of agreement. high scores initially showed little change on retesting, agreeing with the statements to the sane extent even though the meaning was reversed. low I score patients are while those with high It is more evident that, in our population, critical I scores are more and discriminating persons, undifferentiating and �.26.. and stereotyped in their reactions. is related to the process of selection This observation or patients for convulsive therapy. A high degree of atereotypy or thinking and communication is inconpatable with the establishment of a conventional psychotherapeutic relationship, preventing the psychoanalytically-oriented psychotherapy stressed at Hillside Hospital. It follows that the high sill be F score patients unsuccessful in psychotherapy and nest likely reterred for convulsive therapy. To answer the second end patients were given the treatnent period) and F third questions raised above, 69 scale before, during (at 10-12 after convulsive therapy. Ten of these and the control constituted random, group at selected 'patients, received subconvulsive electrostinulation. nean There was a increase of 05.7 during treatment in the convulsive group, a difrerence significant at the control group (+0.5). The showed an SS level. In contrast, the insignificant change during the cane pertd extent or increase in the convulsive patients was �-27- related to the degree of cerebral dysfunction as found to be determined by delta delta (h0% +8.6. activity on the EEG. Those F patients with high or more of the sanple record) had a nean increase of low with delta indices, however, showed a patients statistically insignificant increase of the The +3.h. Following treatnent scores were comparable to the pretreatnent levels. These findings support and elborate previous observations the effects of convulsive therapy. on the F Greater agreement with seere scale statements during treatment stereotypy and difficulty in discrimination. show conventional The change in I n . P score thus seen part of the same process shown by the z characteristic language changes of increased denial, evasion, qualification, I and use of cliches and stereotyped orpressions It is also comparable to the increased visual tactile perception ( and ( ) difficulty in and figure-ground ( ). complex discninination )- Details of these findings were presented at the Eastern Psychological Association in 1958 and will be elaborated at the �forthcoming Divisional nesting of the American Psychiatric Association in H. ﬂew Zork. Aspects of the TherapistaPatient Relationship Affecting Choice of Therapz. As indicated previously the selection or therapy involves other aspects than the actual behavioral pattern or the patient. In the past year further efforts to been undertaken, emphasizing relationship. clarify this problem have factors in the therapist-patient he have hypotheSised increased tension, frustration and that such factors as hostility in the therapist~ patient relationship, as well as implicit and explicit pressures present in the environment have a significant influence in referral for sonatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests ﬁr sonatotherapy. These interviews were designed to referral. It there was found a sudden change elicit the basis of the that in only relatively few cases was in the patient's clinical status which directly led to the referral. most In instances there had been �-29- or progression no change the presenting eynptons. in‘ Factors of impending included the to timing contributing the referral diccherge, avoiding administration discharge, and pressure tron the patient's family or ward personnel. It res also noted were'treatod that ptiients with ainilarhehcvior patterns given senatotherapy and others none. The 4‘ renged reasons for this raged from'"whin" to quantitative difference! differently, some . in synptonetelogy and individual preferences for type of treatment. initial The conclueien wen that in a significant 0; cases, factors other then clinical indication played number a role in the referral. These sane extraneous factors also influenced the timing or the referrals is e results of these findings Referral Sheet" to was completed by the From c ’Scnatic Treatment developed‘(see form at end or report) to therapist whenever somatic therapy is reqneeted. this questionnaire we hope to obtain further information regarding indications for somatic treatment, more specific data �-30. concerning the therapist-patient interaction, and a more definite idee of the therapist's expectations for such treatment. I. Individual Differences in Selection of, to Convnlsive.Theragz. and Response In the elucidation of individual differences related to sonstic therapy, a variety of peripheral-cognitive procedureshave been used. tachistoscopic perception of enbedded colored figures The has been given to 65 of 35 consecutive were 20 patients. experimental group consisted The convulsive referrals for therapy. The controls patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment. All subjects were tested prior to treatment, and after four weeks; the convulairee were tested s third tine two weeks following the cessation of treatment. It was found increase in that there mean number was a statistically significant of errors with convulsive therapy, while following treetnent there was e significant decrease from the pretreatment scores. at Controls made significantly fewer errors �.31- (practice effect). errors between patients classified (per cent time delta) were significant difference in There was a when compared as showing low with high high retest correlations for all groups. EEG changes changes. EEG Marked There individual ditferences in response patterns were noted prior to treatment. With brain changes there was a reduction in perseveration, conpletion patients, and contabulation