1 100 6561 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/0a74924969c48b97fad064f4d827441c.pdf e33e0604bf1a53d201e8e551507b5084 PDF Text Text Founded in 1887 by G. STANuIY HALL OFFPRINTED FROM THE AMERICAN JOURNAL OF PSYCHOLOGY EDITED BY KARL M. DALLENBACH UNIVERSITY OF TEXAS AND M. E. BITTERMAN BRYN MAWR COLLEGE E. B. NEWMAN HARVARD UNIVERSITY WITH THE COOPERATION OF E. G. BORING, Harvard University; W. K. ESTES, Indiana University; J. P. GUILFORD, University of Southern California; HARRY HBLSON, University of Texas; E. R. HILGARD, Stanford University; FRANCIS W. IRWIN, University of Pennsylvania; G. L. KREEZER, Washington University; D. G. MARQUIS, Social Science Research Council; GEORGE A. MILLER, Harvard University; W. B. PILLSBURY, University of Michigan; LEO PosTMAN, University of California; W. C. H. PRENTICE, Swarthmore College; T. A. RYAN, Cornell University. THE ROLE OF SET IN THE PERCEPTION OF ‘SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island September, 1959, Vol. LXXII pp. 384—392 Published b The American Journal of Psychology. Department of sychology, University of Texas, Austin. Tex. �Founded in 1887 by G. STANLEY HALL OFFPRINTED FROM THE AMERICAN JOURNAL OF PSYCHOLOGY EDITED BY KARL M. DALLENBACH UNIVERSITY OF TEXAS AND M. E. BITTERMAN BRYN MAWR COLLEGE E. B. NEWMAN HARVARD UNIVERSITY WITH THE COOPERATION OF E. G. BORING, Harvard University; W. K. ESTES, Indiana University; j. P. University of Southern California; HARRY HELSON, University of Texas; E. R. HILGARD, Stanford University; FRANCIS W. IRWIN, University of Pennsylvania; G. L. KREEZER, Washington University; D. G. MARQUIS, Social Science Research Council; GEORGE A. MILLER, Harvard University; W. B. PILLSBURY, University of Michigan; LEO POSTMAN, University of California; W. C. H. PRENTICE, Swarthmore College; T. A. RYAN, Cornell University. GUILFORD, THE ROLE OF SET IN THE PERCEPTION OF SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island September, 1959, Vol. LXXII pp. 384-392 Published by The American Journal of Psychology, Department of Psychology. University of Texas, Austin, Tex. �THE ROLE OF SET IN THE PERCEPTION OF SIMULTANEOUS TACTILE STIMULI By HYMAN KORIN and MAX FINK, Glenn Oaks, Long Island The influential role of ‘mental set’ in determining a subject’s response to a perceptual task has been well documented.] In studies of the perception of simultaneous, tactile stimuli, various patterns of response have been observed which seemed to be the result of a set induced by suggestion. This investigation was undertaken to determine the relation between different conditions of ‘set’ and the frequency and type of perceptual error elicited in tests with simultaneous, tactile stimuli. Recently the advantages of the simultaneous stimulation of different body-parts in tests of tactile perception have been stressed.2 Simultaneous stimulation may elicit perceptual errors under conditions in which successive single stimulations are correctly perceived. When two stimuli are applied to body-parts at the same time, only one stimulus may be reported —an error referred to as 'extinction’; or one stimulus may be perceived correctly and the other mislocalized—an error called 'displacement.’ Occasionally, if a single stimulus is interspersed in the testing-sequence, it may be reported correctly, but an additional, extraneous stimulus may also be reported—an error of ‘confabulation.’ Such errors of extinction, displacement, and confabulation are significantly increased in patients with brain dysfunction. When errors of extinction and displacement occur, they are elicited in a consistent pattern. Thus, on stimulation of the hand and face, the stimulus to the face is usually reported correctly, while that to the hand is mislocalized or not reported. By testing various combinations of bodyparts, an ‘order of dominance’ may be determined in which stimuli to the face and genital areas are most often perceived and those to the hand are for publication September 23, 1958. From the Department of Experimental Psychiatry, Hillside Hospital, Glenn Oaks, Long Island, New York and aided in part by Grant M-927, National Institute of Health, US. Public Health Service. 1]. J. Gibson, A critical review of the concept of set in contemporary experimental psychology, Pryc/aol. 32111., 38, 1941, 781—817; Robert Leeper, Cognitive processes, in S. S. Stevens (ed), Handbook of Evperimeoto] Psychology, 1951, 730-757. 2M. B. Bender, Disorder: in Perception, 1952; M. B. Bender, M. A. Green, and Max Fink, Patterns of perceptual organization with simultaneous stimuli, A.M.A. Arc/a. Neural. é Put/riot, 72, 1954, 233-255; Fink, Green and Bender, The facehand test as a diagnostic sign of organic mental syndrome, Neurol., 2, 1952, 46-58. * Received 384 �SIMULTANEOUS TACTILE STIMULI 385 least often perceived. Between these extremes, stimuli to the shoulder, foot, buttock, breast, back, thigh and abdomen are perceived in a gradient.3 Theories involving factors of rostral dominance,‘ maturation,“ inattention,6 and inherent body-image,7 have been advanced to explain the organization of these perceptual patterns, but no one theory has adequately explained all the facts. We have ascribed significance to the relative intensity of the stimuli and the thresholdvalue in the frequency and the pattern of the 'extinction’ error, when electrical stimuli are applied at threshold and suprathreshold intensities.8 The present study was undertaken to assess the relation between ‘set’ induced by suggestion and errors of 'confabulation’ and 'displacement.’ The specific problem studied is whether an 'inquiry’ into the testing pro— cedure is significantly related to the frequency and type of these errors. Since these errors are most prominent in $5 with cerebral dysfunction, patients undergoing convulsive and subconvulsive therapies were studied. Subjects. The 55 were 61 consecutive psychotic patients referred for electroconvulsive therapy. Their ages ranged between 21—67 yr., mean age being 46 yr. Thirtyseven of them received convulsive therapy; 14 first received subconvulsive therapy and then convulsive therapy; and 10 received subconvulsive therapy alone. The 55 were selected for convulsive or subconvulsive treatment on a random basis by the supervising psychiatrist. Procedure. Two model S-4B Grass square-wave stimulators were synchronized to deliver either single or simultaneous electrical stimuli. An isolation unit was connected with each stimulator to eliminate artifacts and the Output was visually monitored by an oscilloscope. A switch-box was inserted in the circuit to permit independent selection of the various parts of the body. The active and indifferent electrodes for each part were small 3fig-in. steel disks, placed l-in. apart and secured with tape. Bentonite electrode paste was rubbed into the skin of each area before the electrodes were applied. 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 a slight tap-like sensation would be felt. The electrodes were then placed on (a) the dorsum of the hands, (b) the mandibular area of both cheeks, and (c) the medial aspect of the calves of the legs. aBender, Green, and Fink, op. .cit., 253-255. 4R. Cohn, On certain aspects of the sensory organization of the human brain: I. A study in rostral dominance as determined by ipsilateral simultaneous stimulation, ]. new. mem‘. Dis., 113, 1951, 471-484; II. A study in rostral dominance in chil1, 1951, 110-122. Neurol., dren, 5 Louis Linn, Some developmental aspects of the body image, Int. ]. Pryc/ooanol., 36, 1955, 1-7. 6Macdonald Critchley, The phenomenon of tactile inattention with specific references to pariental lesions, Brain, 72, 1949, 538-561. 7Bender, op. cit., 77-88. 8 Hyman Korin and Max Fink, Role of stimulus intensity in perception of simultaneous electrical cutaneous stimuli, I. Hillside H0511, 6, 1957, 241-250 �386 KORIN AND FINK Thresholds for the various body-parts were first determined. At a frequency of 0.3 cycles per sec. and a pulse-duration of 50 m.sec., the voltage was increased in uniform increments of 5 v. to the hands and 1 v. to the cheeks every 6.7 sec. (2 pulses) until 5 perceived 100% of the stimulations. After a 10-sec. interval, voltages were decreased until the sensation was no longer reported. After another 10sec. interval, voltages were increased by 1 v. every 6 sec. until the patient again reported 100% of the stimulations. This reading was considered the minimal voltage required to produce threshold-sensation. After thresholds were determined, testing with a random series of 4 single and 6 double simultaneous stimulations followed. The body parts tested were the right hand and left cheek (heterologous stimulation) and the right cheek and the left cheek (homologous stimulation). Stimuli were applied either simultaneously or to one part singly, in a mixed order, for 10 trials. The order of presentation of the heterologous and homologous stimulation was alternated. Failure to report the interspersed single stimuli served as an index that the perceptual threshold had changed. At such times the threshold was again determined, and the 10 test-trials were repeated. Threshold changes, however, occurred infrequently during testing. The patients were tested in two groups: an ‘inquiry' group and a 'no-inqury’ group. The ‘inquiry’ group, consisting of 24 convulsive and 9 subconvulsive 55, was asked the question ”anywhere else?" after each response to a stimulation. No question was asked of the 'no-inquiry’ group, which consisted of 27 convulsive and 15 subconvulsive $5. (The total number of Ss exceeds 61, since 1 S in the 'inquiry’ group and 13 Ss in the ‘no-inquiry’ group were included both in the convulsive and the subconvulsive series.) Electroencephalograms were obtained weekly, on a day following a treatment. These records were quantitatively measured for the degree of induced slow-wave (delta) activity.9 Both the convulsive and the subconvulsive treatments were administered three times weekly on alternative days. Remltr: (1) Errors of confabulation. A response was scored as a confabulation if two stimuli were reported when only a single stimulus was applied. The observations are noted in Table I. In the 'inquiry’ group, confabulatory errors were elicted before treatment from both types of Ss—convulsive and subconvulsive. During treatment, the mean error increased from 0.08 to 0.72 among the ‘convulsive’ Ss and from 0.22 to 0.70 among the ‘subconvulsive’ ones. After treatment, the mean number of confabulations persisted in the ‘subconvulsive’ 55 (1.00) but declined in the ‘convulsive’ ones (0.10); the difference 0.90 being significant at better than the 5% level.10 In the 'no-inquiry’ 9Max Fink and R. L. Kahn, Relation of EEG delta activity to behavioral response in electroshock: Quantitative serial studies, A.M.A. Arc/9. Neural. <5 Psytbidt., 78, 1957, 516-525. 1” The Mann-Whitney ‘U'-test was used to test the significance of these data and those that follow as the scores were not drawn from a normally distributed population. Since the 'U'-test is based on rank-order of the scores, the differences between means are only grossly related to level of significance. �387 SIMULTANEOUS TACTILE STIMULI group, few confabulations occurred at any interval of testing for either the convulsive or the subconvulsive 55. Before treatment, the subconvulsive, ‘inquiry’ 55 made significantly more confabulatory errors than the subconvulsive, ‘no-inquiry’ 55. In a comparison of the ‘inquiry and ‘no-inquiry’ procedures during treatment, the differences were significant both in the convulsive and subconvulsive groups of $5. The differences during treatment are based on the substantial increase in the number of confabulations of the ‘inquiry’ group. After treatment, the confabulations of the convulsive, ‘inquiry’ group decreased to the pretreatment level, and the differences between the convulsive, 'inquiry’ and ‘no-inquiry’ groups were not significant. Though the mean TABLE I MEAN NUMBER ERRORS 0P CONFABULATION No inquiry Inquiry Period convul’ subr convul. sive (N: 24) Pretreatment Treatment Post’treatment * p<o.os; .08 .72 . 10 (N= 9) . 22 .70 I .oo Tp<o.o3; ——————— convul’ subr convul. sive (N: 27) (N: 15) o .11 . 06 o .05 —-— Diff. between inquiry and no! —— inquiry convul’ subr sive convul. .08 .22: .61]L . o4 .65T — Diff. between convulsive and subconvulsive —— inquiry n0r inquiry . 14 .02 . 90* 0 .06 — Ip<o.01. number of errors of the subconvulsive, 'inquiry’ 55 increased after treatment, a comparison between the ‘inquiry’ and 'no-inquiry’ subconvulsive 55 could not be made. Data were not obtained after treatment from the subconvulsive ‘no-inquiry’ 55 because they were transferred to convulsive treatment and were not available for testing. (2) Error; of dirplacement. A response was scored as a displacement if the locus of one of two stimuli was reported correctly and the other incorrectly. Displacements were rarely elicited from the Ss in any of the groups (Table II). The mean number of displacements tended to increase during treatment for the convulsive 55, but the differences from the pretreatment period lack significance. ( 3 ) Error: of extinction. An error was scored as an extinction if only one of two simultaneously applied stimuli was reported. The difference in the number of errors of extinction between the ‘inquiry’ and ‘no-inquiry’ groups was not significant at any period during the course of therapy both for the convulsive and subconvulsive 55 (Table III). During treatment, the mean number of extinctions decreased in all groups. At this period, �388 KORIN AND FINK the difference between the convulsive and subconvulsive, 'inquiry’ 55 was significant. After treatment the errors of all the groups decreased further. (-4) Errors of confaémlatz'on and change: in EEG. An analysis was made of the number of confabulatory errors elicited in convulsive Ss in relation to the degree of electroencephalographic change. ‘Inquiry’ $3 with high degrees of delta activity made significantly more confabulatory errors than inquiry patients with moderate and low degrees of delta activity (Table IV), while few errors were reported by the ‘no-inquiry’ Ss regardless of the change in the EEG. The mean scores of the moderate and low EEG among the ‘inquiry’ 55 was similar to the mean scores of the ‘no-inquiry' ones. N0 EEG slow-wave activity or low degrees of such activity occurred in TABLE II MEAN NUMBER ERRORS Post—treatment * DISPLACEMENT Convulsive Period* Pretreatment Treatment or inquiry . o6 . 09 . 08 Subconvulsive no’inquiry - . 07 . IO . 02 inquiry o .02 . 06 nOrinquiry 0 .01 o Inter! and intrargroup differences are not significant at any period. the subconvulsive 55. As had been indicated, however, the number of confabulatory errors of the subconvulsive group increased significantly during and after treatment. This increase resulted from increasing confabulatory errors in four of the nine patients. Dircmrz'on. Errors of displacement, confabulation, and extinction are elicited when sequences of multiple and single tactile stimuli are applied to various parts of the body. In clinical tests with touch stimulation, these errors are most prominent in patients with cerebral disease.11 Theories which have been advanced to account for the occurrence of such errors have therefore emphasized endogenous factors involving the central nervous system. Numerous studies of the role of set in perception indicate, nevertheless, that the frequency and type of response to a perceptual task may be markedly altered by the immediate aspects of a situation.12 In this study the stimulus-situation has been varied to bring about differing conditions of mental set. The endogenous factors have not, however, been 11Pink, Green, and Bender, op. cit., 46-58. 12Leeper, op. cit, 752-757; Max Pollack, W. S. Battersby, and M. B. Bender, Tachistoscopic identification of contours in patients with brain damage, I. romp. playriol. Pry/301., 50, 1957, 220-227. �389 SIMULTANEO US TACTILE STIMULI neglected and the relation between the effects of diflerent degrees of brain dysfunction has also been determined. In the course of convulsive therapy a marked increase in the number of confabulatory errors is brought about by the ES query: “anywhere else?” which followed every stimulation. Of the convulsive 55 who were asked this question, confabulations were elicited primarily in the group with high degrees of EEG slow-wave activity (marked cerebral dysfuncTABLE III MEAN NUMBER ERRORS 0F EXTINCTION Period Inquiry ———————-——— convul— sive Pretreatment Treatment Postvtreatment * subr convul. (N: 24) (N: 9) I6 2.03 1.37 I . 67 1.14 2. .89 Diff. between No inquiry ————— convulv sive (N= 27) 2. 76 1.71 1.44 sub convul. (N: 15') inquiry and n0vinquiry -——-—~—convulr subv vulsive convul. 2. 37 1.27 —— .60 .32 .07 .70 \ .13 — Diff. between convulsive and subconvulsive N0 inquiry .49 .39 .89* .44 — .48 inquiry p<o.os. TABLE IV RELATION BETWEEN EEG DELTA ACTIVITY AND MEAN NUMBER OF CONFABULATORY ERRORS Degree of Delta activity Group inquiry no inquiry .81 .10 high moderatealow Diff. Signif. (N= 9) (N=2I) .19 (N= 10) .07 (N: 6) .62 .03 p<0.05 N.S. tion) and not in the group with low and moderate degrees (minimal cerebral dysfunction). The importance of the inquiry is emphasized by the consideration that, regardless of changes in the EEG, there was little tendency for confabulatory errors to occur among the convulsive 55 when no inquiry was made. Thus both inquiry and high degrees of EEG delta activity provided the milieu favorable to evoking confabulatory errors in the c0nvulsive therapy 55. Subconvulsive 35 present a different picture. Although virtually no delta activity is induced by subconvulsive therapy, the number of confabulatory errors of four of the nine subconvulsive Ss queried increased substantially during the treatment. Furthermore, while the confabulatory errors of these four subconvulsive Ss persisted and even increased following the course of therapy, the errors of the convulsive Ss queried, in contrast, decreased to the pretreatment level. Patterns of reversible error manifested �390 KORIN AND FINK by convulsive 55 have been reported in the various studies of the effects of electroshock on different types of mental functioning.13 It was expected, however, that confabulations would not be elicited in subconvulsive $5 at is cerebral that earlier observations of view dysfunction in period, any not induced in these patients.14 An explanation for the differences between the ‘convulsive’ and subc0nvulsive ‘inquiry’ 55 is that their therapies had differing effects on the factor of practice. In 'convulsive’ 55, treatment diminished the practiceeffect, including those both with low and high degrees of slow-wave EEG activity. For each test-interval, it was as if the ‘convulsive’ 55 were starting anew. Under these conditions, only $5 with high EEG delta activity manifested a confabulatory set within a single test-period. After the course of therapy, with the disappearance of the delta activity, convulsive 35 were performing at the pretreatment-level. In the ‘subconvulsive’ $5, the set established in the pretreatment-interval was reinforced during each test-period during treatment. Thus the subconvulsive S 5 made even more confabulatory errors after treatment. The results for the subconvulsive group of 55 indicate that certain of them Such brain-function. of alteration without make an errors confabulatory may 53 are apparently influenced by the E and may be described as being suggestible or acquiescent. The failure of the convulsive $5 to establish a set which persisted for prolonged intervals of time, as did the subconvulsive SS, sugS’s If convulsive from effect derived for the basis therapy. a therapeutic gests such mental set, an interpretation as a pathological, regarded are symptoms is particularly appropriate. From the point of view of concepts of mental set, the effect of induced convulsions is to bring about a disruption of maladaptive patterns of behavior. The number of displacement-errors remained the same regardless of whether an inquiry was made. These errors occurred much less frequently than confabulations. During treatment, approximately 30% of the convulsive $5 of both the ‘inquiry’ and ‘no inquiry’ groups responded with at least one displacement. This finding compares closely with the results of 33% with displacements obtained in a study of a similar population of Hyman Korin, Max Fink, and S. Kwalwasser, Relation of changes in memory and learning to improvement in electroshock. Conf. Neurol., 16, 1956, 88-96; Max Fink, R. L. Kahn. and Hyman Korin, Effects of diffuse altered brain function on XV C(mf. of Pryc/ool. Proceed, 1958, 238—239. perception. 1“ Fink, Kahn, and Green, Experimental studies of the electroshock process, Dir. New. $315., 19, 1958, 113-118. ’3 �SIMULTANEOUS TACTILE STIMULI 391 electroshock Ss in which touch-stimuli were applied by the clinical method. Errors of displacement are not a prominent type of error in an electroshock population. With regard to errors of extinction, differences were not significant between the ‘inquiry’ and ‘no inquiry’ groups. The high number of errors of extinction before treatment and the subsequent decrease in errors during treatment, noted in this study, is in contrast to the results obtained with clinical tactile techniques. If clinical methods are used, few errors of extinction are elicited before treatment and there is a marked increase in error during treatment. The results obtained in this study are probably related to the initial difliculty experienced by Ss in perceiving electrical stimuli at threshold and the rapid adaptation to the technique in further testing. These factors play a greater role than the changes induced by the treatment. In initial studies with threshold electrical stimuli, it was believed that a more sensitive test of changes in brain-function than the clinical tactile method could be devised.15 For clinical purposes, however, the perceptual patterns obtained with electrical stimulation lack sufficient discriminability as indices of brain dysfunction. In part, the deficiencies of the method may be ascribed to the necessity for using fixed electrodes and limitations in switching arrangements at threshold. For clinical testing, therefore, simultaneous tactile stimuli applied rapidly in a varied sequence remains the best index of altered brain function.1‘6 Summary and conclmiom. This study of the perception of simultaneously applied tactile stimuli was undertaken to determine the relation between the frequency of perceptual errors to the inquiry made by E. The relations among inquiry, perceptual response, and the degree of brain dysfunction were also considered. In the test-procedure, the threshold (100% point) for square-wave electrical stimuli applied to the hand and cheek of 61 psychiatric patients was determined. Sequences of two simultaneous and single stimuli were applied in a mixed order for the hand and cheek (heterologous stimulation) and both cheeks (homologous stimulation). Heterologous and homologous trials were alternated for each patient. For one group, an inquiry was made following each response to a stimulation, while in a second 15 16 217. Fink, Green, and Bender, op. (13., 46-58. Green and Fink, Standardization of the face-hand test, Neurology, 4, 1954, 211- �392 KORIN AND FINK convulsive 55 treated either made. or The by were was no inquiry group, subconvulsive courses of therapy, at three times a week for 12—20 applications. There was a significant relationship between the frequency of confabulatory errors and the inquiry (suggestion-induced set’) in both convulsive and subconvulsive patients. The confabulatory tendencies of these patients, however, differed greatly. Although the errors for both increased during treatment, errors decreased after treatment for the convulsive differfurther. increased The subconvulsive but in the errors group group, ences between 'inquiry’ and 'no inquiry’ groups with regard to errors of extinction or displacement were insignificant. In 'convulsive-inquiry’ 55, the confabulatory errors of those with high degrees of EEG slow-wave activity were significantly more frequent than those with a low or moderate degrees of slow wave activity. The results of this study lead to the following conclusions: (1) In tests with simultaneous electrical tactile stimuli the number of confabulatory errors is related to an induced set suggested by ES inquiry. (2 ) The number of confabultory errors is increased in $5 with braindysfunction in relation to an inquiry, but may also be induced in patients without brain-dysfunction who are acquiescent and susceptible to suggestion. (3) The frequency of errors of displacement or extinction is not related to the ‘inquiry’ procedure. ��”era Role of Stimulus Intensity in Perception of Simultaneous Tactile Stimuli Hyman Karin, H!» on. and max From ELY. fink, MOD. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Aided by Institute 10-9 ’57 of the National Institute of Mental Health, National of Health, 11.5. Public Health Service. grant M—927 .M/J- I 44/ f7 �III: Role of Stimulus 10/9/57 Intensity in Perception of Simultaneous Tactile Stimuli and his coIn the course of the extensive investigations by Bender stimuli, workers (1, 2, 3,) into the perception of multiple simultaneous of two stimuli the pattern of failure of subjects to accurately report one Since led to a concept of an "order of dominance" in cutaneous perception. dominance to biologic and then, the relationShip of the observed pattern of been the subject of psychiatric concepts of body image and body scheme has considerable speculation (h, 7, 8, 1h). The interrelationship of body areas was initially clearly demonstrated was noted in simultaneous tactile tests of face and hand (2) in which it that the stimuli to the hand were frequently not reported or mislocalized. inference These phenomena of "extinction" and "displacement“ led to the that cheek area stimuli were "dominant" to reports, Bender, Pink inance for and Green (3, 10, tactile stimuli in ll, fell stimuli. In subsequent 12) described a pattern of dom- which the face and the primary genital areas were the most perceptive or dominant body dominant; and the shoulder, hand areas; the hand was the foot, buttock, breast, back, thigh, between these extremes in a mild gradient. least and abdomen These observations were made were most in normal adults and children and psychiatric patients, but the major portion clearly discerned in patients with brain disease. Indeed, of the data relates to a group of patients with severe diffuse brain dys- function under observation in a general psychiatric hospital. Bender, The basis for these phenomena is unclear. In their review, Green and Fink (3), after considering hypotheses ascribing significance to and neurophysiologic anatomic, psychophysiologic, genetic, environmental �i "no one theory‘adequately explains the organization factors, conclude that of .2- this pattern. Learning and maturation are probably factors, but appears to be mostly inherent." brain disease and normal young it (h, 5), in studies of patients with Cohn children, emphasized the rostral order of significance to "an ontogenetic or phylogenetic thalamic residue in the sensory organization of the human brain." He noted specifically, also, that this pattern was primarily associated with "the dominance and ascribed over-all sentient function of the brain." A elaboration of a maturational more extensive and developmental explanation of the order of dominance was proposed by Linn (1h). Taking the infantile patterns of sucking and feeding as a model, Linn ascribes primitiveness in the development of 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 face dominance to role as an exploring and tension-relieving appendage holds second place in awareness to its stimulation of the more of the hand to it wherein exciting A its its mouth and genitalia. 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 attentuated sensations on the impaired side," patients is probably no more than an which may be demonstrated besides the tactile - that "tactile inattention in parietal and concluded instance of local neglect or disregard, at times in many other spheres of consciousness whether motor, visual or spatial." �.3... A psychophysiologic explanation workers (10, 11), who found no tactile threshold for was eschewed by Bender and relation between the order of touch or pin prick. (8), however, insisted that these patterns an overcome by were only apparent when They hand stimulus by a stimulus four stimuli to the hand. dominance and Denny-Brown, Meyer and Horenstein alteration or loss of two-point discrimination. that the extinction of the his co- The dominance there was further demonstrated to the leg could be of the cheek to the hand could not, however, be altered by ten stimuli to the hand. following data further emphasizes psychophysiologic factors. These The studies represent the initial report of the technic of simultaneous hand of tactile stimulation tests to the alteration in brain function induced measurment of the In the course of of an investigation into the application problem of by electroshock therapy. this study electrical stimuli were applied to the cheek and psychiatric patients. Stimuli were either at threshold or supra- threshold levels. Two (a) aspects of the data are presented: The effect of alteration of relative strength of stimulus in the order of dominance (b) :3va JECTS The on face-hand tests; and Relation of perceptual thresholds to the order of dominance. ms I-‘IETHOD: subjects were electroshock therapy. mean age was 3h consecutive psychiatric patients referred for The range of their ages was between 21 and 65 and the h5. 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 electro- �.11.. shock therapy and no patient had clinical or EEG evidence of altered brain function. Two model S—hB Grass squareswave stimulators were synchronized to deliver either single or unit was connected was monitored two simultaneous electrical stimuli. to each stimulator to eliminate artifacts visually by an oscilloscope. A An isolation and the output switch bdx 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 3/8" steel discs placed 1" apart and secured with tape. Bentonite electrode paste (Medcraft) was rubbed into the skin of each area before the electrodes were applied. patient was placed on a couch in a relaxed and supine pbsiticn.. 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 The 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 first determined. At 50 body parts were a frequency of .3 cycles/second, and a pulse duration of milliseconds, the voltage was increased in uniform time increments of .67 seconds (2 pulses) monitored from the oscilloscope, ceived 100 percent of the stimuli. Increments of hand and increments of 1 5 until the subject pervolts were applied to the volt to the cheeks. After a ten second interval, until sensation disappeared.' After another ten second interval, the voltage was gradually increased by 1 volt each 6 seconds until the patient reported 100 percent of the stimuli again. This reading was the voltage was decreased considered the minimal voltage required to produce threshold sensation. �-5- and After the thresholds were determined, testing with a series of single double simultaneous stimuli followed. The body parts tested were the right and hand and left left cheek (heterologous stimulation) and the cheek homologous stimulation). taneously or one part singly in a Both mixed order parts right cheek were stimulated simul- for ten trials for each of the iollowing conditions:(l) threshold (2) suprathreshold (10 percent above the threshold), (3) one body part at suprathreshold and the other at threshold and (h) the reverse (3). The order of presentation of conditions (1) and (2) for conditions (3) was alternated for different subjects and (h). Similarly the order of presentation of the heterologous logous stimulation was and the same was done and homo- alternated. Single stimuli were introduced as a control. Failure to report the single stimulus indicated that the threshold had changed. occurred, stimulation was increased until a and 10 new threshold When this change was determined trails were started anew. RESULTS: A. Threshold Values. The threshold stimulation for perception cheeks and legs. (Table for the hands, was determined I). TABLE Mean Thresholds and I Standard Deviations of Body Parts Right Hand Hand Left Right Left 7.85 29.25 22.35 2h.50 19.52 h.86 1h.88 '13.60 13.99 Left Cheek Cheek Threshold (volts) 6.76 Standard Deviation h.h7 Mean Right Leg Leg ' 13.6h �~6The threshold values for the hands and legs are 3 to h 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. B. Extinction Patterns: difference between the The or the left number of extinctions of the right cheek on stimulation of both parts with hand 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 extinctionszhzeach 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 was dominant over the cheek with greater mean frequency (2.08) than the cheek was dominant over the hand (1.0h) for the threshold - suprathreshold condition. This tendency is also evident at suprathreshold. If it is considerefi when both that the parts were stimulated mean threshold for the hands �mua mama mmbn mmma nwmmw eUHmmwowa mmeOWmmw ma mmuo m& ma mcwuwdwwmmwowa mfi mum mum ofimmw oummw fin pa mcmumwuwmmuowm mcvumdunmmuowa efiflmmUowa awnmmwowa Kama counudwoum ow .wm m.wo H.0m zwmb H.ww nummw mxdwunawoum ow mxaqudMosm afiammwowo om saws ow H.wm .mm .mm abwbm mum H.mm cummw -mma mmuo HH madusodwoum mun mcwwpdwummwowa mmum mow v.0: m.om .m4 .OH <muwwnm dwwwmwmuom mwwe:Hdeou z.m. wAAuow vAnuow 2.m. mwmswwwombom �Emma abomw Hmwfi wear wumue wows avummuowm drummvown ma mcwuwawuwmwowm mchm&UHmmwowm owmmw ofimmw numGWm owwmwm ma ma QUGmW mum mw ma ma grammwowa meU& mum mcvum: awnmmuowm on .om .wm .Hm .ww saws nonmwdHOUm Hmwd mxwucnduoam Kama Qummw ow mxauuodwoum awwmmwowm on ow 3mm: avwbm H.mm .H# .w4 .rw mum mumwfi . mxwwannwoum md woaw.nwmme owmmw mcwumauammUowo won <muewum H.mm .mm .Hm .om wanmuwuom mdwstwmawou u‘AmoH v_Auom z.m. z.m. mumsuwwnmbnm HHH - �-7- is approximately 30 volts, while for the the difference in incidence of extinction stimulation was set at ten percent may be explained. above the threshold stimulus was therefore increased by 3 is cheeks the threshold volts 7 volts, Suprathreshold value. The hand and the face stimulus by only increase, although proportionately equivalent, appears to have given greater relative strength to the hand 1 volt above the threshold value. Such an stimulus. C. Incidence of Extinction: Regardless of pattern, the mean total of the number of extinctions 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 differences between the mean was greater number of when extinctions obtained on homologous stimulation of the cheeks lack statistical significance but the results are in the direction that a greater number of extinctions occur when two body which indicate 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 extinctions are elicited total when homologous number of parts are stimulated. These findings on the extinctions are in agreement with previous observations (2). �2. TABLE Mean IV of Combined Number of extinctions For Varying Conditions of Threshold and Suprathreshold Both Parts at Threshold A - Cheek B — Band A - Left B - Right % Cheek Cheek Both Parts SuprathreShold 3.11 1.63 .85 .56 Differences between the at mean number of % Stimuli A B - SuprathreShold - Threshold A B 1.68 1.31 extinctions at threshold - Threshold — 2oh3 1.10 and the other three conditions of stimulation are significant for the cheek and hand but are insignificant for both cheeks. SupraThreshold �-8DISCUSSION: pattern of extinction following stimulation.with threshold and suprathreshold stimuli has been determined. In contrast to the findings The of Bender, link and Green (2), face stimuli were not reported more frequently than hand stimuli when either simultaneous threShold or suprathreshold stimuli were applied. Under these conditions, neverthless, it is clear that the pattern.of extinction for any the body parts can be readily altered by stimulus varying the relative strength of the stimuli. Thus,a suprathreshold applied to the hand tends to obscure a threshold stimulus applied to the cheek and when these stimuli intensities are reversed, the cheek tends to obscure the hand. Theories which hold that dominance of the cheek over the hand is due to an inherent factor, perceived body image, rostral dominance, developmental principle, or a learned factor, are not supported by these observations. If any of these been elicited factors were involved, a pattern of face when dominance should have the hand and cheek were stimulated with equivalent stimuli at threshold and suprathreshold intensities. Although, more recently, Bender (3) has advanced an inherent factor theory, he previously attributed the extinction phenomenon to differences in the thresholds of the various body parts and to the intensity of the stimulation used (1), strength of the The finding. in this study, that differences in the simu taneous stimuli can supports a stimulus intensity hypothesis. alter the pattern By of extinction inference, differences in threshold also play a significant role. That an intense stimulus elsewhere could raise the pain threshold as This much as 35% has been denonstrated by Hardy, Wolf and Goodell (13). �-9:- 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, particularly of the hierarchy determined by Bender and his coworkers, may be elicited when presumably equivalent stimuli are applied by touch of hand. The results of this study suggest an explanation. Stimuli of differing intensities are required to elicit a threshold sensation for various body parts. ’Uhen these stimuli are increased 10 percent, 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. differences in threShold for the hand and cheek, the tactile to the cheek stimulus/is proportionately more above the threshold than the stimulus to the hand. Thus the cheek is perceived more frequently than the hand stimulus and Because of the has been considered "dominant." A threshold hypothesis was rejected (3) on the basis that the thresholds for pressure and pain do not strictly corre5pond to the dominance order elicited by the double simultaneous stimulation tests. Most difficult to reconcile is Von Frey's finding that the pressure threshold obtained by Von Frey (16) of the glans penis, which is second in dominance rank only to the cheek in tested, is 111 grams per square millimeter; While the hand, whichzislll least dominant, is only 12 grams per a group of ten body parts the threshold of 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 �.10- is virtually there no pressure sense the perception of pain, warmth, and in the glans penis or clitoris, although cold is well developed. It is quite with touch possible that the punctate pressure threshold does not correlate there the genital area is concerned but that instead some other sense or combination of senses Thresholds and is involved. for the dorsum of the hand and the cheek obtained by Von Frey other investigators indicate that the cheek is considerably more sensitive in agreement with the thresholds obtained in this study. In a recent study of thresholds at various body sites Sigel than the hand. These findings are dorsum of the (15) reported that "leg areas including thigh and ankle, also definite tendency for higher thresholds. Scalp, The anterior chest temple, forehead and face tended to have lower thresholds. lower thresholds. arm and anterior wrist areas showed a tendency for and hands and the palm showed a upper Neck areas, ment there Bender and abdomen and upper back showed no is no disagreement with definite trend." In this state- the order of dominance as determined by his coworkers. the experimental results obtained here, it is proposed that the may dominance hierarchy elicited under the conditions of simultaneous testing of the be explained in rational terms on the basis of the relative strength From stimuli and the area stimulus theoretic constructs:n threshold, without the invocation of other �-llSUM-JURY: Using square wave the hands, cheeks, and electrical stimuli, the threshold for perception in calves were detennined in 3h 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. MWSmmmmwsmmwdmcrfimhwmwswmmmwddmmmwwm the differences between the number of extinctions in either part were NOT significant. With stimuli of unequal intensity, however, (one stimulus at threshold and one suprathreshold) 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; ans greater in heterologous than in homologous patterns of stimulation. LOPELEQ-‘Pist The tests may clinically observed order of dominance in simultaneous tactile he explained by psychophysiological phenomena without resort to theoretic constructs. Differences in the hireshold of perception in various body parts provide the basis for the observed pattern of errors on simultaneous tactile tests at suprathreshold levels, �Biblio ranhv 1. W“ Bender, M;B. (1952): Disorders in Perception Sprin Bender, HgB., Fink, M; and Green, M.A. (1951): Patterns in Perception Tests of Face on Simultaneous field, Illinois. and Hand, A.M.A: Arch. Neurol. & Psychiat. éé} 355-362. 3. Bender, H.B., Green, H.A. and Fink, M. (l95h): Patterns of Perceptual Organization with Simultaneous Stimuli, EgyChiat., Neurol. n lg: 233-255. Cohn, R. (1951): On Certain Aspects of Human A.M.A. Arch. Brain: A the Sensory Organization of the Study in Rostral Dominance as Determined by Ipsilateral Simultaneous Stimulation, J. Nerv: Ment. Dis. 113: h71~h8h. S. Cohn, R. (1951): On Certain Aspects of Sensory Organization of the Brain: II — Human A Study in Rostral Dominance in Children, Neuroloav, 1; 119-122. Critchley, n. (1953): Critchley, M. The Parietal Lobes, a Go. (19h9): Phenomenon of Tactile Inattention with Special Reference to Earietal Lesions. Denny-Brown, London: Edward Arnold 3., Meyer, J.S: grain, 12: 538-561. and Horenstein, S. (1952): The Significance of Perceptual Rivalry Resulting from Parietal Lesion, grain, 15; h33~h7la 9. Dunoker, K. (1937): Some Preliminary Exneriments on the Mutual Influence of Seine, Psychpl. Forsdh, g1: 311-326. 10. Fink, M. and Bender, H.E. (1953): Perception of Simultaneous Stimuli in Normal ChilCren, 1-Ieurologq, ;: 27~3h. Tactile �Bibliograghv 11. Fink, H., Green, M.A. and Bender, M.D. (1953): Perception of Simultaneous Tactile Stimuli by Mentally Defective Subjects, gig. , Q1: . LLB-449 12. Fink, M., Green, M.A. and Bender, M.B. J. Merv. & Ment. (l952):The Face-Hand Test as a Diagnostic Sign of Organic Mental 85ndrome, Neurologz, g; hé-SB. 13. Haroy, J.D., wolf, H.S. and Goodall, H. (19h0): Studies on Pain. New Method for measuring Pain Threshold: Observations Summation of Pain, J. Clin. Invest., l2: on A Spatial 6&9-658. Linn, L. (1955): Some Developmental Aspects of the Body Image, 223! J. Eszchoana1., 2g; 1-7. Sigel, H. (1952): Cutaneous Sensory Threshold Frequency Squareédave Current: Site II. - The Stimulation with High Relationship of and Skin Diseases to the Seesory Threshold, Body J. Invest. Derm., lg: hh7-h51. 16. Von Frey, E. (189M): Beitrage zur Physiologie des Schmerzinns, Egg. Sachs. Ges. 17. diss., Von Frey, M. (1895): gé: 185-196 and 283-296. Beitrege znr sinnephysiologie Haut, Ber. Sachs. 99g. ‘L;iss., £2: 166-18u. �Karin: Amer. J. Psychol. VI: 8-12-58 Role of Suggestion-Induced Set in the Perception of Simultaneous Tactile Stimuli Hyman Korin.fh.D. and max Fink M.D. From the Department of Experimental Paychiatry, Hillside Hospital, Glen Oaks, L.I., (in part) by grant 14-927 of the National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Eastern PSydhological AsSOCiation, Philadelphia, April 11, 1958. Aided N.Y. �Role of Suggestion-Induced Set in the Perception of Simultaneous Tactile Stimuli influential role of "mental set" in determining subject response to a perceptual task has been well documented (1). In studies of the The perception of simultaneous tactile stimuli, various patterns of response were observed which seemed to be the result of "suggestion-induced set." This investigation was undertaken, to determine the different conditions of "set" relation between and the frequency and type of perceptual error elicited in tests with simultaneous stimuli. Recently the advantages of the simultaneous stimulation of body parts in tactile perceptual tests has been stressed (2). simultaneous stimulation may elicit The technique of perceptual errors under conditions in which successive single stimuli are correctly perceived. 'are applied to body parts at the same time, for example, only may be reported - may be perceived correctly and the other'mislocalized an error referred to as "extinction"; or "displacement." Uccasionally, if testing sequence, these stimuli - stimuli two stimulus one one stimulus error called single stimuli are interspersed in the may be an correctly reported, but an additional, extraneous stimulus, (referred to as a "confabulation") Such ‘When errors of extinction, displacement, may also and confabulation are be reported. significantly increased in patients with brain dysfunction. 1. R. Leeper, Cognitive processes, in 5.5. Stevens, Handbook of Experimental Psychology, 1951. 2. M. B. Bender, Disorders in Perception, 1952; Bender, Patterns of perceptual organization with simultaneous stimuli; A.M.A. Arch. Neurgl. & Psychiat. M.A. Green and M. Fink, 1g: 195h, 233-255; Fink, Green and Bender. The face hand test as a diagnostic sign of organic mental syndrome, Neurcl. g: 1952, h6—58. �.2errors of extinction and diaplacement occur, they are elicited in a consistent pattern. Thus, on stimulation of the hand and face, the stimulus to the face is usually reported correctly while that to the hand When is mislocalized or not reported. parts, an "order of and testing various combinations of dominance" may be described genital areas are often perceived. By in which body stimuli to the face most often perceived and those to the hand are least stimuli to the shoulder, foot, are perceived in a gradient (3). Between these extremes, buttock, breast, back, thigh and abdomen Theories inyolving factors of rostral dominance (h), maturation (S), inattention (6), and inherent body image (7) have been advanced to explain the organization of these perceptual patterns, but no one theory has adequately explained all the facts. Previously (8) we have ascribed significance to the relative intensity of the stimuli and the threshold value in the frequency and the pattern of the "extinction" error, when electrical stimuli are applied 3. Bender, h. Green and Fink, 02. cit., 233-255. certain aspects of the sensory organization of the brain. I: A study in rostral dominance as determined by ipsilateral simultaneous stimulation, g, Nerv. Ment. Dis. Eli: 1951, h7l-h8h; II: A study in rostral dominance in children, 32339;. I, 1951, 110-122. R. Cohn, On human S. Linn, Louis: Some developnental aspects of the body images, Int. Jour. Psychoanal. 2gp 1955, 1-7. 6. Critchley, The phenomena of tactile inattention with specific references to parietal lesions, Brain 1;, l9h9, 538-561. M. _ 7. Rnder, 8. Op. Cite, 77-88. Fink, Role of stimulus intensity in perception of simultaneous electrical cutaneous stimuli, J. Hillside Hosp. H. Korin and M. Q, 1957, 2&1-250. �.3threshold and suprathreshold intensities. The present study was undertaken to assess the-relation between "suggestion-induced set" and errors of confaoulaticn and diSplacement. The Specific problem studied is whether in the testing procedure is significantly related to the frequency and type of these errors. Since these errors are most prominent an "inquiry" in Subjects with cerebral dysfunction, patients undergoing convulsive and subconvulsive therapies were studied. Subjects: The subjects were 61 consecutive psychotic electroconvulsive therapy. patients referred for Their ages ranged between 21 and 67 and the ho. Thirty-seven patients received convulsive therapy, While fourteen first received subconvulsive therapy and then were transferred to mean age was convulsive therapy. Ten patients were treated with subconvulsive therapy only. Patients were selected for the convulsive or subconvulsive treatment on a random basis by the supervising psychiatrist. �Procedure: Two model S-hB Grass squaredwave stimulators were synchronized to deliver either single or simultaneous electrical stimuli. An isolation unit was connected with each stimulator to eliminate artifacts and the output was visually monitored by an oscilloscope. A switch box was inserted in the circuit to permit independent selection of the various body parts. The active and indifferent electrodes for each body part were small 3/8" steel discs, placed 1" apart and secured with tape. Bentonite electrode paste was rubbed into the skin of each area before the electrodes were applied. The patient was placed on a couch in a relaxed and supine position. alleviate undue anxiety the nature of the testing was described. It was emphasized that a slight tap-like sensation.would be felt. The electrodes To were then placed on (a) the dorsum of the hands, (b) the mandibular area of both cheeks and (c) the medial aspect of the calves of the legs. Thresholds for the various body parts were first determined. At a frequency of .3 cycles per second and a pulse duration of the voltage was increased in SO millbeccnds, uniform increments of five volts to the hands volt to the cheeks every 6.7 seconds (2 pulses) until the subject perceived 100 per cent of the stimuli. After a ten second interval, voltages and One were decreased second until the sensation was no longer interval, voltages were increased patient again reported 100 by 1 reported. After another ten volt every 6 seconds per cent of the stimuli. This reading until the was considered the minimal voltage required to produce threshold sensation. After thresholds h single were were determined, and 6 double simultaneous the right hand and left testing with a random stimuli followed. In body series of parts tested cheek (heterologous stimulation) and the right �-scheek and left cheek (homologous stimulation). Stimuli were applied either simultaneously or to one part singly, in a mixed order for ten trials (Table homologous I). The order of presentation of the heterologous and stimulation was alternated. TABLE I Failure to report the interSpersed single stimuli served as an index that the perceptual threshold had changed. Such a change occurred infrequently, and at these times the threShold was again determined, and the 10 testing trials were repeated. patients were tested in The "no-inquiry" group. The and nine'subconvulsive two groups: an "inquiry" group and a "inquiry“ group, consisting of 2h convulsive subjects, was asked the question-"anywhere after each responseto a stimulation. No question "no-inquiry" group, which consisted of 27 convulsive and was asked else" of the 15 suboonvulsive patients. This total exceeds 61, since one patient in the inquiry group and thirteen in the no-inquiry group were included both in the convulsive and the subconvulsive series. Electroencephalograms were obtained day following a treatment. in each patient weekly These records were quantitatively for the degree of induced leW'wave (delta) activity (9). on the meaSured Both the convulsive and the subconvulsive treatments were administered three times weekly on alternate days. 9. Pink and R.L. Kahn, Relation of EEG delta activity to behavioral reSponse in electroshock: Quantitative serial studies, A.M.A. Arch. Neurol. & Psychiat. 78 M. 1957: 516‘525 o �TABLE I Order of Presentation of Stimuli Right Hand Left Cheek Right Cheek Left Cheek 'Right hand-Left cheek Right cheek Right hand Right cheekéLeft cheek Left cheek Left cheek Right hand-Left cheek Right cheek Right hand-Left cheek Right cheek-Left cheek Left cheek Right cheek-Left cheek Right hand-Left cheek Left cheek Right hand Right cheek-Left cheek Right hand-Left cheek Right cheek Right hand-Left cheek Right cheek-Left cheek �“HW1 Results: A. two Confabulation Error: stimuli were reported A reaponse was scored as a confabulation when only a single stimulus was applied. if The II. observations are noted in Table TmBLE Convulsive vs Subconvulsive: II Confabulatory errors were elicited pretreatment both in the convulsive and the subconvulsive patients. During treatment the errors increased with approximately the same frequency. The in the convulsive treated patients and from .22 to .70 in the subconvulsive treated patients. Post-treatment, mean error increased from .08 to .72 however, the mean number of confabuLations persisted in the subconvulsive patients (1.00) but declined in the convulsive patients (.10). The difference in number of errors between the convulsive and subconvulsive groups is significant post-treatment, but not in either the pretreatment or treatment periods. In the no-inquiry group few confabulations occurred at any interval of testing for either the convulsive or the subccnvulsive patients. Inquiry vs No-Inquiry: While the differences in the mean number of errors reported by the subconvulsive and the convulsive patients lacks 'significance pretreatment, that between the subconvulsive inquiry differed significantly from the subconvulsive no-inquiry patients. During treatment the number df confabulations increased, and this difference in a comparison of the inquiry and is significant the no-inquiry procedures, both in the convulsive and subconvulsive groups. These differences during the treatment interval are based on the of the inquiry group. substantial increase in the number of confabulations �Hangs». Wmdgmgmfi womduagmggd Ex» % dwm awm mmdm * .1. 6 u w .8. .8. .8 A A km .8 Zn»: conqspmw<m A Huncwnw Foo mum mumswwwomsom. .8 moouwm. .8 .mm .E o 2% mucoouafiwmw<w 3M55L23H¢3m% duo awm mm¢m ac: .8 swwow zaps zug oon<deH<m mwwwmwmsomm domd zusvoa zongncwuw mowwoz. AHNV n cwwtmmu swm .om 0 ow zuwm Hpmnm mscoonqswmw<m Iml mwbnm HH smmsm mvuPHmm oouwmcspmdwob awn muw ad: we onww .8 wome .3 .0m Hunmwuq. oouafiwqum ZonHunnMHw Upwwmwmbom «ama wuwowm .3. wm mou mwommpw % dmmma u .0m .3 Hupswflw. ZouHunswww dwawmuobom mzwoqachqum mwmbwmwombom HmHmdma on 5. is Hmbw ac wow enamw Hm4mH .8 * éwmmm ow om .8 .E Hunzwaw wawmambom mayooudcpmw<m oon<¢wqumu mguooudcwqum oos<sHmH4m. - u .oo o zoquncwuw uwwmmambnm �-9After the course of therapy, the confabulations of the convulsive inquiry patients decreased to the pretreatment level, between the convulsive inquiry and no-inquiry groups not significant. In contrast, the mean number and differences at this time were of errors of the subconvulsive inquiry patients increased. Data for the post-treatment subconvulsive no-inquiry group was not available as these patients to convulsive treatment A and were not were usually transferred available for post-treatment tests. comparison between the inquiry and no-inquiry subconvulsive patients post-treatment cannot be made. B. Displacement Error: one of two stimuli was reported A reSponse was scored as a displacement correctly and the other was if mislocalized. rarely elicited in any of the greups (Table III). of displacements tended to be greater, however, during Displacements were The mean number treatment for the convulsive patients but the differences from the pretreatment interval lack significance. �—10‘TABLE mean Number III of Digplacement Errors Convulsive No-Inqyiry Inquiry Subconvulsive No-Inquiry Inquiry Pretreatment .06 .07 0 Treatment .09 .10 .02 .01 Post-Treatment .08 .02 .06 0 Inter and intra group differences are not significant 0 at any interval. �-llC. Extinction Error: An error one of two simultaneously applied stimuli extinction error between the inquiry at any scored as an "extinction" was reported. was if only difference in The and no-inquiry groups was not significant interval during the course of therapy both for the convulsive and subconvulsive patients (Table IV). During treatment, the mean number of extinctions decreased in all groups. this interval, the difference At between the convulsive and subconvulsive inquiry patients was Postetreatment the errors of D. Confabulation number Error all and significant. the groups decreased further. EEG Change; An analysis was made of the of confabulation errors elicited in convulsive patients in relation Inquiry patients with high to the degree of encephalographic change. degrees of delta activity made significantly more confabulation errors than inquiry patients with moderate and low degrees of delta activity. (Table V), while few errors were reported in the no-inquiry patients regardless of the degree of and low EEG inquiry groups EEG was change. The mean similar to the score of the moderate mean scores of the no-inquiry ‘ patients. No EEG slow wave subconvulsive activity or patients. number of confabulation significantly during low degrees of such occurred activity/in the However, as had previously been indicated, the errors of the subconvulsive group increased and after treatment. increasing confabulation errors in four This increase resulted from of the nine Pqu-u-u-Iu-o-O-u ‘- patients. �eaflsma Wmfimfifia womdlawmmdsmuw H.w< PS who 2n»: ooudswmwdm .x. annwnw 6A. .mw FE ”7% zuw mfidaobdspmwdo 00“ :wms H.rr ffi mid Zamq ZdSUmH oosagHmH<m ow zoquncHHw wabm I VB PS spun mdeHOdHob zuHm mscoos<¢wmw<w H< muaoum .ON .3 .8 Huncwuwu oon<cwmw<m ZOIHsnsHHw mHHmmHmbnm ZOIHSQsHHwHsnzwnw. t .S .3 wawmnmuom mcvaon<cwmw<m . bHHonmbom mzvooudcwmw<m .rw .mw .5 oosdswquou Hangwaq * I .E .3 uwmwmwmbow mcvoob<¢wmw<m zongnsqu aoadcwmwdm. �.13.. TABLE V Relation Between Degree of EEG-Delta Activity and Number of Confabulation Errors Mean Degree of Delta Activity High Mean Number Confabulation Errors ) ) ) Inquiry No Inquiry .81 (N.=9) .10 (N=21) Mederete-Low Difference .19 (Halo) .62 .07 (N=b) .03 Significance p 4 .05 N.S. �Discussion: elicited Displacement, confabulation and extinction errors are sequences of multiple and single tactile stimuli are applied to tests with touch stimulation, these errors are In clinical when body parts. most prominent in patients with cerebral disease (10). Theories Which have been advanced to account for the occurrence of such errors have therefore emphasized endogenous factors involving the central nervous system. That the fre- quency and type of response to a perceptual task may be markedly altered by the immediate aspects of a situation is indicated by the numerous studies of the role of set in perception (11). In this study the stimulus situation has been varied to bring about differing conditions of mental set. factors have not been neglected, and the relation between the effects of different degrees of brain dysfunction has also been However, the endogenous determined. In the course of convulsive therapy a marked increase in the number of confabulation errors is brought about by the examiner's query of "anywhere else?" following each stimulation. of the convulsive patients who were asked the question, confabulations were elicited primarily inthe group with high degrees of EEG 81 w wave activity (marked cerebral dysfunction) and not in the group with low and moderate degrees (minimal cerebral dysfunction). The importance of the inquiry is thus enphasized by the consideration that activity, there was little tendency for confabulation errors to occur in convulsive patients when no inquiry was regardless of changes in EEG 10. Fink, Green and Bender, op. 11. Leeper, op. M. Pollack, cit., - cit. , 146-58. . .S. Battersby and M.B.Bender, Tachistoscopic identification of contours in patients with brain damage, J. Comp. Physiol. Bszghol. g9, 1957, 220-227. made. �.15Thus both inquiry and high degrees of EEG delta activity provided the milieu faVOrable to evoking confabulatory errors. patients present a different picture. Although, virtually delta activity is induced by subconvulsive therapy, the number of Subconvulsive no confabulation errors of four of the nine subconvulsive patients queried increased substantially during the treatment. Furthermore, While the confabulation errors of these subconvulsive patients persisted and even increased following the course of flierapy, those of the convulsive patients queried, in contrast, decreased to the pretreatment level. Patterns of reversible decrement manifested by convulsive patients has been reported WW studies of the effects of electroShock in the of mental functioning (12). However, it was on different types expected that confabulations elicited in subconvulsive patients at any interval, in.view of earlier observations that cerebral dysfunction is not induced in these would not be patients (13). An explanation for the differences between the convulsive and convulsive inquiry patients is that their therapies had differing sub— effects- the practice factor. In convulsive patients, treatment diminished the practice effect in all subjects, including those both with low and high on degrees of slow wave activity. Fbr each test interval, it was as if the 12. H.Korin, M. Fink and S. Kwalwasser, Relation of changes in memory and learning to ercts improvement in electroshock, lg, 1956, 88-96; M. Fink, R.L. Kahn andon of diffuse altered brain function of Psychol. Proceed., 1958, 238-239. EE’Conf. perception, Conf. Neural. 13. Fink, R.L. Kahn and M.A. Green, Experimental Studies of the electroshock process, Dis. Nerv. 528. 12, 1958, M. 113-118. �-16convulsive patients were starting anew. patients with high EEG Under these conditions only delta activity manifested a confabulatory set within a single test period. After the course of therapy, with the disappearance of the delta activity, convulsive patients were performing at the pretreatment level. In the subconvulsive patients, the set established in the pretreatment interval test period during treatment. more confebulatory The may make Such was re-enforced during each Thus the subconvulsive patients made even errors post-treatment. results for the subconvulsive group indicate that certain patients confabulation errors without an alteration of brain function. patients are apparently influenced as being suggestible or acquiescent. by the examiner and may be described The failure of the convulsive patients .to establish a set which persisted for prolonged intervals of time as did the subconvulsive patients suggests a basis for the therapeutic effect derived from convulsive therapy. ‘If the symptoms of the patient are interpretation is particularly appropriate. From the point of view of concepts of mental set, the effect of induced convulsions is to bring about a disruption of maladaptive patterns regarded as a pathologic mental set, such an of behavior. The number of displacement errors remained the whether an inquiry was made. than confabulations. same regardless of errors occurred much During treatment approximately 30% patients of both the inquiry These less frequently of the convulsive and no-inquiry groups responded with one diaplacement. This finding compares at least closely with the results of 33% with displacements obtained in a study of a similar population of electroshock patients in which touch stimuli were applied by the 1h. M. Fink, unpublished data. clinical method (1h) �Displacement errors are not a prominent type of error in an electroShock pepulation. With regard to the extinction error, differences were not significant between inquiry and no-inquiry groups. The high number of extinction errors pretreatment and the subsequent decrease in errors during treatment, in this study, is in contrast If clinical-tactile to the results obtained with clinical tactile techniques. extinction errors are elicited increase in error during treatment. The methods are used, few is a marked results obtained in this Study are probably related to the initial difficulty experienced by the patient in perceiving electrical stimuli at threshold pretreatment and there the rapid adaptation to the technique in further testing. play a greater role than the changes induced by the treatment. and In that a initial studies Bore with threShold electrical stimuli, it These factors was believed sensitive test of changes in brain function than the clinical- for clinical purposes the perceptual patterns obtained with electrical stimulation lack sufficient tactile method (15) could be devised. however, discriminability as indices of brain dysfunction. In part, the deficiences of the method may be ascribed to the necessity for using fixed electrodes and limitations in switching arrangements at threshold. For clinical . testing, therefore, simultaneous tactile stimuli applied rapidly in varied sequence remains the best index= of altered brain function (16). 15. Fink, Green.and Bender, gghgit,, h6-58 16. M. Green and M. Fink, Standardization of the face-hand test, Neurology, h l95h, 211-217. �-18.. Summary: tactile This study of the perception of simultaneously applied stimuli was undertaken to determine the relation between the frequency of perceptual errors to the inquiry made by the examiner. The relation between inquiry, perceptual response and the degree of brain dysfunction was also considered. In the test procedure, the threshold (100 per cent point) for square wave electrical stimuli, applied to the patients was applied and in a mixed order to both cheeks trials made determined. Sequences of was two simultaneous and for the hand (homologous were alternated hand and cheek of 61 psychiatric single stimuli and cheek (heterogenous stimulation) stimulation) Heterologous and for each patient. For one group, an homologous inquiry was following each reSponse to a stimulation, while in a second group, Patients were treated either-by convulsive or subconvulsive courses of therapy, at three times per-week for 12-20 applications. no inquiry was made. There errors significant relationdhip between the frequency of confabulation the inquiry ("suggestion-induced set") in both convulsive and Was and subconVulsive a patients.v However, the confabulatory tendencies of these patients differed. Although the errors for both increased during treatment, errors decreased post-treatment for the convulsive group, but in the subconvulsive group errors increased inquiry errors further. differences between and no-inquiry groups with regard to were extinction or displacement insignificant. £:;.convulsive-inquiry patients, the confabulatory errors of patients with high degrees of more frequent than those of wave The activity. slow-wave patients with a low activity were significantly or moderate degrees of slow �.19- Conclusions: tests with simultaneous electrical tactile stimuli the number of Confabulatory errors is related to an induced set suggested uy the In examiner' s inquiry. The number of confabulatory errors is increased in patients with brain dysfunction in relation to an inquiry, but may also in patientS'without brain dysfunction.who are acquiescent be induced and susceptible to suggestion. The frequency of displacement or extinction errors to the inquiry procedure. is not related � Dublin Core The Dublin Core metadata element set is common to 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 Role of set in the perception of simultaneous tactile stimuli. Amer J Psychol. 72:384-392. 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OFFPRINT FROM THE AMERICAN JOURNAL OF PSYCHOLOGY 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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Most often the mislocslisstion or displacement occurs to another part or the subject's body but occasionally there is displacement into extrspersonsl space or onto the examiner (exosomesthesis) (8). Displacement of stimuli �2. across the mldllno of the body (alleatheala) is another form of displaoomont Normal adults initial trials orrots that may show of the among occur (9). errors in perception teat. characteristically of face dominance). all subjects correctly - be those is perceivod correctly As correct (phen- additional tests are tho errors disappear so that by the.tenth to on the oonaiot of extinction of the stimulus on the hnhd wheroao the face stimulus - may done trial noarly porcolvo both stimuli and continue 0o subsoQuent trials. has been tarmod a ”negatlvo faoe~hand This type of response test." lt oocura not only with normal gdulto but also in patients wito nohlzophronla, depression, or oovoro anxiety{ In contrast to the preceding groups, patient tith' an organic mental tyhoromo show extinction‘and diaplaoef want not only during the initial trials or the ‘tost but ’ after 10 total: of testing or as long on testing is continued. Such a rooponse is termed a ”positive taco—hand �3f test.” -by A normal "positite fees-hand test“ is also manifested ohildren, normal aged persons. fectives asvwell as syndrmhe. by patients with and mental de- an organic mental ~ Because of the differentiel_response or these several groups of subjects, the face-hand test has become useful clinically in detecting the presence of organic brain disease. During the course of our studies, however, it hes been noted thst patients with an organic mental syndrone vary ' greatly in the type and frequency of peroeptuel errors. Also, subjects without organic brain disease ‘ occasionally manifest a positive faoefhend test. The questions thieh arose from these observations are: 1) Is it . poeeiole to classify or standardize the different types of errons ooeuring in subjects with e positive race-hand test? 3 2) Gen these different types of response he corb related with the several groups or subjects previously mentioned?; 3) In there e type of response which can be �llld to ooour absolutely only in notiente with eeyere 4 dieeeee of the brain? 'The present study ie an attempt to enerer these questions.‘ ~ “ ‘ . lethod end Resultez. We test reviewed our previous records of the face-hand done in almost syndrome, normal 1000 adulte, patients with organic mental and schizophrenia adults, as well an in lesser numbere~of normal children, normal aged persons, and subjects with mental defioienoy, depression or severe anxiety. Additional groups or some of theee subjects were aleoteeted in different types of stimuli. e systematic manner with The criteria ueed‘to form- ulate a standardization of the race-hand test were: 1) ‘type of perceptual errorx'a) frequency or the variOue type: or error: with different types of stimuli (touch, rubbing, scratching, or pinprick); quency of errors when 3) effect on the fre~ the Subject ere-witnesses the applio' cation of the stimuli (factor of attention). Fifteen to thirty trials ' or the test were usually done for each eubjeet. �5. Based on theoe criteria, it was possible to divide oeticnte showing a poeitive race-hand test into four groups. The oheracterietio reeponeee for each group are V ' in Teble I. summarized Qheee reeponeee with examples are described more fully in the following peregraphe. mm I Features of the Different Type: of Positive Face-Hand Test \ One-glue Extinction only with , a touch stimuli, Two-Blue Three—glue Extinction Extinction ~pinprick placement with touch, rubbing with touch, rubbing, and and deep ~ stimuli die- and pinprick ’stimull Four-Rina Same as three-plus with at least one or the following feeturoe: e) exosomeetheeie b) alleetheeie c) frequent pereervetion d) occurrence of errors while subject eye— witnesses the areas stim- ulated. One~Plue Face-fiend show These Test: errors only of extinction The subjecte in this gnoup~ and not of displacement. errors occur only with touch stimuli. When pinprick �6. in need, both stimuli are perceived correctly, although errors will again uppeer when touch stimuli are reintro- duoed. A 6h year old because of a 1% men with mild diabetes was admitted year history or difficulty in walking. For at leeet the same period of time the patient had been depressed, The elept and ate poorly. and wee impotent. only neurological finding was a elow, heeitent, shuffling gait. There vascular dieeaee. payohomotor was The peripheral patient appeared depressed. showed retardation, and cried readily. Senecrium intact. Spinal fluid, eere normal. The was no evidence of The EEG, and X—reya of the spine diagnoeie wee involutional psychosis. gait difficultiea were thought to be secondary to the depression. this patient hand test. A shoeed a onesplue response on the raoe~ sample of his response: rollove: �7. ' com stinging touch: right chcokolort hand' right cheek touch loft chock—right hand touch right check—right hand '“touch loft chockwlcft hand touch right check-loft chock touch right hand-loft hand touch right chock—loft hand touch lelt chock-right hand touch loft check-right hand ' left cheek right cheek left cheek T222 of Error extinction extinction oxtinction extinction correct correct right chock‘ extinction correct correct touch right check-right hand 'right cheek touch left chock—loft hand left cheek extinction extinction pinprick right chock—left hand correct pinprick loft chock-right hand oorncct pinprick right chook-right_hand correct pinprick loft chock-left hand corrcct touch right cheek-loft hand correct touch loft check~right hand loft chock extinction ' adamant: Although this type patients with cerebral disease, it Or response occurs in is not alwaya charac{'5 w (M . [cal/ca toriatic for this group. It is also seen in caciiihf defrlswod’ a; MAJ (as: t/(O‘fili‘d 4"/ Mo, fitter (a! amt/11:5 Skits} .(achizophrcnia, and, occasionalgy, in normal adults. �8. Two-Plus Paoe~fiand Test: In this group extinction ' occurs with pinpriok and rubbing stimuli as well as with These errors.may be touch stimuli. just as frequent with both types of etimhli or may be more conspicuous with touch than sith pinpriok is not present, but or rubbing. may ooour on an A.72 year old man had a 5 weeks and Displacement occasional trial. history of mental. behavioral changes. This. consisted of disorientation, confused behavior, and internittent autism. thero was an examination organic mental syndrome characterized by partial disorientation, defects in recent and oiroumlooutions illnoss, On in answering questions, denial of and pain asymbolia. logical disabilities. l-raye were normal. memory, evasione The A There were no other neuro~ spinal fluid, and EEG, pneumoenoephalogram showed skull diffuse ,oerebral atrophy. This patient's responses on the face-hand characterise the two-plus type or response. A test sample �of these responses followc: Stimulfis touch touch touch touch touch touch lett cheek~right hand right cheek-left hand left chock-left hand right cheek—right hand right chookéleft cheek right hund~1ert hand touch right cheek~left hand I . Roseanne ngo of Error left extinction extinction extinction extinction cheek right cheek left cheek right cheek correct correct right cheek pinpriok left cheek-right hand left cheek pinpriok right cheek-left hand oorrect’ pinprick loft cheek~lort hand left.choek pinpriok right cheek-right hand right cheek pinprick left cheek-right hand left cheek Gonncnt: extinction. extinction extinction , extinction extinction This roaponco occurs most often in patientcv with cerebral disease although patients with anxiety state, I depression or schizophrenia may also exhibit it. It is not seen in normal adults. Three-Plus Paco—Hand Test: This group is characterised by the Occurrence of displacement as well as with both touch and pinprick stimuli. The extinction frequency of �10; extinction and displaoomont may be aqual or unequal and, likewise, the number of errors with touch and pinprick otimuli will be variable. A 57 year old chronic alcoholic was found in the in a stuporous condition. Hia Itroot. breath had an alcoholic odor and there oas a laceration over his right foroooad. There here no hospitol focal neurological signs. During the doy the patient graduolly Spooch woo rambling and was was and skull had savoro memory defects There were no X~ru§a were fialluoinationsti' nofonl. The diagnosis ocuto and chronic alcoholism with deterioration; A hand fluid And 35‘ expressed taranoid ideas aod was He hoatilo'hnd asafiultivo. ISpihal fully oooacioualgii. at timeo almost incoherent! oomplotoly‘diooriontod with confahulation. become first sample of this pationt'a toot, indicative of fallout: responooa on the race- a throe—plgo rooponao. in go ‘ �114‘ szg Rcaponso Stimulus of Error right chcck~left hand right chock-left hand displacement touch loft check~right hand right hand—left hand displacement touch right cheek-right hand right cheek extinction Touch touch touch loft loft cheokfiloft hand Correct cheekoright hand. left chock extinction touch right chock-loft hand right check—left check diaplacomont touch right hand-left hand .correct pinprick right chock~1c£t hand‘ right-choek-lcft chock displccomcnt pinprikk loft chock-right hand loft chock-right cheek displacement ‘ pinprick right chock—right hand right cheek left check pinprlck left chock-loft hand FourvPlus Facc~Hand Test: extinction cxtincticn This group shows the. sovercat porcoptual errors. In addition to frequent extinction and displaccment ac scan group. one or . all in the threc~pluc of the following phononcna may be sccn' with touch andfilr pinprick stimuli: 1) oxoaomcsthesia; 2) allcsthosic; 3) frequent pcrservation of responses; h) the occurrence of perceptual errors even while the subject keeps his apes open and eye witnesses tho arcas' stimulated. �12. A 60 year old man had a oriéntation, torgetfulness, examination he ShOfiBd a three year history of interest. and loan of On sovare organic mantal syndrome manifested by cemplete digorientation. marked -d6fect3, and inability to calculate. 'oodperativo. d18~ He was mamary alert There were no other neurological Spinal fluid and skull x-raya were normal. EEG and signs.' showed modernta, diffuse biaynohronoua slaving with slow alpha. A diffuse curcbral atrophy. pneumoogoephalograg disclosed A sample of the patient's roaponsee; 1ndlogt1ng a' fqur-plua face-hand tagt, is as fellows: Stimulus touch right cheek~ left hand touch left cheek» hand right aheek sonal spaco~ , v‘ right.oheok oxosomosthaaia extinction , _ oheek— lart left hand 10ft hand extinction , touch touch right hand- ‘ left-hhook-oxtrlporu , touch right cheekhand . , right right ‘, ‘ of Errér Tzfio Haazonse right cheek , oorrhot perseveration ' ' �13. touch right ohook- right chook~loft left hand touch left oheok¢ hand right pinpriok right hand loft ohook- loft right hand 'pinpriok right cheek- right right hand pinpriok loft ’lort hand loft chaok— pinpriok (eyes open) right cheek-left adamant: hand cheek—loft hand right ohook-lott left pinpriok loft chaak~ ohook ohook allosthosia displaoomont extinction _ cheek~oxtrnporaonnl apnoo displacement extinction cheek oxoaomeathosia right cheek—extrAporaonal oxosomosthoain space Throo~plua and four-plus responses invariably indicate disoaae of the brain. normal chock They are never found 1o adult: or in patients with psychiatric disorders. In oddition to tho difforont groups of subject: diaounsod above, the responses of normal children above fears 0! ago, normal hove ngod also been studiod. 3 persons, and montal defectives The distribution or the responses, or the children and aged poraooa are related moinly to age. The youngest children and the oldest adults show threo-plus and four—plus reopensoa. With changes in �age away from thine extremes, one-plus and two~plus re- spouses become more frequent. or the subjects with mentel deficiency, those with fiho lowest mental age have throe- plua and four—plus responses while one-plus and two-plus in subjects with higher mental 33035 'neoponses predominate Table II summarizes the distribution or the four different tfpes of responsesamong the various groups of subjects. ShOfl Only three-plus may be patients with and four-plus roséonses._ Such responses considered diagnostic of an organic mental syndrbme. TABLE ‘ an organic mental syndrome I; Frequency of One-Plus to Four~P1us Positive Pacerfiend Test in Different Groups of Subjects Negative Ono~ F5H.test Pius organio nental Syndrome 10% 7% 1% Normal Adults (below 60’ 99% year: or age) “yachixophrenio Adults nearly noooae- Two~ Plan Patients with anxiety nearly occae~ states all ionelly Petients with paycho~ neerly genie depression all‘ Four~ Plus Plue_ 25% 335- o o ' 25% o _ ' ' all ionally Three» rare neVer never more never never �15;- Discussion: In answer to the questions raised in the intreduetlon, our results indicate that four general types of positibe Itsce-hsnd test occur and that these different types can be correlated with different groups of subjests (Table Our attentien there was a was ii). focused mainly on the question of whether type sf response which occurred only in pamienss with severe disease of the brain. All cases with a threeplus or foursplus response have organic brain disease. Suoh'responses are never seen in nermel adults or patients- Iith psychoaenic disorders, even theugh these groups occasionally show one~plus may or two-plus responses. Patients with oerehral disease manifesting s four~ plus response invsrihbly show vsneed foam or mental changes. the severest or most adOtherwise there is no correlations between the type.n! positive faoeahand test and the severity of she senserisl defense. Same good istients with severe mental changes may have only a twenplus �» response; In addition, 10% of patieoie with an ofganio mental syndrome hove a negative face~hand ereelized that the use of ‘fov the groups 16. teet.’ It is to four ~plus nomenclature a one implies an increasing degree of cerebral ‘. -dyafunntion. This nomenclature ‘ was used because of con(1 lenience and much an implication is not intended; . We? This classification of a positiiefiface-haod should ‘ be useful clinically. In feeting neurological patients, the exect type of positive face-hand -corded, was will test should be re- rather than the deeignetion "the taceuhend test positive" as has been make it easier to of politifie faoe«hand done until now; Judge whether the Such a prooeedure particular type test manifested; indieatee definite cerebral disease or whethef‘it may not be a mnnifestatioh of anxiety or depression.‘ The use or such a classification will also make it easier to compare the response of patients at different times during their illnees. In addition. . , it should be valuable in clinical experimental work,'euoh an the reopen-e or patients to drugs. eleetroehock trentmont; ate. �17o Ema 1“,? : .A stanfiardization of the dittorgnt face-hand responses is prgsented. A fiypea of positive one-pins face—hand that consists of gxfiinotion only with'touoh stimuli. Itwo~plus reapgnsg 1a charactfigixéd by A extinction with pinprick and rubbing gtimfiix,‘gs.wéll as with touéh stim- uli? A three~plu3xfesponés consists cf extinction plus diapfiacafiont with touch, rubbing, #nd pinprick stimuli. A four—plus rggpénso has all tha charactériatics of a ‘ é three-plus rgaponsa and in addition at least one of tbs following features: a) exo§bmeathesia; b)_allesthesia;. c) pérseveration of respongea;'d) occurrenoa of evbn while the errors subject aypeyitneéaas tha Afifilication of fha stimuli. ‘Three—plfis éfidttour«plua responses invaritbly M-rindictte_¢1aeaaé of Fhé braig. One-plus and two~plua rdaponaea ocgur in patient; with brain disease but are alab maniteated by a hmélllfiumber of normal alulta and . patients with psychogenic disorders. Pationts with a; r �183 four-plus response the Invarest mental changes but show otherwise there is no correlation betwoon-tho aovopgyy' of the montql changes and the . 7- test manifested. - . face-handV.‘ typo-of'politivo (J ’ " . , 'w L �19. REFERENCES 1. BENDER, u.a., PINK; 3. and GREEN, n. - Puttarnn 1n paficegtiun on simultawawus fiesta a: face and hand. Arch.Neurol.&Pq1chiat., fig: 355—362, September, 1951. 2. M.B., and PINK, M. ~ Tactile perceptual tests in the differential diagnosis or psychiatric disorders. J.Hillaido 3032., A: 21-31, Jlnunry, 1952. 3. FINK, M., GREEN, M., and BENDER, M.B. BENDER, tastNo.an dia'noatlo 1, ‘g: h'ar8, - The raoa4hand Sign or disease or the Jan~Feb., 1952. brain. Nburolo . FINE, H. and BENDER, M.B. - Dovelopmunt of perception 9f simultaneous tnctile'stimull in normal children. 2 27-3L, January, Neurolo 1953. JAFFE, J. and BENDER, M.B. ~ Barceptual patterns fol— lowing general anesthesia. J.Nouro.Neurosurg.&Psychiat., gg: 316-321, Hovombor, 1951. and BENDER, M.B. ~ Cutaneous perception in the aged. Aroh.Neurol.&ngphint. fig: 577. 1953. g. BENDER, fl.B. - The phenomenon of sensory displacement. GREEN, M.A. ,Armh.Neurol.&Pq;oh1at., 95: 607-621 May. 1951. 8. SHAPIRO,.M.F., PINK, m. and BENDER, v.3. ~ Exosomesthesia or displacement of cutaneous sensation into extruporsonnl space. Aroh.Rouvol.8:Psgchi-.at., 9. gag: 1.81-1.93, Oct. 1952. Patterns in allasthosia body scheme 3:: other g4: 501~515, Arch.Neurol.&Pa;chiat., aensorysphohamena. Oct. 19 2. BENDER, and M.B. and NATHANSON, H. — their relaticu ta disorder or 3 �3?}!DAMIM’1'IM 63‘ m FAW $33!? a, mu: 1. Green, 3. 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I mI Immu- mu mm a: mmmd‘ «gammy. adult?!» ‘Ia-I um: roux-III �13* ”I’m: slaw in mt. ”van“ yum ohms” ‘bat a» mum um. man 1: ma autumn” Miami: m “writ: the m: to“ Wand» autumn“ of thin that and of mm mm uni t1» tarp". an» 1. Italy at isthmus clinically Match or with. rut-had unnatural“: in magma-u work ��I 3"? ’ flu-h'S-S.%F#M ___________Z;#__~__'——_ ��15 November 50 Dear Dr. Bender, of outline the studies in which Following is an I an participating under your supervision: a. Being prepared for presentation: i. Patterns in perception in simultaneous tests of the face and the hand 2. The Face-Hand test in the Organic Eental Syndrome 3. Patterns in perception in simultaneous tests of parts of the body other than the face and the hand 4. Caee report- Ethel Beckhorn Nos. 1-4 with‘Dr. Green. 5. Dyecheirie (with Dr. Shapiro) i" i‘b. Under study: 1. 08? changes following arteriography 2. Gomplicatione of arteriography; evaluation of the indications for the use of arteriogrefihy and the diagnostic value of the technic // Both of these studies with Dr. Stein. c. Proposed for study under grant by Rational Foundation > ~ for Infantile Paralysis: ',// n, , 1. Relation of sdaptation time, D. S. S. and threshold stimuli in hemiplegia 2. Patterns and factors in the responses of children to D.S.S.; comparison with patients with organic mental changes 5. Gen extinction and displacement be observed in normal subjects using threshold etimnli ? ��S.R. 5004-590M-701102(50) . Q.CITY OF 114 NEW YORK—DEPARTMENT OF HOSPITALS ....................................................................................HOSPITAL CaseNo..._....__.._____ PROGRESS RECORD Name...”...................................................................................... Admitted........................................................................ 19 .......... Ward ....................... Observations and Opinions of Visitings, Consultants and House Stafi. A Final Discharge Note Must Be Entered on This Sheet. Sign and Date Every Entry. .1 e . @an A ‘ I PM ‘ - "Wx. Ei‘f~ “. is _ \ [and V5“;- R‘- j "” r 4 iLIJJzJOU» SMCJE , A ' ""19“...“ '>. - Binding for Blank Leave _____________________———_———————-———————————— Continue Notes on Other Side �....................................... Division -_ ___.____________.____.______.~________. Name__________._____.____—____________ Admitted_____.______19___ Ward__.______ HISTORY Case No...........-.--..._.......... �Prev /‘ M. ‘ .‘2. fir M/- > mmf‘ég: WW “W $79“me w /W Cm _ " '2) 05/- m [4 W.“ 4.xMWafl- Y.‘ET>:0<I!WI.’:.6-m¢ 3. ‘ , m “V x-‘6 ' /MM 7 5% Wxép (a; £44, flZZp/raa ‘ ' 414w" ' *W V » dpg, fast/aw. . ." ~ , ‘ ‘ ” WW w 44}, W flm J‘ ' %¢ ./ Wugfiéfly‘é {It/*4: ‘7' ' £4cfl/r/ofl / ‘ (a) c“: M 447‘ 014M; .— . W M¢W7 (a) flfl ‘ lg‘ :11 I " 'I Cc) .A ”..th M 71 M 06‘,” f dams. M @5447 {a} )Lgpi ' ‘ CW “(:1 ‘ . 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V ' I ' - MMWQ M(M)/Zm i M NK‘Z me/W 5' Wbfi-gc % '4’ [find/ff IV ,7/C/Wfl7 MKLKKWWL) Wot/Logbook, ‘ ,t, 611%11f3/144». ”fa/two! 4/1“ 7- (WW) AL 14mg Ego; Kilo/offéfi: 354‘: J)»; 4995] 27134 2 WWW/4i lnfi w. 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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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/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. 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It Inthnao II. indicatod that thaiq «tannin in vurbu: p$ttara :ad nonpvcrbul Impact. 01 bahtvtor tantrihatod ta II Indornt‘ndtag at tho psychophyltologtanl cttnots a! tin drug and ti. 203’ 01 ltlcuugo 1n &dnp~ an... ‘0 until no. tho control cramp. it's colltntnd a! puttnuta with yortphcr:l atria. cptnsl root In! our! lotion: ant Ilaccllnanoun Indian: uni aarglaul cauda‘anun. that. In: boon no IyItOIttlo tuvnut- am. “me. a: ”that: an aunt unu- Wat“ can mm» Ital: chain's. It. pntpoactot a! tit tant to n Intton 01 pnxtoutu Inuvitaltaod In! unatal £11.»... to: 1) ovuluntc turthnr tho dtucuncttc validity at tho pcooo‘uro. 3“ this study in, by the administration “to ”tum o: um «smug W1“ tom 1We units: 3&ttoat- with than; lhfl'! otlur a) fig Omnnflcustv. putt-3t. udltltlous t6 grunts. lllllidt lonpltul v.39 lcloatod. i£d vacantly rocutv.‘ olnatmoachoot trtatnnax or who v.90 alt-teal}: diaorinntoi tor. IIBII‘O‘a $11t1~tifiht satcrvltun U‘f. 0:33:06. night ytttauta twinned tho taut. thruc alumna innutttctou‘ who �«i- an unattaiul “1mm. m m ”that m puny (Wham m pro-um utmm. than; a to“; a! to nun“ m m: mm“); “in“. I. “W m m and. u “but, tho 3““th «mam iuhtsam ta cltntail diucaoati. u1*&auci flout ttri caln$dtru£ $6 is?! and 13 I» mm mutton. nutptm at pm“ tum: W“. a.“ mum Inn 16» u. «an with a “can at :1 m mn. him and data; m taunts-anon a mu]. owl-taunt); a: mm. «a ”that u: «and tutmumuy tar ”atom. at “luau. W muons an band on ”aim anor— nuou at «mun ”km a! amtntnun n4 «aux ohm“ n ”tints um um. “um (42 (a) m m u sum: laminae-1y an truth? It: am you cm W? "on mahmnutmpw Wimotymutm? me grammar? 1: your mum mutuapuu MM? ”iu'tmhmumuuv mm but a m at!» man: at an W? M «It you an this? night? Int M W's «in? Int mill 1. ti“? “at ya: it 1- st? u. n I!“ m a! the that “no n It an" Inn put «or ms In “in" a: m Am vi.“ ti. mtm Mt. tho ”$1.31! m and «udtuml mum to out“: turn“ mum: to: at um 01 5mm 0! "about: cat’s-«Mon: I! you that 0! n m on“ haw Mu mu mt mu m ”at In? a» 39“? m mu: mm an aim mum}: 1: a «mum at «utum mm at a an a! 0.0! h at! mm”. tho ”that m and to «on» A. a. manta“ I“ m no: 109 to 1. m tumult us mum“ at“ no pun.“ am up“ ”um a am: use an m “mu“. “m“. an“. as cm" a: own“ mm“ m mun». nu. ma «sum 0.5 in 1. 10“. of W“ �*3. “amm- o: u. mum: «tau a: no a... no tout mt injnotod anyondcd on tin apptsrnnno a! u naslnnl uxtcnt at tho trig. In tut! atudy tan qfinntttr 311:3 rascal iron 0.! an to 0.5 03. than tan phyulaloflianl nation .1 ti. drug was nunttosfi. tic pgttoat In. xitcrvtvvud with t). nguo tartan o! quoutitufl. I! an ¢rror was main fin. quanttnn.van rtpuutod aluodiutcly to actor-tn. its parttatinaa. a;1y porutntant armor: Igru boon rngnvdod an tudtsattvo u! truth dtuouou 31am. 3% hi. but: tound that tarsal auntrolu any unit ttuamiant nintulou (1). . Inhavtar . in» t9 . 13$: uttan a: . rtcnc paticut. us I grow» filowud Inn, owurt tfidlaattanl a! tour Iii Ctnfirtflt in tit tilt iitlutttu. fhti was shall. by tho titan :nlbcr vb» 2633.06 tho tout nltogntlor. Son. iua&cd ta calault that! doctor: at tint: inntltan 1131:. watt. othsru war. tau frightenud to .fitfl? tho caantnattoa soon. 3"» 3.3:; than. via tcotilhu its: that! unit nalbcraus naniloatnttonu at dintwuat. Savnrul flirt raiuotaat at 1:. 401a - on. flitting up throughout the cutaro procedurc. on. Gonna illtll Utopia: all fact on tin 1100:. ktuptlt that! than tttaad. Inns patients tutti tor apoettta Gettilu a! tit tout - it: ’II’OIO, Ihlt drug thaw tut. ;n%tlug. why the: It?! uoln¢t0d. Ihnthnr this II! a ”truth tant”. Ibuthor ti. results var. euniidnntlll and. unusual}. vhnthnr that would 30 ta slut; at not hunt want ti.) Ilrt nsgtuc. an. putaoat Into: 1: ho vIrQ '91-; to h. hillod. Aunthnr 3330‘ thtt : turn. be pruunnt. I... tatttntn ‘33ud an to potty-nu and acvarul tun granular. or 3‘1: "I abouldn't 5": ¢nnn.” than. u:a110ututtona o: ovation sad tuapaeton vars haul an». marina than unto announsqrud thin tun tout 1‘s tdiifliutCtOd to putIQntu 1: stunts! Inu3ttnls. BIltkn pntiontu with phyttaul alsoasu: vim usuully 3:1: ti s "stat” a st;tunnnt than: Ifl‘tllt will or tnavta: It: houpttul. thQfli puttonsg �'T ant: taro Uilhll autitda tn. tumullnta nttnsti‘g. Inch ll “tilt :11 3‘: in tin IIIVirflO should 11'. in punau an: h:rnouy* tr ”good intlth 1.! tin ntct unfit? II ”I; lifl‘ht‘t nhnuld flirty a lion tollut.' turthurunmt. titan vat & [rcattr toxicity in tit: group in czar... tilt: gnu. distthXttnu in turns .1 aqua athnr pcraan :3 ”13!.Iiflht an: I but a llxaht Iorvcuu trashinvn” OH “I, uni: trout}: in ny‘ugglagthtr.” Alfihtthtta1_sndtuu. 1) lorntutcna gyrornz fithttvo Innattona 11'! a! ti. ‘0 pattnust nhnuod pcruzatant ohms... of Io~ hgvtor stutlir co tin-c could in hrtlu flaunt... it u IIU'IOII rarest (l).puuattvu tauntinn: that gvnlud tron an» to soar plus anpculinc en ti. lumbar at nuntloatuttoan a! itnursoattttoa nah 6.33:1 chain. on tbtt 5.31.. tho lava pontttvo «use: 1: :81: study thou-d a an; plus roasting. it. tout was rcpoutud tn turn: at those «:30: sud-nbolod a ports-tuna: a! th. an. plan rauult in tun and n Ingnttvc ranalt 1n tho thlrd. a: than: £11. putxnntn. turn: lhfllid «vidnnoc of hrtln taunts. by athnr nothads oi atudy. Out. a haw 01 It. had a pauittvu Inoonhlnl fitnt (6). ti 33:09:51.356 toourd. sun nu titrated uptunl fluid protoil on two Oflflhfitflll. Anetta: it! u «an. o: Paritnnantnn. r30 thtrt attuan psych-mun mu. mam: at tho u. a in: vus$ttvn an... had 0th.: fliflll of br‘tn difitllfl. an. In: t 64 run: 91‘ Inl‘vho porbtltontly tOIOWROd to ”Byflnahnl annpttnl" ‘hili ands! tho inslumauo at tho drug. It had a nnrnnl BEG :34 no prouu-pttwu Ovtdtiui a! brain dtloan¢. fit. othtr puttnut loath4 1h; Ioaptt‘l ti "auklaua.snrlfi altar h‘vtnc pinata it narroatlv in exam Oahu proav to rtoutving tho drug. Tin flaccid tautntntrttaon at tho toit in this has ' , m , .-‘ , .. at»: unvb n.3oust110 mum litflltn a) trgggtnut Irrorns 1r£anxcns array: (a.¢§ iVFORfl 'hiflh var: otthot $90.30 ulnouuly corrected or oowrnotod who: tn» ancatian nun iuuodttttly rn’nntnd) tn cranniatlnn and :nurvaaas a: titans: haw. not bat: ra~ �ubm mm u «W‘u u but; «an. :3 ampmm: nun. .mm:Oriflfllfll a! ti. untowar. II unaxrol.tfibsn¢tu (1). In the preaeat «tidy. Icaad nclttou. tin zlcilnnno in luv. hxvais b¢tn aortas of no £3 19% includod ¢$Viit tho luaorroct puttomnn, or 33%. III» neat trworx. rant. eats" au‘ *fltyuhtntrtn Initituad' ti"”l111l$dl 91:30 in. Iflhlfil than. fifi hunt or 1‘ a friend’s blunt ‘hn utult hon: tiring ochlttulnt1:¢ tat such I» "t plaoc to but. .0033. boxorc. Ian. pustunau «nod cuphauttul ”a piaan t¢ tctah honlth to bank rtcnpcrnttan," tar "a plan; vu11.* not hospital with tun not: ntmaunduuu panama.” ”u “Ilhtfl” tad “thy cronttst drag char but simply tut rocctvin: to print shnranu I!!! dilitrfl.” mm “at thy um “I 331th ”pittl.” M flan motion! m Bivtfl. rtponxtd. tunnvnr. tun arisinnl rampant. run anti: tbs lacuna at third airman in rtuponun to was Intod twist it lrcqummh and hospitaltnttion i11n¢as about qunuttaun booth. in» iflhaoct 0! pinion anothir tuttrviov. yrcudvuc tin 1: 1: as or stain. turalvod tcttau the patterned parucn santhar or tbs statnan: had dynaribufi it: tun patio-t prcvtauuxy 'hnr¢xa exportnnoo 1: an for huapttnltnutmu: ayuntuun in it! first action. Tins til ratio: Thu ‘ at. at mm m mum «umxu :19“ by an ”aunt u «z umhad”um ’ 1 lowly "mum.” "the mun. in law In abused to uobnll in tho mm mm n: «mud m m “tun am m Thu Qfifllll drug tnlknd thaut a tritnd who htd onnaor. 0N0! filo htnlth a! tolnttvos. tho aonauru at for: tha toot trcqnoutly vuuld ohuugud to "t ui¢l that my on: tie!“ Invue jut “thnfi t Isak tiaalrtac tho ill ntny unit.“ Thar. "anth&ac mo was tare Qt 1:32 but taut? and eliahlitii an ?Iot tar yubllcntten.* that. in: tits ;.tondna¢y ta 0:919: ¥uun puttanss It. stloattva spoctitatty in audit! to quantlaun. for non. 111:..hanpttul tho ca has oust tan: that said had originally doowtrs ha! tilt $hfll. Git“! rtrllo‘ thtt tbs! had noun inaiuat tbttr Iowa �cxuupla finalists guru that: Ififlltibt tn t not. ’Uflaiifl way stuttn‘ tar that tic: ivy. In ”t traatngut roe. lindins at! thc corridor." in tho Lustunaa at tho cryptic tilt!!! taro ocaasleually [1103 I! could help :0 out thin p;t1¢nt who. who: 13306 :0: a 11.». 3‘14 ":1 you I with you 3: you «call than I with you wasti‘. Thifli pattorna Ifift net aititrant 12am thus. used fly itnlau‘t. ti! tho tutti-or patient: vtth-phynsnnl.tnaa'ooittcl that. dtnplnetntut to Ind atonnd yoxuau. gruntnr apoetliaity and .alnctzvonou: a: ruppoulu at tn¢rosaod use of aliahfii and filtflfl tor. notud uadmr tbs tnfluttcc tn. drug. 4» 12w. In I311 pstttntn thfl rouyoano to thc rtflflflit in tall 3 prfibluu rulnttng John doc-Id to-ba & tribulia rupwosuntntson of nuns inaction. $0 illnous. houpttalinstion. tn: procedurc ttaclt or tint: centidnrcdv finial rolttxuns. 1h: aoutont at tats. rfiiwfiflfltl will bu at “ hint. rcpartud b. vtll p&t$ara and 9.17 it. papa: Iipttttfl udllutnn 53 pntiauts, 16 did not roapond cathnr hetero or flaring dru; 4111£~ trutian. llovun pattcnt- aavvcr-d hyirntorrtn; ta thsir can x! :nltiua 1n tun {first yuruon.uu¢h a. “:t would b. a spot int. I anal could no hunt? or “thy Join in my bctns but.." at: pafituttn adulntna thin try: at purnaanl rctcronan both taint. gut dating tin tr;tton $1 tun drug '31:. 