in some and and increase in others, with no unique patterns attributed to cerebral dysfunction. Even in those patients with high his response pattern was showing completion type to make such EEG 'stjh' changes, the ntein naintained. Thus a errors prior to treatment ore patient would continue errors with convulsive therapy, although the threshold at which completion was shown might change. Details of this study were_presented at the Eastern Psychological Association in Atlantic city, April 1959. The Red and h? Irene Test (after Witkin) was administered to Harked somatic for referred therapy. consecutively patients individual dirierencee in performance were correlated with age, �w _‘“ .v .32-‘ education and score on the Calibrnia vertical Judgment of the frame (field dependent) F scale. Patients whose ﬁes strongly influenced by the sunnunding were more frequently referred for convulsive therapy than drug therapy. No significant change ‘ was found with drug or.convulsive treatment. convulsive groups retest correlations drug For both/and were high (.86 and on differences in the individual considered that is It Frame test reflect personality factors that are in psychiatric treatment. .88). Rod and of importance �5 “J a , :1: 7/16/59 L, wig/r 1 _/ Function Brain Altered Following Electroehcck ‘ 24.927 Progress Report - Febmary 1. 1958 - September 1, 1959 m: L previous In our studies we have demonstrated that an understanﬁng of the convulsive therepy process required a nultifectoriel approach involving neurophysiologic, perceptual, personality, paychodynemic and eocielogic eepecte cf behavior. Thus is essential it wee ehcwn that: The convuleim to the therapeutic process (Fink, Green end Kuhn, 1958); murcmeielegic changes reflective of altered brain function ere e a Heinetein, 1956; Fink & Kenn. 1957) neceeeery prerequisite for behavioral change end ixproveemt‘ the (Kuhn, Fink biochemical beeie of the convulsive therapy preceee lay level of cholinergic activity of the central nervous is an mm increased (Fink, 1958); there are characteristic perceptual chengee with altered brain function induced by convulsive therapy (Fink, Kuhn and Korin, 1957; Kehn and Pink, 1957); retina cf improvement after convulsive therapy are related to personality characteristics defined by Rorschach and {mm (Kahn and Fink, 1958). interviews (Kuhn and Fink. 1957); end that evaluations of �mm (Kuhn 8.: -2. were related to changes in syntactic aspects of language Fink, 1958). In the pest eighteen (18) months these statics wen completed and extended, and an investigation of poychophamcologic agents begun. The {mark View we for these investigation: of convulsive therapy (Veimtedn Fink and Kahn, 1957) extended mandarin patients (Pink, The been the nmxrophyeiologic adoptive Kahn, 1955; Knhn 8c at all, 1956; to other physiodynenic treatmmta or 1957) . tho convulsive therapy process were relieving aspect- of studied: 1. Siﬂficence or the Commune Mologic, A cooperative study of neuro- paychologic and bohemian). effects of electrical and inhalant (Indoklnn) induced convuhicaa. 2. @2326 Basic of NeuroMiologg-c Chang: Further studies of the effects of acute wtmtric 3. “notation agents on both the Mgwogo AoEm of of marinentnl anticholinergic 'noml“ and and pout-convulsive EH}. Comm Thomas 3. Relation of the factors or age, education, nativity and �n3. mmotm (mound w the California max-aw, duration of 1:. Chang“ clung» to EEG hoapiuuuum, of F 1" scale) with selection of diagnosis and diochnrgo ratings. scale with treatmnt, and relation of those indiceo. h. Mother-Lg and Conwlsivo Tim-ram: In aupervioory sessions, alterations in psychotherapy with convulsive thorapy were studied. W: 5- Both patterns or change and individunl diffomnooo on tuohistoocopio figumﬂ ground ﬂicker immoy domination tutu, critical and perception of the upright with induced ‘ emulsions were studied. 5093*ch are «tended to dmg therapies and the following studies undertakom 1. 1010 :1. c: Relation of EEG charge on acute and ohmnic administration of poychophamoouticals to clinical behavioral change. b. EEG as a screening device for psychomrnceuuc potency. �.. h .- c. Elation of 6. EEG EEG clause: to hallucinogenic activity. effects at neginide. 2. Omnicstion Patterns: Relation of induced neurophyeolcgie change to dyadic diversifi- cation and syntactic language maeuree. 3. Aspects of the Therapist .. Patient Relationship affecting choice of somatic therapy. metudiec View have supported and expanded the mumphyaiologxo-adapuu of convulsive therapy, and dancnetrated that. such a applicability to our understanding of the mode munch has of action of psycho- phamacologic agents. PROGRESS A. tar: l. REPORT: Gasman new?! PROCESS ﬁgniricance of the Convaleion: A cmmrable study of Indoklcn and electrically-induced convulsime in psychiatric therapy was control eubccmuleive completed. An mm demonstrated changes occurred almost exclusively electrocomruleive therapy. The earlier convulsive- that. uinIicant behavioral in patients receiving grand mal present report is an assessment at �-5the relative neurophysiologic, behavioral and clinical effects of hm different of. methods inciting convulsions - electrical cuxjreet) and inhalant (indoklon) . (eltemating 'consemtive patients referred for convulsive therapy Thaw-nave classified into were tendonly Won / 3Wt, / . ,:./ patients and by two groups the steward - «isms Model-oft mowed in alternating current in. in twelve by the inhalstion of heMlumdetlvl—ether findeklon). In both groups treatment was ochinistered three times a .5 {f} [f book for a total of IKE/o: x! I! if / 3' 10 to 21; applications, determined on the basis clinical criteris by the supervising psychiatrist. ,f‘. \ A All patients were tested one to two days prior to the treatment, following 10.12 treatments, and first m weeks renewing the lost tacatment. In addition to evaluations of behavioral. change, tests included nouns-es of intellectual function (five aubtests In the Kodachr-Bellme Intelligence Scale), perception (figure-groom! discrimination using wedded geamtric figures, the perception of pewdeochrcnstic color plates at high speeds of toohictoocopic exposure, and the Stmt moguls“ figure: test), and lucid �.- 6 1e etﬂtude (the Lennon revision of the California 1" Scale). An testing of each the periods, obtained during electroencephalogram was on! mom-ed for the per cent. time slow we (6 ope or slower) activity from a continuous 66 second sample. The to failed Insults show any significant inter-group teat differences between the electroshock and indoklon groupe at each of the three test periods. Inbregtoup groupe made onlyale, that during treatment both increased errors on the intellectual and perceptual taste, end had higher _ hmr, showed some on the F scale. By two weeks otter the terminal-g for tion of treatment both groupe returned to near pretreatment. levels ' moat mete. Both groupe were comparable for the degree of indeeeed wave activity after for the 10-12 treatments. indokloa group was 51% and The EEG slow per cent time slow activity for me electroshock group It? 5%. within each group individual differences in behavioral change were the with thoee change of neurophysiologic the degree to reload behavioral change. the greateet sharing delta cent tine highest per �-7mm: order correlations batman changes in test performance and degree of slow wave activity with treatment. were positive fer all proeedwes, except the eomehension subtest of the Wechalar-Bellevm, level of statistical significance for digit. span 1" scale (4* .33, 13 .05). .01), object Assembly (hub, and reached a (+ 1,61, p p .05), ucmnoacopac perception (+.67, p of embedded figures («13, p This study demonstrated .01) and perception .05). that up different eonvulsant. agents produce similar neurophysiologic and behavioral changes. eencluded that. the behavioral change It was is related in convulsive therapy/to the degree of altered brain function, and an non-speciﬁc for the type of agent. used to induce the eohvulsion. (mud, in part, at the Eastern Psychological Assecatien, Atlantic City, April, 1959). 2. modicum ”mate of the Convulsive The significance of high voltage There}?! l’ﬁt‘eceae2 m delta activity in the convulsive therapy process (Ruth 213.1) 1951, 1957; Fink and Wm, 1957) and the report that this delta activity ministration (mate was blocked by the of the antteholinergic agents atropine and scepolamine and Johnson, 1957) provided the basis t‘or mane studies. As �- 8 a. there Here attendant unpleuent systemic etfeote with the comm-tre- tion of these agents, report: describing diethulne as an entioholmcrglc effects (Jenknor compound with potent neurologlc but mm manic and Loohner,19553 Lechner, 1956) 13+. us studies similar to those of Ulett and John-on using (Rink, 1956). These observations with diethacine this to mderteke compound lot to the investiga- tion of other experimental antichollnerglc agents. Clinical and electroencephalographic responses to the intravenou- adninistration of dicthaxine and atropine in plychntrlc patients at therapy were studied. Each The Win. 2299, is bemctyam, JD 318, dB 336 various: etegee of convulsion a potent antiohollnergic agent 121 um. eubjecte were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with Wes. A total of 107 observations were rude, a. since variety of some subjects were studied with more than one compound. The observations were 8 channel made in the EEG laboratory ucing a standard instrument and needle electrodes. In each coupound under study was tual, the mastered intravenously at a set rate �-9 .. per minute until clinical behavioral oz- eleetrogrephic changes were observed. It was was observed that salinistrstion of these sntichonnergic agents associated with e) dosynchmmisstion of bloom of post-convulsive delta activity; EEG 1:) rhythms with s alerting, excitstory behavioral response with illusory, delusional end Mllucinatory mention, and c) systemic effects of muscular weakness, dryness of the south, dry skin and techycerdia. end systemic effects The electromﬂuc, behavioral were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis in central of, convulsive therapy nervous system cholmergic Observations that LSD, lies in an increase activity. substantive, nasceline sympathemnetic and antihistaminic agents - and diphenhydmmns also induced convulsive d‘ delta desynchronisation, blocking post EEG activity clinical oucitstory scﬁviw support the suggestion that the and mvioral md electrogrsphio patterns of these compounds are also based on alteration in synoptic activity. Increased synaptic activity (cholinergic, synpethclytic effects) is sssocieted with - EEG Immora- synchreniseticn, and clinical sodation and euphoric; while decreased �.. 1o - synapmc activity (anticholimrgic, sympathmimtnc) is mandated with dosynchmniution and clinical excihtory and hallucinogmic EEG states, thus supporting the Wthesia mually described mama by Wilder (19514). algont, atropine, Deacrepant observations with the anticholinergic are considered to be related to significant differences in dosage. (Presumed, in put, San d‘ Biological Paymatry, the Society at first Francisco, 1958 and awarded tbs Award of that Society; and, in part, at City, 1959. Published, in part, 380-387, 19573 and accepted 3. Socio a. A. E. Bennett cal 01 A A 1. A American EEG PsycIﬁItrio Research Somty, Atlantic Arch. Neural. & cMat. g9. for publiaation, ma Olin. Nemﬂmool.) shiatric Treatment ate of Duration at Hoggtaluation. Dawn and .' Madam Evaluation. In an earlier study of the Hillside Hospital populationmahn, Pollack birth :3: and Pink, 1957). it was noted social attitudes that age, causation, place of F