11v: runpondnd tn thln~£aahtnn only titar utructurdd Alénottob. titrtrwtvo pattuats guru thn asunl turn at an a ' a: tilt third 303:. In theta. tho taaouax a! tin unttnn.ur umpnrtonn; tritium: or par-on :ppnutcd to nyutalauo not. :upnct a! £3. pnttnmt‘a ‘hau nottvuttog. annuity pttzalas who rcupondod to tho «nosttoa a: ch. 1133103 in tin primdntg antirvxcv unad tho ‘5‘; pattutn nitat wail. ‘lfiflflliti indaatxon. aovoa 01 than. patlnntn told tho I!IO John It: tovird float} might pattonta problem. th. at reprouontatton u not. ulltgnrtcal static: war. rolatod in 15 tantsaats. In?! tho tnaluley : ”John” bum mum m» m m an aura ran. um: um“ " �1 47“ 2.13th 3) Gianna. tualudod withfiruuul, avarauttvtty. ultaruttouu. u'pnnrunnn 91 unite er lixodrnuttta ”ladle” hohavtor. an... in loot uni tit it: Cruz. th: rulntud a story 011, with Tvtlvu pataontn thaw-d Itil‘rllII rcaattous. Ia tho lfltlflll for. tho puticut tuilod ca rosyend to any quantaonn tow ported: 13:11.. luau novtrnl innntdn co halt II hour. In othnr anutnuaau tho quouttunn had rntpnauo; tint. In: tn:ohorou‘ Innhltagi or analogiaua and tuna-plat. Icutcnunu Iflrfl ulna. At finch tans. tin withdrawal sayqarcd t: to u solauttvu pruuocs s‘nuc tin tu§d¢QIuto roupous¢ oocurrvd 9:133:11: with qn3;ttona rotating O0 tit ptttont’u illnonu. what quatttoun a! u fifi!‘ tuaoaunnn tfltflrfi via. to no rapdutna,novurnl tin.» ta filiait int. or its. a! n tin pattnlt often unnuoraé unwakly. «13:91: and aauplntcty. quknd Itthlrmlal in: not: unnuunl control puxlontu ta ulnar:l hospitnln hut in: oaaurrod tttqucntly tn taint. such an tho dag, LI patxcntn ittl hrt13.d1:0uno. Tb: patient: unto ovorlutivn aural. tho 303:. Infinity tit: countutod 0d *hyttuta uncut-at: of tan baud. at»: or Inna. a}. bliskiuu, a? v.9uxtod ifilfiiflfl and adaasttt' at elatitla. taunting: tho pttitnxu boos-n vary riitlaan. nut up in 5.6. sud Inliltti on having a algnrottu. an. unison: sinned prolalcou uhtvurinc at It: Uliil. bcdy tor nlvurll Iiifllfifl. titular thuvud bthnvtnr vital roan cabana ontntostc ponawtnc. uponttnaoualy balding an. urn in it: at! law atvbrnl utuutou and thin holdtu. 1t 1: vnrtnu$ paitttain pliant by tho Usualllr. (stilts: 11%.?t‘tfill 1n toad taro nottd in 16 putlontu. it. pr.» aunt‘s was an “uuptnrtc diruction, lithouch in its 0...: ‘DG pgttuut itann. tanrlul sad Quartilud tawgra tun alone at tho 1n$¢rvtau. Implawta in: slow: by tactanlod untltic, fltltltit'or laughtng. 5ohuu| Ind larvalfltalt a! vullabltlc. I... pitttttu Gauntltad thtt tho! KIII‘I thoucbt tho! hut ”on. GU!!! ‘00 I031.“ fihranotd attituinu In tattontod �.3. w tantalum min mm mm and mm m mum at”. utnclod~vith ouphnrta unntfoutattann. it»: on. pattuns, who till I! :alt 330‘ and “vtuld 1110 than unto otttu.” antvmmtd quanta... with such tzpwnanlauu us “that «a you tat-k it in. IE“ dealt-n 10.1” and “not boll fiflfll‘ 1 tauv.” Thu iactdnnoa :nn anuvau a! thil. oaptartc ranutxoun was cougarghln tn than. pravtausly tau-d in both nor-n1 it. «0.12.1 sad ital: dilussud cvuuva. Vurvtng ingrown a! suit. inhuviac var. Ihfliu, but IOU. ill patxonln. In ntvbru1.oaaan this hohtvtur it. until in tint! stunting baakaurd; Ihili tin drag It; 301:: imitatod. I... vurtod in. tango o1 th¢ir oonattac. altnrnntcly filfi' sun 1.3:, at tuna a tiuzwaanc rhythm. an. patient bartnd out tit IHIDUII it m aaaoaiullr vauntntnt in 16 mm» mm“ um» mtm mwmam m wmntm :- ‘ollphonn aparttor annulus. ga. pntitnt rcopouaol tittaghnut tin tstnrvtuv wit! nxxugnrntud nyllnbta unacnt gun druuutic pant... tn0$lr flflfi‘ ”triath“ oxprofintens Inch an "an. 1:. 1:.” low «In! uttsunro‘ mainly ma brought m: to m ward. platinum” um an in in stgtt at tho ether pstiaats. out Bitiltt, who actod in s art-nth: tin taut. upongannaunly tauntini *1 li.‘ applause.” Inch ladle huha'tor is diffiuult to grad. stutlctlonlly but it. In contra! not. ItrlOd thin 3:6 30.. abuarvtd in tin prtvtouuly ntullol control Iron... 81: canon puttuntu ibfl'fld saw. for. of filitrfld count; it» hatter and»: In. anxlutncc at tho crux. thia raaaod tron tilting ch! onnninug’u It‘d and Vbrhtl rauurln can: a: calling than “dust" to tho huhuvtor or an. putlatt uh. triad to Etna ti. nunuiulr. A for atlnru ratatou‘od It: Invoucnt: Ilcguatlvn at fituual activity at ynrtly-oa’0001 tin-n.1th in rattloul 10c Invclcntc. gnu «nude unannr throughout axncuasxal the tumult: a! tin Itfiflr gravid. :uritur duta ro'nrlilc �.9- "1““, u imam tut far can «tum. a a! the prwodum tho at tho M of aluminum: In“: “at“. mun: nu. chum a flu. the ”an“ mud ”yo-tun" mo nu um um Mint” ma ‘W 1- “ti up: in an «item 0!. Malay Mum ”am“ of imam-gm or mama. «luau: mu). «1’ film: as may. :3 a ”cum “W a! ”you“: ”that: in a at“. butt“ (1). only an o! a. n a you on “at a! put-«tn without m M manna“ for 8! ms, and n mitt" m1: 0! «a 31m. is» I “an a: 1 «u ”out” m1“ u our no m1 mmh m n inseam. 01 m 1- m m ”cm“ with ma “mu mm 1: ma «mu mmn. It my be 0.01““ an nth it is with]; as! n ”that without mwu mm diam to ”on I; ”out" mum. at “um ham “than with ma a nutuuully Ituutmt. “mu and «w In that. a! m 11" um [um mitt” rm!“ W W um "um 0! mm dam...umon patient t” In mum-um, 1n 1mm “warm I am“ cumulanu. an. u: an um. “mu” «- Wlmlmua am» 1.at the mm «a $13013. with. malt nu cm a on ”flat this study a ”11 u u m at tho ”than panama mac n a man an «11.5.»: “um A “no mun who m cm to you: at an. uncut. «um: “mm an have not ant to» a no on.“ a: u- n the min a!tutthismm.” mum In new mum. It a with)... to no than: u um am a tit m 1: on,» mm. “I not“ (7) m t. a th- wart“. if imlfim a! nun! ”in.“ with an“). “no m1“ «can! tut in g 0! flu in“ Ilth ~mum1" Wm thin II! to m '1“! «17 by tin ”pliant“ 0! nun a: in I“ m tam-nu tut utm a: ommtm. a» “muby and minus: (a) Ll. at ”mutual {mun m min a! mu Manna» an autumn he ”any“ 1: wt a: th W. man W cm man“ new m W.W W Watt �VF . «10~ "T diacloottc Iflrknl’ or ;.ann$n1 hanpttgx. 1‘ annitdbriac tun nltatfitiuna in mytholis czprunatoa about: by than. pltliitu it in noccuuary an raviiw you: grovioua fittn t01n¢tll‘ mo tho Ianlsnlsuu a! luu;:tcntnttol for place tad ttloihnd 6.31:1 at tllnnat. It hit but: 589*! tit: thouo phanouana 3!! an: 60:06:: Iaroain I: nttrthutuhlo ta brill using. 1113!. runs; that tiny arc tun mafitfilu rattan: or tut In“: or u :uaaiiennl 001.11%: rcprcn-ntod 1: I... tent at tho brain, Thur arc. rtthnr. tor-a at ninytutton or fiotcnsn that It. pntltut usnn in situations a: Itvcsa in n niltau of altcrcd luaral inacttnn. In dxnurinututiau, ti. stanuuqd tine-at plan. in tha uylhtiaa ruprcuontutxum or new; letifttifll a¢_thn ynttunt. usually thst a! hdbu GOItI¢ null and iota: homo ant a nanatoatntlou at 19:: a! unwary. That it: gattnnt in apt to stttn a tint untoautiuc :1: 11130.33 to .11: tit a... a: a small hospital at & vixen that. hs'hn- but: far noun-tttvtnl illnnia; ta least. tum hospital 33:: hit noun: at to uohxniulaxc tint ha has 10:: the knapittl. In cltnet, the ytttans 1n oxygenatus his 1: mt»: when puma. pinata: us than no no: in that: «algxn‘l retornnttul aunuoxt but it vuhielsu tor in: exproslanl WM a: the 1W muamva mu manta“. 1mm: ‘.. 1mm at mu {aunties in noeoasary to prnvid. can typo a: neural orgnnisttton in! ‘hn nuantonanee of this new synbolie synten the behavior 113.11 a: tin tOtult a: tin tuturtntton or t numb.» at ttatort u vhtt 1331.! (I) It! cull-d tn. orgnutuumvnviranmaat—ohfiurvur euuplnx. wax: tualud0t not «:1: tbs antral arznnt:at1an. but the ltct $1 tau disability ttucll. tho putlogt'n untivltion ta b: I'll, tn. tnturpnrooatl tituttton a! $I. intaxvicv. and the paticnt'a 11!. axpcriauct and parsoaaltty. tar .i‘nplo. 1! tin interview in warriod out with utcrxli I;to: that. am. In ch33... 8| lungsmtp. If tho oat-tun! docs not qunctten tho pttlaut to limit: you to slap. haunt: with, “It!” man 1am my what marital: ditteront rgnctinun flldfir unytal madiuu bocxuuc ox dittovunl typcu of puricn:lxty Ind uttstndua taunt! incapacity. �-11canxrol pattantu mitt physlaul disabiltttofi ain'toexskud with hint: dlncauo. vita quittiunnd unfit: smrtni todtun. ‘law «he! ulturuttana in lttcfllflfl. Tho: «a nut deny thuir tiflt’fifiltt‘i in qadnrw 13¢ ‘tluntaunl itniion nor an thug than luutl‘u diuortcatnttun tar plaeo or tint. fin! to hau0Vtr. "Iinautcrnwwt" quantinns about illltui it! an: 0! than ”oblon- ta mu 0! am»: an. tuphnnlauc. humor. “1“. Ind «lights. I. n.prcriou- ntndy (3) 1t in; potatud out that vita tun pattcat tuxrodumod nuathar ’Ofiflfl nttcr toagtviac tin drug I. it. up: nnuoasartly ruvunltau that had htthgruo Dana ”ro’wouaud” but yum oitlu clovosntng bin tuclluul 1a a nun mm mxulmtm. ”ml“ «mu». who um: 91 no a: a. tuna“ m. m M he that in. ion: unployod. :ppaaru to h. thfit a! siting tin strong a! ti. tuvsrnuncntnl attusttun tan or ultcrtna tit unurul orunltluttou in first-h tit incllrould In! tho tansuilcd an. at tlnpttv. unehnatlli. la prcvlonn studio. (3) (19). it kiwi itlealnoi its '13::ttotaut a! it. ctphorlu ‘sfl ludto bahnrtar tilt II Otttu notod 1%tt unytnl cudtun. 1% it: pointed out thut tutu hihtvlflt «quid not to intarptotud tiny}: in.Instantaal-phnyiolaui¢nl tart. flint ta ”onrttcll imprunstau” or as a ”rulounu at anhtbtttOH.” lhthur. tiny It. tynbol;¢ unit: at annptattau an it» unu-nrha1 upturn cougar-b1. to tho ammunitiant ahaaunc in vuriu: zanannuo. on» anuno‘ stat. that tic Gran Ithflfl or an. annual. 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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/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/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/35b321c800690bb601799adad174ab44.pdf 460a6759754060bc775314593ce1e71c PDF Text Text I ‘ 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 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 institutions, Table B. II Inter—hospital Comparison 1» The Sociopsychological Variables distribution of the variables of social class, age, education and California F Scale score is presented in Table III. Table III among the three institutions . a) Social Class: The 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 distribution in the institutional populationso �� Dublin Core The Dublin Core metadata element set is common to 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, Am J Psychiatry. 1950;107(5):381-3. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-1a-002 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 <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 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§. 駧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/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/0f6719a23fdc7ec86b84e3ad0121dcb7.pdf 2c174223139f67b6ca449ef570bd2067 PDF Text Text SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY K MAX POLLACK, PH.D. Reprinted from THE Vol. 132, N0. L 2 Copyright © AND MAX FINK, M.D. JOURNAL OF NERVOUS AND MENTAL DISEASE by The Williams Printed in U.S.A. 1961 & February, Wilkins C0. 1961 �JOURNAL or NERVOUS AND MENTAL DIsEAsE Volume 132, No. 2, February 1961 Reprinted from THE Printed in U.S.A. SOCIOPSYCHOLOGICAL CHARACTERISTICS OF PATIENTS WHO REFUSE CONVULSIVE THERAPY MAX POLLACK, PH.D.1 The growing recognition of the relation of social factors to referral for and response to somatotherapy in psychiatric treatment has stimulated increased study of “drop-outs”— patients who refuse to start or to continue treatment. Although the problem of “dropouts” is a major one in somatotherapy, it has received little attention. In convulsive therapy it is considered one of the most fre— quent “complications” of treatment (1) yet it is infrequently discussed (3, 7) and no systematic studies have been devoted to it. Systematic studies of “drop-outs” have been limited for the most part to patients in psychotherapy in out—patient facilities (4, 5, 9, 19, 20). These studies have consistently shown marked differences in social and psychological characteristics of patients who remain in psychotherapy and those who fail to continue. Those patients who remain in therapy have more years of education and who those class social than of higher are leave. In addition, their social attitudes, as measured by the California F Scale, show “less so—called conventionalism, stereotypy and less of an uncompromising insistence that ‘right’ and ‘wrong’ can be distinguished” (20). In sociopsychologic studies of the patient population of Hillside Hospital (12, 13) age, education, place of birth and degree of stereotypy, as measured by the F Scale, were related to selection for, and response to, convulsive therapy. Those patients who were older, had fewer years of education, were foreign-born and who manifested high scores on the F Scale were most likely to receive convulsive therapy, be hospitalized for Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., New York. 1 and MY—2715, National Institute of Mental Health, U. S. Public Health Service. Aided by grants MY—2092 AND MAX FINK, M.D. a shorter period, and be rated as improved at time of discharge. In contrast, patients who were younger, better educated, native-born and who obtained low scores on the F Scale, most often received psychotherapy as their sole form of treatment, were hospitalized for a longer time, and were more likely to be discharged with a rating of unimproved. Thus, the determination of psychiatric treatment was viewed as an interactive process, and related to the background, cultural values and communicative pattern of both therapist and patient. In view of this relation of psychosocial factors to selection for and response to treat— ment, it was postulated that in a psychotherapeutically—oriented hospital patients who refuse or fail to complete convulsive therapy would be significantly younger, better educated, and be less stereotyped and conventional than patients who completed a course of therapy. This study was undertaken to test this hypothesis. PROCEDURE The seventy-five consecutive iii-patients (27 males and 48 females) referred for con— vulsive therapy at Hillside Hospital during the one year period from October 1, 1957 to September 30, 1958 were included in this study. Hillside Hospital is a non-profit institution for the treatment of voluntary patients. Psychoanalytically-oriented psychotherapy is regarded as the primary method of treatment, with various somatotherapies available when necessary. All pa— tients are seen for individual psychotherapy three times a week, with psychotherapy continuing when other treatment, 6.9., convulsive therapy, is administered. Three social (age, education and nativity) and one psychological measure (the Cali153 �154 POLLACK A ND FINK fornia F Scale), were employed. A ten-item modification of the F Scale (6, 14) was administered to 53 referrals prior to treatment. In this task, the subject reads 10 statements and indicates whether he agrees or disagrees with each statement, and to what extent. The score given for each item ranges from one to seven and the range of total scores is ten to seventy. The greater the subject’s agreement, with the statement, the higher the score obtained. The statements themselves are extreme, conventional and stereotyped expressions. lr‘or example, one statement is, “If people would talk less and work more, everybody would be better off.” Patients were referred for convulsive therapy by the psychiatric resident with the ap— proval, frequently at the suggestion, of his supervisor. The referral form requesting treatment was sent to the psychiatrist in charge of the convulsive therapy unit for medical examination and the institution of treatment. Thus, it was possible to determine those patients who were referred for treatment but who refused to start. Convulsive therapy was generally administered three times a week, and grand mal convulsions were induced with the standard Medcraft alternating current instrument. RESULTS Of the 75 referrals for convulsive therapy, 13 refused treatment. Of these, seven failed to start and six refused to continue treatment. In the latter group, the number of treatments ranged from three to eight— short of the generally prescribed course of at least twelve treatments. TABLE 1 Mean Age, Education and F Score by Group N Group ' Acceptance Refusal Mean Difference (One—tailed t p< test) 62 13 (figs) Educa- 0:325) 40.3 11.6 29.7 13.7 — 10.6 +2.1 2.5 1.9 .01 .025 F Score 48.7 37.7 — 10.0 2.2 .025 Social and Psychologic Factors: The group of patients who accepted a full course of convulsive therapy was significantly older, less educated and manifested a higher mean F score than the group that refused treat— ment (Table 1). Furthermore, 37 per cent of the acceptance group were foreign-born as compared to eight per cent of the refusal group. While there was considerable overlap between groups with respect to these factors, the refusal group was more homogeneous than the acceptance group. Thus, there were no patients in the refusal group who had less than ten years of education (69 per cent of the group had attended college) and none were over fifty years of age. In contrast, 27 per cent of the acceptance group never went beyond grade school (eight years or less) and 31 per cent were fifty years or older. Differences in occupation between groups paralleled the differences in education. Thus, none of the patients in the refusal group were unskilled or manual workers. They were in clerical, professional and business vocations, Whereas ten subjects in the acceptance group were unskilled workers. Housewives were excluded from this tabulation. Relation to Diagnosis: The discharge diagnoses of seventy-three patients fell into four major categories: psychoneurosis, schizophrenia, manic-depressive, or involutional psychoses. Two patients were classified as “psychotic depression” without further specification. Although there was no statistically significant difference in diagnostic composition between the group accepting and those refusing treatment, the groups were dissimilar with respect to the incidence of the involutional psychoses (Table 2). No patient in the refusal group was discharged with a diagnosis of involutional psychosis, whereas 24 per cent of the acceptance group were so diagnosed. There was also a high positive correlation between this diagnosis and the sociopsychological factors studied. Thus, the mean age (56.7 years) and F score (61.4) were higher while the years of educa- �155 REFUSAL OF CONVULSIVE THERAPY tion (9.2 years) was lower than that for the total refusal group (Table 1). Relation to Improvement Ratings: At the discharge conference held by the Medical Director each patient is assigned one of four improvement ratings: recovered, much improved, improved or unimproved. The incidence of recovered and much improved ratings was significantly lower in the refusal group (Table 3). Six patients, all in the ac— ceptance group, were rated as recovered. The hospital discharges were more closely associated with refusal or discontinuation of treatment in the refusal group. DISCUSSION The present study confirms and extends previous findings in this laboratory (2, 12, 13) in demonstrating the importance of social factors and their psychological correlates in the selection for and response to psychiatric treatment. It supports the hypothesis that in a psychoanalytically-oriented hospital patients who refuse convulsive therapy would more closely resemble those who remain in psychotherapy and differ from those who are selected for and treated with convulsive therapy. The lower 1“ scores in the refusal group than in the acceptance group are correlated with a less compliant attitude toward authority and a more analytic approach in interpersonal activities. Review of the patients’ hospital records revealed that negativism, belligerence, uncooperativeness and attempts to manipulate the staff were more common in the refusal group. For example, 38 per cent of the refusal group as compared with only 17 per cent of the acceptance group formally petitioned the Medical Director for discharge from the hospital. (Almost all these patients withdrew their request for discharge shortly after the initial request). Referral for convulsive treatment was more often associated with problems of management, e.g., disturbing the ward or eloping from the hospital, than for depressive or confused thinking. In contrast, a higher TABLE 2 Discharge Diagnosis by Group Group Manic. Depressrve Psychosis Schizo. - Psychoneurosls phrenla Acceptance7 (11%)25 (40%) 2 (15%) 7 (54%) Refusal X2 13 4 Involu. tlonal Psychosis (21%) 15 (24%) (31%) 0 (0) = 2.28, p = n.s. TABLE 3 Discharge Improvement Ratings by Group Group Acceptance Refusal X2 Recoveredfi Much Improved 34 (55%) 3 (23%) Improved Unimproved (31%) 5 (38%) (15%) 5 (38%) 19 9 = 6.41, p = .05 percentage of the acceptance group were referred for convulsive therapy for alleviation of depressive symptoms. There is increasing evidence that accept— ance or rejection of psychiatric treatment is related to learned attitudes toward treatment by both patients and therapist (8, 9, 16, 17, 21). Most often these attitudes which correlate with socio-economic status are formed far in advance of treatment, and are most likely an intrinsic part of the person’s repertoire of behavior. Thus, patients from lower class backgrounds more frequently view psychiatric treatment as nonverbal and in physical terms whereas typically “the middle class patient is predisposed toward the acceptance of psychotherapy even before he arrives at the clinic” (9). In the sample studied there were many expressions of a negative attitude toward convulsive therapy long before the referral for convulsive therapy had been made. One patient, in treatment for several years prior to her current hospital admission, terminated treatment and transferred to another psy— chiatrist on each occasion when convulsive therapy was recommended. Another patient asked to sign the voluntary certification form on admission, appended the following note. “P.S., If I am given shock treatment �156 POLLACK AND FINK I’ll either kill myself or leave the hospital.” Other patients, particularly those who have been in individual psychotherapy prior to hospital admission, state that their previous therapists instructed them not to submit to convulsive therapy in that it would be harm- ful. Perhaps more important than either attitude of the patient or the psychiatrist is the factor of consistency of attitudes. Klerman et al., (17) have reported that young resident psychiatrists with psychoanalytic orientations frequently have unfavorable attitudes toward somatic therapy and are ambivalent about prescribing such treatment. In the present study there were many indications that referral for convulsive therapy was not the “free” choice of the resident physician but was made only after considerable pressure by administrative and nursing person- nel. A recent study by Kaplan and Lefkowits (15) of staff and environmental factors associated with referral for drug therapy in this hospital demonstrated that the psychiatrist’s tolerance for disturbed behavior was much higher than that of nurses and other personnel. Frequently the resident physician placed a premium on helping the patient modify his behavior without resort to somatotherapy. A similar observation was made by Sabshin and Ramot (21) and by Klerman (17) who found that “psychiatrists treating a patient with psychotherapy were unusually reluctant to add drug therapy.” Such attitudes may be conveyed to patients either overtly or covertly. Such observations reinforce the findings of Pasamanick, Dinitz and Lefton (18) that “despite protestations by clinicians that their reference is always the individual patient, clinicians, in fact may be so overly committed to a particular psychiatric school of thought, that the pa— tient’s diagnosis and treatment is largely predetermined.” The studies here would suggest that the psychiatrist’s ambivalent attitude toward treatment is not a general attitude but is related to the “social distance” of the patient to himself. The psychiatric resident frequently has less difficulty in recommending somatotherapy for a lower class patient but is indecisive when it comes to making a similar treatment referral for a patient who is culturally more like himself. The findings that objectors to convulsive therapy were more often discharged from the hospital as clinically unimproved is consistent with previous observations (7). Gordon (7) classified objectors into two categories—poorly oriented catatonic subjects who offered resistance to the treatment and responded with clinical improvement; and a better oriented group who objected to treatment on an attitudinal basis claiming they were “not in need of them.” This latter group were refractory to the clinical benefits of the treatment. Almost all of the patients in the refusal group of the present study could be classified in the latter group. It is of interest that most of the patients who refused convulsive treatment were prognostically poor selectees for convulsive treatment. In previous studies (2, 10, 11) we have shown that the incidence of ratings of improvement at discharge in young, welleducated, low F score patients was signifieantly lower than in the older, less educated, more stereotyped patients. The refusal group is part of that group of patients who are neither “ideal” patients for convulsive treatment nor are they very responsive to milieu treatment and psychotherapy. While referral for convulsive therapy in this and other hospitals has been markedly reduced within the past few years, the problems associated with attitude toward treatment, of which treatment refusal is but one aspect, are of persistent importance. In the absence of specific therapies for the majority of psychiatric disorders the further study of decision-making in psychiatric treatment may help delineate the forces associated with selection of therapy. �157 REFUSAL OF CONVULSIVE THERAPY SUMMARY 8. HAEFNER, D. 1’., SACKs, REFERENCES Treatment of Mental Disorder, p. 223. Saunders, Philadelphia, 1953. 2. FINK, M., KAHN, R. L. AND POLLACK, M. Psychological factors affecting individual differences in behavioral response to convulsive therapy. J. Nerv. Ment. Dis., 128: 243— 1. ALEXANDER, L. 248, 1959. 3. FLESCHER, J. The “discharging function” of electric shock and the anxiety problem. Psychoanal. Rev., 37: 277-280, 1960. 4. FRANK, J. D., GLIEDMAN, L. H., IMBER, S. 1)., NASH, E. H., JR. AND STONE, A. R. Why patients leave psychotherapy. A.M.A. Arch. Neurol. Psychiat., 77: 283—299, 1957. 5. FREEDMAN, N., ENGELHARDT, D. M., HAN— KOFF, L. B., GLICK, B. S., KAYE, H., BUCHWALD, J. AND STARK, P. Drop-out from outpatient psychiatric treatment. A.M.A. Arch. Neurol. Psychiat., 80: 657—666, 1958. 6. GALLAGER, E. B., LEVINSON, D. J. AND ERLICH, I. Some sociopsychological charac— teristics of patients and their relevance for psychiatric treatment. In Greenblatt, M., Levinson, D. J. and Williams, R. W., eds. The Patient and the Mental Hospital, pp. 263—285. Free Press, Glencoe, Ill., 1957. 7. GoRDON, H. L. ()bjectors to electric shock treatment are refractory to its therapy. New York J. Med., 46: 407—410, 1946. AND MAsoN, A. S. Physicians’ attitudes toward chemotherapy as a factor in psychiatric patients’ As part of a continuing investigation of the relation of sociopsychological factors to psychiatric treatment, the present study was concerned with the sociopsychological characteristics of patients who refused to start or to continue convulsive therapy. Thirteen of the 75 consecutive voluntary patients referred for convulsive therapy refused treatment during a one year period in a psychoanalytically-oriented institution. These patients were younger, better edu— cated and had lower scores on the CaliforniaF Scale than the group that accepted convulsive therapy. The diagnosis of involutional psychosis was absent in the refusal group, and patients in the refusal group were more often discharged as unimproved. The acceptance or rejection of psychiatric treatment is discussed in terms of learned attitudes toward psychiatric treatment by both patient and doctor. J. M. . responses to medication. J. Nerv. Ment. Dis., 131: 64—69, 1960. IMBER, S. D., FRANK, J. 1)., (,iLIEl)MAN, L. H NASH, E. H. AND SToNE, A. R. Suggesti— bility, social class and the acceptance of psychotherapy. J. Clin. Psychol., 12: 341— 344, 1956. 10. KAHN, R. L. AND FINK, M. Personality factors in behavioral response to electroshock 11. therapy. J. Neuropsychiat., 1: 45—49, 1959. KAHN, R. L. AND POLLACK, M. Prognostic application of psychological techniques in convulsive therapy. Dis. Nerv. Syst., supp. 20, pp. 180—184, 1959. 12. KAHN, R. L., POLLACK, M. AND FINK, M. Social factors in the selection of therapy in a voluntary mental hospital. J. Hillside Hosp, 6: 216—228, 1957. R. L., POLLACK, M. AND FINK, M. Sociopsychologic aspects of psychiatric treatment. A.M.A. Arch. Gen. Psychiat., 13. KAHN, 1: 565—574, 1959. L., POLLACK, M. AND FINK, M. Social attitude (California F Scale) and convulsive therapy. J. Nerv. Ment. Dis., 14. KAHN, R. 130: 187—192, 1960. 15. KAPLAN, A. AND LEFKOWITS, H. J. Influence of staff attitudes and environmental factors on treatment selection. J. Hillside Hosp. In press. Staff attitudes, decisionmaking and the use of drug therapy in the mental hospital. In Denber, H. C. B. Research Conference on the Therapeutic Community, pp. 191—214. Thomas, Springfield, 16. KLERMAN, G. L. 111., 1959. 17. KLERMAN, G. L., SHARAF, AND LEVINSON, D. J. M., HOLZMAN, M. Sociopsychological characteristics of resident psychiatrists and their use of drug therapy. Amer. J. Psy- chiat., 117: 111—117, 1960. B., DINITZ, S. AND LEFTON, M. Psychiatric orientation and its relation to diagnosis and treatment in a mental hospital. Amer. J. Psychiat., 116: 127—132, 1959. 19. ROSENTHAL, D. AND FRANK, J. D. The fate of psychiatric clinic out-patients assigned to psychotherapy. J. Nerv. Ment. Dis., 127: 18. PASAMANICK, 330—343, 1958. 20. RUBENSTEIN, E. A. AND LORR, M. A. A com- parison of terminators and remainers in outpatient psychotherapy. J. Clin. Psychol., 12: 345—348, 1956. J. 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Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sociopsychological characteristics of patients who refuse convulsive therapy. J Nerv Ment Dis. 1961 Feb; 132:153-7. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-54-020 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Vol. 132, N0. 2 February, 1961 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/9a3312b18cdf6e7ffc1390135fa8f24f.pdf 7ebf0740040bf69f9525e1f11a533ee3 PDF Text Text 20 Soci0psychological A3pects of Psychiatric Treatment A Report of Treatment in Three Voluntary Hospitals ROBERT L. KAHN, PhD, NEW YORK; MAX FINK, MD, ST. LOUIS; AND NATHANIEL SIEGEL, PhD, BETHESDA, MD IN THEIR STUDIES of the New Haven treated primarily by psychotherapy, and repsychiatric patient population, Hollingshead ceived poorer discharge ratings. These and Redlich reported significant relation— clinical factors were also related to a measscale.""5 California F the of in the individual’s stereotypy, ure position ships between an social—class structure and the incidence of Higher F scores, ie, greater stereotypy, were treated illness, types of diagnosed disorders, often found in patients diagnosed as inand kinds and duration of psychiatric treat— volutional psychosis who were referred for ment administered.1 The influence of the convulsive therapy, hospitalized for shorter economic status of the patient on the avail- periods, and were more often rated as much recovered. improved or of however, was personnel, treating ability It was suggested that differences in psy— not excluded. should chiatric hospitals treatment in the social factors of among Studies of the role social factors of influence in— similar reflect a of hospitalized patients treatment Hos— Hillside within noted for patients dependent of their financial status and the as decided it to this To was test suggestion pital. undertaken of treatments were availability 1957 Hillside the of the procedures 1957. employ this In in hospital, at Hillside Hospital Hosinstitutions—Hillside in three instudy a variety of treatment modes, including dividual psychotherapy, pharmacotherapy, pital, the C. F. Menninger Memorial Hosand convulsive therapies were available to all pital, Topeka, Kan, and the Massachusetts inThese Boston. Health Mental Center, patients regardless of their ability to pay. In our surveys 2'3 we observed that patients stitutions were selected with the expectation hospitalized for the shortest periods were that diverse treatment modalities were older, had less education, and were more equally available to populations of different often of foreign birth. These older, less- social classes. Each provided short—term educated patients were predominantly treated treatment of voluntary patients and did not by convulsive therapy and received more provide custodial care. Each is a residency favorable clinical discharge ratings. In con- training center with a full—time supervisory trast, younger, native—born, more—educated staff and active research units, emphasizing patients were hospitalized for longer periods, psychoanalytically-oriented psychotherapy. This study was designed to determine the Submitted for publication June 21, 1965. From the Department of Experimental Psychiatry, Hillside in— three the of characteristics population Hospital, Glen Oaks, Long Island, NY 1959-1962. Currently at the Department of Psychiatry, University of Chicago, social with class, to stitutions age, respect the of at the Psychiatry Department Chicago (Dr. Kahn); Missouri Institute of Psychiatry, University of Missouri and F score; and to relate these education, School of Medicine, St. Louis (Dr. Fink); and the National characteristics to treatment variables of type Institute of Mental Health, Bethesda, Md (Dr. Siegel). Reprint requests to 5400 Arsenal St, St. Louis, Mo 63139 of duration of hospitalization, treatment, (Dr. Fink). ' Arch Gen Psychial—Vol 14, Jan 1966 �EPIDEMIOLOGY—DUNHAM Small City,” in Epidemiology of Mental Disorder, B. Pasamanick (ed), \Vashington, DC.: American Association for the Advancement of Science, 1959, publication No. 60. 46. Hollingshead, AB, and Redlich, F.: Social Class and Mental Illness ew York: John Wiley & Sons, Inc., 1958. 47. Morris, ].N.: ealth and Social Class, Laneet 12303—305 (F 1959. 48. Dunham, Dis— “Anomie and Mental .. order,” in Anom and Deviant Behavior, M. B. Clinard (ed.), Ne k: The Free Press of Glencoe, a division of the acmillan Co., 1964. 49. Buck, C.; Wanklin, M.; and Hobbs, G.E.: Symptom Analysis of Ru l—Urban Differences in First Admission Rates, ] erv Ment Dis 122 280-82, ].A., and Kohn, M.L.: Social Isolation and Schizophrenia, Amer Soc Rev 20:265— 58. Clausen, 273 (June) 1955. 59. Stein, L.: Social Class Gradient in Schizo- phrenia, Brit J Prev Soc Med 11:181-195 (Oct) 1957. 60. Carstairs, G.M., and Brown, G.\V.: A Census . (July) 1955. M.B.: Al native Hypothesis for the Explanation of Some f Faris and Dunham’s Re— sults, Amer J Soc 47 48-52 (July) 1941. 51. Schroeder, C. : Mental Disorders in Cities, Amer Soc 47 :40-47 ( 1942. 52. @degaard, (3.: E igration and Insanity: Study of Mental Diseas Among Norwegian Born Population in Minnes , Aeta Psychiat Neural, 50. Owen, suppl 4, 1932. 53. @degaard, Incidence of Psychoses 0.31m in Various Occupations, Soc Psychiat, vol 2, No. 2 (Autumn) 1956. 54. Ekblad, M.; Psychiat c and Sociologic ‘ 19 , of Psychiatric Cases in Two Contrasting Communities, J Ment 5 ' 72—81 (Jan) 1956. 61. Dunha r .W.: Community and Schizo— phrenia : Epidemiological Analysis, Detroit: Wayne Sta University Press, 1965. 63. Leig lot: Comm Psychiatry, , lisher, 1960. 64. Leigh ger, New Y. 65. LClgh the Epidemi demiology bank Memori b , .H.: “A Proposal for Research in y of Psychiatric Disorders,” in Epi— ental Disorder, New York: Mil‘ o Fund, 1950, pp 128-135. 66. Krame M.; “Discussion of H. W. Dunham’s article”. 'n Causes of Mental Disorders: A Review of miologieal Knowledge, 1959, New York: Milban emorial Fund, pp 271—273, 1961. 67. Miles, H.C., et A Cumulative Survey of All Psychiatric Expe nce in Monroe County, New York: Summary of ata for the First Year (1960), Psychiat Quart 3| ‘ 58-487 (July) 1964. 68. Dohrenw , B., and Dohrenwend, B.: The Problem of Valio in Field Studies of Psychological Disorder, ] Abn Psyehol 70 :52-59, 1965. 69. Benedict, P.R., nd Jacks, I.: Mental Illness in Primitive Societie Psychiatry 17 :379—390 (Nov) . . ’ E.: Mental Ment Hyg (April) 1935. 55. \Vinston, M.; Compa t e Study of Disease Incidence in Admissions to ase Psychiatric Hospi— tal in Middle East, Men ei 922118—127 (Jan) 56. Simms, 1946. 57. JaCo, E.G.: The Social Isolation Hypothesis and Schizophrenia, Amer Soe Re-zv 19:567-577 (Oct) 1954. 1954. 70. Hollowell, Philadelphia 1955. : .A.: Culture and Experience, niversity of Pennsylvania Press, Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL diagnosis, and discharge evaluation among the institutions. Method A census of all voluntary, adult patients in residence in the institutions was undertaken in January While Menninger and Hillside Hospitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evalua— tion or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their nonvoluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead two-factor index—a weighted score of education and occupation—was used.“’6 The study population consisted of 173 patients at Hillside, 100 at Menninger, and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult, however, because of vari— 1959. ous methodological differences discussed below. These difficulties were most marked in the intrahos— pital comparisons and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, reflected in the tables by the varying population sample sizes. Results I. Methodological Problems—When re— porting studies from one institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. In TABLE 1.—Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction, narcissistic personality Anxiety reaction, narcissistic personality Narcissistic personality Narcissistic personality, alcoholism, chronic infantile personality Passive aggressive personality, alcoholism Infantile personality, schizophrenic reaction, schizoaiicctive type General Classification Psychoneurosis Psychoneurosis Personality trait disturbance Sociopathic personality disturbance Sociopathic personality disturbance Schizophrenic psychosis 21 gathering comparable data from multiple in— stitutions, however, the differences between institutions are accentuated. While these in— stitutions were selected as comparable in teaching, research, and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designa— tion of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. Designation of Type of Treatment: The criteria for designating that a patient , received “psychotherapy’ differed among the institutions, making comparisons (lif— 1. ficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with a psychiatric resident physi— cian were considered part of routine ad— ministrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising resident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines—psychiatric residents, psychologists, social workers, nurses, and medical students. Formal records of such sessions were not routinely included in the patient’s record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident physi— cian responsible for each case. 2. Diagnosis: Individual institutional di— agnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table 1, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Arch Gen Psychz'al—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL 22 Discharge Ratings of Improvement: Ratings of improvement at the three hos— pitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological, and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table 2). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. II. Interhospital Comparisons—1. Sociopsychological Variables: The distribution of the variables of social class, age, education, and California F scale score among the three institutions is presented in Table 3. A. Social Class. The anticipated differ— ence in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. B. Age. There were no differences in age distribution in the institutional populations. C. Education. The populations also differed in educational attainment, with patients having more years of education at Men— ninger Hospital than at Massachusetts Mental Health Center. While 41% of the patients at MMHC had not completed high school, only 32% at Hillside and 23% at Menninger did not graduate. D. F Score. Differences in the distribution of scores on the California F scale were also observed. Fifty-one percent of Menninger patients had F scores below 30, and only 8% with scores of 50 or above—the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside 31% of the patients had F scores below 30 while at MMHC only 20% were be- 2.—Comparative Ratings of Clinical Condition at Time of Hospital Discharge TABLE 3. low 30. Menninger Hospital Thus, differences in social class, tional attainment, and performance on the F scale were observed. These differences permit a test of the hypotheses relating socio— psychological factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables: A. MM HC Improved Recovered Much improved Unimproved Improved Social adjustment Character structure Recovered Markedly improved Moderately improved Slightly improved Unimproved Unimproved Improved Unimproved Syndrome Complete remission Improved Unchanged (or worse) Selection of Treatment. Among the institu— tions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table 4). B. Duration of Hospitalization. The three institutions differed with regard to patient’s length of stay (Table 4). Patients at Men— ninger Hospital were hospitalized longest, with 65% of the patients remaining for 12 months or more, compared to 31% of the Hillside patients and only 5% at the Massachusetts Mental Health Center. The modal stay of the Hillside group was beComparison: for 'Sociopsychological Variables TABLE 3.——Interhospital ' Hillside Hospital Menninger Hospital N 87 31 % I II III Social class l 17 13 28 28 O 5 20-39 40+ x2= N <12 12-15 16+ 121.5, df = 3.9, dr= 4, 100 23 % 54 23 x2 = 9.7, df = 4, [ F score { I N Arch Gen Psychiat—Vol 14, Jan 1966 x2 51 P % 41 8 = 39.2, (if = <0.001. 173 19 % 58 23 95 15 % 52 33 173 32 % 51 17 91 41 P: NS 92 10-29 30-49 50-70 L P 8, 100 19 % 59 22 <20 education 28 V = 72 3% 2O 1 x2 M M HC 51 IV N Age 133 7% 34 34 L Years of educa— Hillside Hospital 4, P % 49 10 <0.05 163 33 % 50 17 <0.001 76 20 % 38 42 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL TABLE 4.—Inicrhospital Difi‘ercnccs in Treatment Variables Menninger Hillside Hospital Hospital MMIIC 100 Ty pe of treatment Psychotherapy [ Duration of hospitalization Somatic Other 21% 43 36 x2=82.,8 df=4, P <0.001 NMo <7 Mo >11 M0 7- 11 100 22 % 13 65 x3=90.,6 df=4, P RecoveNred,1 % evaluation much1m- proved Improved Unimproved x2=29.3, df= N Discharge diagnosis 80 19 4, 89 24 % 68 8 173 27 % 42 31 67 % 27 172 23 % 88 28 % 5 5 P 62 15 61 171 52 22 S5 54 10 <0001 95 43 % 5 Schizophrenia Affective psychosis Psychoneurosis 52 & personality disorder xa = 23.8, df = 4, P <0.001 % % 17 26 29 tween 7 and 11 months while two thirds of the MMHC patients were discharged within six months of hospitalization. C. Discharge Evaluation. In each hospital, most patients were evaluated at the time of discharge as “improved” (Table 4). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as “unimproved” and only a single patient was scored “recovered” or “much improved.” The highest percentage of “recovered” or “much improved” ratings (28%) and the lowest proportion of “unimproved” (10%) were found at the Massachusetts Mental Health Center. D. Diagnosis. For statistical analysis three diagnostic groupings were made: TABLE 5.—Duration of Hospitalization, by Age Percentage of Age Group Staying Over One Year Age Below 20 20-29 30—39 40-49 50+ Menninger Hillside MMHC 81 73 61 30 36 42 14 6 6 0 0 36 30 20 0 schizophrenia, affective disorders, and psy— choneurosis and personality disorders (Table 4). The diagnostic proportions of patients within these groups were similar for Hill— side and MMHC, as slightly more than half were diagnosed as schizophrenia and one quarter as psychoneurosis or affective dis— order. In contrast, at Menninger Hospital psychoneurosis and personality disorder ac— counted for more than 50% of the popu— lation. III. Intrahospital Comparisons—The lack <0.001 99 Discharge 173 36 % 64 — 23 of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intrahospital comparisons. However, the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Men— ninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals—the younger patients re— maining for the longest periods. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table 5) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. Comment The patients of three voluntary psychiatric hospitals exhibited significant interinstitutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables—duration of hospital— ization, selection of treatments, and dis— tributions of diagnoses and discharge evaluations.7 Expectations based on our earlier intra-Hillside Hospital study were confirmed. The institution serving upperclass patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the Arch Gen Psychiat—Vol 14, Jan 1966 �24 SOCIOPS‘YCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL three institutions. Similarly, the institution serving lower—class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations. The contrasts between in— stitutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, defini— tions of psychotherapy, and the details and amount of recorded data. While these stylistic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater de— pendence on social class variables than ordinarily acknowledged. Such population and treatment variable relationships are interactive processes, de— termined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients present. Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, ie, where objective criteria defining diseases of known etiology are absent, as in schizo— phrenia, psychoneurosis, personality and be— havior disorders. Under these conditions of perceptual and situational ambiguity, the ob— server’s attitudes and expectations become significant aspects of his perceptions, classi— fications, and decisions. A similar situation was clearly documented by Pasamanick et al 7 in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards (lid not differ in type of admission, marital status, education, age, or residence. Significant differences did occur, however, in the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the popula— tions were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners. Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another. Literal adherence to these concepts produces paradoxical results. For example, Menninger Hospital with more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizo— phrenia, and yet, reports the poorest treat— ment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results. In the absence of independent criteria for the quality of care or the assessment of com— parability of populations for degree of ill— ness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions. Since the evalua— tions are based on the institution’s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psy— chiatric characteristics. In our initial Hillside study3 it was postulated that different criteria of improve— ment were utilized for persons of different social background. It was suggested that the higher the person’s social background the more complex the criteria employed. This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutions. Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower—class persons we are apt to assess improvement in relation to symptom relief or the patient’s capacity to resume work, while for upper—class persons the criteria emphasize such complex intangibles as “de— veloping insight,” or “working through one’s problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But dif— ferences in institutional style made it diffi— cult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, di— agnostic classifications, or length of hos— pitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient popula— tions. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labo— ratories, for the lack of confirmation may reflect differences in populations and psy— chiatric criteria as much as errors in the original hypotheses. The use of the terms “schizophrenia” or “psychoneurosis” to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by “objective” criteria rather than our present methods, so highly dependent on institu— tional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. 25 Summary Population characteristics, defined by social class, age, education, and F score; were related to treatment variables in three voluntary teaching hospitals. Treatment vari— ables included type of treatment, duration of hospitalization, diagnosis, and discharge evaluation. Interinstitutional differences were observed in patient social class, years of education, and distribution of California F scores, but not age. The variations in treatment characteristics among institutions were significantly differ— ent in the predicted direction. The institution serving upper-class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses, and more com— plex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions. Similarly, the institution serving lower-class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diag— noses, and the better discharge evaluations. These variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hos— pitalization, and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasized. Aided, in part, by grants MY-2092 and MY-2715, of the National Institute of Mental Health, US Public Health Service and the Nassau County Mental Health Board. Dr. Max Pollack aided in gathering material for this study. REFERENCES Hollingshead, AB, and Redlich, F.C.: Social C lass and Mental Illness: A Community Study, New York: John Wiley & Sons, Inc., 1958. 2. Kahn, R.L.; Pollack, M.; and Fink, M.; Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J Hillside Hosp 6:216—228, 1957. 3. Kahn, R.L.; Pollack, M.; and Fink, M.; Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitali— zation, Discharge Ratings and Diagnosis, Arch Gen Psychiat 1:565—574, 1959. 1. al: The Authoritarian sonality, New York: Harper & Brothers, 1950. 4. Adorno, T.W., et Per— Kahn, R.L.; Pollack, M.; and Fink, M.; Social Attitude (California F Scale) and Convulsive Ther— 5. apy, J Nerv Ment Dis 130 2187-192, 1960. N.H., et al: Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals, Soc Problems 10 :191-196, 1962. 7. Pasamanick, B.; Dinitz, S.; and Lefton, M.; Psychiatric Orientation and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer J Psychiat 116:127-132, 1959. 6. Siegel, Arch Gen Psychiat—Vol 14, Jan 1966 �26 Families of Children Wit nia hi hood SchizoPhr Early Sc ected Demographic Informajion L IS HENDRICKSON LOWE, MA, INDIANAPOLIS PREVIOUS STUDIjS regarding the etiological importance of l‘family background in childhood schizophr ia have produced Kanner4 i ressions. and diverse findings has stated that autistic hildren are usually found to have intellige , sophisticated pareducational attaine high have who 3a ents level. In his populatio 10f autistic patients, grad— school high the we of parents 94% and 49% fathers of while 74% uates, of the mothers had co 'pleted college. In another publication,3 he ‘emarked on a low incidence of divorce :1 ng these families. Bender,1 on the other h d, has noted that 'ong the parents no such trends exist of schizophrenic childre seen at Bellevue, " t " wide variety of backgrou It has also been rep ed that a fairly in is a s common to of ratio boys high these that and ion, schizophrenic pop children are freq fly the firstborn in their male-fe— the lists nder2 sibling group. 1 in a group of 142 male ratio as 7 of under chil age. en years schizophrenic autistic 27 of ulation with a Phillips,6 is which boys, that noted were children, also He 6:1. ratio male—female 0 early a autistic of ition ordina data on presents children. In the general opulation, the ex— is 44.12%.6 children firstborn of rate pected In a group of 635 disturbed (but nonautistic) children, Phillips found that 27 the of while firstborn, 76.38% were autistic children, 81.5% were firstborn. that to data these suggest Phillips interprets autistic children differ from the normal population in matters of sexual ratio and ordinal position as do lesser disturbed chil:1 of the suggestion out dren. He points continuum, with more vere childhood dis— turbances appearing cw comitantly with a higher ratio of boys 'l girls, and with a ‘l stborn children. It higher proportion of should be noted that ny data on ordinal position can be undistood better when viewed in conjunctio with maternal age at the birth of the chi these various re— Discrepancies amo ports of data may be due to disparities in om which samples patient populations were drawn. Bender nd Kanner, however, drew their patient ample from different population groups ,' ith respect to socio‘anner’s probably came economic status. largely from peopl in higher socioeconomic groups in a unive ity community while Bender had a wide population to draw from in New York ci . Since this poten— tial error is compounc d by the relatively low incidence of c'dhood schizophrenia in the general . The p pose of the present paper is to make .available pertinent information collected etween 1955 and 1963 in the Chil— dren’s S :VICC of LaRue D. Carter Me— morial Ho' ital, Indianapolis. The data on children is compared with that schizophre obtained on y-\turbed children given diag— childhood schizophrenia. noses other Since LaRue Hospital is the only nit for disturbed residential treatmen youngsters in the stat of Indiana, the patient population is probably representative of all geographic areas of the state as well as a variety of socioeconomic backgrounds. t Ca Method Subjects.—Included in the study were the children whose preadmission diagnosis was one of emotional disturbance, whether or not the child was admitted Arch Gen Psychiai—Vol 14, Jan 1966 Submitted for publication March 18, 1965. From the Indiana University Medical Center. . Reprint requests to 64 Mercury Ct, West Springfield, Mass 01089. �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts MEntal Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �In their studies of the New Haven psychiatric patient population, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure hand the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to payu In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth, These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingsa In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)c Higher F scores, i.e,, greater stereo— typy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered, In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -‘ Hillside Hospital, the C. F° Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classes° Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho— analytically—oriented psychotherapy, This study was designed to determine the population character— istics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �..2.~ METHOD A census of all voluntary, adult patients in residence in the institutions was undertaken in January, 1959. While Menninger and Hillside HOSpitals had voluntary patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statuso The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrathospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample sizeso The �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. criteria for differed among At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res~ ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger HOSpital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systemso Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono �Table I Discharge Ratings of Improvement: Ratings of im~ provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)a For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsw Table B. II Inter—hospital Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having mOre years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Manninger did not graduateo c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight per~ cent with scores of 50 or above —- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attain— ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC Hospitalization: (68%) (Table IV), three insti~ tutions differed with regard to patient's length of stay (Table IV)9 Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per-cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization° b) Duration of The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diag— disorders, and �psychoneurosis and personality disorders (Table IV). The diag— nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the population° Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsidec Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods“ While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a yeare The Table —-—\ V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7), The —— Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psy— chiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, gig}, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his per— ceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners, Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions° Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria employedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been great— ly impressed by the methodological problems of studies across in— stitutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hos~ pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis'l to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective'' criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationw Inter—institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted direction. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc \Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. These differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo Such �REFERENCES l. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. Sanford, Brothers, R. N. The New Authoritarian Personality° York, 1950, 990 pp. J. and Harper and 2. Hollingshead, A. B. and Redlich, F. C. Social Class and Mental Illness: A Community Study. John Wiley and Sons, Inc., New York, 1958, 442 pp. . L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. Kahn, R. L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, G Ps h' Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, Sociopsychologic Voluntary Mental Discharge Ratings and is 565-574. Fink, M. Social Attitude (Cal— Scale) and Convulsive Therapy. .lefiflah_lkflflfi_Dlfi,, M. and 1960, lfifl: 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Ameri_la_£sxchiat., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete_Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociogsxchological Variables MEnninger Hospital N I Social Class III Hillside Hospital Massachusetts Mental Health Center IIIIIKEEIIIIIIHIIIIIEIIIIIIIIIIIIIIIHEIIIIIIII 31% 7% II 51 20 III 17 34 . . IV 1 34 V O 5 X 2 = 121.5; df=8: p<.OOl IIIIIIIIIIIIIIIIHNIEIIIIIIIIIIIHHIIIIIIIIIIIIIIIJBHIIIIIIII 19/ Ag e 20- 39 IIIINIIIIIlllllflflddflllllIIIIIIIHHEIIIIIIIIIIIEHIIIIIIIII Years of Educatio < 12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables jMenninger N Treatment Massachusett Mental Healt Center .m-m-mHospital Type of Hillside Psychotherapy Hospital Somatic Other =82 8 Duration of , Hospitallzatlon 7 df= 4 . .001 months 7-11 months ~11 months Discharge Improved Evaluation Unimproved X = Schizophrenia 29.3' df=4' .<.001 ' Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 52% 54% 22 17 26 29 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 30 40-49 30 20 50+ 36 MMHC 14 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Agg Below 20 Hillside 81 20-29 73 30-39 61 30 ho-h9 30 20 50 + MMHg �TABLE IV Interhospital Differences in Treatment Variables Menninger Hillside Massachusetts .m---Hospital N Psychotherapy Somatic of Treatment Type WW Other l Duration of Hospitalization Hospital Mental Health Center 9 21% 36% 2b% h3 6h 68 36 -- 8 » . _ . _..W.xi:82-8:.§_£:-hz P<-001 mud-Mm...“ w...» W 7-11 months x2=90.6; df=h; p<.OOl Recovered, Improved Discharge Evaluation f ‘> . 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Thane imfitndmmumfwfinbcmfiamlumpmdfln Wmmmdmbmmdmmmwmd. obtain mm Mammuammfinpmblmofflumdaulm 65.1ch data. But in style made it difficult to mmblc ofmantiwstafiatim,apocidlyinfiuommimofmmimie Mics. Mmofdismmfim,dimficfludflafimsor Mdmitmufimumminmmmwfiu to extensive of warm imtitutims mien countable popuhflms the m clan-1y m swim mm m for staff attitudn cad styhumllusocialclasspaminpatimtpomlafiom. cholicve mmfmmmommfiufaflmofmimfisummflm mbmmrmdmmimmmmmmmw sdmbmduudbymmiwmulu. Manudobmatimtobo Whamlnbomtmy,ttnmfimdsmmtavaflablctodaym mmmmmmmmrwmmmm. �-13- Inam‘asod attunticn must ho paid to tho althodblogiaal prcblumn of classifying mjom mlthads, so highly dnpgndant an m criteria institutional by ”objcativa" than the present and obonrvur attitudul mmmmmmmammm-pmmm. �Wmmnsxm 1. Infimowydmmic-mmmmgmfitnn, WWmmammmmmtm-hbm. Populatimsmdcflmdbyaomlelus,m,adumtimmfsm. mmmhmmtypoofumt,dmfimofhmpitmadm. Wwflmmmflm. 2. 3191131121“: inurhwfitutianl diffm m obscured in Wflmofpatimtsoahlelus,ymofodmutimm diuudbufimofcuifwml‘m,butmtago. mmmmmwummmum timmfmmbouigflfimflydifimtinmpmdicmd 3. dim. It. mmmmymammmnmnm mumtwithmmclusdflfmwmgimflmdmsmdm thuidiosynmtie. 5. matrmmmmmmummmof W,mumof)mpimnmim,mdmammultnbam mmwfimdtmmm,mmmdfmmobjwdw «imamimdmofmmfimsismim. �REFERENCES 1. Adorno, T.w., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New Brothers York, Harper R.N.: The Authoritarian Personality, 1950. Two-Factor Index of Social Position, Hollingshead, A.B.: mimeo— graphed publication. Mental and Class Social F.C.: Redlich, & New John Sons, Inc., Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: §g_p., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: 565—57h, 1959- (CaliM. M.: Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, fornia Scale) Kahn, 122: 187-192, 1960. Pasamanick, B., Dinitz, Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: tion and Its Relation to Diagnosis and 1959. 127-132, Amer. J. Psychiat., llé: Hospital, Siegel, N.H., Kahn, R.L., Pollack, and Treatment in Three M. and Pink, M.: Social Class, Diagnosis Psychiatric Hospitals, Social Problems, 10: 191—196, 1982. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved ~W‘_ Improved Moderately Improved Unimproved Slightly Improved Improved Unimproved Unimproved Syndrome .._.W Complete Remission Improved Unchanged (or worse) Markedly Improved W- �III TABLE InterhosEital Comparisons for SocioEsychological Variables Hillside Menninger ; Hospital Hospital Education 17 ’ (92) N 3 Score 1 i ’ F Massachusetts Mental Health ; 10-29 1 3o-h9 W7 51% i ’41 g (163) 33% 50 10 g i 76 20% 1 '1 38 } 50-70 8 1 i 17 g M �TABLE IV Interhospital Differences in Treatment Variables Massachusetts lHillside iMenninger Mental Health Center IHospital ‘Hospital ‘Psychotherapy of Treatment Type Somatic h3 Other Duration of Hospitalization 36 ’ 7-11 months 1 months Recovered, Improved Discharge Evaluation Much Improved 61 ’ . 'Unimproved 10 % I 9 . - _ mw.,,__,‘<2=29-3s df=1v fianQwawiwflj I Discharge Diagnosis tr-‘a-m-th-A _ ...-A.Wn‘.m Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde .W--- 85 Sh% 1? 26 29 ”- -.- —-”“— w- �TABLE V Duration of HosEitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside Below 20 81 h2 20-29 73 36 30-39 61 3O hO-h9 3O 20 50+ M9 �‘— ‘7 -w vuwlr-u'rflmmm —-u-- “Tm—“vii W Hm: W. 21, man 911.13. Hill-M- Wu}. P. 0. Dan: 33 man Odes. the You: W81 , mm. mm mmmlht: MWWIMBWMbyaWo-n I whammmm'mmmmmmrmunm. Midwinbutlmzldlfluewrymm IMMMM Mtfizhfwwblmw . Wumflulntdmfimfm Wh.metMtoajml,ImflAlihto$smm-d Hm,I mmmmwmuwmmm. singlubmmtittoamoffiujwmmmwm to . 81 FILE. ‘ ‘ mm,mmmqumummxwmt mwmumwtm-mmdtmjmw. WWW. ma: �flv psychiatric treatment, haMflm and research December 2h, l96h Dr. Max Fink Missouri Institute of Psychiatry Shoo Arsenal St. St. Louis, Missouri Dear Max: (E) / (:> let, the have reread I In reply to your letter to and objections my original paper on sociological aspects the skirts I feel no altered. it in way this paper are whole problem of diagnosis which Nat in a previous paperwhich and than social class, has shown to be more ;important True, variable. be crucial a VA showed to I in the paper disturbed more severely younger same institution within the of time period a and longer for kept patients are treated and all this is relative to the philosophy of the the in not reported at all is This viewpoint institution. paper. form. in present its of in publishing favor not it I am Should you have some specific need for seeing it published, removed. was name my providing no objection I would have collaborate to want should you authormanship, of Speaking variables and psychological EEG and psychiatric on the findings I would have no objection. My best wishes to you, Martha and the kids for a Joyous New Year. have him I and Turan to tell Please give my regards ordered a copy of his book. Sincerely yours, of the 10m»; MP:gp Pollack, Ph.D. Senior Research Associate Max �m 21, 196‘! mmmrmtmmmgm-ormw;md fdfluMdmmm-Jmlofwmommfia Mfllhdmlafhyuhhm. mfiwmhfin ”magma-mum. hmmhmyw. and: Enema-mu cc: Pollack Ph.D. Nathmial siegel, Ph.D. Max �MONTEFHMHCHUSPVRHJAND MEDHLMACENTER 111 EAST 210TH STREET. BRONX, NEW YORK 10467. TELEPHONE: 212/TU 1-1000 January 19, 1965 Fink, Director max M.D. Missouri Institute of Psychiatry suoo Arsenal Street St. Louis, Missouri 63139 Dear Max: I think the paper is fine, and would touch it as little as possible. Your choice of Journal is excellent. For my part, go ahead and submit it. The only change concerns the here - "Mbntefiore Respital and Mbdical Center" and the revised address as revised name shown on this letter. It to see you and I pleased that you are doing well. was good am Best regards to Martha. Sincerely, RLK:FB Rdbert L. Kahn, Ph.D. Head, Section on Psyology Division of Psychiatry �DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 December 31, 1964 NATIONAL INSTITUTES OF HEALTH AREA CODE aoI TEL: ass—mo In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink, Director Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: I was pleasantly surprised to see the paper on "Sociosociological Aspects of Psychiatric Treatment in Three Voluntary Hospitals" again. I was really delighted that you resurrected it and have taken responsibility of submitting it to one of the journals that you listed. I have no real preference for one of various journals that you mentioned. I would think it would be most unlikely to be published in Psychiatry, but I am sure you share this opinion since you listed it last in your order. In all honesty, in rereading the manuscript, I found it to be much better than I remember it. Most of my comments are of a stylistic nature. Here, however, I would bow to you as the collator of the document to use the style that you prefer. My own penciled comments are, however, on the paper. V/ I think the main contribution that this paper has to make, and should make, has to do with the methodological problems that are involved in doing cross-hospital studies or in doing hospital studies within the same institution over a period of time. As you indicate in the paper, on page 4, that when one reports studies from one institution, the structure of the hospital is either taken for granted or ignored. Cer— tainly, we should be elaborating on this in great detail, and the methodological aspects of doing a study, such as the one we have done, Should occupy a major area of the report in its own right. For this reason, I am not sure I would report methodological problems as we have done on page 4. I think that it should either occupy a place of its own in the discussion or might indeed exchange status with "AH Interhospital Comparisons on page 4, and become the "A" category, or interchange and make Interhospital Comparisons the "#1" category. Most of the things that we want to say are in the paper but, as I have indicated, I am a �2. little unhappy about interweaving our "findings" with the "methodological not being our intent in the original investigation in the also, report. more I, important the I being think ...and, yet, would I of the author be try to should senior paper. believe that you own in and autonomy right its give problems it methodological the spotlight Section." "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/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. 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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/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/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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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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Rejec’t' “1 ram 13 0 ~ 1 o 7 11 3 ° ° 9 11 O1 1 ll] o 57 - 70 7 8 001.23/3 35 > li $7, 2312 Col. 1 ‘1 IJ" | 1 7/01.} TALLY SHEEP 601.26/1 ‘7 ,..,2 Deckf - D11 1 0 1 1 ‘ 0 . / 9 4 . 75" 0011.29/8,9. {Mama 1%‘5‘5 I! I 2 391 3 5 1h 0 o Reject O 5‘3 20111.11 X 11601.26/1 // 2 3 _ — 0. Asa .0 as: 1 111: 1 1 1 35‘ 115 a - r 16 - _ o 1 W—‘i— 01.1 Re I .9.— 1. 9‘ 11 .3- " M-w—«efim 0 H ect 1mm. 01 77 1 55 “_~_ 53 f �Dock: I , “BALL! Qilvcéév 31‘ comes/1 . , 2 a?” sum sol-23k ,Gol.23/1 ” _ 001-23/3 17 3 O l 20 6 . O , O mutt» ‘00“ 6 3 o 3 3 O 33 3 o Reject ICE“. 7 O 3-- o �f x 7“ ,/;.!,/, fl _ TALLY SHEEP g/ 001.2611 ‘7 57‘7“.”— ' 001,237.! 7‘1"" 1" a ! 'i , /’ , 16 h ’* J 5 u fl 7 ,. . ”J--. ., x . . o. V- o . o 2 ~_ - V 0 . 7.1.07 , 0 _-. J ‘1‘ 36 7 , 0 a “I, 74.,47445 Co1.23/3 ‘ 7 ,. Q- . V I 5 7 35"“! 7,001.23/2' 1...,_ 27 . J fiYlI ‘, 2 " bro" Decks" I 16 , i t. .. . . - 57 . . 0 0 , - 13. O I [4' 7 7 II 8 9. 7-07 ll l V 0 I. iii Owfil" Reject H warm. ” “I": afia’ .. ‘ , , . I V. O 0. II. 3 0 O ~ A - D _ .. ~ - , . O , , . - H 4 ’9. {IV/J '11.: farm/1:22.— , , , , .16. , 9 69.19.2311... - . 2 .39.-. 3 S - -h- .0 o Reject MAL X 5‘3 // 2 not“ - .3 - .0 V J.» V. 5 . .35‘ - 0 8' 7 ‘ C? .o . m____9__ 0 f _. - Reflect - __ . . 43 ,a .0 _._V ., 3 , O A -601026/1 - limo), 001.29/8,9. Duh“ - ,, 55 .9— .V 9‘ - .. ,3- «wag—m... 53 / �-3Menninger Hospital, however, a higher percentage (19%) of patients called rated as "unimproved" and only a single patient was "recovered" or "much improved". The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health were Center. d) Diagnosis: For statistical analysis three diagnostic groupings were made: schizophrenia, affective disorders, and psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside in that slightly over half were diagnosed as schizophrenia and approximately one-quarter as psychoneurosis or affective disorder. In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. and MMHC -‘---------’ Table B. Intra-Hospital Comparisons l. Methodological Problems The a IV intra-hospital statistical comparisons variety of methodological problems. of meaningful statistical cut—off were limited by Most prominent was the lack criteria for the subdivision of populations, in part due to the homogeneity of the population within each institution and to the sample size. In the statistical analyses within a single institution several cells were obtained which had �Page 5. COMMENTS BY PSYCHIATRISTS Most of the unfavorable (1) (2) more insufficient " criticism can number of " " be divided into two complaints: sessions per patient paid for by Project patients point, many apparently feel the Project should advertise itself to its eligible subscribers, reminding them of the availability of coverage. 0n the second Favorable criticism was in general directed at expressing approval of the idea of testing psychiatric insurance. There were in addition a surprising number of complimentary remarks about the planning or administration of the Project. SUMMARY typical participating psychiatrist is a man between 35 and 50, practicing in Manhattan. He treats patients in the hospital as well as in his private office, and he also does some clinic work. He has his "Boards" in psychiatry. His usual office fee is $20 or $25. His primary orientation in his practice is analytical and psychological. This does not preclude his prescribing drugs or shock therapy. The interest in the Project is demonstrated by the fact of his participation. If he has some adverse criticism, it is apt to be directed at the number of sessions allowed, which he regards as insufficient, or at the small number of patients who have sought care, which he regards as a reflection of an inadequate educational program. In short, his criticism is generated by his tendency to view the Project as a social rather than an insurance experiment. He feels the Project, Operating in an area where the supply of private psychiatric time apparently exceeds the demand, is in a unique position to promote more psychiatry for more people, which is what he really wants - insurance or no. His APA-NAMH-GHI RESEARCH PROJECT August 30, 1960 �MWQQIPWZMMMWMS. mmuummmumuaumm umm-mmmyutnwmuum mmmummmammw «mummy-"um. mmumtmmmuwm mmnm.mumn nun-1 mm m "WW nu» M m mnflMmMWmuumu-m ml; Wax. m- 1: m», W‘s: ”.mtunmwmmtm.mm Mnmw‘um. mam. uanwmmum.nm ��~19. tut Oil. innfiltution urn vniulruhla ‘u individual dittorunaai among uxaainera.) uwdflflflh‘b an“ “it Tabla fittings at infirOth neat variad in tornat uad antltl. MIR #3: triptrtit¢ Yb: diaahtrmc with a toynrtta cvtlnntion aburnctaralugi¢nl and buhnvtoral changnt. it wan dattianlt tar rating at toc&31, 3R and name had cltbnl ratings in which tribution at taator a: th‘ fldngiaaar first.» (tabla II). 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At HIE payohothorupy can designated as ilturod trc;;noat ndm1n~ procertpttan btllu by a otntt paychiutrict, for which tun pationt wan chargcd t I... Stadium. wi‘h in. puychtatrie rolid¢at wort Ionatdorod part of routtuo Idninistrntivu patina: cure. xx it paythothorapy val defined at transient nautical with thu psychiatric recidont. Stat: paychintrista did not trutt paticnta, but rtatriétcd thotr no£1v1ttul to auporvtstac tht ruaidcat physicianl. At the lane psychathornpy was donixnttod u. 1 function 0! many disciplinol .. pljchlltrie runtdontl, pnyoholoututo. loclnl nurture, nurses and :ndtc;1 studonta. Furnnl record: or Inch caution. var. not routincly includnd 1n the pt‘tcnt'c rcoord and to ‘lccrtuin which pationtc rcccivcd psychotherapy, the resident 1n «Egret or ouch ctno van intervicwed. b) an noun Individual Institution}. Guano-tn Itylou Illa and. saupnriaona difficult. 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E fl m” he 4, ~ ' :'*13I:§ ‘ «a 9".”‘ 1“ 31-3 9 ”‘03:: at" .1 it'We” it”$001 “it" 90. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Social aspects of psychiatric treatment in three hospitals: methodological problems. VA Cooperative Studies in Psychiatry, 6:202-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59-001 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; Siegel, Nathaniel; Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 9 items. 1: Photocopy of publication with Q & A. 2: [preprint]. 3: Draft. 4: The Identification of Patient Populations: Comparability of Subjects in Evaluating Therapies Among Institutions by Max Fink, M.D. 5: The American Psychoanalytic Association Summary and FInal Report of Central Fact-Gathering Committee. 6: Correspondence. 7: Handwritten notes. 8: Social Class. Diagnosis, and treatment In Three Psychiatric Hospitals. 9: Research, drafts, and letters. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/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. 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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/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/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/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/de95bf5b301da53b216f4fe5fa8c04dd.pdf c38414ee0bbef11434639b42d1daddd0 PDF Text Text Reprinted from the A. M. A. Archives of Neurology (“7 Psychiatry November 1957, Vol. 78, pp. 516—525 Copyright 1957, by American Medical Association Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshoek Quantitative Serial Studies MAX FINK, M.D., and ROBERT L KAHN, Ph.D., Glen Oaks, N. Recent theories of'electroshock therapy 1'3 have emphasized the role of neurophysiologic changes as. the basis for the therapeutic ac— tion of electroshock. Consistent with these theories, we have observed a relation between changes in certain measures of brain function and behavioral response. We have noted that evaluations of clinical improvement fol— lowing electroshock are related to changes in orientation and confabulation after intra— venous amobarbital,4 learning and recall,5 and syntactical aspects of language.6 In view of these observations, it could be expected that electroencephalographic studies would show a similar relationship. Numerous observers have reported consistent changes in the electroencephalogram after electrically induced convulsions. There is diffuse slowing with increased voltage and dysrhythmic activity?"12 Fast activity decreases, both in voltage and in percent time}3 and in patients who are intensively treated there is a slowing of persistent alpha frequencies.14 The degree, duration, and extent of delta activity are directly related to the frequency and number of grand mal convulsions?"14 Such activity is usually symmetric and appears maximal in anterior leads, and the electroencephalog— Received for publication June 18, 1957. From the Department of Experimental Psychia— try, Hillside Hospital. Presented at a meeting of the Eastern Associa— tion of Electroencephalographers, Washington, D. C., September, 1955. Aided, in part, by Grant M—927, National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Dalian Foundation for Medical Research, New York. Y. raphic effects usually disappear in the four to eight weeks following the last treatmentfgi9 In contrast to the consistency of these observations, studies of the relationship between the electroencephalographic and the clinical changes show conflicting results. Chusid and Pacella,15 after an extensive review of the literature, concluded that the number of treatments rather than the degree of induced delta activity, was the primary factor related to a favorable therapeutic re— sponse. On the other hand, Hoagland et al.16 reported a relation between changes in the percent time fast activity (more than 13 cps) and independent clinical ratings of be— havioral change._ Roth2 similarly reported a relationship between changes in the clinical state and alterations in the delta response induced by intravenous thiopental sodium. The divergent observations reflect variations in methodology. The present study is an attempt to apply quantitative methods of analysis of serial electroencephalographic records to this problem. The purpose of this study is to determine (1) the relation of changes in electroencephalographic delta activity to the behavioral response in electro— shock, and (2) if a relationship does exist, the significance it may have for an under-standing of the electroshock process. Subjects and Method 1. In the initial series, 24- consecutive patients referred for electroshock were studied. Electro— encephalograms were obtained prior to treatment and at weekly intervals during and after treatment, using an eight—channel Medcraft electroencephalograph and needle electrodes. Recording was bi— polar, and hyperventilation activation was utilized 516 ,. “(34.x �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE during each recording. During the treatment pe— riod, records were taken on the day following a treatment, generally 25 to 31 hours later. Grand mal electroshock therapy was administered by staff psychiatrists, using a Reiter C-47 electrostimulator. Treatment schedules were three times a week, and the number of treatments varied from 9 to 33. As patients showed a clinical response, the psychiatrist tended to give fewer and more widely spaced treatments. There were 15 women and 9 men in the series, and the ages ranged from 24 to 68, with a median of 47 years. Evaluation of EEG Records—A total of 160 records were obtained on these subjects. Following the suggestion of Strauss,17 the delta index was determined for three lead combinations (frontal— parietal, anterior temporal-vertex, and parietal-ear lobe) for 60 seconds of recording for each lead. The delta index is defined as the percent time occupied by waves of 7 cps or slower. The run of each selected lead combination was scanned, and 180 cm. (60 seconds) of recording that was artifact-free was noted. An additive map measure was run along the base of all waves of 7 cps or slower, determining the number of centi— meters occupied by such slow activity. The ratio of this figure to 180 was the delta index of that combination. ’ After these measurements were made, the rec— ord was scanned for the slowest frequency clearly The total record was also scanned for burst activity. The duration of burst activity, the regularity (modulation) of the waves in the burst, and average voltage were noted. In the final estimates of degree of delta activity, the average delta index for the three lead corn— binations, the highest delta index in any one lead, the slowest frequency, highest delta voltage, and duration of longest period of burst activity were listed for each record. The 160 records were ar— ranged in sequence for each index and the per— centile rank determined. The ranks were added and the records then arranged in rank order ac.— cording to this score. On the basis that the higher score reflected a greater degree of delta activity, the upper third of the records was classified as “high—degree delta”; the middle third, as “moderate-degree delta,” and the lowest third, as “lowdegree delta.” An example of each is shown in Figures 1, 2, and 3, respectively. High—degree delta records were characterized by an average delta index of at least 18%, a delta index of 21% or more in one of the three measured leads, a slowest frequency of less than 3% cps, a highest delta voltage of more than 100pv, and a burst duration of at least two and a half slow waves. LF-LO WWWAWWWNIWW WWW RF'RO LAT- LPT WWWVWWW RAT-RPT WWW/WWW PRE-EL seconds. Low-degree delta records were characterized by an average delta index of less than 2%, a highest delta index in one lead of 3% or less, frequencies no slower than 5% cps, voltages of less than 60pv, and burst duration of less than one—half second. W “WW W W identified at least twice in these selected lead combinations, and for the highest voltage of these R P‘E AMNVWWWNVW L F _ LO «wanjVMImWW-flm WMWMWMMW RF- RO awmwwm WW LC-LMT LC-LMT RC-RMT “WW RC-RMT LP-E WWW WW RP-E RP‘E WWWNAMMMMMWMW WWW WWW LAT' L PT LAT-LPT RAT-RPT PRE- ELECTROSHOCK ISECOND , 24 HOURS AFTER EST Fig. 1.—Low-degree delta activity. Fink—Kuhn I50 M, it l2 5-17 . ‘ WWW RAT-RPT WWW PRE-ELEC .mafi-” _,__._---_., __..-_t r-.- 518 �vs WWWWfi ., .v. h A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY LF LO WMWWWWWW WWWWWWWW LC-LMT WWW RC-RMT LP-E KEN-W LAT- LPT WWWWWNWWNWMNA W WWW»! I RAT RPT VWVWWNWWWWWWNwWV‘WWW/wm PRE-ELECTROSHOCK 24 HOURS SECOND 1:5on AFTER EST 4* IO Fig. 2.—Moderate-degree delta activity. L F “ LO WWEJVANWWWJWWWMk/‘W‘mgfaNJWW‘AMW R F - RO JVWMWWWWAW WWW LC'LMT RC-RMT LP-E WWW-”WW . RP-E WWW“ LAT- L PT WWW RAT-RPT PRE-EL ECTROSHOCK WW ISOMV WWW/meflwx 24 HOURS AFTER EST 4* M Fig. 3.—High-degree delta activity. 518 Vol. 78, N07J., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE I Moderate-degree delta records were between these two groups, with an average delta index between 2% and 18%, a highest delta index in one lead of 3% to 20%, a slowest frequency of 4-5 cps, high— est amplitude of between 60yv and 90,uv, and burst duration of one-half to two seconds. 2. In a second series, of 54 consecutive, unselected electroshock patients, electroencephalo— graphic records were obtained prior to treatment. during the second and third weeks of treatment, and two weeks after treatment. These records were analyzed using measures identical with those in the initial series. Using the original cut-off points, these records were classified as high-, moderate—, and low—degree—delta records, and the initial observations were tested in a predictive study of therapeutic response. Evaluation of Clinical Response—All patients were observed for at least eight weeks after termination of therapy. The patient’s response to electroshock was determined on the basis of the resident psychiatrist’s impression, the staff opinion, the nurse’s notes, and the clinical evaluation of the supervisor in charge of electroshock. The patients were divided into three groups—much improved, moderately improved, and unimproved—according to the following criteria: A. Much Improved: The 11 cases in this group were regarded as showing recovery or marked improvement. These patients no longer presented the symptoms which brought them into the hospital; their doctors felt they were better, and the nurses’ notes confirmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with others and participate in hospital activities. B. Moderately Improved: The six patients in this group showed some improvement but continued to manifest symptoms of mental illness. These patients typically showed symptomatic relief; i. e., acute depressive features might be gone, but the dramatic change, so evident in the first group, was not apparent. Each patient continued to show some noticeable disturbance, such as obsessional thinking, paranoid ideas, or somatic preoccupation. C. Minimally or Unimproved: In this group were placed seven patients in whom change was not clearly noticeable, who showed equivocal or transient changes, or who became worse. They showed fluctuations in behavior, at times appearing less ill. The changes were not sustained, however, so that by the end of treatment they appeared much as before. activity and clinical ratings demonstrated a significant relationship between the early ap— pearance of high—degree delta activity and the “much-improved” clinical ratings. Of the records in patients who were rated as much improved, 80% were classified as high—de— gree delta in the second week, 91% in the third week, and 88% in the fourth week of treatment. Of the records in patients who were rated as unimproved, none showed high—degree delta in the second or third weeks of treatment, and only 20% were classified as high—degree delta in the fourth week. The data are expressed in Table 1 and graphically in Figure 4. TABLE 1.—Electroencephalographic Percentage of High-Degree Delta Records Degree of EEG Delta Activity and Clinical Ratings.——The initial analyses of the relation between the degree of induced delta F ink—Kahn 1. MUCH IMPRO +——Moo. IMPRO\ 50_ .---- UNIMPROVEI TIME A ‘13 A. 4‘“ PERCENT o: C? -.__~_ ,. m <.3 AVERAGE ...__.—_____.-._, c3 MEAN WAVES I50} .—- MUCH +——Moo. IMPROVI IMPROVI ---~ unmpnovso DELTA Treatment Period Much improved (11) OF 1-8 4—6 7—9 10—12 25 80 91 88 Moderately improved (6) 0 16 50 40 Unimproved (7) 0 O 0 20 IOOAv AMP(LITU)DE u- c.’ HIGHEST Indices and Clinical Ratings.——An analysis of the relation between each of the five indices used in the final estimate of the degree of delta activity and the clinical ratings also show significant correlations. In Figure 5A to E, each index is related to the number of convulsive treatments and the eventual therapeutic evaluation. The curves 2. Delta OOACTIVITY 90. 80- DELTA MUCH IMPROVED .—— M00. (III IMPROVE-10(6) ._-— UNIMPROVEDU) ‘ 70' 60‘ DEGREE 504 HIGH 40‘ 20I 0‘ o. O / '\. / 3O~ PERCENTAGE Results DELTA / I-3 / / ' / 4-6 __/' 7-9 NUMBER OF TREATMENTS MEAN L Fig. 5.—A-E, rt each index of delt: ' \\ /' / IO'IZ Fig. 4.—.Re1ation of clinical ratings to development of high—degree delta activity. 519 for the highest—am 5C) and the slow are most similar tc of delta activity ( The other three clearly differentia group from the p2 520 �/\ A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY f3 __J g . MUCH IMPROVEDUJ) IMPROVED (-6) 50_ pgmoo. o----UNIMPROVED(7) < 60’3 . w 2 40- E ,: PD 4 z as. 8 a: ling a: 30m a. aLu > ‘1 qz m 2 - lO- . _,e-’::.—// 0 "5' .V / U 3 :5 .J, Lu o a- //’ 53 a +— m u: I I9Z < g O 0 ________-_ . .......... _______ o 8 g 2 3 g 4§ E g. x «e —«' w D- W to 5 onZ I 4-6 ’ T 7-9 " IMPROVENS) .._.. UNIMPROVED(7) ' T IO-IZ ' -. ' —-—:—-—-"/ ,,«+ / / / {,x’ ”x” 5~ .t’ ----/’/ ,./ " /‘ ,xf “i3u Q (ll) MUCH IMPROVED o——MOD. Z 6-3 IL] +,.__._-,——‘ 0— 3- 6- a2 . 1—3 I 7-9 ----' C OK. 100- 50- ' 4—6 IO-‘IZ I50- ._Muc|-.1:|MPROVED(II) +——MOD. mpnovsom) ,_.- ummpaovso m 0 IL V" T I _. 7-9 A <>K //i1/ ------- °- -----MA’65... x 2 1m 5 NUMBER! OF TREATMENTS (I) . /// // i 2 . NUMBER OF TREATMENTS 4-6 1-3 3 ‘2 /+ ,, ........... ., -—-“"” ’4' , ‘ A -------2’ a: I l— // /" 20 o IMPROVED(II) 0--MO‘D. IMPROVED (6) °~--~U~NIMPROVED(7) LU p— {‘3 -— MUCH m D . o ‘‘‘‘‘ ———— -4fi‘” 415 1-3 719 NUMBER OF TREATMENTS 7 r D I0--I2‘ NUMBER OF TREATMENTS B .9. g 7‘ 3a: 6‘ m n: lL , .9 ,r—e ' -— MUCH IMPROVED (u) +——MOD.IMPROVED(6) o----UN‘IMPROVEO(7) l0-l2 '\. I A .m 5.. 22 9 8 4— .— Fig. 5.—A-E, relation of clinical ratings to each index of delta activity. 33. 3: 3o V 3-. z a 2 2a l _ . I” +’/” //’ “““ ---------- o-""" .fiu‘idifi“ , a _ O O ”_‘..—°V ° I ‘l ‘l l. l-3 4.96 7-9 IO‘IZ NUMBER OF TREATMENTS E for the highest—amplitudedelta activity (Fig. 5C) and the slowest frequency (Fig. 5D) are most similar to the curves for the degree of delta activity (Fig. 4). The other three indices (Fig. 5A, B, C) clearly differentiate the much improved group from the patients with the other two 520 ratings, but fail clearly to distinguish the moderate and unimproved groups. With in— creasing treatment, however, the separation of classes becomes clearer. Each index of delta activity, therefore, demonstrates a relation to the eventual short— term clinical rating which is much like that Val. 78, Nov., 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE TABLE I i/ " . ” Average delta 2.—Interc0rrelati0ns of Individual I ndices and Degree of Delta Activity - - Average 63%qu Longest Dfifiiéi‘é“ 350831153 +0.72 +0.67 +0.80 +0.72 +0.68 +0.84 —0.78 —0.47 -—0.90 Delta One Lead FkZVJSEEy Afiié’fiiie - +0.98 —0.79 _ Degree Highest delta in one lead +0.98 _ —0.67 Lowest frequency Highest amplitude —0.79 —0.67 __ +0.72 +0.72 —0.78 -- +0.57 +0.88 Longest duration bursts +0.67 +0.68 —0.47 +0.57 __ +0.63 Degree of delta activity +0.80 +0.84 —0.90 +0.88 +0.63 -- demonstrated for the combined index of de— gree of delta activity. The intercorrelations of each of these in— dices are shown in Table 2. All correlations are significant at better than the 1% level of confidence, although the highest correlations with the degree of delta activity are noted for the frequency and amplitude measures. The lowest correlations are noted for the duration} of burst activity. These observa— tions indiCater that in future studies or in clinical application frequency response and amplitude changes may serve as criteria for the degree of induced delta activity. 3. EEG Delta Activity as Index of Clinical Outcome—Following these observations, a study was undertaken to determine whether the degree of delta response was predictive of the short—term therapeutic outcome. On the basis of the observation that the much improved patients had developed high—degree delta activity early and had sustained such activity, electroencephalograms were obtained during the second and third weeks of treatment 011 54 consecutive electroshock patients. The records were scored as to whether high—degreedelta activity was achieved dur— ing both, one, or neither of the four—six and seven-nine treatment periods, and the data TABLE were Both high (18) 12 (67%) One high (16) 4 (25%) None high (20) 6 (30%) * (Table 3). Of the patients who manifested high—degree delta activity during the second and third weeks of treatment, 67% were rated as much improved, while only 30% of patients with- . 1 out high—degree delta activity were so rated. Thus, the early induction and persistence of high-degree delta activity are seen to be re— lated to the short—term clinical evaluation. Comment The present study demonstrates a con— sistent relationship between the degree and duration of induced electroencephalographic delta activity and clinical evaluation of behavioral change. While it is conceivable that the difference between our results and previous reports may be due to a variation in population, it is more likely that methodo— logical aspects are important factors. Serial records were obtained during the course of therapy, so that the sequence of electro encephalographic change was evident. The records were obtained at a constant time in— terval following a treatment. Finally, quantitative analyses of the records were made instead of relying on clinical impressions. Of other investigators of this problem, both Moderately Improved 2 (11%) 8 (50%) 4 (25%) 7 (35%) 7 T ship between ind havioral respor therefore, perm changes in the o attendant alterat the physiologic process.* A simil. by Roth 23 on the *The Unimproved 4 (22%) ac’tivity.18’21’22 we. biochemical received limited stu on acetylcholine-chi tion in blood—brain and protein equilibri without definitive C( (35%) Significant at the 2% level of confidence. Fink—Kuhn the induced neu1 behavioral respoi these observation of action of elect 1. Relation ofi Behavior.—Beha accompaniment function. Chang tude, judgment, and insight atten tion, from what extensively docu literature. In this study, e consistently to alt in a fashion whic with states of altc studies of Davis Strauss,19 Ostow have affirmed the activity as an in< tion. Symmetric, has been interpre tion of midline centrencephalic s also indicative oi of consciousness being directly rel: tude, and freqi related to the clinical evaluations. Clinical Rating Much Improved 21 further elaboratii 3.—Patients with High-Delta Activity During Second and Third Weeks of Treatment* EEG Delta Roth 2 and Hoa out systematic E to demonstrate variables and be] Two aspects oi 521 522 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY Roth 2 and Hoagland et al.,16 who carried out systematic EEG analyses, were also able to demonstrate a relationship between EEG variables and behavioral changes. Two aspects of these observations warrant further elaboration: the relation and role of the induced neurophysiologic change to the behavioral response, and the significance of these observations for a theory of the mode of action of electroshock therapy. 1. Relation of Neurophysiologic Change to Behavior.—Behavioral change is a consistent accompaniment of alteration in cerebral function. Changes in mood, language, atti— tude, judgment, thought process, perception, and insight attend changes in cerebral function, from whatever cause, and-- have been extensively documented in the neurologic literature. In this study, electroshock has been shown consistently to alter the electroencephalogram' in a fashion which we have come to associate with states of altered cerebral function. The studies of Davis and Davis,18 Ostow and Strauss,19 Ostow and Ostow,2‘0 and Jung 21 have affirmed the significance of diffuse delta activity as an index of altered brain func— tion. Symmetric, dysrhythmic delta activity has been interpreted as evidence of dysfunc— tion of midline hypothalamic centers—the centrencephalic system?9 Such activity is also indicative of an alteration in the state of consciousness, more marked alteration being directly related to the duration, ampli— tude, and frequency of the slow—wave activity.18'21’22 The demonstrated relation— ship between induced delta activity and beafter electroshock, havioral response the conclusion that therefore, permits in the centrencephalic system with changes attendant alteration in consciousness are the physiologic basis of the electroshock process."< A similar conclusion was presented by Roth 23 on the basis of his studies of the *The biochemical substrate of this process has received limited study. Emphasis, has been placed on acetylcho-line-cholinesterase change,”25 altera— tion in blood-brain barrier,8 and changes in ionic and protein equilibria 26"” by different investigators, without definitive conclusions. 