California measured the by as were related to the aelecﬁm of therapy. Those pation‘ua older, had less education, scores on the F scale, who were were foreign-born am with high stereotype scales were more likely to waive convulsive therapy. �- 11 In oontmt, petiente I ‘ who were .. younger, better eduoehdmetiveobem end obtained it»: theeoree on the 1’" scale, received peyoheﬂmerepy ee their sole router treatment. nutty Another wee undertaken to determine the relations of theee eodepeyohologioal factore to 1) the duration of hospitalization, 2) the Meal evaluations at time of discharge, and 3) the final diegxoaia. The entire impatient edalt population studied. This oomieted on! maize in age from 16 to 171 68 patients, years, no: on March 7, 1957 was 57 men and 11]; mo, a median of 35 years. Patients hospitalized for the shortcut period (1 - 5 months) were noted to be the oldest, have the least education, were more likely to be foreign-hem, and have the highest scores on the “ scale. Younger, native-bum, more educated, loner months). (10 more the or longest each hoepitelieed ship of: F more patients The same these factors to length of hosmtelizetion was found eepehte Ienelyeee them F relation» when were made according to diagnosis and type of (eomleive thempy or peyohotherepy). �,' 12 u. Discharge evaluations of improvemnt were significantly related _ to age - the older patients having the most favorableratingm Miami! of the date by type of treetnent,hovever, demonstrated that among the oeuvulsive therapy patients rating: of recovered or much inproved were given to those patients with the highest F scores, least education and who were foreign-born. Diagnoses of schizophrenia or peyohomuroeie were undated with lower F eeoree, younger ages, more education and native birth. The older, less educated, femignnborn, high more F score patients were frequently classified as involutionel or mic—depressive psychosis. It was postulated that these relationships reﬂect the influence of nodal background and psychological proceeoee, such as the behavioral patterns of communication and modes of expression. These Thane not only oontﬂbute to the pattern of mental illness, but affect all aspects of the patientoﬂxerapiet interactim. (Pmeented at the Beaten: Psychological Association, Atlantic City g April, 1959, and the Acedm of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatg.) �.. 13 .. 13. Treatment. Convuleive with Social Attitude in Gwen: Following the earlier observations that the California is 1“ scale useful in understanding mien-a1 for ccnvuleive therapy and the evaluation of clinical reepcnee following such treatment, ﬁzz-ﬂier studies were undertaken with thieeeale in regard to the {alluring 1) iihet deal the F scale measure in a psychiatric question: a population? 2) Dc 1“ scores change with convulsive therapy? 3) Are these changes related to the degree of altered brain function? entire in-patient population of the heepital was given the The :16 one month scale, in later, was retested with a "reverse“ ﬁnch each statement wee changed The “reverse" scale as to the opposite or! F F scale, the original. scored in the same manner as the ccnventicnal scale, with high ecoree reflecting greater agreement. It was noted that than patient: who made low scores initially, showed an with the statements, disagreement indicating a wedcninant increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients the mde high scores little change on initially shaved same the to etatexunte the with agreeing reteeting, �.. m .. extent even thong: the nearing was reversed. let: P score patients are more critical and It is evident that diesﬂmimting persons , while those with high F scores are more undifferentietihg and stereotyped in their reactions. This aberration is related to the process or selection of patients for convulsive thmpy. thinking and commutation on! A high degree or sterotwpy of is incomtsble with the a conventional psychotherapeuﬁc rehtionship, psychoanalyticslly—oriented psychotherapy stressed Hospital. It follows that the high F establishment meeting the at Hillside score patients will be unsuccessful in psychotherapy and most likely referred for con- vulsive therapy. In anotlmr study, sixtr-ndne patients were given the F scale berm, during therapy. Ten (st 10-12 treatmnt period) patients, selected at group and received subconvulsive mean increase in group a. F random, and after convulsive constituted a control electrostimlsuon. There was s. score of +5.7 during treatment in convulsive a difference significant at the 5% level. In contrast, the �- 15 In conﬁnes. the control group .. showed an insignificant change during the echo period (+0.5). The extent of increase in me convulsive petieﬁts was related to the degree of cerebral dysfunction es <1er by delta sctiﬂw on the m. The patients with my: d6“? (1:010: 3955 of the mp1” 1‘3“”) had a // l'hebe patientsvith mean ' increase e a ’8’6” f low delta indioes, however, off 43.14,. Following treatment the showed an increase 3 2/ 15’03&8tashv ,f 1/ / ”(7/ -/'4,7,3? ,. V ,2” / / ,. /"5 scores were comparable to the levels. ‘ , ‘ “these ,flndmgs support and eleborste previous observations on the [5%. ,2)" , 7752/ 1" cadets” e’f convulsive therapy. Greater agreement with the ,. scale ‘f std/Wes /} F during treatment show conventional stereotypy and 3" /r (35“:ow I _ 1n discrimineuon. Changes in F score thus parallel the fo’hehoteristio hnguege changes or increased denial, evasion, /// " , ,/,.L‘ ,r l7 //qdeiﬂicetlon, ' / / and use of cliches and stereotyped expressions (Kuhn ‘ j" & 2 Fink, i953) . It 1. .1“ ompmble to the increased difficulty in / / l / / cochlea: visual and tactile perception (Flak, fairs-groom discrimination j’(heseo1{;e§ at. Knhn (Karmic Fink, 1957). /ﬂbyohletrlc Association, at the Divisions]. Meeting of the American 