522 effect of thiopental on electroencephalo— graphic delta activity. Another example of the relation of the electroencephalographic delta activity to be— havior is seen in reports of epileptic patients. Landolt 28,29 describes a young epileptic who was ordinarily pleasant, friendly, and cooperative for his clinic visits. At these times, records were consistently dsyrhythmic. On one occasion he was surly, irritable, and withdrawn, and his EEG was without delta activity. On the subsequent visit, the EEG was again dysrhythmic, and a behavioral “improvement” was noted. Similar observations have been reported by Brockman .et £11.30 and Fabing.31 In a previous study4 we had applied the amobarbital test for brain disease 32 in a serial fashion to this group of patients and reported a relationship between changes in this index of cerebral function and be— havioral change. Were other tests of cerebral function to be applied in a similar fashion, it is anticipated that these, too, would demon— strate consistent changes during treatment and a relation to behavioral response, within the limits of the sensitivity of the test to reflect changes in cerebral function. In this context, electroshock may be said to be a method of inducing a state of altered brain function for extended periods, in order to achieve changes in behavior. From this point of view, the development of a significant degree of electroencephalo— graphic delta activity may be a readily determined guide in the rational management of electroshock therapy. In these studies we have examined various delta indices and/or the intercorrelations and have noted that the amplitude and the frequency of the induced slow waves are the best guide to the degree of delta'activity. In patients in whom the behavioral response to electroshock is inconsistent with the therapeutic expectation, examination of the electroencephalogram may provide a criterion for clarification. If the induced slow—wave activity is faster than 4 cps and lower than 100,u.v in anterior temporal—ear lobe or anterior temporal— frontal lead combinations, then there is Vol. 78, Nata; 1957 �EEG DELTA ACTIVITY AND BEHAVIORAL RESPONSE presumptive evidence of inadequate electro— shock therapy. When frequencies less than 3% cps and voltages higher than lOOuv are maintained for a number of weeks, the assumption may be made that an adequate degree of altered brain function had been induced and that other factors (environ— mental, personality, pathophysiologic) were operating to preclude a favorable behavioral response to electroshock. A similar applica— tion can be made for amobarbital tests 4 or syntactic language after intravenous amobarbital.6 2. Theory of Electroshock Action—These studies of the electroshock process have demonstrated that alteration in brain func— tion is induced early and is sustained in patients in whom the greatest degree of behavioral change is noted. We have em— phasized high—degree EEG delta activity and positive amobarbital tests as indices of altered cerebral function, with the knowledge that other indices of altered brain function, applied in the same serial fashion, may also show significant alterations and a relation to behavioral change. We have been impressed that the ratings of improvement are value judgments of the behavioral response. All patients in whom cerebral changes are induced by electroshock manifest changes in behavior. The range of behavioral patterns induced under these conditions is wide. Only certain patterns are evaluated as improved, however, while others are regarded as “unimproved.” “Improvement” is a special case of behavioral response, being a subjective evaluation on the part of the observer that the patient is “better.” Electroshock does not induce “improvement”; it induces a milieu of cerebral activity in which behavior is different than before electroshock. To the extent that the induced behavior in depressed patients is perceived as less complaining, depressed, agitated, or anxious, or in schizophrenic patients as less delusional, hallucinatory, or excited, the patient is evaluated as “im— proved.” When behavior, however, is per— ceived as anxious, agitated, paranoid, complaining, or withdrawn, it is evaluated Fink—Kahn as “unimproved.” The particular type of behavioral pattern induced by electroshock is dependent on a number of factors, such as personality.33 Another aspect of the rating of improvement is the environmental response to the induced behavior. The modification of mutism, withdrawal, and negativism to excitement, overactivity, and irritability may be considered a positive movement by the therapist but a disorganization by the ward physician or family. The goals of the therapist and the family, and their expectations and tolerances, are significant factors in the behavioral response of the patient to therapy, and, also, in the ratings of improve— ment. These same factors are significant in the duration of the electroshock effect. The in— duced change in cerebral function persists for only two to eight weeks following even intensive courses of therapy. In many cases, the behavioral response is limited to this period of altered brain physiology. When in— duced changes in behavior are not adaptive in the milieu of the patient, the behavior reverts to pretreatment patterns. In other instances, the induced behavior is adaptive to the environment, and, we assume, sus— tained thereafter not by the initial change in brain function but by the newly developed interaction of ‘the subject with environment. That this is indeed true is seen by the fre— quent successful adaptation of the patient to the hospital milieu after electroshock, only to have a recurrence of symptoms when dis— charge planning is discussed or discharge is consummated. Altered brain function provides the physiologic milieu in which there is an altered interaction with the en— vironment—the doctor, family, or society. These observations lead to the conclusion that electroshock therapy is a nonspecific induction of persistent states of altered cerebral function. Such altered cerebral function provides the physiologic milieu for an alteration of the organism’s adaptive interpersonal behavior. Changes are in— duced in perception, language, mood, recall, and judgment which constitute a mode of 523 interaction with of behavior indu is dependent up subject, the envii action occurs, an of altered cerebrz A similar View was initially exp and Kahn,1 who tionship of neu: behavioral respor electroshock pr0( the observations Aird et al.3 The neurophys tion of electrosh( definition of the of further elabor: a hypothesis also standing of ther coma therapy, 1( agents. j Summary Serial electroe: weekly intervals referred for elect analyzed for the A significant tween the degrec delta activity an( behavioral chang firmed in a predi 54 patients. Differences bi those obtained It terms of differen A neurophysi tion of the electrt It is concluded t] specific inductio: altered cerebral physiologic miliei tive interpersona Improvement as a special case c these conditions. by an observer factors, including 1 r' 524 �A. M. A. ARCHIVES OF NEUROLOGY AND PSYCHIATRY interaction with the environment. The type of behavior induced under these conditions is dependent upon the personality of the subject, the environment in which the inter— action occurs, and the duration of the state of altered cerebral function. A similar view of the electroshock process was initially expressed by Weinstein, Linn, and Kahn,1 who emphasized the interrela— tionship of neurophysiologic changes and behavioral response. This description of the electroshock process is also consistent with the observations of Ulett et al.,34 Roth,2 and Aird et al.3 The neurophysiologic—adaptive interpreta— tion of electroshock provides an operational definition of the process, which has promise of further elaboration and observation. Such a hypothesis also has application to an under— standing of therapeutic process in insulin coma therapy, lobotomy, and tranquilizing agents. Summary and Conclusions Serial electroencephalograms obtained at weekly intervals in 24 consecutive patients referred for electroshock were quantitatively analyzed for the degree of delta activity. A significant relationship was found be— tween the degree and duration of induced delta activity and the clinical evaluation of behavioral change. The results were confirmed in a predictive study in an additional 54 patients. Differences between these results and those obtained by others are explained in terms of differences in methodology. A neurophysiologic-adaptive interpreta— tion of the electroshock process is presented. It is concluded that electroshock is the non— specific induction of persistent states of altered cerebral function, providing the physiologic milieu in which changes in adaptive interpersonal behavior occur. Improvement after electroshock is seen as a special case of behavioral response under these conditions. The rating is an evaluation by an observer depending on numerous factors, including the type of adaptation, the 524 and expectation of the observer (therapist, family, or administrator), and the setting in which the behavior occurs. goal Mrs. Helen Donovan, Miss Gayle Wankel, and Mrs. Hannah Mosquera gave technical assistance in this study. Hillside Hospital. REFERENCES l. Weinstein, E. A.; Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Psychiat. 109 :22-26, 1952. 2. Roth, M.: Changes in the EEG Under Bar— biturate Anaesthesia Produced by Electro—Coxnvulsive Treatment and Their Significance for the Theory of ECT Action, Electroencephalog. & Clin. Neurophysiol 3 :2612-80, 1951. _ 3. Aird, R. B.; Strait, L. A.; Pace, A] W.; Hrenoff, M K. and Bowditch, S C.: Neurophysiologic Effects of Electrically Induced Con— vulsions, A. M. A. Arch Neurol. & Psychiatl- 75: 3371—3781956. 4. Kahn, R.L ; Fink, M., and Weinstein,,E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A. M. A. Arch. Neurol. & Psychiat. 76 :23—29, 1956. 5. Korin, H.; Fink, M, and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Confinia neurol. 16: 88-96,1956. 6. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communications, edited by P. H. Hoch and I. Zubin, New York, Grune & Stratton, Inc., 1956. 7. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electro— shock, Electroencephalbgi&-Clin. Neurophysiol. 8: (abstract), 158 1956. Pacella, B. L.; Barrera, E. S., and Kalinowsky, L.: Variations in the'Electroencephalogram Associated with Electric Shock Therapy in Pa— tients with Mental Disorders, Arch. Neurol. & Psychiat. 47:367-384, 1942. 9. Proctor, L. D., and Goodwin, J. E.: Clinical and Electrophysiological Observations Following Electroshock, Am. J. Psychiat. 101:797-800, 1945. 10. Bagchi, B. K.; Howell, R. W., and Schmale, H. T.: The Electroencephalographic and Clinical Effects of Electrically Induced Convulsions in the Treatment of Mental Disorders, Am. J. Psychiat. 8. 102 :49-61, 1945. Levy, N. A.; Serota, H. M., and Grinker, R.: Disturbances in Brain Function Following 11. R. Convulsive Shock Therapy, Arch. Neurol. & Psychiat. 47 :1009-1027, 1942. 12. Mosovich, A., and Katzenelbogen, S.: Elec— troshock Therapy, Clinical and ElectroencephaloVol. 78, N00,, 1957 ���mum m 3%: «u mmwgmwzum,mm muJ.MiMMfiW3MhWW m if mwmum. “ w. Mr maummwmmmmmd W. mam. mm W. ‘ ����Wfimmmamhmmuwmmuw (mfimumlmwmmumwmm MQ}WW#WWWMWW W“Nmmmuwmfiummxmwmmmmm Wan. 'meummmmm-umm m MW‘Mflqumemmuw-ua MW“ ' “- MWWW manna a) mxmmmmmmmwmm �������I ‘1“ A— �Wgwmmwmg MWMflmmmgw MWmmtmmum4h mwmm. wmmamm.mwm«mm* �����������. v ,9 M» fl..V 4%5.. ������..: 3 0%» .4 4L, “.4 .:‘ ».:4, J �����«flit WWMM. m twmnmmmm �����.14. u J, wring >,R �‘ ’ ,. "M :jfi" W; Walt ��W W M“ WWW!» mu?Wmmm mm: at W mm: in. {1. a» a) mum at *1?" mm in W WW; W m m at ��77 was“W r I €25” 0551: (”n-hum or Inn-I 4 -5«-r.:.5“......”"55. {/7 m mu “$17115: to Word mm. in Whack: wants." Serum. Studies . "v a» 5, g an m HDandRoborbL ma. 3.5.5» I: M. ' fl at mammal WW; Hillside Hospital, 01m Oaks, truths Want. lbw but. Aid-d, m m by gum. 14-927. mama mum. at Kent-.1 Health, mum). of find/m, v.3. mm Health San-1a.; and the mm mem mum for Mad. Ragnar-9h, nWJa-rlcM mt: , of mammeephalcmphoro, Won, Present!!! aththe mum Duct, WWI} 1955. m: M57» ‘ ' . ' “mm .— ; �Relation 5?? -.._.. a: _ Meet w {Mari-ea m, Delta Activiw to More}. mm in Wanna: antiutive Serial Studies; a: electroshock therapy m ( 1, 2,. 3) have emphasized the rule of neurophysiologic changes as the basis for the therapeutic .1 . mutant with these ,L theories, we have observed auction of a mutual: bum changes a: new means of brain function and behavioral name. We have noted an... $73 WW 40 electmsheek/‘afi- changes in orientation embarbital (2;), flaming and <6) . null and clinical hpmment following cmfabuletion after 111th (Shana syntactical aspects at ' 1% In view of these observations it. could be expected that. electroencephala ogrephie shudiee mld report-ad inflamed relationship. Nmaerous observers have eminent changes in the electmeneephelogm utter eleetzically Mime. rhyfiMc em 1 similar utivity There 18 6.1.th9 slewing with increased voltage and dye. (7 ~ 12). Feet percent—tum (13), and utivity decreases, both in voltage and in in patients we are intensively trauma, there is e naming of persistent alpha frequmcies (1h). The degree, mum and extent or éelte amenity is directly rented to the r'nquemy and amber of grand ml I Wane (8 -- 11;). Such activity is usually swede, appears maximal effects usually disappear 1:1meme in anterior leads, and the in ma mks renewing the 1m treatment-,3. 9). In contrast to the comiateney or them observations, studies of the relationship between the elmtmmephelogrephie and the dilated conflicting menus. ohmic: and mean: (15). after an mag” show mun review of the literature, £9011ch that the amber er treatments rather then the degree of named delta. activity we: the primry factor pantie response. 011 the other hand, rented to a fwomble there- 21qu 93 g}; (16) :0pr a relation how changes in the percent time feet eetivity (more than 13 cps) and ���.4... In the rim]. estimates or degree of deli: activity, the average delta index for the 3 load oombimtiono, the highest 3011:: index in any one load, the ulwest frequency, Most delta. voltago and out-aunt: of longest period of burst activity was listed for each macro. The 160 noorda were mangod in aoquemo for one): index and the percentile ram: dotemined. The ranks wen oddod and the the floor!!! than Imnged in rank order awarding to this score. a: that the higher score refloctod a. grotto; agree of delta activity, the upper third of the mom were classified as “high dogma the middle mm 58 "mm. degree delta“ and the lowest third as film dogmo‘ “main dolu:~, delta? . ohmotorizod by an flange delta index delta 1mm of ‘2135 armors in one o! the three High degree «sum record- wore of at. least. 18%; a mound 1m; voltage mm second», w slam“ frequency of loss than m madman; m: a Inn-at. 3 3/1; ops; highest mu mum of u least 2 1/2 ‘ Low degree dorm noords was characterised by an loss than 2%; slower than S meat. delta 1m in one lead of 1/2 ops; volt-.93 loss than 60 loss than 1/2 nomad. ’Hodornto degree delta groups with an 60-80 20%; Mormons; and 31m“ from Inn-at indoor or or 1am mquanom no naming and burst duration 3% room-do won Minoan ”lose two mugs delta index between 2% and 18%; no load of 3 to mugo delta ‘ mm finite 3mm in of h-S cpl; highest amplimdo bemoan duration of 1/2 to 2 seconds. fiftyafour omomtivo, unselected electroshock patients, oloctmonooplulogmphic records worn obtained prior to trustmne, during the We! and third weeks of treatment, and tam weeks after 13) In a. second aortas of mama‘s. mesa rooonin were mlyud using: the identical moms as in the initial ����W degree the” %%Ru.® was WW3 to datamine whether the at delta response was Mauve of the short bum theramutic cum. m the baéis of thfi observation that the much improved panama had dweloped high dtgrae delta #ctivity unfit-1y and had. sustained such activity, chew mamalogms ware obtained tinting; the second and third weak: of mutant in pltiants. The records- were Scored as ta whether high degree dolta actiut‘y was acldwed timing; both, on: or with: of the h—é and 7.9 treatmnt pariah, the data was muted to the clinical evaluatimm (Table III). Sh eonsecutiva electroshock and mm III ' ‘ EEG man Delta. _ (18) Both High One mgr; .. “Home High (16) (20) f who pntienta without. mm W 2 (113) 12 (67%) h (225‘) u (292:) a (sex) h (25;) 6 (30%) 7 (35%) 7 (355) // anwx‘uaummm,m M down delta activity?» rated. M, the surly 1n- ducbion and persisteme of mg; dogma delta the short mm. clinical 4» Moderatelx manifest high degree delta activity during tha second and onlgrBOSof attainment. or the patients 'mm - ma activity is seen to be related multim Meant at the m1 of cmm. 2% to_ ��J We “WWW“ 1111111111: delta activity has m integrate as evidence of dysfunction at manna centers {mtmmphmc systoml (19) . mpothalandc and Such activity is also indicatim of an alteratim in the cuts of consciousness, with more marked alteration being directly related to this duration, mum. activity (If, 21, 22). me dmstmted roala‘bianchip between induced delta activity and behavioral response after electric and tmquency of the slow wave hint- conclucion that. changes shock, themfom , permits the cephnlic 3513mm with attondant. alteration in conscimmnesa basis of the electroshock pmccas. m the basic cf his stwiea of the Another example of the behavior is tut-h seen £81 ~11 A ‘ 11.:1‘rect . M of me b visits. cooperativefar hie 01.111111 MW”. occaa11m be was 1153110111; mic 9.1213 :1 ported by we delta activity, belmvioral On At. an WW $133114. (23) '1'?—“1/1'54"? W 55130) reports of epileptic patients. Landon ordimrlly pleasant, ffiendly and them times, records the subsequent and 118 warn mimuy unit, Similar was mated. ram 111111 the EEG was again figsrhyth- obaomtionafi fire?” (31). applied the Maximal test 101» brain h nthembml serial fashian to this group of patients, and reporwd a mlatiomhip between changes in this index fwtion and behavioral changci. Herc Other tests of ccmbml {metion to be applied in a disease (32) an a 31:13:: 331131 fashion, 11'. is anticipated that thou, tab, would demonstrate bicchmcal substrate of this process has received 11mm: cm placed 011 acctyldlommholineatemse changes (2 ) (25), W818 has1nbean blooMrain barrier (3) and chasm in ionic and pmtoin nautical (£6) (2{) diffcmnt by aquilibria investigators, witho 1t definitive: con- it The 13111810113 . m surly, inflame and withdrawn, and his 1% ”13111101791331” In a prcvionl atudy (h) wwé‘gm relation Iof clactmcncefiulograpmc delta to (28) (29) describes a young synaptic: who was 011 the Gem-im- % the pigsiclcgic mansion similar 3.11 ���«18‘ {gnawing mu intents.“ name is courses of therapy. In limited to this 40f ,peziari many cases, the behavioral altemé! brain phys‘iolégz'f. When induued in behavior are net. afiaptive in fihe mien of the patient, £16: behavior be pwmamm patterns. In cther instances, the induced behavior is Idaptive to the environment, and, we assume, sustained thereafier not. by the changes" mm in brain function, but by the newly dmleed interaction at M2 subject with envirmmnt. Theft. miss is indeed true is sea: by the fremwnt suscaasm adamuon at the patient to we hospital milieu after electroshock. initial only change to We a marten-ea of symptoms when discharge planning is discussed or is mummied. Altered brag». function provides the Manage Mm: in which there is an altered hibernation with the environment -- the diIcharge doctor, famfily er society. I These ’ obm’cim lead to the canclusion that electroahack tirxerapy flfimum Such Wyenfific induction of persistent states of altered altemd mm; hid. rum um provides the physiologic milieu for m: altera- a -' tion of the organism‘: adaptygtexfgersoml behavior. in pemwp’oion. “a Changes WW3,W, mé‘m, and MW: which Max-scum with the ‘mirmn‘o. Mead ms:- than oonditim is deg-3mm I is The type of upon are induced m constitute 31 new behavior the personality of the 813123“, the environment in which the interaction occurs, and the duration of the stat. cf altered cerebral function. A similar View of the electroahock pmeesa fias initiélly expressed by rm and Kuhn Heimtein, Minibar: (1), who mfimaized the interrelationship of changes and behavioral msponse. This doseription of ma shock pmoess is also consistent with the observatians of Ulett Roth (2) and Aird (3). 533 new electro- $3; (31:): gig}. Th5 meioloMptim Mode. interpretation of electmmock pmviaiea m mutational definition of the pmaaa uhie‘n has promiaa of further 3mm ' 49’ �“on and wax-mum. _ Such a. a; Wilma ‘ standing of therapeutic procesa in quillizing agents. . also has appliuticn to 1mm coma therapy, lobobono' an man». ané tran- �«is. J ‘ , ‘ 1. Serial aloutmmoyhnlogmma Waive W ohm!“ at many intervals in patients Mama! for electroshock were quantitatively for the degree of delta activity. ’ 2. 215 W aimifioant relationahip was found between the degree and aux-afloat of induced delta activity and clinical ”elation of behavioral change. The results wen: confirmed in a meditative study in an additional 51: patients. A 3. Diffemnooa between them results and mono obtain-d by others are explained in toms of differences in m'modolow. h. A mmphyeiologic use is presented. It is duction - adaptive interpretation: of the elootmshock pro» concluded that electroshock is the non-Specific in- pomatantvatatea of altereri cerebral function, providing the ogic 31113:; in inch changes in adaptive interpersonal batman: occur. oi". 3. laymen)“. maponz—ze afar abotroshoch is under those conditions. " The seen u at 81300131 case of #133191“ botanical rating in an evolution by an observer (lemming on numerous faahora, including the type of adaptation. the goal and expectation of the observer (therapist, family or sminiatrator), ting in which the behavior mm. and the set- �4-43.6- Acknfledgemnt : We wish to Ranks]. and m. 31pm: our asppreciation to Mrs. Hahn Ewan, Miss Gayle Hannah fer their mammal assistance in this study. Wm �~17».- 1. Weimtein, E.A., Ling max-spy: Psychiat., z. MW 13., and Kuhn, R. .2 Psychosis During Its Rahtion ta the Log: 22.26, 1952. "zeory of Elan-maxed: J. Shank Thempy, Am. ‘ ' Bui‘biturato Anesthesia Produced by Changes in the m:m, wmm: Electra-convulsive Wmt and Their Significamo for the Theory EEG » act Action, Em. (315.11. Neurophys" 33 261-280, 1951. 3. Aim, R.B., Strait, LA" Pace, Jfi'q Hemoff, 14.x. ind Witch, 5.0.: of fie‘grophysialmc Effec'ta of Electrically Induced Gomulsions, Adidmam. a: Paychiat” 15.: 371-678, 1956. Arch. a; 3.5.: Relation a: mom-banal Test to Clinical Imgmemnt in mctmmack, AJLA. Arch. Neurol. Kahn, 3.1,... Pink, 5:. and Heinatein, 2;; chum... 163 23.29, 1956. S. Hg Fink, aR'Z'Efrim, M. to Legging 19 1o 6. Kahn, 3.1.. and Fink Wt and Fur-- 8.: Relation of Changes in Mmery and Nasser, in Electmahmk, Cont. Mauro]... ya: rm; Changes in 8M6, Language During Electmshoek Therapy, in “PSy‘chopathangy of Cmmication," Trumaaticns Amr. Psychopaflml. Lame” 1955, Gram: Stmttan, Raw York. 7. an», m. ané Hahn, Ram Quantimm Studies of Slaw wave Activity Faun£2 Elactmshock, 8. 1236.. 63.111. Haumpkys" Q: 1538 (Ethan), 1956. 13.1." Barrera, 31.8. ant-3 Kalinowslgr, 2...: Variations in the Elect» encephalogm Maociateé with Electric: Shack Theta: in Patients with fien’oal Eiisordern, Arch. neural. {é Psychiat” :1: 367-681;, 192:2. 9. Metar, Id)... and Goodwin, J.E.: Clinicnl and EleuhroMiologioal Observation! Following mammhmk, Am. J. Psychiat., 391.: $7.800, 1925.. 33336113., ' 3-“ 10. Bagahi, ' '11. My, 3.211., Ewell, 3.33., and Somalia, 8.1.: The Electreencepmlegrarphia Clinical Effecta of Elegtrically Induaegi Comnlsicms in the reament of Mental Disorders, Am. J. Paychiam, gag: 1&9~é1, 1915. HA... Beret... Km” and Grinker, R. Ru Disturbances in 3min Function I“ ComlsiVe Shock ’Faerapj. Arch. fieurol. Pay1914-2a MI 10094027, plain.” cum 12. Hamish A" and Katzenelbgen; 3.: Electmshock themm, 51mm. and 517'éacti‘ofigcehhalogmphic isms-Ems) J. Harv. ‘I Mani... Dis... 39, 9 we» m: ‘ 13. 24A. and “111mm 3.13.: Significance of Changes in Elect. mm, alogram Zhsults from Shock "therapy. J. chiat" 105 ,' 'va'hicit: 11045, 19%. Am. PB ��’19.. 29.’ Landau, Ru Uber )9 undw Vemer-‘mm W:- fur zguatwdsbilder be: PW3hmm$g 1?} 313‘331’ a 1mm,I' 19%50 schizophmxe Neurologio mu! Goo. 918178, W”, Related Type of TrutG.A.: to Thaw ‘3erE} 97-10%a1956. mnt, Confinia neurologica, 30» Bm:m,.fioJo Bmcm, 31.. Ming, IL: Personal cmmication, .3:»:. Veins’oein, ‘EJ... Kuhn, 1m... Sugaxman, Ink. and 1mm; 1“: The Diagmstic Use of murbital "Sedan (”Am-tel sodium“) in Brain Disease, Am. J. Psychiat" ngfisws’h, 1953. ngaa 1n JOC.’ Jaebbsm’ 1956. $16: U... ' Pemmuty raetor‘a 1n mum: Psapmae to m,a.s hilactroahock Tharapy, Gent. Kennel. (in prose). Kahn, R.L. and 833%, 8A., Smith, K. and thconvulsive 6 ham, (3.6.: Evaluation of Convulsive and Shock Therapies W‘.’ at 79m, 1956. Utiliniqg 2., Control. Group, Am. J. �~20- 136mm m 1. Lou Dogma Delta Activity . m Figure 1.1. Moderate Dogma Delta Activity “M 3.11. High Degree Delta Activity Figum 1?. Relation of Clinical Ratings to Development of High Degree Delta Activity. Figure v.0. - 6) Ralation Clinical Ratings to Delta Activity. (11' ill-Ia EAL-k M Index of �12.5553" ’53?! $3.4 vii. ‘ '3 �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263m: STREET GLEN OAKS. N. Y. Flaws-ran: 3-7800 s. A. MILLER. M. D. MEDICAL DIRECTOR JOSEPH MAURICE BAC‘HRIACH ADMINISTRATOR SHRON KWALWASSER- M. D. ASSOC. MEDICAL DIR. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �, v—v—v flu ; {'ZflA/C’ , — S’s/"- 4—'-J-{/ , -:v»- mm- -- -< - - .» ,. - —~ :~- -~--7— «— u « , v-«wy— —— v~vn~~m~——.W»,M—->w— yw—W “H's—WW £46 4/? /7¢3 far]Flaw/t M(",qu ”may Webcw~aa M4£27%01;“, 6W f5 Wm awe/W m Moxie/M M W ¢m MJM WM W ’@.A.:f;4m «4% dw.;&%-m/: Midang/fvaf mam ”I‘M/MM 2/49“”{24414 WMMMWJW M41; {W MWMM W. I, r �“qua-7 r.l_~- ".w. v "/fl/Wd' Q/a 7 _.,;m,‘_<,,,,,..fi_ .mm. uvr...“ 4 ¥ 77“.. ,, Va- .._ , "W, ,V _._ .—-.~ .,. V .7 .,,.‘ ;....- . , .:__,<W dag ,u/ W WM W M ‘ _ ,_.,. . . , qr, .._.; x7443 A4414M4M 7’7 ’ “ 74' m WW/M .W We! l..— my MAJ WM W M :W mm _ . (NV, Aux-5&2; 7 fl £;W Jar/tamed 4 Ztaw a M..WA 2/ M44." 64;“..“4 92%] ”(“44ng l/amflv, (I , �. _. ~...v.;., , r“...— E , . V ~,~~—~ , »- . “-‘"‘ «(y—av“ .v. .r- . 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A WWW AW/MW“ mWngsUfiat/Lg, ‘4 M M MlefWWfl/L‘XW W Wséaz W M» Md WW +2637 '- AAA/M4 M-M.é"/.2£ Wot/(WA (WM mam. �(16) 3 5 flth, % Wk. MW ' - . 3 @3W Mr WM gge ,7 4% W A“ % W twé WK 77'W754’WW J calm/(P6,, (ii) Wot/7! MA: an 32AM“ a (6} W30 W A; 1 ¥ ‘— 6&3,“ A [fl/t “M” C, “5&7: I �LW 23m W (“’W 21%;.“ 2 W15— a. éd// /7// I . $5 (0) /4,' flair!“ M (W ‘-" (Axle—26‘) W/Wr d/flmfi/Wflwxw‘ W4”- (f) kn/WK A [OJ-W [6} gt/M W (4717 (02/2 @WV4 =1 loo-WM W2a.. 23% 26/? VFW A" ,2 Amt“ E �jW/MM/ r_ QawaQ/ducffi @fl )4) 1/) , 3) i W mgW W551” :M / H MM? ge/fsf? )krqu. fifth flaw“ AfiéflQ—m Mfle 2:. / M . - 5/3; ”a“, mgwk /W&”’V : �Bambi, B. It, Emil, R. m, and Schmidt, 3.13.8 inflated convulsions 1n the treatment of triaafily_1 1023‘ 1]7 9 ”The alwtroancaphalogmphia effects mad 3111113511 1:1li an! aim disordem.“ém. J. Pqnhigt. ' Barrera, St American J. Egg and P866118, B: In: “EEG finding! ”‘001amd With 31Wtfl¢ therapy in patients with mental 333.: 206119fl3. 3118.559}... GOldtarb, W" Laughlin, J3 Ma; 8336. Kiwfi’ H. Ea: ”P19163336. 1113111111 $193k dimm.“ Shafikdu VMO Gottlieb, J.S., Ashby, PLO", and Kimble; L.L.:'mamamlogi¢ study of schimphn min and depressim. IV. Ina fluence of electriu cenmlaiva them on, the aodium mm]. reapmua of the saleabmencephalcgrm.‘ Am. J. Psychiat. 10 : 6869696§ 1958:: » Harris, Roma, W.A.:"fisa of cur-are in mtraxol mnmlaant timer: with 15 3 5376 £1 19111“ observations.” maniatric Land 2mm, and Panama, E. Wt electmencephalografixiu England, Hr, whim, Mum, and Cinema, D.E.: " me electroencephalogram hypoglycemia and recovery." 7 J" Wigton, Hughes, Arena Neural. Ward, Am. 13., and at 13816111312. 14.11., and Rims, Jardon, F.:“Electmencephalogmphie studies on patimam meshing electm~shoek mamnt.” 19141. “SWiamm of L.F.: «hmgas in thy alecmenecphu flagram whichmsult from Each, ‘1'. 0., and autumn, Ed 251.13.. Arch. Neural. MO “The other effact of benmdrine and @2th ant: upon the (21mm Shank) EEGJIi'amatiun Pmc. 5:62“ 12%,. 8mm, mm, and Grinkar, 12.3.: Diaturbanaea in brain pastconvulsiw Levy, therapy." 53: shew}: W. ehiatu 50f 53§¥537g 12h3 8: 1mm, mm, 1' Payehnt. & m; J; Haul, B; H0; of schizophrenics curing insulin 1202 559‘5791 3.9;}; Gottlieb, J.S.: ”Chang” in. the eleetmeneephalogrm renewing insulin shack therapy." Neural. and Page and «1.12., J. $1131.01. as: figumg _ Jg.P§Fdhiflta 105‘,h0*h53 19h5v Knott, , mum refluxing wnmlsiw shack mummy.” 1:7: 1009402“: 192:2. Go»; Wu, { G; Rn, Pma‘bor, IN Dr; and 600%, J“ E03 "Parallel psychologisal, psychiatria and Whalesinn). findings: in sahimphmnie patieats undar insulin ahcmk treatment." Am. J... Psychiatr.» 933 1422-4129. 121:1... lbriafiy, LB... and Siam, 573 112*.»718‘ 1913!. maevich, A" nut. and, shoal: therapy.” Arch. Neural. g mint. 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. Ea Camativq tlwtmeneemalogtmhia abs serrations / gnawing electroahaek therapy Am J.and alternating unidimctmm fluematmg m1: 5' using Proctor, trim 1 ' i 13.30.; and Goadwln, Proctor, Harold: VP: Arch. mm,i @533 . 1.7.; 617.6111, conservative approwh to fine 111% uhq of sneak therapy in 1M; ‘ mm arggi‘ijd Suthfirlmd’ Gt Fa: was experience with alwtric: aback treatment in mental (mama-35, with $963.91 regard to vamua psychowmtie 99: phenomena and to certain elcctmteahniaal “Worm”? Agni J. 531M, W5»; fillet-350:1, K. JV, 6111133511, Wk" " A eonsic‘haratim‘ M Mint; Pacella, La 'me aigmflicancegfinf abnormal elentmmfit$3ng; prior t6 electmmnmlsiva many. Taylor, R. 34., and Jr Nam. ‘8; Manta may 1073 2204.23.... Mar, . 51'. B. _ l , w. J”, Lewinger, L., and Wail, A. A“ manager, :4. C‘: l9 1‘ - F mdfleam, thorapwtic result in amiaophrmim ’ ‘ Am. J uW pmlecW» 3.2%}: eomlation or J3 'ghwk eleetmenaephalagmm and Win“ 1023 299‘ 1.9% ‘ ._ , '5 (,1 ”Elaatmmeephalq/{gmkfific studies renewing elwtrie 57-; 112" aback therapy; #13:). Wenml. s: mist.» .: 3 (I {V l l . \ I ‘ V 3 , ‘ 1‘ ‘2 l ‘ 1 "x \f.‘ 1 . ' ‘a I L ‘ ' 2%, ~ ‘ \ ‘ i : ; E ‘ i. ' J ‘ l‘ ‘* a ‘ l v 1,‘ 2‘ ‘2\ 1 E \ '1 . 6 w f ‘ / ‘ , , 4‘ ‘.\ .‘ , "V {3‘ ' w' l 4 i i 4/ e J L 5 ' -’ I“ "7 ,r _ ii e :y , fl ’1'! ,_ ‘ Y . , ‘, y . ' ��1 '___, Y? 3b CW #31 1416mm.) W 2’ 71ml afar}: JJngtu/zw: é/‘f M W .39“. 5““ ww—w—WWWT , {EM-fin. 7/ aux... GMM‘ ”£73 7;. 23/ , rfr3. MM WWW; flV/ZM (36¢ 3 —-—-— W7 " ., @// " " {If 557 nr— j ’7’7 Ik fer" (”a“) ’>’3 yum ¢7 i Lflflyl :7 94,}, ‘/f, 557 ' [5/ f7 l007-/¢v§ ’4’“ [7‘4“ ”3 ”7 - 9% 2/F/. ”I‘lfj " " 547+,4m7m «m 1‘- l7 [%’/&?Jflfl n/V‘é gédnw awn-£5:H " If” 415(fl/Ia 7"(K O’ermlw fif: 7" w 7 W 1 4 o2? 3v : ~———~r .1 £143de WI ,“d. _ L? ' ‘ I T) Q -1 F8 ‘ ,4, ,1, @1574”! 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/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/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/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/d7a08df9cf0427fc8180966376064147.pdf df0afef232047bc6a8f732705fc32387 PDF Text Text USPHS M—927 Final Report ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK (Perceptual Changes Induced by Drugs and Electroshock) the Department of Experimental Psychiatry Hillside Hospital From Glen Oaks, L.I., N.Y. September 1, 1959 �September 1, 1959 FINAL REPORT weal Department of Experimental Psychiatry HILLSIDE HOSPETAL 1., Glen Oaks, L. N. Y. 235$! 1 1. Acknowledgment 2. Summary 3. Summary,Five Years, 195k - 1959 27 h. Publications, 195k 32 5. Presentations 195k - 1959 1959 37 195h #h, 6. Summary #1, September 1, 7. Summary 3,52, January 1, 1956 #3, April 8. Summary - February 1, 1958 1, 1957 September 1, 1959 - 2 January 1, 1956 hZA - April 1, 1957 55A - February 1, 1958 70A Fink, M.D. Principal Investigator max Research Associates (Experimental Psychology) Robert L. Kahn, Ph.D. Research Associates (Neurophysiology) EEG Technician Secretary Hyman Karin, Ph.D. Eric Karp, M.A. Martin A. Green,M.D. 195k 195h-1958 1958 1956 - George Krauthamer,Ph.D.1959 Hanna Mosquera Janet Bowie ' Associates, supported through other grants: Research Research Research Research Associate Associate Associate Associate (Experimental Psychol.) (Psychiatry) (Psychiatry) (Sociology) 1956—1959 Joseph Jeffe, M.D. Donald F. Klein, M.D. 1959 Nathaniel Siegel, Ph.D.l958 - Max Pollack, Ph.D. 1957 �Acknowledgment These studies would not have been possible without the of Founder of Hillside Hospital, and the support interest faith, Dr. Israel Strauss, the Board of Directors, and the Administrator, Mr. Maurice Bachrach, who sustained this program during its early vicissitudes. are also indebted to the Henry Kaufmann and the Dazian Foundations of New York, the Foundations' Fund for Research in and the Nassau Board County of Health Mental the Psychiatry, following pharmaceutical firms: Smith, Kline and French and Laboratories Bristol Geigy Pharmaceuticals, Laboratories, We Wyeth Laboratories, whose support is gratefully acknowledged. �September 1, 1959. M-927 Altered Brain Function Following Electroshock Progress Report #h Max Fink, M.D., February 1, 1958 - September 1, 1959 Director, Department of Experimental Psychiatry Hillside Hospital, Glen Oaks, L.I., N.Y. Associates: Robert L. Kahn, Ph.D.-Research Associate (Experimental Psychology. y) Psycholo Eric Karp, M.A.-Research Assistant (Experimental (Neurophysiology% Martin A. Green, M.D.-Research Associate Hanna Mosquera - Technician Janet Bowie - Secretary �-3ALTERED BRAIN FUNCTION FOLLOWING ELECTROSHOCK SUMMARY: In the past eighteen months, the various studies of the convulsive therapy process were completed and extended, and The begun. agents of psychopharmacologic an investigation framework for these investigations has been the neurophysiologicand 1955; Kahn, (Weinstein view convulsive of therapy adaptive Fink and Kahn, 1957) extended to insulin coma and drug therapies in psychiatry (Fink, 1957). The following aspects of the convulsive therapy process were studied: A Convulsion: comparative study the of 1. gignificance of the neurophysIoIogic, psychologic and behavioral effects of electrical and inhalant (Indoklon) induced convulsions. 2. S Efie a tic Basis of Neuro h siologic Change: Further effects of acute administration of experimental studies of "normal" the both on and agents sympathomimetic anticholinergic and post—convulsive EEG. s There As Convulsive of ects ic 3. Sociopszcholo of the of factors Relation age, education, a. F Scale) the California by (measured and stereotypy nativity to the selection of therapy, duration of hospitalization, diagnosis and discharge ratings. b. Changes of F score with treatment, and relation of these changes to EEG indices. Thera : In supervisory chothera and Convulsive h. PsaIteratIons psychotherapeuggc in the relationship sessions, with convulsive therapy were observed. 5. Perception: Both patterns of change and individual differences on ac stoscopic figure-ground discrimination tasks and perception of the upright with induced convulsions. These studies were extended to drug therapies and the following studies undertaken: 1. Neurophysiologic: EEG of change on acute and chronic Relation a. administration of various psychopharmaceuticals to clinical behavioral change. III: 8/59 �potency. actiVityo b. EEG as a screening device for psychopharmacologic c. Relation of EEG changes to hallucinogenic effects of megimide. 2. Communication Patterns: Relation of induced neurophysiologic change to dyadic diversification and syntactic d. EEG language measures. 3. §pciopsychologic Studies: Aspects of the doctorpatient relationship affecting choice of somatic therapy. studies have supported and expanded the neurophysiologic-adaptive view of convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the mode of action of psychopharmacologic agents. These �~5- ‘mm PROGRESS REPORT A. THE CONVULSIVE THERAPY PROCESS; 1. Significance of the Convulsion: An earlier convulsive-subconvulsive control study had demonstrated that significant behavioral changes occurred almost exclusively in patients receiving grand mal convulsive therapy. The present report is an assessment of the neurophysiologic,behavioml, and clinical effects of two different methods of inducing convulsions - electrical and inhalant. Twenty-five consecutive patients referred for convulsive therapy were randomly classified into two groups with seizures induced in thirteen patients by the standard Medcraft alternating current instrument, and in twelve by the inhalation of hexafluorodiethyl-ether (Indoklon). In both groups treatment was administered three times a week for a total of 10 to 2b applications, determined by clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following the 10-12th treatment, and two weeks following the last treatment. In addition to evaluations of behavioral change, tests included measures of intellectual function (five subtests from the Wechsler-Bellevue Intelligence Scale), perception (figure-ground discrimination using embedded geometric figures, the perception of pseudoisochromatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levinson revision of the California F Scale). An electro- �-6encephalogram was obtained during each of the testing periods, and measured for the per cent time slow wave (6 cps or slower) activity from a continuous 66 second sample. The results failed to show any significant intergroup test differences between the electroshock and Indoklon groups at each of the three test periods. Intragroup analysis, however, showed that during treatment both groups made increased errors on the intellectual and perceptual tests, and had higher scores on the F scale. By two weeks after the termination of treatment both groups returned to near pretreatment levels for most tests. Both groups were comparable for the degree of induced EEG slow wave activity after 10-12 treatments.v The per cent time slow wave activity for the Indoklon group was 51% and for the electroshock group h7.5%. Within each group individual differences in behavioral change were related to the degree of neurophysiologic change - those with the highest degree of EEG change showing the greatest behavioral change. Rank order correlations between changes in test performance and the degree of slow wave activity with treatment were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue, and reached a level of statistical significance for digit span (+ .61, p < .01), object assembly (+ .h6, pr< .05), F scale (+ .38, p (' .05), tachistoscopic perception (+ .67: P <: .01) and perception of embedded figures (+ .h3, p < .05). �-7Two different convulsant agents thus produced similar neurophysiologic and perceptual behavioral changes; and it was concluded that the behavioral change in convulsive therapy is related to the degree of altered brain function, and is non-specific for the type of agent used to induce the convulsion. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April, 1959). 2. Biochemical“nu—On.“— Aspects of the Convulsive«non-mu...Therapy Process: The significance of high voltage EEG slow wave activity in the convulsive therapy process (Roth §t_al, 1951, 1957; Fink and Kahn, 19S?) and the report that this activity was blocked by the administration of such anticholinergic agents as atropine and scopolamine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant systemic effects with the administration of these agents, reports describing diethazine as an anticholinergic compound with potent neurologic but minimal systemic effects (Jenkner and Lechner, 1955; Lechner, 1956) led to studies similar to those of Ulett and Johnson using this compound (Fink, 1958). These observations with diethazine further led to the investigation of other experimental anticholinergic agents. Clinical and electroencephalographic responses to the intravenous administration of diethazine, Win-2299, benactyzine, JB-318, JB-336 and atropine in psychiatric patients at various �-8. stages of convulsive therapy were studied. Each is a potent anticholinergic agent in vitro. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with a A of diagnoses. total of 107 observations were made, variety as some subjects were studied with more than one compound. The observations were made in the EEG laboratory using a standard 8 channel instrument and needle electrodes. In each trial, the compound under study was administevhd intravenously at a set rate per minute until clinical behavioral or electrographic changes were observed. It was observed that administration of these anticholinergic agents was associated with a) desynchronisation of EEG rhythms with a blocking of post-convulsive delta activity; b) alerting, excitatory behavioral response with illusory, delusional and hallucinatory ideation, and c) systemic effects of muscular weakness, dryness of the mouth, dry skin and tachycardia. The electrographic, behavioral and systemic effects were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, mescaline and diphen- hydramine - sympathomimetic and antihistaminic agents - also induced EEG desynchronization, blocking of post convulsive delta �-9- activity and clinical excitatory activity support the suggestion that the behavioral and electrographic patterns of these compounds are also based on an alteration in synaptic activity. Increased synaptic activity (cholinergic, sympatholytic effects) is associated with EEG hypersynchronization, and clinical sedation and euphoria; while decreased synaptic activity (anticholinergic, sympathomimetic) is associated with EEG desynchronization and clinical excitatory and.ha11ucinogenic states, thus supporting a hypothesis initially described by Wikler (195h). It was also suggested in these studies that the discrepant observations of EEG slow wave activity after the administration of atropine was related to significant differences in dosage and to species specificity. (Presented, in part, at the Society of Biological Psychiatry, San Francisco, 1958 and awarded the first A.E. Bennett Psychiatric Research Award of that Society; and, in part, at American EEG Society, Atlantic City, 1958. Published, in part, A.M.A. Arch. Neurol. & 80: and 380-387, 1957; Psychiat. accepted for pufilication, EEG Clin. Neuropfiisiol.) 3. Sociopsychologic Aspects of Psychiatric Treatmen : a. Duration of Hospitalization, Diagnosis and Discharge Evaluation. In an earlier study of the Hillside Hospital population (Kahn, Pollack and Fink, 1957), it was noted that age, education, place of birth and social attitudes as measured by the California F scale, were related to the selection of therapy. Those patients who were older, had less education, were foreign-born and with high stereotypy scores on the F Scale �likely to receive convulsive therapy. In contrast, who and who native-born better were educated, younger, patients were more obtained low scores on the F Scale, received psychotherapy as their sole form of treatment. This study was extended to determine the relations of these sociopsychologic factors to l) the duration of hospitalization, 2) the clinical evaluations at time of discharge, and was final diagnosis. The entire in-patient adult population on March studied. This consisted of 171 patients, 57 men 3) the 7, 1957 and 11h 68 16 from to in women, ranging age years, with a median of 35 years. Patients hospitalized for the shortest period (1-5 months) were noted to be the oldest, have the least education, were most likely to be foreign-born, and have the highest scores on the F Scale. Younger, native-born, more educated, lower F score patients were hospitalized the longest (10 or more months). The same relationship of these factors to length of hospitalization was found when separate analyses were made according to diagnosis and type of treatment (convulsive therapy or psychotherapy). Discharge evaluations of improvement were significantly related to age - the older patients having the most favorable ratings. Analysis of the data by type of treatment, however, demonstrated that among the convulsive therapy patients ratings of recovered or much improved were given to those patients with �the highest born. F scores, least education and who were foreign- Diagnoses of schizophrenia or psychoneurosis were associated with lower F scores, younger ages, more education native birth. older, less educated, foreign-born, high F score patients were more frequently classified as involutional or manic-depressive psychosis. It was postulated that these relationships reflect the influence of social background and psychological processes, such as the behavioral patterns of communication and mode of expression; and that these relationships contribute not only to the pattern of mental illness, but affect all aspects of the patient—therapist interaction. (Presented at the Eastern Psychological Association, Atlantic City, and the Academy of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatry.) b. Changes in Social Attitude with Convulsive and The Treatment. earlier observations that the California F Scale is useful in understanding the reason for referral for convulsive therapy and the evaluation of clinical response Following following such treatment, further studies were undertaken with this scale in regard to the following questions: 1) What does the F Scale measure in a psychiatric population? 2) Do F scores change with convulsive therqay? 3) Are these changes related to the degree of altered brain function? �-12- entire in-patient population of the hospital was given the F Scale, and one month later, was retested with The a "reverse" F Scale, in which each statement was changed to the opposite of the original. The "reverse" scale was scored in the same manner as the conventional scale, with high scores reflecting greater agreement. It was noted that those patients who made low scores initially, indicating a predominant disagreement with the statements, showed an increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients who made high scores initially showed little change on retesting, agreeing with the statements to the same extent even though the meaning was reversed. It is evident that low F score patients are more critical and discriminating persons, while those with high F scores are more undifferentiating and stereotyped in their reactions. This observation is related to the process of selection of patients for convulsive therapy. A high degree of stereotypy of thinking and communication is incompatible with the establishment of a conventional psychotherapeutic relationship, thus inhibiting the psychoanalytically-oriented psychotherapy stressed at this hospital. It follows that the high F score patients will be unsuccessful in psychotherapy and most likely referred for convulsive therapy. In another study, sixty-nine patients were given the F Scale before, during (at 10-12 treatment period) and after �-13convulsive therapy. Ten patients, selected at random, constituted a control group and received subconvulsive electroF in score of +5.7 mean There increase was a stimulation. during treatment in the convulsive group - a difference 5% the level. In contrast, the control group at significant showed an insignificant change during the same period (+0.5). The extent of increase in the convulsive patients was related to the degree of cerebral dysfunction as determined by slow (more The with EEG. delta high the on patients wave activity +8.6. of had mean increase a record) h0$ of the sample than Those patients with low delta indices, however, showed an F the treatment scores were Following +3.h. of increase comparable to the pretreatment levels. These findings support and elaborate previous observations on the effects of convulsive therapy. Greater agreement with show conventional treatment during statements Scale the F in Changes discrimination. and in difficulty stereotypy of changes language the characteristic thus score parallel cliche; and of use increased denial, evasion, qualification, and stereotyped expressions (Kahn and Fink, 1958). It is also comparable to the increased difficulty in complex visual F and 1957) figureKorin, tactile ground discrimination (Kahn and Fink, 1957). (Presented at the Eastern Psychological Association, 1958; and accepted for presentation at the Divisional Meeting of the American Psychiatric Association, New York, November 1959). and perception (Fink, Kahn and �-1hh. Psychotherapy and Physiodynamic Therapy: Previous studies indicated that patients referred for electroshock in this hospital are of two types. The larger older age who have limited education and are foreign born. They tend to be non-introspective persons, stereotyped in their language and thinking, and verbally uncommunicative. Symptoms of depression, agitation, withdrawal and somatization are prominent. The second, and smaller, group of patients are younger,native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of somatization and depression. Four patients, two from each group described above were studied to determine 1) reasons for referral, 2) whether different attitudes were required in psychotherapeutic 3) the relation of the psychotherapeutic management, and approach to the patient's clinical response to convulsive therapy. It was concluded that these patients were referred for convulsive therapy because of difficulty in communication in the psychotherapeutic relationship. In two cases this was a reflection of the patient's limited verbal and introspective capacity related to educational and social factors. In two instances, however, the impaired communication was reflected in acting-out behavior. group are patients of an �-15Following treatment, the older, less educated patients were able to sustain the behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization ‘In the better and denial developed during electroshock. educated patients, the decreased acting-out behavior was associated with increased interpretive psychotherapy. It was suggested that the relationship of psychotherapy to convulsive therapy various with the communication pattern and adaptation shown by the individual patient. Published in the Journal of Hillside Hospital, 1: 17-25, 19 58 ). 5. Perception: have of procedures test perceptual-cognitive variety been studied in patients receiving somatic therapies. a. The Tachistoscopic Perception of Embedded Colored Figures: This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control“ groups of 20 patients treated with phenothiaains medication (thorazine and promazine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, and after four weeks; the convulsive weeks two time a following the third were tested patients A . cessation of treatment. �-15There was a statistically significant increase in mean errors with convulsive therapy, and a significant decrease from the pretreatment scores following treatment. "Control" subjects made significantly fewer errors at each succeeding period. There was a significant difference in EEG low between showing changes as classified errors patients (per cent time delta) when compared with high EEG changes. There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with no unions Even in those to cerebral dysfunction. attributed patterns EEG with high changes, the "style” of his response patients pattern was maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at number of which completion was shown might change. (Presented, in part, at the Eastern Psychological Association, Atlantic City, April 1959). b. Rod and Frame Test (Withinz: This task was administered to h? patients consecutively referred for somatic therapy. Marked individual differences in performance were correlated with age, education and score on the California F Scale. Patients whose judgment of the vertical was strongly influenced by the surrounding frame (field dependent) were more frequently �referred for convulsive therapy than drug therapy. No significant change was found with drug or convulsive treatment. For both drug and convulsive groups retest correlations were high (+.86 and +.88). It is considered that individual differences on the Rod and Frame test reflect personality factors that are of importance in psychiatric treatment. �-18B. PSIGHOPHARMACOLOGIC STUDIES; 1. Neurophysiologic Asgects: According to the neurophysiologic~adaptive view of the convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central nervous function, providing a milieu for changes in the subject's interaction with the examiner and the environment. In these studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Fink and Kahn, 1957). The efficacy of newer psychopharmaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the mode of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharmaceuticals tested in acute experiments an increase in synchrony with or without an increase in slow wave activity has been observed for chlorpromazine, promazine and triflupromazine. Behaviorally, these drugs were associated with a) increasing sedation, drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimization and displacement of symptoms. Barbiturates regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. �-19Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with alerting, hypomania, excitement and increased motor activity. Decrease in voltage and per cent time of slow wave activity in subjects with post-convulsive delta activity with LSD-25, benactyzine, Win-2299, JB-318, JB-336 and diethazine. Of these drugs, benaotyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. was seen electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronization of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpromazine and barbiturates, augmented the per cent time delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethazine, LSD-25 and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. The �-20. Various experimental psychopharmaceuticals were tested. In addition to extensive studies of b-b methy].ethylg1utarimide hexaflnarodiethylether (Indoklon) the following agents were studied; phenyltoloxanine(PRN-Bristol), methonalide (ELM-188, Bristol), tropin-h-chlorbenzhydryl ether (WY-21h9, (Megimide) and Wyeth), dimethylaminoethanel and varieties, Riker), its congeners (Deaner and JB-318, 329 and 336 (various piperidyl- benzilates, Lakeside) and imipramine (Tofranil, Geigy). Because significant behavioral and electrographic changes were observed, a more intensive investigation of imipramine (TofrEnil) was undertaken. In 28 acute experiments, consecutive patients referred for physiodynamic therapies were tested in the EEG laboratory at various stages of treatment. TofrEnil solution (10 mg/cc) was administered intravenously at a set rate (1 cc/ho sec) until electrographic or behavioral changes became prominezit, for a total of h0-125 mg (0.5-2.5 Behavioral observation and electrographic recording continued for one to three hours. In patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral TofrEnil of 75-350 mg was administered. In the acute studies there was initial restlessness, associated with dizziness, dry mouth, "faintness," nausea, mg/kg). and on four occasions, vomiting. These symptoms persisted for lassitude, heaviness eventual drowsiness. Heart rate was 10-20 minutes, and were accompanied by of the extremities and unchanged or slowed. Blood pressure dropped by 20-h0% in �-21.. older (age > 60) patients. Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographoc patterns accompanying these behavioral changes were initiated by a gradual decrease in voltages during the injection. By ten minutes, the per cent time alpha had been halved. In patients with moderate amounts of beta activity, such activity occasionally increased in voltage and per cent time. By twenty minutes, in association with behavioral lassitude, low voltage (to 50 microvolts) random theta frequencies (5-? cps) appeared. In records with post-convulsive delta activity, there was a marked decrease in voltage and per cent time of slow wave activity. These % to two hours. for electrographic patterns persisted There was considerable individual variability in this acute EEG response. In patients who received 100 mg or more of TofrEnil, EEG and behavioral changes were observed in all but three. In six patients, dosage of TofrEnil less than 50 mg were associated neither with EEG nor with behavioral changes. In chronic Tofrénil studies, behavioral changes generally appeared during the second, and were maximal during the third, week of treatment. The most prominent behavioral adaptation was euphoric denial. Patients complained less of somatic displaced their illness became increasingly difficult to discuss symptoms, and denied, minimized or on inquiry. It �-22In six patients them. with significant life relationships and depressive increased and restlessness somatization agitation, restlessness, affect persisted. of cessation the to excitement, insomnia and vomiting, les five patients in noted were symptoms No in change therapy. In three, therapy. showed administration chronic on studies Electrographic Low modulation. record a decrease in voltages with poorer Well 10% appeared. to up cps) activity (5-7 theta voltage few. a in prominent more became defined fast activity after four weeks of NeuroInternationale (Presented at the Collegium the 1958; at September, Psychopharmacologicum, Rome, March, Montreal, Conference on Depression and Allied States, in Published, 1959. EEG Society, June, 1959; and American harmacolo chc Ps of s C.I.N.P.; Proceedin the in gamed. part, Ps Ass. cfiiat. 1959; 32§~332, N. Kline, ed. 19E8. Frontiers, 682-685, and Neurology __3. _E: 1653117159959; _8_: Relationship Therapist-Patient of the 2. Aspects Affecting Choice of Therapy. than other aspects involves The selection of therapy the In the of patient. the manifest behavioral patterns been have problem this further efforts to clarify past year therapist-patient and frustration that We have hypothesized relationship. and implicit relationship hostility in the therapist-patient have a significant environmental pressures or explicit the in factors emphasizing undertaken, influence in referral for somatic therapy. residents with interviews 76 structured In a pilot study somatofor requests and supervisors were initiated following �-23- therapy. These interviews were designed to elicit the basis of the referral. It was found that in only relatively few cases was there a change in the patient's clinical status which directly led to the referral. In most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure from the patient's family or ward personnel. .It was also noted that patients with similar behavior patterns were treated differently, some given somatotherapy and others none. The reasons for this ranged from "whim" to quantitative differences in symptomatology and individual preferences for type of treatment. It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These same extraneous factors also influenced the timing of the referrals. As a result of these findings a "Somatic Treatment Referral Sheet" was developed (see Appendix) to be completed by the therapist whenever somatic therapy is requested. This study is continuing. �-2h. 3. Language Patterns as Measures of Behavioral and Neurophysiologic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that two language measures, a syntactic content analysis (Kahn and Fink, 1958) and dyadic diversifica‘ tion scores of unstructured interviews (Jaffe, Kahn and Fink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interviews on acute administration of various psychopharmacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: amobarbital, benactyzine, chlorpromazine, diethazine, lysergic-acid diethylamide, and Win-2299. Following a routine electrographic recording, an unstructured psychiatric interview, with short periods of structured inquiry, was tape recorded. With EEG running, an intravenous injection was then given at a slow rate. When specific electrographic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was measured for changes in synchronization, shifts in dominant frequencies, and per cent time of slow waves (delta) and beta frequencies. �.25tape recordings were transcribed and measured for the diversification of consecutive 25 word samples of speech of The both participants (dyadic) and for syntactic changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, for each sample the ratio of the number of different words to the total number of words (a diversification score) was calculated. The syntactic language analyses were based on the response to standardized questions using a method previously described (Kahn and Fink, 1958), scoring such changes as syntactic use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophysiologic and behavioral effects of the drugs applied. Amberbital and chlorpromazine are neurophysiologic synchronizing agents. Amobarbital regularly induces high voltage well synchronized fast activity at 20-2h cps, while chlorpromazine administration is followed by increased synchronization of the EEG record and a shift to slower frequencies including occasional slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilization. On the language measures there was an increase in stereotypy and �-26~ repetitiveness associated with increasing use of alterations in tense, displacement and evasion. and / cliches, Diethazine, benactyzine, LSD-25 and Win-2299 are neurophysiologic desynchronizing compounds. These drugs are characteristically associated with decreased voltage and per cent time of alpha activity and increased irregular low voltage fast activity. Behaviorally hallucinatory, excitatory or illusory activity are observed. 0n the language measures there was decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further exploration of language measures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Psychodynamic, Psychoanalytic and Sociamgic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, 1958, and at the American Psychiatric Association, Philadelphia, April, 1959). �-27. SUMMARY lgsh - 1959 out-“n” laboratories of the Department of Experimental Psychiatry were established at Hillside Hospital in September, 19Sh. During this five year period neurophysiologic, and and perceptual), linguistic (personality psychologic sociologic aspects of "somatic" psychiatric therapies have been the principal foci. The Convulsive Therapy: The view of the convulsive therapy process as the induction of a non—specific state of altered brain function, similar to craniocerebral trauma was supported and amplified 1. cerebral Within subjects altered milieu, this 21). ll, were seen to respond in various ways (26), of which the most "successful" was explicit verbal denial (7, 31). This latter (10, adaptation was most prominent in characterologically disposed individuals (36). An alteration in brain function was pre-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were essential to this process (26) but electrical induction was not (B-h2). The alterations in brain function were measured in various ways including electroencephalography (6, ll, 12, 2h, 39), language patterns (b, 7, 1h, 31, h3; B-2h), perceptual tasks (2, 16, 17, 3?, h6; B-26, hl, h2) and tests of Reference numbers are to publications or presentations (Blisted in the appendix. ) �recall (8). It suggested that the neurophysiologic basis of convulsive therapy may lie in an alteration in central synaptic cholinergic - adrenergic relationships, with a predominant shift to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the was relationship of high voltage EEG slow wave activity to behavioral change (6, ll, 26) and the blocking of post-convulsive electrographic and behavioral changes by central anticholinergic agents (21, 3h, 35, bl, h2) and central sympathomimetic agents (h2). A variety of behavioral changes were seen during convulsive therapy (26; B-l7). Such patterns were viewed as adaptations to altered brain function, and were believed dependent upon characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value judgments by the observer of behavioral change in the subject (26). Adaptations characterized by denial mechanisms, both in behavior (B-17) and in language (7, 31) were seen as most favorably rated by the psychiatric staff. Such adaptations were related to habitual modes of conduct (character, personality} (36; B-ll, 32). The persistence of the altered behavioral nodes was noted as dependent upon the degree and duration of altered brain function, the environmental expectations, and the type and �+29- degree of family and medical support (26). Different varying types of behavioral patterns were best supported by psychotherapy (19). Measures of linguistic behavior in structured (7, 31) and unstructured (1h, 29; B-2h) interviews showed characteristic alterations towards increased denial, minimization, displacement, stereotypy and repetitiveness related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21,h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), embedded (Gottschaldt) figures (37; 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years of education, nativity and degree of stereotypy and conventionality (measured by California F Scale) were related to selection of therapy, duration of hospitalization, diagnosis and treatment response in hospitalized patients (15, 36, ho, hS). 2. Neurophysiologic-Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis concerning the mode of action of other therapies such as insulin coma, leucotomy and psychotropic drugs, was expressed (10, 33, 38). This view holds that the efficacy of these therapies depends upon the induction of states of altered brain function, in which �varying adaptive patterns may become prominent. The adaptive pattern is related to the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of drug therapies MY—2092 3. is this hypothesis as applied to psychotropic now in progress, supported by USPHS grants and MY-2715. Insulin Coma Therapy. initial case study showed the significance of denial patterns and of persistent altered brain function for the An behavioral changes in insulin In an insulin coma therapy (3). - chlorpromazine control study, no coma differences in hospital improvement ratings were observed in the two treatment groups (27). Chlorpromazine was safer, easier to administer, permitted continued administration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin some by psychotropic drugs in this institution. h. Pharmacotherapy. The ongoing program in evaluating various psychopharma- ceuticals is derived from these hypotheses. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various new compounds are in progress. EEG patterns, along such continua as synchronization-desynchronization and frequency shift, and various perceptual, perceptual-motor and personality �-31.. and h2) 3h, (21, behavioral bl, to related being tasks, are linguistic changes (21, h3). The neurophysiologic basis of experimentally induced hallucinogenic states has been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis (21, h2) is now being expanded. �.132-" PUBLICATIONS AND PRESENTATIONS 195k - 1959 A. Publications. 195h Patterns of Perceptual Organization with Simultaneous Stimuli. Arch. Neurol. & Psychiat., 72: 233- 255. Bender, M.B ., Green, E. andFFinE, M. 2. Standardization of the Face-Hand Test. “”""§z Neurolo , h: 1. 211-217. Fink, M. and Green, 1955. M. ' Delusional Reduplication of Parts of Body after Insulin Coma Therapy. J. Hillside Hos ital h: 13h-1h7. Kahn, R. L., Fin , . an rau er , h. The Amytal Test in Patients with Mental Illness. J. Hillside Hospital, h: 3-13. Kahn, R.L., Fink,'M. and Weinstein, .A. 3. 1956 Denial of Blindness Following Cerebral Angiography. J. Hillside Hos ital, S: 238-2h5. Fink, M. 6. Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neurophzsiol. Q: 158 (Abst) Fink, M. and Ka n, R.L. 7. Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. & Ps chiat. 76: 23- 29. E. A. Kahn, R. L., Fink, M. and Weinstein, 8. Relation of Changes in Memory and Learning to Improvement in Electroshock. Conf. Neurol. 16: 88- 96. Karin, H., Fink, M. and Kwalwasser, §. 5. 9. Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety. Wachspress, Hillside Hospital killer, . 67- 77. J. S .A. M., Blumberg,'I'WG Fin E, fl. and �~33:. PUBLICATIONS AND PRESENTATIONS 1957 Unified Theory of the Action of Physiodynamic Therapies. J. Hillside Hos ital, 6: 197-206. Fink, M. 11. Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. A.M.A. Arch. Neurol. & Pszchiat..- 78: 516-525. Fink, M. and 10. A w Itajin, ROE. 12. Significance of Individual Variability in the to Electroshock. J. Hillside Green, M.A. 13. EEG An and Response Hospital, 6: 229-2h0. EEG Clinical Response to Megimide. EEG. Clin. Green, M. and Fink, M. Neurophysiol. 2: 180. Objective Study of Communication in Psychiatric Interviews. J. Hillside Hospital, 6: 207-215. J. Jaffe. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hos ital, 6: 216-228. Kahn, R.L., Pollack, M. and Fink, M. 16. Perception of Embedded Figures After Induced Altered Brain Function. Amer. Psychol. 13: 361. Kahn, R.L. and Fink, M. 17. Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli. J. Hillside Hospital, 6: 2hl-2SO. Karin, H. and Fink, M. 18. Perception Experiments in a Study of Ambivalence. Arch. Neurol. & Psychiat. lg: 167-176. Karin, H., Tarachow, S. and Friedman, S. 1958 with Electroshock 19. Psychotherapeutic Techniques Patients. " ‘J. Hillside Hospital, 1: 17-25. Esecover, 3., JaTTe, 3. and Kahn, R.L. 20. Lateral the Sedation Clin. Neurophysiol. l2: 162-163. Gaze Nystagmus as an Index of Threshold. Fink, Mo EEG. �PUBLICATIONS AND PRESENTATIONS 1958 21. Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. A.M.A. Arch. Neurol. & Psychiat. fig: 380.387. Fink, no 22. Effect of Diethazine on EEG and Significance for Theory of Convulsive Therapy. EEG. Clin. Neurophysiol. l2: 207-208. Fink, M. 23. Effect of Anticholinergic Compounds on Post-Convuhive EEG 776 and Behavior. (abst). Fink, EEG. E. Clin. & Neuroph siol. $2: Electroencephalographic Correlates of the Electroshock Process. Dis. Nerv. Sy . $2: 227. Fink, M. and Green, EXperimental Studies of Convulsive and Drug Therapies in Theoretical Implications. A.M.A. Arch. Psychiatry: Neurol. & Psychiat. fig: 733-73h (abet). Fink, M., a n, . . an reen, M.A. 26. Experimental Studies of the Electroshock Process. Dis. Nerv. Sys. l2: 113-118. Fink, M., Kahn, R.L. and reen’ 0 M. 27. Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. J. Amer. Med. Assoc., 166: 18h6-1850. Fink, M., Shaw, R., Gross, G. and Coleman, F.S. 28. ' Clinical and Electroencephalographic Effects of Megimide in Patients without Cerebral Disease. Neurology, 8: ‘ 682-685. Green, M. and Fink, M. Psychiatry, 3;: 2h9-258. Jaffe, J. 30. Communication Networks in Freud's Interview Technique. 29. Language of the Dyad. Psych. Quart. 2g: hS6-h73. Jaffe, J. 31. Changes in Language During Electroshock Therapy. and Ed. P. of Hoch, Communication, Psychopathology Eratton. Kahn, R.Lo and Fink, u n, ., rune M. �-35PUBLICATIONS AND PRESENTATIONS 1959 32. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biol. Psychiatry ed. Massrnan, J., Grune & Stratton, N.Y. pp. 1 -l9 33. Alteration in Brain Function in Therapy. N. ed. Kline harmacology Frontiers, E Co., Boaton, pp. 325-332. Fink, M. 3h. Significance of EEG . Fink, Psycho- Eittle, M. Brown ‘ Pattern Changes in Psychopharmacology. Clin. Neurophysiol. g: 398 (abst). Fink, M. 35. Electroencephalographic and Behavioral Effects of TofrEnil. Canad. Psych. Assoc. J. A: 1665-1718. Fink, M. 36. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. JoNoMoDo 128: 2h3‘2h8- Fink, Mo, Kahn, Roll. and EEG. PoIIacE, HT" 37. Effects of Diffuse Altered Brain Function on Perception. Proc. XV . Int. Con . Psychol. Publ. North-Holland, Amsterdam, pp. 238-239. Fink, M., Kahn, R.L. & Karin, H. 38. Therapy of Schizophrenia: Role of Alteration of Brain Function on Behavior. Congress Re orts II Int. Cong. Psychiatry, I}: E9?-E§3 Kahn, R.L. and Korin, H. labstS. Fink, M., 39. Relationship of Threshold and Duration of Seizures to Degree of EEG Delta Activity Induced During Electroshock. EEG Clin. Neurophysiol. —2: 399 (abst). Green, M. ho. Prognostic Application of Psychological Techniques in Convulsive Therapy. Dis. Nerv. Syg. 32: 180-18h. Kahn, R.L. and Pollack, H. In Press bl. Effects of Psychopharmacologic Agents. szchotropic Drugs, 2: Ed. Bradley P. Fink, b2. Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients. EEG Clin. EEG and Behavioral Neurophysiol. Fink, M. M. �PUBLICATIONS AND PRESENTATIONS In Press (contd) Interview Patterns. The D amics of Psvchiatric Drug There , ed.-3T arwer-Foner, C.C. nomas, Springfield, Ill. Fink, M., Jaffe, J. and Kahn, R.L. hh. Formal Language Patterns as Character Defenses: Implications for Psychoanalytic Technique. Pszchologz of Speech and Hearing Disorders, ed. Barbara, D. ., Grune & Stratton. Jeffe, 3. h3- Drug Induced Changes in Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. A.M.A. Arch. Gen. Pszchiat. Kahn, R.L., Pollack, H. an h6. n, o Set in the Perception of Simultaneous Tactile Stimuli. Am. Jour. Psychol.Korin, H. and Fink, M. The Role of �3. Presentations. 1. Relationship Between Altered Brain Function and Denial in Electroshock Therapy. American Psychiatric Association, Atlantic City. Delusional Reduplication of Parts of the Body after Insulin Coma Therapy. New York Neurological Society, and the New York Society for Clinical Psychiatry, New York. Relation of Changes in Memory and Learning to Improvement in Electroshock. Electroshock Research Association, Atlantic City. h. Quantitative Study of Slow Wave Activity Following Electroshock. Eastern Association of Electroencephalographers, Bethesda. Newer Drugs in Psychiatry. Nassau Neuropsychiatric Society, Long Island. 3. 1956 Changes in Language During Electroshock Therapy. American Psychopathological Association, New York. Electroencephalographic and Clinical Effects of Megimide. Eastern Association of Electroencephalographers, New York. 1957 8. Perception Experiments in a Study of Ambivalence. Section of Neurology and Psychiatry of the New York Academy of Medicine and the New York Neurological Society, New York. Individual Differences in EEG Responsivity. Metropolitan EEG Society, New York. 10. Criteria in Evaluation of Clinical Behavioral Change. Round Table Discussion, American Psychiatric Association, Chicago. 11. Personality Factors in Behavioral Response to Electroshock Therapy. Electroshock Research.Association, Chicago. �938PRESENTATIONS 1957 12. EXperimental Studies of the Electroshock Process. Society of Biological Psychiatry, Atlantic City. Effects of Diffuse Altered Brain Function on Perception. XV International Congress of Psychology, Brussels. Therapy of Schizophrenia: Role of Alteration in Brain Function in Behavior. International Congress of Psychiatry, Zurich. The Relation of Ambivalence to Aggression and Authority in Psychoneurotic Patients. American Psychological Association, New York. 16. Perception of Embedded Figures After Induced Altered Brain Function. American Psychological Association, New 13. York. 17. Behavioral Patterns in Induced States of Altered Brain Function. New York Divisional Meeting, American Psychiatric Association, New York. Objective Study of Communication in Psychiatric Interviews. New York Divisional Meeting, American Psychiatric Association, New York. Significance of EEG Frequency Shift for Psychiatry. Metropolitan EEG Society, New York. Effect of Diethazine on EEG and Significance for Theory of Process of Convulsive Therapy. Eastern Association of Electroencephalographers, New York. An 1958 Correlates of the Electroshock Process. Eastern Psychiatric Research Association, New York. 22. Significance of Individual Variability in EEG Changes During Electroshock Therapy. Eastern Association of Electroencephalographers, Montreal. 23. Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications. New York Neurological Society and the New York Society of Clinical Psychiatry, New York. 21. EEG �-39. PRESENTATIONS 1958 Patterns with Altered Brain Function. Eastern Psychological Association, Philadelphia. The Relation of F Score to Behavioral and Psychological Response with Altered Brain Function. Eastern Psychological Association, Philadelphia. 26. Intensity of Stimulation and Perception of Simultaneous Stimuli in Cerebral Dysfunction. Eastern Psychological Association, Philadelphia. Communication 27. 28. 29. 30. 31. 32. 33. 3h. 35. SociOoPsychological Aspects of Diagnosis and Treatment: Theoretical Implications (Symposium). Eastern Psychological Association, Philadelphia. Drug Induced Changes in Interview Patterns. Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (Tranquilizing) Drugs in Psychiatry, Montreal. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy. American Psychiatric Association, San Francisco. Social Factors in Selection of Therapy in a Voluntary Mental Hospital. American Psychiatric Association, San Francisco. A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon". American Psychiatric Association, San Francisco. Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Electroshock Research Association, San Francisco. Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Society of Biological Psychiatry, San Francisco. Role of EEG Frequency Shift in Behavioral Effects of Drugs. Section of Neurology and Psychiatry, Queens County Medical Society, New York. Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior. American EEG Society, Atlantic City. �shoPRESENTATIONS 1958 Prognostic Application of Psychological Techniques in Convulsive Therapy. Eastern Psychiatric Research Association, New York. 37. EEG and Behavioral Effects of Psychopharmacologic Agents. Collegium Internationale Neuro-Psycho Pharmacologicum, Rome; and Eastern Association of Electroencephalographers, New York. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock. Eastern Association of Electroencephalographers, New York. 1959 Effects of Tofranil. International Conference on Depression and Allied States, Montreal. Sociopsychologic Factors Affecting Therapist-Patient Relationships. American Academy of Psychoanalysis, Philadelphia. Effect of Induced Cerebral Dysfunction in Man and on Tachistoscopic Perception of Embedded Color Figures. Eastern Psychological Association, Atlantic City. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction. Eastern Psychological Association, Atlantic City. h3. Sociopsychologic Aspects of Psychiatric Treatment. Eastern Psychological Association, Atlantic City. hh. Language Patterns as Measures of Behavioral and Neurophysiologic Change. American Psychiatric Association, Philadelphia. EEG and Behavioral �C. Reports in preparation: 1. 2. 3. Experimental Studies of Convulsive Therapy - a monographic review. EEG Patterns and Synaptic Events in Experimental Hallucinogenic States. Comparative Study of Indoklon and Electrically Induced Convulsive Therapies. Studies of the Sedation Threshold. Effect of Induced Cerebral Trauma in Man on the Tachistoscopic Perception of Embedded Colored Figures. Individual Differences in the Perception of the Upright in Hospitalized Psychiatric Patients. Social Attitude (California F Scale) and Convulsive Therapy. Sociopsychologic Factors in Drug Therapy. Modification of Psychotherapeutic and Supervisory Relationships by Altered Brain Function. �’os. Relation Between Altered Brain Function and Denial in Electroshock Therapy Robert L. Kahn, Ph. D. Max Fink, M.D. Edwin A. Read , at the Weinstein, M.D. Annual Meeting American Psychiatric Association, May 1955. the Research Service of the Hillside Hospital, and the Department of Neurology of the Mount Sinai Hospital, New York. From This investigation was supported in part by the Medical Research and Development Board, office of the Surgeon General, Department of the Army under Contract No. DA-h9-OO7 MD-3763 and grant M-927 from the National Institute of Mental Health of the National Institutes of Health, Public Health Service. �Although many theories concerning the mode of action of electroshock and psycholphysiological among the relationships been have offered, therapy (3,h,5,6) studies In previous understood (1,2). remain poor v ogical factors certain function, that was suggested of brain it of patients with alterations of effects the to therapeutic related of the observed patterns of behavior were electroshock. dis(3,6), anosognosia of or illness denial included patterns in and language, (8) changes time and (7), reduplication orientation for place that indicated was It (9). paraphasia misnaming or particularly nonaphasic These than rather of illness the stress to these phenomena were fonns of adaptation neural of milieu the In judgment. Specific defects in memonv, perception or motivations his the expresses damage, patient brain reorganization provided by the with modes of interaction changed of in new s,rmbolic patterns indicative of forms insuch denies the delusion patient In anosoynosic the environment. of an the and operation, fact blindness, of a limb, loss capacity as hemiplegia, as well as other problems in livinfi. In disorientation for place, the way in the symbolic as serves hospital which the patieit be need to the often traumatic situation, representation of some aspect of the the locates or of familiar place a name the he uses well and go home. Thus, misnames and mislocates the the outside hospital. a confabulates journey his to or close hospital academy" skating "roller a as the to hospital 'When a paraplegic patient refers names Mount the (Mount Cyanide, Sinai) hos the ital or a paranoid patient calls home symbolize the patient's feelings in dramatic fashion. In paraphasia, the ob- a to personal related usually are patient jects the Thus, patient and of hospitalization. illness that problem, particularly and and objects the of places body, selects aspects of the environment, parts which are misnamed by the in of his a feelings the exnression for them language his in uses n interaction. new mode of �.3. could be brought out by the administration of amytal sodium ("positive amytal test"). 'With a return of the complaints of pain these changes in behavior were no longer apparent either clinically or under amytal. This sequence of events were repeated during two Subsequent courses of electroshock. While this report supported the hypothesis regarding the therapeutic action of electro- test" in investigating the probdid not represent the usual condition for shock and showed the usefulness of the "amytal lem, it concerned only one case and is given. The theory is further tested in the present study in which a group of potients receiving electroshock for mental illness were given repeated amytal tests before, during and after the course of treatment. The purpose of the study was to determine the relationship between the clinical response to the which electroshock treatment and changes in behavior produced by the drug. theses tested were that those patients more likely to show: (1) evidence The particular hypo- improved with electroshock would be who of brain dysfunction on the amytal test and (2) behavior patterns indicative of denial. METHGD series of amytal tests. In this test, the patient is asked a standard group of questions pertaining to orientation and the patient Each awareness of was given a illness. The drug ution at a rate of .05 grams (1 is then administered intravenously in a cc) per minute until nystagmus, slurred drowsiness and errors in counting backward are noted. now repeated. The The same 5% sol- speech, questions are following changes, when persistent, are called "positive" and are deemed indicative of cerebral dysfunction. 1. Complete denial of illness. 2. Denial of major aspects of illness, such as attributing entry into hospital to a trivial or past illness. 3. Misnaming the hospital, either euphemism as "rest home." its proper name, or in terms of a �ah. Displacement of the location of the hospital, such as to another city. 5. Confabulated journeyt 6. Reduplication of the hospital, as stating that he is in another hos~ pital of the same or similar name. 7. Disorientation for time of day with confusion of day and night. misidentification of the examiner such as calling or an "entertainer". 8._ Gross him a "lawyer" 9. Disorientation for year. The patient was given his first test prior to treatment, and re-tested at weekly intervals. All patients in the series had negative amytal tests prior to the initiation of therapy. Treatments were administered three times a week, so that the patients were generally tested after every third treatment. A test after a treatment. Testing was continued after the termination of therapy until the result had become negative. of and records standard tests memory and learnElectroencephalographic ing ability were also given, but will not be considered in detail in this paper, was always given two days POPULATION Twentyufour patients at Hillside Hospital receiving electroshock with the Reiter Electrostimulator were studied. There authors. The patients were taken on the was no basis of consecutive referrals, and the determination of the necessity for treatment was Some patients were selection of cases by the made by the clinical necessarily excluded because their treatment staff. was terminated or interrupted before they were adequateLy studied. Another was omitted because he had manifestations of brain disease and a positive amytal to electroconvulsive therapy. thirtyvthree. Patients treatments. Some The number who showed test prior of treatments varied from nine to clinical improvement tended to receive fewer of this variability could also be ascribed to differences in the inclination of the resident psychiatrists to use this form of treatment. �~5One patient decided for himself that he had enough treatment and eloped. gnostically, the patients consisted of 1h with depressive schizophrenia and one manic reaction. There were 15 and the ages ranged from 2h series, to 68 reactions, women and 9 men 9 Dia- with in the with a median of h7. of response to E.S.T. Evaluation.Wa— M~~ All the patients were observed for at least eight weeks after completion of treatment. on Determination of the patient's response to electroshock was made staff opinion, the the basis of the resident psychiatrist‘s impression, nurses' notes and the clinical evaluation of one of us (M.F.) who supervised the treatments but was not aware of the amytaltest results. In this way the pat- ients were classified into three groups. gfiwwyarkedlv Improved; The 11 cases in this group were regarded as show- ing recovery or marked improvement. These patients no longer showed the ptoms which brought them symp into the hospital; their doctors felt they were better; and the nurses' notes confirmed such aspects as being able to sleep without medication, better appetite, and improved capacity to get along with the other patients and participate in hospital activities. B. Moderatelv Improvegz_ The six patients in this group showed some improvement but continued to manifest indications of mental illness. These patients typically relief, i;§:, acute depressive features showed symptomatic might be gone, but the dramatic change so evident in the apparent. Each patient continued to show some first group was not noticeable disturbance such as obsessional thinking, paranoid ideas, or somatic preoccupation, C. Minimally or Unimnroved. In this group were placed seven patients in whom change was not ient improvement. somewhat improved. clearly noticable or Some showed But who showed only equivocal or trans- fluctuations in behavior, at times appearing the change was not sustained, so that by the end of �9-6- much did before. as they appeared treatment, they are aware of the difficulties in evaluating improvement. Others might In by these any case, of in patients. change estimates the have differed in and the between first the differences using this threefold classification, We third groups will be distincto OBSERVATIONS l. flggjggL Test Results of The number tests given amytal Reactions. of A. Distribution Positive -um-W from to three thirteen, ranged electroshock of the course each during to patient shown the data Table is In maintained. I, depending on how long treatment was . for the number of and number and percent posthe treatment tests given during The improved patients markedly each in the group. patients itive for all moderthe with unimproved the group, showed many more positive reactions than between these groups. Every markedly improved ately improved patients in On other the treatment. reaction during ient had at least one positive amytal cases unimproved of the and five hand, one of the moderately improved patients the of incaach A the results of comparison showed result. a positive never the than better at significant groups, using chi-square, is statistically level of confidence. TABLE I pat—_ 1% WWW DISTRIBUTION OF POSITIVE ANITAL TESTS DURING TREATMENT ” No. of tests given durinc treatment Markedly improved (ll) Moderately improved (6) Unimproved (7) Number positive % Positive 50 38 76% 39 15 38% hS 6 13% the In groups of Fig. treatment. each l stase at B. Positive reactions who had positive each in of group the patients percentage for are compared » �treatment. of each stage at results after reactions had positive Almost half the markedly improved patients nine to seven after reactions had positive and.all treatments, three only treatments. In the unimproved cases, on of number positive the hand, other the of the course during increase consistent no was and there small reactions was other the between to tends fall improved group moderately the Again, treatment. two. Although some than more received patients 15 treatments the data is not small too became each number in group the because presented beyond this point than more received unimproved patients of the Four of comparison. for purposes mode One the of with consistently negative amytal test results. 20 treatments occasionally an with only treatments 30 received over improved patients erately positive reaction. There were variations in the per- reactions. positive a .e-u' two consecleast at Using week. week to from sistence of positive reactions improved, markedly the of nine of persistence, criterion the as utive positives showed perunimproved group the of one and only two of the moderately improved C. Duration_3§ “-5 one but patients treatment all of termination the ,After sistent positives. The reconvulsion.. the last after nine days had negative amytal reactions treatment. week after second the by test negative a developed maining patient improved group markedly the in D. Factor of awe. Since the patients conceivis reactions, it from depressive suffering be older tended to persons to age be scley related might results test able that the difference in amytal assum— the is this Underlying improvement. clinical to coincidentally and only funbrain altered show of signs to more s likely i older the person that ption | shown. each is 2 for group mean the Table age In electroshock. when given ction �-8. TABLE 2 RELATIONSHIP OF CLIEICAL_IMPROVEMENT TO AGE Than Age Markedly Improved (ll) h7.6h 0' Moderately Improved (6) 50.00 Unimproved (7) 35-29 It is apparent that the first patients. two groups were older than the unimproved Yet, while the mean age of the moderately improved cases higher than the markedly improved group, theSe patients still show is slightly significantly fewer positive reactions. In Table 3 the number of positive reactions during treatment is shown of he over to age. limited years patients the analysis is for In this table the relationship of positive reactions in the different groups remains unchanged from that when the groups are considered as a whole. each group when TABLE 3 OVER hO PATIENTS IN AMITAL'TESTS DISTRIBUTION OF.EQ§EE;VE a... No. of tests given durine treatment_ Number positive % fpsitizg Markcdly Improved (1m) h6 35 76 Mederately Improved (5) 3h 15 hS Unimproved (3) 17 O O 2. Other Aspects of Behavior. were there and disorientation of denial illness explicit and the of drug influence the under both occurred changes in behavior that fashion progressive treatment is of significantly the course clinically during Apart from in those patients who improved. These aspects may be divided into verbal and non-verbal communication. A. can: Channes in Verbal Language. These consisted of denial expressed in �-99.. evasion and in the use of a syntactical pattern involving the third and second When person. asked about their symptoms patients gave such answers as "it's hard to say" or “I forgot" or "I don't know; I‘ve been waiting for the doctors tell as "it's to me." The change what they in syntactical person is illustrated by such remarks call a depression," "I‘m afraid answering the question "what trouble." Sometimes In patients patients is talk of a relative would there One to the start of treatment what will get hurt" or your main trouble" with "what who improved in the non-drug interviews. somebody was a who was is 3223 main sick. notable development of such patterns patient, for example, whenzisked prior his main trouble, said "I'm depressed." such was After two treatments he answered the question with "I don't get along well with my mother-in-law." After five treatments he said "I don't get what you he said know." After ten I that‘s "I all sick; get after eight, what 11 "in and said way after don't my see wife," "right now, it‘s that I do you mean" and "I don't know how to explain it." At the termination of given home" an followed by "I to want main get was as trouble his tr atment, mean," and account of how "good" his wife was. of these group, increased the use the other hand, on In the unimproved language patterns did not occur. They were not present in some, minimally or inconsistently noted in others. In some of the unimproved patients there was than the of drug the under effects of these language patterns actually less use there had been in the pre-amytal interview. ..B. clinical in Changes in Non-Verbal Behavior. and drug interviews most frequently the moderately improved and improved. Euphoric reactions occurred both in in the markedly improved, less least in the group which were considered un- In the unimproved patient classed as manic, euphoric behavior was present in his clinical behavior and was not changed by amytal. �-10—‘ of of four interviews the amytal in apneared Changes in sexual behavior other the of each in one in only but patient the markedly improved patients makthe examiner, caress hug to form of or This took the trying categories. ing remarks with sexual content or engaging in masturbatory ient in the unimproved group showed activity. this behavior both during are-drug A pat- inter— views and under the influence of amytal. Withdrawal or "selective inattention" was shown by nine of the eleven the amytal of the phase drug during markedly improved patients particularly about the questions answer to of failure consisted interview. This behavior fashion. and cryptic in dysarthric responding and hospitalization or illness the other each of groups. in once occurred only the drug under This reaction who appeared the category unimproved two in of that patients It was interest withdrawn before the test became more responsive under the influence of the drug. ravage: there is that indicate these in patients tests the of anwial results damage or brain of and the production improvement between clinical a relation method of determined this by particular an altered state of brain function as The examination. In patients who improve, the amytal test becomes consistently treatment. of the course in early positive In moderately improved or unimproved does not increase and frequency their reactions patients there are fewer positive such function brain methods of evaluating with more treatments. With other the in showed abnormalities All not patients present. close correlation was found frequently as was and * learning impaired record electroencephalographic damage The brain of effects who did not. those who improved as in in patients are not unitary and different methods of study show varying results. more analyzed_in being are these data in patients a The electroencephalographic the show that The findings preliminary be reported elsewhere. detail, and.will amytal the to comparable EEG improvement, to related abnormality is Wegree of test findings. �.11 - in to changes function brain of altered In relating the various aspects behavior after electroshock therapy defects in the formation of In the of language. first symbol it has been helpful to distinguish between patterns and defects in the adaptive uses category one may include such clinical phenomena as loss. of memory and certain types acalculia aphasia, apraxia, finger agnosia, cannot select he but wants he "know" to what say In aphasia, the patient may and movements and sounds of the appropriate elements from the entire category of elements excannot select the defects With patient memory integrate them. them temporal pata in and units arrange significant perience, class solving of problem manifested in tests commonly also tern. Such defects are fre— Such are patients scale. and in certain subtests of the Wechsler-Bellevue them into quently concerned with their and of marked anxiety degrees and exhibit defects frustration. Adaptive changes in language, on the other hand, relate to interaction They behavior. of motivational aspects the with the environment and concern The besame and disorientation. denial of are exemplified in the phenomena and other in defect a conditions as havioral element may appear under certain cases as a part of an be may example, for form of adaptation. Left~ri9ht disorientation, impaired and is of right which the left concept aphasic defect in a paralyzed able to identify seem not may Other however, patients, or lost. or and ear left arm their (non-paralyzed) Show right their left arm, but can relate not does and as long as it of right knowledge left similarly indicate a the not in electroshock of prois action therapeutic to their illness. milieu neural the in providing rather but formation duction of defects in symbol The in which altered forms of adaptation may be maintained. outcome of electroshock treatment by the psychiatrists predict the Other point treatments. the initial amount of "confusion" that occurs after The test amytal Leprovement. to not related was "confusion" where to cases Many �-12.. should be useful as a prognostic guide by defining the nature of these changes. In cases "confusion" some patients the amytal test mainly a matter of memory defect and in these may be negative. On the other hand, some patients imp such Clinical In of evidenae few without treatments "confusion." a after prove instances the amytal procedure may show an alteration in brain function. In may be this study almost half of the markedly improved patients had positive reactions In another case, treated privately by one of us (E.A.W.), within three treatments. after only two result prior to treat- marked improvement of a severe depressed condition was noted convulsions. Yet this patient, who had a negative amytal ment, showed a markedly positive reaction one day These results do not than patients brain damage ectly measure brain damage, but rem that mean who do improved not improve. rather after the second treatment. patients have a The amytal one deduces test greater degree of does not dir- the presence of braincianage the nature of the adaptive changes in communication. Thus patients with brain damaje who do not show such changes are considered to show a negative re- im~ methods of behavioral demonstrating other that sult. It is for this reason paired brain function may not distinguish between improved and unimproved patpositive do and not others amytal a Why some develop test, patients ients. despite many more convulsions is unclear, but factors and to the patient's habitual mode may be related to personality of adaptation to stress. It is be so function brain of altered state treated a that nevertheless, necessary, that these forms of adaptation or denial can be maintained. It is for these which electroshock methods of administering believed that reasons that it is be not seizures will generally unilateral as function brain minimally alter efficacious. Also it affords some explanation as to why electroshock often has a beneficial short term effect while evaluation of long ternleffects little difference between treated and untreated cases. show �-13In considering what constitutes "improvement," it is likely that such evaluations are dependent in considerable degree on the types of verbal and patient denies that imp he rated and is and uncomplaining, affable he has any problems, appears he has developed he that has or does mean not acquired insight that It proved. non-verbal adaptation that the patient uses. a more realistic understanding Thus, when a of his interpersonal relations. exemplified by the patient previously cited who said he This is well was "depressed" in third person when asked about his illness. While his behavior is rated as improved, actual analysis of his language shows that he is using different forms of symbolic the pre-treatment interview, but later used evasion and use of the adaptation. Recent mechanisms of studies have supported the findings concerning the development of denial in the improved patients. Carter (12) confirmed Janis’ (13) findings of consistent evidence of circumscribed amnesias in patients lowing electroshock. He that general memory impairment did not occur, "selectivity" in forgetting of unpleasant material concluded but rather, that there was a from the fol- patient's past life. Komgold (11;) likewise reports selective and "mechanisms of observes (15) Teicher similarly, sensitized forgetting. highly repression" for "emotional" stimuli after electroshock. Another aSpect of the difference between the improved and unimproved groups which may bear a relation to the therapeutic proved patients there were more changes in all not only in verbal patterns. Thus, a patient mechanism was that in in, types of symbolic adaptation, who appeared withdrawn both in the pre-drug and drug interviews had a poorer prognosis than the patient became withdrawn only under the who showed who effects of the drug, Similarly, the patient altered sexual behavior under the effects of the drug had exhibited this behavior during the prenamytal questioning as well, and did not improve with treatment, while the four patients manifesting sexual behavior only under �fill!" the effects of the drug, did improve. The importance of the change in symbolic pattern is also illustrated by the fact that the unimproved manic patient showed no changes in this aspect of his behavior during the amytal test. It is thus likely that the facility of changing symbolic patterns in a situation of added stress is an important one in determining response in all somatic therapies. �SUMMARY AND CONCLUSIONS ment treatelectroshock for consecutively referred (l) Twenty-four patients the during intervals and at regular during were given amytal tests before, courSe of treatment. (2) There proved to be a close relationship between the shorteterm tests. of the anwtal results treatment and.the to sponse patients showed early, persistent re- The much improved positive reactions during patients showed no positive reactions or and increasingly the course of treatment. Unimproved intermediate group who showed infrequently and inconsistently. unimproved the than reactions showed more positive moderate clinical improvement of reincidence positive the much in improved the of short group but fell far An showed them actions. (3) Changes in behavior forms of non-verbal and language were most consistent and pronounced related to denial in the improved group, even in interviews not employing drugs. (h) The improvement clinical that the hypothesis support observations function in of altered.brain milieu of a in electroshockzmequires the creation mainbe may of those denial, Which new patterns of adaptation, particularly tained. �mmmmggzg 1.) Gordon, Fifty H. L. : 2.) Kalinowsky, L. Shock Therapy Theories, Mil. Surg. $92: 397, l9h8. B. and Hoch, P. H. Shock Treatment, PBychosurgery and : Other Somatic Treatment in Psychiatry, (2nd ed.) 3.) ’Neinstein E. & 1..) Psggrchiat. A. and Kahn, R. L. _6}_1_: Syndrome : Ybrk, 1952. of Anosocnosia, Arch. Neurol. 772-791, 1950. 'E‘Jcinstein, E. A., Kann, R. L., Sugannan, L. A., and Linn, L. Use of Amobarbital Sodium in Organic Brain Disease, 889-8911., Am. : Diagnostic J. Psych., llg: 1953. S.) weinstein, E. A., Kahn, L., and Malitz, S. R. Its the "Amytal Test" for Brain Disease: A. M. A. Arch of 6) New weinstein, E. Serial Administration of : Diagnostic and Prognostic Value, “enrol. and Psychiatu 11: 217-226, A. and Kahn, R. L. : 1951.. Denial of Illness: Symbolic and Physiol- ogical Aspects, Springfield, 111., Charles C. Thomas, in press. 7.) Weinstein, E. A. and Kahn, R. L. Brain Disease, J. Neuropath. 8.) & : Patterns of Disorientation in Organic Clin. Neurol. l; 21h-226, 1951. and R. A. L. E. L. A.: Kahn, Sugarman, weinstein, , A. M. A. Arch. Neurol. uplication, 9,) 'weinstein, E. 0rg-tanic Brain Psychiat. M. A. Arch. Neurol. 10.) weinstein, E. A., Linn, L. and Kahn, R. L.: Its Relation to the Therapy: {31: 808-8111, 1952. L.: Non-aphasic Misnaming (paraphasia) in A. and Kahn R. Disease, A. & Phenomenon of Red- & Psychiat.,‘éz: 72-79,l952. Psychosis during filectroshock Theory of Shock Therapy, Am. J. Psych., $925 22-26, 1952. 11.) Mcinstein, E. A. and Kahn, A. M. A. Arch. Neurol. ness, 12.) Carter J. T.: Type convulsive Therapy, 13.) Janis, I. L. : R. & L.: Personality Factors in Denial of Psychiat. Ill- Q2; 355-367, 1953. of Personal Life Hemories Forgotten Following ElectroAm. Psychologist §; 330, 1953. Psychologic Effects of Electric convulsive Treatments Post-treatment Amnesias.) J. Nerv. & Ment. Dis. ill; 359, 1950. (I. �REFERENCESz 1h.) Korngold, M.: An Shock Treatment, 15.) Teicher, A.: Investigation of Am. The continued Psychologist Q; Some Psychological Effects of Electric 381-382, 1953. Effect of Electroconvulsive Therapy actions of Schizophrenic patients, Am. on the Visual Re- Psychologist, g, hhS, 1953. �] ONS I REACT. 90 ._” much Improved (11) '*~ Mod. Improved ‘ 80 ” Unimproved (6) /// (7) / t// ‘\\\\\\_ //////////’ “~. * AMYTAL POSITIVE 3o PERCENTAGE 20 / / / (“” \ " , ,/ . " / x,” I f 10 O ' h-é ,__.._..7..___.-_....-_,_....__.-..;}..-.__ 7-9 10.12 13.15 NUMBER OF TREATMENTS occurring reactions test amytal of positive Fig. I.-—- Percentage treatment. of stages different each at in group �{fw g; ,{1/,m»‘-‘ JUN 26 ”12!. :c. .M Altered Brain Function Following Electroshock H—927 Progress Report - February 1 1958 - September 1 1959 Summary: In the past eighteen months various studies of the convulsive therapy process were completed, a program for the investigation of psychopharnacologic agents consistent with the general hypothesis concerning the node of action of physiodynamic therapies was developed. The physiologic effects of nany interrelationship of the neuro- new compounds with the psychodynanic, perceptual, personality and sociologic aspects of patients' behavior provided the framework for tnse investigations. following areas of study were explained: l) of psychotherapy with physiodynanic therapy; The the interrelation 2) the elucidation of the synaptic chemical events which are the basis of the convulsive therapy process by the acute administration or experimental anticholinergic compounds at various stages of convulsive therapy; and behavioral 3) studies of the acute and clinical effects of a EEG variety of psychopharnacologic agents; h) the use or language indices, such as syntactic and dyadic~ 1959 �-2- diversification analyses, as measures of behavioral neurophysiologic changes with drugs; and 5) a comparative study of indoklon and electrically-induced convulsions in psychiatric therapy; duration of 6) sociopsychologic aspects related to hospitalization, discharge ratings and diagnosis in a voluntary mental hospital; 7) the relation of social attitude to the effects of convulsive therapy; 8) aspects of the therapist- patient relationship affecting aha: choice of therapy; 9) studies of individual differences in the selection of, and behavioral change with, convulsive therapy by perceptual aethods. These studies have supported and expanded the neuro~ physiologic-adapative view or convulsive therapy, and demonstrated that such a hypothesis has applicability to our understanding of the node of action of psychepharnacologic agents. �Progress Report: A; Psychotherapy and Physiodyganic Therapy. Previous observations have shown that two types of patients are referred for electroshock in this hospital. largest number are patients in the older limited education and are foreign born, age groups who have They tend to introspective persons, stereotyped in their thinking language and verbally unconmunicative. symptoms The The be non- and Their predominant are depression, agitation, withdrawal and sonatisaticn. second, and smaller, group of patients are younger, native- born, better educated, and verbally ccnnunicativo with a capacity for intropection. They characteristically exhibit thinking disorders and overactive behavior states, with sonatisation and depression occurring An to a lesser extent. oratory explanatory study was undertaken of four patients, two for each group described above, for the purpose of determining 1) reasons for referral for convulsive therapy, 2) whether the differences in patients required different attitudes in psychotherapeutic nanagenent with electroshock, and 3) the �-1... relation of the psychotherapsutic approach to the patient'e clinical response to electroshock. It was found that all of the patients studied were electroshock because of a failure of connunication referred for in the psychotherapeutic relationship. In a reflection of the limited verbal and cases this was two introspective capacity social factors. In the of the patientdue to educational and other two cases, however,-the inpaired communication primarily due wee to unmanageable acting out. Following treatnent, the older, less educated patients were able to naintain this improvement with a reassuring and to nininication the tendencies denial toohniqne,-supporting during developed electroshock. electroshock eeened to make In the better educated patients, the patients nore’anenable to an psychotherapy. torn of interpretive It or psychotherapy was concluded that the relationship to electroshock varies with the particular_type of communication pattern and adaptation shown by the individual patient. This �-5. the and been Journal written up published in material has or Hillside Hospital, 7: 17-25, 1958. B; Biochemical Aspects of the Convulsive Iherapz Process. The significance or high voltage the convulsive therapy process (Roth and Kahn, 1957) and the EEG 22.;l! delta activity in 1951, 1957; Pink report that this delta activity was 'blocked hy the adninistration of ahtioholinergic'compounds; atropine and scopolanine (Ulett and Johnson, 1957) provided the basis for these studies. As there were attendant unpleasant, 'systenio effects with the administration of these agents, .reports describing diethasine as an anticholinergio'conpound' (Jenknerwith potent neurologic but minimal systemic effects l956) Lechner, studies 19553 to.undertake led Lechner, us and sinilar to those of Ulett (Fink, 1958). and Johnson neing this'conpound These observations with diethasine led to the agents. of other antioholinergic experimental investigation Clinical and electroencephalographic responses to the intravenous administration of various anticholinergic agents �-6in psychiatric patients at various stages of convulsive therapy were studied. These observations were related to hypothesis covering the node of action of convulsive therapy and of hallucinogens. The subjects were ninety psychiatric patients referred for convulsive therapy, ranging in age tron Ivariety of diagnoses. since some The total or 18 to 67, with a 107 observations were made, subjects were studied with more than one compound. A drugs were administered at various stages of the treatment process. The observations were laboratory using a standard electrodes. In each intravenously at a trial, 8 made in the EEG channel instrument and needle the compound under star was adninistered until set rate per minute with clinical behavior or electrographic changes were observed. The compounds studied have been diethasine, Win-2299, benactyaine, JB~318, JB~336, and atropine. Each is a potent anticholinergic agent in vitro. It was observed that diethasine, Win-2299, benactysine, �-7; JB-318 or JB-336 administration therapy were associated with at various stages-of convulsive a) desynchronisatien of rhythms with a blocking of post-convulsive b) EEG delta activity; alerting, excitatory behavioral response with illusory, de- lusional and hallucinhtory ideation, and c)_systenic effects ‘drynessof muscular veakness, degrees of the mouth, dry skin and tachycardia. . The electrographic. behavioral and systemic effects were concurrent. These observations are regarded as consistent with the. suggestion that the physiologic basis of convulsive therapy lies in an increase in central nervous system cholinergic activity. Observations that LSD, amphetamine, nescaline and diphenhydranine- synpathoninetic and antihistaminic agents also induce EEG ~ convulsive of desynchronisation, blocking post delta activity and clinical excitatory activity support the suggestion that both the behavioral and electrographic patterns are based on alteration in synaptic activity. Increased synaptic activity (cholinergio, synpatholytic effects) is �-8. associated with 336 hypersynchronisation, and clinical eedation and euphoria; while decreased synaptic synpathominetxic) is associated with clinical excitatery activity (anticholinergic, EEG and hallucinogenic desynchronisation and states. Discrepant observations with the anticholinergic agents, atropine, are considered to be related to significant differences in dongs and structural chemistry. This material was presented EEG at a meeting of Society in Atlantic City, June 1h, 1958. the American �-90. Acute and Chronic EEG and Behavioral Psychophersscologic Agents. Iffects of According to our neurophysiologic~adaptive view of the clinical the convulsive therapy process, efficacy of repeated induced convulsions is dependent upon the induction of a persistent alteration in central function, providing a nilieu for changes in the subject's interaction with the exaniner. In our studies the best index of neurophysiologic change has been those aspects of cerebral function reflected by delta activity in the electroencephalogram (Pink and Kahn, 1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of a similar hypothesis for the node of action of these agents, and to studies of the relationship and specificity of altered behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of the psychopharnaceuticals tested in acute experiments an in increase in synchrony with or without activity has an increase in slow been observed for chlorpronazine, pronazine and triflupronasine. Behaviorslly, these drugs were associated wave �-10with a) increasing sedation, drowsiness, denial and eqhoria; b) decreasing agitation, panic, excitement hallucinatory activity; of synptons. and and delusional and c) minimization and displacement Barbituratee regularly induced an increase in fast activity with an increase in synchrony, with the associated behavioral changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony; behaviorally they resulted in behavioral alerting, hypcnania, excitement activity. and increased motor Decrease in voltage and per cent time of slow wave subjects with pcst~convulsive delta activity activity in was seen with Lsnazs, benactysine, Win~2299, JB-BlB, JB-336 and diethasine. Of these drugs, benactysine produced increased alerting, excitenent, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional The and paranoid ideation. electrographic patterns were consistenthfiltered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, �.11sedation and minimisation of symptoms were conversely associated with increased EEG the delta range. and hallucinations synchronisation and shift of frequencies to Agitation, tension, panic, excitement, illusions were associated with desynchronisation of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorpronasine and delta activity barbiturates, and enhanced augmented the per cent clinical pattern; agents that chronised frequencies, as diethasine, minimised the LSD-25 and tine desyno benactysine, clinical effects typically ascribed to repeated. convulsions. Following these preliminary observations more intensive undertaken. was of an (Totranil), agent, inipranine investigation In 28 can3:§:::: acute experiments, patients referred for physio- dynamic therapies were stages of treatment. tested in the EEG laboratory at various Tofranil solution (10 ng/cc) was adninistered intravenously at a set rate(l'cc/h0 sec) until electroencephalographic �total of or behavioral changes became prominent, for a mg (.05«2.5 ng/kg). hO-125 Behavioral observation and electrographic recording continued for one to three hours. A second group of ve, withdrawn 16 patients nanifesting depressienl or retarded bdnvior and were whp referred for pharmacotherapy, received daily oral Torranil of 75-250 mg for four weeks or longer. In the acute studies there was initial restlessness, associated with dissiness, dry mouth, 'faintness," nausea, and on tour occasions, vomiting. These symptoms 10-20 minutes, and were accompanied by lassitude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. persisted for Heart rate was Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographic pattern accompanying these behavioral changes were initiated the injection. halved. such In {our By by a gradual decrease in voltages during minutes, the per cent tine alpha had been ten patients with noderateonnouniiof beta activity, activity increased in voltage and per cent time. By twenty �-13minutes, in association with behavioral lassitude, low voltage 6 to 50 nicrovolts) randon theta frequencies (5-7 cps) appeared. In six records with poet-convulsive delta a marked decrease activity. two in voltage and per cent time of slow patterns persisted for These electrographic was wave 5 to hours. variability in the There was considerable individual acute of activity, there EEG response. In patients totranil, but three. who received 100 mg or more angptehavioral changes were observed in all In six patients, dosage of Tofranil less than 50 EEG associatedéwith were either EEG mg or behavioral changes. In the chronic Tofranil studies behavioral changes generally appeared during-the second, and were maximal during the third, week of treatment. The most adaptation was euphoric denial which They conplained or displaced prominent behaioral noted in eight patients. was less of somatic synptois, their illness on inquiry. It and ed ed denial. mininisetien became increasingly difficult to discuss significant lire relationships with then. �' ~1h- in three patients sonatiaation and restlessness increased and depressive affect persisted. In two of these, restlessness, insomnia and vomiting led to cessation of therapy. symptoms were noted change in in five patients after four weeks of therapy. Electrographic studies minimal changes. No on chronic administration shoved Voltages became lower and record modulation poorer. Well defined fast activity became more prominent, and in four subjects, low voltage theta (5-7 cps) activity noted. was Details of these studies were presented at the Collegiun Internationale Neuro«Psychopharmacologicum, at the Conference 1958, and Rone, September 12, on Depression and Allied States, Montreal, March l9~2l, 1959. D. Patterns as Measures of Behavioral and Language Neurophsziolegic Change with Drugs. In previous studies of the convulsive therapy process, was demonstrated analysis ( ) that two language measures, and dyadic syntactic content diversification in interviews ( ) provided objective indices of behavioral change, and were related to the degree of altered brain function. In a further it‘ �-15- test of language measures as indicea of behavioral and neurophysiologic change, they were next applied to recordings or interviews on acute administration of various psychopharnacologic agents. At the present time 72 interviews with patients at various stages of drug therapy have been analysed, using the following agents: anobarbital, benactysine, chibrpronazine, diethasine, lysergic~acid diethylanide, and Vin-2299. Following a routine electrographic recording, an psychiatric unstructured physiologic interview, with slow periods of structured inquiry, was tape recorded. With EEG running, an intaavenous injection was then given at a slow rate. specific electrographic or clinical changes interview was repeated. When were induced, the Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The EEG was shirts in (delta measureg'tor changes in synchronisation, dominant frequencies, and per cent and beta frequencies. tins of slow waves �-16The rthe tape recordings were transcribed and measured for diversification of consecutive 25 word speech and for syntactical changes.‘ samples of dyadic In the dyadid analysis, participants both of behavior verbal the pooled divided into total i;g., the ratio of the number of different number of words. . . The transcribed, samples, and for each sample a diversification 25 word score was calculated, words to the was syntactic language . analysis were based on response to standardised questions using the nothod previously described ( ), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial or symptoms, use of stereotyped expression or clichzs, cryptic response, and withdrawal or silence. Consistent changes were observed in both the dyadic diversification and syntactic language measures in subjects classified according to the neurophpiologic and behavioral effects of the drugs applied. Anobarbital and chlorpronasinc are neurophysiologic synchronising agents; anobmrbital regularly induced high voltage �-17. well synchronised administration fast activity, at was followed by 20-2h cps, while chlorpronasine increased synchronisiation of the record and a shirt to flower frequencies including occasional EEG slow wave burst activity. Behaviorally these drugs are associated with sedation and tranquilisetion, there was an On the language measures increase in stereotypy and repetitiveness associated with increasing use or cliches, alterations in tense, displacement and evasion. Diethasine, benactysine, LSD~25 and Win-2299 of the neurophysiologic deaynchronising.compounds. characteristically induce decreased voltage of alpha activity and increased irregular are examples These drugs and per cent low voltage tine fast activity. Behaviorally they are associated with hallucinatory, excitatory or illusory activity. On the language neasures they induced ' decreasing repditiveness, wider diversity o: words, lesevariability of diversification scores, and decreased use or cliches and alterations in tense. neasures Further exploration of language are suggested as a rational basis for the understanding or the psychologic �-13- effects of the new therepies. Details of these studies have been presented at the Conference on Paychodynenic, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April 11—13, 1958, end Aeeocietion, American the Psychiatric et Philadelphia, April 27, 1959. E. Coupereble study or Indoklon and Electrica11y~ Induced Convaleiona in Pczchietric Therepz. A In our investigation or the-node of action of convulsive therapy we have previouslymnnducted a convulsive-subconvnlsive control study. This study demonstrated that e significant behavioral change occurred almost exclusively in patients receiving grand nel electroconvulsive therapy. The present report in an assessment of the relative neurophysiological behavioral and clinical effects of two different methods of and convulsions current) (alternating electrical inducing inhalent (indcklon). �Twenty—five consecutive patients referred for convulsive therapywere studied. They were randomly divided into two groups, 13 patients receiving grand nal therapy induced by the standard while convulsions were Medcratt alternating current instrument, induced in the renaining 12 by the inhalation of hexafluorodiethyl- ether (indoklon). In both groups treatment time a week for a on the total of 10 to 2h wee administered three applications, determined basis of clinical criteria by the supervising psychiatrist. All patients were tested one to two days prior to the first treatment, following 10-12 treatnents, and following the of lest treainent. The two weeks tests given included intellectual functioning (rive subtests measures ' from the Wechsler- perception (figure—ground Bellevue Intelligence Scale), figures, the perception discrimination using embedded.geonetric of peeuoisochronatic color plates at high speeds of tachistoscopic exposure, and the Street incomplete figures test), and social attitude (the Levincon revision of the California I Scale). An EEG was given during each of the testing periods. �-2066 from continuum slow wave cent a tine activity the per second sanple was used as the index of neurophysiologic change. results failed to The test differences show any between the electroshock and indcklon groups at each of the three test periods. showed significant intergroup Intragroup analysis, however, that during treatment both groups on the intellectual and peripheral on the F scale. By two weeks tests, made increased errors and had high scores after the termination of treatment both groups returned to near pretreatnent levels for most Both groups were comparable slow wave activity in the mean EEG after tests. for the degree of induced 10-12 treatnents. The s user per cent tine delta for the indoklon group was 51%, and for the_electroshock group h7.5%. Within each group individual the of behavioral were to related degree change in differences physiologic change, those with the highest per cent tine delta showing the greatest behavioral change. Bath between change in test activity with treatment and correlation performance and degree of slow wave were positive for all procedures, except the comprehension subtest of the Wechsler-Bellevue)and reached a level of statistical significance for Digit Span (e .61, p <-.Ol), �p( object Assembly (+.h6, .05), tachistoscopic perception (+.67, embedded figures (*.h3, p 4< F scale (+.38, p < p < .05), .01) and perception of .05). This study has denonstrated that two very different convulsant agents may produce similar neurophysiologic behavioral change. and It is concluded that behavioral changes in convulsive therapy are related to the degree of altered brain function, and are non-specific for the type of agent used to induce the convulsion. Details of this study were presented at the Eastern Psychological Association in Atlantic City, April, 1959. Sociopszchological Aspects of Psychiatric Treatment. F. In a previous study of the Hillside Hospital population, it was shown tht the factors or age, education, place of birth and social attitudes as measured by the California I scale, were related to the selection of therapy. ‘Those patients were older, had less education, were foreign-born and with high stereotpy scores on the F scales were more whp likely to receive �-22- convulsive therapy. 'In contrast, patients who were younger, the on low and obtained scores native-born educated, better as psychotherapy received scale, their sole F form of treatment. study the relation determine to was Further undertaken of duration hospitalto factors of eociopsychological 1)_th° 2) the isation, The Hospital 171 16 final diagnosis. 3) the and inspatient of Hillside population adult entire on March 7, 1957 was patients. to 68 57 nan and llh studied. This consisted of from in age ranging wonen, median of 35-years. with a years, It period clinical discharge, of time evaluations at was (1—5 shortest the for hospitalized that patients found the least education, were months) were oldest, had foreign-born, the scores andlad highest been have to most likely on the 1 scale. Iounger,native-born, more educated, lower r '(10 more or the longest score patients were hospitalised months). The sane hospitalisation factors of of length to these rdationship made were when analyses found separate was �-23according to diagnosis and type of treatnent (convulsive therapy or psychotherapy). Discharge evaluations of improvement in the population studied were total related to age, the significantly older patients having the nest favorable ratings. Analysis of the data by type of treatnent, however, demonstrated that the convulsive therapy patients ratings of recovered or among much improved were F given to those patients with the highsst scores, least education and who were foreign-born. Diagnoses of schizophrenia or psychoneurosis were associated with lower and high native birth. F The F scores, younger ages, more education older, less educated, foreign-born, score patients were more frequently classified as involutional or nanic-depressive psychosis. It is postulated that these relationships reflect the ingluence of social background on psychological processes, such as the behavioral patterns of communication, nodes or expression and symbolic values. These not only contribute to the pattern or mental illness, but affect all aspects of �~2h- the patient-therapist interaction. Details of this study have been presented at the Eastern Psychological Association in Atlantic City, Avril, '1959, and at the Academy of Psychoanalysis in Philadelphia, April 26, 1959, and has been accepted for publication in the Archives of General Psychiatry. 0. The Relation of Social Attitude to the Effects of Convuleive Therapz. As F indicated in the previous section, the California scale has been found ueeful in understanding factors related to the referral for convulsive therapy and the evaluation of clinical response following have been undertaken with questions: population? a treatnent. Further studies such this scale in regard to the following 1) What does the F scale neasure in our psychiatric 2) What are the behavioral changes induced with convulsive therapy? 3) How are theee changes related to the degree of altered brain function? �-25answer the To first question, in part, the entire in-patient population of the hospital was given the later One month they were retested with a "reverse" in which each statement original. The was changed "reverse" scale was F scale. F scale, to the opposite of the scuzred in the same manner as the conventional scale, with high scores this procedure reflecting greater to determine agreement. The purpose of whether the to the contents related patients' responses were was of the statements, or were a manifestation of a more general personality aspect, such as acquiescence. It was found that those patients who made low scores originally, indicating predoninant disagreement with the statenents, indicating who made showed a large increase the "reverse" scale, on In contrast, patients a high degree of agreement. high scores initially showed little change on retesting, agreeing with the statements to the sane extent even though the meaning was reversed. low I score patients are while those with high It is more evident that, in our population, critical I scores are more and discriminating persons, undifferentiating and �.26.. and stereotyped in their reactions. is related to the process of selection This observation or patients for convulsive therapy. A high degree of atereotypy or thinking and communication is inconpatable with the establishment of a conventional psychotherapeutic relationship, preventing the psychoanalytically-oriented psychotherapy stressed at Hillside Hospital. It follows that the high sill be F score patients unsuccessful in psychotherapy and nest likely reterred for convulsive therapy. To answer the second end patients were given the treatnent period) and F third questions raised above, 69 scale before, during (at 10-12 after convulsive therapy. Ten of these and the control constituted random, group at selected 'patients, received subconvulsive electrostinulation. nean There was a increase of 05.7 during treatment in the convulsive group, a difrerence significant at the control group (+0.5). The showed an SS level. In contrast, the insignificant change during the cane pertd extent or increase in the convulsive patients was �-27- related to the degree of cerebral dysfunction as found to be determined by delta delta (h0% +8.6. activity on the EEG. Those F patients with high or more of the sanple record) had a nean increase of low with delta indices, however, showed a patients statistically insignificant increase of the The +3.h. Following treatnent scores were comparable to the pretreatnent levels. These findings support and elborate previous observations the effects of convulsive therapy. on the F Greater agreement with seere scale statements during treatment stereotypy and difficulty in discrimination. show conventional The change in I n . P score thus seen part of the same process shown by the z characteristic language changes of increased denial, evasion, qualification, I and use of cliches and stereotyped orpressions It is also comparable to the increased visual tactile perception ( and ( ) difficulty in and figure-ground ( ). complex discninination )- Details of these findings were presented at the Eastern Psychological Association in 1958 and will be elaborated at the �forthcoming Divisional nesting of the American Psychiatric Association in H. flew Zork. Aspects of the TherapistaPatient Relationship Affecting Choice of Therapz. As indicated previously the selection or therapy involves other aspects than the actual behavioral pattern or the patient. In the past year further efforts to been undertaken, emphasizing relationship. clarify this problem have factors in the therapist-patient he have hypotheSised increased tension, frustration and that such factors as hostility in the therapist~ patient relationship, as well as implicit and explicit pressures present in the environment have a significant influence in referral for sonatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests fir sonatotherapy. These interviews were designed to referral. It there was found a sudden change elicit the basis of the that in only relatively few cases was in the patient's clinical status which directly led to the referral. most In instances there had been �-29- or progression no change the presenting eynptons. in‘ Factors of impending included the to timing contributing the referral diccherge, avoiding administration discharge, and pressure tron the patient's family or ward personnel. It res also noted were'treatod that ptiients with ainilarhehcvior patterns given senatotherapy and others none. The 4‘ renged reasons for this raged from'"whin" to quantitative difference! differently, some . in synptonetelogy and individual preferences for type of treatment. initial The conclueien wen that in a significant 0; cases, factors other then clinical indication played number a role in the referral. These sane extraneous factors also influenced the timing or the referrals is e results of these findings Referral Sheet" to was completed by the From c ’Scnatic Treatment developed‘(see form at end or report) to therapist whenever somatic therapy is reqneeted. this questionnaire we hope to obtain further information regarding indications for somatic treatment, more specific data �-30. concerning the therapist-patient interaction, and a more definite idee of the therapist's expectations for such treatment. I. Individual Differences in Selection of, to Convnlsive.Theragz. and Response In the elucidation of individual differences related to sonstic therapy, a variety of peripheral-cognitive procedureshave been used. tachistoscopic perception of enbedded colored figures The has been given to 65 of 35 consecutive were 20 patients. experimental group consisted The convulsive referrals for therapy. The controls patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment. All subjects were tested prior to treatment, and after four weeks; the convulairee were tested s third tine two weeks following the cessation of treatment. It was found increase in that there mean number was a statistically significant of errors with convulsive therapy, while following treetnent there was e significant decrease from the pretreatment scores. at Controls made significantly fewer errors �.31- (practice effect). errors between patients classified (per cent time delta) were significant difference in There was a when compared as showing low with high high retest correlations for all groups. EEG changes changes. EEG Marked There individual ditferences in response patterns were noted prior to treatment. With brain changes there was a reduction in perseveration, conpletion patients, and contabulation in some and and increase in others, with no unique patterns attributed to cerebral dysfunction. Even in those patients with high his response pattern was showing completion type to make such EEG 'stjh' changes, the ntein naintained. Thus a errors prior to treatment ore patient would continue errors with convulsive therapy, although the threshold at which completion was shown might change. Details of this study were_presented at the Eastern Psychological Association in Atlantic city, April 1959. The Red and h? Irene Test (after Witkin) was administered to Harked somatic for referred therapy. consecutively patients individual dirierencee in performance were correlated with age, �w _‘“ .v .32-‘ education and score on the Calibrnia vertical Judgment of the frame (field dependent) F scale. Patients whose fies strongly influenced by the sunnunding were more frequently referred for convulsive therapy than drug therapy. No significant change ‘ was found with drug or.convulsive treatment. convulsive groups retest correlations drug For both/and were high (.86 and on differences in the individual considered that is It Frame test reflect personality factors that are in psychiatric treatment. .88). Rod and of importance �5 “J a , :1: 7/16/59 L, wig/r 1 _/ Function Brain Altered Following Electroehcck ‘ 24.927 Progress Report - Febmary 1. 1958 - September 1, 1959 m: L previous In our studies we have demonstrated that an understanfing of the convulsive therepy process required a nultifectoriel approach involving neurophysiologic, perceptual, personality, paychodynemic and eocielogic eepecte cf behavior. Thus is essential it wee ehcwn that: The convuleim to the therapeutic process (Fink, Green end Kuhn, 1958); murcmeielegic changes reflective of altered brain function ere e a Heinetein, 1956; Fink & Kenn. 1957) neceeeery prerequisite for behavioral change end ixproveemt‘ the (Kuhn, Fink biochemical beeie of the convulsive therapy preceee lay level of cholinergic activity of the central nervous is an mm increased (Fink, 1958); there are characteristic perceptual chengee with altered brain function induced by convulsive therapy (Fink, Kuhn and Korin, 1957; Kehn and Pink, 1957); retina cf improvement after convulsive therapy are related to personality characteristics defined by Rorschach and {mm (Kahn and Fink, 1958). interviews (Kuhn and Fink. 1957); end that evaluations of �mm (Kuhn 8.: -2. were related to changes in syntactic aspects of language Fink, 1958). In the pest eighteen (18) months these statics wen completed and extended, and an investigation of poychophamcologic agents begun. The {mark View we for these investigation: of convulsive therapy (Veimtedn Fink and Kahn, 1957) extended mandarin patients (Pink, The been the nmxrophyeiologic adoptive Kahn, 1955; Knhn 8c at all, 1956; to other physiodynenic treatmmta or 1957) . tho convulsive therapy process were relieving aspect- of studied: 1. Siflficence or the Commune Mologic, A cooperative study of neuro- paychologic and bohemian). effects of electrical and inhalant (Indoklnn) induced convuhicaa. 2. @2326 Basic of NeuroMiologg-c Chang: Further studies of the effects of acute wtmtric 3. “notation agents on both the Mgwogo AoEm of of marinentnl anticholinergic 'noml“ and and pout-convulsive EH}. Comm Thomas 3. Relation of the factors or age, education, nativity and �n3. mmotm (mound w the California max-aw, duration of 1:. Chang“ clung» to EEG hoapiuuuum, of F 1" scale) with selection of diagnosis and diochnrgo ratings. scale with treatmnt, and relation of those indiceo. h. Mother-Lg and Conwlsivo Tim-ram: In aupervioory sessions, alterations in psychotherapy with convulsive thorapy were studied. W: 5- Both patterns or change and individunl diffomnooo on tuohistoocopio figumfl ground flicker immoy domination tutu, critical and perception of the upright with induced ‘ emulsions were studied. 5093*ch are «tended to dmg therapies and the following studies undertakom 1. 1010 :1. c: Relation of EEG charge on acute and ohmnic administration of poychophamoouticals to clinical behavioral change. b. EEG as a screening device for psychomrnceuuc potency. �.. h .- c. Elation of 6. EEG EEG clause: to hallucinogenic activity. effects at neginide. 2. Omnicstion Patterns: Relation of induced neurophyeolcgie change to dyadic diversifi- cation and syntactic language maeuree. 3. Aspects of the Therapist .. Patient Relationship affecting choice of somatic therapy. metudiec View have supported and expanded the mumphyaiologxo-adapuu of convulsive therapy, and dancnetrated that. such a applicability to our understanding of the mode munch has of action of psycho- phamacologic agents. PROGRESS A. tar: l. REPORT: Gasman new?! PROCESS figniricance of the Convaleion: A cmmrable study of Indoklcn and electrically-induced convulsime in psychiatric therapy was control eubccmuleive completed. An mm demonstrated changes occurred almost exclusively electrocomruleive therapy. The earlier convulsive- that. uinIicant behavioral in patients receiving grand mal present report is an assessment at �-5the relative neurophysiologic, behavioral and clinical effects of hm different of. methods inciting convulsions - electrical cuxjreet) and inhalant (indoklon) . (eltemating 'consemtive patients referred for convulsive therapy Thaw-nave classified into were tendonly Won / 3Wt, / . ,:./ patients and by two groups the steward - «isms Model-oft mowed in alternating current in. in twelve by the inhalstion of heMlumdetlvl—ether findeklon). In both groups treatment was ochinistered three times a .5 {f} [f book for a total of IKE/o: x! I! if / 3' 10 to 21; applications, determined on the basis clinical criteris by the supervising psychiatrist. ,f‘. \ A All patients were tested one to two days prior to the treatment, following 10.12 treatments, and first m weeks renewing the lost tacatment. In addition to evaluations of behavioral. change, tests included nouns-es of intellectual function (five aubtests In the Kodachr-Bellme Intelligence Scale), perception (figure-groom! discrimination using wedded geamtric figures, the perception of pewdeochrcnstic color plates at high speeds of toohictoocopic exposure, and the Stmt moguls“ figure: test), and lucid �.- 6 1e etfltude (the Lennon revision of the California 1" Scale). An testing of each the periods, obtained during electroencephalogram was on! mom-ed for the per cent. time slow we (6 ope or slower) activity from a continuous 66 second sample. The to failed Insults show any significant inter-group teat differences between the electroshock and indoklon groupe at each of the three test periods. Inbregtoup groupe made onlyale, that during treatment both increased errors on the intellectual and perceptual taste, end had higher _ hmr, showed some on the F scale. By two weeks otter the terminal-g for tion of treatment both groupe returned to near pretreatment. levels ' moat mete. Both groupe were comparable for the degree of indeeeed wave activity after for the 10-12 treatments. indokloa group was 51% and The EEG slow per cent time slow activity for me electroshock group It? 5%. within each group individual differences in behavioral change were the with thoee change of neurophysiologic the degree to reload behavioral change. the greateet sharing delta cent tine highest per �-7mm: order correlations batman changes in test performance and degree of slow wave activity with treatment. were positive fer all proeedwes, except the eomehension subtest of the Wechalar-Bellevm, level of statistical significance for digit. span 1" scale (4* .33, 13 .05). .01), object Assembly (hub, and reached a (+ 1,61, p p .05), ucmnoacopac perception (+.67, p of embedded figures («13, p This study demonstrated .01) and perception .05). that up different eonvulsant. agents produce similar neurophysiologic and behavioral changes. eencluded that. the behavioral change It was is related in convulsive therapy/to the degree of altered brain function, and an non-specific for the type of agent. used to induce the eohvulsion. (mud, in part, at the Eastern Psychological Assecatien, Atlantic City, April, 1959). 2. modicum ”mate of the Convulsive The significance of high voltage There}?! l’fit‘eceae2 m delta activity in the convulsive therapy process (Ruth 213.1) 1951, 1957; Fink and Wm, 1957) and the report that this delta activity ministration (mate was blocked by the of the antteholinergic agents atropine and scepolamine and Johnson, 1957) provided the basis t‘or mane studies. As �- 8 a. there Here attendant unpleuent systemic etfeote with the comm-tre- tion of these agents, report: describing diethulne as an entioholmcrglc effects (Jenknor compound with potent neurologlc but mm manic and Loohner,19553 Lechner, 1956) 13+. us studies similar to those of Ulett and John-on using (Rink, 1956). These observations with diethacine this to mderteke compound lot to the investiga- tion of other experimental antichollnerglc agents. Clinical and electroencephalographic responses to the intravenou- adninistration of dicthaxine and atropine in plychntrlc patients at therapy were studied. Each The Win. 2299, is bemctyam, JD 318, dB 336 various: etegee of convulsion a potent antiohollnergic agent 121 um. eubjecte were ninety psychiatric patients referred for convulsive therapy, ranging in age from 18 to 67, with Wes. A total of 107 observations were rude, a. since variety of some subjects were studied with more than one compound. The observations were 8 channel made in the EEG laboratory ucing a standard instrument and needle electrodes. In each coupound under study was tual, the mastered intravenously at a set rate �-9 .. per minute until clinical behavioral oz- eleetrogrephic changes were observed. It was was observed that salinistrstion of these sntichonnergic agents associated with e) dosynchmmisstion of bloom of post-convulsive delta activity; EEG 1:) rhythms with s alerting, excitstory behavioral response with illusory, delusional end Mllucinatory mention, and c) systemic effects of muscular weakness, dryness of the south, dry skin and techycerdia. end systemic effects The electromfluc, behavioral were concurrent. These observations are regarded as consistent with the suggestion that the physiologic basis in central of, convulsive therapy nervous system cholmergic Observations that LSD, lies in an increase activity. substantive, nasceline sympathemnetic and antihistaminic agents - and diphenhydmmns also induced convulsive d‘ delta desynchronisation, blocking post EEG activity clinical oucitstory scfiviw support the suggestion that the and mvioral md electrogrsphio patterns of these compounds are also based on alteration in synoptic activity. Increased synaptic activity (cholinergic, synpethclytic effects) is sssocieted with - EEG Immora- synchreniseticn, and clinical sodation and euphoric; while decreased �.. 1o - synapmc activity (anticholimrgic, sympathmimtnc) is mandated with dosynchmniution and clinical excihtory and hallucinogmic EEG states, thus supporting the Wthesia mually described mama by Wilder (19514). algont, atropine, Deacrepant observations with the anticholinergic are considered to be related to significant differences in dosage. (Presumed, in put, San d‘ Biological Paymatry, the Society at first Francisco, 1958 and awarded tbs Award of that Society; and, in part, at City, 1959. Published, in part, 380-387, 19573 and accepted 3. Socio a. A. E. Bennett cal 01 A A 1. A American EEG PsycIfiItrio Research Somty, Atlantic Arch. Neural. & cMat. g9. for publiaation, ma Olin. Nemflmool.) shiatric Treatment ate of Duration at Hoggtaluation. Dawn and .' Madam Evaluation. In an earlier study of the Hillside Hospital populationmahn, Pollack birth :3: and Pink, 1957). it was noted social attitudes that age, causation, place of F California measured the by as were related to the aelecfim of therapy. Those pation‘ua older, had less education, scores on the F scale, who were were foreign-born am with high stereotype scales were more likely to waive convulsive therapy. �- 11 In oontmt, petiente I ‘ who were .. younger, better eduoehdmetiveobem end obtained it»: theeoree on the 1’" scale, received peyoheflmerepy ee their sole router treatment. nutty Another wee undertaken to determine the relations of theee eodepeyohologioal factore to 1) the duration of hospitalization, 2) the Meal evaluations at time of discharge, and 3) the final diegxoaia. The entire impatient edalt population studied. This oomieted on! maize in age from 16 to 171 68 patients, years, no: on March 7, 1957 was 57 men and 11]; mo, a median of 35 years. Patients hospitalized for the shortcut period (1 - 5 months) were noted to be the oldest, have the least education, were more likely to be foreign-hem, and have the highest scores on the “ scale. Younger, native-bum, more educated, loner months). (10 more the or longest each hoepitelieed ship of: F more patients The same these factors to length of hosmtelizetion was found eepehte Ienelyeee them F relation» when were made according to diagnosis and type of (eomleive thempy or peyohotherepy). �,' 12 u. Discharge evaluations of improvemnt were significantly related _ to age - the older patients having the most favorableratingm Miami! of the date by type of treetnent,hovever, demonstrated that among the oeuvulsive therapy patients rating: of recovered or much inproved were given to those patients with the highest F scores, least education and who were foreign-born. Diagnoses of schizophrenia or peyohomuroeie were undated with lower F eeoree, younger ages, more education and native birth. The older, less educated, femignnborn, high more F score patients were frequently classified as involutionel or mic—depressive psychosis. It was postulated that these relationships reflect the influence of nodal background and psychological proceeoee, such as the behavioral patterns of communication and modes of expression. These Thane not only oontflbute to the pattern of mental illness, but affect all aspects of the patientoflxerapiet interactim. (Pmeented at the Beaten: Psychological Association, Atlantic City g April, 1959, and the Acedm of Psychoanalysis, Philadelphia, April, 1959. Accepted for publication, Archives of General Psychiatg.) �.. 13 .. 13. Treatment. Convuleive with Social Attitude in Gwen: Following the earlier observations that the California is 1“ scale useful in understanding mien-a1 for ccnvuleive therapy and the evaluation of clinical reepcnee following such treatment, fizz-flier studies were undertaken with thieeeale in regard to the {alluring 1) iihet deal the F scale measure in a psychiatric question: a population? 2) Dc 1“ scores change with convulsive therapy? 3) Are these changes related to the degree of altered brain function? entire in-patient population of the heepital was given the The :16 one month scale, in later, was retested with a "reverse“ finch each statement wee changed The “reverse" scale as to the opposite or! F F scale, the original. scored in the same manner as the ccnventicnal scale, with high ecoree reflecting greater agreement. It was noted that than patient: who made low scores initially, showed an with the statements, disagreement indicating a wedcninant increase on the "reverse" scale, indicating a high degree of agreement. In contrast, patients the mde high scores little change on initially shaved same the to etatexunte the with agreeing reteeting, �.. m .. extent even thong: the nearing was reversed. let: P score patients are more critical and It is evident that diesflmimting persons , while those with high F scores are more undifferentietihg and stereotyped in their reactions. This aberration is related to the process or selection of patients for convulsive thmpy. thinking and commutation on! A high degree or sterotwpy of is incomtsble with the a conventional psychotherapeufic rehtionship, psychoanalyticslly—oriented psychotherapy stressed Hospital. It follows that the high F establishment meeting the at Hillside score patients will be unsuccessful in psychotherapy and most likely referred for con- vulsive therapy. In anotlmr study, sixtr-ndne patients were given the F scale berm, during therapy. Ten (st 10-12 treatmnt period) patients, selected at group and received subconvulsive mean increase in group a. F random, and after convulsive constituted a control electrostimlsuon. There was s. score of +5.7 during treatment in convulsive a difference significant at the 5% level. In contrast, the �- 15 In confines. the control group .. showed an insignificant change during the echo period (+0.5). The extent of increase in me convulsive petiefits was related to the degree of cerebral dysfunction es <1er by delta sctiflw on the m. The patients with my: d6“? (1:010: 3955 of the mp1” 1‘3“”) had a // l'hebe patientsvith mean ' increase e a ’8’6” f low delta indioes, however, off 43.14,. Following treatment the showed an increase 3 2/ 15’03&8tashv ,f 1/ / ”(7/ -/'4,7,3? ,. V ,2” / / ,. /"5 scores were comparable to the levels. ‘ , ‘ “these ,flndmgs support and eleborste previous observations on the [5%. ,2)" , 7752/ 1" cadets” e’f convulsive therapy. Greater agreement with the ,. scale ‘f std/Wes /} F during treatment show conventional stereotypy and 3" /r (35“:ow I _ 1n discrimineuon. Changes in F score thus parallel the fo’hehoteristio hnguege changes or increased denial, evasion, /// " , ,/,.L‘ ,r l7 //qdeiflicetlon, ' / / and use of cliches and stereotyped expressions (Kuhn ‘ j" & 2 Fink, i953) . It 1. .1“ ompmble to the increased difficulty in / / l / / cochlea: visual and tactile perception (Flak, fairs-groom discrimination j’(heseo1{;e§ at. Knhn (Karmic Fink, 1957). /flbyohletrlc Association, at the Divisions]. Meeting of the American 3' ‘81 I ‘- r {'1' 4" Karin, 1957) and the Eastern Psychological Association, 1958; and aeoepced for?" presentation ‘ 8: New York, November 1959.) �~16- h. Psychotherapy and thsicdzgamic Therapy: Previous studies indicated that patients referred for of electroshock in this hospital are/two types. The largest number are patients in the older education and are foreign born. age groups who have They tend to be limited non-introspective persons, stereotyped in their language and thinking and verbally unconnunicative. Their predominant symptoms are depression, agitation, withdrawal and somatisation. The second, and smaller, group of patients are younger, native-born, bettereducated, and verbally communicative with a capacity for introspection. They characteristically exhibit thinking disorders and overactive behavior, with lesser degrees of aonatisation and depression. Four patients, two for each group described above were studied to determine 1) reasons for referral, different attitudes management, and 2) whether were required in psychotherapeutic 3) the relation of the psychotherapeutic �-17. approach to the patient's clinical response to convulsive therapy. It was suggested that these patients were referred for convulsive therapy because of a failure of communication in the psychotherapeutic relationship. a In two cases this was reflection of the patient's limited verbal and introspective capacity related to educational and social factors. instances, however, the impaired communication by unmanageable was In two manifested acting out behavior. Following treatment, is older, less educated patients were able to maintain a behavioral change with a reassuring, supportive technique, amplifying tendencies to minimization and denial developed during electroshock. In the better educated patients, electroshock decreased acting out was associated with increased use of interpretive forms of psychotherapy. It uas concluded that the relationship of psychotherapy to convulsive therapy varies with the communication pattern �~18 - and adaptation shown by the individual patient. (Published in the Journal of Hillside S. Hos ital, 1: 17-25, 1958). Perception: A variety of perceptual-cognitive test procedures have been studied in l. patients receiving somatic therapies. Tachistoscopic Perception of Colored Figures: The Embedded This task was studied in an experimental group consisting of 35 consecutive referrals for convulsive therapy, and "control" groups of 20 patients treated with phenothiazine medication (thorazine and pronasine) and ten patients receiving no somatic treatment, matched for age. All subjects were tested prior to treatment, were and tested akhird time after four two weeks weeks the convulsive patients following the cessation of treatment. There was a number of there statistically significant increase in errors with convulsive therapy, was a significant decrease mean and following treatment, from the pretreatment scores. "Control” subjects made significantly fewer errors (practice �-19- effect). significant difference in errors between There was a patients classified as delta) when compared showing low with high EEG changes (per cent changes. EEG tine There were high retest correlations for all groups. There were marked individual differences in response patterns prior to treatment. With brain changes there was a reduction in perseveration, completion and confabulation in some patients, and an increase in others, with patterns attributed to cerebral dysfunction. patients with high pattern was EEG no unique 3V0“ in thOBO changes, the ”style" of his response maintained. Thus a patient showing completion type errors prior to treatment would continue to make such errors with convulsive therapy, although the threshold at which completion was shown might change. were Details of this study presented at the Eastern Psychological Association in Atlantic City, April 1959. 2. Rod and Frame Test gWitkinzs This task was administered to h? patients consecutively referred for somatic therapy. Marked �- 20 - with correlated age, were in performance individual differences education and score judgment of the frame (field on vertical was dependento were more frequently referred for No significant treatment. found with drug or convulsive convulsive groups It retest cerrelations change For both drug and were high (*.86 and +.88). is considered that individual differences Frame whose influenced by the surrounding strongly therapy. than drug convulsive therapy was Patients the California F.ecale. on the Rod and of importance are that factors test reflect personality in psychiatric treatment. B. PSYCHOPHARHAOOLOGIO STUDIES 1. Neuroghzsiologic Studies: view the of neurophysiologic~adaptive the to Acoprding convulsive therapy process, the clinical efficacy of repeated induced convulsions is dependent upon the induction of a providing function, nervous central in alteration persistent the with interaction the in subject's a milieu for changes examiner and the environment. In these studies the best been of those has aspects change of neurophysiologic index the electnoin by delta activity reflected function cerebral �enoephalogran (Fink and Kahp,1957). The efficacy of newer psychopharnaceuticals in altering psychotic behavior patterns has led to the suggestion of aI/fl ,1 1} similar hypothesis for the node of action of these agents{ and to studies of the relationship and specificity of altfired behavioral patterns to neurophysiologic change as reflected in electroencephalography. Of an the psychophsrmaceuticals tested in acute experiments increase in syhchrony with or without an increase in slow wave and activity has been observed for chlorpromasine, pronasine triflupronasine. Behaviorally, these drugs were associated with a) increasing sedation,drowsiness, denial and euphoria; b) decreasing agitation, panic, excitement and delusional and hallucinatory activity; and c) minimisation and displacement or synptons. an Barbiturates regularly induced increase in fast activity with an increase in synchrony, with the associated behavorial changes of sedation, euphoria, denial and minimization. Amphetamine and methamphetamine increased fast activity without increased synchrony and behaviorally were associated with behavorial alerting, hyponania, �- - 22 excitement and increased motor activity. and per cent time of slow wave post-convulsive delta activity Decrease in voltage activity in subjects with was seen with LSD-2S, bcnactyzine, Win-2299, JB~318, JB~336 and diethasine. Of these drugs, benactyzine produced increased alerting, excitement, tension and panic; the other drugs also produced illusory sensations and hallucinatory, delusional and paranoid ideation. The electrographic patterns were consistently altered concurrently with behavioral changes both in the acute and chronic administration studies. Tranquilization, euphoria, sedation and minimization of symptoms were concurrently associated with increased EEG synchronization and shift of frequencies to the delta range. Agitation, tension, panic, excitement, illusions and hallucinations were associated with desynchronisaticn of frequencies. Similar patterns were demonstrated in subjects with prior delta activity. Agents that tended to synchronize frequencies, as chlorprcnazine and barbiturates, augmented the per cent tine delta activity and enhanced the clinical patterns; agents that desynchronized frequencies, as diethasine, LSD-25 �-23and benactyzine, minimized the clinical effects typically ascribed to repeated convulsions. Various experimental psychopharnaceutioala were tested. In addition to extensive studies or 3-3 methylethylgiutarimide (Heginide) and hexetluorodiethylether (Indoklon) the following nhsnyltoloxanine (PHD-Bristol), methenalide agents were studied: (BLH~lfll;lhristol), tropin-h-Ghlorhenzhydryl ether (WI-21h9, Wyeth), dinethylaninsethanel and verieties, Riker), JB-3;;, its oongeners (Deaner and 329 and 336 (various piperidyl- Geigy). and (Torrinil, Lakeside) inipranine bensilatss, significant behavioral Because or 31:31 changes, a was and electrogrephic intestigation of imipramine (Torrinil), nere intensive undertaken. In 28 acute experiflmenta, consecutive patients referred for physiodynnmie therapies were tested in the EEG TofrEnil solution of treatment. various stages at laboratory (10 ng/oc) was administered intravenously until electrographic or behavioral changes a total of h0-12S mg at a set rate (1 cc/ho sec) became prominent, (0.5-2.5 mg/kg). Behavioral observation for �«Zh- and In electrcgraphic recording continued for one to three hours. patients referred for pharmacotherapy because of manifest depressive, withdrawn or retarded behavior oral Torranil of 75-350 mg administered. was In the acute studies there was initial restlessness, associated with dissiness, dry mouth, “taintness,” nausea, and on tour occasions, voniting. These symptoms persisted for t 10-20 minutes, and were accompanied by lasdtude, heaviness of the extremities and eventual drowsiness. unchanged or slowed. Blood Heart rate was pressure dropped by in older (age>’ 60) patients. 20-ho% Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrcgraphic patterns accompanying these behavioral changes were initiated during the injection. had been halved. activity, such by a gradual By in decrease in voltages ten minutes, the per cent tine alpha In patients with moderate anounts of beta activity occasionally increased in voltage and �-25per cent time. twenty minutes, in association with By behavioral lassitude, low voltage (to theta frequencies (5—? 50 nicrovolts) random In records with post~ cps) appeared. convulsive delta activity, there was a marked decrease in voltage and per cent time of slow graphic patterns persisted for i wave to two There was considerable individual acute EEG of Torrinil, EEG who These electro- hours. variability in this received 100 mg or more all and behavioral changes were observed in In six patients, dosage of TorrEnil less than 50 but three. were In patients response. activity. associated neither with EEG mg nor with behavioral changes. In chronic Torranil studies, behavioral changes generally appeared during the second, and were maximal during the week of was treatnent. The most prominent euphoric denial. behavioral adaptation Patients complained less of somatic symptoms, and denied, minimized or displaced inquiry. It became lite relationships third, their illness on increasingly difficult to discuss significant with then. In six patients sonatisation and �restlessness increased and depressive affect persisted. In three, restlessness, agitation, excitement, insomnia and vomiting, led to the cessation of therapy. No change in sfgntons were noted in five patients after four weeks of therapy. Electrographio studies a decrease on chronic administration showed in voltages with poorer record modulation. voltage theta (S~7 cps) activity up to defined fast activity 10% r‘ became more p~ominent appeared. Low Well in a few. (presented at the Collegian Interantionale Neuro-Psychopharmacologicum, Rome, September, 1958) at the Conference on Depression and Allied States, Montreal, March, 1959] and American EEG Society, June, 1959; Published, in part, in the 3 Proceedings of C;I.N.P. Psychopharnaoology Frontiers, ed. 3. 9 Kline, 325-332, 19593 Canad. J. Neurologz, g} 682~685, 1958. Pe chiat., 1959 (in prose); �-272. Language Patterns as Resource of Behavioral and Nauroghzsielogic Change with Drugs. In previous studies of the convulsive therapy process, it was demonstrated that syntactic two language measures, a content analysis (Kahn and Fink, 1958) and dyadic diversification a scores or instructured interviews (Jaffe, Kahn and Pink, 1958) provided objective indices of behavioral change, and were related to the degree of altered brain function. "In a further test of these language measures as indices of behavioral and neurophysiologic change, they were applied to interview on ’ acute administration of various psychopharnacologic agents. Seventy-two interviews with patients at various stages of drug therapy have been analyzed, using the following agents: emobarbital, benactyzine, ohlorpronazine, diethazine, lysergie— acid diethylanide, and Win-2299. unFollowing a routine electrographic recording, an structured psychiatric interview, with short periods of {\‘\ structured inquiry, g was tape recorded. With EEG running, intravenouq injection was then given at a slow rate. When on �—28- specific electrogrsphic or clinical changes were induced, the interview was repeated. Recording periods of EEG and verbal behavior were alternated for the duration of the observation period. The shifts in (delta) The EEG was measured for changes in synchronization, dominant frequencies, and per cent time of slow waves and beta frequencies. tape recordings were transcribed and measured for the diversification of consecutive participants (dyadic) and for 25 word samples of speech of both syntactical changes. In the dyadic analysis, the pooled verbal behavior of both participants was transcribed, divided into 25 word samples, and for each sample the ratio of the number of different words to the words (a diversification score) was calculated. total The number of syntactic langw ge analyses were based on the response to standardized questions using a method previously described (Kahn and rink, 1958), scoring such changes as syntactical use of person, alteration in tense, evasion, qualification, displacement or verbal denial of symptoms, use of stereotyped expression or cliches, cryptic �-29withdrawal and or response, silence. the both dyadic observed in were changes Consistent diversification classified and syntactic language neasurss in subjects behavioral and according to the neurophysiologic effects of the drugs applied. neurophysiologic are and chlorpronasine Ancbarbital high inducing regularly imobarbital synchronising agents. at activity fast synchronised voltage well chlorpronasine administration synchronisation of the EEG was 20¢2h cps, while increased folloudd by record and a shift to slower occasional slow including frequencies wave burst activity. sedation and with associated Behaviorally these drugs are tranquilisation. in stereotpy and On increase was an there measures the language with increasing associated repetitiveness displacement in and-evasion. cliches, tense, alterations of use Diethasine, benactysine, LSD—25 and Wine2299 areheuro» compounds. desynchronizing physiologic These drugs are and decreased per voltage with associated characteristically �-30- cent tins of alpha activity and increased irregular low voltage fast activity. or Behaviorally hallucinatory, exoitatory illusory activity are observed. there was On the language measures decreasing repetitiveness, wide diversity of words, less variability of diversification scores, and decreased use of cliches and alterations in tense. Further explaation of language neasures are suggested as a rational basis for the understanding of the psychologic effects of the new therapies. (Presented at the Conference on Peychodynanio, Psychoanalytic and Sociologic Aspects of the Neuroleptic Drugs in Psychiatry, Montreal, April, l958, and at the American Psychiatric Association, Philadelphia, April, 1959. 3; To be published). Aspects of the Therapist-Patient Relationship Affed ting ” Choice of Therapy. The selection of therapy involves aspects other than the manifest behavioral patterns of the patient. In the past year further efforts to clarify this problem have been undertaken, emphasising factors in the therapist-patient relationship. We �-31have hypothesized that frustration therapist-patient relationship and and hostility in the implicit or explicit environmental pressures have a significant influence in referral for somatic therapy. In a and pilot study 76 structured interviews with residents supervisors were initiated following requests for sonato~ therapy. these interviews were designed to elicit the basis of the referral. It was there a sudden change in the patient's clinical status which vas found that in only directly led to the referral. In relatively few cases most instances there had been no change or progression in the presenting symptoms. Factors contributing to the timing of the referral included impending discharge, avoiding administrative discharge, and pressure tron the patient's fanily or ward personnel. It was also noted that patients with similar behavior patterns were treated differently, sons given eonatctherapy and others none. The reasons for this ranged from ”thin" to quantitative differences in syntonatology and individual preferences for type of treatment. �-32- It was concluded that factors other than clinical indication played a role in the referral in a significant number of cases. These the timing of the As a extraneous factors also influenced referrals. result of these findings Referral Sheet" was developed be completed by the requested. same From a ”Sonatic Treeteent (see for: at end of report) to therapist ehenever somatic therapy is this questionnaire and continued and ward personnel interviews we hope to obtain therapist further infernation regarding indications for somatic treatment, more specific data concerning the therapist-patient interaction, and a more definite idea of the therapist's expectations for such treatment. �Soptonbor 1, 1959 A an»- « FINAL REPORT H~927* ’ Doportmont of Exporinontnl Psychiatry HILLSIDE HOSPITAL Glen Oaks, L. 1., N. I. Aoknowlodgnont Summury, Five Yours, 195k - 1959 Summary #h, Feb. 1, 1958 - Sept. 1, 1959 Publications, 195h - 1959 Prosontationl, Initial studios 19Sh ~ 1959 a. b. 2S 30 bogun 1:11 1953, supportod by tho Board of Diroctora' nooonroh Fund. Supported by Nationul Institute of Mental Honlth Fund, Soptombor l, 195k - August 31, 1959. Study continuing with support of grant MI-2715, United Statos Public Health Sorvico (Jan. 1, 1959) �Acknowledgment studies reported here would not have been possible without the faith and support or the Founder at Hillaide Hospital, Dr. Iorael Strauss, the Board of Directors and tho Administrator, Hr. Maurice Bachraoh, who auetained this program during its early vicissitudes. Financial Support was also given during this period by the Kaufman Foundation, the Foundatione' Fund for Research in Psychiatry, the Daaian Foundation of New fork; the following pharmaceutical firms: Smith, Kline and French Laboratoriea, Wyeth Laboratories, Geigy Pharmaceuticals, and Bristol Laboratories; and the Mental Health Board of Nassau County. The �SUMMARY 14-927 19Sh - 1959 laboratories of the Departnent of Experimental Psychiatry were established at hillside Hospital in September, 195k. During this five year period neurophysiologic, psychologic (personality and perceptual), lingustic, and socioloéic aspects of "somatic" psychiatric therapies have been the principal foci. The 1. Convulsive Therapy: The view of the convulsive therapy process as the induction or a non-specific state or altered brain functbn, similar to. craniocerebral trauma (10, ll, 21) was supported and amplified with this altered cerebral milieu, subjects were seen to respond in various ways (26) of which the most successful was explicitf verbal denial (7, 31). This latter was most prominent in characterologically disposed individuals (36). in alteration in brain function was pro-requisite to behavioral change (7, 8, 11, 26). Grand mal seizures were this to essential process (26) but electrical induction was not (Boh2). Such alteration in brain function was measured by various ways including electroencephalography (6, ll, 12, 2h, 39, language patterns (h, 7, 1h, 31, h}, B-Zh), perceptual tasks (2, 16, 17, 37, hé, 8-26, h1, h?) and tests of recall. A variety of behavioral changes were seen during convulsive therapy (26, 8—17). Such patterns were lbwed as adaptations to altered brain function,wand were believed dependentlupon Refcrbnce nunEers are to publications or presentations (5- I listed in the appendix. �characterologic and environmental factors (7, 25, 26, 36, ho). Clinical ratings of improvement were seen as value Judgments by the observer of the behavioral changes in the subject (26). Adaptations characterised by denial mechanisms, both in behavior (3—17) and in language a, 31) were assessed with the best rating of improvement. Such adaptations were noted to be related to habitual nodes of conduct (character, personality) (36, Bull, ‘ 32). durability of the altered behavioral nodes was seeh‘. to be dependent upon such factors as the degree and duration of altered brain function, the environnental expectations, and the type and degree of family and medical support. Different behavioral patterns were best supported by varyinc types of The psychotherapy (19). It also suggested that the neurophysiologicgbasis or convulsive therapy nay lie in an alteration in central synaptic cholinergic ~ adrenergic relationships, with a predominant shirt to increased cholinergic activity as the operationally significant pattern. Such interpretations were based on the relationship of high voltage EEG slow wave activity to behavior! change (6, ll, 26) and the blocking of the electrographic and behavioral changes in central anticholinergic agents (21, 3h, 35 hl, ht) and by central synpathonimetics (ha). Heasures of linguistic behavior in structured (7, 31) and unstructured (1h, 29, B-2h) interviews showed characteristic was �- 3 - alterations towards increased denial, minimisation, displacement, stereotypy and repetitiveness, related to the degree of altered brain function (B-Zh). These changes were blocked or reversed by anticholinergic hallucinogens (21, h3). Various perceptual tasks provided indices of behavioral change and were related to the degree of altered brain function. These included the perception of simultaneous tactile stimuli (17), snbedded (Gottschaldt) figures (37, 8-16), and tachistoscopically exposed words (37) and embedded color figures (hl). Sociopsychologic aspects of age, years or education, nativity and degree of stereotypy and sonventionality (measured by California F Scale) were also studied and were related to selection or therapy, duration of hospitalization, diagnosis and treatment response/ in hospitalized patients (15, 36, ho, hS). 2. Neurophysiolegic~Adaptive Hypothesis of Somatic Therapy. Based on these studies, a hypothesis of the node of action of other psychiatric therapies such as insulin coma, leucotony and psychotropic drugs, was expressed (10, 33, 38). This view holds that these therapies are also methods of inducing varying states or altered brain function, in which varying adaptive patterns may become prominent. The adaptive pattern is viewed as dependent upon the type, degree and duration of altered brain function, the personality of the subject, and tolerances and expectations of the environment. Examination of this hypothesis as applied to drug therapies is now in progress, supported by USPRS grants HI-2092 and HI-2715. �Insulin Coma Therapz. in initial case description (3) showed the significance of denial patterns and persistent altered brain function to the behavioral change in this form of therapy. In an insulin cons - chlorpronazine control study (27), no differences in hospital improvement ratings were observed in the two treatment groups. Chlorpronazine was safer, easier to administer, permitted continued adninistration and allowed for greater degrees of concurrent relationship therapy than insulin coma. These observations led to a replacement of insulin come 3. by psychotropic drugs in h. this institution. Pharmacotherapz. Also derived from these hypotheses is the ongoing program in evaluating various psychopharnaceuticals. Electrographic and linguistic analyses of effects of acute intravenous administration and chronic clinical administration of various are in progress. EEG patterns, along such continua as synchronisation~desynchronisstion, and frequency shift are being related to behavioral (21, 3h, bl, ha) and linguistic changes (21, h3); The neurophysiologic basis of experimentally induced hallucinogenic states have also been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (h2). Initial work on this hypothesis ( ) is now being expanded. new compounds �.32.. In addition to these phenomena, other patterns of language and non- verbal aspects of behavior have been observed which can also be understood as symbolic forms of adaptation to illness. These include the syntactical use of the second and third person, changes in mood, withdrawal and selective inatten- tion, and alterations in sexual behavior (6). in enduring fashion in patelectroencephalographic records indicated diffuse cere- These types of behavior have been observed ients whose lesions and bral dysfunction; In patients with brain damage who did not Show delusional denial and disorientation on ordinary clinical examination, the phenomena might be elicited in sodium. an interview following the intravenous administration of amytal This observation furnished the basis for the ”amytal test" for brain disease in which the persistence of certain patterns of denial and disorient- ation is considered an indication of cerebral dysfunction (h,5). In considering further the relationship between brain damage and the mechanism of denial it has been demonstrated that the premorbid personality important in determining what type of symbolic adaptation occurred. Thus, was pat- ients with the most striking and enduring manifestations of anosognosia were those who had habitually used verbal denial and rationalization as a means of coping with On their problems (10). the basis of these observations the hypothesis was developed that the of creation the convulsions in induced lay of action electrically therapeutic a milieu of brain function in which the patient might express his problems in symbolic fashion, particularly in the form of explicitly denying them. A case reported in which a patient received electroshock treatment in an attempt to relieve intractable pain associated with a Spinal cord tumor (11). After was a number of treatments, coincident with the appearance of disorientation for state, the patient dennot clinically apparent they a place and time, paraphasic misnaming and a euphoric ied pain. ‘dhen these associated.phenomena were � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Relation Between Altered Brain Function and Denial in Electroshock Therapy (research), 1955-1959 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-2-002 Date A point or period of time associated with an event in the lifecycle of the resource 1955-1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: research with Robert L. Kahn, and Edwin A. Weinstein Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/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... 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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/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. 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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/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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Eflwftlififi trip: Sadiugtaa thlt an ultawutiaa in brain to-hohavfiawtl altar: «at rfitlfili a: 1x 'ffi'fii fiflfiVQIfl$ti tharnrr. ran try. it hnhuvioral atgnga in: fitlh vclntid ‘Q,Vfiifitfl£ paranptuul, payuhaxactc, and.a¢uiul maptatn #1 taaivtdial': htttfi 3nd hakartor. prtuwut atudy «cannatmutua niauitianai t! fiicaahtpa htiuuou tau dfllvtu ut’pwctucauvuluavu usurnphywitisxin thlfitt (35$ glam invfl tnttvaty Ina unuhmrbttal gait rntycnu¢3 Ind firmwtfiuniuunt-§ortwptau1~wur*6mtlitr tunatttufinc (a: traritus atndxnu at: 1nragtisitn txantayn ‘ it: it. » aduuutiaut&,10111,‘luriuhnah puttarm, taguVwaraunA fitfl‘rtflifii$1fifi)t wail: studxgn u: Ringlt ampuuta or nttrtvhrmzcanggu IS‘ rtrtunllt hflfifl‘rfli but. annurallr Rafi tntnbitshnd tisuttinaut to .ttiufihtpa, than: Qiuutvutlaaa tnflieufifi that $hn vain nnd iuarug fit ah:act an xuurtpaauitlngis ratptuafi uzritgdand ht rtInSaa ta yfifiiflnflltiw§(ptt‘i’fitfllfifilcttfitwfi _ 7 . : y n\. ‘I‘fiflii! inn fiat, ”.36. rrwn tn: btpartnuut u: .111 11/59 films Wilt, flute: 5“. 1.1; ‘R4 nfibfift Ly i333, ?h§na inp§r$mmnta1 Payuhxatry, 3%.}; ’Ufflht tillntén fluupifinl. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Psychological factors affecting individual differences in behavioral response to convulsive therapy. J Nerv Ment Dis. 1959 Mar;128(3):243-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-36-002 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Pollack, Max Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 3 items. 1: Reprint from THE JOURNAL or NERVOUS AND MENTAL DISEASE Volume 128, N0. 3, March 1959. 2: [preprint]. 3: 2 drafts and one abstract. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/9060c539e20c3ba0581d3baa1fe2596c.pdf 225bfe4d17bc385ee38289963bbb494a PDF Text Text l...“ I 3% Protocol for Pilot Project. on Effect of Drug on Corebrsl Emotion ‘ 1. Object: (a) (b) on of dmgn To study the effect To observe the emotional responses to such ohangca and the perception of sensory stimuli; in function. first drug selected is LSD-25 (Sandoa) - on erect preparation which, in very minute doses, produces a time state with altered perceptions, emotional reactions and occasionally hallucinatory phenomena. Studies or porcep’onol change-s in the visual, amnion", an! anaesthetic senses are planned. Special enmhasis is to be placed on the more complex functions of spatial and temporal orientation; discrimination of size and shape; body may; and the perooption of multiple Simmons stimuli .111. (1) (2) (3) (h) In the emotional aphoro, the following questions are oonsidorud: Are the emotional responses secondary to or simultanemm with the perceptual changes? Are the “spams: consistent in repeated exporinonta in each In each class of oubjoabo? subject? Are the emotional moponooa related to personality structure in Hal? any predictable fashion? In there any relation of the mouse to drug aotim and tho ability of the subject to utilize the mohanisn of denial? In addition, there are thornpoutio oonoidorations: Dona 131) have org arrest on depressions? fl; 2 Does 15]) have am- valun in eliciting pmhiatrio material in bloom,- impressed subjects? 2. Subjects: (a) ‘ The subjects are in "Normal” controln~ at three groups: hospital yeraomol or hospitalized patients a general hospital. (b) Psychiatric subjects at Hillside Hog) (1 Depression a» psychotic anti (2 Scbimphronin (3 N9W1Co ital: “satin. (o) Neurological subjects at Mt. Sinai Hospital: (1) Cerebral (119%,me or diffuse. cord disease. Spinal £2) 3) Spinal root disease. 30 W05! subject is to be heated in a similar fashion prior to drug ingestion) during the period of drug activity; and after. Subjects Each tmatodhyESTandinsulinmtoboexanimddmingaxflafiortho Repeated sessions with each subject course of such treatments As the drug action has a duration 0: 2 to 5 hours, arc planned. The testing new be divided testing proceduren my be extensive. into three mops: Neurologcal. a) gb Modical. c) tholoacal. ‘\ �3a.. Neurological: 1. Routine neurological.- 2" Visual. Perception of color mixed and ambiguous figures taohistoscopi celly exposed; and cation ion or relative size and distance. . , ‘ 3. Tactile. he Double simultaneous stimulation or various Amt”. Perception modalities. of latrines” identification of sounds and estimation of time intervals. 5. Special studies of bochr image. Bbo Medical: Observation of the subjects by members of the Department of Medicine has been ”quested (Dr. A. Blmberg) and is under consideration. BiocheMcsl studios of hormonal studios secondary to drug activity is under consideration, with emphasis on the possible role of adrenal function in the reactions as measured to the pattern of wxfltosteroid excretion. 3c. Psycholouoalt Clinical psychological testing is considered an integral port 0 The cooperation of Dr. M. Ger-vita has been rethis survw. An evaluation 0:: personality structure and habitual quested, methods of reaction to stress will be studied in each subject. In addition, special testing procedures to study the mechanism of denial are under stuck ha a. member of the psycholomstafrz:,-;LC (lire Antinoph). Specific testing procedures include the following tests: a Rorschach. b Bender Gestalt. c d TvoTl Special tests for denial. he Supplies, Foods, Eton: The drugs have been made available to me for experimental purposes; Funds for the at no charge kw Sundae Pharmaceutical Company. equipmt moesssry for testing have been placed at my disposal by the Neurological Research Fund of the Mt. Sinai Hospital. The following items are requested from Hillside Hospital: (1) Office space and the use of one room in Treatment Dormitory during experimental days. (2) Availability of records and permission to request occasional coowration of Homing Department and of the Record Room staff. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Protocol for Pilot Project on Effect of Drugs on Cerebral Function, January 1953 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-1-001 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/c8ad48ee340bb2be9a377798690b07da.pdf 3394a0c397923bbc0e9ed1a479ee352e PDF Text Text K . K. K K K .K y » K K . , a . K . K r KK . K K K K . K K . K. K KKK K K K K . . KI . _ KK K K K K . K K K K K K K K K K K . K K A K K K K K K K K K . K .K K K K _ K K K K K K S . K K . KK K K . K K K K. _ K K K K K . _ K K K K K KK K K K K K _ K. K _ K K K ‘ K .K K K K K _ K K .K K K K K K K K . KK K .\ K K KKK.KK I. K. K .K K K e? .p . K. K Jr K. . K K. K K K K KK . . w . K _ .K K K. K . K K. K K K . . _ K K K K K . . K K K K. KK K K K K . K K K _ K K K K K K K .K K _ K K . K K K K K K K K K K K K _ K K K . . K K K K K K K K K K K K K K K K K K K . K K K KK .K . K �2 9th Annual Report JANUARY 1, 1956—DECEMBER 31, 1956 Glen Oaks, Queens FOUNDED 1927 Joseph S. A. Miller, M. D., Medical Director AN AFFILIATE OF THE FEDERATION OF NEW YORK 0F JEWISH PHILANTHROPIES �Hillside Hospital is a non-profit, non-sectarian mental hospital for the treatment of voluntary patients suffering from early and curable mental symptoms. Patients are admitted regardless of their ability to pay. Hillside provides training for physicians in post-graduate psychiatry and psychotherapy and puts major emphasis on research in all phases of treatment. The hospital considers itself a pilot institution, pioneering in the human and efficacious application of psychiatry to the mentally ill. The hospital is licensed in the New York State Department of Mental Hygiene. It is approved for a two-year residency in psychiatry by the Council on Medical Education of the American Medical Association, the American Board of Psychiatry and Neurology and the American College of Surgeons. The Dental Department is certified by the American Dental Association as an approved hospital department. Hillside Hospital is an affiliate of the Federation of Jewish Philanthropies and a participant of the United Hospital Fund and the Greater New York Fund. HIGHLIGHTS Page 3 Hillside gets Ford grants Israel Strauss Adolescent Pavilion in its second year . . . . Page 6 . . . . Page 10 Hillside affiliating institution for student nurses at Queens college . Page 11 Social Service strengthens rehabilitation program . Page 14 . Chlorpromazine added to regular hospital drug formulary Research program strengthened . . . . . Page 18 �1956 has been a year of “Shakedown" for Hillside during which its Board and Executive Officers have experienced the first full year of operation without the supporting advice of its founder, Dr. Israel Strauss, who died during 1955. In view of the change throughout the organization of the hospital, it has been a year of consolidation and improvement. We are indebted to Dr. Dudley D. Shoenfeld, our Vice President, for his invaluable counsel in helping to reorganize the staff planning in the hospital. He was greatly assisted in this work by Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser REPORT OF THE PRESIDENT OF THE BOARD OF DIRECTORS and Maurice Bachrach. has frequently been necessary for the Governing Board to ask advice and guidance from the Medical Board. We have had splendid cooperation from them. The two presidents of the Medical Board serving through the calendar year, Dr. Samuel Atkin and Dr. David Epstein, have been particularly helpful. It During 1956, the hospital has been able to expand its services in the OutPatient Department through the use of funds made available by the State Mental Health Authority through the N. Y. State Department of Mental Hygiene, and funds from the City of New York through the New York City Community Mental Health Board. Further funds from the City of New York for indigent mentally ill persons have enabled the hospital to maintain its services at a high level and to serve that segment of the community which most needs the services of a philan- thropic hospital. The research program, conducted at Hillside under the guidance of Dr. Maximilian Fink, has made excellent progress. The directors continue their deep interest in all areas of psychiatric research and anticipate further broadening of these activities. Psychiatry as a science still is in a rather fluid state and many new avenues of exploration offer hope and ideas. The compelling need is to look intensely for new information. At long last, throughout the United States, substantial organizations have become cognizant of these needs. Among these, the great Ford Foundation has allocated many millions specifically for research in psychiatry. In addition, large sums have been allocated to the country’s hospitals. In 1956, Hillside received a grant of $104,000. At Hillside we bring a sympathetic attitude to our patients, solace and encouragement to their families and decided improvement to a large proportion of the persons we treat. We make judicious use of all modern therapies available in the field and our record of improvement is excellent. We can be proud of it. But we aspire to find new and better techniques that will send more patients out of the hospital completely “recovered” rather than “improved”; new methods that will permit release of patients in a far shorter time than is now required. to these goals that we at Hillside are dedicated and we firmly believe that, as elsewhere in medicine, these aims can only be achieved by means of widespread and continued research. It is Alvin E. Coleman �REPORT OF THE MEDICAL DIRECTOR During 1956, Hillside Hospital completed almost thirty years of continuous operation, rendering high-level psychiatric services to the community. During these three decades, the Hospital increased its bed capacity for inpatients fivefold, established a ranking place as a therapeutic center for both inpatients and outpatients, became a notable hospital for resident training in the field of psychiatry and, in the past few years, developed an important research department. For over eight years, it has been a proud member of the family of the Federation of Jewish Philanthropies and, in conjunction with other agencies in Federation, it has developed and rendered meaningful aftercare and rehabilitative services. During the past year, there was an improvement in the coordination of professional services rendered in both the adult and adolescent inpatient departments. There was considerable expansion in our outpatient service with improvement of procedures and treatment in the aftercare clinic. Our practical experience with the Adolescent Pavilion and our attempts to augment our research programs have pointed up the need for expansion, both in personnel and in space. Every few years the advent of some special form of physical treatment—shock, surgery, and now new drugs—has reopened the debate concerning so-called specific versus non-specific treatments, short-term versus long-term hospitalization and therapy, treatment of many patients or clients rather than a few. All of these can really be related to the general question of the importance of quality versus quantity. One of the distinguishing features of American medicine is its goal and also, think, its practice of rendering qualitatively better medical services, as opposed to mere quantification. I Hillside Hospital has developed a distinctive philosophy which has led to the creation of a unique structure to implement its philosophy. Since the field of psychiatry is still in its developmental stages, it is characterized by frequent and rapid changes in all phases of its thinking and practice. Each change is a challenge to the Hospital’s established structures and points of view and we must continually decide whether a psychotherapy-centered, multi-disciplined treatment program such as ours delivers the best service that can be devised for the relatively long-term curable patient. How is a mental patient best served by a psychiatric hospital? This, of course, will depend on the type of mental patient. Some patients are easily treated by a consultation or two, by a course of shock treatment, or with tranquilizing drugs, or with a rest or vacation. Some need only a course of physical treatment with return within a month or two to their homes, to continue whatever treatment they may need in a clinic or with a private psychiatrist. Others, and these are the ones that Hillside has more experience with, require hospitalization of at least six to twelve months. These are patients who cannot or should not remain at home or in the community, and cannot therefore benefit from either a single psychiatrist's or clinic’s ministrations but rather need the hospital milieu or therapeutic environment of a team of professionals working with the patient, with �a psychiatrist at the center to emotionally re-educate the patient. Such emotional re-education through the process of properly understood and related inliving experiences lead to a patient becoming aware of emotional aspects that he did not suspect he had before and to recognize that there are more people who care rather than so many who are hostile to him. If at the same time, as at Hillside, important relatives, especially the nearest of kin are worked with by a professional trained in that field, the psychiatric social worker, the family's attitudes concerning the patient and his illness are changed for the better; and if this happens, the patient now has not only regained much of his lest esteem and self-confidence, but the very family environment has been improved and guarantees that the patient may continue and even enlarge upon gains initially made in the hospital. Thus, not only a single patient has been treated, but there has been complete reorientation of an entire family. Authorities in dynamic psychiatry, in child welfare and development, in community welfare, in the field of geriatrics, all agree that the most important ingredient in the total treatment of emotional problems at any age, is the psychological understanding and the meaning of the symptoms, even the physical ones, as various ways of attempting to meet the problems of anxiety and emotional crises. Of the various psychological and dynamic approaches to the problems of behavior, none have contributed as much as psychoanalysis. Hence the practice of hospital psychoanalytic psychiatry at Hillside. This is by no means to lessen the importance of the adjunctive services and especially of the medical and physical agents. The physical symptoms are often parallel or concomitant expressions of 'certain types of emotional distress and emotional disorder; and physical agents like drugs, are often very effective in shortening periods of acute panic or distress and thus allowing for earlier or more meaningful participation in psychotherapy. Since the problems of emotional disorder are mainly interpersonal ones, problems of getting along properly or happily with other people, psychotherapy whether in or out of a hospital is in our opinion the basis of all therapy of persons with severe emotional disturbances. The past year has been characterized by a rapid growth of psychiatric services in general hospitals. These, by their very nature, deal with more acute physical and mental disorders, while special psychiatric hospitals treat those psychiatric problems which specifically require more extensive hospitalization, removal from home and community for a long enough period to afford an opportunity for reeducation and resocialization of the patient. It is therefore clear that the two types of hospitals deal with different problems and have different basic principles, precisely because they deal with different types of patients. The growth of the general hospital practice of psychiatry is therefore not a factor toward the displacement of the special hospital but rather for the widening and enrichment of the total constellation of treatment services available to psychiatry, so that the general and special hospitals enhance and reinforce each other for the benefit of all patients. Joseph S. A. Miller, MD. �ADOLESCENT PAVILION Age range of patients The Israel Strauss Adolescent Pavilion is now in its second year. It is a dramatic example of the kind of pioneering Hillside Hospital does. The Pavilion provides a treatment program for emotionally disturbed girls between the ages of 12 and 16. It is an unusual experiment in tackling a major problem of our society . . . the rehabilitation of girls who are unable to live and function successfully in the community. Practical aspects of treatment Grave concern with the number of severely disturbed young people in our country has not resulted in enough practical work. The Adolescent Pavilion is a brave in all and facilities with the deal this experience to problem, using attempt psychiatric therapy of the Hillside Hospital in a treatment program oriented to the special needs of these patients. The number of girls who can be treated is very small compared to the need. But the knowledge to be gained from experience with them should prove immensely valuable. Flexibility of program The Adolescent Pavilion has its own, specially-designed living quarters and treatment facilities, and a separate staff. Its program is necessarily fluid and flexible enough to allow the constant adjustments necessary in a new and untried field. Some changes from original plans became necessary as work progressed this year. Twenty patients were admitted in 1956 and 25 discharged. Capacity of the Pavilion was reduced to 16 since it proved impossible to work successfully with the 20 originally planned. Basic treatment philosophy The basic treatment philosophy remains the same. The aim is to provide a wholesome living experience within the Pavilion with as intensive psychotherapy as seems advisable for the individual patient. But the concept of such a wholesome experience has gradually, step by step, taken in more areas, personnel and facilities beyond the Pavilion’s confines. As soon as girls are able, they are encouraged to use recreational and planned activities at the main hospital, to make contacts with the other staff there and to socialize with adult patients. As they are able, the girls are permitted to go to the nearby public high school and out into the community. A basic concern is to try to help with those aspects of the personality that are ill while never forgetting to encourage arid develop those that remain healthy. Family or family-type Work with parents or parent substitutes is intensive and a very important part of the treatment. When they are able, the girls are permitted and encouraged to spend time with family or friends. Some girls, unfortunately, have no family to go to. The use of volunteer help to fill this vacuum is being further explored. After-care and follow-up Another important need is the provision of after-care and follow-up. Unlike the mature patient, the Pavilion deals with personalities not yet fully formed. Their potential is unknown. It takes time to find out how fruitful the work will be. It had been hoped that close follow-up would be possible by providing after-care relationships �for all the girls in the Hillside Out-Patient Clinic. This proved impractical because it interfered too much with the ordinary pursuits of young people who, in most cases, lived at great distances from the hospital. For those girls who cannot conveniently use the Clinic, a variety of good treatment facilities elsewhere are recommended. encouraging to report that referrals to the Pavilion have come this year from more widespread sources, including a variety of family and social agencies, schools, treatment centers, private physicians and girls' residence clubs. It is also encouraging to report that, while it is too soon to reach any conclusions from the work in progress, the hospital does feel the work of the Adolescent Pavilion is becoming increasingly helpful. It is Prognosis for the future �I 7‘" . «F ‘ HillSIde In 1956 treated 561 ts, of ”709189 hospital days. The e-‘fi Q‘fit‘rhte were patients. Of thefiital treated», 365 fine Evaluatipnfig discharged :- . ’ ' I I; eme '. I Is . 