3' ‘81 I ‘- r {'1' 4" Karin, 1957) and the Eastern Psychological Association, 1958; and aeoepced for?" presentation ‘ 8: New York, November 1959.) �~16- h. Psychotherapy and thsicdzgamic Therapy: Previous studies indicated that patients referred for of electroshock in this hospital are/two types. The largest number are patients in the older education and are foreign born. age groups who have They tend to be limited non-introspective persons, stereotyped in their language and thinking and verbally unconnunicative. Their predominant symptoms are depression, agitation, withdrawal and somatisation. The second, and smaller, group of patients are younger, native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of aonatisation and depression. Four patients, two for each group described above were studied to determine 1) reasons for referral, different attitudes management, and 2) whether were required in psychotherapeutic 3) the relation of the psychotherapeutic �-17. approach to the patient's clinical response to convulsive therapy. It was suggested that these patients were referred for convulsive therapy because of a failure of communication in the psychotherapeutic relationship. a In two cases this was reflection of the patient's limited verbal and introspective capacity related to educational and social factors. instances, however, the impaired communication by unmanageable was In two manifested acting out behavior. Following treatment, is older, less educated patients were able to maintain a behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization and denial developed during electroshock. In the better educated patients, electroshock decreased acting out was associated with increased use of interpretive forms of psychotherapy. It uas concluded that the relationship of psychotherapy to convulsive therapy varies with the communication pattern �~18 - and adaptation shown by the individual patient. (Published in the Journal of Hillside S. Hos ital, 1: 17-25, 1958). Perception: A variety of perceptual-cognitive test procedures have been studied in l. patients receiving somatic therapies. Tachistoscopic Perception of Colored Figures: The Embedded This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control" groups of 20 patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, were and tested akhird time after four two weeks weeks the convulsive patients following the cessation of treatment. There was a number of there statistically significant increase in errors with convulsive therapy, was a significant decrease mean and following treatment, from the pretreatment scores. "Control” subjects made significantly fewer errors (practice �-19- effect). significant difference in errors between There was a patients classified as delta) when compared showing low with high EEG changes (per cent changes. EEG tine There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with patterns attributed to cerebral dysfunction. patients with high pattern was EEG no unique 3V0“ in thOBO changes, the ”style" of his response maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at which completion was shown might change. were Details of this study presented at the Eastern Psychological Association in Atlantic City, April 1959. 2. Rod and Frame Test gWitkinzs This task was administered to h? patients consecutively referred for somatic therapy. Marked �- 20 - with correlated age, were in performance individual differences education and score judgment of the frame (field on vertical was dependento were more frequently referred for No significant treatment. found with drug or convulsive convulsive groups It retest cerrelations change For both drug and were high (*.86 and +.88). is considered that individual differences Frame whose influenced by the surrounding strongly therapy. than drug convulsive therapy was Patients the California F.ecale. on the Rod and of importance are that factors test reflect personality in psychiatric treatment. B. PSYCHOPHARHAOOLOGIO STUDIES 1. Neuroghzsiologic Studies: view the of neurophysiologic~adaptive the to Acoprding convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a providing function, nervous central in alteration persistent the with interaction the in subject's a milieu for changes examiner and the environment. In these studies the best been of those has aspects change of neurophysiologic index the electnoin by delta activity reflected function cerebral �enoephalogran (Fink and Kahp,1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of aI/ﬂ ,1 1} similar hypothesis for the node of action of these agents{ and to studies of the relationship and specificity of altﬁred behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of an the psychophsrmaceuticals tested in acute experiments increase in syhchrony with or without an increase in slow wave and activity has been observed for chlorpromasine, pronasine triflupronasine. Behaviorally, these drugs were associated with a) increasing sedation,drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimisation and displacement or synptons. an Barbiturates regularly induced increase in fast activity with an increase in synchrony, with the associated behavorial changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with behavorial alerting, hyponania, �- - 22 excitement and increased motor activity. and per cent time of slow wave post-convulsive delta activity Decrease in voltage activity in subjects with was seen with LSD-2S, bcnactyzine, Win-2299, JB~318, JB~336 and diethasine. Of these drugs, benactyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. The electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were concurrently associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronisaticn of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorprcnazine and barbiturates, augmented