5 ', I I 2 __ way f. ou come In a ~ I. ’ gcomparison. - f ‘quOfi rials». " ndon nt ' ‘ to denote mental condition at the time of Idischarg ient’ 5 condition gmbebaviqr he en left This is g 'uII a}; I: ‘ 1"7.” : ' o’ I ‘ _ I I . I I no chan-e I "”3 '_ .' .- or ’ f I : I I file-5V; "j ' m“ iable Rent; m that symptoms have disapfibare nd the patient conseemefin good ‘e'ans Ion at the hospital, but there is no certainty of how he will function when he Eats back into I own an ial and working community; recovered means that, in “i has bee ef‘mucharrlfirmd reas c ad . tioma‘t ' I. atient will be or better" I; he did befor ‘ 1 -I r 3“ .92 *I f _ "1"" . _ I ’ . mandfuw;¥ tmhfi tateat I Mu ,, . lmpr. 4O 36 39 . �m O S PIT �PSYCHOTHERAPY AND MEDICAL SERVICES Major process of Psychotherapy continues to be the major emphasis and the core of treatment at Hillside Hospital. Other forms of therapy, each in its own way very important to the patient’s progress, are all part of the treatment program and are prescribed according to the patient’s particular needs. However, one of the main criteria for accepting patients at the hospital is their ability to participate profitably in psychotherapy. Analysis of hospital Patients are seen individually by well-qualified psychiatrists for psychoanalytically oriented treatment three or four times a week. Each patient is assigned to a specific psychiatrist who remains ”his doctor” for the length of his stay. The psychiatrist is the leader of the hospital “team” that plans and supervises the patient’s day-to-day treatment. The other members of the team are a psychiatric social worker, a psychologist, professional representatives of the adjunctive services — Occupational Therapy, Group Activities and Creative Therapy — and the Nursing Department. Types of therapy in use, including new drug therapies . . . facilities for treating the “whole" patient: physically and psychotherapeutically Group therapy continues to be used for selected patients. The hospital continues the use of electroshock therapy for about one-third of patients, especially those suffering from more severe emotional disorders. The extent to which it is used has, in many cases, been modified in accordance with the results of research conducted by the Department of Experimental Psychiatry. During 1956, as a result of a controlled research study, Chlorpromazine was substituted for insulin coma in certain patients. It had been found safer, easier to administer, and to have fewer side effects. For certain other patients at the hospital, insulin coma is still the treatment of choice. Chlorpromazine has now been added to the drug formulary of the hospital and made part of the regular therapeutic procedures. There is continuing work and interest at Hillside in Reserpine and the other newly developed drug therapies. Growth of non-psychiatric The Intra-mural Clinic and allied medical services of the hospital are concerned with the non-psychiatric, physical problems of the patient. Close cooperation between the medical staff and the psychiatric staff has brought the hospital nearer its goal of “treating the whole patient.” hospital treatment treatment “team" medical services The lntra-mural Clinic The continued cooperation of a large visiting staff in all the various branches of medicine, made it possible for the clinic to see 411 patients for a total of 11,844 visits this year. The Dental Department 10 The Dental Department, newly certified by the American Dental Association as a qualified hospital dental department, anticipates adding a dental intern to the staff. New equipment and a newly decorated interior have done much to facilitate and improve treatment. The dental clinic treated 736 patients this year, an increase of almost 25% over 1955. �f . The Psychology Department, in response to increased demand for psychological examinations, added one full-time psychologist this year and provided for the addition of two more early in 1957. Almost twice as many tests were admin- The Psychology Department istered this year as last. The department has been accepted and used as an integral member of the hospital team. Its services have been called for in pre-testing hospital personnel, and in connection with vocational counselling and rehabilitation plans worked out by the Social Service Department. The Nursing Department continues to pioneer in training nurses and aides in the special skills required for proper care of the mentally ill. The nurse fulfills a unique position in being in direct contact with the patient for long period of time. And yet the only training she generally receives in psychiatry is a brief threemonth period during student training. This department has organized two special training programs, one for psychiatric aides and one for nurses, which enable them to perform more effectively and with more understanding as working members of the hospital team. addition, members of the professional nurse staff participated in trips to various private and state psychiatric hospitals to observe new methods and techniques. In During the past year, students from Central lslip continued visits to Hillside as part of their psychiatric training. This year, Hillside became the affiliating institution for basic psychiatric experience for student nurses at Queens College. The hospital was fortunate in acquiring for its own staff 10% of the college’s first graduating class. The Nursing Department �Three departments of the hospital, make an essential contribution to each patient’s therapy. Each has a specific function and each is prescribed as a regular part of treatment planned in cooperation with the psychiatric staff. Group Activities Department The Group Activities Department organizes meaningful social, educational and work activities that draw patients into groups where they will have opportunities to form relationships with other patients and deal with situations that mirror community life. Each member of the department’s staff of professional social group workers is assigned as a member of a psychiatric team which plans a program designed to meet a patient’s specific problems. The group worker reports on the patient’s performance and reactions to group ‘and social situations. .Under the guidance of the staff, patients participate in self-government groups, special interest classes, a choral group, athletic activities, and current events discussions; they publish a newspaper, operate a patients’ library and engage in club activities suited to various age levels. In addition, they plan and take part in social functions, attend religious services and enjoy a varied program of evening entertainments which frequently include appearances by outstanding celebrities who generously give their time and talent. This year has seen the development of an adult education program, in conjunction with Adelphi College, which, in a ten-week course, offers popular subjects similar to those offered by the extension programs of universities and the New York City Board of Higher Education. Occupational Therapy Department Occupational Therapy the patient works in various crafts such as ceramics, wood, metal, leather, jewelry making, weaving and needlework. They offer him a creative outlet that increases his self-confidence, helps him to discover new skills and has therapeutic value in relieving tensions. By observing the way a patient reacts to tools and materials, how he copes with success or failure and how he carries out instructions and responds to authority, the staff is able to gauge his problems and his progress. In 1956 two registered therapists were added to the staff, bringing the total to six. Each therapist is part of the hospital team that plans the occupational program for each patient according to the patient's needs. In This year, for the first time, craft classes were scheduled which offer patients interested in particular crafts an opportunity for more intensive and specialized instruction. Another innovation was that the Commissary, a patient-run store, was brought under the direction of this department and patients were assigned there by doctor's prescription as a form of vocational training. 12 �distinguished visitor this year was Miss Ruth Shamah, Israeli delegate to the World Federation of Occupational Therapists, who spent three months at Hillside working and observing the methods used in the department. A Creative Therapy is a very special psychodiagnostic and therapeutic tool de~ vised by Dr. Ernest Zierer and his associate, Mrs. Edith Zierer. It consists of a series of controlled painting tests designed to reveal the patient's unconscious conflicts. The results are tabulated and interpreted in diagrams which present a “personality profile” considered to be a reflection of the patient’s ability to solve his life problems. Creative Therapy Department The department administered 1,423 tests during the year. In addition to regular consultations with the hospital team, progress reports were discussed at special conferences with treating psychiatrists and the supervisors. I3 �THE PATIENT Work of the Social Service Department The Social Service Department is the patient’s most direct and constant link with his family and the community outside the hospital. Its activities before admission, during the patient’s stay at the hospital and after he leaves, make easier both for the patient and for his family the many adjustments necessary to meet the economic and emotional problems that complicate successful treatment. 14 Number of yearly interviews and contacts the course of its work this year, the Social Service Department conducted 5,137 interviews with patients, 5,095 interviews with relatives, 7,555 telephone contacts with social agencies and 6,701 telephone contacts with relatives of patients. The department processes all admissions, functions actively throughout the patient’s stay and is intimately concerned with the patient’s welfare on discharge and for several months thereafter. Rehabilitation aspects of the social service program the past year the department has made a concentrated effort to strengthen the rehabilitation aspects of the social service program of the hospital. Experience has shown that the best results are achieved when maximum support is extended immediately on discharge and continued through the first six months to a year. Future plans are particularly concerned with opening up new avenues of cooperation with community agencies whose services can do so much to help the patient again become a useful and happy member of his community. In 1956 the following agencies have made marked and increased contributions in this connection. Contributing agencies to rehabilitation programs The Foster Home Program, which exists jointly with the Jewish Community Service of Long Island, was used to place newly discharged patients in a supervised family environment. This year the program also was used for patients awaiting admission to the hospital, with the result that hospitalization was averted in at least one case. In In ' �AND THE COMMUNITY The Altro Workshop which provides discharged patients with transitional gainful employment was used by thirteen patients during 1956. Through a grant by Mrs. Israel Strauss and the Federation of Jewish Philanthropies, a joint program with the Jewish Family Service of New York was initiated. This service permits discharged patients who need further counseling to get immediate help. Expansion of this service is expected to show the value of continued and prompt counseling in averting rehospitalization. Together with the Jewish Family Service of Long Island, the department developed a special program that helps keep the home intact when a mother has to be hospitalized. Homemakers are assigned to fill the gap during the mother’s absence and sometimes even after the mother returns, if this seems necessary. The program with the Division of Vocational Rehabilitation has been expanded. A vocational counselor is available to patients one day a week. Vocational guidance begins while the patient is still in the hospital and may continue after discharge. Training facilities are provided for those whose adjustment to the community might be made easier by learning new skills. The department is especially appreciative of the cooperation of the New York City Department of Education. The Home Instruction Program provides two teachers who come to the hospital several days a week to give instruction to patients under 21 who have not completed high school. The results have been very successful; 40 patients received instruction this year and six were graduated. During the coming year the program will be expanded to include patients over 21, who, on completing the work, will be able to take High School Equivalency examinations. Follow-up reports indicate that many patients develop an interest in carrying their education further after leaving the hospital. The Casework Program started last year in the After-Care Clinic, for the purpose of coordinating rehabilitative planning, has proven its effectiveness and is now an established service offered to patients and their families. The Social Service Department has continued to work very closely with the Federation Employment and Guidance Service. Their excellent facilities make it possible for many patients to receive job placement and vocational guidance soon after leaving the hospital. 15 �HILLSIDE LEAGUE The Hillside League and the work of “The Bridge" The Hillside League is an organization of former patients of Hillside Hospital. After facing almost certain extinction in 1954 and having an encouraging revival in 1955, it has made astonishing strides in the past year. That many of its planned goals have been achieved is due, in large measure, to the untiring and selfless efforts of “The Bridge, Inc.", a group of women and their husbands who conducted a successful fund raising drive and who continue in their wholehearted devotion to the League. Activities at Bridge headquarters 1956, the Hillside League moved to new quarters (supplied by “The Bridge”) at 231 West 83rd Street, in Manhattan. Here, in an area many times the size of its original rooms, members enjoy a comfortable, newly furnished lounge, equipped with a phonograph, television, table games and cards. The area is flexible enough to provide for large groups as well as intimate gatherings. The League is open every evening from Monday through Friday and one week-end a month for large social functions. Help with personal Hillside psychiatric social worker has been assigned as a full-time director of the League and is available for individual consultation and for referral service with regard to housing, employment, further treatment and other personal welfare problems. Thanks again to the efforts of “The Bridge,” the volunteer staff of the League has grown to meet the needs of a much larger membership. Membership From a low of 38 in 1954, the active membership has grown to almost 200, and in addition the League draws upon an active mailing list of almost 500. A club program, with membership arranged according to age group and interest has been an important development made possible by the increased membership welfare problems In A and staff. The Hillside League looks forward to the next year as one in which it will be well equipped to fulfill a vital function in helping patients continue the progress made at the hospital. QUEENS OUT-PATIENT CLINIC Hillside Hospital believes that in the Queens Out-Patient Clinic it has developed a pilot unit that demonstrates the highest level of clinical functioning and serves as a center for stimulating interest and training in psychiatry. Work of the clinic 16 The Clinic offers psychotherapy on a twice-a-week basis, up to a year’s duration, to residents of Queens, Nassau and Suffolk Counties, who require treatment but �are unable to pay for private care. For a family with an average income psychiatric service can become a severe economic burden. The Clinic meets an urgent need in a community rapidly growing in population but relatively lacking in out-patient psychiatric facilities. The Clinic setting, in addition, offers the advantage of psychiatric social work consultation for members of the patient’s family. ’ Intensive screening, by means of psychological tests and pre-admission consultation, make it easier for the treating psychiatrist to make early plans for the patient's treatment program. In contrast to the usual lengthy course of psychiatric treatment, the Clinic has developed a philosophy of attempting to accomplish limited goals. Often, by relieving his symptoms, the Clinic frees a patient to continue on with his life, with the strengths he utilized before he became ill. The Clinic treated 271 patients in 1956, the average length of treatment being eight months. Thirty psychiatrists, accepted after very careful selection, work on a part-time basis to make this extensive program possible. Permanent staff Goal of the clinic's treatment program Number of patients and staff members members of the Hospital are always available for consultation. 1956, the Clinic initiated a separate service for administering electroshock therapy on an out-patient basis. Recovery, on the whole, was dramatic, rapid and tremendously appreciated by the patient and family since it meant avoiding hospitalization. In MANHATI‘AN AFTER-CARE CLINIC The Manhattan After-Care Clinic serves Hillside patients as a link between their hospital stay and the resumption of community life. This is often a very trying time because the patient may suddenly be subjected again to old family stresses, job strains and social difficulties. The Clinic, conveniently located at Mt. Sinai Hospital, is open five nights a week and the average course of treatment is twice-a-week for a period of three months. Function of the clinic Successful accomplishment of the Clinic’s goals depends in good measure on cooperation between Clinical Assistants and Social Service Caseworkers. The Clinic takes this opportunity to acknowledge the extent to which that cooperation exists and functions. Accomplishment of goals l7 �THE HOSPITAL treatment of the mentally ill depends on intensive research . . . on a better understanding of why people become mentally ill and a surer knowledge of how treatment effects improvement. Hope for this rests with a wide variety of professional research workers in the many disciplines concerned with human behavior. As in any other field of medicine, progress in the Research and progress Research in mental illness is spurred on by the grave and immediate need for new insights and is complicated by the fact that the field of exploration is limited, almost entirely, to human beings, rather than lower animals. Hillside's hope is to include every possible approach. Work continues along those lines that seem to offer the most promise. Areas of basic study Psychotherapy remains the area of basic study and treatment. But because past experience has amply demonstrated that electroshock therapy is, for certain conditions, the most valuable of the known physical therapies, the hospital has devoted a major effort this year to study and further elaboration of its use and effects. Three other studies whose purpose was to devise more clearly objective methods of evaluating progress in therapy were developed, and a control study of Chlorpromazine-insulin coma was completed. Department of Experimental Psychiatry This year, the Research Service Was redesignated as the Department of Experimental Psychiatry, indicating its continued growth and anticipating the addition of a Department of Clinical (Psychodynamic) Research. Two new members were added to the staff in 1956. Support for the program came from contributions of the Board of Directors, from the renewal, for three years, of the Electroshock Study Program of the National Institute of Mental Health of the U. 8. Department of Health, Education and Welfare, and from the Kaufman Foundation of New York. Departmental research in Medicine and Biochemistry Research in the Department of Medicine concentrated chiefly on a study of new drug therapies. The Department of Biochemistry continued work on studies of hormonal balance and undertook a study of the relationship between certain physiological defects and schizophrenia. Funds for the latter were provided by the National Institutes of Health. �AND THE COMMUNITY During the year, increased recognition of the staff and work of the hospital came from a large number of lay and professional publications. The hospital is keenly aware of the value of this public interest because greater attention by the general public to the field of mental health will lead to greater support by govern- Publications and Presentations ment and private agencies, foundations and institutions. Berkowitz, Anne: A Study of the Caseworker’s Function at Hillside Hospital, J. Hillside Hospital, 5: 56-60, 1956. Fink, M: Denial of Blindness Following Cerebral Angiography, J. Hillside Hospital, 5: 238-245, 1956. Fink, M., Kahn, R. L. and Korin, H.: Relation of Tests of Altered Brain Function to Behavioral Change Following Electroshock; Presented at the Divisional Meeting, American Psychiatric Association, Montreal, November 8, 1956. Fink, M. and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol., 8: 158, 1956. Goldenberg, H., and Goldenberg, V.: Inhibition of Serum Cholinesterase by Lysergic Acid Derivatives. Sumicro Detection of LSD, J. Hillside Hospital, 5: 246-257, 1956. Goldenberg, H.: Decantation as a Precision Step in Colorimetric Analysis, Anal. Chem., 28: 1003, 1956. Goldenberg, H.: Recent Advances in Enzyme Methodology; Presented at a Symposium sponsored by the American Association of Clinical Chemists at the 123rd Meeting of the American Association for the Advancement of Science, New York, December 1956. Goldenberg, H.: Concerning the Inhibition of Pseudocholinesterase by Hallucinogens; Presented at the New York Academy of Sciences, April 1956. Green, M. A. and Fink, M.: Electroencephalographic and Clinical Effects of Megimide; Presented at the Eastern Association of Electroencephalographers, New York, December 5, 1956. Green, M. A.: The Use of Electroencephalography in Differentiating Psychogenic Disorders and Organic Brain Diseases, Amer. J. Psychiat., 113: 27-31, 1956, (with P. Bergman). Green, M. A.: Neurological Manifestations of Conversion Hysteria, Trans. A.N.A., 80: 196-198, 1956. Jaffe, J.: Experimental Alteration of Communication in Doctor-Patient Relationship; Presented at the Nassau Neuropsychiatric Society, April 15, 1956. Kahn, R. L. and Fink, M.: Changes in Language During Electroshock Therapy; Presented at the American Psychopathological Association, New York, June 1, 1956. Kahn, R. L., Fink, M. and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Psychiat., 76: 23-29, 1956. Kahn, R. L., Fink, M. and Korin, H.: Studies of Mode of Action of Electroshock; Presented at the Nassau Neuropsychiatric Society, April 15, 1956. Kahn, R. L., Linn, L. and Weinstein, E. A.: Personality Factors Influencing the Rorschach Responses in Organic Brain Disease; Presented at the New York 19 �Neurological Society, February 14, 1956. Also, Arch. Neurol. & Psychiat., 76: 226-267, 1956. Kahn, R. L., and Pollack, M.: Effects of visual, vestibular and somatosensorimotor deficit on autokinetic perception, J. Exp. Psychol., 52: 398-410, 1956, (with Battersby, W. S. and Bender, M. B.). Kahn, R. L.: Patterns of Social Interaction in Brain Disease, Amer. J. Psychiat., 113: 138-142, 1956, (with E. A. Weinstein). Kahn, R. L.: Confabulation as a Social Process, Psychiatry, 19: 383-396, 1956, (with Weinstein, E. A. and Malitz, S.). Kahn, R. L.: Delusions About Children Following Brain Injury, J. Hillside Hosp., 5: 290-301, 1956, (with Weinstein, E. A. and Morris, G. 0.). Korin, H., Fink, M. and Kwalwasser, 8.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. Neurol. 16: 88-96, 1956. Lurie, Abraham, Miller, Joseph S. A., Bellak, L., Black, B. F.: Rehabilitation of the Mentally Ill Through Controlled Transitional Employment, Amer. Orthopsychiatric Assoc., 1955 Annual Meeting. Also, Digest of Neurology and Psychiatry, July 1956, Institute of Living. Lurie, Abraham: Book review—Delinquent Boys by Dr. Albert K. Cohen, J. Jewish Communal Services, Summer 1956. Lurie, Abraham: Integrating Services for Improved Patient Care; Discussant at 50th Anniversary of Social Service Dept. of Mt. Sinai Hospital, October 18, 1956. Lurie, Abraham: Identifying Casework Responsibility in a Multi-Discipline Health Setting; Workshop Chairman, National Conference of Jewish Communal Service, 1956. Pinsky, Louise: The Impact of Mental Illness on a Patient’s Family, Jewish Communal Service, Spring 1956. Pollack, M. and Kahn, R. L.: Unilateral “Spatial Agnosia” (“lnattention”), Brain, 79: 68-93, 1956, (with Battersby, W. S. and Bender, M. B.). Wachspress, M., Blumberg, A. G., Fink, M. and Miller, Joseph S. A.: Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety, J. Hillside Hospital, 5: 67-77, 1956. Zierer, Ernest and Zierer, Edith: Dynamics of Creative Therapy; Presented at the University Clinic in Tubingen, Neckar, Germany. Zierer, Ernest and Zierer, Edith: Structure and Utilization of Creative Therapy; Presented at the Institute of Psychotherapy and Depth Psychology in Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: Non Artistic Creative Activity; Presented at the Art Academy of Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: Seminar on Creative Therapy as applied at Hillside Hospital and Extramurally; Presented at the meetings of the Zierer Study Group in Stuttgart, Germany. Zierer, Ernest and Zierer, Edith: What is Creative Therapw Presented at the broadcast over the Suddeutscher Rundflunk “Millelwelle.” Zierer, Ernest: Dynamics of Creative Therapy; Presented at the National Psychological Institute for Psychoanalysis, New York. Zierer, Ernest and Zierer, Edith: Structure and Therapeutic Utilization of Creative Activity, Amer. J. Psychotherapy, 10: 481-520, July 1956. ' ‘ 20 �TEACHING AND TRAINING The Resident Training Program at Hillside continues to emphasize the interrelation between the training program and the treatment program. Each resident carries a case load of about 15 patients under the supervision of staff and visiting instructors, and attends lecture conferences conducted by the medical directors. Lecture seminars in the fields of psychopathology and psychotherapy, and reading seminars, are conducted by special instructors chosen from the hospital staff. Qualified residents are assigned to the department of Experimental Psychiatry for clinical and other psychiatrical research projects. During the year there were 18 residents in training. The Resident Training Program The hospital training program extends also to Clinical Assistants in the Outpatient and After-care clinics and on-the-job training of personnel. Regular lec- Training for other staff members The Sunday Clinical Conferences, open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians, are part of the resident training program and are based on cases prepared by the residents. They continue to make a significant contribution to the training picture on the New York Psychiatric scene. Sunday Clinical Conferences The Annual Israel Strauss Lecture, established in 1955 in honor of Hillside’s founder and late president, was delivered this year on April 8th. The speaker was William Malamud, MD, Professor and Chairman of the Department of Psychiatry and Neurology of the Boston University of School of Medicine. His Israel Strauss Lecture Hillside's Committee on Community Education continues active and its program of lectures to the laity promote interest and understanding of mental hygiene problems in the community. Community Education The Medical Library, considerably enlarged by the acquisition of the entire medical library of the late Dr. Israel Strauss, was able this year to increase its services and usefulness to the staff by the employment of a full-time librarian. Medical Library The Journal of the Hillside Hospital again showed an increase in the number of its subscribers, an indication of the prestige and general acceptance it enjoys. A 504 page Israel Strauss Memorial Volume containing articles by psychiatrists and other friends of Dr. Strauss, was published in 1956. Journal of the tures and conferences are scheduled for nurses and attendants, social workers, members of the various adjunctive services and for affiliating students from other educational institutions. subject was “Current trends in basic psychiatric research.” Hillside Hospital 21 �REPORT OF THE ADMINISTRATOR Deficits While the cost of running the Hospital increased again, from $1,175,635 to $1,326,454, the deficit this year has been substantially reduced because the City of New York increased its contribution toward the care of the indigent mentally ill from $14 to $16 a day. The average number of patients per day. 192, remained the same as last year —97% of capacity. However the length of stay increased somewhat and the total number of patients treated was 561 this year compared to 575 in 1955. Comparison of costs: 1955-1956 . . . Salaries Food . . . . Maintenance and Grounds Administrative EXpenses Medical Supplies . Repairs and Replacements Clinics . . . . . Total Total No. Patients Total Patient Days . . . . Average income per patient day Average cost per patient day Average loss per patient per day . . . . . . 1955 1956 $732,977 106,397 50,551 67,017 28,130 25,279 165,284 $797,805 113,428 59,436 82,608 23,950 35,105 214,122 $1,175,635 $1,326,454 575 69,903 561 70,189 $14.45 $15.34 $15.44 $15.84 $ .89 $ .40 Costs of expanded out-patient services should be noted that the largest portion of the $150,819 increase was used for expansion of the Out-patient service. This increase was entirely offset by grants from the New York City Community Mental Health Board, the State Mental Health Authority, and increased subvensions from the Federation of Jewish Philanthropies. Increases in salaries reflect a rise in salaries and salary rates rather than an increase in personnel. Other increases reflect the general pattern of rising costs for goods and services. Costs of the Israel Strauss Adolescent Pavilion 1956 it was decided to compute the costs of running the Israel Strauss Adolescent Pavilion separately from those of the main hospital. While the pavilion operates as an integral part of the hospital, it is a new and costly experiment, which, if included, somewhat distorts the general operating picture. It In The operation of the Adolescent Pavilion showed a deficitof $37,752, an increase of 13% over 1955. The difference is entirely accounted for by salaries for additional personnel found necessary for successful operation. Maurice Bachrach 22 �SOCIETY OF THE HILLSIDE HOSPITAL ‘President . . . Alvin E. Coleman *Chairman of the Board Roy Foster *Honorary Chairman of the Board Leon Lowenstein *Vice-President Dudley D. Shoenfeld, M.D. *Vice-President D. Herbert Beskind ‘Vice-President George W. Galinger Manuel Lee Robbins +Treasurer Alfred Levinger ‘Ass’t Treasurer Arnold S. Askin Ass’t Secretary Hilda Strauss Assistant Secretary Alfred Appel 'Secretary Board of Directors A. Leon Lowenstein“ Roy Foster" Jacob Abrams George W. Galinger‘ Arthur Garson Maurice Glinertt Mrs. Henry Goldman, Jr. Meyer Goldstein Louis A. Green M. Victor Leventritt Alfred Levinger? Morris L. Levinsonrl: Milton B. Loeb Sandor Lorand, M.D. Alfred Appel Arnold S. Askin“ John M. Bendheim D. Herbert Beskind‘ Saul Blickman Alvin E. Coleman Morris David Edwin Elson1~ Thomas Epstein Arthur C. Fatt‘ David Finkle David Finn: Charles H. Meyer“ Arthur Murray Manuel Lee Robbins” lrving Rosenbaum S. H. Scheuer“ Walter Scheuer Dudley D. Shoenfeld, M.D.‘ Harry Silverson Hilda Strauss Nathan Wigod Morton 8. Wolf Walter D. Yankauer Chairmen of Standing Committees Medical Affairs Committee D. Herbert Beskind Executive Committee Roy Foster House and Grounds Committee George W. Galinger Co-Chairmen Nathan Wigod Jewish Hospital Coleman Liaison Committee—L. Alvin E. I. Legal Committee Charles H. Meyer Publicity Committee Arthur C. Fatt Finance Committee Arnold S. Askin Social Service Committee Hilda Strauss Personnel Committee Meyer Goldstein ‘Executive Committee Members tDeceased in 1956 *Elected in 1956 23 �PROFESSIONAL AND ADMINISTRATIVE STAFF Medical Director Joseph S. A. Miller, MD. Associate Medical Director Simon Kwalwasser, M.D. Administrator, Maurice Bachrach, B.S. George Yessin, M.D. Jack H. Tabor, M.D. Supervising Psychiatrists Gerhard Schauer, M.D. Martin A. Green, M.D. Robert Navarre, M.D. Eugene Glynn, M.D. Supervising Psychiatrist Israel Strauss Adolescent Pavilion Alice Slater Stahl, MD. Director of Out-Patient Services Robert R. Luttrell, MD. Director of Research in Experimental Psychiatry Maximilian Fink, M.D. Internist, Arnold Blumberg, MD. Director of Laboratories, Harry Goldenberg, Ph.D. Resident Staff Ruth Adams, M.D.* Stanley Brodsky, M.D. Frederick Coleman, M.D. Warren Cox, M.D. Ilhan Ermutlu, M.D. Harold Esecover, M.D. Stefano Fajrajzen, M.D. Marie Friedman, MD. Stanley M. Friedman, MD. Ruth Fuchs, M.D. Harold Galef, MD. Robert S. Gilbert, M.D. Eugene D. Glynn, M.D.“ Victor Goldin, MD. Michael Gould, MD. David N. Graubert, M.D.* George E. Gross, M.D.* Peter Guggenheim, M.D.+ A. Russell Lee, MD. Joel Markowitz, M.D.* Robert Nodine, MD. Paul Pressman, M.D. Arthur Root, M.D. Jack R. Royce, M.D.* Robert Shaw, M.D.* Charles G. Silverman, M.D.* Myron Stein, M.D. Morton Wachspress, M.D. Leon Lefer, M.D. Other Professional St aff Heads Nathalie Burbach, R.N., M.A. Director of Nursing Abraham Lurie, M.S.S.W. Director of Social Service Abraham Levine, Ph.D. Director of Psychology Ernest Zierer, Ph.D. Director of Creative Therapy Eileen P. Fisher, B.S. Director of Occupational Therapy Zetta Putter, M.S. Director of Group Activities Angelina Canavan, B.A. Dietician Department Heads Dorothy Croghan Accounting Supervisor Lillian Dailey Office Manager Thomas R. Lumley Superintendent of Buildings & Grounds Sarah Travers Executive Housekeeper ‘Completed residency in 1956 fin military service 24 �MEDICAL BOARD *President *Vice-President ‘Secretary . . . M. David Sidney Tarachow, M.D. Sidney L. Green, M.D. Epstein, M.D. *Treasurer * Ex-President David Warshaw, M.D. Samuel Atkin, M.D. Psychiatrists Samuel Atkin, M.D.‘ Arnold Eisendorfer, MD. M. David Epstein, M.D.“ Margaret E. Fries, M.D.* I. Peter Glauber, M.D. George S. Goldman, M.D. Sidney L. Green, M.D.‘ William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, MD. Emanuel Klein, M.D. Sidney Klein, M.D.“ Samuel 2. Orgel, M.D. H. L. Rachlin, M.D.“ Lawrence J. Roose, M.D. Irving J. Sands, MD. Robert A. Savitt, M.D.* Martin Schreiber, M.D. l’sidor Silbermann, M.D.* Otto Sperling, M.D. Sidney Tarachow, M.D.‘ Non-Psychiatrists Director of Department of Medicine Lester Cohen, MD. 'Director of Department of Surgery Director of Department of Neurology Morris B. Bender, M.D. Director of Department of Gynecology Julius Jarcho, MD. ‘Department of Dentistry David Warshaw, MD. Paul Scheman, D.D.S. Chairmen of Standing Committees Adolescent Pavilion Sidney L. Green, M.D. Education of Resident Staff Arnold Eisendorfer, M.D. Community Education and Public Relations Robert A. Savitt, M.D. Group Psychotherapy Samuel 2. Orgel, M.D. Credentials Committee for Psychiatric Staff and Promotions Martin Schreiber, M.D. Manhattan After-Care Clinic Sarah R. Kelman, M.D. Credentials Committee for Non-Psychiatric Staff and Promotions David Warshaw, M.D. Credentials Committee for Resident Staff Sidney Klein, M.D. Queens Out-Patient Clinic William Karliner, M.D. Research Committee Hyman L. Rachlin, M.D. Publications Committee I. Peter Glauber, M.D. Journal Sub-Committee Sidney Tarachow, MD. 'Ex-officio 25 �CONSULTING, ATTENDING AND VISITING STAFFS: AND CLINICAL ASSISTANTS Consultants Psychiatry Leonard Blumgart, M.D. Sandor Lorand, M.D. Nathaniel S. Selby, M.D. Dudley D. Shoenfeld, M.D. A. M. Rabiner, M.D. Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, MD. I. Jesse Levy, MD. Neurology Hans Strauss, M.D. I. S. Wechsler, M.D. Dentistry Morris Fierstein, D.D.S. Attending Psychiatrists Samuel Atkin, M.D. Arnold Eisendorfer, MD. M. David Epstein, M.D. Margaret E. Fries, MD. I. Peter Glauber, M.D. George S. Goldman, M.D. Sidney L. Green, MD. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D. Samuel 2. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, MD. Robert A. Savitt, M.D. Martin Schreiber, M.D. lsidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Frank Berchenko, M.D. Cornelius Beukenkamp, M.D. Mark L. Gerstle, Jr.+ Soll Goodman, M.D. Attilio Laguardia, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Martin H. Orens, M.D. Abraham Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Nathaniel S. Lehrman, M.D. Harold S. Leopold, MD. William W. Pike, M.D. Adjunct Attending Psychiatrists Edward R. Adelson, M.D. Renato J. Almansi, M.D. Herman S. Alpert, M.D. Irving L. Bauer, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Isadore H. Cohn, M.D. Alexander J. Friedman, MD. Albert E. Goldbert, M.D. Albert Harrison, MD. Thomas Hora, M.D. tResigned in 1956 26 David Milrod, M.D. Hugh Mullan, M.D. Helene Papanek, MD. Benjamin B. Rubenstein, M.D.+ Irvin Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Aaron Stein, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Arthur Zitrin, M.D.1- �Visiting Director Lester Cohen, MD. Visiting Physician George Sabrin, M.D. Visiting Physician L. Rosenblum, M.D. Visiting Physician A. Blumberg, MD. Associate Physician M. Kalkstein, M.D. Associate Physician J. Weinstein, M.D. Visiting Neurologist Medicine Adjunct Physician A. L. Berger, M.D. Adjunct Physician W. B. Brett, M.D. Visiting Dermatologist C. Stritzler, M.D. Associate Dermatologist Joel Schweig, MD. Adjunct Dermatologist N. Goldfarb, MD. Neurology Morris B. Bender, MD. Associate Neurologist Adjunct Neurologist Harry Harter, M.D. Director David Warshaw, MD. Visiting Surgeon Sidney Hirsch, M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist L. G. Goldberg, MD. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Director Julius Jarcho, MD. Visiting Gynecologist M. Warner, MD. Visiting Gynecologist H. Dubrow, M.D. Surgery Kurt Adler, M.D. Associate Orthopedist J. Schneiderman, M.D. Visiting Proctologist B. Warner, M.D. Visiting Ophthalmologist E. Seretan, M.D. Associate Ophthalmologist A. Minsky, M.D. Visiting Otolaryngologist S. Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. Gynecology Associate Gynecologist Jack Cohen, MD. Associate Gynecologist B. Greenblat, M.D. Adjunct Gynecologist Eugene Streim, M.D. Radiology Visiting Radiologist Bernard Epstein, M.D. Director Paul Scheman, D.D.S. Associate Director J. G. Rubin, D.D.S. Associate Stanley Spiro, D.D.S. Associate Dentist B. Schwaid, D.D.S. Adjunct Dentist B. Lebow, D.D.S. Adjunct Dentist H. Lewis, D.D.S. Dentistry Adjunct Adjunct Adjunct Adjunct Adjunct Adjunct Dentist Dentist Dentist Dentist Dentist Dentist H. Adler, D.D.S. J. Goldberg, D.D.S. S. Platt, D.D.S. S. Plotnick, D.D.S. E. Friedman, D.D.S. M. Protell, D.D.S. Optometry Staff Optometrist Edward L. Steinberg, O'.D. Podiatry Staff Podiatrist Sam Sokolov, Pod. D. 27 �Clinical Assistants in Manhattan and Queens Clinics _ Lester I. Abend, ‘M.D. Ruth Adams, M.D. Romano Antonelli, M.D. Howard Boskey, MD. Paul Bradlow, M.D. Arline Caldwell, M.D. Mischa Caplan, M.D. Dominick J. Carlisi, M.D. Lionel Chertoff, M.D. Rita M. Chalef, M.D. Gloria Chung, MD. Julius Colantuond, M.D. Fred Dalton, M.D. Edward Einhorn, M.D.1- Joseph Feldman, M.D.+ Philip Friedland, M.D.t Hans Freymuth, M.D.1Arthur Gillman, M.D.t Harry Gonda, MD. David Graubert, M.D. Martin Hurvitz, M.D. Howard Hess, M.D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Buck Luria, M.D. Meyer Monchek, M.D. Mathias Nachumi, M.D.1- Beatrice Nachtigal, M.D. Iris Orens, M.D. Edward Pinney, Jr., MD. Joshua Ramot, M.D. Willem W. Roosen, M.D. Henry Rosberger, M.D. Joseph D. Rosen, M.D. Gabriel Rubin, MD. Herman Tannor, M.D. Leon Tec, M.D. Clara Torda, M.D. Morton Wachspress, M.D. Irving Waitzel, M.D.l‘ tResigned 1956 STSANDL . are necessary to a v TO THE HOSPITAL he Society. The following form, however, se of the Hillside Hospital, the sum of - rty, such as bonds, stocks, etcetera, is serted instead of the words “the sum of 28 �l .,v . I ' I ., ‘ ,- . . �Glen Oaks, Queens, New York, �Hillside Hospital is a non-profit, non-sectarian mental hospital for the treatment of from Patients mental curable and are early symptoms. voluntary patients suffering admitted regardless of their ability to pay. I Hillside provides training for physi- cians in post-graduate psychiatry and psychotherapy and puts major emphasis on research in all phases of treatment. The hospital considers itself a pilot institution, ill. the to the and human mentally in efficacious application of psychiatry pioneering I The hospital is licensed in the New York State Department It is approved of Mental Hygiene. Medical Council the in on by psychiatry for a two-year residency Education of the American Medical Association, The American Board of Psychiatry and Neurology and the American College of Surgeons. The Dental Department is Association Dental American the as an approved hospital department. by certified I Hillside Hospital is an affiliate of the Federation of Jewish Philanthropies and a York Fund. New Greater the and Fund United the Hospital participant of M. DAVID EPSTEIN, M.D. �I The responsibilities and functions of the Medical Board fall roughly into two broad categories: 1. It is a consultative and advisory body to the Medical Director and the Board of Directors in all matters pertaining to medical functioning of the Hospital. In this capacity, it assists materially in the formulation of basic policy, and in the establishment of both short-range and long2. In addition, it range plans, directions and goals performs duties relative to the implementation of these plans and policies and plays an active role in the practical day-to-day operations and needs of the hospital, whether this be in terms of active supervision of the junior members of the staff, supervision of the Out Patient Clinic or the After-Care Clinic, careful and methodical screening of all candidates for positions on the professional staff, either House or Visiting, or working with other departments within the hospital, such as Psychology or Social Work It is not possible to report on all the activities of the Medical Board since the last report was rendered. However, some of the more important areas of Board activity are worthy of individual mention During the past year, the Liaison Committee of the Medical Board, working with the Medical Director and Lay Board, has been able, after long and delicate negotiations, to bring to a successful culmination the question of the establishment of a Psychiatric Service at our neighbor institution, the Long Island Jewish Hospital. One of Hillside’s Attending Psychiatrists will organize a staff at Long Island Jewish Hospital and will maintain liaison with Hillside Hospital. We will be glad to continue to render whatever assistance we can, and we look forward to a productive, progressive collaboration between the two institutions The Journal of the Hillside Hospital, under its able editor, has continued to grow and is achieving ever wider recognition in the professional world. The caliber and standards of the publication have remained consistently high. In the field of publication a new project has been recommended and will shortly be carried out, viz. a series of monographs I I I I on important psychiatric subjects to be issued under the The Adolescent imprimatur of Hillside Hospital I Pavilion, a pilot project established several years ago, and a rather unique undertaking, has taken a great deal of time and work. It has gone through a variety of growing pains in its early exploratory and experimental period, but it is now an established and important aspect of the Board’s interest and efforts. Although it continues to present problems, or better, because it does, much is being learned about problems of adolescent psychopathology and their treatment and a sizable body of knowledge is being accumulated which will no doubt lead to advances in understanding and to important research results. In addition, the Pavilion continues to After much serve as an important training facility careful study and planning, the Medical Board has set the machinery in motion to establish a new project. This is to be a Child Therapy Unit, for the intensive treatment of a selected group of children and their parents where necessary, to be operated as part of the Out Patient Department. Such a unit would be a most valuable adjunct to our training program and will also help in filling an urgent need in the community. The basic set-up is ready to start functioning as soon as one or two remaining obstacles are overcome, and it is ardently hoped that this plan will be brought to fruition in the very near future Possibly two of the most important functions of the Medical Board are the organization and supervision of the Educational and Research Divisions of the Hospital. Under the guiding hand of the Educational Committee, our Resident Training Program continues to operate most successfully and the program of formal and didactic training and supervision is more than adequate. The Committee is constantly studying and re-evaluating the educational program, always seeking ways and means of refining and improving teaching methods at the Resident level, a universal problem with which every training hospital has to cope. Currently, the Committee is exploring ways of expanding and rounding out the train- I I ing program, with a View to having Hillside accredited for a three-year residency, possibly with the aid of affiliations with other institutions. Such a development would be eminently desirable In the area of Research, much has been accomplished and the Committee or the Board charged with this responsibility has functioned most actively. In collaboration with the Directors of the various research divisions, a large number of projects have been studied and evaluated. In addition, several members of the Board and Attending staff are engaged in individual research projects of great interest and promise. The Board is still seeking ways of expanding the Research Program, broadening it to make it more inclusive and comprehensive by adding a Research Division devoted to the more purely psychological aspects of mental disorders. Unfortunately, our efforts thus far have not been successful, but the search for a suitable and available person to head such a program goes on actively. It is with profound regret that we are compelled to note the loss through retirement of two of our oldest and most respected Board members— Doctors Julius Jarcho and David Warshaw, both of whom have become Consultant Physicians, from which lofty eminence we trust their invaluable advice and experience will continue to be available to us A closing word now about our view of the future. We have no doubt that Hillside Hospital now stands at a critical point in its historical development and evolution.Great and important changes can be expected and far-reaching decisions will have to be made. These changes are made necessary by the need to expand and to be prepared to meet the exigencies of a rapidly expanding science of Psychiatry and even more rapidly growing community needs for service and for trained personnel. We must gear ourselves and plan with foresight for these changes. Hillside can and should become a vital element in the psychiatric world and an important training and research center. To make it such will require Vision, courage, perhaps even daring, and cooperation on the part of all who are associated with it. I I �//2 I TQM/r/M' e/0 poéra/ In 1957, Hillside saw many changes, some obvious, some not yet evaluated, in attitude and treatment, in financial status, in acceptance in the eyes of the comI of am constructive these For signs progress, munity happy to commend our staff, the professional and nonprofesslonal personnel, the Medical Board and the everready help and unselfish interests of the Board of DirecAs a non-profit, non-sectarian hospital for the tors treatment of voluntary patients suffering from early and curable mental symptoms, the function of Hillside as a teaching and research center has enabled it to pioneer in many forms of therapy. To help in this area, an unusual number of grants were awarded to Hillside in 1957. Some $256,400 were allocated for research and nonthe contributions Of the making up operating purposes. grants, the largest was $104,800 from The Ford Foundation. Other sums were: Max Einhorn Estate, $50,000, Hillside Hospital Board of Directors, $50,000, and the US. Public Health, Institute of Mental Health, $35,000 Increasing attention from the nation’s press is being focused on the research, training and therapy programs of leading mental hospitals. We believe this is of great help to everyone in the field of mental health. No small share of this publicity was directed at Hillside Hospital during 1957 However successful this side of Hillside’s remained still the in on 1957, emphasis was program the patient. At Hillside, the first person a patient sees I I I I is his doctor. The large medical staff is concerned with various aspects of his recovery, but the doctor assigned to each patient is the most important person to look to for treatment, consultation, advice and help. The social worker assigned to help with the problems of the patient outside the hospital, as well as within its walls, stays with him as long as needed. The nurses and attendants offer to the patient the understanding of A new special training and constant association booklet dealing with these aspects of a patient’s relationship with the staff, and endeavoring to answer his questions and allay his doubts, has been written and made available to patients and their doctors, as well In 1957, as consultants and interested researchers the three alternate ways of dealing with Hillside’s patients and their varied needs evolved more strongly. A patient is helped to rejoin his family and the community not only by Hillside but by the various private and state employment groups, interested voluntary organizations, as well as the family which ideally gained new insight and understanding under the guidance of the social service worker He may need the continued attention of a social service worker, sometimes for as long as eight months. A continuous relationship such as this gives anchorage and stability to the patient. Should further psychotherapy be needed, he is referred to the After-Care Clinic, the Jewish Family Service, or other I I I I When the discharged patient cannot be sent back home, because the original environment is not suitable to maintaining recovery he is placed in private residence care through our liaison with the Jewish COmmunity Services of Long Island. Happily settled in newer, more sympathetic surrounding, the patient then can be seen in therapy for six to eight months. This time limit is arbitrarily set in the belief that the patient can be moved to a dynamic effort to With the entire emphasis of recover more quickly Hillside on an “open hospital,” the tendency more and more is to treat and hold the patient so far as possible in his normal environment. Carrying this a step further, Hillside now believes that its future lies not in enlarging the hospital’s facilities, but in expanding the pré-hospital The main orienguidance, and Out Patient Service tation, therefore, of the patients and staff at Hillside is to the inevitable return to the community and useful citizenship. The goal of the hospital’s treatment services. organizations I I both at the in patient and out patient levels, is to provide the best qualitative treatment for our patients, so that the result, ideally, is not merely an improved or recovered individual, but an improved or reclaimed family unit or small segment of the present and future community. Joseph S. A. Miller, M.D. �I 1957 was a good year for Hillside Hospital, and no apparent recession set in, with regard to the work of the hospital, or the demands made upon it were concerned. During the year, new ideas were presented and developed, such as the training of registered nurses in psychiatry at Hillside, in collaboration with the Queens Medical College. This plan inured to the benefit of the hospital in that some of the nurses remained to practice with us. Additional funds secured from the New York City Community Mental Health Board and the Nassau County Mental Health Board permitted the further expansion of services in the Out Patient Clinic where, at the end of 1957, we were treating 205 patients each week We suffered a great loss through the death of our long time Treasurer, Alfred Levinger, who had been one of the original founders of the institution. During 1957, the Board of Directors created the new position of Honorary Director, and the first Director so honored was Mrs. Israel Strauss, the wife of the founder of our institution. Saul Blickman, one of our directors ‘of long One of the most standing, was similarly honored important events of the year was the appointment of Dr. Lewis L. Robbins as Director of Professional Siervices. Dr. Robbins, a nationally known psychiatrist, who has been with the Menninger Foundation for 18 years, will join the Hillside staff in July 1958 Our research work has continued and expanded through the financial aid of several government organizations and private I I I flflflflfl/fl ' foundations, as well as donations of the Hillside Board of Directors. During 1957, the staff of the Department of Experimental Psychiatry extended our knowledge of the way various treatments affect our patients and have clarified our understanding of electroshock, insulin coma, and the newer tranquilizers. Their studies have been presented before national and local psychiatric and psychologic societies, and eight reports have been published during the year. Three reports were presented at the International Congress of Psychiatry in Zurich and of Psychology in Brussels during the summer The need for greater research efforts is apparent to all who are even casually interested in this field of health, and it does seem incumbent upon the governments of the United States and of each state, as well as private funds, to offer more generous support for these efforts. But surely, within the foreseeable future, progress will be made and we, at Hillside, are not alone in believing this. At the 1957 convention of the American Hospital Association, Dr. Julian P. Price, Chairman of the Joint Commission on Accreditation of Hospitals of the American Medical Association said: “The chemical nature of certain mental diseases will be discovered and their control brought about through the giving of drugs.” RecognizingIthe tremendous human values this will have, not to mention the enormous dollar savings, let us try our best to hasten this day with our own efforts and money. I ALVIN E. COLEMAN �of 545 total treated patients. Hillside a 1957, Admissions and Discharges—1n with an average daily census of 192. New admissions totalled 81 and readmissions after been an had discharged 351 of the end patients the 32. totalled By year, of summaries statistical the is similar to data This average stay of 182 days. recent years. %/tm/ / MARRIED F No. of patients treated Males Sex Females Admission (13-19 (20-29 Age (30-39 (40-49 (50-59 (60 plus No. of patients admitted Average no. days hospitalized (adults) WIDOWED M F DIVORCED & SEPARATED M F �I In any evaluation of discharges, it is important to realize that the terms used to denote mental condition at the time of discharge only signify a comparison between the patient’s condition and behavior when he came to the hospital and when he left, a relatively short period The following comparisons use terms which are defined as follows. Unimproved means there has been I no change; improved means that symptoms or problems have been somewhat helped but still persist to an appre- ciable extent; much improved means that symptoms have disappeared and the patient seemed in good condition at the hospital, but there is no certainty Of how he will function when he gets back into his own social and working community; recovered means that in addition to what has been said for much improved, there is reasonable expectation that the patient will be able to return tO his community and function as well, or better than he did before he became ill. %/ , DIAGNOSIS ADULTS ADOLESCENTS /lflfl// a) a TOTAL NO. OF PATIENTS WHOLE SHOCK THERAPY 5'2 0F INSULIN COMA THERAPY % % RECOVERED MUCH IMPROVED IMPROVED UNIMPROVED Psychoneurosis 63 3 66 19% 12% 10% 46% 40% 4% Manic depressive psychosis 84 1 85 24‘} 34% 27% 43% 27% 3% Involutional psychosis 63 63 18% 39% 22% 49% 20% 9% 1 8% 26% 50% 16% 40% 20% 40% 39% 36% 12% 118 9 127 36‘)? Others 8 2 10 3% Totals 336 15 351 100% Schizophrenia % 76% 14% 18% 13% �%y¢%/%¢Q/% m/ giwzéw %%éa/ I One of the main criteria for accepting. patients at Hillside is their ability to participate profitably in psychotherapy. Patients are seen individually three times a week for psychoanalytically oriented treatment by their assigned psychiatrists. The psychiatrist is the leader of the hospital “team” that plans and supervises the patient’s day-to-day treatment. The other members of the team are a psychiatric social worker, a psychologist, professional representatives of the adjunctive services—Occupational Therapy, Group Activities and At Hillside, the staff is Creative Therapy—and the Nursing Department much larger in proportion to the number of patients than in other mental hospitals. Thus, Hillside’s emphasis is entirely on the patient as an individual. Although all the latest physical and pharmaceutical techniques are used as needed, such as electroshock, insulin, Serpasil, treatment does not revolve the to since these supplementary around only they techniques are primarily psychotherapeutic approach. All departments bring into play the tools of treatment, prescribed according to the patient’s particular needs, and all aimed not only at relieving him of symptoms, but getting at the causes as well, so that he may be returned to full usefulness as a human being. The Psychology Department. under the direction of Dr. Abraham Levine, continued to expand both in staff and services. In addition to six new staff Uma Dr. for Hillside training a diagnostic year’s provided appointments, The Vocational CounselChowdhury, a cultural anthropologist from India ling Program was expanded through the addition of staff members. The Department conducted 222 new adult patient examinations, 21 examinations for the adolescent patients and 248 Out Patient examinations. 117 psychological I I discharge examinations were administered for In Patient adults, 8 for adolescents, and 19 for Out Patients. The Nursing Department. under the direction of Mrs. Nathalie Burbach, participated in all initial presentations, discharge conferences and team meetings, enabling them to offer more understanding and knowledgeable nursing care. 36 Psychiatric Aides were trained, and 57 student nurses from Queens College received psychiatric nursing experience. Central Islip School of Nursing continued to send student nurses for semi-weekly visits to compare opera‘ tion of state and private hospitals, and student nurses and nursing personnel from St. Vincent’s Psychiatric Unit in Manhattan Visited to obtain information generally helpful in the preparation of patients transferring from St. Vincent’s The Intramural Clinic has continued to handle all major to Hillside An of hospitalization. patients’ the during course arising physical problems overall supervision of the effect of the drugs used in psychotherapy was conducted with special emphasis on Chlorpromazine and Meprobamate. 1756 examinations were conducted for treatment in such specialized fields as Dermatology, Gynecology, Medicine, Neurology, Ophthalmology, Orthopedics, Otolaryngology, Podiatry, Proctology, Radiology, Surgery and The Dental Department made Urology 1123 examinations including restorations, I I �extractions, prosthetic treatments, and X-rays. Under the direction of Dr. Paul Scheman, a staff of 12 Visiting dentists continued to adapt consultation and treatment procedures to the special needs of the mental patient. The department, certified by the American Dental Association, presented a series of lectures for dentists who treat “problem patients”. tMa/QMM/féze gar/12w The Occupational Therapy Department. under the direction of Eileen P. Fisher, in order to give more intense individual treatment, registered no more than 45 patients at a session. No therapist has more than twelve patients to work with at a time. Though the Department treated fewer patients per month, the average daily attendance remained the same, since there was closer followa up on all patients and a closer relationship with individual doctors. The Department works closely with all members of the psychiatric team, particularly the social workers. A special class program was organized on a selective basis, offering individual instruction in ceramics, jewelry and sewing. A student training program is being planned as a result of approval as an alfiliating center for students from New York University Lectures on the principles and uses of Occupational Therapy in a psychiatric hospital were given to student nurses, new personnel and visitors. I The Creative Therapy Department. under the direction of Dr. Ernest Zierer and his associate, Mrs. Edith Zierer, continued experiments with con- trolled painting tests, designed as a psychodiagnostic tool to stimulate the patient into projecting his unconscious conflicts by painting. An average of 42 patients were treated daily. A total of 4,509 paintings were analyzed and a total of 1,593 tests administered A new questionnaire form of tests was added to help the patient gain insight into his actions and reactions. The patients are encouraged in regularly scheduled individual sessions to give verbal interpretations of their paintings within the framework of the situation, also tied in with the test results Lectures were given to visiting psychiatrists, social workers and students. I I �@fiéfl/ [lflfl/ fl @ammmw/ / �I Hillside Hospital believes in treating the mental patient within the community, rather than in isolation, away from family and familiar surroundings. Directly responsible for improving communications between the patient, his family and his community is Hillside’s Department of Social Services. Under the direction of Abraham Lurie, the Department works to help the patient keep his place in society, and return to it In 1957, the Dea better, more useful citizen partment was reorganized to include the Group Work Division. The Department, therefore, now consists of two divisions: The Casework Division, directed by Louise Pinsky, an assistant director of the Department, and the Group Work Division, directed by Arnold Eisen, also an assistant director of the Department As a result of this merger of staffs, there have been several improvements and developments in the program offered patients, and it is believed that the goal of integrating the patient with his family and the community is closer through these changes. The Casework Division. with the knowing cooperation of the patients and their families, works to maintain and strengthen family ties, and to I I solve, with the patients, their individual problems of rehabilitation. Through the Division, the hospi- tal reaches out from the patient to the family to the community. This link is established and maintained before the patient enters Hillside and continues for as long after the patient has left the hospital as seems necessary. In dealing with the realities of the home and the community situations that have contributed to the problems of the patient, the Division is concerned with such specifics as working opportunities, living arrangements, care of children, care of aged and interim financial support Last year, a total of 1,566 applications for admission to the hospital were received. The majority of referrals (89%) came from the New York City area, but applications were received from every geographic section in this country and also as far away as Brazil As in previous years, twice as many female applicants as male applicants sought admission. Patients were referred by psychiatrists, social agencies, hospitals, churches, synagogues, courts, schools, trade unions, as well as by communities, expatients, and through publicity. Of particular significance was the fact that the percentage of I I patients not found suitable for admittance was 19.2%, as compared with 25% the previous year and 26% in 1955. Thus, the trend, started two years ago, after the establishment of an Intake Service, continues to demonstrate the effectiveThe activity ness of pre-screening applications of the casework division is reflected in the following statistics: I Interviews with patients, including Out Patient Dept. and Adolescent Unit .................... 5,110 Interviews with relatives, including Out Patient Dept. and Adolescent Unit .................... 5,860 Collateral Interviews ............................ 186 Interviews with discharged patients ............ 253 Interviews with relatives of discharged patients ...................... 256 Telephone contacts with social agencies ...................................... 5,425 Telephone contacts with relatives of patients .................................... 10,077 The Group Work Division is concerned with �providing a milieu in which patients can form social relationships, assume responsibilities, develop new interests and learn new skills and so begin to find places, first in the hospital community, and then in the outside community Among important developments this year was an orientation and intake program designed so that the new patient, helped by the social group worker, quickly learns the social structure of the hospital, and examines some of the groups available to him. With help, he makes preliminary choices based on previous experience as well as current social interest and need As part of the trip program, another new development, patients go to bowling alleys, ice and roller skating rinks, and restaurants. Some patients undertake longer trips to museums, the United Nations, or other places. Since this requires planning, it is a measure of the group’s ability to unite in a common goal and These new to sustain interest in the activity developments supplement the program which is the patient’s most direct link with the community I I I he has voluntarily left behind. With a group worker assigned as advisor, all patients meet regularly in democratic self-government. They work to solve their problems in living together, assume some responsibility for group discipline, and plan their social life. Many activities are carried out by delegated members who serve on planning committees to choose books and records, plan parties and dances, and other social activities An important aspect of life at Hillside is the chronological grouping based on age and similarity of interest. There are currently clubs serving all ages and giving each patient a chance to be a member of a social unit of his choice. The Library Group, for example, selects new books and magazines for patients from a practically unlimited list. The Newspaper Group is responsible for the writing and production of a monthly literary magazine, “Inside Hillside” and other publications In addition to these self-chosen activities, all patients participate in a series of current events discussion groups, in order to keep informed about daily events in the community they hope to rejoin. Patients are encouraged to assume leadership in all matters—and share their skills with each other. As a result, at varying intervals during the year, there have been patient-conducted groups in such varied activities as tennis, I I �bridge, play reading, and theatrical production The Group Work Division operates with a director, supervisor, four social group workers, two graduate social work trainees, eleven undergraduate field work students, two part-time musical teachers, and 25 part-time volunteer workers Last year, ten graduate social workers were placed at Hillside for specialized training. The Division works closely with two outside organizations, The Bridge, a group of women who help recently discharged patients to re-establish themselves socially, to find jobs, and to maintain themselves financially while doing so, and The Hillside League, a club for ex-patients of Hillside. Located in quarters maintained by The Bridge, at 231 West 83 Street in Manhattan, the League offers social club privileges to members, including games, TV and meeting space, and, in addition, provides special help in finding housing, employment, further treatment, and solving other personal problems in readjustment The QueEns OII‘I‘ Pafien‘l‘ Clinic. located at the Hospital, provides psychotherapy for residents of Queens, Nassau and Suffolk Counties who are unable to afford a private psychiatrist. Directed by Dr. Robert R. I I I Luttrell, the Out Patient Clinic insures the availability of qualified specialists who focus on early treatment and prevention of emotional illness. The geographical location of the hospital’s clinic, in a corner of Queens, bordering on Nassau County, makes a resource for psychiatric care available to one of the country’s fastest growing population In 1957, the clinic treated 316 patients areas in individual psychotherapy. Of these, 134 cases were carried over from 1956 and 182 were started in treatment. 163 were discharged during the year from individual psychotherapy. Group therapy, a new development in 1957, has resulted in six discharged of the 23 patients in the group. Eight patients received electroshock therapy and 67 patients were seen in continuous casework. 267 psychological tests were performed and 285 patients were evaluated by the “intake” team. I Diagnoses of discharged patients were: Psychoneurosis ..............................................53 Schizophrenia and manic depressive ............ 46 Involutional melancholia .............................. 9 Character disorder ........................................55 Conditions at discharge were: Improved ...................................................... 1 14 Much improved ............................................ 20 Not improved .............................................. 29 I Average length of treatment at the clinic was about nine months. Because the clinic is an out patient facility, families remained intact and there was little or no loss of jobs. As with in patient care, fees are based on ability to pay, with the average fee about $6 per week. (The cost to provide this service is approximately $30 per week.) Another out patient service provided by the Hospital is the After Care Clinic which operates five evenings a week at Mt. Sinai Hospital, a convenient location for most patients. The Clinic assists the discharged Hillside patient to resume his community status, and deals with the immediate problems of job replacement, living and resumption of old environmental contacts that may have originally contributed to the patient’s illness Group psychotherapy was instituted on a trial basis in this clinic during 1957 in an effort to meet some of the continuing needs of these patients. I I �17% mm/ %fi”2fl7flfllgy Research. When one out of ten adults is hospitalized for mental illness every year, it is obvious that much is still to be learned about why people become mentally ill. As much as has been learned about the care of the mentally ill in the past 20 years, there are still new areas to be studied, such as blood chemistry and the delayed effects of the electroshock treatment Hillside believes that in addition to treating mental patients, it is obligated to undertake research. So advanced is the hospital’s outlook that it is one of the few mental hospitals with a biochemistry laboratory. Although the amount of current research on the subject of mental illness is infinitesimally small, Hillside employs a stafl of scientists and trained researchers seeking the answer to why people become mentally ill and a surer knowledge of how treatment effects the improvement of mental patients The Department- of Experimental Psychiatry. during 1957, under the direction of Dr. Max Fink, completed the first phase of its studies on the mechanism and effects of therapeutic techniques presently employed. Following the elucidation of the neurophysiologic and psychologic bases of the process of convulsive therapy, a control convulsive-subconvulsive study was undertaken in 1956 and completed in 1957. This study clearly demonstrated the changes in brain function which are the necessary prerequisites for change in behavior; and the psychologic, sociologic and language aspects which are fundamental In concurrent to “improvement” after convulsive therapy studies, the equivalence of chlorpromazine therapy for insulin coma, and the advantages of newer drug therapies were demonstrated in a chlorpromazine-insulin coma control study. Consequent upon these observations, an hypothesis of the mode of action of tranquilizers was described and a program of be- I I I I havioral assay of new drugs undertaken Basic studies into patterns of communication continued. By applying new techniques of psycholinguistics, objective methods of evaluating behavioral change and “improvement” were described and are now being tested. Studies in tactile and visual perception, neurophysiologic and psychologic bases for individual differences in response to drugs and convulsive therapy, and biochemical changes in spinal fluid after induced convusions continued Support for this program increased through grants from the Foundation’s Fund for Research in Psychiatry, the National I �Institute of Mental Health, and the Psychopharmacology Center of the National Institute of Health. A research grant of $31,700 was awarded to Hillside by the Foundation’s Fund for Research in Psychiatry. The grant was given to Dr. Joseph Jaffe of the hospital’s Department of Experimental Psychiatry for research in the nature of the psychiatric interview. The Biochemistry Department was concerned principally with blood enzyme levels in the hospital patients and with their urinary alkaloid excretion patterns. Results of a third study flatly contradicted European reports of a blood test for schizophrenia. Under the direction of Dr. Harry Goldenberg, laboratory co-workers determined that serum cholinesterase levels in patients receiving electroshock therapy vary according to sex, with female patients generally higher. Work with rats suggests that these findings may be related to an abnormal adrenal metabolism Preliminary studies on the more acutely ill mental patients revealed an excessive excretion of aromatic metabolites in the urine, in agreement with the reports of other workers. It is not yet known whether this phenomenon has a causal relationship to schizophrenia European claims of a blood test for schizophrenia which is based on serum oxidase (ceruloplasmin) assay were unsubstantiated. Positive tests were obtained in various conditions other than mental disease (pregnancy, upper respiratory infections, cancer), while many well-fed patients gave negative tests. It was concluded that the I I European patients who were studied probably were suflering from a Vitamin C deficiency. M ~”‘wafirm/WNWwWa/WM‘ WM l/lMWn/WWVWVWW vv 4 MUM/WWWW4“:WM WW “WA/WWW Mil/wk} WWW «WWW-mekmrmwwvymmm AWWx W'WWVWWWWWMrMWW/VW MANN“ �I During 1957, members of Hillside’s staff were much in demand as guest lecturers and convention speakers. As the hospital continues to prove its value as a pioneer in the “open hospital” philosophy, more and more demands are made on the staff for intensive training courses, lectures and publications. Staff members spoke at meetings of national organizations including the American Psychiatric Association, and the National Conference of Jewish Communal Service, state groups including the New York State Society for Mental Health, and local groups including the North Queens Mental Hygiene Association and the Queens County Mental Health Society I Staff members reported on therapy and research and other results in a large number of professional publications, The Journal of the Hillside Hospital, edited by Dr. Sidney Tarachow, included articles by staff members and also outside contributors. �Publications 1957: R. L. I Esecover. H.. Juffe. J. and Kuhn. R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. (in press) and Green. M. A.: Experimental studies of the Electroshock Process Dis. Nerv. Syst. ( in press) I I I Fink. M.. Kuhn. Fink. M.. Shuw. R.. Gross. G. and Colemun. F. 5.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. (in press) Threshold, EEG Clin. Neurophysiol. (in press) I I Fink. M.: Lateral Gaze Nystagmus as an Index of the Sedation Fink. M.: Individual Differences in EEG Responsivity. Read at Metropolitan EEG Society, New York, February 1957 Fink. M.: Criteria in Evaluation of Clinical Behavioral Change: Neurophysiologic Aspects. Presented at A.P.A., Round Table, Chicago, May 1957 I and Green. M. A.: Experimental Studies of the Electroshock Process. Read at the Society of Biological Psychiatry, Atlantic City, June 1957 Therapy of Schizophrenia: Role of Alteration in Brain Function in Behavior. Presented at Int. Congress of Psychiatry, Zurich, Sept. 1957 Korin. H.: Effects of Diffuse Altered Brain Function on Perception. Presented at the XV Int. Congress of Psychology, Brussels, August 1957 Behavioral Patterns in Induced States of Altered Brain Function. Read at the New York Divisional Meeting, A.P.A., Nov. 1957 Shift for Psychiatry. Read at Metropolitan EEG Society, N. Y., Nov. 1957 81 I Fink. M.. Kuhn. R. L. Fink. M. and Kuhn. R. I..: Fink. M.. Kuhn. R. L. and Fink. M. and Kuhn. R. L.: Fink. M.: Significance of EEG Frequency I Fink. M.: Effects of Diethazine on EEG and Significance for Theory of Process of Convulsive Therapy. Read at Eastern Association of Electroencephalographers, New York, Dec. 1957 Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. I I I I Fink. M. and Kuhn. R. L.: Relation of EEG Delta Activity to Behavioral Response in Psychiat. 78: 516-525, 1957 I Fink. M.: A Unified Theory of the Action of Physiodynamic Therapies, �J. Hillside Hosp. 6: 197-206, 1957 I Goldenberg. H.. and White. D. L.: Chromatographic, Electrophoretic and Colorimetric Procedures for the Psychotomimetic and Psycho- therapeutic Drugs; Presented at the Meeting-in-Miniature of the Metropolitan-Long Island Sub-section, New York Section, American Chemical Society, Brooklyn, New York, February 15, 1957 I Goldenberg. H.. and Goldenberg. V.: Specific Colorimetric Determination of Cholinesterase Activity in Blood and Spinal Fluid; Presented at the Meeting-in-Miniature of the Metropolitan-Long Island Sub-section, New York Section, American Chemical Society, Brooklyn, New York, February 15, 1957 Inhibition of Serum Cholinesterase by Mental Drugs, Ann. N. Y. Acad. Sci., 66: 466-467, 1957 Electroshock, J. Hillside Hosp. 6: 229-240, 1957 Juffe. J.: Criteria in Evaluation I Juffe. J.: I Green. M. A.: Significance of Individual Variability Study of Communication in Psychiatric Interviews. Read at the New York Divisional Meeting, A.P.A. Nov. 1957 Response to Electroshock Therapy. Presented at Electroshock Research Association, Chicago, May 1957 Induced Altered Brain Function. Read at Amer. Psychol. Assoc., New York, August 1957 Hosp. 6: 216-228, 1957 I I I I in EEG Response to Juffe. J.: I An Objective Kuhn. R. L. and Fink. M.: Personality Factors in Behavorial Kuhn. R. L. and Fink. M.: Perception of Embedded F igurm After Kuhn. R. L. and Fink. M.: Perception of Embedded Figures After Induced Altered Kuhn. R. L.. Pollack. M. and Fink. M.: Social Factors in Selection of Therapy in 3 Voluntary Mental Hospital, J. Hillside Tarachaw. S. and Friedman. S.): Perception Experiments in 241-250, 1957 I I I I I Kuhn. R. L. and Fink. M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press) N. Y. Neurol. Society, N. U., Jan. 1957 Goldenberg. H.: An Objective Study of Communication in Psychiatric Interviews, J. Hillside Hosp. 6: 207-215, 1957 of Clinical Behavorial Change: Psycholinguistic Aspects. Presented at A.P.A., Round Table, Chicago, May 1957 Brain Function, Amer. Psychol. 12: 361, 1957 I a Study of Ambivalence. Read at Section on Neurology & Korin. H. (with Psychiatry of N. Y. Academy of Medicine and Karin. H. and Fink. M.: Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli, J. Hillside Hosp. 6: Korin. H. (with Tarachow. S. and Friedman. S.): Perception Experiments in a Study of Ambivalence, Arch. Neurol. & Psychiat. 78: 167-176, 1957 I Karin. H. (with Tarachow. S. and Friedman. S.): The Relation of Ambivalence to Aggression and Authority in Psychoneurotic Patients. Read at Amer. Psychol. Assoc., New York, Sept. 1957 I Karin. H. (with Tarachow. S. and Friendman. 5.): Studies in Ambivalence. Presented before Schilder Society, New York, Oct. 1957 I Pollack. M. (with Goldfurb. W. and Dorsen. M.): Pain Reactions in Schizophrenic Children. Presented at Amer. Orthopsychiatric Assoc., Chicago, March 1957 I Polluck. M. (with Krieger. H. P.): Oculmotor and Postural Patterns in Schizophrenic Children. Presented at Amer. Academy of Neurology, Boston, April 1957 I Pollack. M. (with Buttersby. W. S. and Bender. M. 3.): Figure-ground Perception in Patients with Cerebral Tumor. Read at Eastern Psychol. Assoc., N. Y., April 1957 I Pollack. M. (with �Battersby. W. S. and Bender. M. B.): Defects in Visual Perception in Brain Tumor Patients. Presented before Int. Congress of Psychol., Brussels, July 1957 M. I Pollack (with Battersby. W. S. and Bender. M. B.): Visual Deficit After Brain Damage in Man as Measured with Rapidly-Exposed Chromatic Stimuli. Presented at Amer. Psycho]. Assoc., New York, Sept. 1957 l Pollack. M. (with Goldfurb. A.): Cultural and En- Vironmental Factors Affecting Complex Perception in the Institutionalized Aged. Presented at the Gerontological Society, Cleveland, Oct. 1957 l Pollack. M.: Brain Damage, Mental Retardation and Childhood Schizophrenia. Presented at New York Divisional Meeting, A.P.A. Nov. 1957 and“; a. I Pollack. M. (with Goldfarb. W.): Face-Hand Test in Schizophrenic Chil- dren, AMA. Arch. Neurol. & Psychiat. 77: 635-642, 1957 farb. W.): Patterns of Orientation I Pollack. M. (with Gold- in Children in Residential Treatment for Severe Behavior Disorders, Amer. J. Orthopsychiat. 27: 3, 538-552, 1957 Battersby. W. S. and Bender. M. I Pollack. M. (with BJ: Tachistoscopic Identification of Contour in Patients with Brain Damage, J. Comp. Physiol. Psychei. 50: 3, 220-227, 1957 (with Battersby. W. S. I Pollack. M. and Bender. M. 3.): Visual Deficit After Brain Damage in Man as Measured with Rapidly-Exposed Chromatic Stimuli, Amer. Psychol. 12: 7, 468, 1957 I Pollack. M. (with Goldfarb. W.): Cultural and Environmental Factors Affecting Complex Perception in the Institutionalized Aged, J. Gerontol., 12: 4, 437-438, 1957 I Zierer. E. (with Zierer. Edith): Leonardo Da Vinci’s Artistic Proclivity and Creative Sterility, The American Imago, Vol. 14, No. 4«, 1957. Each publication is a tribute to the vision of the hospital’s founder, the late Dr. Israel Strauss. �gar ZM/ *w U 473/ c Jywwflky The Residenf Training Program at Hillside continues to emphasize the interrelation between the training program and the treatment program. Each Resident carries a case load of about 15 patients under the supervision of staff and visiting instructors. and attends lecture conferences conducted by the medical director. Lecture seminars in the fields of psychopathology and psychotherapy, and reading seminars, are conducted by special instructors chosen from the hospital staff. Qualified Residents are assigned to the Department of Experimental Psychiatry for clinical and other psychiatric research projects. During the year there were 18 Residents in training, 15 in the adult in patient service and three in the Israel Strauss Adolescent Pavilion The hospital training program extends also to Clinical Assistants in the Out Patient and After-Care Clinics and on-the-job training of personnel. Regular lectures and conferences are scheduled for nurses and attendants, social workers, members of the various adjunctive services and for affiliating students from other educational institutions. Included in the latter was the establishment of a very important affiliated training program for student The Sunday Clinical Connurses from Queens College ferences. open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians, are part of the Resident training program and are based on cases prepared by the Residents. They continue to make a significant contribution to the training picture on the New York The third annual Israel Strauss Lecture, psychiatric scene established in 1955 in honor of Hillside’s founder and late president, was delivered this year on May 5th. The speaker was Norman Reider, M.D., Chairman, Education Committee of the San Francisco Psychoanalytic Institute. The topic of his lecture As anticipated, the Medical was “Transference Psychosis" Library has become a very important feature of the teaching and research activities of the hospital The Journal of the Hillside Hospi‘l‘al again showed an increase in the number of its subscribers and an indication of its greater influence and wider acceptance in the field. Thus the Journal has met the expectations with which it was launched in 1952. I I I I I ��The Israel Strauss Adolescen'l' Pavilion. in its third year, continues as a resident treatment center for a selected group of emotionally ill girls between the ages of 13 and 17. Due to the experimental nature of work with adolescents, only a limited number of applicants are accepted. Because of the intensiveness of the program, adolescent girls are kept at the Pavilion under treatment for a much longer period of time than the adult patients. In 1957, the average period of hospitalization for the adolescents was 300 days, as compared to 192 days for the adults I Although there have been recurring problems with shortages of trained personnel, the pilot program of the Adolescent Pavilion has proceeded as planned, and many new discoveries have been made The seventeen girls who Were admitted in 1957 were afforded the opportunity for intensive psychotherapy and a well- I structured living experience. In an atmosphere reminiscent of a girls’ boarding school, a professional team has worked to make this unique program succeed. The team, under the direction of Dr. Alice Slater Stahl, includes three psychiatrists, a psychologist, nurses, teachers, an occupational therapist, a group activity worker, plus the non-professional help of nurses’ aides, members of the housekeeping and kitchen departments and volunteers. A two story building includes all therapy facilities as well as dining and lounging areas. The semi-private rooms are furnished to allow for the fact that disturbed adolescents are often more destructive than adult patients I It is �believed that if Hillside can work out techniques for treating emotionally ill adolescent girls, much can be learned about the problems of child guidance and juvenile delinquency. Certainly much of what has been learned in the past year can be applied to adult treatment. During the year, it was discovered that the original plan for isolating the girls did not work out as Well as integrating certain aspects of the program with adult activities. It has also been found that certain adolescents made more rapid recovery when transferred to adult cottages. The plan to let the girls attend school in the outside community was abandoned in favor of school inside the Hospital, though sep- arate from the Pavilion since the experience of “going to school” is important to the youngsters The girls became in- I terested in sewing and put on two fashion shows of their handiwork. One of these fashion shows was the highlight of the 10th Annual Hillside Hospital Field Day. They also made the drapes for the dining and recreation rooms in the Pavilion. In addition, unusual work has been done in ceramics, painting and metals I Of the 120 applications received during the year, 26 patients were screened and 17 were admitted. An attempt was made to evaluate each applicant to determine suitability of $52,400 from The Ford Foundation was used to expand the research, training and patient facilities, including extensions and improvements of the Adolescent Girls Pavilion During the year, the Out Patient Clinic of the Adolescent Unit provided I treatment for 22 girls. Four doctors worked to provide a total of almost 450 psychotherapeutic sessions. Two social workers continued their casework and counselling services with the families, and helped with vocational planning, schooling, job hunting and social problems The After Care program has I provided short term aid in the transition period between the hospital and community life, as well as longer term psychotherapy. Work With Other Organizations. No organization dealing with patients can operate in a completely isolated manner. Hillside’s emphasis on treatment of the patient as a whole, with particular regard to the family, pre-admission care, and post discharge care and follow-up, has resulted in working relationship with the following agencies whose invaluable cooperation has made these programs possible: ALTRO WORKSHOP FEDERATION EMPLOYMENT AND GUIDANCE SERVICE based not only on the criteria of illness, but upon the patient’s ability to benefit from the hospital’s facilities, as well as the DEPARTMENT OF PSYCHOLOGY OF COLUMBIA UNIVERSITY existing group composition at the time. There was an average waiting period of three months after acceptance A grant JEWISH FAMILY SERVICE OF NEW YORK I JEWISH COMMUNITY SERVICES OF LONG ISLAND NEW YORK ASSOCIATION FOR NEW AMERICANS �/% fifiwl/ 7/ [Ma/whzm'éW/Mt This Annual Report has given a great deal of data regarding service to patients, treatment facilities and research. It has summed up a large complex organization’s work on behalf of the mentally ill, their families and the community which surrounds them. A most significant aspect of our work is the extent to which we have been able to mobilize financial support from many sources. Perhaps the most concrete and rigorous index of the adequacy of a philanthropic organization’s performance can be gleaned from the way in which it is supported in the realistic world of finance. It is therefore significant that we passed this rigorous test quite successfully during 1957. Our work received excellent support from the City of New York, through its contributions toward the care of the medically-indigent, mentally-ill patient. The Federation of Jewish Philanthropies of New York gave substantial help in deficit financing. Without Federation’s tremendous interest, its constant readiness to give advice and assistance, and its careful and generous consideration of our financial requirements, Hillside could not have developed the excellent and challenging programs described in this report. Our research programs, started only a few years ago, have begun to command increasing attention in the psychiatric world and significant attention—support-wise—in the community at large. More than fifty percent of our research expenditures were met by outside sources, such as the United States Public Health Service and various foundations. The total research deficit was met by contributions from our Board of Directors and their friends Our chief items of expense are for treatment and training programs. The table below gives the comparative total cost of these programs for 1956 and 1957. I The In Patient Service continued to operate at 97% of capacity, while— at the same time—the average income per patient day followed the trend established several years ago of rising each year, in this case by 130 per day. The average cost per patient day, however, rose by $1.53. Therefore, the average loss per patient day in the In Patient Service rose from 40c to $1.80. These changes rise out of the whole complex of increasing cost of operation. In 1956, total expenses of $1,326,454. represented a rise of 12.82% over the previous year; in 1957, with expenditures rising by $169,238, the percentage increase was virtually the same—13%. It is interesting to note the extent to which this year’s increase is related to inflationary forces in the community, or to actual improvement or changes in services rendered. It is therefore significant that those aspects of expense which are most stable and most clearly related to the price index—Salaries, Food, and Maintenance and Grounds—rose by 7%, 5% and 5% respectively, while the following items more clearly related to quality and quantity of service rendered rose as follows: Administrative Expense 20% Medical Supplies Repairs and Replacements Clinics (Out Patient Service) 24% 39% 30% Again, as in the past several years, the Out Patient Clinic Services accounted for the largest item of increase, reflecting the continued expansion of our preventative programs. This expansion was made possible entirely by grants from the New York City Community Mental Health Board, the State Mental Health Authority, the Federation of Jewish Philanthropies of New York and, during 1957 — for the first time — by the participation of the Nassau County Mental Health Board. Included in the increased cost of Out Patient Services was the expansion of the Foster Home Care Program for discharged patients, carried jointly with the Jewish Community Services of Long Island and made possible by the Federation ofJewish Philanthropies. MAURICE BACHRACH COMPARISON OF COSTS 1956-1957 1956 Salaries ................................................................ $ Food .................................................................... Maintenance and Grounds ................................ Administrative Expenses .................................... Medical Supplies .................................................. Repairs and Replacements .................................. Clinics .................................................................. 1957 797,805. 113,428. 59,436. 82,608. 23,950. 35,105. 214,122. 3 855,848. Tofal ............ 1.326.454. 1.495.692. Total No. Patients ................................................ Total Patient Days ................................................ Average Income per patient day ........................ $ Average cost per patient day .............................. Average loss per patient per day ........................ $5 119,350. 62,654. 98,952. 29,811. 49,021. 280,056. 561 545 70,189 15.44 15.84 $ .40 $ 69,987 15.57 17.37 1.80 �PRESIDENT—Alvin E. Coleman* CHAIRMAN OF THE BOARD—Roy Foster* HONoRARY CHAIRMAN OF THE BOARD—Leon Lowenstein‘ VICE-PRESIDENT—Dudley D. Shoenfeld, M.D.* Herbert Beskind” VICE-PRESIDENT—George W. Galinger* SECRETARY—Manuel Lee Robbins* TREASURER—~Arn01d S. Askin“ VICE-PRESIDENT—D. ASSISTANT SECRETARY—Alfred ASSISTANT SECRETARY—~M. Appel Victor Leventritt ASSISTANT TREASURER—Arthur Carson ASSISTANT TREASURER—Harry Silverson HONORARY DIRECTORS—Hilda Strauss and Saul Blickman Board of Directors A. Jacob Abrams Alfred Appel Arnold S. Askin“ John M. Bendheim D. Herbert Beskind“ Saul Blickman Alvin E. Coleman" Morris David Thomas Epstein Arthur C. Fatt" David Finkle David Finn Roy Foster“ George W. Galinger“ Arthur Carson Maurice Glinert Meyer Goldstein Jacob Epstein KatzT M. Victor Leventritt Budd LevinsonT Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein* Charles H. Meyer* ' Walter Scheuer Dudley D. Shoenfeld, M.D.* Harry Silverson Hilda Strauss Irving Weissglassi Nathan Wigod Morton S. Wolf * Walter D. Yankauer“ Arthur Murray Manuel Lee Robbins* Irving Rosenbaum S. H. Seheuer‘ Chairmen of Standing Committees Foster MEDICAL AFFAIRS COMMITTEE—D. Herbert Beskind FINANCE COMMITTEE—Arnold S. Askin EXECUTIVE COMMITTEE—Roy HOUSE AND GROUNDS COMMITTEE— George W. Galinger, Nathan Wigod—Co-Chairmen LEGAL COMMITTEE—Charles H. Meyer SOCIAL SERVICE coMMITTEE—Hilda Strauss LIAISON coMMITTEE—L. 1. Jewish Hospital—Alvin E. Coleman PUBLICITY COMMITTEE—Arthur C. F att PERSONNEL COMMITTEE—Meyer Goldstein PLANNING coMMITTEE—Meyer Goldstein GIFTS AND LEGACIES COMMITTEE—Walter D. * Executive Committee Members T Elected in I957 Yankauer �Miller, M.D. ASSOCIATE MEDICAL DIRECTOR—~Simon Kwalwasser, M.D. ADMINISTRATOR—Maurice Bachrach, B.S. SUPERVISING PSYCHIATRISTS—George Yessin, M.D. Gerhard Schauer, M.D. Robert Navarre, M.D. Zenos M. Linnell, M.D. Harold Esecover, M.D.* MEDICAL DIRECTOR—Joseph S. A. DIRECTOR, ISRAEL STRAUSS ADOLESCENT PAVILION— Alice Slater Stahl, M.D. SUPERVISING PSYCHIATRIST, ISRAEL STRAUSS ADOLESCENT PAVILION, OUT PATIENT DEP’T.—Eugene Glynn, DIRECTOR OF OUT PATIENT SERVICES—Robert M.D. R. Luttrell, M.D. DIRECTOR OF RESEARCH IN EXPERIMENTAL PSYCHIATRY— Maxirriilian Fink, M.D. INTERNIST—Arnold Blumberg, M.D. DIRECTOR OF LABORATORIES—Harry Resident Staff Norman Ackerman, M.D. Barre Alan, M.D. Stanley Brodsky, M.D.* Bernard Cohen, M.D. Frederick Coleman, M.D.* Warren Cox, M.D. Alan Dobrow, M.D. Necdet Ecder, M.D. Ilhan Ermutlu, M.D. Stefano Faj rajzen, M.D. Marie Friedman, M.D. Stanley M. Friedman, M.D.* Ruth Fuchs, M.D.” Harold Galef, M.D.* Robert S. Gilbert, M.D.T Victor Coldin, M.D.* Michael Gould, M.D. Sherwin Harris, M.D. Edwin Kleinman, M.D. A. Russell Lee, M.D.” Leon .Lefer, M.D.* Henry Lefkowits, M.D. Sidney Lytton, M.D. Robert Nodine, M.D. Goldenberg, Ph.D. Paul Pressman, M.D. Arthur Root, M.D.* Alvaro Rozo, MD. Herbert Schulman, M.D. Myron Stein, M.D.* Carl Towbin, M.D. Margery Wile, M.D. Other Professional Staff Heads Goldie Krupa, R.N.—DIRECTOR OF NURSING Abraham Lurie, M.S.S.W.—DIRECTOR OF SOCIAL SERVICES Abraham Levine, Ph.D.—DIRECTOR 0F PSYCHOLOGY Ernest Zierer, Ph.D.—DIRECTOR 0F CREATIVE THERAPY Eileen P. Fisher, B.S.—DIRECTOR OF OCCUPATIONAL THERAPY Arnold Eisen, M.S.S.W.——DIRECTOR OF GROUP WORK DIVISION Angelina Canavan, B.A.——DIETITIAN n Department Heads * Completed residency in 1957 1’ Deceased 1957 Dorothy Croghan—ACCOUNTING SUPERVISOR Lillian Bailey—OFFICE MANAGER Thomas R. Lumley—SUPERINTENDENT 0F BUILDINGS & GROUNDS Sarah Travers—EXECUTIVE HOUSEKEEPER snag—hr, g .. f �PRESIDENT—M. David Epstein, M.D.* VICE-PRESIDENT—Robert A. Savitt, M.D.* SECRETARY—Sidney L. Green, M.D.* TREASURER—Paul Scheman, D.D.S.* Ex-PRESIDENT—Samuel Atkin, M.D.* Samuel Atkin, M.D.* Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, M.D. I. Peter Glauber, M.D.* Emanuel Klein, M.D. Sidney Klein, M.D. Samuel Z. Orgel, M.D. H. L. Rachlin, M.D.* Lawrence J. Roose, M.D. George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Robert A. Savitt, M.D.* Martin Schreiber, M_D_ Isidor Silbermann, M.D.* Otto Sperling, M.D Sidney Tarachow, M.D.* Cohen, M.D.* DEPARTMENT OF NEUROLOGY—Morris B. Bender, M.D. DEPARTMENT OF DENTISTRY—Paul Scheman, D.D.S. DIRECTOR OF DEPARTMENT OF MEDICINE—Lester DIRECTOR OF DIRECTOR OF ADOLESCENT PAVILION—Sidney L. Green, M.D. COMMUNITY EDUCATION AND PUBLIC RELATIONS—Robert A, Savitt, M.D. C‘REDENTIALS; COMMITTEE FOR PSYCHIATRIC STAFF & PROMOTIONS—— Martin Schreiber, M.D. CREDENTIALS COMMITTEE FOR NON-PSYCHIATRIC STAFF & PROMOTIONS:— Paul Scheman, D.D.S. STAFF—Arnold Eisendorfer, M.D. GROUP PSYCHOTHERAPY—Samuel Z. Orgel, M.D. MANHATTAN AFTER-CARE- CLINIC—Sarah R. Kelman, M.D. EDUCATION OF RESIDENT PATIENTCLINIC—William,Karliner, M.D. RESEARCH COMMITTEE—Hyman L. Rachlin, M.D. QUEENS OUT Peter Glauber,M.D. JOURNAL .SUB-COMMITTEE—Sidney Tarachow, M.D. ‘iTDQM;MIT-'I‘EE‘FOR ADIUNCTIVE‘ SERVICES—4'1. 'Peter Glauber, M.D. PUBLICATIONS COMMITTEE—e41. :CREDENTIALSCOMMI‘TTEE TORSUPERVISING- PSYCHIATRIC AND RESIDENT STAFF—— Sidney Klein, M.D.. COMMITTEE FOR LIAISON WITH LONG ,ISLANDRJEWYSH HOSPITAL..— Arnold/Eisendorfe‘r, M.D. , ‘*E’ixéé tsive :Coimmitte'e» M ember; \ i" 'V I ' > v , ‘ ' : " �%[7ZMW% WWM/ W Consultants Psychiatry up OZ Medicine Neurology Leonard Blumgart, M.D. Sandor Lorand, M.D. Irving J. Sands, M.D. Nathaniel E. Selby, M.D. Dudley D. Shoenfeld, M.D. Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, M.D. .1. Jesse Levy, M.D. A. M. Rabiner, M.D. Surgery Gynecology Dentistry Hans Strauss, M.D. I. S. Wechsler, M.D. David Warshaw, M.D. Julius Jarcho, M.D. Morris Fierstein, D.D.S. George S. Goldman, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D. Attilio Laguardia, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, M.D. Robert A. Savitt, M.D. Martin Schreiber, M.D. 5011 Goodman, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Martin H. Orens, M.D. William W. Pike, M.D. Aaron Stein, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Albert E. Goldberg, M.D. Albert Harrison, M.D. Thomas Hora, M.D. Abraham Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Harold S. Leopold, M.D. David Milrod, M.D. Irving Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Attending Psychiatrists ' Samuel Atkin, M.D. Frank Berchenko, M.D. Arnold Eisendorfer, M.D. M. David Epstein, M.D. Margaret E. Fries, M.D. I. Peter Glauber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Cornelius Beukenkamp, M.D. Alexander J. Friedman, M.D. Mark L. Gerstle, J r., M.D. Adiunct Attending Phychiatrists Edward R. Adelson, M.D. Renato J. Almansi, M.D. Herman S. Alpert, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkofi, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Hugh Mullan, M.D. Helene Papanek, M.D. �MD. VISITING PHYSICIAN—George Sabrin, M.D. DIRECTOR—Lester Cohen, Rosenblum, M.D. VISITING PHYSICIAN—A. Blumberg, M.D. ASSOCIATE PHYSICIAN—M. Kalkstein, M.D. ASSOCIATE PHYSICIAN—J. Weinstein, M.D. ADJUNCT PHYSICIAN—A. L. Berger, M.D. ADJUNCT PHYSICIAN—W. B. Brett, M.D. VISITING DERMATOLOGIST—C. Stritzler, M.D. ASSOCIATE DERMATOLOGIST—Joel Schweig, M.D. ADJUNCT DERMATOLOGIST—N. Goldfarb, M.D. VISITING PHYSICIAN—L. VISITING NEUROLOGIST—Morris B. Bender, M.D.T ASSOCIATE NEUROLOGIST—Kurt Adler, M.D. ADJUNCT NEUROLOGIST—Harry Harter, M.D.I Hirsch, M.D. VISITING NEUROSURGEON—Joseph Siris, M.D. VISITING UROLOGIST—L. G. Goldberg, M.D.’r VISITING UROLOGIST—Daniel Kaufman, M.D. ADJUNCT UROLOGIST—Albert Sutton, M.D. VISITING SURGEON—~Sidney VISITING ORTHOPEDIST—A. H. Lewert, M.D. Schneiderman, M.D. VISITING PROCLTOLOGIST—B. Warner, M.D. VISITING-OPHTHALMOLOGIST——E. Seretan, M.D. VISITING GYNECOLOGIST—M. VISITING GYNECOLOGIST—H. Warner, M.D. Dubrow, M.D. Cohen, MD. ASSOCIATE GYNECOLOGIST—Bernard Greenblat, M.D. ADJUNCT GYNECOLOGIST—Eugene Streim, M.D. ASSOCIATE GYNECOLOGIST—Jack VISITING RADIOLOGIST—Bernard Epstein, M.D. DIRECTOR—Paul Scheman, D.D.S. ASSOCIATE DIRECTOR—J. G. Rubin, D.D.S. ASSOCIATE DENTIST—B. Schwaid, D.D.S. ASSOCIATE DENTIST—B. Lebow, D.D.S. ADJUNCT DENTIST—H. Lewis, D.D.S. ADJUNCT DENTIST—H. Adler, D.D.S.’r ADJUNCT DENTIST—S. Plotnick, D.D.S. ADJ-UNCT DENTIST—E. Friedman, D.D.S. ADJUNCT DENTIST—M. Protell, D.D.S. ADJUNCT DENTIST—L. Basson, D.D.S. STAFF OPTOMETRIST—-Edward L. STA-FF Steinberg, O.D_. OPTOMETRIST—Bernard Attinson, O.D. ASSOCIATE ORTHOPEDIST—J. Minsky, M.D. OTOLARYNGOLOGIST—S. Clayton, M."D. ANE-S'THESIOLOGIST—Ceorges Bean, M.D. ASSOCIATE OPHiTHALMOLOGIST——A. VISITING VISITING STAFF 'PODIATRIST—Sam Resigned 195;? I Deceased 1795-7 T Sokolov, Pod.0. �Lester I. Abend, M.D. Ruth Adams, M.D.* Romano Antonelli, M.D. Howard Boskey, M.D. Paul Bradlow, M.D. Stanley Brodsky, M.D. Arline Caldwell, M.D. Mischa Caplan, M.D. Daniel Chansky, M.D. Lionel Chertofi, M.D. Rita M. Chalef, M.D. Gloria Chung, M.D.“ * Resigned I 957 Ralph W. Clemments, M.D. Julius Colantuono, M.D.* Frances Colonna, M.D. Fred Dalton, M.D.* Irving J. Farber, M.D. Robert D. Ferrell, M.D. Philip Friedland, M.D. Harvey Coldey, M.D. Victor Goldin, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Harry Gonda, M.D. David Graubert, M.D. Howard Hess, M.D.* Martin Hurvitz, M. D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Peritz Levinson, M.D. Buck Luria, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatrice Nachtigal, M.D. Iris Orens, M.D.* Edward Pinney, J r., M.D. Joshua Ramot, M.D.* William Roosen, M.D. Phoebe Rosen, M.D. Joseph D. Rosen, M.D. Henry Rosberger, M.D. J ehuda Rozanski, M.D. Gabriel Rubin, M.D. Charles Silberman, M.D. Herman Tannor, M.D.“ Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. Aimee Wiggers, M.D. �Hillside Hospital is a member of: AMERICAN HOSPITAL ASSOCIATION AMERICAN PSYCHIATRIC ASSOCIATION FEDERATION OF JEWISH PHILANTHROPIES GREATER NEW YORK HOSPITAL ASSOCIATION HOSPITAL ASSOCIATION OF NEW YORK STATE NATIONAL CONFERENCE OF JEWISH COMMUNAL SERVICE NEW YORK STATE DEPARTMENT OF MENTAL HYGIENE NEW YORK STATE DEPARTMENT OF SOCIAL WELFARE NEW YORK STATE WELFARE CONFERENCE QUEENSBORO COUNCIL FOR SOCIAL WELFARE UNITED HOSPITAL FUND WELFARE AND HEALTH COUNCIL OF NEW YORK CITY We are fully accredited by: JOINT COMMISSION ON ACCREDITATION OF HOSPITALS 1%gzlled/ZJ ”42/ QWMJ . OF THE UNITED STATES AND CANADA (NO p recise words are necessar y to a valid le g ac y to the We are approved for re51dent tralnlng by: . . é % WM . . Society. The following form, however, may be suggested.) AMERICAN MEDICAL ASSOCIATION AMERICAN DENTAL ASSOCIATION ' We .C arr y Jom t progr am S i n which 5 p ecific s e rvice~b to p atients are ad, , , mlnlstered by the hospltal and pald for by tax-supported publlc agenCIes: I give to the Society of the Hillside Hospital, for the use 0/ the Hillside ' _ _ Hospital, the sum of _ $_—__—_(if land or any specific property, NASSAU COUNTY MENTAL HEALTH BOARD such as bonds ’ stocks ’ ece t ‘e r a, iS g i”e n ’ a b r'“3f NEW YORK CITY COMMUNITY MENTAL HEALTH BOARD should be inserted instead of the words “the sum of NEW YORK STATE MENTAL HEALTH AUTHORITY NEW YORK CITY DEPARTMENT OF HOSPITALS DIVISION OF VOCATIONAL REHABILITATION, NEW YORK STATE DEPARTMENT OF EDUCATION NEW YORK CITY, BOARD OF EDUCATION UNITED STATES PUBLIC HEALTH SERVICE, INSTITUTES OF MENTAL HEALTH We have established programs of community education and community mental hygiene with: QUEENS COUNTY MENTAL HEALTH SOCIETY NASSAU COUNTY MENTAL HEALTH SOCIETY ' descnp tio " 0/5 h 5 P r 0P3 r‘9’ $_____”). �An afliliate 0f the Federation of Jewish P/zilant/Lropies of New York �31:! ANNUAL REPORT V~ A FOR THE YEAR 1958 HILLSIDE HOSPITAL GLEN OAKS, QUEENS, N. Y. ��Federatwn f 0 a partzczpant 0f- the Fund and the Créat‘erg ��TABLE OF CONTENTS report of the director of professional services report of the medical director report of the President of the Medical Board report of the President of the Board of Trustees treatment psychotherapy and medical services psychology department intramural clinic nursing department department of dentistry occupational and creative therapy adolescent pavilion organization chart insert social service department casework division group work division Manhattan after-care clinic Israel and Hilda Strauss League Queens out-patient service Training programs Sunday clinical conferences Israel Strauss lectures medical library research experimental psychiatry department of biochemistry medical department Hillside publications Hillside journal grants and awards received 1958 report of the administrator society of the Hillside Hospital 3 4 6 7 10-13 ‘10 10 11 11 11 12 12 16-17 14-19 14 15 18 18 18 19 19 19 19 22-23 22 22 23 24- 25 25 27 30-32 �report of the director of professional services LEWIS L. ROBBINS, M.D. As a very new member of the staff of Hillside Hospital, I should like to look ahead rather than participate in a review of the past year. A forward-looking plan for the future development of Hillside Hospital is essential if it is to serve best the needs of the community today and tomorrow. The three main areas of activity at Hillside today are clinical service, education and research. We will never lose sight of our primary day-to-day service, which is the treatment of the mentally ill. Yet to consider enlarging the capacity of Hillside—to help more of the people who are psychiatrically ill—is not the answer for the future. Experience of larger institutions indicates the weakness of this approach. When the capacity of a psychiatric hospital is expanded beyond a certain point, individualized treatment of patients gives way to regimentation. The result is that the quality of clinical service falls. It is more probable that Hillside can best serve the community by striving to advance our knowledge of psychiatry for the greater good of everyone, whether or not he is ever a patient at Hillside Hospital; and by training professional personnel who will later make use of what they have learned here in other institutions throughout the country. The main shortage in psychiatry today is knowledge. Although there have been tremendous advances in the past 50 years, much remains to be learned. And while much has been spent in the development of all types of psychiatric facilities, relatively little financial support has been given to psychiatric research. It is therefore recommended that the excellent facilities of Hillside Hospital and its present and potential relationships with other institutions in the area be utilized primarily for the advancement of psychiatric knowledge. A unique and productive approach would be the long-range goal of an Institute for Advanced Psychiatric Studies established at Hillside. Although there exists today an excellent research program at Hillside, it represents but a small fraction of the many types of AHEAD research that could be successfully conducted here. The clinical program of the hospital provides a great variety of clinical problems, as well as opportunity for thorough observation. The forward-looking philosophy of Hillside Hospital, along with its utilization of personnel from many different disciplines, constitute an excellent foundation for the development of a broad research program. Such a research program would develop spontaneously if personnel were adequate—both qualitatively and quantitatively—to take care of our clinical responsibilities. A staff must be developed who are not only good clinicians but who also possess an interest in and capacity for both teaching and research. The need for trained personnel in psychiatry is urgent. Hillside already has accepted education as one of its principal functions; and this function could very well be expanded without detracting from the research objectives which may be established. Hillside Hospital thus will continue to be a pilot institution providing the best psychiatric treatment currently available, constantly striving to develop newer and better methods, and sharing its experience with others for the welfare of the general community. Its future is limited only by the imagination of its staff, the leadership of its Board, and the support of its community. 3 �the of report medical director JOSEPH S. A. MILLER, MD. This will be my last Annual Report as Medical Director of Hillside Hospital. When I came to Hillside in 1947, there was a one-half time Assistant Medical Director, six Residents, one and a half social workers, no psychologists, and only a fair complement of nurses and attendants. There were eighty-eight patients. There was no out-patient department, and only the beginnings of an after-care program. There was no organized research. The teaching was carried on by the Medical Director and by members of the Medical Board. From about 1948 on, the services and facilities of the hospital began to grow. The new Lowenstein Pavilion was opened in 1949 and practically doubled the bed capacity. The number of Residents was increased to twelve and, in addition to a full-time Associate Medical Director, Staff or Supervising Psychiatrists were added. More attention was now paid to the discharge and rehabilitation plans and, with the interest and support of the Federation of Jewish Philanthropies, with whom we had just become affiliated, we enlarged our Social Service Department. In 1951, we began a small out-patient clinic and also improved the services of our aftercare clinic. With the construction of the Elizabeth Sloman Lowenstein Building in 1954, the small out-patient clinic was developed into a service able to treat some two hundred patients twice weekly. That year, also, the Israel Strauss Pavilion for Adolescent Girls was established. Supervised clinical training and teaching of the Residents was enhanced; teaching in basic clinical psychiatry, clinical diagnosis and psychotherapy was extended; regular stated clinical, diagnostic and discharge conferences were instituted; and we appointed special instructors to give didactic instruction in psychopathology and psychotherapy. 1951 saw the beginning of organized research at Hillside with a biochemistry research laboratory set up under Dr. Werbin. He was succeeded in 1954 by Dr. Harry Goldenberg, who now heads our Bio-chemical Research Department and who has made some original contributions which have been recognized and supported by grants from the United States Public Health Service and by funds from our own Board of Trustees. The largest contributions in the field of organized research were made in the area of experimental psychiatry, especially electroshock therapy and tranquilizers, headed since 1954 by Dr. Maximilian Fink. There have been other significant changes and trends. First of all there has been a change in the type of mental patient coming to the hospital. Our patients now are of the borderline-psychotic type, although they still fall generally within the qualifications for voluntary admission. There has been a definite drop in the average age of the patients from the mid-thirties to the midtwenties. Significant, this year was the replacement of the insulin coma treat- ment by the tranquilizer, chlorpromazine. We also improved and enlarged our occupational therapy and group activity services, and, under the able direction of Dr. Aaron Stein, our group psychotherapy programs. Our out-patient services, ably directed by Dr. Robert Luttrell, and our community mental health clinics, with support from the New York City and Nassau County Mental Health Boards, have been regarded as models of clinic operation. Our attending psychiatrists, notably Drs. Martin Orens and Abraham Lenzner, have contributed greatly to the teaching and clinic conferences. At the close of the year a well-defined program for the out-patient treatment of school age children was completed. The Israel Strauss Adolescent Pavilion completed 4 years of operation. The experiences gained there will mean not only an improved teaching and treatment program, but also, in the not too distant future, a worth-while research program. Our Resident Training Program has maintained its high standards, but has pointed up the need for more in-hospital or on-the-premises teaching and clinical supervision. This in turn has called for a larger number of better qualified supervising or staff psychiatrists, a call we have begun to meet. We have been aided to a generous extent by National Institutes of Mental Health in receiving a number of training grants for our Residents and teaching grants for our special instructors. There is a need for a more comprehensive research program involving projects which will deal, in a more integrated fashion, with the physical, mental and ecological factors in development and treatment of emotional disorders. The Journal of Hillside Hospital has, under the able direction of its editor-inchief, Dr. Sidney Tarachow, achieved a national reputation in scientific circles. �In the decade since Hillside joined the family of Federation, we have benefited not only from their planning and other special committees, but even more from the association with Federation’s hospitals and agencies in common purposes. Mt. Sinai Hospital provided us with space for processing and interviewing patients in our after-care clinic for discharged patients. Since 1950, we have had a rich and fruitful liaison with the Jewish Community Services of Long Island, through which we have been able to establish supervised psychiatric services as well as a very worth-while family care or foster home program for our discharged mental patients. This program resulted in our winning the Milton Weil Award from Federation in 1955. As soon as the Long Island Jewish Hospital had begun its operations, we helped establish their psychiatric service. We are indebted to them for their outstanding help. Mention ought to be made here too of our help from the Federation Employment Service, and our dual participation in a vocational rehabilitation program with the Altro workshops. I want to mention also, our ever-friendly relations with the Jewish Family Service, who have not only provided office space for our Social Services Department in Manhattan, but have also been cooperating with us in a long-range case work guidance program for our discharged patients. In these days of the “open hospital” and the establishment of psychiatric services and out-patient clinics in general hospitals, the question arises about the future of the separate or special mental hospital. The answer is that there will always be patients who will require in-resident therapy in a controlled therapeutic environment. The small psychiatric hospital need not be separated— indeed it should work in close relationship with the community and its hospitals, institutions and agencies. Hillside will become more and more of an open hospital in the modern sense, depending largely upon the education of, and acceptance by, the community. However, within the framework of its special treatment, teaching, and research services, it ought to remain as far as possible, autonomous. The mental hospital provides the essentials for the emotional re-educative process in which the patient is able to re-live and review his earlier and unsuccessful relationships. He learns to become a better functioning part of the new and smaller society of the hospital, and this in turn fits him for better or improved adjustment in the larger society outside. The small mental hospital employs facilities for more individualized treatment—where he may be observed in his behavior toward others and taught how to live with them, and how to exploit his own personality assets. Fortunately for Hillside, my successor, Dr. Lewis L. Robbins, has a rich background of professional experience in teaching, treatment, research and administrative ability. His views and attitudes in regard to the special mental hospital—the types of psychiatric and other professional personnel needed, the hospital environment and the various adjunctive needs of the patients— are salutory and knowing. I close my final report on Hillside with the utmost confidence in the future that awaits this great institution. I am proud of the many achievements made during my stewardship. It is needless to state that this could not have been done except with the help of a marvelous staff as well as the cooperation of the Medical Board and the Board of Trustees. My thanks to all the professional staffs and employees of the hospital, and especially the heads of departments. And I want especially to thank my two “Chief Lieutenants” who worked with me for the good of the hospital and contributed so much to its success during the past decade: Dr. Simon Kwalwasser, Associate Medical Director and Mr. Maurice Bachrach, able and talented Administrator. I greet Dr. Lewis L. Robbins, with whom it is a pleasure to have been thus briefly associated in the common venture at Hillside, and who, I am sure, will raise the hospital standards and services to even greater heights. Although this is my last Report on the Hospital as Medical Director it is not really a “bill of divorcement”. I am happy and proud to have been asked to continue as a general consultant to the Hospital, and as a special instructor to the Residents. I cannot close on a better note than by greeting the more than a hundred Residents who trained under me during these past'12 years. Hillside can well be proud of them, scattered as they are over the United States, and contributing, wherever they are, to the treatment, teaching and research aspects in the field of psychiatry based on their early training and treatment experiences of their Alma Mater—Hillside. �the of report President of the Medical Board ROBERT A. SAVITT, M.D. 6 During the past year the Medical Board has continued to function actively in its role as an advisory and consultative the and Director Medical the to group Board of Directors. Through its standof which comprised committees are ing the various echelons of the attending staff, the Board is directly involved in all of the medical activities of the hospital. The Credentials Committee for the Supervising and Resident Staif under the chairmanship of Dr. Roose, has spent countless hours interviewing and processing applicants for psychiatric residency training. Over a period of collected is on information being years the method of choosing residents. It is expected that when this is collated and correlated, it will yield valuable guide the for criteria in determining posts choice of psychiatric personnel. As in previous years the residency training program continues to be a major interest of the Medical Board. In this connection Dr. Arnold Eisendorfer’s committee has held periodic conferences with Dr. Miller, the Medical Director, in order to further advance the means whereby Hillside will become accredited for a three year residency. One of the important recent advances in resident education and training has come by way of the revised group psychotherapy program. This is expertly directed by Dr. Aaron Stein and coordi- nated by Dr. Samuel Orgel.’s committee. Better liaison has been established between the psychiatric attending staff and the hospital’s adjunctive services. Dr. I. Peter Glauber and his colleagues are formulating a series of conferences and lectures which will increase the mutual exchange of educational and scientific information with the Psychology and Social Service Departments. Under the superb guidance of its editor, Dr. Sidney Tarachow, the Journal of the Hillside Hospital has expanded its circulation and widened its scientific achievement in this country and abroad. Currently, several manuscripts are being carefully considered by the Publications Committee for selection in the projected Hillside Hospital Monograph Series. On the basis of liaison agreements entered into during the past year with our neighbor, Long Island Jewish Hospital, a Psychiatric Service has been established at that hospital. It is being administered by Dr. Samuel Lehrman of our Board in collaboration with a number of additional psychiatrists from our attending staff. The Adolescent Pavilion has raised many provocative questions and problems which are gradually approaching resolution. It is expected that our experiences will serve as points of orientation and enlightenment for other psychiatric facilities dealing with the treatment of adolescents. Dr. Margaret Fries and her co-workers are elaborating a method of organizing clinical data which will be of great value in the study of adolescents, is expected to find a place in the total resident educational program throughout the hospital. The Medical Board activities also reach out into the community of which Hillside is an integral part. Many of its attending psychiatrists render valuable service to the Queens Out-Patient Clinic and the Manhattan After-Care Clinic in terms of training and supervision of the in and colleagues, presenyounger tation of periodic clinical conferences. The Israel Strauss Memorial Lecture has become a notable yearly medical event which attracts a large audience from the psychiatric and related scientific professions. The annual Hilda Strauss Mental Health Lecture has also reached deeply into the local community’s stream of mental hygiene activities. It is with deep regret that the Board reports the loss of its beloved member, Dr. Sidney Klein. He died in August 1958, and left behind a legacy which exemplified his love and loyalty to Hillside. Under the terms of his will this is to be devoted to special studies in child and adolescent psychiatry. A suitable memorial in his honor is being planned. I wish to express my deepest appreciation to my many colleagues on the attending staff, to the Medical Director, the Director of Professional Services, to the Board of Directors and those too numerous to mention, for their cooperation and devotion to Hillside Hospital. �report of the President of the Board of Trustees ALVIN E. COLEMAN A milestone in the 31 year history of Hillside Hospital was the appointment of the internationally known psychiatrist, Dr. Lewis L. Robbins, as Director of Professional Services. At the same time that Dr. Robbins is helping us to look ahead, he has helped to put the current program of the hospital in a significant perspective. Our prime object is the continued improvement of the quality of the treatment available to our patients, and the scope and value of the knowledge that we are able to impart under our teaching and research programs. Each year it seems more evident that the future of the treatment of mental disease rests in the ability to conduct extensive research in order to learn entirely new methods. We are fortunate to have on our staff capable and farseeing men who are leading us along challenging pathways to the future. During 1958, a Department of Medicine, headed by Dr. Arnold Blumberg, was added to the research program. The Department of Experimental Psychiatry, headed by Dr. Maximilian Fink, did some outstanding work in the field of electroshock and tranquilizer drug effects upon the patients’ personality and behavior. The U. S. Public Health Service allocated a 5 year grant of $268,000 for this department and appointed Dr. Fink to serve as a consultant to the Council of the National Institute of Mental Health, which itself passes upon applications for grants from those working in this field. Four pharmaceutical houses, Bristol Laboratories, Wyeth Laboratories, Smith, Kline 81 French, and Geigy Chemical Company, provide financial grants for further detailed study of how the new psychotropic drugs affect human behavior. The general use of insulin as a mode of treatment was discontinued because it has proven to be too hazardous for results obtained and that the same or similar results are now apparently available through the use of new drugs. The Department of Biochemistry, headed by Dr. Harry Goldenberg, made substantial progress in further studies based upon the premise that mental illness is accompanied by metabolic and other biochemical defects which can be detected. Dr. Goldenberg’s work, too, has received considerable recognition by the U. S. Public Health Service in the form of substantial public grants. Further plans for the modification of the building and the treatment program are now being studied. Six new offices were added to the pavilion for adolescent girls at a cost of $35,000. A joint psychiatric service with Long Island Jewish Hospital, our neighbor, was established through the appointment as Chief of this service of Dr. Samuel Lehrman, Attending Psychiatrist of Hillside and a member of our Medical Board. Through the aid and encouragement of the Nassau County Mental Health Board, it was decided to open a Child Therapy Unit in April, 1959. This will be 50% supported by funds from Nassau County. During 1958, Hillside received a number of important bequests including the balance of the funds left to it under the will of the late Edwin Elson, our former Trustee; the total of this bequest was $52,000. We also received $20,000 from the estate of Dr. S. Klein, who had for many years been a valued member of our Medical Board; and $37,950 from the estate of Wilhelm Levinger, brother of our beloved former Trustee, Alfred Levinger, who had been one of the founders of this hospital. We were awarded a grant by the U. S. Public Health Service of $150,000 toward the minimum required sum of $300,000 for the construction of a building to be used solely for research in mental health. One of our ever-loyal and generous trustees, Mr. Si Scheuer, made it possible for us to promptly qualify and accept this munificent grant by himself giving us $50,000 towards the construction of this building, which will be knOWn as the Scheuer Building for Research. A 75th birthday was celebrated by one of our most distinguished trustees who has done so much for the Hospital by making possible the magnificent facilities it now enjoys, namely our Honorary Chairman, Leon Lowenstein. We all wish him many more happy birthday anniversaries. 7 ��N 1958, there 342 patients who had this Hillside themselves treatment. admitted to numHospital Of for voluntarily ber, 211 were new admissions, and 131 were readmitted patients of whom 27 I were had previously received treatment at Hillside. the Included in males, 236 106 the 342 female females. were patients, 0f total are the 23 girls admitted to and treated in the Adolescent Pavilion. The average daily census of patients was 195; and the average stay of each ‘ i .‘ ‘ 9.. ’v;'r‘{1 'v: .2» ‘ . - “Amway-713w v ,, . patient was for 196 days. Upon discharge front the hospital, a patient’s condition is evaluated on a he when behavior mental his and basis: enthe status in diflerence comparative tered the hospital, and when he left. The five categories are listed below, (figures in parentheses indicate the number of patients who left Hillside in 1958) Unimproved (41): no change in condition. have still but been alleviated persist problems or Improved (137): symptoms to an appreciable extent. Much improved (134): symptoms have disappeared and the patient seemed in good condition while hospitalized; however there is no certainty as to his behavior when he returns to his normal environment at home and at work outside of the hospital. Recovered (24). the prognosis is that the patient will be able to return to his social and working community and function as well, or better than he did before he became ill. Without Mental disorder (5) Qied (1 ) OSPITAL ‘ �STAFF EXECUTIVES Abraham Levine, Ph.D. Sylvia Markham, M.A. Leonette Vanderhost, M.A. Director, Psychology Dept. Associate Psychologist Senior Psychologist treatment psychotherapy and medical services The center and core of the treatment program at Hillside is psychotherapy. The ability of the patient to benefit considerably from psychotherapeutic treatment in this area is one of the main criteria for admission. The patient must voluntarily admit himself and be in an early and incipient stage of mental illness. (The long-term, chronic case, requiring custodial care, is referred to other institutions.) The Hillside patient has thus been selectively admitted, receives psychotherapy a minimum of three times a week. In addition, patients participate in group therapy, and all of the other accepted modern therapies, activity therapy, occupational, creative and recreational, drug therapy, and milieu therapy. é 10 _ / s .. .4 . Each team of psychiatric, nursing, social service and other professional personnel of Hillside Hospital meets regularly to pool its knowledge to help its patient along the road to mental health. psychology department The department continued to make its contribution to the understanding of a In the concept of milieu therapy, the whole life of the patient in the hospital, including associations and activities are designed to facilitate his treatment. The therapeutic program thus changes as the patient changes. To conduct this extensive program, Hillside utilizes a “team” approach integrating the skills of the specialists on its staff, under the general supervision of the medical director. Leader of the team is the psychiatrist who is assigned to a patient upon admission, and who remains in charge of the patient for the duration of his stay. Working closely with the psychiatrist, and coordinating the efforts toward the mental health and welfare of the patient are consulting psychiatrists, psychologists, psychiatric nurses, occupational and creative therapists, psychiatric social workers and psychiatric attendants. The team concept is a broad one, and under it conferences are held at which are presented initial diagnosis of newly admitted patient; periodic reports on status of patient and his response to treatment; pre-discharge consultation and rehabilitation, or after-care plans. patient’s strengths, weaknesses, and highly complex psychic states by means of psycho-diagnostic examinations. Objective results obtained through these tests have been helpful to the hospital staff in delineating a history of conflicts, defenses, personality. The tests help to reconstruct and chart the patient’s life to show what forces were at work to bring him to the hospital. They provide much informative material needed to plan treatment. Psychological tests are administered upon admission and before separation from the hospital. Last year 541 tests were administered to hospitalized patients and out-patients. Expansion of the department has made possible the inclusion of a vocational counseling program. This program has been especially helpful in developing a placement program within the hospital where a patient may acquire work experience that helps prepare him for the future when he leaves the hospital and returns to his community. In 1958, a doctoral candidate from the Department of Psychological Foundations and Services at Teachers College, Columbia University participated in the psychological counseling program. �STAFF EXECUTIVES Mrs. Goldie Krupa Miss Nancy Jeffries Miss Jean Hendry Miss Helen Schippincase Miss Eleanor MacPhillips Miss Flora McCartney Mrs. Alice McDonough Mrs. Edna Telesca Director of Nurses Assistant Director 0 f Nurses Nursing Instructress Day Supervisor Afternoon Supervisor Night Supervisor I ntra-M and Clinic Nurse Departmental Secretary nursing department intramural clinic This department maintains the patient’s physical health and cares for his non- psychiatric medical needs. Frequent consultations are held between Hillside’s staff and the Intramural Clinic’s specialists to integrate the mental and physical treatment programs. Under the direction of Hillside internist, Dr. Arnold C. Blumberg, the Intramural Clinic handled 2184 patient visits in 1958. The greatest number of patient referrals to Clinic specialists, were in the fields of Internal Medicine, closely followed by Opthamology, Dermatology and Gynecology. Important services also were rendered in Orthopedics, Otolaryngology, Proctology, Surgery, Urology, Neurology, Podiatry and Radiology. Plans have been made for the Intramural Clinic specialists to take an active part in a psychiatric training program for non-psychiatric physicians. Last year an In-Service Training Program for registered nurses was instituted. The program, which consists of lectures by psychiatric supervisors and doctors, has been of tremendous value to the nursing staff. Knowledge gained and shared has enabled the nurses to perform more effectively to the benefit of the patients and the hospital. The policy of conducting field trips through the hospital for students from Central Islip and St. Vincent’s Schools of Nursing was continued. In addition, during 1958, for the third consecutive year student nurses from Queens College received their psychiatric nursing experience at Hillside. F orty-four students participated in the teaching-working program. The training program for psychiatric aides was recognized by the Queens County Mental Health Society, which presented awards and certificates of honorable mention to four aides trained by the Nursing Department. The awards were made to focus public attention on the important role played by the indispensable psychiatric aides, who contribute so much to the patient through their interest, kindness, attention and skill. department of dentistry Approved by the American Dental Association, it is the oldest intramural department in the hospital. Its staff of 10 dentists, directed by Dr. Paul Scheman, last year received 1112 visits and rendered professional services in orthodontia, periodontia, restorative dentistry and oral surgery and X-ray. New dental equipment acquired in 1958 made it possible to vastly improve the dental care to patients. Members of the department frequently appeared before dental organizations to read papers and give lectures on methods of treating dental patients with emotional problems. ‘ ; I 11 �O. T. STAFF EXECUTIVES Director Eileen P. Fisher Joseph C. Chase Senior Occupational Therapist Adult-Section Esther Burack Senior Occupational Therapist Adolescent Pavilion occupational and creative therapy 12 Two adjunctive services at Hillside, which make an important contribution to the patient and staff are the Occupational and the Creative Therapy departments. Each of these departments has a specific function, and each is prescribed as a regular part of treatment in cooperation with the psychiatric staff. The OCCUPATIONAL THERAPY department, which is a member of the treatment team, performs a dual function. It provides a program under which a patient can work in various handicrafts, which offer a creative outlet that increases his self-confidence. It also helps the psychiatric staff by reporting on the patient’s attitudes and reactions while he is so engaged. From these reports, which detail responses to success or failure with a project such as weaving, jewelry making, ceramics, the psychotherapist gains further insight to his patient not only at work, but also in his relationship with others in the group. In 1958, the department had maintained a close association with the hospital team. Occupational therapists attended meetings three times a week to contribute their knowledge of a patient, and also submitted regular progress reports to the psychiatric staff. The addition of one therapist to the staff during the year made possible the initiation of an occupational therapy program right in the patient’s room. This enables the therapist to reach a more disturbed patient more quickly and to give him more individual attention. At year’s end, a new prescription form was devised to effect an even closer working relationship between the C. T. STAFF EXECUTIVES Director Dr. Ernest Zierer Creative Therapy Associate Edith Zierer Director doctor and the occupational therapist. The form contains pertinent information which provides a direct guidance line and a higher degree of integration between the psychiatrist and the occupational therapist, indicating areas of concentration that will be most helpful to the patient. CREATIVE THERAPY at Hillside is a specialized form of art therapy devised and developed by Dr. Ernest Zierer. Department Director and his associate, Mrs. Edith Zierer. This therapeutic and psychodiagnostic tool involves the administration of a series of painting tests that reveal a visual expression of the patient’s attitudes toward recurrent life situations. This unique program furnishes a “personality profile” of the patient. This profile supplies the psychiatric staff with documented findings delineating the patient’s stress and frustration tolerances, strength of motification, actual and potential functional capacity and his ability to “integrate” into the societal structure. During the year, an average of 49 patients took part in the program daily and a total of 1640 tests were administered. adolescent pavilion STAFF EXECUTIVES Dr. Alice Stahl, Director Dr. Zenos M. Linnell, Supervisor Dr. Eugene Glynn, Director of After-Care Clinic Dr. Sidney L. Green, Consultant Mrs. Kathleen Cliggett, Head of Nursing Mrs. Sylvia Riback, Senior Social Worker The Israel Strauss Adolescent Pavilion, now in its fifth year, was a pioneering venture of Hillside Hospital. It was 1. 2; �set up to treat and rehabilitate adolescent girls who need hospitalization for emotional problems during a most crucial transistory period of their lives. Hillside Hospital, in venturing into this hitherto neglected field, recognized that adolescence is an ideal time to employ the knowledge and skill of modern psychiatric care to help young people when help can be decisive. The Pavilion provides individual psychotherapy, milieu therapy, a school program, a group activities program and nursing care for girls between the ages of .13 and 17. It also conducts an intensive social work program with the families of all patients to create a healthier climate and better understanding at home, of the girls’ problems. The 23 patients admitted to the Pavilion in 1958 remained in the hospital for an average of 315 days, as compared to the 182 days for adults. The conditions range from transient behavior problems to the major psychoses. The staff includes a supervisor, three resident physicians, three registered nurses, two social workers, two school teachers, a group activity worker, an occupational therapist and 16 psychiatric aides. The patients live in a two-story building that includes all therapy facilities, studio-type bedrooms for two girls, dining rooms, lounge and recreation areas. The girls, however, attend school classes in another building to simulate as much as possible the atmosphere of “going to school”. As soon as they are able to, girls are encouraged to join in recreational activities outside their own group in the Pavilion. There have been two notable advances during the year. The first is a more structured and individualized program. Under this program the group work department offers a . variety of activities and each patient is required to sign up for two of those activities. The structured program helps the patient to do what she cannot do for herself. The second advance has been to use the concept of individual and group responsibility to foster growth. Housekeeping duties have been assigned to girls and the relationship between various privileges and the patients’ readiness to exercise self control has been stressed. As the Pavilion gains wider recognition among members of the 4" psychiatric profession, greater numbers of referrals continue to come in from distant parts of the country. However, to maintain its high standard of individual attention,the Pavilion restricts its patients to 16 at any given time. The operation of the Adolescent Pavilion is in conformance with the basic thesis of Hillside Hospital; early treatment for those mentally ill patients who can benefit in a relatively short period of time. Even though the adolescent years are directly related to the Hillside orientation, it was obvious at the time the Pavilion was set up, that the adolescent years are the “difficult years.” This period of greatest individual change also is the period about which relatively little is known to the psychiatrist. Five years of treatment of adolescent girls have resulted not only in the improvement of the patients involved but also have led to insights and approaches to modified and new treatment concepts. These results already have been applied to adolescents, as well as young adults. Follow-up studies of discharged adolescent patients presently are being conducted. In summary, the operation of the Adolescent Pavilion has provided an exciting area for a combined treatment and research project. i 13 �CASEWORK DIVISION EXECUTIVES Abraham Lurie Director, Dept. of Louise Pinsky Sylvia Solovey Sylvia Riback Seymour Silverberg Social Service Department casework division 14 The Social Service Department is the hospital’s most direct link between the patient and his family. The department’s function is to help the patient and his family cope with the personal, social and economic problems caused by the illness. It helps a patient come into the hospital, to stay in the hospital by working with the family members in an effort to relieve pressures on the patient, and finally, to leave the hospital, and return to a good home climate. This is accomplished by participating directly and actively in the planning that concerns the patient. To accomplish this, in the course of 1958, the Casework Division of the Social Service Department conducted 11,593 interviews with patients, (including those in the Adolescent Pavilion and the Out-Patient Department) and their families. There were, in addition, 10,517 telephone contacts with relatives of patients. This represents an increase over last year’s figures because a drop in median age of patients, to include many more teenagers, made it necessary for social workers to spend more time with patients and their families. About 35% of the adult patients admitted in 1958 to the hospital are between the ages of 17 and 25. This is due to two principal factors: the policy of selecting patients in the early stages of mental illness, and also the fact that young people are more Social Services Assistant Director, in charge of Casework Supervisor Supervisor Executive Director of the “Bridge” likely to seek hospital help when they are mentally ill. (Older people frequently reflect social taboos concerning this type of hospitalization.) The preponderance of young people has changed the social structure of the hospital in many ways including such things as the types of group activities. In 1958, a more intensive effort was also made to screen the 790 male and 1220 female applicants to determine those who could best benefit from the treatment of the hospital, prior to their screening at the clinic. Collaborative relationships with social agencies were continued. One of the most active joint programs was with the Jewish Family Service, which permits discharged patients who need further counseling to get immediate help. At the close of the year, 18 patients (and their families) were receiving aid. Though still a pilot project, this two year old program offers considerable promise for further expansion. Nineteen patients were placed during the year through the F oster Home Program, conducted jointly with the Jewish Community Services of Long Island. This extremely active and important program benefits those patients who, which home have to discharge no upon to return, or who should not, for their well-being return to the same environment in which they lived before admission to the hospital. An invaluable service, which, on occasion, makes possible the hospitalization of a mother, is the Homemaker Service, conducted with the cooperation of the two aforementioned Jewish agencies. This service, supplied to temporarily motherless children, enables the mother-patient to derive maximum benefit from therapy by freeing her from worry about the care of her children. In 1958, 10 families were helped over this particularly difficult time through this program. The Altro Workshop, in the East Bronx provides transitional employment to discharged patients and was used by 13 patients during 1958. The work gainful providing by program, in a protective shop where each employee works at a rate of speed that does not tax him, makes it easier for the �ex-patient to eventually resume normal employement in the community. The Federation Employment and Guidance Service, the New York State Employment Service and the Division of Vocational Rehabilitation have continued to cooperate to the fullest in helping patients secure job placement soon after leaving the hospital. The school program provided by the New York City Board of Education was particularly significant in 1958 because of the large number of young patients. Sixty-two patients under the age of 21, who had not yet completed their high school educations were enrolled; 17 were graduated, and six patients passed their high school equivalency examina- tions. The mental patient, unlike the general hospital patient, usually requires longer care and long-time follow-up after discharge. These social service programs indicate Hillside’s recognition of this fact, and the hospital’s community responsibility to provide leadership and coordination of other agencies who could help in the continued care of mental patients during, and after hospitalization. Thus, dozens of private agencies (particularly those affiliated with the Federation of Jewish Philanthropies) and public agencies are able to pool their resources. work division group The Group Work Division, under the direction of Arnold Eisen, focuses on the re-socialization of the patient, re-orienting him to group living. The patient is helped to function in an improved manner with his family, friends, employer, fellow-employees and the community in general. A major change in 1958 has been the increased development of community links and a closer coordination with the Casework Division. During the year this division developed a number of new services, programs, ideas and approaches: The New Patients Orientation Group, formed to soften the impact of hospitalization on a new arrival and to supply factual, comforting information to help alleviate fears. Development of Community Program Resources, under which community agencies open their doors to patients on specified occasions. Trips have been made to YMHA, YWHA, YWCA and YMCA branches in Manhattan, Jamaica and North Hills. Special Cooperative Services with Community Agencies: In cooperation with the Federation Employment and Guidance Service, Group Vocational Guidance sessions were held to discuss the job market, stimulating patient interest in the post-discharge period. Under the Discharge Plan expatients returned to the hospital to tell patients of their experiences at the postdischarge social rehabilitation center, the Hillside League. This has been most effective in relieving separation anxiety. Joint Patient-Family Programming is an outgrowth of Field Days, at which both visitors and patients participate in recreational activities. As an experiment, patients were permitted to invite members of their families to a dance at the hospital. The success of this social event has resulted in planning of other joint events in the future. Internal Programming in 1958 was responsible for establishing several additional lounges, dance therapy, English lessons for foreign-language speaking patients, and other similar programs. A weekly newspaper, edited and published by the patients is now available in addition to their quarterly literary magazine. 15 ��., ~ g _ f TAk 7., . a u, 1 .«f ~ . . I ‘ 1.. . . e. . at. 5,. w ., , >11. .K .,, . . m 7 . ,i . .m.«:, ¢ , . .. L . .w . . . m k . v . . ¢iyu§$ta$flw€u1qfim . . \ _.. sub A w ~ m . . v- 4% .. . A. f, . . is» n , N . , ‘ g . ‘ ‘ . / , _ «JD, . . . m a a h ., . . 1: , .. 2 I 1:“ K, fl - w a _ ,. x . . . V . . \ g _ . ., . . _ . . W I K I . . u ‘ . . < l V m . q v I . . _ . ~ v. .. o . . . :8 , ; ‘ V . ‘ . .P A ‘ v �L , Bid-"“1 ' . Gfi'emiggry R5e'sea-rqh: Fé‘llby’fi Adjupptjve" ' ’ I , ', Therapies v V ' "' VCI'mlc'al ' ‘ V SoCi’al swipes �‘ ” BOARD ' ;‘ COMMITIEES: Medical Advisory Board . 7, Outside/Affiliations f ‘ Dietary AVDM-IvNiS-TR'ATI'VE‘ SERV‘IQE ' As'sT. ADMINISTRATOR ‘ ADMINISTRATOR Buildings Grounds _ Department . Auditing Secreta rial 0“. Pool» Finance Budgets Diets Menus Dayshift Night Shift ., rchasing Inventory Cleaning 1 P_u 1? Linen Decorating Sto res .- 7 ChefsStaff " . Water Gas Heat Buildings ~ Kitchen Dining Rooms ”Po rters Storekeeping ’ Payrblls Reports Construction .Ma'i nte n anee Craftsmen Porters Attendants ’La'bo‘re'rs Gardeners. Linen Room Engineers Laundry ‘ ' ‘ . Typing. Personnel Supplies Purchases ~' '7 . Medical Budgetary Control ‘ Reports 0 _ ' . Mail Room _ Communications -' , '1 . Medical" _ Statistics 'Grougnds Maids .. gitceou»nts._ : ' i=Bookkee‘pers‘iv~ . ‘ ,Audito rs 'QI e rks Secre'ta ries ' Q, .' Typists - Receptionist Telephone Operators ‘ Typing Pom Trucks“ Cars Gatem’en security A. .4..._. n a em. Hillside Hospital a nd. its Patients . _ ' ��STAFF EXECUTIVES Director of Out-Patient Services Robert R. Luttrell. MD. Assistant Director of Robert Navarre, M.D. Out-Patient Services Miss Sylvia Solovey Mrs. Joan Weisman Mrs. Anne Wexler Mrs. Ida Baumstein Mrs. Estelle Pitts Manhattan after-care clinic The Manhattan After-Care Clinic, located is at week, five a nights open Mt. Sinai Hospital, a convenient location for most discharged patients. It assists the Hillside discharged patient to resume his role in the community and to deal with the immediate problems of job adjustment and resumption of old environmental contacts. Approximately 30 patients are seen twice Weekly in an effort to bridge their adjustment from the hospital setting to the community setting. The treatment is intense but brief. The importance of this Clinic cannot be underestimated because this helps people who come to the clinic to avoid readmission to the hospital. If they can be helped during the first few months, their chances of adjustment in the community are greatly improved. Group or individual therapy is provided, depending on the needs of the patient. Israel and Hilda Strauss League The Israel and Hilda Strauss League is an organization maintained for the social rehabilitation of former patients of Hillside Hospital. Situated in quarters at 231 West 83rd Street, Manhattan, the League furnishes a meeting place for social and recreational purposes. A lounge is equipped Supervising Social Worker Sta]? Psychologist Caseworker Caseworker Caseworker Queens out-patient service with a record player, radio, television, magazines and table games. Its existence is made possible through the devotion and unflagging efforts of a group of women volunteers from the community who sponsor the League by raising funds and by offering personal services. The group name “The Bridge”, is symbolic of the purpose of this volunteer organization; $30,000 was raised last year by “The Bridge” for the League. A former Hillside psychiatric social worker, Seymour Silverberg, is assigned as a full-time director of the League. He is available for individual consultation and referral service relating to housing, employment, further treatment and other personal welfare problems. Active membership in the League is now 366, an impressive growth compared to its start in 1954 with 38 members. Devoted volunteer participation has kept pace with the membership. The Queens Out-Patient Service was established to help the emotionally disturbed person before his mental health problems grow and require hospitalization. Psychotherapy is offered to residents of Queens, Nassau and Suffolk Counties who require treatment but cannot assume the economic burden of private care. Selection is made on the same basis as that for in-patients: patients suffering from acute emotional illness are selected after careful screening to determine their likelihood of responding to intensive treatment of a year or less, based on twice-a-week visits. In 1958, 33 psychotherapists worked on a part-time basis to treat 306 patients in individual psychotherapy and 30 patients in group therapy sessions. Usual length of treatment consisted of eleven months. Of the 306 patients treated, 156 were patients admitted to the Clinic in the previous year, and 150 were new patients. To select the 150, 222 patients were fully screened by social workers, through psychological tests and interviews with psychiatrists. Statistics, however, do little to reveal the amount of anguish and tension successfully resolved. They must be translated into the numbers of families kept together, the jobs saved, the fears allayed. �Training programs Hillside’s Resident Training Program continues to emphasize the interrelation between the training program and the treatment program. In 1958, there were 20 Residents in training. Each Resident carried a case load of about 15 patients under the supervision of staff and visiting instructors. In addition, he atttended lecture conferences conducted by the medical director. Instructors from the Medical Board conducted lecture and reading seminars in the fields of psychopathology and psychotherapy. Qualified Residents were assigned to the Department of Experimental Psychiatry for clinical and other psychiatric research projects. Seven student case workers from three schools of Social Work were assigned to the Casework Division of the Social Services Department; and six graduate students received training in the Group Work Division of the Department. The training programs extend to Clinical Assistants in the Out-Patient and After-Care Clinics and on-the-job training of personnel. Regular lectures and conferences are scheduled for psychologists, nurses and attendants, social workers and members of the variOUS adj unctive services. Israel Strauss lecture The Annual Israel Strauss Lecture, established in 1955 in honor of the founder and late President of Hillside, was delivered in 1958 on April 20. The speaker was Dr. Paul H. Hoch, Commissioner of New York State Department of Mental Hygiene. His subject was The Open Hospital. Sunday clinical conferences The Sunday Clinical Conferences, open to and attended by psychiatrists and other professional personnel and by outstanding visiting physicians are part of the Resident Training Program and are based on cases prepared by the Residents. They make a significant contribution to the training programs in the field of psychiatry in the metropolitan area. Medical library The Arany Lorand Memorial Library with Miss Rosalind Lazarus as Librarian continued its rapid expansion program. During the year, 470 books and monographs were added, and 110 periodicals subscribed to. The personal library of the late Dr. Sidney Klein was incorporated. A generous bequest of Joseph Meyer was applied to the psychiatric collection. A gift in the name of Dr. Attlio Laguardia was used to augment the teaching collection. l 19‘ ��- ‘ , ». V , ESEAR CH at Hillside Hospital is a multi-disczplined combined approach of biochemists, chemists, physicists, psychologists, psychiatrists, sociologists and statisticians. Even though the treatment program at Hillside is psychoanalytically oriented, the hospital recognizes that every approach must be explored and utilized in order to increase knowledge and improve the therapy of mental patients. Serious mental illness, with all its disruptive influences, today touches one family in three, since one person in 10 requires hospital treatment for a psychiatric disorder at some time during his life. Hillside believes that the mental health problem requires a total approach, and that progress in the treatment of the mentally ill depends vitally on a program of intensive, never-ending research. A stafir of scientists and trained researchers is constantly engaged in the laboratories, in a program of test-tube probing into the mental health program. Research goes on at Hillside on three fronts: in the Department of Experimental Psychiatry, in the Department of Biochemistry and in the Department of Medicine. ESEAR0 �STAFF EXECUTIVES Director Max Fink, M.D. Research Associate (Psychiatry) Joseph .laf’fe, M.D. Research Associate (Psychiatry) Donald F. Klein, MD. Sr. Research Associate (Experimental Psychology) Robert L. Kahn, Ph.D. Research Associate (Experimental Psychology) Max Pollack, Ph.D. Research Associate (Sociology) Nathaniel Siegel, Ph.D. Research Assistant (Experimental Psychology) Eric Karp, B.A. Associate in Research (Neurophysiology) Martin A. Green, MD. Associate in Research (Psychiatry) Abraham A. Kaplan, MD. Barre Alan, M.D. Henry Lefkowitz, M.D. TECHNICAL STAFF Fellow (1 957-58) Fellow (1958-59) Mrs. Janet Bowie .lean Kolodny Hannah Mosquera Blanche Zaitz experimental psychiatry 22 During 1958, the major emphasis of the staff of the Department of Experimental Psychiatry shifted from the evaluation of convulsive therapy to systematic investigations of newer drug therapies. These investigations were based on the theories developed in the Department in 1957, which derived from the successful evaluation of the mode of action of convulsive therapy. Studies were conducted on measures of speech behavior developed in the Department during 1956 and 1957. In an extension of the communication studies, the language indices were applied to drug therapy. The evaluation of convulsive therapies was continued in 1958, by comparing the effects of indoklon, an inhalant convulsant, with electroconvulsive therapy. Results indicated that while the indoklon worked, it was a poor substitute for ECT. The study was important because it illustrated graphically that the convulsion was the important factor, not the electrical stimulus. Investigations into the relations of sociologic factors to the selection of therapies at the hospital showed that not only were the factors of age, education and birthplace significantly related to the choice of therapy, but these factors were also related to the results of therapy, the diagnosis and the duration of hospitalization. Similar studies of the population of other primarily psychotherapeutic hos- pitals, and the Hillside Out-Patient Clinic were also undertaken. A grant from the Mental Health Board of Nas- sau County helped support and augment these studies. The acute drug interviews were but One aspect of the continuing evaluation of the biochemistry of convulsive therapy. Other research projects during the year consisted of perceptual studies in patients receiving psychodynamic therapies; the inter-relation of psychotherapy with physiodynamic therapy; and the inter-personal factors in therapists, as well as patients, leading to the referral for physiodynamic therapies. Three members were added to the staff during the year, and the department received support through continuing grants of the Foundations’ Fund for Research in Psychiatry, the National Institute of Mental Health, the Psychopharmacology Service Center of the National Institutes of Mental Health, the Mental Health Board of Nassau County; and from Bristol; Geigy; Smith, Kline 81 French; and Wyeth Laboratories. Staff members were honored with two awards: Dr. Maximilian Fink received the first annual A. E. Bennett Psychiatric Research Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on EEG and behavior; Dr. Joseph Jaffe received the Cralnick annual award for his report on the application of analysis of changes in formal aspects of speech in psychotherapy. department of biochemistry The Department of Biochemistry, headed by Dr. Harry Goldenberg as Director and Dr. Vivian Fishman as Senior Biochemist showed a major growth during 1958, with the assistance of three research grant awards from the National Institutes of Mental Health. The laboratory staff was increased to seven members to make possible more intensive fundamental biochemical studies as well as the initiation of several collaborative clinical projects. The change in the hospital treatment program from shock therapy to chemotherapy introduced new problems which required laboratory assistance. As an aid to the drug therapy program, toxicological tests were set up to detect various pharmaceutical preparations in body fluids. The laboratory was called upon periodically during the year to confirm suspected drug intoxication. A chemical study was carried out with Dr. Arnold Blumberg, of the Department of Medicine to assess the prognostic significance of the physiological response to mecholyl. While this study was in progress, it was noted that mecholyl triggers the release of adrenaline in the urine, as well as smaller amounts of related substances. In connection with adrenaline studies it was observed that preferential excretion of adrenaline occurred in normal subjects in the laboratory following the induction of a stress reaction with the drug LSD. Maj or emphasis in the laboratory continued on the premise that mental disease is accompanied by detectable chemical changes in the body. Blood and urine studies were undertaken to determine whether there is any correlation between body chemistry and the various psychiatric disorders. Studies were also continued on enzyme systems concerned with the elimination of toxic substances from the body. �Intensive studies were also made to demonstrate metabolic defect in the liver whereby toxic substances are formed but not eliminated at a sufficient rate to maintain sanity. At Hillside, it is felt that a balanced biochemical program, involving both chemical and other fundamental studies will best serve the present and future welfare of the hospital. Inter-departmental clinical studies help to bind the various hospital activities into one fabric; and the theoretical studies provide more lasting insight into the physical aspects of mental disease, whose corrective treatment offers a more lasting support to psychotherapy. medical department As new drugs are introduced into the treatment of emotional disorders, studies of the basic physiology open new vistas in the understanding of the pathology of mental disease. During 1958, the Medical Department under the direction of Dr. Arnold C. Blumberg collaborated with the Department of Biochemistry on studies of the inter-relation of the adrenaline system and emotional disease. All patients on drug therapies were screened and medically controlled by the Medical Department. Toxic reactions to the drugs were carefully scrutinized and a report on the hypotensive response to toxic doses of meprobamate were submitted for publication. Alterations in liver function with the phenothiazine derivatives were also observed in cooperative studies with the Department of Biochemistry. �Hillside publications During 1958, the Hillside Hospital Staff made numerous appearances as guest lecturers and speakers at conventions in this country and abroad. They appeared before major national professional societies, as well as before lay groups. In addition to national and local societies, reports on hospital programs were presented at conferences in Rome and Montreal. Staff members reported on therapy and research in a large number of professional publications, and in the Journal of the Hillside Hospital. FINK, M.: Lateral Gaze Nystagmus as an Index of Sedation Threshold, EEG. Clin. Neurophysiol. 10: 162-163. FINK, M.: Effect of Diethazine on EEG and Significance for Theory of Convulsive Therapy, EEG. Clin. Neurophysiol. 10: 207-208 (Abst.). FINK, M.: Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior, A.M.A. Arch. Neurol. & Psych. 80: 380-388. FINK, M.: Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Signifi- cance for Theory of Convulsive Therapy. Presented at the Society of Biological Psychiatry, May, 1958 in San Francisco. 24 FINK, M.: Role of EEG Frequency Shift in Behavioral Effects of Drugs. Presented at Section on Neurol. & Psychiat., Queens County Medical Society, June, 1958 in New York. FINK, M.: Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior. Presented at the American EEG Society, June, 1958 in Atlantic City. FINK, M., SHAW, R., GROSS, G., COLEMAN, F.C.: FINK, M.: EEG and Behavioral Effects of Collegium Internationale Neuro-Psycho M.: Clinical and EEG. Effects of Megimide in Patients without Cerebral Disease, Neurology 8: 682-685. FINK, M., GREEN, M. A.: EEG Correlates of Significance of Individual Variability in EEG Changes During Electroshock Therapy. Presented at the Eastern Association of Electroencephalographers, March, 1958 in Montreal. Psychopharmacologic Agents. Presented at Pharmacologicum, September, 1958 in Rome; and also at the Eastern Association of Electroencephalographers, December, 1958 in New York. the Electroshock Process. Presented at the Eastern Psychiatric Research Association, February, 1958 in New York. FINK, M., GREEN, M. A.: Electroencephalo- graphic Correlates of the Electroshock Process, Dis. Nerv. Syst. 19: 227 (Abst.). FINK, M., JAFFE, J.: Drug Induced Changes in Interview Patterns. Presented at the Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, 1958 in Montreal. Comparative Study of Chlorpromazine and Insulin Coma Therapy of Psychosis, J .A.M.A. 166: 1846-1850. GREEN, M., FINK, GREEN, M. A.: A.: Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock. Presented at the Eastern Association of Electroencephalographers, December, 1958 in New York. GREEN, M. H.: Chairman of Symposium on Catechol Amines. Held at the New York Academy of Sciences, October, 1958. GOLDENBERG, H.: Biochemical Aspects of Mental Disease. Presented at the Jewish GOLDENBERG, Chronic Diseases Hospital, Brooklyn, New York in February, 1958. FINK, M., KAHN, R. L., GREEN, M. A.: Experi- GOLDENBERG, FINK, M., KAHN, R. L., POLLACK, M.: Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive H., BLUMBERG, A. G., GOLDENBERG, V.: Influence of LSD and Vasotonic Drugs on Urinary Excretion Patterns. Presented at the 125th Meeting of the American Association for the Advancement of Science, Washington, D.C., December, 1958. FINK, M., KAHN, R. L.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19: 113-118. H., GOLDENBERc, V.: Urinary Excretion of Aromatic Metabolites in Mental Disease. Presented at the 125th Meeting of the American Association for the Advancement of Science, Washington, D.C., Decem- mental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications. Presented at the Neurological Society and New York Society of Clinical Psychiatry, March, 1958 in New York. Therapy. Presented at the American Psychiatric Association, May, 1958 in San Francisco. FINK, M., KAHN, R. L., GREEN, M.: Experi- mental Studies of Convulsive and Drug Therapies on Psychiatry: Theoretical Implications, A.M.A. Arch. Neurol. & Psych. 80: 733-734 (Abst.) H.: New Analytical Procedures Based on Dye Partition Analysis. Presented at the Long Island Jewish Hospital, New Hyde Park, New York in March, 1958. GOLDENBERG, GOLDENBERG, ber, 1958. H., WHITE, D. L.: Standardized Method for the Assay of Serum Oxidase Activity (Ceruloplasmin) , Clin. Chem. 4: 551, 1958. GOLDENBERG, �Presented at the 10th Annual Meeting of the American Association of Clinical Chemists, Iowa City, September 1958. V.: Colorimetric Determination of Carboxylic Acid Derivatives as Hydroxamic Acids, Anal. Chem., 30: 1327, 1958. GOLDENBERG, GOLDENBERG, V., GOLDENBERG, H.: An Im- proved Method for the Estimation of Serum Copper, Clin. Chem. 4: 551, 1958. Presented at the 10th Annual Meeting of the American Association of Clinical Chemists, Iowa City, September 1958. J., KAHN, R. L., FINK, M.: Communication Patterns with Altered Brain Function. Presented at the Eastern Psychological Association, April, 1958 in Philadelphia. JAEEE, J., SLorE, W. H.: Interpersonal F actors in Denial of Illness, A.M.A. Arch. Neurol. 81 Psychiat. 80: 653-656. JAFFE, .IAFFE, J.: Language of the Dyad, Psychiatry 21: 249-258. F INK, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Hoch, P. and Zubin, J., Eds., Grune 81 Stratton. KAHN, R. L., M.: The Relation of F Score to Behavioral and Physiological Response with Altered Brain Function. Pre-' sented at the Eastern Psychological Association, April, 1958 in Philadelphia. KAHN, R. L. FINK, KAHN, R. L., FINK, M.: Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. Presented at the Electroshock Research Association, May, 1958 in San Francisco. KAHN, R. L., POLLACK, M.: Socio-Psycholog— ical Aspects of Diagnosis and Treatment: Theoretical Implications. Presented at the Symposium—Eastern Psychological Association, April, 1958 in Philadelphia. KAHN, R. L., POLLACK, M.: Social Factors in Selection of Therapy in a Voluntary Mental Hospital. Presented at the American Psychiatric Association, May, 1958 in San Francisco. KAHN, R. L., POLLACK, M.: Prognostic Application of Psychological Techniques in Convulsive Therapy. Presented at the Eastern Psychiatric Research Association, October, 1958 in New York. H.: Intensity of Stimulation and Perception of Simultaneous Stimuli in Cerebral Dysfunction. Presented at the Eastern Psychological Association, April, Philadelphia. KORIN, LEVINE, A.: A Comparative Evalution of Latent Schizophrenic and Overt Schizophrenic Patients with Respect to Certain Personality Variables, J. Hillside Hosp. 7: 131-152. P.: Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. 81 Psychiat. 79: POLLACK, M., KRIEGER, H. 720-726. Predictions of Outcome, in Youthful Offenders at Highfields, Weeks, H. Ashley, Ed. U. of Michigan Press, Ann Arbor. SIECEL, N.: L.: Juvenile Delinquency. Presented to the Sociology Department at Hofstra College on November 26th, 1958. VANDERHOST, Hillside Journal POLLACK, The Journal of the Hillside Hospital showed once again an increase in the number of its subscribers as an indication of its greater influence and wider acceptance in the psy— chiatric and related fields. In this country and throughout the world about 1200 copies are subscribed for by medical schools, training hospitals, social service agencies and many institutions in other countries, particularly Israel. In 1958, 15 major articles by members of the Hillside staff and by other professional contributors, were published in four issues. Contributions come from various parts of the US. and especially the West Coast. The Journal offers an unusual feature by reporting clinical conferences in full including the entire discussions. Now in its 7th year the Journal is still under the able leadership of Dr. Sidney Tarachow. The Editorial Advisory Board consists of Morris B. Bender, M.D., Dudley D. Schoenfeld, M.D., and Sandor Lorand, MD. The Associate Editors are Renato Almansi, M.D., Abraham S. Lenzner, M.D., Samuel R. Lehrman, M.D., Joseph S. A. Miller, M.D., Aaron Stein, M.D. POLLACK, M., BATTERSBY, W. S., KAI-IN, R. L., BENDER, M. B.: Intellectual Deficits in Pa- Grants and Awards Received 1958 LEVINE, A., HARRIS, J., CAMINSKY, I., LURIE, A., BACHRACH, M., MILLER, J.: An Explora- tory Vocational Counseling Program in a Mental Hospital, J. Hillside Hosp. 7: 153-161. 5.: Pathological Reactions in Women After Parturition. Presented to the Department of Obstetrics at St. Albans Naval MARKHAM, Hospital on December 13th, 1958 in New York. S.: The Dynamics of Post-Partum Pathological Reactions as Revealed in Psychological Tests, J. Hillside Hosp. 7: 178-189. MARKHAM, POLLACK, M.: Visual Perception and Attention in Normal and Abnormal Children. Presented at American Orthopsychiatric Association, March, 1958 in New York. M.: A Critique of “Pre-Conscious” Perception and the “Poetzl Phenomenon”. Presented at the American Psychiatric Association, May, 1958 in San Francisco. POLLACK, M.: Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: 442-428. tients with Space Occupying Lesions of the Cerebrum. Presented at the Eastern Psychological Association, April, 1958 in Philadelphia. ........ Foundations Fund for Research U. 5. Public Health Service in Psychiatry .................. $74,460 16,250 25 �«saw». �report of the administrator “Kim. MAURHIIBACHRACH The 1958 Annual Report strikes a new note which reflects the tremendous strides that are being made in the field of mental health. The hospital’s operations during 1958 were effected by the profound changes which came with the introduction of the psychotropic drugs. Chemotherapy has enabled us to entirely discontinue Insulin Shock Therapy and is reducing the use of Electro Shock Treatment to a point where it may soon be eliminated. These changes produced certain changes in our expense picture, in that the cost of giving the physical therapies, which are being abandoned, is reduced. But, there are attendant increases in costs for drugs and, more importantly, a need for expansion of personnel in the adjunctive and activities therapies. Another profound influence is introduced by the Professional Department program which our Director of Professional Services, Dr. Lewis L. Robbins, had recommended at the end of 1958. It is almost certain that the implementation of these recommendations including, as they do, a considerable increase in the number of full time Staff Psychiatrists, as well as expansion of the Social Service, Occupational Therapy, Psychological and Group Activities Staffs, will change our expense picture considerably, although they may have no impact on the 1958 experience as such. Comparison of Costs 1957-1958 1957 Salaries .......................................... $855,848 Food .............................................. 119,350 Maintenance and Grounds ............ 62,654 Administrative Expenses .............. 98,952 Medical Supplies .......................... 29,811 Repairs and Replacements .......... 49,021 Clinics ............................................ 280,056 Total ................ $1,495,692 1958 $936,330 127,142 72,049 108,693 31,997 48,101 337,712 $1,662,024 The above table shows that the total cost for the entire Hillside Hospital complex increased by 11% during 1958. One-half of this total increase occurred in salaries which increased by 9%. This is in keeping with our experience for the past ten years, where salaries have been increasing steadily at the rate of seven to ten percent per annum due largely to the need of the Hospital to keep pace with the increasing cost of living. Very little, if any, of this increase during 1958 can be ascribed to additional staff. The largest percentage increase, 21%, was in the cost of Out-Patient Services. This reflected a combination of increased costs and continued expansion of clinical work from Out-Patient Services, but this should be contrasted with the 307(increase in the cost of Out-Patient Services during 1957. This indicates that although our Out-Patient Services are still expanding, the rate of expansion is slowing down. The other items, food, maintenance and grounds, administrative, medical supplies and repairs and replacements, increased by varying amounts, but they are all in keeping with the general picture of roughly 1071 increase for all expenses. Service Statistics 1957 Total Number of Patients ........................ 545 Total Patient Days .................................. 69,987 Average Income per Patient Day ............ $15.57 Average cost per Patient Day .................. $17.37 Average loss per Patient Day .................. $ 1.80 1958 536 70,691 $16.58 $18.73 $ 2.15 The data given in the above table refer to ln-Patients only. The total number of patients treated and the number of patient days show no significant change over 1957. The average income per patient day as well as average cost per patient day increased with costs rising faster than income, so that the average loss per patient day rose from $1.80 to $2.15, an increase of 16%. The reason for this increase in the average loss per patient was that, although there was a slight increase in average income per patient day, all of this increase coming from fees paid by patients or the patient’s family, the per diem rate paid by the City of New York remained the same during 1958, in spite of increased costs. Our research programs continued to expand with a concurrent increase in cost; but these increases were almost entirely absorbed by increased support by the National Institutes of Mental Health, so that deficits arising out of research operations were held to a relatively modest figure, $35,000, which was made up by the Board of Trustees of Hillside Hospital. 27 �Financial Support Picture Hillside Hospital has been fortunate over the years in the support it has received from the Federation of Jewish Philanthropies. Year after year, since 1948, the Federation has carefully reviewed the Hospital’s fees and supplied a grant which was always consonant with the Hospital’s deficit requirements. Our gratitude to the Federation of Jewish Philanthropies is profound and we hope that we will continue to deserve the support of the Jewish Community, as it is expressed through the Federation. We have received legacies from time to time, and as our reputation and tradition grows, these are becoming .increasingly more. The following is a list of legacies received by the Society of the Hillside Hospital from 1948 to 1958. It is interesting to see that each year the number and amounts of these legacies is growing. We hope that a larger and larger number of persons who desire to benefit humanity and especially to bring about some amelioration of the suffering of the mentally ill, will find it possible to name Hillside Hospital as a beneficiary in their Wills. Amount Simon Lefcort ................................ $ 2,000 Leonora Solinger Baum ................ 23,317 (A) Florence Tim .................................. 1,000 Rose Simon .................................... 456 Max Richter .................................... 5,000 Solomon Rothfeld .......................... 10,000 Harry T. Epstein ............................ 8,835 250 Year 1948 1949-1958 1949 1949 1950 1950 1952 1953 Beatrice S. Bowman ...................... 1953 Aaron C. Horn ................................ 3,000 Flora Haas ...................................... 60,000 (B) 1954 250 Dora Monness Shapiro .................. 1955 Robert L. Leeds .............................. 2,500 Charles Benoff ................................ 1956 380 28 Max Einhorn .................................. 77,155 897 Julius Grossman ............................ 1956 Hermenia Goodman ...................... 2,000 Christine King ................................ 1,058 Wilhelm Levinger .......................... 37,950 Joseph Meyers ................................ 2,500 (C) 1957 Notes: (A) Approximately $2,300 per year in perpetuity (B) Restricted for care of Adolescent Girls (C) Restricted for Medical Library 1957 1958 1958 1958 During 1958, the following persons other than Trustees made gifts to the Hospital as noted below: Amount Bernard M. Baruch, Jr ......................................... 3 500.00 Bristol Laboratories .............................................. 2,500.00 Grand Street Boys Foundation ............................ 675.00 Jack Bleibtreu ........................................................ 185.00 Wyeth Laboratories .............................................. 1,500.00 Lightolier .............................................................. 1,000.00 Susan Greenwall Foundation ................................ 200.00 Smith, Kline 81 French Laboratories .................... 2,500.00 Gustave Levy .......................................................... Edward Goldberger ................................................ Alfred Hazan .......................................................... J. A. Samuels .......................................................... Gaisman Foundation .............................................. Laurence Alexander .............................................. 100.00 500.00 100.00 100.00 100.00 150.00 William J. Hammerslaugh .................................... 500.00 Henry Homes ........................................................ 1,000.00 l.M.M. Charities .................................................... 500.00 Carol B. Loeb Foundation ...................................... 1,000.00 Blanche Ittleson .................................................... Blanche Freeman .................................................. 100.00 Sylvia 100.00 Krohn ............................. 100.00 Arabel Foundation ................................................ 1,000.00 Eugene Blum .......................................................... 4,000.00 Edward L. Fabian .................................................. 5,000.00 Geigy Chemical Corp ............................................. 5,000.00 Lawrence Mark ...................................................... 100.00 Louis Neiweg .......................................................... 1,049.00 Samuel Silverman .................................................. 200.00 Our gratitude to these benefactors is of course profound. It is our hope that as our work becomes known to a larger and larger circle of interested individuals, they will send us gifts for the support of our work. ��Director, Israel Strauss Adolescent Pavilion Alice Slater Stahl, M.D. Supervising Psychiatrist, Israel Strauss Adolescent Pavilion Zenos M. Linnell, MD. Director, half—time, Adolescent After Care Clinic Eugene Glynn, MD. Society of the Hillside Hospital Officers President Alvin E. Coleman * Chairman of the Board Roy Foster* Honorary Chairman of the Board Leon Lowenstein* Vice-President Dudley D. Shoenfeld, M.D.* Vice-President D. Herbert Beskind * Vice-President George W. Galinger* Secretary Manuel Lee Robbins* Treasurer Arnold S. Askin * Assistant Secretary A. Jacob Abrams Assistant Secretary M. Victor Leventritt Assistant Treasurer Arthur Garson Assistant Treasurer Harry Silverson Honorary Directors Hilda Strauss and Saul Blickman Board of Trustees A. Jacob Abrams Jonas AdlerT Alfred Appel Arnold S. Askin* John M. Bendheim D. Herbert Beskind* Saul Blickman 30 David BunimT Alvin E. Coleman* Martin ColemanT Morris David Thomas Epstein Arthur C. Fatt* David Finkle David Finn Director of Out-Patient Services Robert R. Luttrell, MD. Assistant Director of Out-Patient Services Robert Navarre, MD. Director of Research in Experimental Psychiatry Maximilian Fink, M.D. Roy Foster* George W. Galinger* Arthur Garson Maurice Glinert Meyer Goldstein Jacob Epstein Katz Carl L. Kempner‘l' Harold P. KurzmanT M. Victor Leventritt Budd Levinson Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein* Charles H. Meyer* Arthur Murray Manuel Lee Robbins* Irving Rosenbaum S. H. Scheuer* Walter Scheuer Dudley D. Shoenfeld, M.D.* Harry Silverson Hilda Strauss Irving Weisglass Nathan Wigod Morton 5. Wolf* Walter D. Yankauer* Chairman of Standing Committees Executive Committee Roy Foster Medical Affairs Committee D. Herbert Beskind Finance Committee Arnold S. Askin House and Grounds Committee George W. Galinger Nathan Wigod, Co-Chairman Legal Committee Charles H. Meyer Social Service Committee Hilda Strauss, Honorary Chairman M. Victor Leventritt, Chairman Personnel Committee Meyer Goldstein Internist Arnold G. Blumberg, MD. Director of Laboratories Harry Goldenberg, Ph.D. Resident Staff Nominating Committee Walter Yankauer Gifts and Legacies Committee Walter Yankauer Committee on Administrative Savings Arnold S. Askin Building Committee D. Herbert Beskind 81 George W. Galinger, Co-Chairmen *—-Executive Committee Members f—Elected in I958 Professional and Administrative Stafi' Medical Director Joseph S. A. Miller, MD. Director of Professional Services Lewis L. Robbins, MD. Associate Medical Director Simon Kwalwassr, M.D. Administrator Maurice Bachrach, B.S. Supervising Psychiatrists George Yessin, M.D. Gerhard Schauer, M.D. Harold Esecover, M.D.* William Benjamin, M.D. Morton Wachspress, MD. Norman Ackerman, M.D.** Barre Alan, M.D. Reva Berstock, M.D. Bernard Cohen, M.D.** Warren Cox, M.D.** Alan Dobrow, M.D. Necdet Ecder, M.D. Elhan Ermutlu, M.D.** Marie Friedman, M.D.** Michael Gould, M.D.** Sherwin Harris, M.D. Raymond Hollander, M.D. Doris Kells, M.D. Edwin Kleinman, M.D. Henry Lefkowits, M.D. Sidney Lytton, M.D. Stanley Machlin, M.D. Harvey Mandel, MD. Robert Nodine, M.D.** Paul Pressman, M.D.** Henry Rosett, M.D. Alvaro Rozo, M.D. Mollie Schildkrout, M.D. Jack Schnee, M.D. Herbert Schulman, MD. David Steinman, M.D. Carl Towbin, M.D. Margery Wile, M.D. Other Prof esional Staff Heads Director of Nursing Goldie Krupa, R.N. Director of Social Services Abraham Lurie, M.S.S.W. Director of Psychology Abraham Levine, Ph.D. �. .W. <| ', Psychiatrists affix] .4; Director of Creative Therapy Ernest Zierer, Ph.D. Director of Occupational Therapy Eileen P. Fisher, B.S. Director of Group Work Division Arnold Eisen, M.S.S.W. Dietitian Angelina Canavan, B.A. Supervisor Clinical Laboratory and X-Ray John Croghan, R.T., M.T. Department Heads Accounting Supervisor Dorothy Croghan Manager Lillian Dailey Superintendent of Buildings & Grounds Thomas R. Lumley Executive Housekeeper Sarah Travers Ofl‘ice *—Resigned in 1958 **—Completed residency in 1958 Medical Board President Robert A. Savitt, M.D.* Vice President Sidney Tarachow, M.D.* Secretary Sidney L. Green, M.D.* Treasurer Paul Scheman, D.D.S.* Est-President M. David Epstein, M.D.* Manhattan After-Care Clinic Sarah R. Kelman, M.D. Samuel Atkin, M.D. Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, MD. I. Peter Glauber, M.D.* George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D.* Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D.iL Samuel R. Lehrman, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D.* Lawrence J. Roose, MD. Robert A. Savitt, M.D.* Martin Schreiber, M.D.* Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D.* Consulting, Attending and Visiting Staffs Non-Psychiatrists Psychiatry Director of Department of Medicine Lester Cohen, M.D.