the per cent tine delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethasine, LSD-25 �-23and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. Various experimental psychopharnaceutioala were tested. In addition to extensive studies or 3-3 methylethylgiutarimide (Heginide) and hexetluorodiethylether (Indoklon) the following nhsnyltoloxanine (PHD-Bristol), methenalide agents were studied: (BLH~lﬂl;lhristol), tropin-h-Ghlorhenzhydryl ether (WI-21h9, Wyeth), dinethylaninsethanel and verieties, Riker), JB-3;;, its oongeners (Deaner and 329 and 336 (various piperidyl- Geigy). and (Torrinil, Lakeside) inipranine bensilatss, significant behavioral Because or 31:31 changes, a was and electrogrephic intestigation of imipramine (Torrinil), nere intensive undertaken. In 28 acute experiﬂmenta, consecutive patients referred for physiodynnmie therapies were tested in the EEG TofrEnil solution of treatment. various stages at laboratory (10 ng/oc) was administered intravenously until electrographic or behavioral changes a total of h0-12S mg at a set rate (1 cc/ho sec) became prominent, (0.5-2.5 mg/kg). Behavioral observation for �«Zh- and In electrcgraphic recording continued for one to three hours. patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral Torranil of 75-350 mg administered. was In the acute studies there was initial restlessness, associated with dissiness, dry mouth, “taintness,” nausea, and on tour occasions, voniting. These symptoms persisted for t 10-20 minutes, and were accompanied by lasdtude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. Blood Heart rate was pressure dropped by in older (age>’ 60) patients. 20-ho% Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrcgraphic patterns accompanying these behavioral changes were initiated during the injection. had been halved. activity, such by a gradual By in decrease in voltages ten minutes, the per cent tine alpha In patients with moderate anounts of beta activity occasionally increased in voltage and �-25per cent time. twenty minutes, in association with By behavioral lassitude, low voltage (to theta frequencies (5—? 50 nicrovolts) random In records with post~ cps) appeared. convulsive delta activity, there was a marked decrease in voltage and per cent time of slow graphic patterns persisted for i wave to two There was considerable individual acute EEG of Torrinil, EEG who These electro- hours. variability in this received 100 mg or more all and behavioral changes were observed in In six patients, dosage of TorrEnil less than 50 but three. were In patients response. activity. associated neither with EEG mg nor with behavioral changes. In chronic Torranil studies, behavioral changes generally appeared during the second, and were maximal during the week of was treatnent. The most prominent euphoric denial. behavioral adaptation Patients complained less of somatic symptoms, and denied, minimized or displaced inquiry. It became lite relationships third, their illness on increasingly difficult to discuss significant with then. In six patients sonatisation and �restlessness increased and depressive affect persisted. In three, restlessness, agitation, excitement, insomnia and vomiting, led to the cessation of therapy. No change in sfgntons were noted in five patients after four weeks of therapy. Electrographio studies a decrease on chronic administration showed in voltages with poorer record modulation. voltage theta (S~7 cps) activity up to defined fast activity 10% r‘ became more p~ominent appeared. Low Well in a few. (presented at the Collegian Interantionale Neuro-Psychopharmacologicum, Rome, September, 1958) at the Conference on Depression and Allied States, Montreal, March, 1959] and American EEG Society, June, 1959; Published, in part, in the 3 Proceedings of C;I.N.P. Psychopharnaoology Frontiers, ed. 3. 9 Kline, 325-332, 19593 Canad. J. Neurologz, g} 682~685, 1958. Pe chiat., 1959 (in prose); �-272. Language Patterns as Resource of Behavioral and Nauroghzsielogic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that syntactic two language measures, a content analysis (Kahn and Fink, 1958) and dyadic diversification a scores or instructured interviews (Jaffe, Kahn and Pink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. "In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interview on ’ acute administration of various psychopharnacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: emobarbital, benactyzine, ohlorpronazine, diethazine, lysergie— acid diethylanide, and Win-2299. unFollowing a routine electrographic recording, an structured psychiatric interview, with short periods of {\‘\ structured inquiry, g was tape recorded. With EEG running, intravenouq injection was then given at a slow rate. When on �—28- specific electrogrsphic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The shifts in (delta) The EEG was measured for changes in synchronization, dominant frequencies, and per cent time of slow waves and beta frequencies. tape recordings were transcribed and measured for the diversification of consecutive participants (dyadic) and for 25 word samples of speech of both syntactical changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, and for each sample the ratio of the number of different words to the words (a diversification score) was calculated. total The number of syntactic langw ge analyses were based on the response to standardized questions using a method previously described (Kahn and rink, 1958), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic �-29withdrawal and or response, silence. the both dyadic observed in were changes Consistent diversification classified and syntactic language neasurss in subjects behavioral and according to the neurophysiologic effects of the drugs applied. neurophysiologic are and chlorpronasine Ancbarbital high inducing regularly imobarbital synchronising agents. at activity fast synchronised voltage well chlorpronasine administration synchronisation of the EEG was 20¢2h cps, while increased folloudd by record and a shift to slower occasional slow including frequencies wave burst activity. sedation and with associated Behaviorally these drugs are tranquilisation. in stereotpy and On increase was an there measures the language with increasing associated repetitiveness displacement in and-evasion. cliches, tense, alterations of use Diethasine, benactysine, LSD—25 and Wine2299 areheuro» compounds. desynchronizing physiologic These drugs are and decreased per voltage with associated characteristically �-30- cent tins of alpha activity and increased irregular low voltage fast activity. or Behaviorally hallucinatory, exoitatory illusory activity are observed. there was On the language measures decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further explaation of language neasures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Peychodynanio, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, l958, and at the American Psychiatric Association, Philadelphia, April, 1959. 3; To be published). Aspects of the Therapist-Patient Relationship Affed ting ” Choice of Therapy. The selection of therapy involves aspects other than the manifest behavioral patterns of the patient. In the past year further efforts to clarify this problem have been undertaken, emphasising factors in the therapist-patient relationship. We �-31have hypothesized that frustration therapist-patient relationship and and hostility in the implicit or explicit environmental pressures have a significant influence in referral for somatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests for sonato~ therapy. these interviews were designed to elicit the basis of the referral. It was there a sudden change in the patient's clinical status which vas found that in only directly led to the referral. In relatively few cases most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure tron the patient's fanily or ward personnel. It was also noted that patients with similar behavior patterns were treated differently, sons given eonatctherapy and others none. The reasons for this ranged from ”thin" to quantitative differences in syntonatology and individual preferences for type of treatment. �-32- It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These the timing of the As a extraneous factors also influenced referrals. result of these findings Referral Sheet" was developed be completed by the requested. same From a ”Sonatic Treeteent (see for: at end of report) to therapist ehenever somatic therapy is this questionnaire and continued and ward personnel interviews we hope to obtain therapist further infernation regarding indications for somatic treatment, more specific data concerning the therapist-patient interaction, and a more definite idea of the therapist's expectations for such treatment. �Soptonbor 1, 1959 A an»- « FINAL REPORT H~927* ’ Doportmont of Exporinontnl Psychiatry HILLSIDE HOSPITAL Glen Oaks, L. 1., N. I. Aoknowlodgnont Summury, Five Yours, 195k - 1959 Summary #h, Feb. 1, 1958 - Sept. 1, 1959 Publications, 195h - 1959 Prosontationl, Initial studios 19Sh ~ 1959 a. b. 2S 30 bogun 1:11 1953, supportod by tho Board of Diroctora' nooonroh Fund. Supported by Nationul Institute of Mental Honlth Fund, Soptombor l, 195k - August 31, 1959. Study continuing with support of grant MI-2715, United Statos Public Health Sorvico (Jan. 1, 1959) �Acknowledgment studies reported here would not have been possible without the faith and support or the Founder at Hillaide Hospital, Dr. Iorael Strauss, the Board of Directors and tho Administrator, Hr. Maurice Bachraoh, who auetained this program during its early vicissitudes. Financial Support was also given during this period by the Kaufman Foundation, the Foundatione' Fund for Research in Psychiatry, the Daaian Foundation of New fork; the following pharmaceutical firms: Smith, Kline and French Laboratoriea, Wyeth Laboratories, Geigy Pharmaceuticals, and Bristol Laboratories; and the Mental Health Board of Nassau County. The �SUMMARY 14-927 19Sh - 1959 laboratories of the Departnent of Experimental Psychiatry were established at hillside Hospital in September, 195k. During this five year period neurophysiologic, psychologic (personality and perceptual), lingustic, and socioloéic aspects of "somatic" psychiatric therapies have been the principal foci. The 1. Convulsive Therapy: The view of the convulsive therapy process as the induction or a non-specific state or altered brain functbn, similar to. craniocerebral trauma (10, ll, 21) was supported and amplified with this altered cerebral milieu, subjects were seen to respond in various ways (26) of which the most successful was explicitf verbal denial (7, 31). This latter was most prominent in characterologically disposed individuals (36). in alteration in brain function was pro-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were this to essential process (26) but electrical induction was not (Boh2). Such alteration in brain function was measured by various ways including electroencephalography (6, ll, 12, 2h, 39, language patterns (h, 7, 1h, 31, h}, B-Zh), perceptual tasks (2, 16, 17, 37, hé, 8-26, h1, h?) and tests of recall. A variety of behavioral changes were seen during convulsive therapy (26, 8—17). Such patterns were lbwed as adaptations to altered brain function,wand were believed dependentlupon Refcrbnce nunEers are to publications or presentations (5- I listed in the appendix. �characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value Judgments by the observer of the behavioral changes in the subject (26). Adaptations characterised by denial mechanisms, both in behavior (3—17) and in language