* Leonard Blumgart, M.D. Sandor Lorand, M.D. Irving J. Sands, M.D.l~ Nathaniel E. Selby, M.D. Dudley D. Shoenfeld, M.D. Director of Department of Surgery Sidney Hirsch, M.D.* Director of Department of Dentistry Paul Scheman, D.D.S.* Chairman of Standing Committees Adolescent Pavilion Sidney L. Green, M.D. Credentials Committee for Psychiatric Attending Stafl & Promotions Martin Schreiber, M.D. Credentials Committee for Non-Psychiatric Visiting Staff & Promotions Paul Scheman, D.D.S. Education of Resident Stafl Arnold Eisendorfer, M.D. Group Psychotherapy Samuel Z. Orgel, M.D. Queens Out-Patient Clinic Martin H. Orens, M.D. Sub-Committee for Child Guidance Clinic Isidor Bernstein, MD. Research Committee Sidney Tarachow, M.D. Publications Committee I. Peter Glauber, M.D. Committee for Adjunctive Services I. Peter Glauber, M.D. Credentials Committee for Supervising Psychiatric and Resident Stafl Lawrence J. Roose, M.D. *—Executiue Committee Members i—Deceased in 1958 Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, MD. I. Jesse Levy, MD. Neurology A. M. Rabiner, M.D. Hans Strauss, MD. I. S. Wechsler, M.D. Surgery David Warshaw, M.D. Gynecology Julius Jarcho, M.D. Dentistry Morris Fierstein, D.D.S. Attending Psychiatrists Samuel Atkin, M.D. Frank Berchenko, M.D. Isidor Bernstein, MD. Arnold Eisendorfer, MD. M. David Epstein, M.D. Margaret E. Fries, MD. I. Peter Glauber, M.D. George S. Goldman, MD. Paul Goolker, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Sidney Klein, M.D.T Attilio LaGuardia, M.D.TT Samuel R. Lehrman, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, MD. Robert A. Savitt, M.D. Martin Schreiber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Aaron Stein, M.D. Sidney Tarachow, MD. Associate Attending Psychiatrists Renato J. Almansi, M.D. Alexander J. Friedman, MD. 5011 Goodman, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Abraham S. Lenzner, M. D. Martin H. Orens, M.D. William W. Pike, M.D. Geraldine Pederson-Krag, M.D. i—Deceased in 1958 H—deceased I959 31 �Visitings Optometry Medicine Staff Optometrist Edward L. Steinberg, OD. Director Lester Cohen, M.D. Staff Optometrist Bernard Attinson, OD. Visiting Physician George Sabrin, M.D. Visiting Physician Louis Rosenblum, M.D. Podiatry Staff Podiatrist Sam Sokolov. Pod.O. Visiting Physician Arnold G. Blumberg, M.D. *—Resigned in 1958 Associate Physician Jerome Weinstein, M.D. Clinical Assistants in Manhattan and Queens Clinics Adjunct Physician Arnold L. Berger, M.D. Adjunct Physician Wilbur B. Brett, M.D. Visiting Dermatologists Conrad Stritzler, M.D.* Associate Dermatologist .loel Schweig, M.D. Adjunct Dermatologist Norman Goldfarb, M.D. Neurology Adjunct Attending Psychiatrists 32 Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkofi, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Albert Harrison, M.D. Thomas Hora, M.D. Abraham Kaplan, M.D. Eugene Kaplan, M.D. George P. Krupp, M.D. Peter Laderman, M.D. Harold S. Leopold, M.D. (on leave) David Milrod, M.D. Helene Papanek, M.D. Irving Salan, M.D. Frederick F. Shevin, M.D. Jay Stanton, M.D. Samuel Tabbat, M.D. Fred U. Tate, M.D. Leonard Weinroth, M.D. Herbert Wieder, M.D. Associate Neuroligist Kurt Adler, M.D. Surgery Director Sidney Hirsch, M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist Daniel Kaufman, M.D. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Associate Orthopedist Julius Schneiderman, M.D. Visiting Proctologist Benjamin Warner, M.D. Visiting Ophthalmologist Edward Seretan, M.D. Associate Ophthalmologist Arthur Minsky, M.D. Visiting 0tolaryngologist Sam Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. *—Resigned in 1958 Gynecology Visiting Gynecologist Marie P. Warner, M.D. Visiting Gynecologist Hilliard Dubrow, M.D. (on leave) Associate Gynecologist Jack Cohen, M.D. Associate Gynecologist Bernard Greenblat, M.D. Adjunct Gynecologist Eugene Streim, M.D.* Radiology Visiting Radiologist Bernard Epstein, M.D. Associate Radiologist Paul Steinhorn, M.D. Dentistry Director Paul Scheman, D.D.S. Associate Director J. Gordon Rubin, D.D.S. Associate Dentist Benjamin Schwaid, D.D.S. Associate Dentist Bernard Lebow, D.D.S. Adjunct Dentist Henry Lewis, D.D.S. Adjunct Dentist Samuel Plotnick, D.D.S. Adjunct Dentist Elsa Friedman, D.D.S. Adjunct Dentist Martin Protell, D.D.S. Adjunct Dentist Leon Basson, D.D.S. Lester I. Abend, M.D. Edward R. Adelson, M.D. Romano Antonelli, M.D. Howard Boskey, M.D. Paul Bradlow, M.D.* Stanley Brodsky, M.D. Arline Caldwell, M.D.* Daniel Chansky, M.D. Lionel Chertofl, M.D. Ralph W. Clemments, M.D. Frances Colonna, M.D. Stefano Fajrajzen, M.D. Irving J. Farber, M.D. Philip Friedland, M.D. Ruth Fuchs, M.D. Harvey Goldey, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Harry Gonda, M.D. Martin Hurvitz, M.D. Gunthar Jacob, M.D. Wilbur Jarvis, M.D. Norman Levy, M.D. Peritz Levinson, M.D.* Zenos Linnell, M.D. Buck Luria, M.D. Howard Mele, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatrice Nachtigal, M.D. Iris Orens, M.D. Edward Pinney, Jr., M.D.* Phoebe Rosen, M.D.* Joseph D. Rosen, M.D.* Jehuda Rozanski, M.D. Gabriel Rubin, M.D.* Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. Aimee Wiggers, M.D.* *—Resigned in 1958 ��HIL LSIDE HOSPITAL ‘3 ��JANUARY 1, 1960—JUNE 30, 1961 Society of the Hillside Hospital Board of Trustees GLEN OAKS, NEW YORK OFFICERS PresidentD. Herbert Beskind Vice Presidents George W. Galinger Charles H. Meyer ' S. H. Chairman, of the Board Alvin [3. Coleman Scheuer Walter Honorary Chairmen of the Board Roy Ecstie'r Leon towenste‘in Dudley‘D.-Shoenfeld, MD. D. Yankauer Treasurer Arnold .s. Askin Assistant Treasurers Arthur Garson MauriCe Glinert Secretary Jacob Epstein Katz Assistant Secretaries A. Jacob Abrams M. Victor Leventritt M EM B EIR‘S' A. Jaco‘b‘Abram's; George W. G'alinger Arthur Garson Maurice Glinert Meyer Goldstein" Jacob Epstein Katz’r Carl L. Kempner Harold P. Kurzman Robert L. Leeds, Jr. M. Victor Leventritt Budd Levinson Milton B. Loeb Sandor Lorand, M.D. Jonas Adler Alfred Ap'per Arnold S. Askin* John M. Bendheirn D. Herbert Beskind" ' David Bunim Alvin E. C'Ol'eman' Martin Coleman Thomas Epstein Arthur C. Fatt Roy Foster“ Leon Lowenstein* Charles H. Meyer Charles Revrson Manue‘lLee Robbins S. H. Seheuer Dudley D. Schoenfeld, John W. Straus Irving Weisglass Nathan Wigod M-.D.* Morton 8,. Wolf Adolph Woolner Walter D. Yankauer CHAIRME-N of STANDING COMMITTEES of THE BOARD of TRUSTEES Executive committee Alvin E; Coleman Finance. Committees Maurice Glin'ert Sub-Committee on Investments Adolph Woolner Gifts & Legacies Committee Jacob E-.; Katz - *Executiv.e Cémmittge‘ ' ”Deceased House & Grounds Committee George W. Galinger Nathan Wigod Legal Committee Charles H. Meyer Medical Affairs Committee M. Victor Leventritt New Building Committee David Bunim Nominating Committee Walter D. Yankauer Personnel Committee Harold P. Kurzman Public Relations Committee Arthur C. Fatt Social SerVice- Committee Maurice fGIin‘ert �ever—changing approach to the treat- President’s Report Hillside Hospital was founded in 1927 by Dr. Israel Strauss and his colleagues of the Committee of Jews for Mental Health, whose objective was to provide good psychiatric care to those who could not afford to pay for the service. Today’s Hillside Hos— pital is one of the few voluntary, nonprofit psychiatric hospitals in the United States. In 1958, the Board of Trustees determined to establish new goals for their hospital. Our physical size and personnel resources anticipated recent recom— mendations of the Joint Commission on Mental Illness. We endorse these recommendations and wish to participate in the solution of this major health problem by continuing our treatment program, by seeking an improved quality of patient care, and by providing outstanding professional training for doctors, nurses, social workers and other professionals. To accomplish these goals and to broaden the treatment program as a basis for fundamental research in mental illness, Dr. Lewis L. Robbins assumed the responsibilities of Medical Director. Dedicated lay members of the Board of Trustees together with the staff and the distinguished physicians who served on the Medical Board, have been continually reviewing the ment of mental illness and evaluating new concepts of care. The character of Hillside Hospital as a pilot institution seeking to broaden the frontiers of understanding mental illness is now well integrated. The years 1960 and 1961 saw the planning of a new building program designed to provide the physical facilities for current concepts of treatment, professional development and research. An activities therapy build— ing is needed to house the manifold creative, occupational, athletic and social activities which we know are so vital in the treatment of our patients. Equally important, offices, conference rooms and working areas must be created for the broader research program which will include, in addition to biochemical research and experimental psychiatry, a comprehensive effort in dynamic psychiatry. Adequate residence facilities are necessary to house our staff members. Funds toward the cost of these physical improvements are substantially in prospect and it is entirely possible to contemplate that construction can begin during 1962. In this progress report of today’s Hillside, I take great pleasure in the accomplishment of the first and major phase of progress toward the long range goals we have set. The efforts, wisdom and material support of the trustees of the Society and the Federation of Jewish Philanthropies, and the informed and dynamic leadership which Dr. Robbins provides, instills great confidence that the image of tomorrow’s Hillside will shine even brighter than today’s. D. HERBERT BESKIND President, Society of the Hillside Hospital �Professional and Administrative Staff Samuel Davis Assistant Administrator ADMINISTRATION Lewis L. Robbins, M.D. Medical Director STAFF PSYCHIATRISTS William Benjamin, M.D. Muriel Benton, M.D. Max Fink, M.D. Maurice Bachrach Administrator David Graubert, M.D. Irwin Greenberg, M.D. B. Bernie Herron, M.D. Elsa Katz, M.D. Donald Klein, M.D. John c. Kramer, M.D. Henry Lefkowits. M.D. Robert R. Luttrell, M.D. Robert Navarre, M.D. Paul Salkin, M.D. Alice S. Stahl, M.D. Barbara Ure, M.D. Morton Wachspress, M.D. George Yessin, M.D. PROFESSIONAL DEPARTMENT HEADS ACTIVITIES THERAPIES Morton Wachspress, M.D. NURSING EXPERIMENTAL Jean Axten, R.N. Director Frances Anderson, R.N. Associate Director PSYCHIATRY Director Max Fink, M.D. Eli Levy Director Assistant Director Joseph Chase Director, Occupational Therapy PSYCHOLOGY LABORATORY HarryrGoldenberg, Ph.D. Director Phyllis Hurteau, R.N. Associate Director lnservice Education John Croghan OUT-PATIENT DEPARTMENT Supervisor ADOLESCENT PAVILION Alice S. Stahl, M.D. MEDICAL LIBRARY Director James Montgomery MEDICAL SERVICES BIOCHEMISTRY Arnold Harry Goldenberg, Ph.D. G. Blumberg, M.D. Director Director RODSrt R. Luttrell, M.D. DII'CCTDI' Harvey Goldey, M.D. Assistant Director Hershey Marcus, M.D. Director Child Therapy Unlt Abraham Levine, Ph.D. Director CREATIVE THERAPY Mrs. Edith Zierer Director SOCIAL SERVICES Abraham Lurie Director Louise Pinsky Assistant Director, Casework Sidney Pinsky Supervisor, Group Work SOCIOLOGY Nathaniel Siegel, Ph.D. ADMINISTRATIVE DEPARTMENT HEADS FOOD ACCOUNTING SERVICE SERVICES Sol Fuchs Dorothy Croghan HOUSEKEEPING OFFICE BUILDINGS and SERVICES GROUNDS Robert Jones May K. Bottomley Thomas Lumley CLINICAL ASSISTANTS ADULT UNIT Nobel Endicott, M.D.. Sumner Goldstein, M.D. Curtis. Kendrick, M.D. Lionel Chertoff, M.D. Ralph Colp, Jr., M.D. Alan Dobrow, M.D. Raymond Edelman, M.D. Dahiel Miller, M.D. iris Orens, M,D. Esther Robbins, M.D. Jack Schnee, M.D. Maurice Shilling, M.D. JamesWatson, M.D. CHILDREN’S UNIT Sidney Finkel, M.D. John Price, Jr., M.D. Esther Robbins, M.D. Mollie Schildkrout, M.D. PSYCHIATRIC RESIDENTS Lucie Arato, M.D. Paul Ar'onow, M.D. Peter Ferber, M.D. Edward Gelardin, M.D. Seymour Gers, M.D. WarrenH. Goodman, M.D. Joseph Gross,'M.D. ' ‘ Edward‘s. Hartmann, M.D. Jerome L, Jacobs, M.D; Abraham Jankowitz, M.D. Henry K‘aminer, M.D. Herbert J. Levo’witz; M.D. Arnold Lieber, M.D. Julia Mehlman, M.D. Herman Oliver, M.D. Raymond W. Rakow, M.D. Rita S. Reuben, M.D. Ger-aid D. Roberts, M.D. Judy M. Roheim, M.D. Bertram H. Rosen, M.D. Ronald'Sa‘german, M.D. DECEMBER George Satran, M.D. Martin Shepard, M.D. Herbert J. Steinberg, M.D. Dan'ield Weitzner, M.D. Charlotte M. Zitrin. M.D. 31,1960-JUNE 30,1961 �Medical Director’s Report When one considers that there are hundreds of thousands of patients in public and private hospitals in the United States, one is forced to the conclusion that this represents a tremendous waste of human lives and community resources. The majority of these patients are in large public hospitals which have been viewed by the Joint Commission on Mental Illness as too large to provide the necessary individualiza— tion of treatment and the therapeutic relationships which are so important. Hillside Hospital with its 375 admissions and discharges per year does provide the type of treatment needed, but the service we can give is but a mere drop of water in the vast ocean of human misery. It would take us forty—five years to treat as many patients as are currently in just one of the nearby public institutions. The solution to the problem of mental ill— ness does not lie in the expanding of treatment facilities as much as it does in finding better answers to the causes and treatment of emotional dis— orders, and in passing on our knowledge to all those who are needed to treat the mentally ill. In accordance with these principles, Hillside Hospital has chosen to make research and training its primary goals. As always, it continues to be a pilot institution providing the best psychiatric treatment that is currently available, and is constantly trying to develop new knowledge and to share what we learn with others. The development of research and education are never any better than the clinical programs on which they are based. Conversely clinical pro— grams which do not include educational and research activities become sterile. During these past three years, our emphasis has been on further im— proving our clinical services and concomitantly expanding the psychiatric residency training program. Although there has been much progress in the several on—going research programs, the improvements in our clinical and educational activities should provide opportunities for considerable new effort in this important area. This report treats of our progress in connection with the restated goals of our hospital. The problems in finding solutions to the questions of mental illness are enormous, but we are taking steps towards assisting in the finding of needed answers. The work, the effort, support and dedication of our trustees and staff augur well for the future. LEWIS L. ROBBINS, M.D. Medical Director �Progress Toward Our Stated Goals move from closed to open units as was previously the practice. An open hospital has been estab— lished. Doors are rarely locked. I The therapeutic activities now I constitute the major of the part I Goals are quoted from the survey and report made by Dr. Robbins in late 1958. TREATMENT and TRAINING “The psychiatric hospital should be thought of primarily in terms of its staff and of the facilities for occupational therapy, recreational therapy, educational therapy, group living experiences and the like; as a total community in which the bed is used only to sleep in at night. A psychiatric hospital should be a thera— peutic community in which every aspect of the patient’s stay is designed to meet his therapeutic needs. To insure the best possible results includes not only the prescription of the specific treatment procedures mentioned . . .and the type of therapy best suited to meet the needs . . . but also the ‘emotional atmosphere’ in which they are to be carried out.” Patient care has been much more I individualized. staff has been reor— I Our treatment and treatment teams esganized tablished. Led by a full time senior staff psychiatrist the team is composed of staff psychiatrists, psychiatric residents, social caseworkers, I group workers, psychologists, nurses, and activities therapists. In order to stabilize patients in re— lation to stall, patients now remain on the same living unit, rather than I patients’ program. The treatment program has been approved by the Joint Commission on Hospital Accreditation. A children’s outpatient clinic has been opened. “The patients admitted to Hillside Hospital fall into the groups of those patients with severe psychoneuroses, early or incipient psychoses, and rather severe character disorders. Such patients require the optimum of psychiatric talent for help and one should be able to bring to bear in their treatment the best skills that are available. Even the most experienced psychiatrists need to have the participating skill of an adequate staff both qualitatively and quantitatively in all the areas of psychology, psychiatric social work, psychiatric nursing and the adjunctive therapies.” An Activities Therapy department has been established. The Occupational Therapy staff has been increased. I I Recreational Therapy staff I The has been increased. has been A work patient program I initiated. activities therapy Occupational are I related to work and to treatment I I rather than just to arts and crafts training. A pilot vocational rehabilitation program has been established with Altro Workshops. A program in which volunteers plan and lead patient activities has been established. �“One fact which seems to work against the success of the admission policy is the accumulation of a waiting list for admission.” The patient waiting list has been eliminated. The admission screening process has been improved. I I “The main shortage in psychiatry today is knowledge. . . One of the major responsibilities of every psychiatric facility is not only to provide the best possible service to patients, but also to train personnel. Psychiatry like all other branches of medicine, is best learned by intimate contact with patients and with one’s teachers, rather than in the classroom. Thus, the clinical stafi is simultaneously a faculty working in close day to day personal contact with the students The resident. . .can only meet the clinical needs of the patients in his care if he is given adequate supervision by more experienced teachers. The resident psychiatrist is a very busy person having on an average twelve patients at a time and admitting a new patient approximately every ten days. It is not possible to add some very necessary experiences (such as outpatient psychotherapy) to the residency program because of their already very heavy schedules. It would be desirable to increase the number of residents, not only to provide training for more doctors, but also to decrease the case— load for each resident. There has long been a desire to develop a full three year residency training program at Hillside Hospital. Experi- ence again has demonstrated that it is better for residents to obtain all of their psychiatric training in one place rather than to move from place to �place. This provides them with a more integrated three year educational experience. Specialized experience in certain areas, such as psycho- somatic medicine, geriatrics and neurology can be developed through liaison with other nearby institutions. It is, therefore, recommended that the excellent facilites of Hillside Hospital and its actual as well as potential relationships with other institutions be used primarily for the advancement of psychiatric knowledge. I I I I I The full time psychiatric staff has been greatly enlarged. The number of psychiatric resi— dents has been increased. The number of patients per doctor, and the number of residents per supervisor has been reduced. The quality of supervision has improved. Residency training in psychiatry has been approved by the American, Medical Association for three years. I dency training has increased qualiApplicants for psychiatric resi- I I tatively and quantitatively. The number of grants from the United States Public Health Service for training has been increased. Clinical training has been extend— ed into the Adult and Children’s Out-Patient clinics. I been improved and increased. of function Educational voluntary I non-paid attending staff increased. affiliations for psychiatTraining I ric residents established with Formal classroom training has I Creedmoor, Long Island Jewish Hospital, Montefiore Hospital and Meadowbrook Hospital. Graduate and undergraduate training in psychiatric nursing in I I affiliation with Queens College and Adelphi College. Inservice training program for nursing personnel established. Graduate training in Psychiatric Social Work and Group Work in affiliation with Adelphi College, Columbia University, Yeshiva and New York University. RESEARCH “A lthough millions and millions of dollars have been spent in development of all kinds of psychiatric facilities, only a small amount of money has been spent in the important area of psychiatric research . . . Far greater sums of money are being spent for research and other illnesses which have a much smaller incidence than do psychiatric disorders . . . Re— search is developed in most hopitals, as a derivative of the clinical and educational activities in the institution . . . investigations which must go forward on many fronts simultaneously; physiological, psychological and social. Because man is a biological, psychological and social being, the ultimate.answers in respect to psychiatric illness will not be found in any one area alone even though from time to time one may seem more promising than the others. Therefore, it is also encumbent upon every psychiatric institution not only to treat patients as well as our present knowledge permits and to educate psychiatric personnel, but also to continue to investigate the nature of psychiatric illnesses in order to eliminate many gaps in our knowledge.” I The research programs in experimental psychiatry, biochemistry and medicine have been in existence for many years under the re- �spective leadership of Dr. Max Fink, Dr. Harry Goldenberg and Dr. Arnold Blumberg. These programs have continued to produce valuable achievements, some of which are reported below. It is’ hoped that the next few years will see even greater emphasis on the research aspects of the goals for Hillside Hospital. I I Eight percent of the total Hillside Hospital budget is currently devoted to research. National recognition of the research work done at Hillside Hospital. Dr. Donald Klein was appointed as a United States Public Health Service career investigator. Dr. Max Fink was appointed to the committee on Clinical Psychopharmacology of the National Institutes of Mental Health, who sponsor a national program for the screening of new drugs in the treatment of mental illness, joining Dr. Lewis L. Robbins, who has continued as Consultant to the Review Committee in Mental Health Research; and the sponsorship of the first International Conference on the EEG and Human Psychopharmocology, at the World Congress of Psychiatry, Montreal, June 1961 by the Department of Experimental Psychiatry. Dr. Harry Goldenberg, was hon— ored by appointment as Chairman of the Van Slyke Awards Committee, Chairman of the divisional meeting of the American Association for the Advancement of Science, and panel member of the Eastern Analytical Symposium. Dr. Vivian Fishman’s drug research studies were recognized by the National Institutes of Health with an invitation to present her findings before the Psychopharmacology Round Table in Atlantic City. EXPERIMENTAL PSYCHIATRY Dr. Fink and his staff completed their survey of forty psychotropic compounds and showed the electroencephalogram (EEG) to be the best available measure of psychotropic drug activity. Typologies of patient response to I I two major psychotropic com— pounds—chlorpromazine and imipramine were defined. This work enables psychiatrists to determine the best drug for each patient. BIOCHEMISTRY Dr. Goldenberg and his staff investigated the chemical changes which occur in chlorpromazine due to glandular activity. Animal trials led to the discovery that two products (“metabolites”) derived from chlorpromazine may be equivalent or superior to the parent drug. Other animal studies were carried out in the laboratory dealing with the stress phenomenon; these experiments have led to observations that may be significant to the solution of the problems of senile psychosis and atherosclerosis. I I MEDICAL RESEARCH Dr. Blumberg in his program of medical research has developed a firm basis for the mecholyl test. He has demonstrated the stability and the reliability of this test in chemical use. It is now used as an effective medical screening device to determine the patients receptivity to somatic psychiatric treatment. I �Publications A FINK, 'M_.: .EEG Techniques in Study of Psychotropic Drugs. Discussion.Actaiof Int.'I Meeting‘oh Techniques for Study of Psychotropic Drugs, Modena, Soc. Tip'o'grafic‘a Mo'de'nse, 1961. FINK, M. and KAHN, R. L.: Behavioral Reproducibility of the Mecholyi Test, Psychosomatic Med. 22: 1,1960. Convulsive Therapy. A.M.A. Arch. Gen. Psychiat. 5: 30-36, BLUMBERG A. 'G., LADERMAN- P. and FINK, M. Efficacy of Divided and FINK, M., KAHN, R. L. KARP, E.. POLLACK, M., GREEN, M., ALAN, B. and LEFKOWITS, H. 1.: Inhalant Induced Convulsions: Significance of the Theory. of theConvulsive Therapy Precess. A.M.A‘. Arch. Gen. Psychiat. BLUMB_,ER,G G.: 'Single Dose Schedules in Insulin' Coma Therapy, Am. 1. Psychiatry 116: 839-40, March, 1960.; and KLEIN, D F.: Severe PapiIIedema Associated With BLUMBERG, A. G. Drug Therapy, Am. J. Psychiat. 116:: 168- 170, 1961. BLUMBERG, A, G. and GOLDENBERG. H. Relation of the Mec‘hoiyl Test to Catechoiamine Excretion, Proc. Soc. Exp. Biol. 6: Med 106: 867-869, 1961. H. Union and Management Trainees: A Comparative Study of BOGARD, Personality and Occupational Choice, 1. of Applied Psychology 44: 56-63, 1-960. Nursing Staff Functions in a Treatment Setting, 1. Hillside Hosp. 9: 88-93,1960-. CLIGGETT, K.: Occupational Therapy at the Adolescent PaVIIion, 1. Hillside Hosp. 9: 80-87, 1960. ENGEL, R.: a Case of Depersonalization, 1. Hillside Hosp. 9: 106-127 1960. FAJRAJZEN, 8.: _On Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients, EEG Clin. Neurophysiol. 12: 359-369, FINK, M.: 1960.- FINK, M.: EEG and BehaviOraI Effects of Psychopharmacologic Agents. In. Neuro-PsychopharmacoiQE-Yy ed. P, Bradley. Amsterdam, Elsevier, pp. 441-446, 1960. FINK, M., 1AFFE, 1. and KAHN, R. |:.: Drug IndUCed Changes in Interview Patterns: Linguistic an‘d Neurophysiologic lndices. In Dynamics of Psychiatric Drug Therapy. red. G. J. Sarwer-Foner, Springfield, "L, C. C. Thomas, 1960, pp. 29-44. FINK, M.: EEG and Behavioral fects of Tofranii, Ef- EEG C-IiII. Neuro- physiol. 12: 243-44 (abst.) 1960. FINK, M.: Differential Treatment and Prognosis in schizophrenia, by R. D. Wirt and W. Simon. Book Review, A..M.A Arch. Gen. Psychiat. 2: 121- 122,1960. Problems of Antagonists to Psychotropic Drugs. Discussion. Neuro—Psychophar‘macology 2: 30-32, ed. E. Rothlin. Amsterdam, Eisevier, 1961. FINK, M.:- Patterns In 11961. 4: 259-266, 1961. V. and‘GOLDENBERG, FISHMAN, H.: MetaboIi-sm of Chiorpromazine: 0rganIc-Extractable Fraction from Human Urine. Proc. Soc. Exp. Biol. 6: Med.104: 99,1960. 3.: Helping the Disturbed Adolescent Acéept Hospitalizatibn. Social Work 6.69 75.1951 FREEMAN, M.‘E. and FRIEDMAN, M. R.: .AfMethod-of Organizing Clinical Data: A Teaching Aid for Training ResiFRIES." dents apy. Psychoanalytic PsychotherHillside Hosp. ‘9: 25-47, 1960. in 1. GALE, M. .and SHATZKY, B.: P.S. 611 y—Queens Annex: ASchool in .a Psychiatric Hospital. 1. Hillside Hosp. 9: 94-99, 1960. Aftercare Program for Adolescents. 1. Hillside Hosp. 9,: 61'65, 1960. GOLDENBER-G, H., FISHMAN, V., WH'ITTIER, 1. and BRINITZER, W.: Urinary Aromatic Excretion Patterns schizophrenia, A.M.A. Arch. Gen. Psychiat. 2: 221.1960. in GOLDENBERG, H. and FISHMA-N, V.: Species Dependence of Chiorpromazine Metabolism, Proc. Soc. Exp. Biol. 8: Med. 106. #26884 1961. GREEN, S. L., KWALWASSER, S., and STAHL,.A. S.: The Role of the Psychiatrist in a Residential Treatment Unit. for AdoleSCen'ts. PSychi‘at. Quart. 34: 662-691, 1960. Relation Between Threshold and Duration of Seizures a'nd Electrbgraphic Change During Convulsive Therapy. 1. Nerv. Ment. Dis. 130: 235-239, 1960. M. A.: Approaches to Psychiatric Consultation in a Research Hospital Setting. A.M.A. Arch. Gen. Psychiat. 3: 691-697, 1960. GREENBERG, I.: I.: Acute lnterc-urrent Psychosis During the Course -of Familial Periodic Paralysis. Am. 1. GREENBERG, Psychiat. 116: 260-263, 1961. I.: Comparison; of the Cross-Cultural Adaptive. Process with Adolescence. compr. Psychiat. 2: GREENBERG, 44-50, 1961. 1.: ESECQVER, H., KAHN, R: L. and FINK, M.: Modification of 1AFFE, 1.. Psychotherapeutic Transactions by Altered Brain Function. Am. 1. Psychother. 15: 46-55, 1961. 1AFFE,1., FINK, M., and KAHN, R. L: Changes in Verbal Transactions with Induced Altered Brain Function. J. Nerv. Ment. Dis. 130: 235-239, 1960: Language Patterns as Character Defenses: Implications for Psychoanalytic Technique. Psychological' and, Psychiatric Aspect of Speech and Hearing, Disorders, ed. D. A. Barbara. Springfield, III., C. C. Thomas, 1960. pp. 138-151. 1AFFE, Formal 1.: and FINK, M;: Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. J. Neuropsychiat. 1: 242245, 1960. KAHN, R. L. and FINK, M.: Figure-Ground Discrimination after Induced Altered Brain Function. A.M.A. Arch. Neurol. 2: 547-551, 1960. KAHN, R. L., POLLACK, M. and FINK, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Ment. Dis. 130: 187-192, 1960. KAHN, R. L., POLLACK, M. LGLYNN, E.: An GREEN, Social Factors in the Doctor-Patient Relationship. In PsyChoanaly'sis and Social Process, ed. 1. Masserman. New York, Grune 8: Stratton, 1961, pp‘. 81-88. 1AFFE, and POLLACK, M.: Sociopsychological Factbrs Affecting Therapist-Patient Relationships. Psychoanalysis and Human Va'lues, ed. 1. Masserman, New York, Grune 8: Stratton, 1960. pp. 155-168. KAHN, R. L. and POLLACK, M.: The Relationship of Mental and Physical states in Institutionalized Aged Persons. Am. 1. Psychiat. 117: 120-124, 1960 (with Goldfarb, A. I. and Gerber, l. E.). KAHN, R.» L. and POLLACK, M.: Brief Objective Measures for the Determination of Mental Status in the Aged. Am. 1. Psychiat. 117:, 326-328, 1960 (with Goldfarb, A. I. and Peck, A.). KAHN, R. L. Staff Attitudes Toward Psychiatric Treatment in .a Voluntary Mental Hospital. 1. Hillside Hosp. KAHN, R. L.: 10: 97-106, 1961. KAHN, R. L., POLLACK, M. and GOLDFARB, A. I.: Factors Related to In- dividual Differences in Mental Status of Institutional Aged. In Psychopathology of Aging, New York, Grune & Stratton, 1961, pp. 104-113. and LEFKOWITS, H. 1.: Influence of Staff Attitudes and Environmental Factors on Treatment Selection. 1. Hillside Hosp. 10: 8496, 1961. KAPLAN, A. I. �Alterations of Visual Excitability in Patients with Lesions of the Cerebral Optic Pathways. KARP, E.: Trans. A.N.A. 156-159, 1959 (with Battersby, W. S. and Wagman, I. H.). Neural Limitations of Visual Excitability: Alterations Produced by Cerebral Lesions. Arch. Rural. 3: 24-42, 1960 (with Battersby, W. 5., Wagman, I. H. and Bender, M. D.). KARP, E.: ROSEN, B. H.: Case Report of Auricu- lar Fibrillation Following the Use of Imipramine (Tofranil). J. Mount Sinai Hosp. 27: 6, Nov.-Dec., 1960. Effect of Interpersonal Relationships Upon Verbal Conditioning. J. Abnormal I. Social Psychology 60: 241-6, 1960. SAPOLSKY, A.: KAVAZANJIAN, T.: The Role of the Clinical Psychologist in the Adoles- and STAHL, A. 3.: The Treatment Of “Provocative” Behavior in the Disturbed Adolescent. J. Hillside Hosp. 10: 67-81, 1961. 1960. STAHL, A. 8.: The cent Pavilion of the Hillside Hospital. J. Hillside Hosp. 9: 65-71, F.: Mepazine (Pacatal): Clinical Trial with Placebo Control KLEIN, D. and Psychological Study. Psychopharm. 1: 280-287, 1960 (with J. R. Whittier, G. Levine and D. Weiss). and GREEN, 3. L.: Treatment Program at the Israel Strauss Pavilion for Adolescent Girls. J. Hillside Hosp. 9: 14-24, 1960. KWALWASSER, S. LEVINE, A.: Appraising Ego Strength from the Projective Test Battery. J. Hillside Hosp. 9: 228-240, 1960. LINNELL, Z. M.: Authority as 3 Treatment Modality with Adolescents in a Psychiatric Hospital. J. Hillside Hosp. 9: 48-60, 1960. LURIE, A. and PINSKY, L.: Collabora- tion between Psychiatric Hospital and Community Agencies in the Rehabilitation of Mental Patients. Mental Patients in Transition, ed. Milton Greenblatt, Springfield, ”L, C. C. Thomas, 1951. Effect of Brain Tumor on Perception of Hidden Figures Sorting Behavior and Problem Solving Performance. Dissertation Abstracts. 20: 8, 1960. POLLACK, M.: POLLACK, M.: Comparison of Childhood, Adolescent and Adult Schizophrenias. A.M.A. Arch. Gen. Psychiat. 2: 652-660, 1960. POLLACK, M.: The Face-Hand Test in Retarded and Non-retarded Emotionally Disturbed Children. Am. J. Ment. Def. 64: 758-761, 1960 (with E. Gordon). and FINK, M.: Socio~ psychological Characteristics of Patients who Refuse Convulsive Therapy. J. Nerv. & Ment. Dis. 132: 153157, 1961. POLLACK, M. POLLACK, M., KARP, E., KRAUTHAMER, 6., KLEIN, D. F. and FINK, M.: Neuropsychologic Response Pat- terns of Some Psychotropic Drugs. Neuro-Psychopharmacology 2: 381384, ed. E. Rothlin. Amsterdam, Elsevier, 1961. ROBBINS, L. L. and WALLERSTEIN, R. 8.: Operational Problems of Psychotherapy Research: 1. Initial Stud- ies. Bull. Menninger Clin. 24: 164189, 19690. SCHILDKROUT, M. S. First Five Years of the Israel Straus Adolescent Pavilion Program. J. Hillside Hosp. 9: 5-13, 1960. WALLACH, S. S., WALLACH, M. B. and 6.: Observation of Involuntary Eye Movements in Certain Schizophrenics. J. Hillside Hosp. 9: 224-227, 1961. YESSlN, ZIE‘RER, E. and ZIERER, E.: The Integration Quotient in Creative Ther— apy. J. Hillside Hosp. 9: 156-170, 1960. �Administration and Finance 5‘ The extent of future development of Hillside Hospital will depend upon the readiness of the community to support its program. At this point it is not possible to project our budget for five or ten years in the future, but it is possible to choose a course of development and to have some general awareness of the fact that expansion of Hillside’s program . could easily double . . . the current budget. In addition to the staff augmentation, there will, of course, have to be a concomitant increase in housekeeping, administrative personnel and it is evident already that additional facilities, not only for stafl but also for patients, are required. The current dining facilities are already overtaxed and the areas for occupational, educational and rec— reational activities are much too limited and inadequate. Consideration must be given, therefore, to con— struction not only of a research building, but also more adequate facilities for patient activities, stafi meeting rooms, library and dining rooms.” The charts graphically illustrate the financial operation of our hospital during the fiscal year ended June 30, 1961. Sizable deficits were incurred in our in-patient and outpatient services because of the increase in the quality of patient care. As we continue to make progress and as we continue to improve wages and salaries, we believe that these deficits will increase if we are to continue to meet our stated objectives. Without the financial assistance of the Federation of Jewish Philanthropies and our Board of Trustees, the progress of which this report treats, would have been impossible. The professional development program has required corresponding expansion and improvement of administrative services. Housekeeping and Maintenance services have been enhanced through the application of industrial management techniques. HILLSIDE Hospiut GLEN OAKS KIFF. COLEAN, VOSS 3 SOUDER THE OFFlcE 0F YORK a SAWYER N, Y. ARCHITECTS �Work measurement, preventative maintenance, a planned painting program and modern equipment have been emphasized. These programs have resulted in significant improvements in hospital appearance and services so important to the “therapeutic community.” To provide the base for effective organization to achieve stated goals of our hospital, an intensive personnel management program has been planned and implemented. Personnel policies have been developed, consolidated, and published, job analyses have been performed, a job grading program has been established, a merit evaluation program has been implemented, and salary scales were increased for professional and service staff. The results of these efforts have been an increas— ingly stable and efficient employee group of high morale. Our most immediate need is for the space which will express the professional development program in physical terms. Psychiatrists’ oflice space is inadequate, teaching facilities including our Medical Library are limited, Activities Therapies areas are widely dispersed and insufficient, and Research space does not meet current needs. To meet our space needs, we have developed a master plan for future construction. Our plans provide for construction of an Activities Therapies building, addi— tional research facilities, and a staff housing project. Following construction of these buildings, we will reconstruct presently existing facilities so that they too, may meet present and future space needs. SERVICE COSTS ln-Patient Service‘ COST $26.65 L088 $1 .56 INCOME *Average per patient-day SERVICE STATISTICS ........................ Number of in-patients treated ........... Number of out-patients treated .......... Number of out visits ................... ln-Patient days 69,941 539 659 14,614 INCREASE IN EXPENDITURES TREATMENT and TRAINING 1958-1959 $924,703 1960-1961 UP 42% $1,310,908 RESEARCH 1956-1959 1960-1961 $ 152,638 $ 198,275 UP 30% ADMINISTRATIVE SERVICES‘ 1956-1959 $ 729,595 $904,863 1960-1961 UP 24% MAURICE BACHRACH Administrator TOTALS 1958-1959 $1,806,936 1960-1961 $2,414,046 *lncludes Administration. Accounting, Food Service, Housekeeping, Maintenance, Office Services and Medical Records. �JANUARY 1, 1960—JUNE,30, Jeena' Attending Psychiatric Staff ATTENDING PSYCHIATRISTS Hyman L. Rachlin, M.D.‘ Lawrence J. Roose, M.D.* Samuel Atkin, M.D.* Frank Berchenko, M.D. Robert Savitt, M.D.' Martin Schreiber, M.D.* Isid'or Silbermann, M.D." Otto Sperling, M.D.t Aaron Stein, M.D.* Sidney Tarachow, M.D.* A. lsidor Bernstein, M.D. Arnold Eisendorfer, M.D.' M. David Epstein, M.D.I' Margaret E. Fries, M.D.‘t I. Peter Glauber, M.D.t George S. Goldman, M.D.‘T Paul Goolker, M.D.* Sidney L. Green, M.D.* William Karliner, M.D.‘ Sylvan Keiser, M.D. Sarah R. Kelman, M.D.‘ Emanuel Klein, M.D. Simon Kwalwasser, M.D. Samuel R. Lehrman, M.D.‘ Abraham S. Lenzner, M.D. Joseph s. A. Miller, MD! Martin H. Orens, M.D.: Samuel Z. Orgel, M.D.* ASSOCIATE ATTENDING PSYCHIATRISTS Renato J. Almansi, M.D. Alexander J. Friedman, M.D. SoIl Goodman, M.D. Abraham I. Kaplan, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Geraldine Pederson-Krag, M.D. William W. Pike, M.D. Jay Stanton, M.D. ADJUNCT ATTENDING PNYCNIATRISTS ’lebur Jarvis; M D_. ‘ Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Beli’nkoff, M.D.. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Rita M. Chalef, M.D. Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Michael Gould, M.D. Lebert Harris, M.D. AIbErt Harrison, M.D. Thomas Hora, M.D. Martin Hurvitz, M.D. Eugene H.Kaplan,.M.D. .Paul Kay, M.D. George R. Krupp, M. D. Peter Laderma'n, M. D.. Myer D. Mendelson, M.Dd" David Milrod, M. D. Helene Pap‘anek, M.D Henry Rasner, M. Irving Salan, M. D. Frjéd' U. Tate; M. D. B. Frank Vogel, MDi. Leonard Weinroth, M D ‘ . D Herbert Wie’de'r, M.D. Consulting Physicians and Surgeons MEDICINE Lester Cohen, M.D.* George Sabrin, M.D. Louis Rosenblum, M.D. Jerome Weinstein, M.D. Wilbur 8. Brett, M.D. Arnold L. Berger, M.D. DERMATOLOGY Joel Schweig, M.D. Norman Goldfa’rb, M.D. Eugene L. Bodian, M.D. GENERAL SURGERY Sidney Hirsch, M.D.* Stephen Deckoff, M.D. UROLOGY Daniel Kaufman, M.D. Albert Sutton, M.D. ORTHOPEDICS A. H. Lewert, M.D. Julius Schneiderr‘n‘an, M.D. PROCTOLOGY Benjamin Warner, M.D. NEUROLOGY Kurt Adler, M.D. Joseph Siris, M.D. Martin Green, M.D. OPHTHALMOLOGY Edward Seretan, M.D. Robert Jampel, M.D. OTOLARYNOLOGY DENTAL sen VICLE Director Palil Schemari, .:D D. S.- ‘ Associate Director J. GordonRuDin, D'.‘D._S.. Associate Dentists Benjamin S'c'hwai‘d} '73-'Bernard: Lebow, D. D.S. Adjunct Dentists Lepn Bas'son, D. D. S‘Carl Blacharsh D Herbert Eormani‘ EISa Friedman, Henry Lewis, D. Martin Protéll, D S; ' Sam Clayton, M.D. Samuel Henken, M.D. ANESTHESIOLOGY Georges Bean, M.D. GYNECOLOGY Marie P. Warner, M.D. Bernard Greenblat, M.D. Jack Cohen, M.D. RADIOLOGY Bernard Epstein, M.D. Paul S’teinhorn, M.D. PODIATRY William Rieder, Pod.0. OPTOMETRYSERVICE Edward Steinherg, OJDf. Professional and Non-Professional Employees We wish to express our appreciation to the following professional employees, who helped make our progress possible. and non- professronal PROFESSIONAL EMPLOYEES ACTIVITIES THERAPY Judith Conrad Karen Diaslo Laura Dunlap Ann Elliott Miriam Gozali Phyllis Holland Mona Jones Mary Marrone Lila Martin Marion Sheffer _ Richard Thaler Joan Tucker Yaeka Umemura Alida Vasquez CLINICAL LABORATORY and x41" Kathryn Boone carolyn siegel DENTAL Bertha Sckipp MEDICAL RESEARCH Stephen Deckoff, M.D. Laura Zaves, R.N. PHARMACY Eleanor Palais RESEARCH IN BIOCHEMISTRY PSYCHOLOGISTS Howard Bogar'd, Ph.D. Eugene Friedman, Ph.D.. Benjamin Lapkin, Ph.D. Ira Rosenblatt, Ph.D. ‘Formerly Member of the Medical Board Allen Sapolsky, .Ph D‘. Stanley Schlff, P D.'-. Eelix Steiner, P Leonette V‘anderhost”. Florence Volkman‘ TR'es‘igneJ Robert Burnett . Vivian Fishman Ph. D. ' Audre Heater) Michael Rabinowitz; Daniel [White- wgeeasea‘? . �RESEARCH IN EXPERIMENTAL PSYCHIATRY Ira Belmont, Ph.D. Romeo .Cartolano llana Goldschmidt Abraham Kaplan, M.D. Eric Karp, M.A. Donald Klein, M.D. Jean Kolodny John C. Kramer, M.D. Hanna Mosquera Max Pollack, Ph.D. Arthur Willner, Ph.D. REGISTERED NURSES Marie Cafiero Isabelle Copeland Ann Dispensa Carol Enggasser Maureen Rolston Rose Schulbaum Helen Stein Zelda Feigenbaum Evelyn Feminella Marion Fitzgerald Millicent Goldberg' ‘Ilse Hurst Ann Kelley Joseph Kelly Patricia Kenney Elaine Kirs’chenbaum Ann Klemballa Mar'y' ‘Kohnke Kathleen Le'eFlora McCartney Joann Mastrole Martha Morey Janet Moses _ NanCy Steinhardt Gladys :Stokes‘ .Cfa‘therine' Szakmary Hele‘n Thrasher EditthitoIo Dorothy Urban Helen Zeigler LICENSED PRACTICAL NURSES Mar-y Corrigan Maud Drun'canson Heathlean English Theresa Homrd Betty Ann Kelly Luverne Reeves Mary Nigro Myra Pesk0witz MYrtle‘Re‘mbe‘rt Shirl‘eyi Piot’nic‘k Gloria Swan Ruth Thiele‘ Catherine Wall Sylvia :Riback Nancy Rosenbaum Lita Schmidt S'eymotir Silverberg Gisela Tauber Alice Thompson Ellen weinstein Isabelle Young; SOCIAL SERVICES Casework Division "Robert F ishman BeatriCIe Freeman “Sally Gold Regina G‘oldstein Beatrice 'Hartley Grace HaWKi‘ns Mildred Heller Connie Israel SarahKlionsky Sondra Match Anita Mehr :SOCIAL se‘nwces Group Work DiVision Ellen Brathwaite Deugla‘s‘Glangw Barbara ‘Goldstein Robert'Handman Elaine Heyman Geraldine’Lauter Beverly Luther Adele Orlinsky SERVICE AND NON-PROFESSIONAL EMPLOYEES BUILDINGS and GROUNDS Adam Biali'k Edward Brady John R. CivinSkas Edward Fitzgerald Gustavo Greco Frank Greene George Jungk Bernard Keena Salvatore Lav Manna George Loblein Nero Moyd Stanley Novak Walter Roland Jr. Albert Schmid Joseph Seagren’ Albert Senese John-Skinder Thomas- Slaton Ignazio Taormina Leroy Watkins CLERICAL and BDOKKEEPING Accounting Department Arline Fle’ischmann Lillian Ingbe‘r Lillian Schaeffer Ethel Siegelman Jeannette Silver Dorothy Streir Office Services Irene Attinson Mary Benesta’d John Borgner Diane Brafm'an Jane Buckley Elizabeth cox Irene Djinkin Claire Dubin Leonora Edelstein Eugenia Fievss Marlene Forman ,Norma’Friedman. Shirlee G'alanty Sara Gingold EdWard Golove Frances Gullo James Hand Norberto Medina Adele Harris Grace Hyams Ida NoVick Martin Novick Gaspari Orlando SyIVI'a Hymo‘witz Belle Kapner Edna Kappes. Rose Landgarten Esta Levy Dorothy McClary Inge Mai Yetta Mintz Catherine Muff Florence Offsie Aileen Olton Elinor Paur Mary Pignoni Regina Pi'lchick Gloria Podrid Rita Rodon Joseph Ryan Dorothy Saults, Rose Sa‘vader Dorothy ‘Schnirman Belle Schultz Charlotte Sinovoi B'ettyStarr Edna Telesca Walter Theisen Crannie Weinstein Edna Weis'sman Lott‘e Wollman BIanche-Zaitz rooo seninces Francesco Ca‘nnetto Emma Casamassima Walter Davis, Jr. Arthur DWyer Pardo Faro Alphonse’Gross Ella Jacobs Jimmy Knight- Barbera Alfred Lemaire Gustavo Lescouflair Sarah Littles Anna Lueatorto Michael McDonough Arthu’r Martin Fortunate La Arthur Pitts Irwin Powell B'azil Allen Rivers Walter Rodney Eva Schwartz Helen Thompson Tindel Thompson HDUSEKEEPINC Low‘ell Booker Louis Burgie George Cables Jesus Cora James Cuozzo Jimmy Lee Dasher Nathaniel Glover Charles T. Hill Gerard Honore Joseph Hope ‘ William Hyman Heie'n Jackson, Ruby Jackson Marion Johnson Ernest King Harry‘Lewis August Lo Piccolo Annie Miller Roosévelt Mitchell Robert Reddick Agnes Schuster Willie Lee Skinner Ray Warren Blanche White William Wood PSYCHIATRIC AIDES Olga Allen Marion Bell Althea Bing; George" ‘Bi n‘gha‘m William Black, Jr. Beatrice Blake Annie Bo‘n'd Joseph Britt Joan Brown Lawrence Burger Raymond Burger Frances Butler Sylvester campbell Malcolm carter Annie Clements Alma Clinton Frederick Coley May Conrad Teresa Cooney Hatti'e'Cummings Catherine Eames Annie M. ‘Ervin Ellen Es‘aw' Guillaume Esse‘rs Irish Ford Herbert Franklin Idella Gaston Nettie Gordon Dolores Griffin Juliet Haipern Mabel Harper Essie Harris Linda Hart George Heller Alberta Hopkins Ethel HopWood June Johnson Anna Mae JonesThomas Kelson, Jr. A‘s‘a’lee‘Kirby Helen Olsen Clemmie Palmer Joseph Petty Ida Pulliam Elizabeth Rodriquez Dorothy Schrantz Carltdn Scott Lessie Mae Scott MildredShaw Grace Shieh Virginia'Smith Chauncey smokton Henrietta Strachan Bessie Sumner Louise Thiell Marion Thomas Walter T. Thomas Clyde Trotman Jean Trotman Clarence Tully Thomas Valentine, Jr. Martha Visalli Martha Welch Hazel White Leona Willett LaWrence Williams Anna Wolfberg Leon Wolfberg Clarence Young Edgar Zephyrine . Barbara Knight Doris Kraemer Josephine Lafayette Arthur Lanier Leslie. Lee Miriam Lee .Alic‘e'Leliukevicz Georgina Lohman Grace Lozano Thel‘matMac‘k Mildred March Laura Matthews Dolores Mitchell waiter Moore Ronald Myles designed and IIIUstrated by VISUAL SERVICES Inc. �HILLSIDE HOSPITAL .. is licensed by the New York State Department of Mental Hygiene. g .. is approved for resident training by Council on Medical Education, American Medical Assmiation. American Board of Psychiatry and Neurology. . . is .. .. accredited by American Psychiatric Association. Joint Commission on Accreditation of Hospitals. is a member of American Hospital Association. Hospital Association of New York State. Greater New York Hospital Association. Greater New York Fund. Unite'd'Hospital Fund. Welfare and Health Council of New York City. National Conference of Jewish Communal ServiCes. cooperates with Adelphi College. Altro Workshops. Federation Employment and Guidance Service.Jewish Community Service of Long Island. Jewish Family Service of New York. Long Island Jewish Hospital. New York City Board of Education. New York State Employment Service. New York State Department of VacatiOnal Rehabilitation. Queens College of the City of New Yerk. The Educational Alliance . - _ is .. a partieipating hospital in Master Plan for Hospitals and Related Facilities: for The Hospital Council of Greater New York. A ‘ ~ ‘ A ‘ » Hillside Hospital is a constituent agency of the Federation :of Jewish: Hiii'li'aothirepies .of‘Neinork �for psychkunk:fleaflnent haflfihg and research January 19, 1962 Dear Fellow Employee: of the Hillside Hospital's Progress Attached to this letter is a c read this As and 61. 1960 family your you the fiscal for Report year made toward have we that reminded of the be progress Report, you will the establishment of Hillside as a leading hospital for psychiatric treatment, training and research. been have would possible not which Speaks, Report of this progress, without the dedication, loyalty and effort which you and your fellow would we For few shown the have this, last during years. employees like to extend our thanks. The Cordially, W X. ”m4/69/ Lewis L. Robbins, M. D. Medica1.Director ', Maurice Bachrach Administrator LLRfiMB/SD/mb �32nd Annual Report HILLSIDE HOSPITAL Glen Oaks,Queens,N.Y. �Hillside Hospital is a nonprofit, nonsectarian mental hospital for the treatment of voluntary patients, suffering from early and curable mental symptoms and admitted regardless of ability to pay. The Hospital is a pilot institution, pioneering in and advancing the scientific frontiers of the human and efficacious application of psychiatry to the mentally ill. Hillside provides organized training for physicians in postgraduate psychiatry and psychotherapy. Major emphasis is placed on advanced research in all phases of treatment. ��........... REPORT OF THE MEDICAL DIRECTOR ................... PROFESSIONAL AND ADMINISTRATIVE STAFF MEMBERS. 5 6 TREATMENT 8 REPORT OF THE PRESIDENT OF THE HOSPITAL 3 SOCIETY OF THE HILLSIDE HOSPITAL BOARD OF TRUSTEES. 4 . . . ...................................... 11 TRAINING ........................................ RESEARCH 14 ....................................... STAFF PUBLICATIONS PRESENTATIONS 16 ............. REPORT OF THE PRESIDENT OF THE 18 ...... MEMBERS OF THE 19 .................... REPORT OF THE ADMINISTRATOR 20 ..................... PROFESSIONAL NONPROFESSIONAL AND MEDICAL BOARD MEDICAL BOARD AND EMPLOYEES ...... 1959 32nd Annual Report HILLSIDE HOSPITAL Glen Oaks, Queens, N.Y. �______WHM._.._» This is my fifth and last annual report as President of the Board of Trustees of Hillside Hospital, and I am happy indeed to be able to state that during this last L. Robbins Lewis Dr. of service, my year has become Medical Director of the Hospital. His broad gauged plans have been submitted to our Board, and accepted for the future development and general planning of the treatment, teaching and research programs of the Hospital. There have been many changes here at Hillside since the death of our founder, Dr. Israel Strauss in 1955, and my election as the second president. I am confident that the original ambitions of our founder to improve treatment, to instruct as many as we can, and above all to attempt to really learn the “why” and “what” of mental illness have been furthered. I believe that my able successor, D. Herbert Beskind, will follow these same general pathways. During this past year, among other interesting incidents, may be mentioned the adoption by Hillside of the personnel policy of the Greater New York Hospital Association, the conversion of our insulin recovery dormitory into offices and conference rooms for research, and the raising of the basic rate of compensation by New York City from $16.00 to $20.00 per day. Costs continue their unbroken upward course, and the day of the “lowcost” hospital seems doomed. Adequate service combined with low cost appears to be a paradox. The need for additional buildings is, of course, generally present with most progressive hospitals, and we are no exception. During this year it has become apparent that we simply must have an Activities Therapy Building, since we just do not have enough room for our patients in the present quarters; and a specialized research building is really necessary since research is so obviously demanded to improve treatment results. Both of these buildings will, hopefully, begin construction in 1960. We have been granted $125,000 from the estate of our former Trustee, Edwin Elson, for the Activities Therapy Building; and we have been able to match this amount with a grant of $150,000 from the United States Public Health Service, for a research building. An incidental, but most important effect of the construction of these buildings will be to create space which may be used for critically needed living-in quarters for our personnel. Such quarters will improve the well-being of our staff, something which has always been of great importance to us. Dr. Joseph S. A. Miller, our former Medical Director, resigned during 1959 with plans to enter private practice; he continues, fortunately, to serve the hospital as a consultant and teacher. We all wish him every success in the years to come. In closing this, my last report, I wish to refer to two principles affecting com— munity activities which to me seem important. One that has guided me in my own decisions, is that it is important to rotate top board officers. Such action not REPORT OF THE PRESIDENT OF THE HOSPITAL Alvin E. Coleman only affords opportunity to more individuals 'to serve, more variety in ideas, but probably, more efficiency, on the basis of the old adage that “a new broom sweeps clean”! The second principle is possibly more important since it refers to the motivation of why “we seek to serve.” Laymen who donate their time and thought to community affairs do so, of course, to be of service to those less fortunate than themselves. However, an important additional motive is the gain of ego gratification from having a controlling part in decisions vital to their institution. Such emotions bring satisfaction to us, and are no doubt an important part of the broader life. It is this drive which makes the boards of or— ganizations so effective, and I believe that the autonomy of each board of each organization is absolutely essential to maintain this effectiveness. It seems to me that any serious interference with this autonomy would greatly weaken organizational actions, would make board memberships a mere fiction, and would soon cause board members to lose interest and drop active participation in institutional activities. This would be calamitous. It is with mixed emotions that I pass along the gavel of leadership. Mine is not only a sense of great satisfaction and pride in having been able to serve such an outstanding institution, but also is a feeling of humility at the vastness of the horizon and the smallness of the job accomplished thus far. May I express my deep appreciation and friendship to the professionals of the hopsital, and to the members of the Board of Trustees who have worked with me and so greatly helped me, and with whom it has been a privilege and a pleasure to serve. �OFFICERS‘ President Alvin E. Coleman Chairman of the Board Roy Foster Honorary Chairman of the Board Leon Lowenstein Vice Presidents Dudley Shoenfeld, M.D. D. Herbert Beskind George W. Galinger Secretary Manuel Lee Robbins Assistant Secretaries A. Jacob Abrams M. Victor Leventritt Treasurer David Finn Roy Foster George W. Galinger Assistant Treasurer Arthur Garson Members: A. Jacob Abrams Jonas Adler Alfred Appel Meyer Goldstein Arnold S. Askin Arnold S. Askin John M. Bendheim D. Herbert Beskind David Bunim Alvin E. Coleman Martin Coleman Morris David Thomas Epstein Arthur C. Fatt David Finkle Arthur Gar-son Maurice Glinert Jacob Epstein Katz Carl L. Kempner Harold P. Kurzman M. Victor Leventritt Budd Levinson Morris L. Levinson Milton B. Loeb Sandor Lorand, M.D. Leon Lowenstein Charles H. Meyer Arthur Murray Charles Revson Manuel Lee Robbins Irving Rosenbaum S. H. Scheuer Walter Scheuer Dudley D. Shoenfeld, M.D. Harry Silverson John W. Straus Irving Weisglass Nathan Wigod Morton S. Wolf Walter D. Yankauer Morton S. Wolf Walter D. Yankauer CHAIRMEN OF STANDING COMMITTEES Executive Committee Roy Foster Medical Affairs Committee D. Herbert Beskind Finance Committee Arnold S. Askin House & Grounds Committee George W. Galinger Nathan Wigod Legal Committee Charles H. Meyer Social Service Committee Hilda N. Strauss, Honorary Chairman M. Victor Leventritt, Chairman Personnel Committee Meyer Goldstein Nominating Committee Walter Yankauer Gifts Jr Legacies Committee Walter Yankauer Committee On Administrative Savings Arnold S. Askin Building Committee D. Herbert Beskind, George W. Galinger, ‘As a/ Novenlber 15, 1959 Honorary Trustees: Saul Blickman Hilda N. Strauss Executive Committee Members Arnold S. Askin D. Herbert Beskind Alvin E. Coleman Arthur C. Fatt Roy Foster George W. Galinger M. Victor Leventritt Leon Lowenstein Charles H. Meyer Manuel Lee Robbins S. H. Scheuer Dudley D. Shoenfeld M.D. SOCIETY OF THE HILLSIDE HOSPITAL BOARD OF TRUSTEES A4. ‘,.. A �The function of an annual report is to look backward briefly in order to assess how well one is looking ahead. Much that took place during this past year indicates that Hillside Hospital has been making steady progress toward achieving the best clinical program that current knowledge permits in order to provide a base for achieving its research and training goals. During the year, the staff was reorgan— ized into sections consisting of members of each of the professional disciplines: phychiatry, psychology, social work, activities therapies, and psychiatric nursing—and each section was given responsibility for all the patients living in a particular ward and/or cottage. The patients are no longer being transferred from one living area to another; they now remain in contact with the same personnel throughout the length of their hospital stay. This plan permits the members of the staff assigned to each section to integrate and co-ordinate their efforts much more effectively, thus further facilitating our goal of individualizing treatment. Through administrative changes in our intake procedures, we have eliminated our long waiting list, making it possible for many patients to enter the hospital within twenty-four to forty-eight hours. All patients who are approved are admitted within two weeks. At the end of the year, Hillside Hospital was officially approved by the Central Inspection Board of the American Psychiatric Association and by the Joint Commission on Accreditation of Hospitals. These organizations regularly inspect psychiatric hospitals to insure the maintenance of high levels of patient care. The detailed report of their inspection indicated that, on all counts, our treatment program, staff and physical plant met their higher standards. In April of this year the Children’s Out-Patient Clinic was opened and is now in full operation. In addition to providing treatment for disturbed children and their parents, this clinic offers supervised experience in child psychiatry for psychiatrists practicing in the community, as well as for physicians in our residency training program. This additional clinical activity will also serve as an important part of future research. Hillside Hospital has long accepted its responsibilities for training psychiatric personnel. In July, we increased the number of psychiatric residents in training from eighteen to twenty-five and have developed an educational program to teach residents in each of the three years of residency. In addition, training beyond the residency level is being added for psychiatrists in the hospital as well as in our out-patient clinics. During 1959, the Nursing Department instructed students from several hospitals and nursing schools. The Psychology Department provided instruction in Vocational Counseling; Occupational Therapy had students from Columbia University; the Department of Social Services maintained its training programs with the New York School of Social Work and with Adelphi College. The Department of Experimental Psychiatry has been providing research training in connection with the psychiatric residency. All these and other departments have been most active in many aspects of training, further details of which follow. Above all, the staff of Hillside Hospital has continued its interest in advancing our knowledge through research. A list of numerous presentations and publications indicating research being done at REPORT OF THE MEDICAL DIRECTOR Lewis L. Robbins, M.D. Hillside is included in this report. It should be noted that it is our determined philosophy to carry out investigations in all these three areas; psychology, biology and sociology and to share our findings with others in the hope that much-needed advances in our field can be achieved. It is also gratifying to find our judgments about the value of our research activities and the competence of our research staff confirmed by several foundations and other agencies. Among those which have generously supported our research programs are the Nassau County Commu- nity Mental Health Board and the National Institutes of Mental Health. Numerous other developments have taken place during the past year. We have altered our former insulin unit to provide class rooms, conference rooms, a one-way viewing room, and offices. We have inaugurated a careful study of all of our physical facilities in order to meet our developing needs. Our volunteer program has been considerably augmented and staff has been added in several departments to further benefit our patients. Co-operative programs with Long Island Jewish Hospital have added to both our treatment and training programs and give promise of valuable further collaborative activity. All that has been accomplished during the past year has been based on the fine work of many people over many years. Outstanding have been the contributions of Dr. Joseph S. A. Miller, who after many years of distinguished service, retired in August from the position of Medical Director. To him, and to all the staff, past and present, the writer is indebted for providing such a solid base on which to build our future. Also, to the Medical Board and to the leadership of its President, Dr. Robert A. Savitt; and to the Board of Trustees which, under the leadership of its President, Alvin E. Coleman, has given advice and support—~the writer is gratefully indebted. �ADMINISTRATION Medical Director Joseph S. A. Miller, M.D.* Lewis L. Robbins, M.D. Associate Medical Director Simon Kwalwasser, M.D. Administrator Maurice Bachrach, B.S. Assistant Administrator Samuel Davis, B.A., M.S. STAFF PSYCHIATRISTS William Benjamin, M.D. Muriel Benton, M.D. Calvin Cheek, M.D. David Graubert, M.D. Henry Lefkowits, M.D. Zenos M. Linnell, M.D. Gerhard Schauer, M.D. Barbara Ure, M.D. Morton Wachspress, M.D. George Yessin, M.D. PROFESSIONAL DEPARTMENT HEADS Creative Therapy Ernest Zierer, Ph.D., Director Edith Zierer, Ass ’t Director Experimental Psychiatry Maximillian Fink, M.D., Director Internal Medicine Arnold Blumberg, M.D., Director Israel Strauss Pavilion for Adolescent Girls Alice Slater Stahl, M.D., Director Laboratories Harry Goldenberg, Ph.D., Director John Croghan, R.T., M.T., Supervisor Nursing Goldie Krupa, R.N., Director Nancy J efiries, R.N., Assistant Director Occupational Therapy Eileen Fisher, B.S., Director Out-Patient Services Robert R. Luttrell, M.D., Director Harvey Goldey, M.D., Assistant Director Robert Navarre, M.D., Assistant Director Aaron D. Weiner, M.D., Director Child Therapy Unit Psychology Abraham Levine, Ph.D., Director Social Services Abraham Lurie, M.S.S.W., Director Louise Pinsky, M.S.S.W., Assistant Director, Case Work Division Arnold Eisen, M.S.S.W., Assistant Director, Group Work Division CLINICAL ASSISTANTS Lester I. Abend, M.D. Edward R. Adelson, M.D. Romano Antonelli, M.D. Marion Axel, M.D. Howard Boskey, M.D. Stanley Brodsky, M.D. Daniel Chansky, M.D. Fred B. Charatan, M.D. Lionel Chertofl’, M.D. Ralph W. Clemments, M.D. Frances Colonna, M.D. Stefano Fajrajzen, M.D. Irving J. Farber, M.D. Philip Friedland, M.D. Ruth Fuchs, M.D. Harold Galef, M.D. Harvey Goldey, M.D. Sumner I. Goldstein, M.D. Clara Gonda, M.D. Eugene Glynn, MD: Director Adolescent After-Care Unit Lebert Harris, M.D. Martin Hurvitz, M.D. Gunthar Jacob, M.D. Norman Levy, M.D. Zenos Linnell, M.D. Buck Luria, M.D. Howard Mele, M.D. Daniel Miller, M.D. Meyer Monchek, M.D. Beatric Nachtigal, M.D. Maurice Nadelman, M.D. Iris Orens, M.D. Joseph D. Rosen, M.D. J ehuda Rozanski, M.D. Leon Tec, M.D. David M. Tillim, M.D. Clara Torda, M.D. PSYCHIATRIC RESIDENTS Bruno Bellinfante, M.D. Reva Berstock, M.D. Richard Brown, M.D. Sevin Eker, M.D. Richard Frenkel, M.D. Robert Glauboch, M.D. Feridun Gunduy, M.D. Halldor Hansen, M.D. Harry Gonda, M.D. Paul Hansch, M.D. PROFESSIONAL AND ADMINISTRATIVE STAFF MEMBERS Sherwin Harris, M.D. Raymond Hollander, M.D. John Kramer, M.D. Leslie Langlois, M.D. Jay Lefer, M.D. Genesia Liu, M.D. Dorothy Lieberman, M.D. Harvey Mandel, M.D. Mark N essel, M.D. Richard Resnick, M.D. Alvaro Rozo, M.D. Mollie Schildkrout, M.D. Jack Schnee, M.D. David Steinman, M.D. Michael Trupp, M.D. Shirley Wallach, M.D. Daniel Weitzner, M.D. ADMINISTRATIVE DEPARTMENT HEADS Accounting Services Dorothy Croghan Buildings cf Grounds Thomas R. Lumley Dietary Services Angelina Canavan, B.A. Housekeeping Sarah Travers Ofi‘ice Services Lillian Dailey ’Resigned I959 ��The function of the Hillside Hospital InPatient Service is to provide treatment to patients suffering from the early and curable symptoms of mental illness. It is not the intention of Hillside Hospital to meet the overwhelming need of the com— munity for psychiatric treatment facilities. Limitations of funds and the inability to provide an expansive treatment pro— gram compatible with the Hospital’s training and research goals make limitation of the number of in-patients necestherathe if be the This case must sary. peutic community is to be a real treatment modality. It is therefore our purpose to provide a treatment program which is consistent with Hillside Hospital’s image of itself as a pilot institution in the field of mental health. Basic to the treatment of patients at Hillside Hospital is a concept of the therapeutic community. The effective relationships between patients and staff, as well as those between patients themselves is a basic element of the treatment program. Moving psychiatric patients from nursing unit to nursing unit, as their conditions improved, meant changed relationships as each move was made. This structure did not provide the best therapeutic situation for our patients. Therefore, in 1959, it was decided to reorganize the treatment service on the premise that patients remain in the units to which they are admitted throughout their entire hospital stay. This arrangement provides further advantages to the treatment program. Not only are staff psychiatrists, psychiatric residents and nursing person- nel able to develop sustained relationships as a therapeutic team, but the patients are also able to develop such relationships with each other, without having to face the problems associated with a constantly ’s patient environment. Further, changing self—government is stabilized by this arrangement. Finally, the entire administrative organization of the hospital has been facilitated by this organizational change in that sustained accountability for the total treatment program is now possible. In connection with this reorganization, several significant changes took place within the Nursing Service during 1959. Provision of adequate nursing care within the revised organization required the restructuring of staffing patterns. A major segment of the nursing service was reassigned to provide the equal distribution of technical, semi-professional and professional nursing skills to all patient units. In the effort to improve staffing patterns, two new personnel categories were created in 1959—Counselor and Senior Psychiatric Aide. As a result of changes in the hospital treatment program, there have been corresponding changes in the assignment of the case work staff of the Social Services TREATMENT TRAl N l N RES EA Department. Two psychiatric social workers are now assigned to each administrative unit. It is now possible to co-ordinate work— social the of work the closely more ers with the work of other members of the team. The casework division has been making increasing use of group counselling. The group approach is now used by the case work in the Hillside Hospital After-Care Clinic. Social workers who function in connection with the InoPatient Service are supplementing individual contacts with visits with patient ’s relatives with group counselling. The admissions policy of the hospital in radically and reviewed changed was 1959. By making it possible to accept appointments for patients applying for admission during any week day, the delay in accepting patients has been drastically reduced. In addition, excessive waiting lists for in-patient admission have been virtually eliminated through the efforts of the Social Work Division, and the staff psychiatrists. Assessment of patient suitability for admission and rapid processing of patients who are accepted for admission is now possible. 1959 saw further expansion of the services of the Group Work Division of the Social Services Department in the provision of additional social and recreational facilities to the in-patient group. Patient government, social clubs, service groups, special interest groups and the the from comvolunteers for program munity were considerably expanded. �The Psychology Department in 1959 continued its program of diagnostic evaluation of the patient, in keeping with its function within the treatment team. The Vocational Counselling Unit of the Psychology Department continued to provide vocational counselling, training and placement services to our patients. The Vocational Counselling Unit joined with the Group Work Division in 1959, in the establishment of a secretarial skills program which was taught to patients by volunteers. The Occupational Therapy Department saw marked growth in 1959. To enable this department to treat the entire patient population and to eliminate waiting lists for this service, the staff was increased from five to twelve therapists. This permitted more intensive function by occupational therapists in the therapeutic team. Further, a high level of individualized occupational therapy is now possible. An Art Therapy program was also inaugurated in 1959. The Creative Therapy Department continues to perform its dual function as a diagnostic and therapeutic unit. _ Nonpsychiatric medical needs of Hillside Hospital patients are met through the Intramural Clinic. The Hospital Internist participates in initial and dis— charge conferences concerning patients whose physical problems are significant in the planning of the total therapeutic program. Consultants in every branch of medicine give freely of their time to the support of patient care. Further, the services and facilities of the Long Island Jewish Hospital are utilized wherever indicated. An excellent Dental Unit is also provided to meet the particular dental needs of the mentally ill patients. This latter clinic is also fully staffed by dentists who serve voluntarily. The Hillside Hospital Out-Patient Department provides psychiatric care to residents of Queens, Nassau and Suffolk Counties who cannot pay for private psychiatric care. In 1959 an average of over one hundred persons were treated each week. In addition to individual psychotherapy, three group psychotherapy programs were established. 1959 also saw the staffing pattern of this clinic improved by the addition of more highly qualified doctors to insure the provision of a treatment program consonant with the goals of the Hospital. The out-patient selection process, too, was revised to afford immediate consultation Within twenty-four to forty-eight hours for all applicants. On April 1, 1959, the Child Therapy Unit of Hillside Hospital Out-Patient Department was opened with the help of a grant from the Nassau County Mental Health Board. A pilot project in the provision of psychotherapy for children, this clinic is further intended to provide the base for the expansion of future child care services at Hillside Hospital. The staff of the Child Therapy Unit consists of a psychiatrist in-charge, three clinical assistant psychiatrists, a psychologist and a social worker. Major emphasis is given to therapy or guidance for parents of children under treatment. Such treatment is usually focused on considering the parents’ reaction to the child’s prob— lems, or the parents’ role in the origin of the difficulty. In the nine months of 1959 during which this clinic was in operation, forty children plus their parents were seen in complete diagnostic evaluation. Fifteen children and their parents were accepted for treatment in this facility. A variety of after-care services have been developed for Hillside Hospital’s former patients. The Foster Home Care Project with the Jewish Community Services of Long Island; the After-Care Clinic which is part of our own Out-Patient service and is provided at Mt. Sinai Hospital; a supportive social case work service with the Jewish Family Services of New York; and a rehabilitation center, “The Bridge,” which provides a resocialization program and supports the Hilda and Israel Strauss League of former patients. �x» �The need for well-trained personnel in the field of psychiatry cannot be overstated. Recent years have seen the devel— oping awareness of the assistance which psychiatric knowledge can bring to the broad spectrum of human problems. All of the specialties of medicine are becoming increasingly aware of the psychiatric elements in the etiology and treatment of physical disease. In the field of public health, education, and welfare, psychiatry is playing a role of ever increasing importance. Further, public acceptance of the practice of psychiatry and the advances made in this field make mandatory the provision of suflicient personnel to meet the nation ’s mental health needs. Hillside Hospital, because of its relatively small size and carefully selected patient population, is ideally suited to develop and share psychiatric knowledge. In accepting its responsibilities for the training of psychiatric personnel, Hillside Hospital is helping to meet the need not only for trained psychiatrists, but also for related professional personnel in the field of mental health. In order to meet the increased need for psychiatrists, Hillside Hospital expanded its teaching program in 1959. The number of psychiatrists in training was increased from eighteen to twenty-five in a teaching program that is expected to require three years for completion. The residency pro— gram itself was improved by the inclusion of training in out-patient care and in research. Historically, the In-Patient Service of Hillside Hospital has not only provided quality patient care, but has also afforded the means for the training of psychiatric staff. The reorganization of the treatment service in 1959 provided for better patient care. The development of discreet administrative patient units affords the psychiatrist in training an opportunity to develop sound therapeutic relationships with an integral patient group. Furthermore, this arrangement allows the development of equally sound relationships between resident and supervising psychiatrists, resident and nursing staff, and resident and activities therapist, thus providing not only a good therapeutic milieu, but a more salutary training milieu. TREATMENT TRAINING RESEARCH To provide for the training of psychi- atric residents in the treatment of other than the hospitalized patients, the OutPatient Department now provides the resident with a learning experience which is similar to that which the psychiatrist has in his office practice. This program, which was initiated in 1959, provides for the training of five psychiatric residents, who function part time during the third year of their psychiatric residency. Supervision by the Director of the Out—Patient Department and members of his staff obtains in planned individual and group conferences. To provide for the development of increased knowledge and skills by practicing psychiatrists in the local community, a planned program has been developed. Clinical assistants who are actively in the practice of psychiatry, receive further training under the supervision of the Director of the Out-Patient Department and members of the attending staff. The Child Therapy Unit which was initiated in 1959, also serves a significant additional training function for practicing psychiatrists in the community. Three clinical assistants, who spend half their time in this clinic, receive individual supervision as a function of the Director of the Child Therapy Unit and from other highly trained psychiatrists. Clinical conferences, seminars and reading conferences, team meetings, planning conferences and psychiatric staff conferences provide further for the teaching program. ���Research at Hillside Hospital in 1959 was carried out not only in three departments whose function lies primarily with re— search, but in addition, clinical studies were carried out by individuals of various professional departments. EXPERIMENTAL PSYCHIATRY The study program in the Department of Experimental Psychiatry increasingly focused on the drug treatment process. Based on an extensive experience with newer drugs for mental illness, a detailed drug evaluation study was started in the fall. The selection of treatment, and behavioral, psychiatric, psychologic, neurophysiologic and sociologic aspects of change are being investigated. These examinations are undertaken to learn how drugs influence mentally ill patients, and to test a theory developed in this Department in 1956. In this theory, drugs are seen to affect behavior by changing both brain function and the psychologic attitudes of subjects. In the experimental psychology studies, increasing emphasis has been placed on individual differences in perceptual and cognitive behavior as related to the type of behavioral response with treatment. Study of these indices as predictors of change in addition to the usual use of indices of the effects of the treatment has demonstrated significant relationships. The introduction of an electronic frequency analyzer of the Ulett-Loeffel type in August, 1959—a device to rapidly measure the various electrical waves recorded from the brain—significantly expanded the electro-encephalographic 14 program. An analysis of changes in the various patterns in the EEG made possible the critical and more precise determination of neurophysiologic effects of various drugs. During the year, 404 records were recorded, and of these, 59 were clinical consultation requests. The sociologic programs undertook an analysis of the differences in patient attitude to treatment of the various staff groups, as the resident doctors, nurses, social workers, etc. ; tolerance of the staff for different types of emotional upset and referral for somatic treatment; and changes in the Hillside Hospital patient population between 1957 and 1959. In order to understand the relation of social factors to the treatment of mental illness, an elaborate tri-hospital study comparing sociologic characteristics, treatment referral rates and discharge ratings in the Menninger Foundation, the Massachus— sets Mental Health Center and Hillside Hospital was begun. TREATMENT TRAINING RESEARCH In language studies—an area that is receiving increased attention in psychiatry—the staff organized and participated in a unique seminar at the New York Divisional Meeting of the American Psychiatric Association. Various psycholinguistic experts employing their individual methods of study, analyzed two tapes of an analytic treatment, and compared their results. They showed the value of combined methods in providing an objective measure of the psychotherapy process. Eighteen reports were published during the year and eleven papers were presented before the national societies. The staff was instrumental in the organization of the New York Divisional Meeting of the American Psychiatric Association, and presented reports at four of its symposia. The staff also participated in the International Conference on Depression and Allied States that was held in March in Montreal. Changes in staff during the year included the appointment of George Krauthamer, Ph.D. as neurophysiologist, and Donald F. Klein, MD. as psychiatrist to the Department. Dr.' Robert L. Kahn, after five years of service, left to assume the position of Head of the Section of Psychology, Division of Psychiatry of Montefiore Hospital. Dr. Joseph Jaffe, while continuing as an Associate in Research in this department, assumed the position of Faculty Member and Associate Director of Research of the William Alanson White Institute. �Continuing support for the program was obtained from the Board of Trustees, extensive program support from the National Institute of Mental Health of the United States Public Health Service, and with grants from the Mental Health Board of Nassau County. BIOCHEMICAL RESEARCH Biochemical research was focused on aromatic substances in the urine of psychiatric patients and on the metabolism of the newer psychotropic and hallucinogenic drugs. For many years, the possibility that psychiatric patients excrete compounds not present in normal subjects has provided the basis for special studies. This program analyzes urine samples for a wide range of chemical substances which are similar to known hormones. It attempts to determine whether psychiatric patients from Hillside Hospital and Creedmoor State Hospital differ from normal subjects. With the widespread use of new drugs in psychiatry, it has been important to determine the way these compounds affect metabolism. One program has been devoted to tracing the changes which chlorpromazine undergoes in the body. For this study, special techniques of analysis for chlorpromazine derivatives have been developed. The focus now is in relating the kinds of derivatives and the rate with which they are produced to their clinical effects. The metabolites of adrenalin are the object of another study with the Medical Department. In patients receiving the Mecholyl Test, urine samples are analyzed before and after the test for various derivatives of adrenalin. Blood studies to determine the enzymes responsible for changing adrenalin are in progress. Recently, a special colorimetric technique for O-methyl transferase was developed. In experimental animals, as well as in the laboratory, the metabolism of hallucinogenes has been studied. Derivatives of lysergic acid related to the vitamin B complex and have been produced and are being tested for hallucinogenic activity and metabolic pathways. MEDICAL RESEARCH The major efforts of medical research in 1959 continued to be directed toward an understanding of the mechanism of the Mecholyl Test. The reliability of the Mecholyl Test, using newly developed equipment for recording blood pressure, first was undertaken. These studies demonstrated that the two initial readings of the test were reliable measures. They, furthermore, established the limits of change in the test as a basis for continued studies. In addition, in co-operation with the Biochemistry Department, a study of the relation of metabolites of adrenalin to this test was begun. In the drug evaluation program, the Medical Department assumed control of new medications and of a variety of physiological tests. These included the electrocardiogram and liver and thyroid function studies, as well as the Mecholyl Test. CLINICAL STUDIES A study of the factors affecting the selection of somatic treatment, Drs. A. Kaplan and H. Lefkowits noted that the recommendations for special treatment were as often based on extra medical factors as on the type of behavior of the patient. They described various degrees of symptoms and tolerances for different behaviors. In the Out-Patient Department, Dr. R. Luttrell and his staff have been interested in the prognostic factors in selecting pa- tients for Out-Patient Department treat- ment. Mr. Lurie and Miss Pinsky of the Social Service Department have done a follow-up study of Hillside Hospital patients who have been referred to The Foster Care Program. The results of this study have been gratifying in terms of the evaluation of the program and of the indication of future direction. In clinical psychology a special study of the psychological characteristics of post-partum depressive reactions was instituted. Toward the end of 1959, an extensive review of the Pavilion for Adolescent Girls, a pilot program in this field, was prepared for publication in the ensuing year. I5 �efforts of the Hillside Hospital staff in the area of research will be seen in the following listing of publications and presentations. BLUMBERG, A.—Use of An Automatic Sphygmomanometer in the Mecholyl Test, Journal of Hillside Hospital, Vol. 8, #3, pp 179, An index of the July, 1959 BLUMBEEG, A., ROSETT, and DOBROW, A.—Severe Holland, Amsterdam, pp. 238-239 PINK, M. KAHN, R.L. and KORIN, H.—Therapy of Schizophrenia: Role of Alteration of Brain Function on Behavior, Congress Reports, II Int. Cong. Psychiatry, II: 492-493 and KORIN, H.—Relation of Tests of Altered Brain Function to Behavioral Change Following FINK, M. KAHN, R.L. In’duced Convulsions, The First International Congress of Neurological Sciences (III: EEG, Clinical of Internal Medicine, Vol 51, Neurophysiology and #3, pp 607, September, 1959 Epilepsy), Pergamon, 613-619 London, M.——Effect pp. of an PINK, Anticholinergic Agent, PINK, M.——EEG and Behavioral Effects of Diethazine, on EEG and Tofranil, International Behavior; Significance for Conference on Depression Theory of Convulsive and Allied States, Montreal Therapy. Biological Psychiatry, ed. Masserman, PINK, M.—Language J ., Grune and Stratton, N. Y. Patterns as Measures of pp. 184—194 Behavioral and Neurophysiologic Change, rINK, M.—Alteration of Brain Function in Therapy. American Psychiatric Association, Philadelphia Psychopharmacology Frontiers, ed. Kline, N., FISHMAN-GOLDENBERG, Little, Brown 85 00., Boston, v., SPOERRI, mar—Coloripp. 325-332 metric Determination of Dicarbozylic Acid rINK, M.——Significance of Derivatives as Hydroxamic EEG Pattern Changes in Acids, Anal. Chem. 31: Psychopharmacology. EEG Clin. N europhysiol. 2: 1735, 1959. Hypotensive Reactions to Overdosage of MeprobamatHThe Annals 398 (abst.) rINK, M.—Electro- encephalographic and Behavioral Effects of Tofranil. Canad. Psych. Assoc. J. 4: 1668-1718 rINK, M. KAHN, R.L. and GOLDENBERG, 11., FISHMAN, v., WHIT’I‘IER, J., BRINI'EZER, W. —Urinary Aromatic Excretion Patterns in Schizophrenia A.M.A. Arch Gen. Psychiat., in press GOLDENBERG, H, WHITE, D.L.-- Colorimetric Determination Factors Affecting Individual of O-Methyl Transferase. Difierences in Behavioral Presented at the 126th Response to Convulsive Meeting of the American Association for the Therapy, J .N .M.D. 128: 243-248 Advancement of Science, 1959 December 27, Chicago, and R.L. M. KAHN, PINK, KORIN, H.—Efl’ects of Diffuse GOLDENBERo, H., FISHMAN, v. Altered Brain Function on —Chromatographic Studies Perception. Proc. X V Int. of Chlorpromazine Metabolism in Man. Presented at the 126th Meeting of the American Association for the Advancement of Science, Chicago, Dec. 27, 1959 POLLACK, M.—-—Psychologica1 of Threshold and Duration of Social Attitude to Psychiatric Seizures to Degree of EEG Treatment, N.Y. Divisional Meeting, A.P.A., New York Delta Activity Induced During Electroshock, EEG. KAHN, R. L., with WEINSTEIN, Clin. N curophysiol. 2: E. A. and BERGMAN, P.——Effect (Abst.) of Electroconvulsive Therapy on Intractable Pain. JAFFE, J.—-—Communication A.M.A. Arch. Neurol. and Networks in Freud’s Psychiat. 81 : 37-42 Interview Technique, Psych. Quat. 32: 456-473 KAHN, R. L., with WEINSTEIN, E. A.——Symbolic ReorganizaJAFFE, J.——Symposium on ‘‘ tion in Brain Injuries, in Psycholinguistic Analysis Handbook of Psychiatry, ed. of the Psychiatric Interview ’ ’, Divisional Arieti, S. Basic Books, N. Y., Vol. I, pp. 964-981 Meeting, A.P.A. New York KARP, E.—Behavioral Changes JAF‘FE, J.——Social Backwith Different Methods of ground and the DoctorPatient Relationship, Acad. Induced Cerebral Dysfunction, Eastern Psychoanalysis, New York Psychological Association, KAHN, R.L. and BLACK, M.— Atlantic City of Application Prognostic Psychological Techniques in KORIN, H. and FINK, M.— The role of Set in the Convulsive Therapy, Dis. N erv. Sys. 30: 180-184 Perception of Simultaneous A. Tactile Jour, Stimuli, and R. POLLACK, M., L., KAHN, 384-392 72: Psychol. M.—Sociopsychologic FINK, KRAUTHAMER, G.—Form Aspects of Psychiatric Perception Across Sensory Treatment in a Voluntary Mental Hospital; Duration Modalities, Am. Psychol. 14 : of Hospitalization, Discharge 396 (Abst.) Ratings and Diagnosis, KRAU’I‘KAMER, G.———Personality A.M.A. Arch. Gen. Psychiat. Correlates of EEG, 1 : 565-574 Metropolitan EEG Society, New York KAHN, R. L., and PINK, M.— Personality Factors in LEVINE, A.—A Comparative Behavioral Response to Evaluation of Latent and Electroshock Therapy, Overt Schizophrenic Patients J. Neuropsychiatry 1: 45-49 with Respect to the Concept KAHN, R. L.—Socioof Ego Strength. Journal psychologic Factors of Hillside Hospital, VIII, Affecting Therapist-Patient No. 4, Oct. 1959, pp. 243-266 Relationships, American LEVINE, A.—“App1'aising Academy of Psychoanalysis, ego-strength from the Philadelphia projective test battery” KAHN, R. L.—Socio——Society for psychologic Aspects of Projective Techniques, Psychiatric Treatment, New York, May 1959 Eastern Psychological Association, Atlantic City Cong. Psychol., Publ. North- GREEN, M.—Relationship of KAHN, R. L.—Re1ation STAFF PUBLICATIONS AND . . 16 .m_............,,.... PRESENTATIONS LEVY, E.—The Role of the Volunteer In The Treatment Program of a Mental Hospital, Social Work with Groups, 1959, (New York Natl. Assoc. of Social Workers), pp 109-119 LURIE, A., HIRSCH, 8.— Establishing a Hospital Social Service Department, Journal of Social Work (Vol. IV, No. 2—April 1959) ‘ A.-—‘ Structure of LURIE, Field Work Training” Workshop, Council on Social Work Education, Philadelphia, Pa., January, 1959 LURIE, A.—“The Use of Group Process Within Medical Settings”. National Conference of Jewish Communal Service, Pittsburgh, Pa., May 1959 ‘Forecasting the Place and Role of the Aging in our Society during the next decade”. Little White House Conference on Aging, sponsored by the Community Council of Greater New York, LURIE, A.——‘ December 1959 POLLACK, M.—Effect of Induced Cerebral Dysfunction in Man on Tachistoscopic Perception of Embedded Color Figures, Eastern Psychologic Association. Atlantic City POLLACK, M. with BENDER, M. B., and BATTERSBY, W. s.— Complex Visual Perception in Patients with Brain Tumor. Proc. XV Int. Cong. Psychol., Publ. NorthHolland, Amsterdam, pp. 236-237 POLLACK, M.~—‘ ‘ Comparison of Intellectual Functioning in Childhood,” Adolescent and Schizophrenics, N. Y. Divisional Meeting, A.P.A., New York STAHL, ALICE—”The Role of the Psychiatrist in the Adolescent Pavilion. ’ ’ Midwinter Divisional Meeting of A.P.A. ��The past years has been one in which the Medical Board has shared in the period of transition now in progress at Hillside Hospital. Acting in an advisory and consultative capacity, the Board has aided the Medical Director and the Board of Trustees in bringing into sharp focus the aims and aspirations of Hillside Hospital : to become a leading center for psychiatric treatment, training and research. In keeping with the current spirit of transition at Hillside Hospital, the Medical Board has done considerable soul searching in order to reappraise its role in the affairs of the hospital. The Board is comprised of people who are outstanding in the fields of psychiatry and psychoanalysis. Some of its members are training analysts on the faculties of the three Psychoanalytic Institutes in New York City. Others have achieved aca- demic distinction as members of medical school faculties and hospital staffs. It is expected that gradual evolutionary changes will take place which will enhance the value of this reservoir of psychiatric experience and knowledge. In the past it has made major contributions to the academic deveIOpment of Hillside Hospital. Together with the devoted membership of our chiefs of Medicine, Surgery and Dentistry, the Board is a source of expert advice in the major activities of the hospital. The year has brought other changes, too. Dr. Sidney Tarachow, the first editor of the Journal of Hillside Hospital, has retired as the Journal’s guiding light, after ten years of unflagging devotion. Under his direction the Journal has become an outstanding contributor to the body of scientific knowledge and literature. It is expected that in the near future an issue of the Journal will be dedicated to Dr. Tarachow, as a token of our appreciation, esteem and affection. Dr. Aaron Stein of our Board has succeeded as editor. The various committees under the able direction of their chairmen have continued to function energetically in the many areas noted in previous years. To them and to the attending and visiting REPORT OF THE PRESIDENT OF THE 18 MEDICAL BOARD Robert A. Savitt, M.D. staffs I offer deepest thanks for their advice and co-operation. I particularly Wish to express my compliments to Mr. Alvin E. Coleman, the President of the Board of Trustees, and to Dr. Lewis L. Robbins, the Medical Director, for their valued and rewarding relationship to the Board. Conferences with these men and their dedicated colleagues have always been stimulating, informative and constructive. In closing, I take extreme pleasure in welcoming Dr. Sidney Tarachow to the Presidency of the Medical Board. He will give it the energetic devotion it so much deserves. �MEDICAL BOARD President Robert A. Savitt, M.D.* President-Elect Sidney Tarachow, M.D.* Secretary Sidney L. Green, M.D.* Treasurer Paul Scheman, D.D.S.* Eat-President M. David Epstein, M.D.* Psychiatrists Samuel Atkin, M.D. Arnold Eisendorfer, M.D.* M. David Epstein, M.D.* Margaret E. Fries, M.D. I. Peter Glauber, M.D.* George S. Goldman, M.D. Sidney L. Green, M.D.* William Karliner, M.D.* Sylvan Keiser, M.D. Sarah B. Kelman, M.D. Emanuel Klein, M.D. Samuel R. Lehrman, M.D. Joseph S. A. Miller, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D.* Lawrence J. Roose, M.D. Robert A. Savitt, M.D.* Martin Schreiber, M.D.* Isidor Silbermann, M.D. Otto Sperling, M.D. Sidney Tarachow, M.D.* Non-Psychiatrists Director of Department of Medicine Lester Cohen, M.D.* Director of Department of Surgery Sidney Hirsch, M.D.* Director of Department of Dentistry Paul Scheman, D.D.S.* CHAIRMAN OF STANDING COMMITTEES Adolescent Pavilion Sidney L. Green, M.D. Credentials Committee for Psychiatric Attending Staff Promotions Martin Schreiber, M.D. & Credentials Committee for Non-Psychiatric Visiting Staff & Promotions Paul Scheman, D.D.S. Education of Resident Stafl" Arnold Eisendorfer, M.D. Group Psychotherapy Samuel Z. Orgel, M.D. Manhattan A fter-Care Clinic Sarah B. Kelman, M.D. Queens Out-Patient Clinic Martin H. Orens, M.D. Sub-Committee for Child Guidance Clinic Isidor Bernstein, M.D. Research Committee Sidney Tarachow, M.D. Publications Committee I. Peter Glauber, M.D. Committee for Adjunctive Services I. Peter Glauber, M.D. Credentials Committee for Supervising Psychiatric and Resident Stafl‘ Lawrence J. Roose, M.D. CONSULTING, A‘ITENDING AND VISITING STAFF-'5 Consultants Psychiatry Leonard Blumgart, M.D.? Sandor Lorand, M.D. Nathaniel E. Selby, M.D. Dudley D. Schoenfeld, M.D. Medicine Alfred Angrist, M.D. Morris S. Bender, M.D. Oscar Levin, M.D. I. Jesse Levy, M.D. YNeurology A. M. Rabiner, M.D. Hans Strauss, M.D. I. S. Wechsler, M.D. Surgery David Warshaw, M.D. Gynecology Julius Jarcho, M.D. Dentistry Morris Fierstein, D.D.S. Attendings Attending Psychiatrists Samuel Atkin, M.D. Frank Berchenko, M.D. Isidor Bernstein, M.D. Arnold Eisendorfer, M.D. M. David Epstein, M.D. Margaret E. Fries, M.D. I. Peter Glauber, M.D. George S. Goldman, M.D. Paul Goolker, M.D. Sidney L. Green, M.D. William Karliner, M.D. Sylvan Keiser, M.D. Sarah R. Kelman, M.D. Emanuel Klein, M.D. Samuel R. Lehrman, M.D. Abraham S. Lenzner, M.D. Joseph S. A. Miller, M.D. Martin H. Orens, M.D. Samuel Z. Orgel, M.D. Hyman L. Rachlin, M.D. Lawrence J. Roose, M.D. Robert A. Savitt, M.D. Martin Schreiber, M.D. Isidor Silbermann, M.D. Otto Sperling, M.D. Aaron Stein, M.D. Sidney Tarachow, M.D. Associate Attending Psychiatrists Renato J. Almansi, M.D. Alexander J. Friedman, M.D. Soll Goodman, M.D. Louis Kaywin, M.D. Bruce Kendall, M.D. Geraldine Pederson-Krag, M.D. William W. Pike, M.D. Jay Stanton, M.D. Adjunct Attending Psychiatrists Edward R. Adelson, M.D. Herman S. Alpert, M.D. Alvin B. Balaban, M.D. Irving L. Bauer, M.D. Benjamin J. Becker, M.D. Julius Belinkoff, M.D. Milton M. Berger, M.D. Lionel H. Blackman, M.D. Rita M. Chalef, M.D.:t Isadore H. Cohn, M.D. Irving J. Crain, M.D. Joseph H. Feldman, M.D. Jules Glenn, M.D. Albert E. Goldberg, M.D. Michael Gould, M.D.i Albert Harrison, M.D. Thomas Hora, M.D. Wilbur Jarvis, M.D.i Abraham I. Kaplan, M.D. Eugene H. Kaplan, M.D. George R. Krupp, M.D. Peter Laderman, M.D. Myer D. Mendelson, M.D.* David Milrod, M.D. Helene Papanek, M.D. Henry Rosner, M.D.t Irving Salan, M.D. Frederick F. Shevin, M.D. Fred U. Tate, M.D. B. Frank Voge], M.D.