a, 31) were assessed with the best rating of improvement. Such adaptations were noted to be related to habitual nodes of conduct (character, personality) (36, Bull, ‘ 32). durability of the altered behavioral nodes was seeh‘. to be dependent upon such factors as the degree and duration of altered brain function, the environnental expectations, and the type and degree of family and medical support. Different behavioral patterns were best supported by varyinc types of The psychotherapy (19). It also suggested that the neurophysiologicgbasis or convulsive therapy nay lie in an alteration in central synaptic cholinergic ~ adrenergic relationships, with a predominant shirt to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the relationship of high voltage EEG slow wave activity to behavior! change (6, ll, 26) and the blocking of the electrographic and behavioral changes in central anticholinergic agents (21, 3h, 35 hl, ht) and by central synpathonimetics (ha). Heasures of linguistic behavior in structured (7, 31) and unstructured (1h, 29, B-2h) interviews showed characteristic was �- 3 - alterations towards increased denial, minimisation, displacement, stereotypy and repetitiveness, related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21, h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), snbedded (Gottschaldt) figures (37, 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years or education, nativity and degree of stereotypy and sonventionality (measured by California F Scale) were also studied and were related to selection or therapy, duration of hospitalization, diagnosis and treatment response/ in hospitalized patients (15, 36, ho, hS). 2. Neurophysiolegic~Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis of the node of action of other psychiatric therapies such as insulin coma, leucotony and psychotropic drugs, was expressed (10, 33, 38). This view holds that these therapies are also methods of inducing varying states or altered brain function, in which varying adaptive patterns may become prominent. The adaptive pattern is viewed as dependent upon the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of this hypothesis as applied to drug therapies is now in progress, supported by USPRS grants HI-2092 and HI-2715. �Insulin Coma Therapz. in initial case description (3) showed the significance of denial patterns and persistent altered brain function to the behavioral change in this form of therapy. In an insulin cons - chlorpronazine control study (27), no differences in hospital improvement ratings were observed in the two treatment groups. Chlorpronazine was safer, easier to administer, permitted continued adninistration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin come 3. by psychotropic drugs in h. this institution. Pharmacotherapz. Also derived from these hypotheses is the ongoing program in evaluating various psychopharnaceuticals. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various are in progress. EEG patterns, along such continua as synchronisation~desynchronisstion, and frequency shift are being related to behavioral (21, 3h, bl, ha) and linguistic changes (21, h3); The neurophysiologic basis of experimentally induced hallucinogenic states have also been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis ( ) is now being expanded. new compounds �.32.. In addition to these phenomena, other patterns of language and non- verbal aspects of behavior have been observed which can also be understood as symbolic forms of adaptation to illness. These include the syntactical use of the second and third person, changes in mood, withdrawal and selective inatten- tion, and alterations in sexual behavior (6). in enduring fashion in patelectroencephalographic records indicated diffuse cere- These types of behavior have been observed ients whose lesions and bral dysfunction; In patients with brain damage who did not Show delusional denial and disorientation on ordinary clinical examination, the phenomena might be elicited in sodium. an interview following the intravenous administration of amytal This observation furnished the basis for the ”amytal test" for brain disease in which the persistence of certain patterns of denial and disorient- ation is considered an indication of cerebral dysfunction (h,5). In considering further the relationship between brain damage and the mechanism of denial it has been demonstrated that the premorbid personality important in determining what type of symbolic adaptation occurred. Thus, was pat- ients with the most striking and enduring manifestations of anosognosia were those who had habitually used verbal denial and rationalization as a means of coping with On their problems (10). the basis of these observations the hypothesis was developed that the of creation the convulsions in induced lay of action electrically therapeutic a milieu of brain function in which the patient might express his problems in symbolic fashion, particularly in the form of explicitly denying them. A case reported in which a patient received electroshock treatment in an attempt to relieve intractable pain associated with a Spinal cord tumor (11). After was a number of treatments, coincident with the appearance of disorientation for state, the patient dennot clinically apparent they a place and time, paraphasic misnaming and a euphoric ied pain. ‘dhen these associated.phenomena were � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation Between Altered Brain Function and Denial in Electroshock Therapy (research), 1955-1959 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-2-002 Date A point or period of time associated with an event in the lifecycle of the resource 1955-1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn, and Edwin A. Weinstein Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research