* Leonard Weinroth, M.D. Herbert Wieder, M.D. VISITINGS Medicine Director Lester Cohen, M.D. Visiting Physicians George Sabrin, M.D. Louis Rosenblum, M.D. Arnold G. Blumberg, M.D. Associate Physician Jerome Weinstein, M.D. Adjunct Physicians Arnold L. Berger, M.D. Wilbur B. Brett, M.D. Associate Dermatologist Joel Schweig, M.D. Adjunct Dermatologists Norman Goldfarb, M.D. Eugene L. Bodian, M.D. Neurology Associate Neurologist Kurt Adler, M.D. MEMBERS OFTHE MEDICAL BOARD Gynecology Visiting Gynecologist Marie P. Warner, M.D. Associate Gynecologists Jack Cohen, M.D. Bernard Greenblat, M.D. Rodlology Visiting Radiologist Bernard Epstein, M.D. Associate Radiologist Paul Steinhorn, M.D. Optometry Stafl‘ Optometrists Edward L. Steinberg, O.D. Bernard Attinson, O.D. Podiatry Stafi’ Podiatrist William Reider, Pod.O. Surgery Director Sidney Hirsch, M.D. Adjunct Surgeon Stephen Deckofl", M.D. Visiting Neurosurgeon Joseph Siris, M.D. Visiting Urologist Daniel Kaufman, M.D. Adjunct Urologist Albert Sutton, M.D. Visiting Orthopedist A. H. Lewert, M.D. Associate Orthopedist Julius Schneiderman, M.D. Visiting Proctologist Benjamin Warner, M.D. Visiting Ophthalmologist Edward Seretan, M.D. Associate Ophthalmologist Arthur Minsky, M.D. Visiting Otolaryngologist Sam Clayton, M.D. Visiting Anesthesiologist Georges Bean, M.D. Dentistry Director Paul Scheman, D.D.S. Associate Director J. Gordon Rubin, D.D.S. Associate Dentists Benjamin Schwaid, D.D.S. Bernard Lebow, D.D.S. Adjunct Dentists Henry Lewis, D.D.S. Samuel Plotnick, D.D.S. Elsa Friedman, D.D.S. Martin Protell, D.D.S. Leon Basson, D.D.S. Herbert Forman, D.D.S. *Executive Committee Member f Deceased 1959 IAppointed in 1959 19 �The body of our Annual Report indicates that 1959 was a year in which the Professional Development Program, introduced by Dr. Lewis L. Robbins, was launched. The goals of the program have been outlined and the beginnings of its implementation have been described above. Additional personnel required by this program were initially engaged as of July, 1959, and were gradually added during the second half of the year, so that the 1959 calendar year data does not show appreciable expenditures for the Professional Development Program as such. COMPARISON OF COSTS 1958-1959 1958 — TOTAL OPERATION 1959 % INCREASE 16. Salaries $1,241,350. $1,442,458. 3. Food 127,142. 131,083. Maintenance and Grounds ( 8.) 78,914. 72,408. Administration 29. Expenses 111,300. 143,860. Medical Supplies 55,217. 49,289. (11.) Repairs and Replacements 48,101. 41,727. (13.) 13. Total $1,662,024. $1,880,825. This table shows that the total expenditures for all operations increased by 13%; the percentage increase from 1957 to 1958 was 11%. Salaries and wages increased by 16%. This is in keeping with our experience of the past ten years in which this item rose by ten to fifteen percent per year. Almost the entire rise in this figure was caused by increases in rates rather than by the addition of new positions. The chief factors in this increase were the across-the-board increase of about 13% to all nonprofessional employees and provision of time and one-half for overtime for all employees. These actions were taken by the Board of Trustees in accordance with the “Statement of Policy Regarding Personnel Practices” promulgated by the Greater New York Hospital Association and subscribed to by the Board of Trustees. Increased salaries were also provided for all categories of the professional staff. The impact of the Professional Development Program as such was hardly felt in 1959 ; its further implementation will produce a more appreciable impact during 1960. . 20 Food costs increased 3% in accordance with the rise in the food price index. Out-patient services expenses increased by only 6% as compared with 30% in 1957 and 21% in 1958. This reflects the stabilization of this operation after a period of constant growth dating back to 1954 when the large Queens Out-Patient Service was established. The largest increase was in administration expenses which rose by $32,000, or 29%. The following were the chief components of this increase: INCREASE IN DOLLARS ITEM Office Equipment $3,500 Medical Care Prepayment for Employees 8,000 Social Security and Retirement Contributions 9,300 Personnel Expenses 6,300, Medical Care Prepayment for employees (Blue Cross and Blue Shield coverage for the employees and their families) was initiated in July, 1959 as part of our over-all improvement of personnel practices. Social Security and retirement contributions rose both as to rate and volume. Personnel expenses rose in accordance with liberalized policies as to travel and other allowances for professional staff. SERVICE DATA: IN-PATIENTS Total number of patients treated Total patient days Average income per patient day Average cost per patient day Average loss per patient per day 1958 1959 % INCREASE — —— 536 70,691 537 70,219 $16.58 $18.83 + 13.5% $18.73 $21.69 + 15.8% $ 2.15 $ 2.86 + 33% REPORT OF THE ADMINISTRATOR Maurice Bachrach �With total number of patients treated and the number of patient days virtually unchanged, average income per patient day rose by 13.5% while average cost per patient day rose by 15.8%. The average loss per patient day rose by 33% over 1958. Thus, In-Patient Service developed a gross operating deficit of $200,826 for the year in spite of an increase of $4.00 in the per diem rate paid for indigent patients by the City of New York as of July 1. Without this increase, this loss figure would have been appreciably higher, since 75% of our In-Patient Service (50,000 patient days) is assigned to indigent patients. Most of our deficit both for In-Patient and Out-Patient Services was met by a grant from the Federation of Jewish Philanthropies of New York, while an increasingly large deficit is being met by our own trustees. Our Board of Trustees meets the operating deficit for treatment and training programs as well as for research, which is their sole responsibility. As we continue to put more and more of the Professional Development Program into action, our gross expenditures for the In-Patient Service will continue to out-run foreseeable increase in operating income. Closest integration of planning and effort between the hospital administration, our Board of Trustees and the Federation of Jewish Philanthropies of New York can lead to construetive solutions of the support problems which lie ahead during the next few years. The most potent ingredient of such integration is close agreement as to the hospital’s goals as they have been expressed in the programs promulgated by Dr. Robbins in 1958 and 1959. These goals promise the provision of the highest attainable level of patient care and are so incontravertible, that they must stimulate all concerned to meet them in spite of the difficulties to be encountered. The growth of the professional programs must be accompanied by parallel development of administrative services. Careful application of sound administrative procedures to every phase of all of our programs will tend to make these programs more effective and to introduce elements of management that can decrease cost without impairing service. During 1959, Mr. Samuel Davis joined our staff as Assistant Administrator. We willnow be able to plan for increased appli- cation of administrative processes in the professional areas. More time and effort will be available for improvement and intensification of personnel administration. An important function for administration during the next year will be to develop major projects in conjunction with Dr. Robbins and the professional staff and appropriate board committees, a master plan outlining the physical development of the hospital for at least fifteen years ahead, a survey of existing plant and buildings and a comprehensive site plan leading to the development of a research building and an activities therapy building. The hospital’s administration will continue to maintain constructive relationships with community agencies such as the Nassau County and New York City Community Mental Health Boards and the various co-operating social agencies, as well as Long Island Jewish Hospital. Efforts to intensify and improve the areas of co-operation will continue. The board has already authorized the creation of an effective public relations program which will lead to wider and more productive community participation in the life of the Hospital and greater usefullness of the hospital in the life of the community. The task of administration during 1959 has been a great one. None of our accomplishments and none of our plans for the future would have been possible without the devoted and intelligent assistance of the department heads who worked so closely with us. It is therefore more than appropriate to state that Mrs. Angelina Canavan, Dietitian; Mrs. Dorothy Croghan, Accounting Supervisor; Mrs. Lillian Dailey, Office Manager; Mr. Thomas R. Lumley, Superintendent of Buildings and Grounds; and Mrs. Sarah Travers, Executive Housekeeper supplied the basic day-to-day services which provided an essential foundation on which professional programs are built. They worked unceasingly with sometimes inadequate staff, to meet the challenge presented by the growing Professional Development Program of the hospital. 21 �The following professional and nonprofessional employees supported the treatment, training and research goals of the Hillside Hospital in 1959: PROFESSIONAL Biochemical Research Dr. Vivian Goldenberg Grace Kittel Susan Rea Dr. Bernard Searle Daniel White Creative Therapy Edith Zierer Dental Technician Sheila Berger Experimental Psychiatry Romeo Cartolano Dr. Robert Kahn Eric Karp Dr. Donald Klein Jean Kolodny Dr. George Krauthamer Hanna Mosquera Dr. Max Pollack Dr. Nathaniel Siege] Intramural Clinic Laura Zaves Laboratories Theresa Midulla Medical Librarian Ellin Resnick Nursing Service Registered Nurses Frances Anderson Susie Mae Behlmer Marie Cafiero Kathleen Cliggett Mary Cressy Mary Ann Dalton Ann Dispensa Jean Hendry Nancy Jeff eries Mary Jones Sandra Kraner Grace Lyons Eleanor MacPhillips Flora Mae McCartney Catherine McCormick Helen Murray Yolande Paquet Lorraine Schaefl’er Helen Schippicase Rose Schulbaum Suzanne Smith Barbara Steinbach Zurline Thornhill Edith Titolo Anna Urbach Helen Ziegler Licensed Practical Nurses Alma Clinton Mary Corrigan Hope Fox Theresa Howard Alice McDonough Isabell Pierce Rosemary Stevenson Gloria Swan Catherine Wall Delores Williams Psychiatric Aides Martha Adams Olga Allen Marion Bell Patricia Bell William Black, Jr. Beatrice Blake Annie J. Bond Joseph Britt Lawrence Burger Frances Butler Sylvester Campbell Frederick Coley May Conrad Teresa Cooney Naomi Cotter Hugh Cracker �Catherine Eames Annie Ervin James Faulkner Janie Ferguson Marion Flood Irish Ford William Godett Margaret Griller Katherine Hammel Mabel Harper Linda Hart Pauline Hawkes George Heller Sandra Heller Lawrence Hood Alberta Hopkins Ellen Kennedy Joan Kelley Asalle Kirby Carole Kornfeld Doris Kraemer Josephine Lafayette Ernest Lambert Grace Lau Leslie Lee Miriam Lee Alice Leliukevicz Ella Mae Leonard Lillian Leslie Anna Lewin Georgine Lohman Ellen Long James Merrill Edith Minor Bertha Monroe Helen Olsen Clemmie Palmer Elizabeth Rodriguez Barbara Sang Lessie Mae Scott Samuel Scott Mildred Shaw Nancy Smith Virginia Smith Marian Thomas August Tosi Martha Visalli Catherine Williams Thomas Wolf Anna Wolfberg Leon Wolfberg Edgar Zephyrine Occupational Therapy Karen Beutlich Joseph Chase J udity Conrad Laura Dunlop Martha Ittelson Mona Jones Deanna Levine Mary Marrone Doris Metzger Helene VViller Pharmacist Robert M. Frank Psychology Ira Rosenblatt Dr. Allan Sapolsky Dr. Stanley Schiff Charles Silver Dr. Felix Steiner Leonette Vanderhost Florence Volkman Social Services Case Work Division Ida Baumstein Anne Connery Barbara Fishman Robert Fishman Beatrice Freeman Evelyn Furman Sally Gold Regina Goldstein Selma Hornstein Sarah Klionsky Sandra Match Anita Mehr Sylvia Riback Esther Sanders Lita Schmidt Seymour Silverberg Sylvia Solovey Gisela Tauber Lewis White Group Work Division Aaron Beckerman Frieda Bradlow Denis Dryden Judith Dufly Edward Fitzgerald Geraldine Lauter Eli Saul Levy Evelyn Mason Naomi Miller Holmes Morrison William Pressman Frances Rubinstein Philip Schwartz Virginia Zaremba NON PROFESSIONAL Accounting Department Arline Fleischmann Lillian Ingber Henrietta Lyons Ethel Siegelman Jeanette Silver Dorothy Strier Buildings & Grounds Erich Brau Walter Foley Frank Groene William Hannigan Robert Hill George Loblein Nero Moyd Stanley Novak Edward Reeder Frank Reinlein Walter Roland, Jr. William Roland, Sr. John J. Rose Albert Schmid Joseph Seagren Albert Senese Dietary Services George Canavan Francesco Cannetto Emma Casamassima Flozell Clarke Hubert Cooke Thomas Duncan Arthur Dywer Pardo Faro Elaine Fields George Fields Alphonse Gross Ella Jacobs Fred LaBarbera Alfred Lemaire Gaetano Mandala Arthur Martin Ida Novick Martin Novick Gaspari Orlando George Perreta Arthur Pitts Walter Rodney Eva Schwartz Broadie Taylor Thomas Tucker Ester Watkins Leroy Watkins Housekeeping Cle Anderson Betty Bruckman James Cuozzo George Czinczinger Stanley Durant William Garland Fulgencio Gerena Nathaniel Glover Joseph Hope William Hyman Robert Jones Harry Lewis Charles McLeod Richard Newton Roosevelt Mitchell PROFESSIONAL AND NON PROFESSIONAL EMPLOYEES Dorothy 0 ’Berry Arturo Orengo Booker Richardson Rafael Salazar Agnes Schuster General Walker Ray Warren Blanche White Ofiice Services Irene Attinson Celia Bernstein John Borgner Janet Bowie Diane Brafman Manuel Brown Irene Dinkin Claire Dubin Regina Freedman Lillian Freifeld Norma Friedman Edward Golove Frances Gullo Adele Harris Sylvia Hymowitz Joan Kase Edna Kappes Yetta Levitt Inge Mai Sylvia Marcella Fradele Marcus Yetta Mintz Catherine Mufi Dorothy McClary Margaret 0 ’Connor Mary Pignoni Gloria Podrid Frances Roth Joseph Ryan Dorothy Saults Charlotte Sinovoi Miriam Slater Jeanette Sobel Edna Telesca. Walter Theisen Edna Weissman Lotte Wollman Blanche Zaitz 23 ��HILLSIDE HOSPITAL is licensed by. . . . . The New York State Department of Mental Hygiene. is approved for resident training by... . . Council on Medical Education of The American Medical Association The American Board of Psychiatry and Neurology. is accredited by . .... The American Psychiatric Association The Joint Commission on Accreditation of Hospitals is a member of..... The American Hospital Association Hospital Association of New York State Greater New York Hospital Association Greater New York Fund The United Hospital Fund Welfare and Health Council of New York City The National Conference of Jewish Communal Services cooperates with. . . . . Adelphi College Altro Workshops Federation Employment and Guidance Service Jewish Community Service of Long Island Jewish Family Service of New York Long Island Jewish Hospital New York City Board of Education New York State Employment Service New York State Department of Vocational Rehabilitation Queens College of the City of New York is a participating hospital IWhIle no precnse form ..... and Related Facilities for essential for making a valid bequest to HIIISIde Hospital, the following may be used: give to the Society of the Hillside Hospital, the sum of $ TheHospitaICounciIof Gr t rN wY rk HI::;DEeHO:PITAL I ISAMEMBER OF . . . IS . . . . . , I land or any specn‘uc property, such as bonds, stocks, etcetera, IS given, a brief descrlpH tion of the property should be inserted instead .of the phrase "the sum of If . . . . . . $____. THE FEDERATION or JEWISH PHILANTHROP'ES' �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-007 Date A point or period of time associated with an event in the lifecycle of the resource 1960-1963 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Hillside Hospital Annual Report (published copies), 29th, 30th, 31st, 32nd; Hillside Hospital A Report of Progress, 1960/61; Letter; Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/e160cd659a1c0564650ed815c2ffda05.pdf 287e408e3d76bfef4519f4c1ea5b9ae6 PDF Text Text ( g , a n I E . ! r l , E i P me: plated the 70110113; Wt. it. own» 1957. tho first wu- of of W mun-y oa- of tho clan-pu- of natal 1.1an“. WW with. 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Why" m of tho é : mnm- Hospital. flu sun and“: m “aA. m, W am. um lab-n 11.9. Edi. 11.». m, Ill: mm, m. “lemma. I» Bub. " - -.. _, “mt mu (Wong) W " " * .u " I (me) (Noun-um Why) _ “ - a wzutmpmmwmmayuM7 E i ‘ amurmwmmunnahrmummm,m hum). mum at rum mu. an Wanna cm» at munmmmanummmmumm. mm, mm . w m. E “n.— fi__.__4w-~m_——__V O ”in. n ,. — �Richard Weiner FROM: FOR RELEASE FINN INCORPORATED 13u.East 59 Street RUDER & MAX York 22, New York PLaza 9-1800 New FOR: 7, 1958 HILLSIDE HOSPITAL A Island psychiatrist whose research points to the underlying Long changes necessary to reverse the depressive type of mental honored this Dr. week by Max be Fink, Director of the Department of Experimental Psychiatry at Hillside Hospital, A. E. illness will a major national psychiatric association. Glen Oaks (Queens), New York, will receive the first Bennett Neuropsychiatric Research Foundation Award. The Society of fé Biological Psychiatry will present the award at the group's 13th Annual Meeting in San Francisco, California, on May 11. The meeting is part of : '1‘ the American Psychiatric Association Annual Meeting. Dr. Fink will present a paper on his work Cholinergic Agent, Diethazine, on EEG titled, "Effect of Anti- and Behavior: Significance for Theory of Convulsive Therapy." The report describes experimental studies of the neurophysiologic for "shock" therapies. Dr. Fink and his associates at Hillside Hospital have observed that changes inla specific enzyme and biochemical bases system of the brain, acetylcholine-cholinesterase, are intimately to improvement in electroshock. However, changes related in the opposite direction are accompanied by hallucinations, delusions, and psychotic behavior. that decrease the activity of the acetylcholine normally present, in the brain excite psychotic activity. They also reverse the electroshock Drugs effect. Some of the newer hallucinogens, such as lysergic acid (LSD) and , �-2mescaline, are most potent in this regard. halts the hallucinogenic action of these shock effect. The On the other hand, chlorpromazine compounds and enhances Hillside research extends the understanding of the the electro- mode of action of convulsive therapies by defining the biochemical bases for the observed neurophysiologic effects. The studies have been supported by the National Institute of Mental Health and the Board of Directors' Research Fund of Hillside Hospital. Dr. Fink is Secretary of the Section of Convulsive Disorders and Brain Function of the American Psychiatric Association and President- Elect of the Nassau Neuropsychiatric Society. Hillside Hospital, an affiliate of the Federation of Jewish is a non—profit, non-sectarian hospital for psychiatric treatment, training and research. Philanthropies of New York, #### �_ »‘.>\7"» >v.— '— ~v- 16 Peace Missionary May ;’Have to Pacify “Family ' i i . ' i Mrs. Lola Stone, pretty young Long Island. housewife who’s on an interna— tional peace mission to ban nuclear tests, may have some pacifying to do when she gets home. The husband and two children of the globe-trotting proud of her campaign, but they miss her and Wish she’d 'peace missionary are hurry home to Kanes Lane, Huntington Bay. , .TA Reiecis 1 "‘We think she’s wonderful, we’re quite proud of her, but it urts some time,” her husband, Robert, said with a smile. ‘We’re counting the days.” Mrs. Stone is one of a group of five pacifists on a 4,000- Protest mile tour of European capitals ‘ By MBA ‘ They have been stalled in Helsinki for a week because of the reluctance cf the Soviet Union to grant them entry The Transit Authority today visas. brushed aside a Motorman’s “We are hoping the visas Benevolent Association protest will come through,” Mrs. Stone that it would be “dangerous” told her husband by phone for‘ motormen to leave their from Helsinki. “The most imcontrols on the EMT Myrtle, portant part of our mission Avenue line to help operate the lies ahead. We hope this is doors. just a routine delay.” “The MBA is making a DR. MAXIMILLIAN FINK The group flew from Idlemountain out of a molehill,” a wild April 14, and stopped at TA spokesman said. London, Paris, Bonn and West Theodore Loos of Jamaica, Berlin to interview national the association’s president, proleaders and “just plain people.” tested yesterday that a train’s Despite a brush-off "at 10 brakes might slip -— and the Downing St., official residence train start rolling—while the of British Brime Minister Harmotorman was out of his cab. old Macmillan, the overall re“Under our order,” the Tranaction was “favorable and opsit Authority spokesman said, timistic,” Mrs. Stone reported. “the motormen will have to l.The scheduled last lap of the leave his cab only under cerjourney was to be Russia, tain conditions . . . and those A Long Island psychiatrist where the group hoped to perconditions Only crop up once will receive the first A. E. Ben- suade Kremlin officials to in a blue moon. Even if the motorman leaves nett Neuropsychiatric Re- agree to an unconditional ban on nuclear testing as “a demhis controls, he’ll never be search Foundation Award. more than four feet from the He is Dr. Ma'ximillian Fink onstration of their sincerity.” Expenses of the trip are brake.” of 13- Bayview Ave., Great being borne by “Non Violent The TA said its order applied only to a few stations on Neck, director of experimental Action Against Nuclear Weapthe Myrtle Avenue line. At psychiatry at Hillside Hospital, ons,” the same group that sponsored the voyage of the those stations, there’s no Glen Oaks. “Golden Rule,” stopped change collector at night, so Dr. Fink ‘will receive the ketch, the conductor on the train col- award. Sunday from the Soci- by the Coast Guard off Hawaii. lects fares. The motorman will ety of Biological Psychiatry at be asked to help the conductor its annual convention in San Fishermen Angry out when a “big crowd” boards Francisco. the train. Over Empty Pond He is being honored for re“We only pick up an aver- search- into the effect of HARTFORD, Conn. (UP)— age of four persons per trip at “shock” Red-faced officials of the State all those stations put together,” “we’vetherapy. been able to discover Fish and Game Department the TA spokesman said. “We the mentally ill respond admitted somebody goofed . . almost never get a crowd how to shock therapy,” Dr. Fink when angry fishermen pomt') \ ' there." explained. “And, just as im- ed out in a department-proportant, we’ve learned why vided pamphlet that Day Pond some persons do not respond in Colchester was stocked with ”at trout and open for fishing. to such treatments.” j t'Dr.’ Fink has livedtin Long The anglers had risen before I Island since 1950, and was ap- daWn! ion:- opening day and made thetrip to the Mind, ' r 3 _ ' ‘ ' Psychiai‘risfs Will Honor L. Docfor _ _ giteconsider '11:, , Q . . ’ . U �1/15/59 Department of Egperimental Psychiatry and the of presentations a chronologic Following is list of members Experimental the of Department of the publications Psychiatry during 1958. M Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo 3. eds., Grune E Stratton, (Kafin, R.L. and Fink, M.) 2. Lateral 3. h. 5. 6. Gaze Nystagmus as an Index of Sedation Threshold, Clin. Neurophysiol. l9: 162-163 (Fink, M.). Effect of Diethazine on EEG and Significance h for Theory 8101. 19: of Convulsive Therapy, EEG. Clin. Neuro 207-208 (abst.) (Fink, H.5. Experimental Studies of the E1ectroshock Process, Dis. Nerv. Syst. l2: 113-118 (Fink, M. and Kahn, R.L.). Comparative Study of Chlorpromazine and Insulin Coma 18h6-1850 166: J.A.M.A. of Psychosis, Therapy (Fink, M., Shaw, R., Gross, G. and Coleman, F.C.). Eleotroencephalographic Correlates of the ElectroshockM. 227 (Abst.) (Fink, Nerv. Dis. Syst. 12: Process, EEG. and Green, 7. 8. 9. 10. l1. R.,. Language of the Dyad, Psychiatry El: 2h9-258 (Jaffe, J.). Clinical and EEG. Effects of Megimide in Patients without M. 682-685 (Green, Cerebral Disease, Neurology g: and Pink, M.) Effect of Anticholinergic Agent, Diethazine, & on EEG and Psych. fig: 380-388, Behavior, A.M.A. Arch. Neurol. (Fink, M.). Experimental Studies of Convulsive and Drug Therapies on A.M.A. Arch. Theoretical Implications, Psychiatry: Neurol. & Ps ch. 80: 733-73h (Abst.) (FinE, R., Kahn, R.E. and Green, M77. Brain Damage, Mental Retardation and Childhood Schizophrenia, 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat.‘12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. A.M.A. Arch. of Denial in Factors Illness, Interpersonal& Ps chiat. fig: 653-656 (Jaffe, J. and Neurol. SiBtEj'W.H.). �1h. B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, e3. U. of Michigan P ress, Ann Arbor (N. Siegel). Presentations: EEG Correlates of the Electroshock Process, at the 1. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, 3. and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies Convulsive of Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal in and Attention Visual Perception ’Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., and F Behavioral Physiological Score to of Relation Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) 7. Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Perception Stimulation Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3- 10. Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, Montreal (Fink, M. and All. 12. 16. 17. 18. 19. Psychological Factors Affecting Individual Differences in Behavioral ResPonse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). Effects of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of Drugs, at Section on Neurol. & Psychiat. Queens. County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Jaffe, J.). ' Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at IEastern Association of Electroencephalographers, December, New York (M.Green). �uuucav twain; by»: anuunsu .lmost as well as if he :ould see. Here he climbs the schdol steps with his ypewriter to attend ‘ a class. \\\\\\ &\\\\\\\\\\\\\\\\ \\\\\\\\\\\“ \\\\\\\ t J} \ MD Records Brain Waves Of Patients , A history written in brain waves is telling the story today 01' how successfully the mentally ill are responding to electro-shock and drug treatments. Dr. Max. Fink, a Great Neck psychiatrist who gave up a profitable private practice to “prospect for Iacts”,»~ has developed a method of evaluating the brain waves of patients at Hillside Hospital, Glen Oaks,_ where he’s been leading an eight--man research team for four years. The brain wave "history”, recorded on graph paper and transmitted by an. electroencephalogram, enables the hospital's staff to “treat patients with more direction” Fink says. It works this way: The encephalogram picks up brain waves of a new patient and records a “base line” on the graph. As the patient is treatedand repeatedly tested the variations are recorded on the graph. Comparisions show whether a patient is . or isn’t . . . responding to a drug or shock treatment. , l f , 1 ; I 1 1 l K 1 ‘ . - - 3|! 1|: 1‘ “THE STUDY gives a new and keener sense of direction in treating the patients,” Fink said. For example: If a patient’s brain wave “history” shows that his response to is suddenly ' ' �“1191110 Jemeqm 01 31110 Buons KlaA 8 S1,, 1112833 301s Amman: amooaq 01 1113111 £11231 S1 911 -aonpu1 119011119110 9111 queued . 12 s1s1sax PWWI‘IXa 9H 'ppas 151111210st 1 ' ha] um 112112, 51901u19110 01121190 puno; aA'eq 9AA” 3511; 'BO‘BId mnsu! me 01111 111 11011 mm 1nd 219111 3111 lent 1elr SSJBABJ KHJBIOG 9113, g 3111 111911311 10 1110 [swam K1219 1; eu1uua1ap d19q 11mm (111 Fsoq am #4,!» '.1c'[ 5111110111 Emma 9111 3,5121 sanp seq wee], 91110:) unease; s‘xum ma; 1111111 19111311111 3,2111 ’Ielld sgqgepuno; [no panoddns A11u1o§ p112 ”3.190111 -‘Kq‘ s; 109(0ch 9111. was Hum ‘l‘summeu p003 KJIBA” paonp v; '-o.1d seq 21031on Jeefi-e-ooo‘oow ép1s111H 112 pomém man ‘ 'sKes a: $11.11 1101129591 9111 $1110 9111 i “‘mou 919111“ pasn s1 as avg ii 13d 08 11190 AIa1'eu11x01dde”, o1 padumg ' .seq eBe1uaJJad 3111, 1911qu 3111 mm; paseapx aq 01 K11ua1o111ns pI—JJBAOOGJ smemman 110qu .10 8111p smeared 0111 10 “3,1130 13d 09 moqe” K1uo ‘1211dsoq 91.13, 12 pasn_ pue paldope sem pomaux aAem pa.11nb‘ax 011m ' KING. .‘mo ‘ ”0198 “'Janeq smamman 51311113. 'JCI sn smone 0), az1111n Apn1s emem 1112.1q PIPS RUM VICI «1-1qu 9111,, qu 01 mammal; man 11 'UOIS -SB.IBB.I 3111, 1199110 p118 An A13131d -1noa 'e 2193 52111 ‘wJo; [eu1 $1.10 511 o; xoeq ssa.1831 o1 su133q uo1z11puoo asoqm .10 ‘luauxaAmduu JO nonessao 'e uaaq $911 91311), sa;eo1pu1 uo111p1100 asoqm waned V 911'), -3AOJlifilt _ Kauanbaa; umoqs qde s1 3113111 mun afiesop 111 .10 peseaxou1 aq — ! B 33’ 000i u1ens pue’ ssans 10 p1.10m 9113, 01111 peseefiu uaqm 1121111 -soq b1 11:10 aAeq em ssa.1 spun 1111M -30.1d 4113; ho inmo- atn “‘1uaned XOGN e or 01 39.1391) 1101112» 9111’ 19111 ZS .r‘»_(’ ’ �February 25, 1959. Department of Experimental Paychiatry Annual Report - 1958 During 1958, the major emphasis of the staff of the Department of Experimental Paychiatry shifted from evaluation of convulsive therapy to systematic investigations of newer psychopharmacologic agents. These investigations, derived from the successful evaluations of the mode of action of convulsive therapy (l95h-l958), reserpine (1955), and chlorpromazine and insulin coma (1956-1957), are based on the neurophysiologic-adaptive hypothesis of physiodynamic therapies developed in the Department in 1957 flggg. é? 197-206). the The many new compounds (J. Hillside interrelationship of the neurophysiologic effects of with the psychodynamic, perceptual, personality and sociologic aSpects of patients' behavior provide the framework for these investigations. In addition, linguistic indices developed in the Department during the past two years by Drs. Kahn and Jaffe are being studied as measures both of behavioral change and of neurophysiologic effect. During the year, the evaluation of convulsive therapies was continued effects of indoklon, an inhalant convulsant, with electroconvulsive therapy. 'This study was undertaken by two senior resident by comparing the psychiatrists, B. Alan and H. Lefkowits, and Drs. Green and Fink. While indoklon therapy was a successful treatment, technicallimitations made poor substitute for the established electrical methods. The it a study was of theoretic value in indicating that the significant element of convulsive therapy was the induction of the grand mal convulsion, with its attendant neurophysiologic effects, independent of the type of agent employed. �V , .2Investigations into the relations of sociologic factors to the selection of therapies at Hillside Hospital were extended by Drs. Kahn and Pollack. Not only were the factors of age, education, birthplace, and score on the California F Scale significantly related to the choice of therapy but these factors were also related to the results of therapy, the diagnosis and the duration of hOSpitalization. These observations were presented in the Sunday Conference of October 16, 1958. and On October 7 the study was repeated; similar studies of the population of other primarily psychotherapeutic hospitals, and the Hillside Hospital Out-Fatient Department were undertaken. To augment these studies, Dr. Nathaniel Siegel was appointed as Research Associate in Sociology, with the support of a grant from the Mental Health Board of Nassau County. In an extension of the communication studies, both the syntactic content analysis and dyadic diversification measures of formal aSpects of speech were applied to an evaluation of the changes in language patterns following the acute administration of various new psychotropic compounds. These measures demonstrated and the neurophysiologic The consistent changes both with the induced behavioral effects of the drugs. acute drug interviews were but one asPect of the continuing evaluation of the biochemistry of convulsive therapy. Previous studies had indicated that repeated induced convulsions resulted in an increased level of central nervous system acetylcholine activity. €g¥:;;;;:;;;;:§ of various anticholinergic stages of convulsive therapy we compounds By the acute administration to patients at various elucidated the synaptic chemical events which are the basis of the convulsive therapy process. �-3In addition, Mr. Karp and Drs. Kahn and Pbllack continued their perceptual studies in patients receiving psychodynamic therapies. The interrelation of psychotherapy with physiodynamic therapy was studied by Drs. Esecover, Jaffe and Kahn; and in the and H. Lefkowits began an latter part of the year, Drs. A. Kaplan investigation into the interpersonal factors in therapists, as well as patients, leading to the referral for physiodynannc therapies. During the year, Dr. H. Korin resigned, and was replaced by Mr. Eric Karp. TWO new staff appointments include Dr. Nathaniel Siegel, Assistant Professor of Sociology at Columbia University, as Research Associate in Sociology; and Dr. Donald Klein, research candidate at the New York Psychoanalytic scientist at Institute, as Creedmoor Institute Research Associate in Psychiatry. Support for this extensive program was provided by the Board of Directors, and continuing grants of the Foundations' Fund for Research in Psychiatry and the National Institute of Mental Health. At year end, this program received considerable Support from the Psychopharmacology Service Center of the National Institute of Mental Health, which augmented extensive commitment by a grant of $268,000. These its already further sums were increased during the year by support from the Mental Health Board of Nassau County which provided funds Smith, Kline & for sociologic studies; and from Bristol, Geigy, French, and wyeth Laboratories ~ who aided the drug evaluation program by grants as well as extensive supplies of the agents During the year, fourteen reports of the work of staff to be studied. members appeared; and twenty reports were presented to major professional societies. �-hIn addition to national societies, work of the Department was presented at the Conference on Psychodynamic, Psychoanalytic and Sociologic Aspects of Neuroleptic Drugs in Montreal, and the International Congress of Neuropsychopharmcology in Rome. Staff first members were awarded two prizes. Dr. M. Fink received the annual A.E. Bennett Peychiatric Essearch Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on EEG and behavior. Dr. J. Jaffe received the Gralnick Foundation annual award for his report on the application of analysis of changes in fonnal aSpects of Speech in psychotherapy. �-5The staff of the Department of Experimental Psychiatry included, at year end: MEX Fink, M.D. Direeees Joseph Jeffe, M.D. Research Associate (Peychiatry) Donald F. Klein, Research Associate (Peychiatry) MQD. Robert L. Kahn, Fh.D. Max Pollack, Pth. Research Associate (Experimental Psychology) Research Associate (Experimental Paychology) Nathaniel Siegel, Ph.D. Research Associate (Sociology) Eric Karp, B.A. Research Assistant (Experimental Peychology) Martin A. Green, M.D. Associate in Research Abraham A. Kaplan, M.D. Associate in Research (Paychiatry) Barre Alan, M.D. Fellow (1957-58) Henry Lefkewits, M.D. Fellow (1958-59) The (Neurophysiology) technical staff included Mrs. Janet Bowie, Jean Kolodny, Mbsquera and Blanche Hannah Zaitz. addendum: In February Dr. George Krauthamer, Ph.D. was appointed as Research Assistant (Experimental Psychology). electroencephalography. He is a trainee in �nan-{u £55, 1959. lupurtuoat at ngcriunutal rayshxttvr ‘lunaal Icpcrt ~ 1955 fitting 1953, it: 3.3.9 atyhnstg I! it. i‘l!‘ at tho fiapartunat it xxptriuaninl firth$¢%ry Ihlf‘ll tron utilisatog at convulsivt thurupr to tru‘unsttc tavnu‘acatinua a: utuar paynhnpitamnnoiauin attain. tunic tsvultxgntaill. inrtth Iron in. littl8if§1 evaluaiiOII or fit. and: of 30‘s.: it nonralltvv thirty: (19$h~1956). IlllrpllO (1958). in: ohlcrv prunastnn uni 13.31%: can. 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M, ‘O ”#3; mm 0m. 30‘. . 3",; 3"“; AW 3.; It!!! ”all, I’D; lint: Luthuui‘s, lpfl. ltflifirti Aasuoiufin (firthtttry) Iliilfflh Atlliilii_ (lupotinuuttl rtvuhaztux) Intonrnh snln¢tutn (invtrilnttll P-vthnlacy) inaalvuh Asaaitnfic (80:103.:71 Icaiirdh Aaltcfiaut .(lagnrlnnntul rurnlnlocy) £::o¢tnto in nasatvcl (lvuruphyntilugy) guspntsia in Ittoarol (rsywhaatry) villuu (19£?~$fi) Ibllov (1955-59) ‘15:: Juan Janet tuulllod urn. tastu1¢i1 loioinr, Inuit. It. luntni aboqutti an: lxanaht 3a1$n. �1/15/59 Department of Experimental Psychiatrz list and the of presentations a chronologic Following is of Experimental members of the Department of the publications Psychiatry during 1958. A.“ Publications: 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo 3. e38., Urune E Stratton, (Kafin, R.L. and Pink, M.) of Sedation Threshold, 2. Lateral Gaze Nystagmus as an Index162-163 (Fink, M.). EEG. Clin. Neurophysiol. lg: EEG and Significance for Theory on of Diethazine 3. Effect of Convulsive Therapy, EEG. Clin. Neurophzsiol. l9: 207‘208 (abate) (Fink, Process, his. h. Experimental Studies of the Electroshock M. and Kahn, R.L.). 113-118 (Fink, Nerv. l2: Coma and Insulin of Chlorpromazine 5. Comparative Study 18h6-1850 166: J.A.M.A. of Psychosis, Therapy G. and Coleman, F.C.). Shaw, Gross, M., R., (Fink, 6. Electroencephalographic Correlates of the ElectroshockM. S Nerv. Dis. st. $2: 227 (Abst.) (Fink, Process, o o stt. and Green, H.$. 7. 8. 9. 10. (Jaffe, J.). Pszchiatrz 3;: Effects of Megimide in Patients without M. Language of the Dyed, Clinical and EEG. 2h9-258 Cerebral Disease, Neurologz Q: 682-685 (Green, and Fink, M.) EEG and on Diethazine, Agent, of Anticholinergic Effect & Pszch. fig: 380-388, Arch. Neurol. L.M.A. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Theoretical Implications, Psychiatry: Neurol. & Ps ch. 80: 733-73h (Abst.) (FInE, 3.. Kahn, F.I. and Green, M77. ll. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Pszchiat. 115: h22-h28 (Pollack, M.). 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat..12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. Arch. A.M.A. of Denial in Factors Illness, Interpersonal& Ps chiat. fig; 653-656 (Jaffe, . and Neurol. Slate, W.H.$. �1’40 B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, e3. U. of Michigan P ress, Ann Arbor (N. Siegel . Presentations: 1. EEG Correlates of the Electroshock Process, at the Eastern Psychiatric Research Association, February, N.Y. (Fink, M. and Green, M.A.). 2. EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). 3. and Drug Therapies Convulsive of Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, Philadelphia (Jaffe, J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication 6. The (Kahn, R.L. and Fink, M.) 7. Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and Stimulation Perception of Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3- 10; Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic ASpects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, and 11. 12. 13. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on Diethazine, of Agent, Anticholinergic Effects and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). on Post Convulsive Effect of Anticholinergic Compounds EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �law HILLSIDE HOSPITAL Glen Oaks, New York March 16, 1959 MEMO TO RESEARCH FROM: RE: ' COWITI'EE JOSEPH S.A. MILLER, M.D., MEDICAL DIRECTOR ATTACHED RESEARCH REPORT I herewith enclosing copy of Dr. sending it a few days in advance of the meeting, familiarize yourself with some of the main facts position to discuss this when it is presented at meeting on March 25th. am Fink's report, so that you might and be in a better the forthcoming �FebmaIy 25, 19590 Department of Experimental Peychiatry Annual Report - 1958 During 1958, the major emphasis of the staff of the Department of Experimental Paychiatry shifted from evaluation of convulsive therapy to systematic investigations of newer psychopharmacologic agents. These investigations, derived from the successful evaluations of the mode of action of convulsive therapy (l9Sh-l958), reserpine (1955), and chlorpromazine and insulin coma (1956-1957), are based on the neurophysiologic-adaptive hypothesis of physiodynamic therapies developed in the Department in 1957 Eggg. the fig 197-206). The many new compounds (J. Hillside interrelationship of the neurophysiologic effects of with the psychodynamic, perceptual, personality and sociologic aspects of patients' behavior provide the framework for these investigations. In addition, linguistic indices developed in the Department during the past two years by Drs. Kahn and Jaffe are being studied as measures both of behavioral change and of neurophysiologic effect. During the year, the evaluation of convulsive therapies was continued by comparing the effects of indoklon, an inhalant convulsant, with electro- convulsive therapy. This study was undertaken by two senior resident psychiatrists, B. Alan and H. Lefkowits, and Dre. Green and Fink. 'While indoklon therapy was a successful treatment, technicallimitations made it a poor substitute for the established electrical methods. The study was of theoretic value in indicating that the significant element of convulsive therapy was the induction of the grand mal convulsion, with its attendant neurophysiologic effects, independent of the type of agent employed. �.2the to factors of the sociologic relations into Investigations Kahn and Drs. extended by were Hillside Hospital of at selection therapies Pollack. Not only were the factors of age, education, birthplace, and score on the California F Scale significantly related to the choice of therapy but and the of diagnosis the to results therapy, related also these factors were the duration of heapitalization. These observations were presented in the Sunday Conference of October 16, 1958. and On October 7 the study was repeated; similar studies of the population of other primarily psychotherapeutic undertaken. were Out-Patient Department and HOSpital Hillside the hoSpitals, To augment these studies, Dr. Nathaniel Siegel was appointed as Research Associate in Sociology, with the support of a grant from the mental Health Board of Nassau County. In an extension of the communication studies, both the syntactic content analysis and dyadic diversification measures of formal aspects of epeech were applied to an evaluation of the changes in language patterns following the acute administration of various new psychotropic compounds. These measures demonstrated consistent changes both with the induced behavioral and the neurophysiologic The effects of the drugs. acute drug interviews were but one aspect of the continuing evaluation of the biochemistry of convulsive therapy. Previous studies had indicated that repeated induced convulsions resulted in an increased level of central nervous system acetylcholine activity. By the acute administration of various tertiary-amine anticholinergic compounds to patients at various stages of convulsive therapy we elucidated the synaptic chemical events which are the basis of the convulsive therapy process. �-3In addition, Mr. Karp and Drs. Kahn and Pbllack continued their perceptual studies in patients receiving psychodynamic therapies. inter- The relation of psychotherapy with physiodynamic therapy was studied by Drs. Esecover, Jaffe and Kahn; and in the latter part of the year, Drs. A. Kaplan and H. Lefkowits began an investigation into the interpersonal factors in therapists, as well as patients, leading to the referral for physicdynamic therapies. During the year, Dr. H. Korin resigned, and was replaced by Mr. Eric Karp. TWO new staff appointments include Dr. Nathaniel Siegel, Assistant Professor of Sociology at Columbia University, as Research Associate in Sociology; and Dr. Donald Klein, research candidate at the New York Psychoanalytic scientist at Institute, as Creedmoor Institute Research Associate in Psychiatry. Support for this extensive program was provided by the Board of Directors, and continuing grants of the Foundations' Fund for Research in Psychiatry and the National Institute of Mental Health. At year end, this program received considerable support from the Psychopharmacclogy Service Center of the National Institute of Mental Health, which augmented extensive commitment by a grant of $268,000. These its already further sums were increased during the year by support from the Mental Health Board of Nassau County which provided funds Smith, Kline & for sociologic studies; French, and wyeth Laboratories - who and from Bristol, Geigy, aided the drug evaluation program by grants as well as extensive supplies of the agents During the year, fourteen reports of the work of staff to be studied. members appeared; and twenty reports were presented to major professional societies. �.1... In addition to national societies, work of the Department was presented at the Conference on Psychodynamic, Psychoanalytic and Sociologic Aspects of Neuroleptic Drugs in Montreal, and the International Congress of Neuropsyohophamacology in Rome. Staff first members were awarded two prizes. Dr. M. Fink received the annual A.E. Bennett Paychiatzic Research Award of the Society of Biologic Psychiatry for his report on the effects of anticholinergic agents on Em and behavior. Dr. J. Jaffe received the Gralnick Foundation annual award for his report on the application of analysis of changes in formal aspects of Speech in psychotherapy. �-5The staff of the Department of Experimental Psychiatry included, year end: Max Fink, M.D. M Joseph Jaffe, MlD. Research Associate (Peychiatry) Donald F. Klein, Research Associate (Psychiatry) MgD. Robert L. Kahn, Ph.D. Research Associate (Experimental Peychology) Pollack, Ph.D. Research Associate (Experimental Psychology) Max Nathaniel Siegel, Ph.D. Research Associate (Sociology) Eric Karp, B.A. Research Assistant (Experimental Psychology) Martin A. Green, M.D. Associate in Research Abraham.A. Kaplan, M.D. Associate in Research (Paychiatry) Barre Alan, M.D. Fellow (1957-58) Henry Lefkowits, M.D. Fellow (1958-59) The (Neurophysiology) technical staff included Mrs. Janet Bowie, Jean Kolodny, Mosquera and Blanche Addendum: Hannah Zaitz. In February Dr. George Krauthamer, Ph.D. was appointed as Research Assistant (Experimental Psychology). electroencephalography. at He is a trainee in �1/15/59 Department of Experimental Psychiatry and the of presentations a chronologic list Following is of members Experimental the of Department of the publications Psychiatry during 1958. Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps chopatholo 3. eds., Grune & Stratton, (Kahn, R.L. and Fink, M.) 2. Lateral 3. h. 5. 6. Gaze Nystagmus as an Index of Sedation Threshold, Clin. Neurophysiol. 19: 162-163 (Fink, M.). EEG and Significance for Theory on of Diethazine Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. 19: EEG. Experimental Studies of the Electroshock Process, Dis. M. and Kahn, R.L.). 113-118 (Fink, Nerv. Syst. 12: Coma and Insulin of Chlorpromazine Study Comparative Therapy of Psychosis, J.A.M.A. 166: 18h6-1850 G. and Coleman, F.C.). Shaw, Gross, R., (Fink, M., Electroencephalographic Correlates of the ElectroshockM. Process, Dis. Nerv. Syst. 12: 227 (Abst.) (Fink, and GreenTWMTfT—___-—*— (Jaffe, J.). 7. Language of the Dyad, Psychiatry 31: 2h9-258 8. without Patients in of Megimide Effects Clinical M. 682-685 (Green, Q: Cerebral Disease, Neurology and EEG. and Fink, M.) 9. 10. on EEG and Effect of Anticholinergic Agent, Diethazine, & Psych. g9: 380-388, Neurol. A.M.A. Arch. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental A.M.A. Arch. Theoretical Implications, Psychiatry: Kahn, M., & (FinE, 80: 733-73h (Abst.) Neurol. Psych. R.E. and Green, M77. 11. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: h22-h28 (Pollack, M.). 12. Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat. 12: 720-726 (Pollack, M. and Krieger, H.P.5. 13. A.M.A. Arch. of Denial in Factors Illness, Interpersonal& and 653-656 J. Ps (Jaffe, fig: Neurol. chiat. Slote, W.H.§. �1h. B. Predictions of Outcome, in Youthful Offenders at H. Ashley, ed. 5. of Highfields, Weeks, Michigan Press, Ann Arbor (N. Siegel). Presentations: the EEG at Electroshock of the Process, Correlates l. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). Experimental Studies of Convulsive and Drug Therapies in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Visual Perception and Attention in Normal and Abnormal Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Communication Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Fink, M.) Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychol~ ogical Association, April, Philadelphia (Korin, H.). The �-3- 10. Socio-Psychological Aspects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, _ and 11. 12. 13. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). on Post Convulsive Effect of Anticholinergic Compounds EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �1/15/59 Department of Experimental Psychiatry and the of presentations Following is a chronologic list of Experimental the members Department of the of publications Psychiatry during 1958. A. Publications: in Therapy, Electroshock During Language Changes in 1. and Zubin, P. Hoch, Communication, of cho Ps atholo 3. eds., Grune & Stratton, (Kafin, R.L. and Fink, M.) of Sedation Threshold, 2. Lateral Gaze Nystagmus as an Index162-163 (Fink, M.). EEG. Clin. Neurophysiol. 19: EEG and Significance for Theory on of Diethazine 3. Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. 19: h. 5. 6. 7. 8. 9. 10. 11. 12. 13. Process, Dis. Experimental Studies of the Electroshock M. and Kahn, R.L.). 113-118 (Fink, Nerv. Syst. 12: Coma and Insulin Comparative Study of Chlorpromazine 18h6-1850 166: J.A.M.A. of Psychosis, Therapy and G. Coleman, F.C.). Shaw, Gross, R., (Fink, M., Electroencephalographic Correlates of the ElectroshockM. 227 (Fink, (Abst.) Nerv. Dis. Syst. 12: Process, and Green, M.,. 2h9~258 21: (Jaffe, J.). the Dyad, Psychiatry Language of without in Patients of EEG. Megimide and Effects Clinical M. 682-685 (Green, Cerebral Disease, Neurology g: and Fink, M.) EEG and on Diethazine, Agent, Effect of Anticholinergic & Psych. fig: 380-388, Neurol. Arch. A.M.A. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Implications, Theoretical Psychiatry: (FEEET'MTT’Kahn, 733—73h & 80: (Abst.) Ps ch. Neurol. fi.f. and Green, M77. Brain Damage, Mental Retardation and Childhood Schizophrenia, Am. J. Psychiat. 115: h22—h28 (Pollack, M.). W..— Oculomotor and Postural Patterns in Schizophrenic Children, A.M.A. Arch. Neurol. & Ps chiat..12: 720-726 ,fPollack, M. and Krieger, H.P.5. Arch. A.M.A. of Denial in Illness, Interpersonal& Factors Ps chiat. fig: 653-656 (Jaffe, J. and Neurol. Slote, W.H.$. �1h. B. Predictions of Outcome, in Youthful Offenders at Hi hfields, Weeks, H. Ashley, ed. U. of Michigan Press, Ann Arbor (N. Siegel). Presentations: EEG Correlates of the Electroshock Process, at the 1. Eastern Psychiatric Research Association, February, M. N.Y. (Fink, and Green, M.A.). EEG Changes in of Individual Variability Significance During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies of Convulsive Studies Experimental in Psychiatry: Theoretical Implications, at New York Society of and Society Neurological Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American Orthopsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, (Jaffe, Philadelphia J., Relation of F Score to Behavioral and Physiological Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) Intellectual Deficits in Patients with Space Occupying Lesions of the Cerebrum, at Eastern Psychological Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychological Association, April, Philadelphia (Korin, H.). �-3Socio—Psychological ASpects of Diagnosis and Treatment: 10. Drug Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic ASpects of the Neuroleptic (tranquilizing) M. Montreal (Fink, Drugs in Psychiatry, April, ‘ and 11. 12. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & Neurol. on Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, M.). 20. Relationship between Seizure Threshold and Duration of Seizures to ERG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �1/15/59 Department of Experimental Psychiatry and the of presentations Following is a chronologic list of EXperimental members the of Department of the publications Psychiatry during 1958. Publications: A. 1. Changes in Language During Electroshock Therapy, in of Communication, Hoch, P. and Zubin, Ps cho atholo M.) and E R.L. (Kahn, Fink, Grune Stratton, J. eds., 2. Gaze Nystagmus as an Index of Sedation Threshold, 3. h. 5. 6. 7. 8. 9. 10. 11. 12. 13. Lateral M.). 162-163 (Fink, Clin. Neurophysiol. 19: EEG Theory for and on Significance of Diethazine Effect of Convulsive Therapy, EEG. Clin. Neurophysiol. lg: EEG. Process, Dis. Experimental Studies of the Electroshock Nerv. Syst. 12: 113-118 (Fink, M. and Kahn, R.L.). Coma and Insulin of Chlorpromazine Comparative Study 18b6-1850 166: J.A.M.A. of Psychosis, Therapy and G. Coleman, F.C.). Shaw, R., Gross, (Fink, M., Electroencephalographic Correlates of the ElectroshockM. 227 (Fink, (Abst.) Nerv. Dis. Syst. 12: Process, and Green, fi.$. 2h9-258 (Jaffe, J.). the of g1: Dyed, Psychiatry Language without in Patients EEG. Megimide of and Effects Clinical M. 682~685 (Green, Cerebral Disease, Neurology g: and Fink, M.) EEG and on Diethazine, Effect of Anticholinergic Agent, & 380-388, Q9: Neurol. Arch. A.M.A. Psych. Behavior, (Fink, M.). on and Drug Therapies Convulsive of Studies Experimental Arch. A.M.A. Implications, Theoretical Psychiatry: Kahn, (Fink, & fi., 80: 733-73h (Abst.) Ps ch. Neurol. R.I. and Green, M77. Childhood and Schizophrenia, Mental Retardation Damage, Brain Am. J. Psychiat. 115: h22-h28 (Pollack, M.). Oculomotor and Postural Patterns in Schizophrenic Children, & Ps chiat._12: 720-726 Neurol. Arch. A.M.A. (Pollack, M. and Krieger, H.P.5. Arch. A.M.A. of Denial in Illness, Factors Interpersonal& and 653-656 J. Ps (Jaffe, chiat. g9: Neurol. Slote, W.H.$. �1h. B. at Predictions of Outcome, in Youthful Offenders U. H. of Ashley, ed. Weeks, Highfields, ichigan Press, Ann Arbor (N. Siegel). Presentations: the at EEG Electroshock of Process, the Correlates 1. Eastern Psychiatric Research Association, February, M. N.Y. 2. (Fink, and Green, M.A.). EEG Changes in Significance of Individual Variability During Electroshock Therapy, at Eastern Association of Electroencephalographers, March, Montreal, (Green, M.A.). and Drug Therapies Convulsive of Studies Experimental in Psychiatry: TheoreticalNewImplications, at York Society of Neurological Society and Clinical Psychiatry, March, N.Y. (Fink, M., Kahn, R.L. and Green, M.A.). Abnormal and Normal and in Attention Visual Perception Children, at American OrthOpsychiatric Association, March, N.Y. (Pollack, M.). Patterns with Altered Brain Function, at Eastern Psychological Association, April, and M.). R.L. Fink, Kahn, Philadelphia (Jaffe, J., and F Behavioral Physiological to Score of Relation Response with Altered Brain Function, at Eastern Psychological Association, April, Philadelphia, Communication The (Kahn, R.L. and Fink, M.) 7. with Space Occupying Intellectual Deficits in Patients Eastern Psychological Lesions of the Cerebrum, at Association, April, Philadelphia (Pollack, M., Battersby, W.S., Kahn, R.L. and Bender, M.B.). Simultaneous of and of Stimulation Perception Intensity Stimuli in Cerebral Dysfunction, at Eastern Psychol— ogical Association, April, Philadelphia (Korin, H.). �-3- 10. Socio-Psychological ASpects of Diagnosis and Treatment: Theoretical Implications, Symposium - Eastern Psychological Association, April, Philadelphia, (Kahn, R.L. and Pollack, M.). Drug Induced Changes in Interview Patterns, at Conference on Psychodynamic, Psychoanalytic, and Sociologic Aspects of the Neuroleptic (tranquilizing) Drugs in Psychiatry, April, Montreal (Fink, M. _ and 11. 12. 16. 17. 18. 19. Jaffe, J.). Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, at American Psychiatric Association, May, San Francisco (Fink, M., Kahn, R.L. and Pollack, M.). Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy, at Electroshock Research Association, May, San Francisco (Kahn, R.L. and Fink, M.). EEG on of Agent, Diethazine, Effects Anticholinergic and Behavior: Significance for Theory of Convulsive Therapy, at Society of Biological Psychiatry, May, San Francisco (Fink, M.). Social Factors in Selection of Therapy in a Voluntary Mental Hospital, at American Psychiatric Association, May, San Francisco (Kahn, R.L. and Pollack, M.) A Critique of "Pre-Conscious" Perception and the "Poetzl Phenomenon," at American Psychiatric Association, May, San Francisco (Pollack, M.). Role of EEG Frequency Shift in Behavioral Effects of & on Neural. Section Psychiat. Queens Drugs, at County Medical Society, June, N.Y. (Fink, M.). Effect of Anticholinergic Compounds on Post Convulsive EEG and Behavior, American EEG Society, June, Atlantic City (Fink, M.). EEG and Behavioral Effects of Psychopharmacologic Agents, at Collegium Internationale Neuro-Psycho Pharmacologicum, September, Rome, and Eastern Association of Electroencephalographers, December, N.Y. (Fink, M.). Prognostic Application of Psychological Techniques in Convulsive Therapy, at Eastern Psychiatric Research Association, October, N.Y. (Kahn, R.L. and Pollack, MI). 20. Relationship between Seizure Threshold and Duration of Seizures to EEG Change During Electroshock, at Eastern Association of Electroencephalographers, December, New York (M.Green). �\\.\" ‘\ Soptubor 1, 1959 rm m2 mm H.927 Dumb-at of mparimntal Psychiatry HWPM WEE Glen H. L. m, 1. thmm 3. 3mm 8mm, h. Publications, 1951: - 1959 5. Presentations, 1951; 6. Smnmry #1, September 1. - 1959 1951:: - 7. Sunny #2, Mary 1. 8. Smmry #3, April 1, 1957 2. #1:, February 1, 1959 Five Years, 199; - - Sophombor 1956 ~ January 1, 1956 Am; 1, - February March Asaoomboa EEG 1957 1, 1958 Ha: (kparmanul 1, 1959 1959 Principal Investigator Research Associates I. I.) Psychology) (Neurophysiology) Technician Secretuy m,n.n. Robert L. Kahn.Ph.Do Hymn Karin, £11.13. Eda M,M¢A. Martin A. momma. mummfiub. 19%4953 1958 ’ 1956 .1951; 1959 ‘- 1957 1956 Joseph Jaffe,M.D. Donald F. K1o1n,24..n. 1959 Nathaniel 319301,Ph.D. 1958 «- Georgo Hanna Mosquera Janet Baltic Associates, supported throng: other grants: Research Associate Mouth Associate amorob Associate Research Associate (kperimntal Paydnol.) ( Psychiatry) (Psychiatry) (Sociolm) Max Pollackfihon. . «- - �he mm: Amwhmr reporwd here would nab have has: possible without the interact and support of the Ecuador of Hillside 808mm, Dr. 18ml Sinus, flu Hard of Directors and the Hr. Maurice when faith sustain“! an. pmm aux-mg its only uwnmau. W, mutter, Wemflsoindcbtodtothexmmnnandmm Ina-k, the Pomdntiona' Fund for Board of Nassau County and the um and Rosearoh I Waumdflu in Psychiatry, the 1mm Health mm sum. My Wane-la, tonamg pharmoouticll and Ranch Laboratories, Wyeth Laboratories, Bristol Laboratories, thou support in amt-fully achnfladgod. �3m. m Dam“ me labor-mm- of on of Exparimntsl Psychiatry oatsblishad so musics Homul in Smtmber, 1951:. During this fivc your period mumpbyuoloéio, psychologc (personality and pamptm), linguistic, and sociolcgio upsets of 'soutic" psychiatric have been tho pmipu [£001. mums 1. WC The Thong: =, visit or the convulsive mnpy process as the induction of a nonnspeciftc state of altered brain function, similar to omnioosrsbnl trams was supportcd and uplifled (10, 11. 21). Within this altered osrobn}. milieu, subjects were seen to respond in variom ways (26) , ”lino: m9}: post "successful" no explicit verbal dsnial (7. 31). This lotto)? adsptation was most prominent in chamooerclogioflly disposed indvidmls (36). J? in altshflon bran function was pro-requisite to boluvionl orange Grand m1 scams were column]. to this 26). 11, 8, (7* The alterations but (26) induction was (34:2). not electrical pm: in mmfunction were measured in various ways including doom(6.n,12,2h,39), language patterns (h.7.3h.31.h3; Mb). pen-mm mu (2,16,17,37,h63 magma) and tests of real]. (8). 1n Wham "v I". 316mb numbers tho appsndix. on to publications or pneumatic” (B- ) listed in �variety of beluvieml changes lure eeen during convulsive therapy (26; 8-17). Such patterns were viewed as edepteticne to altered brain A Motion, and were believed dependant upon chencterologic end environ- mental tactore (7, 25, 26, 36, ho). Clinical retina: of improvement cbeemr or the behavioral change. in the subject (26). Adaptations chmcterieed by denied www.mm 1n behavim' (13.17) and in language (7. WM— Such adaptations! were related to habitual node. were new as value Judgments by the W or conduct (character, The ML (inability per-MW) BMW (36; 3-11, 32). of the altered behavioral nodes wee noted ee dependant upon the degree and duration of mm alterec breln function. the expectatlone, an! the type and degree of family and medical support. Different behavioral patterns were beet supported by WIt m eke typee or psychothonpy (19).. that the ’nemphwelolcglcel beele of lie in on duration in central emptic suggeeted M? commune therepy any cholinerglc - cannot-31c relationship, with a predominant to incremd cholinergic activity as the operationally significant wt :3th. illumination: were based on the nutimdllp of man voltage EEG Olav wave activity to behavioral change (6, 11, 26) and the blocking at Such poet-mun ; electmgrephic and behavioral changee by central entichonnergic agents (21; 3h: 35; bl. 1&2) and by centre]. unpethwmtic agents (ha). ”664%? ;;;m u— 00'“ ? 4, @3. M‘,£~§. W m 4/: “3/93,”?1 will, ’?.L<»Jv%ué~éiy.i �-3.‘ Become of linguistic behavior in structured (7, 31) and unstructured (1h, 29 ; 13-21.) creaeed denial, interviews shoved characteristic alterations towards in- minutiae, displacement, stereotypy and repetitivemes, related to the degree of altered brain function (8.214). These changes were blocked or reversed by enticholinsrgic mlucinogm (21. ha) . Various perceptual tasks provided indices of behavioral, change and were related to the degree of altered brain function. These included the perception of cinulteneoue tactile figures (37; 3-16), color tigorcs (1:1). and stimli (17), embedded (Gottschsbdt) techistoaoopioelly exposed words (37) and embedded upsets or age, years of education, nativity and degree of stereotypy and conventionslity (measured by Column F Scale) were related to selection of therapy, duration or hospitalisation, e diegmeie and treetsent response in hospitalised patients (15, 36,. to, 1:5). Sooiopsyohologic 2. Nsmmmlogio—Adspuve mom-1e of Sonauc' Theron. Based on these studies, a hypothesis of the node of action of other psydxistx'ic therapies such as insulin coho, leucotoav and psychotropic drugs, was expressed (10, 33, 38). This View holds that the efficacy of these therapies depends upon the indiction of states of altered brain The become which prominent. in adoptive varying mttems my much, adaptive pettem is releted to the type, degree end duration of altered brain function, the personality of the subject, and tolersnoes end expectaflons of the environmnt. Elicitation of this Wthesis as applied to drug therapies is our in progmss, supported by uspm greats 111.2092 and 111-2715. ' ' �3. Eula Gena Thong. in iniflal case yettem e'mdy showed the significance both or denial and peraieten’e in insulin coma altered brain function for the behavioral change (3)} thenpy In an insulin chlorpruesim control stuck, no differences in hospital. immanent ratings were observed in the eve treatmnt gronpl (27). Chlorpruuine was eater, easier to administer, pernitted continued coma «- administration and allowed for greater degrees or concurrent relatimehip therapy then insulin insulin In. eon-a. These observations cm by psychotropic drugs led to a mlaoenent d in thin institution. Phameabherapz. in evelmting various peyohophamoeutieele is derived from then methane and linguistic analyses of intmenone of effects acute azhinietretien and chronic clinical emu-tration of variom nu compound: are in progress. EEG patterns, along such The ongoing program Mamie continue as eynehmiaatien-deeynahroniuflun and tmqnency units are being related to behavioral (21, 3h, The neuromyeiologic 141, 1:2) and linguistic changes (21, 1:3). basis of experimentally induced hallucinogenic etetee have also been interpreted as an alteration in synaptic chemical relations, such that the effective levels of cholinergic activity is decreased (ha). Initial work on this hypotheail (21. ha) in now being �WERE 195, 'mmWnumucm-mmw Mann WIWQWMWW. mwnmmmmmmmum mmuaummmmamrm; Mahatma! W mmummmmmmmm,m W, wmmmuarmmmm. mama“: “Wt. Mad. W3; and Mummmuwmeuvfl. awning” mmmuammwmwmmmmu WMoututmdm. �“Wm mmuwdmdmw. ammawmm mmnmummummmmmw wmmbfltwmm.ndatm,$m mmmummmm mmummumamm mwam-uwummmrw,ummm m.m,mmmmwmammsm WQMWQIWWWMSwtu-umw wwmmwammpammmmvs? “1959; nmumwwmmummm ammwmmmm,mmawmm ”www.mwmnuumm Wumnmwm.mmmuw mammwmaasgmmm nmnm,mmmtnmmmnm mamamwmtmmmmwmu:m -muramn.t.mnummungnrmmmww vmwmmmmmmma am QWWM.WWMW”M¢:M,10§ wmumu. mammmuamsmaumu Wuwmumdthynm. WWWufiMWq anti-Hum mmmmuumxmnmnmmmumm �Wfimmum, unlimpmmting Watfmofiu tho It»?! also participated in tho Intomtiml New W. Allied sum held in Mansion in m mm. and on cm: in out: during the your mama tin £111:an or George Knuth-gr,- am. :and Dmld P. mm, 11.1). "as to the Bowman Dr. mutt L. m. “hr the flares-Mao, htttommammumd'ma‘ mmucnof WW, waist of Dr. Hospital. mum POM, 11me Jam MW wanna. manning ammuummummpmh «ma tho patina: of Faculty Huber and Wu Director of the White Hanson at mums. mun mm confirming mmttorthommm obhinndfmamfioudot of mm Hum: of Dix-om, mm m the mm ham). mum at prom the mud sum mus mu: serum, and mu supper: from the Health Board of 13mm county. �Why Wm M aunt-m « .. 199 In I‘m. 11.». Ian-u 1. Dan. 11.8. mran-u. 3.3. L. in: am m. M. I. m1, W(up.W. I'd. M. m m. m 15.3. 3.9. mum”. unh- Mn. A. 3.». um. mun-emu, Maul am m (Wily) mu m (ham m) m m Mb (Win W) m m (mm) m um um (W) Wh‘ 'W) (W m Ann-cw. W ma:unm(W) Must. a um :- mm (mm) m(m~ml an. ' * ' (may) M M. m mm Jun mum �Hillside Hospital Department of Experimental Psychiatry Following is a chronologic list of the presentations and publications of the members of the Department of Emperimental Psychiatry during 1959. A. Publications: 1. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biological & Grune N. Y. pp. 18h-19h ed. Masserman, chiat P, Stratton, J., , (Fink; Egg. 2. Alteration of Brain Fpnction in Therapy. Psychopharmacology Frontiers, 6d. Kline, No, Little, Brown & COO, Boston, pp. 3 Fink, Mo .3. Significance of EEG Pattern Changes in Psychopharmacology. g(Fink, ) M. ). 2 : 398 (abst. Neurophysiol._ EEG Clin. h. Effect of Electroconvulsive Therapy on Intractabie Pain. A.M.A. Arch. Neurol. and Ps chiat. fil: 37-b2 (weinstein, E. A., Kahn, R. L., and Eargman, P.5. 5. Electroencephalographic and Behavioral Effects of Tofranil. Psych. Assoc. J. g; 1665-1718 (Fink, M.). 6. Canad. Psychological Factors Affecting Individual Differences in Behavioral Response to Convulsive Therapy, J. N.M. D. 128: 2h3-2h8 (Fink, M., Kahn, R. L., and Pollack, M.). 7. Effects of Diffuse Altered Brain Function on Perception, Phat Int. Con . Ps chol., Publ. North-Holland, Amsterdam, pp. 23 8- 239 (Fink, M., Kahn, R. L., and Korin, H. ). 8. Complex Visual Perception in Patients with Brain Tumor. Proc. XV Int. Con . Ps chol., Pub1.North-Holland, Amsterdam, pp. 2 33-237 (gander, M. B., Battersby, w. 3., and Pollack, M. ). 1/5/60 �9. Therapy of Schizophrenia: Role of Alteration of Brain Function on h92Behavior, Con ess Re orts II Int. Con . Ps chiat II: h93 (Abst. nk, M., Kahn, R. L., and Karin, H.5. 10. EEG of Seizures of and Duration to Degree Threshold Relationship of Delta Activity Induced During Electroshock, EEG. Clin. Neurophysiol. g: 399 (Abst.) (Green, M.). ll. Prognostic Application of Psychological Techniques in Convulsive Therapy, Dis. Nerv. Sys. g9: 180-184 (Kahn, R. L. and Pollack, M.). 12. Communication Networks in Freud's Interview Technique, Psych. Quat. 33: h56-h73 (Jeffe, J.). 13. Sociopsychologic ASpects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discha e Ratings and Diagnosis, A.M.A. Arch. Gen. Ps chiat. l5 565-S7h Kahn, R. L., Pollack, M., and Fink, M.5. Set in the Perception of Simultaneous Tactile Stimuli, Jour. Psychol. 12.: 38h-392 (Korin, H. and Fink, M.). The Role of Am. Perception Across Sensory Modalities, (Abst.) (Krauthamer, G.). Form Am. Psychol. lg; 396 16. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First International Congress of Neurolo ical Sciences (III: §EG Clinical Neurosfigsiology and Epilepsy5, PBrgamon, London, pp. 513—519 (Fink, M., Kahn, R.L., and Karin, H.). 17. Personality Factors in Behavioral Response to Electroshcnk Therapy, J. Neuropsychiatgy l; h5-h9 (Kahn, R. L. and fink, M=). 18. Symbolic Reorganization in Brain Injuries, in Handbook of Paychiatgy, ed. Arieti, 3., Basic BOOkS, No Yo, V01. I, pp. 9 "9 l (Weinstein, E. A. and Kahn, R. L.). �B. Presentations: l. EEG and Ebhavioral Effects of Tofranil, International Conference on Depression and Allied States, Montreal (Fink, M.). 2. Sociopsychologic Factors Affecting Therapist-Patient Relationships, American Academy of Psychoanalysis, Philadelphia (Kahn, R.L.). 3. Effect of Induced Cerebral Dysfunction in Man on Tachistoscopic Perception of Embedded Color Figures, Eastern Psychologic Association, Atlantic City (Pollack, M.). h. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction, Eastern Psychological Association, Atlantic City (Karp, E.). 5. Sociopsychologic Aspects of Peychiatric Treatment, Eastern R. (Kahn, L.). City Atlantic Association, Psychological 6. Language Patterns as Measures of Behavioral and Neurophysiologic Change, American Psychiatric Association, Philadelphia (Fink, M.). 7. Personality Correlates of (Krauthamer, G.). EEG, Metropolitan EEG Society, 8. Relation of Social Attitude to Psychiatric Treatment, Meeting, A.P.A., New York (Kahn, R.L.). 9. Comparison of New York N. Y. Divisional Intellectual Functioning in Childhood, Adolescent and Adult Schizophrenics, N. Y. Divisional Meeting, A.P A., (Pollack, M.). New York 10. Symposium on "Paycholinguistic Analysis of the Psychiai‘ic Interview", N. Y. Divisional Meeting, A.P.A., New York (Jaffe, :.). 11. Social Background and the Doctor-Patient Relationship, Acad. Psychoanalysis, New York (Jaffe, J.). �Hillside Hospital Department of Experimental Psychiatry Following is a chronologic list of the presentations and publications of the members of the Department of Experimental Psychiatry during 1959. A. Publications: 1. Effect of an Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy. Biological Ps chiat , ed. Masserman, J., Grune & Stratton, N. Y. pp. 18h-19h (F%:E, M.;. Alteration of Brain Function in Therapy. Psychopharmacology Frontiers, ed. Kline, N., Little, Brown & 00., Boston, pp. -3 , . . 3. Significance of EEG Pattern Changes in FBychopharmacology. g(Fink, ) M. ). 398 (abet. Neurophysiol._2: EEG Clin. . Effect of Electroconvulsive Therafig on Intr:1ctabm Pai A.M.A. Arch. Neurol. and ngchiat. Ql: 37- (weinstein, E. A., hahn, R. L., and rgman, P. . Electroencephalographic and Behavioral Effects of Tofrénil. Canad. 14.3 1663“].715 (Fink, Mo). ASSOC. J. szch. Psychological Factors Affecting Individual Differences in Behavioral Reaponse to Convulsive Therapy, J.N.M.D. lag; 2h3-2h8 (Fink, M., Kahn, R. L., and Pollack, M.). 7. Effects of Diffuse Altered Brain Function on PercWptio Prsc. XV Int. Con . P chol., Publ. North-Holland, Amsterdam, pp. 53 3- 239 (335E, M., Kahn, R. L., and Korin, H. ). Complex Visual Perception in Patients with Brain Tumor. Proc. XV Cong. Psychol., Publ. North-Holland, Amsterdam, pp. 2 33-?37 n er, M. B., Battersby, w. 3., and Pollack, M. ). 1/5/60 Int. �“beam, 9. Therapy of Schizophrenia: Behavior, h93 C as Re 14., Alteration of Brain Function on 1:92Con . Ps chia rts II Int. II: , H321 '£.""‘EER"', orinL", ‘. an hn, Role of 10. Relationship of Threshold and Duration of Seizures to Degree of EEG Delta Activity Induced During Electroshoclc, EEG. Olin. Neurophzsiol. _2_: 399 (Abst.) (Green, M.). 11. Progncs tic Application of Psychological Techniques in Convulsive Therapy, Dis. Nerv. Sys. g9: 180-184 (Kahn, R. L. and Pollack, M.). 12. Communication Networks in Freud’s Interview Technique, Psych. Bust. 23: 156-1473 (Jafi‘e, J.). 13. Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discha e Ratings and Diag10818, AeMeAe Arch. Gene P3 Chiate ;: 565-571; Kahn, Re Lo, Pollack, M. '. 14., and—Tink"—‘T, 1h. The Role of Set in the Perception of Simultaneous Tactile Stimuli, Am. Jour. Psychol. 1g: 38h-392 (Korin, H. and Fink, M.). tion Across Sensory Modalities, Psychol. 3;: 396 15. Form Perce 16. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First Internatior; 3.1 Congress of Neurolo ica3_Sciences (LII: EEG, Clinical Neurop._,jsiolog and Epilepsy), firgamon, London, pp. 13- 19 ink, M. , v-iahn, R.L., and Karin, H.) . (Abst. (Krauthamer, G.). Am. 1?. Personality Factors in Behavioral Response to Electroshntrk Therapy, J. Neuropgychiatg l: h5-h9 (Kahn, R. L. and :nk, ). 18. Symbolic Reorganization in Brain Injuries, in Handbook of Pa hia ed. Arieti, 3., Basic Books, N. Y., Vol. I, pp. '935-931 (Weinstein, E. A. and Kahn, Re Le). ; �B. Presentations: 1. EEG and Behavioral Effects of Tofranil, International Conference on Depression and Allied States, Montreal (Fink, M.). 2. Sociopsychologic Factors Affecting Therapist-Patient Relationships, American Academy of Psychoanalysis, Fhiladelphia (Kahn, R.L.). Man on Tachistoscopic Cerebral Induced in Dysfunction of 3. Effect Perception of Embedded Color Figures, Eastern Paychologic Association, Atlantic City (Pollack, M.). h. Behavioral Changes with Different Methods of Induced Cerebral Dysfunction, Eastern Psychological Association, Atlantic City (Karp, E0). 5. Sociopsychologic Aspects of Paychiatric Treatment, Eastern R. (Kahn, L.). City Atlantic Association, Psycholqgical 6. Language Patterns as Measures of Behavioral and Neurophysiologic M.). (Fink, American Fhiladelphia Association, Paychiatric Change, 7. Personality Correlates of (Krauthamer, G.). EEG, Metropolitan LEG Society, 8. Relation of Social Attitude to Psychiatric Treatment, Meeting, A.P.A., New York (Kahn, R.L.). 9. Comparison of New York N. Y. Divisional Intellectual Functioning in Childhood, Adolescent and Adult Schizophrenics, N. Y. Divisional Meeting, A.P,A., (Pollack, M.). New York 10. Symposium on "Pbycholinguistic Analysis of the Piychiai-ic Interview", N. Y. Divisional Meeting, A.P.A., New York (Jaffe, q.). 11. Social Background and the Doctor-Patient Relationship, Acad. Psychoanalysis, New York (Jaffe, J.). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-006 Date A point or period of time associated with an event in the lifecycle of the resource 1958-1959 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Department of experimental psychiatry annual reports; Letter acknowledging that Fink will receive the first A. E. Bennett Neuropsychiatric Research Foundation award; Newspaper clipping, Long Island Daily Press, Psychiatrists will honor L.I. Doctor; Lists of publications of the members of the department of experimental psychiatry; Newspaper clipping, MD Records Brain Waves of Patients; Summary 1954-1959; Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/c825cf38265f35eaf923d1fdede27f5a.pdf 8e37b7104043290b0428aed652df73e2 PDF Text Text Manhasseit Medical Center Hospital 4CZ54@/¢/;fié€rn.2%éui%§C}¢%;lfléd536/ c<lgeyi N ]E W Y O R K PEARL A.KLICK ADMINISTRATOR 35K TELEPHONE MANHASSET 7-4000 1: "VINE February 25, 1957 Dear Doctor: Quarterly Medical Staff Meeting of the Manhasset Medical Center Hospital will be held on Thursday, March 7, 1957, at 8:h5 P.M., promptly at THE ALLISON, 1583 Northern Boulevard, almost directly opposite the hospital. The PART faRT 1. Review and analysis of Clinical werk in the Surgical and Medical Sections for the month of December 1956, and the months of January, February 1957 inclusive. 2. A. Surgical Section - Ralph S. Emerson, M.D., Chairman B. Medical Section - 3 ‘§~ “ Lawrence S. Kryle, M.D., Chairman Tissue Committee Report - Howard L. walker, M.D., Chairman SCIENTIFIC PROGRAM - Arnold G. Blumberg, M.D., Chairman "THE TRANQUILIZERS IN PSYCHIATRIC PRACTICE AND THEIR APPLICATION TO GENERAL PRACTICE." Dr. Maximilian Fink Director of Research in Experimental Psychiatry Hillside Hospital, Glen Oaks, N. Y. COLLNTION. Respectfully yours, John G. Connell, M.D. President - Medical Board Telephone number The MA 0 Allison is 7"558’4v at Harry H. Abrahams, M.D. Secretary - Medical Board ~fig ��mmmwm,wmpmmmmmmmm at then obs-mum, w an both» that m. WW WMMwnwmmoma-pmiwhcwnmmw Mx «811.1% unit-(unmask mmmumtmwumatmimummmmm ”demhmlm,wmm mummmmmmmaMaummmmwm m Intact. 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H. emclmd that, in to 111M131: new therapy, ehloxpmine m mar, easier to aura contmlhbla in its effects. and had fmr $5.60 attach. We 3190 amended tint n9 evidame had appear“ in the fiftm math: a! the study that. either than” had altered thy basic. schiaaphmie process, nor did my real that either tom of therapy had a greater specificity far schizophnnie illnesses. At the concluaim of the stndy, the ladies). Biroctur placed in tin for» ulary and a um 13¢th a. its use 13m IV smut: mm”, the maidont staff. W: @10me During this” period Dr. Green has evalufld magma, for its ability to bring out debuts in brain mum. The "port. at his findings mm meant-ad at. the aid-winter muting of the Eutem lasaeiation of Bleetroancephalographam. dials :6. Pro «aka 8: It. is anticipated that tha mark now in prams: in we will continue for the remainder of the year. 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In addition to the panama]. listed 31am the Department the timofflwwtmport,mhmappointad, maparttimbasis, mm at. mm assistant in psychalngy. Dr. Pomek, who has his 111.11. from Kw York: University in 1955, has bean a mum-oh psychologist at tho Haunt Sinai Hospital and the 145mm rmdaum for emu Research for the past six Ha is experienced in both pamanauty and perceptual ”pants in march. years. It. in anticipatod that he will be appoint“ an 2. m1 tin basis on My 131:. A the individual differences in bahavior with specific ambush to study pram Pamela, as on tho perceptual and ation has been made pemmnty sweats has teen «“10de by his and applic- to various foundations for support. mauve April 131:, than will be appeintod to the Duparfanent, a Assistant for linguistic analyses. Under the hem of the E) funds warn and: mm“ x. devised ‘by m: 21:: «:1th Firm.” far a technical assistant he carry Dr. Jane. manna»! 1mm Grant (see out. Senna the language for Renaud: in Psyuhutry has gxmtad Dr. Jute sun or [26,919 plml $5,700 overhud far continuum Fund support for two years in than of the study “Language of the Dyna“ which has been dmlopod during hm past year. �flan MMMMmWVWWrmum. mama-mm «mumspm 1st. 3957 unmmmt. 1959. mmmmmummmmuwudmmwm mararmmawmmmwmam £100»,me mumwmmmxmm-mwmmwmzwnmm ammwmnmmummmsumw,wmmmm InWr,;mawrthammkqu atmmwmammmmmtmummm mummuuwnhumamunumsmmumwwm nmr,nr.ammmmnm mmmmw. inmwmmmmmwhgmwnwnmemum mm‘dWomx-l. kWawflmWfis dWWWWMMmmmmmammm in m Widv mom 153mm my. autism “MW tho Em MWMWtWamrdmmawvmmmuMmr flammmrmmu»hpoumha1umtorpnmumu an Week mum}: mama. th- smosy or Mom-1 WW, tho Inumhiml Wan of RM and the Imam-Mom}. 0mm! fer WW.‘ hmumnmmmmwwwumwunmmm ma for humfiml Puma? ”W4. Mm: WM: mum mummnnmmmmmammwnam thrmthMme,uthw-omcmmmmm summeodmga. Womanhmmmmmwupummmma mmwwm.hflo,umupmmungmormm mum»“momwmdummotmmrdmwmmmm Chum; �vammamwmmmmmmamw fowlmm. unnaommmwanmnmmum or J. Mt. 1: in Manny mm}. m 3mm mm: Dr. anti-u”. main mum” at. an mum Alma: mu mum means with an W Wthmmuthortmmmmho- W, matmwmmmmumum. of Dr. a mmmamnmsmvm‘mmmm Morn a: thin-Baum: an «an in an «Mama and m... other 19%. numtatmthm; WW: mwmmwmm. DnlgmmbmnmngtMpmbhmof smwwmmmmuhmm 0 Wm wmwammmw‘mflammwhmmm. mm puma pm: mm mm is um We Wm mmuwappmuwmmumm. hummmpmaaar with acumen ”mm. Elam during typu of no bu been mpcmm flu «mm-hock maniacal... 69min supports.“ an! that. and In thin new: be mmmwumum. Dr. 3. Fri-mm contributed mun-My to mmamm mm. mmmmmmwwmw. In WWmnodWMme,mmofmmmtmm mm m a may mm“ mm: m- m on at .m u» mam mm: mmmmmmmuw. Manama, WM” W 1913!! a: tum-3mm Mammary: Wm Max Pink. 11.13. �March 1957 Personality Factors in Behavioral Beeponse to Electroshock Therapy Robert L. Kahn, Ph. D. andMax Pink, From New 14. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by grant 14-927 of the National Institute of Mental Health, l“aficional Institutes of Health, APublic Health Service. Presented a the Electroshock Research Association, Chicago, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy is variable. In previous studies of the factors related to this variability we that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the e1ectroencephalogram.and the amobarbital test for brain disease (10), were most likely to show a clinical The (h) (6) which (7). improved rated was present study is an as response investigation of the role of personality in the behavioral reSponse. An explicit hypothesis concerning this relationship has been derived noted from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), that patients who we reported develop such language patterns as explicit denial of ill- and of and symptoms; displacement qualifitemporal Spatial personal, ness; cation, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) in their studies of neurological patients with cerebral dysfunction. They characteru ized this behavior as the "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "ex€M)On the of these the denial" basis verbal observations, personalit plicit hypothesis was advanced that those patients who most closely approximated this "explicit verbal denial" personality type would be more likely to havioral changes after The purpose EST show the be- which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reaponse to electroshock therapy show proved. differentiated; and patients with greater "denial" tendencies are more likely behavioral changes after electroshock therapy which are rated as imp 2) whether to can be �.2POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. staff, The selection of patients for treatment was made by the psychiatric independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of I47, and included 21 men and 142 women. METHOD Prior to treatment each patient was evaluated according to the following methods : l. Structured EM Interviews: Personality was evaluated in inter- patient' 3 family. At the opening of the interview, the relative was asked to describe, in his own words, the patient's usual interests and attitudes. The relatives were encouraged to talk about any aspect they wished, and the interviewer followed the trend of their talk, rather thm proceeding in a serial fashion. The interviewer asked questions, however, to been 15 obtain information in m described as charspecific areas which have views with members of the acteristic of the "explicit verbal denial" personality,“. The number and withgibrelative varied according to the degree of type of questions required spontaneous production and the infomant' 3 capacity to comprehend and 00mm:- icate. The informant was encouraged to give concrete examples of all state- ments. basic items included the presence and extent of each of the following features: 1) stress verbal symbols such as resolutions, homilies, cliches and The rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and property; 3) regard illness as an imperfection or disgrace, keeping neighbors, and are it a secret from the family and reluctant to seek medical care; troubles and are considered practical persons who )4) "shake off" their advise others; 5) have drive and compulsive energr, and are guilty or uneasy if own much not occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive . �.3to criticism, regarding it as an attack on their integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly affectionate or emotional; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; 1h) do not have temper outbursts; 15) and are not After the interview, each item if score of 0 was given 1 2 was rated on a 13) do not discuss sex openly; ludic (25). scale of 0, 1 or 2. A the aSpect was noted to a minimal degree; a score of indicated that the characteristic was moderately present; while a score of indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant score is termed the "denial personality score". 2. Clinical Evaluation: Each patient weekly intervals during and evaluation prior to and at following the course of treatment. The clinical was determined by was interviewed the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the pat- ient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: much improved, moderately improved, or unimproved, criteria outlined previously (6). 3. Language gtggy: In addition to the clinical interviews, following the each patient standardized series of questions determining his attitude was examined with a toward his illness. trouble?" and "If you Two of the questions asked were, “What is youi'mein had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim responses were analyzed for changes in language according to the method previously described (7). RESULTS The relatives of scores ranged from O h? patients were interviewed. The<ienia1 personality to 25, with a median of 11. For statistical comparison �.14- the patients were divided into two groups. Patients with scores ranging from 11 0 to to 25 were 10 were frm considered the "high denial" group, while those with scores classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews were most likely to be rated as much improved, and patients with low scores, however, the basis, with chance only one case was considered unimproved (Table 30% I). In clinical response rating occurred on a of the patients being regarded as mimproved. I TABLE Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Total Unimproved Personality Score 11 0 - 25 1h 9 1 2h 10 7 9 7 23 21 18 8 it? Total The proved difference in the denial scores between the patients, when compared sigzificant.* Although the much and moderately im- to the unimproved patients is statistically much improved patients have a higher mean score is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with than the moderately improved group, this difference low denial scores were also evaluated as showing a marked improvement. While trig/1:119 group of seven patients is a small one , certain common characteristics can be described. Although these subjects lack the competitive security needs of the high denial subjects, they or imaginative capacity or ability to think Si ~K- vb; { {ran-M at 1% level of confidence by show drive, prestige and a similar lack of creative critically of their Mann-Whitney U Test. own or other's �.5relate to the environment primarily by non-verbal forms of commmication. They are described by their families as laughing or crying feelings. They excessively; and as showing anger by muteness, ”go into a shell," ”walk out of the room in a huff,” or by violent tempers with table-pounding, throwing objects or direct physical assault. These patients are "ludic," by Weinstein and Kahn (12) to denote comic, language analysis described in a in clinical interviews term used tragic, or melodramatic behavior.* 1m: previous study (7), the 3. Personality score and Meg -a Applying the technic of i__n_ changes in language were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, £33. have been described as characteristically occurring after electroshock. ified according to the plicit language As in the previous study, each patient was class- dichotomy of whether or not he showed three or more ex- changes. Patients with high denial personality scores showed a greater number of language changes, than those with low denial personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes the 1% is .71, significant + at better than level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Langggge Changes 0 - 2 3 or more Personality Scores 11 .- 25 (20) 8 12 - (20) 17 3 25 15 o 10 Total This term was taken from Piaget who applied behavior of young children (8). *- it to the play and imitative �h. Illustrative Cases: Case 1. High Denial Personality Score: A 61-yearbold housewife was admitted to the hospital with a 15 history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her month surroundings, and wandering aimlessly about the ward. The patient reaponsible person with and was unable home. her husband as a conscientious, dependable, integrity. She had no hobbies, outside interests, was described by much to relax. She was ”mortally As a consequence, she busied herself with chores at afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she openly showed no affection or emotion, never discussed sex and rarely lost her temper. She had "a long memory for little things if she felt that she was wronged," a ”streak of stubborness," and would "just as soon hold another person responsible for her mistakes." She was proud and would ”rather go without food" than borrow or take money from others. According to the denial criteria, her score After 20 electroshock treatments, she was 20. became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doc"model" ”while her who, a reluctant to discuss her personal patient toi/called feelings, asserted that she had no difficulties at hue-'had home, a wonderful band.uho was very good to her, considered herself lucky and eagerly anticipated her discharge.” Case She was discharged with a 2. A Low rating of "much improved." Denial Personality Score: hl-year-old housewife was admitted to the hospital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission the patient �was' noted to pay little attention showed psychomotor The whom He it patient retardation and was was described by was not easy to her personal appearance, cried readily, circumstantial in speech. her husband as a "negative personality” with to get along because she was opinionated and argumentative. regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. An excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, however, she would become either completely mute, or "very nasty, just don't know any better.” Although considered a “cold" person, able to talk freely about sex. She frequently complained of physical implying you she was ailments and went to physicians readily. She was ”naive" and "unrealistic," believing, for example, that she had a flair for writing although others con- sidered her amateurish. Her personality score was rated as h. patient received eighteen electroshock treatments, which were terminated at her own insistence because she was too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed,” but The felt that hospital. it was doubtful that she could benefit from further treatment She was discharged with at the the recommendation for continued psychother- apy. DISCUSSION The structured family interview was designed to test the specific hypo- thesis derived from earlier observations that patients with the "explicit verbal denial” personality are most likely to Show both the language and behavioral changes to electroshock therapy which are rated as the examiner. The much improved by data supports this hypothesis and is also consistent with �the theory of the mode of action of electroshock therapy advanced by Weinstein, that “....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial is facilitated in characterologically Linn and Kahn in 1952 (9). They suggest diaposed individuals." The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. 0n the basis of the present data and methods of analysis a broader view of personality patterns in relation to improvement with as clinically EST is now possible. improved are characterized by such Those patients who are rated features as: l) non-empathic - unable to think critically or sensitively about the needs,feelings, or - commun- ications of others; 2) non-introspective - - unable to think critically about their own feelings or needs; unable to achieve insight even with the collaboration of others in a psychotherapeutic relationship; 3) rely heavily on nonverbal communication - - even tial when they are talkative there is little referenp communication, the words being cliched, stereotyped, or representative of feelings and emotions rather than transmitters of information and h) highly conventional - - without imaginative or creative capacity, and with few resources to deal with stressful or With re8pond new this pattern as the situations. common background, two classes of patients who to treatment can be defined: a) the driving, conscientious, independent, successful, emotionally-controlled person who can be characterized as the ”explicit verbal denial” personality type; b) the chronically inadequate, affectd::;;;&rfrom and ively labile ludic, dependent person, an impoverished socio- cultural background. While both types are rated as improved in their short tenm response to electroshock, preliminary folloWhup observations indicate that the "explicit verbal denial" personality type clinical response, while the Indie group is more likely to sustain the is likely to relapse quickly. �Consistent with our previous studies we have found that altered brain fun- ction is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change shown with altered brain function, however, vary markedly in different patients. ment of symptoms and are states, become withdrawn, Some Show mood rated as improved. Others develop paranoid agitated or show additional somatic or are rated as unimproved. In this study in those cases we who were memory complaints, and here stressed the personality factors whose behavioral reSponse was considered the patients changes and denial or diSplace- rated as improved. we have not rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information in this regard is minimal, as this problem has not'been approached with a specific hypothesis. raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support These observations the concept of a characteristic predepressed personality. Abraham (I) noted that states of depression occurred in obsessional persons. Arnot ‘2) describes depressions as being overly conscientious and perfectionistic. Hamilton and (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior....displayed a lack of imagination....narrow range of interests....thorough, cone Mann scientious, meticulous devotion to duty....lack of feeling for point of view of others....hard, uncompromising drivers....oversensitive....reserved.“ Cohen, et a1 (3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with prdblems of interpersonal relatedness; stereotyped; conventional; having for communicative interchange; and unaware of little capacity other persons' feelings toward �.10himself or of his feelings toward others. They emphasized the patients' inability to communicate verbally and suggested that the therapeutic relationship should be in nandverbal terms rather than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a that is pattern similar to those personality asPects which have been described as the "explicit verbal denial" personality. The factor of personality could thus most explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which to a depressive reaction are those which forms of therapy. These factors enable make him him make a person susceptible responsive to noneverbal to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism, and prestige-consciousness, which produce a catastrophic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed ”improved” by the family and the therapist. �SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electro- shock therapy were studied by means of a structured family interview. 2. The 3. The which results that aSpects of personality can be differentiated are significantly related to the response to treatment. show basic personality pattern of the patients who reSpond best can be characterized as a) non-empathic, b) non-introspective, c) communicate non- verbally, and d) highly conventional and stereotyped, with or creative capacity. h. 'Within the context of this of improved patients. One group is common little imaginative core, there are two main subdivisions comparable to the ”explicit verbal denial" personality, showingifizch features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chron- ically inadequate and dependent, coming from deprived socio-cultural back- grounds, who are affectively 5. labile and ludic. relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors The which contribute to a depressive reaction, contribute to a behavioral change under the conditions of altered brain function following electroshock therapy which is evaluated as improvement. �~12REFEEENCES 1. Abraham, K.: Selected Papers Press Ltd., 1919. Amot, on Psychoanalysis. London: The Hogarth Predepressed Personality, A.M.A. Arch. Neural. Chiato, L6: 617-618, 1956. The 12.: & Psy- 3., Baker, G., Cohen, R. A., From—Reichmam, F. and Weigert, E. V.: In Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 1.1: 103-137, 1951. Cohen, M. Pink, and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol., Q: 158, 1956. M. Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression (Hock, P. and Zubin, J. , eds.) , New York: Grune & Stratton, 199-209, 1952. L., Fink, M. and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, 11.14.11. Arch. Neurol. & Psydliato, 16-: 23-29, 1956. Kahn, R. 7. Kahn, R. L. and Fink, 14.: Changes in Language During Electroshock Therapy, in Psychopatholog of Commication (Hock, P. and Zubin, J. , Eds.) in press. ‘ 8. Piaget, J.: Play, Dreams and Imitation in Childhood. New York: W. W. 9. Weimtein, E. 1., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. PSYChiato’ 3:99.: 22.26, 1952. 10. Weinstein, E. A., Kahn, R. L., Sugaman, L. A. and Linn, 1a.: Diagnostic Use of Amobarbital Sodium ("Anwtal Sodium") in Organic Brain Dis- ease, ll. Weinstein, Am. J. Psychiat., 113: 889-891;, 1953. E. A. and Kahn, R. L.: Personality Factors in Denial of & A.M.A. Arch. Neural. Psychiat., 92: 355-367, 1953. ness, Ill- Weinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. , 2: 98-106, 1951;. 13. Weinstein, E. A. and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. Springfield, 111.: Charles C. Thomas, 1955. �April 1, 1957. MEMORANDUM TO: Medical Affairs Committee FOR: Dr. Joseph S. A. Miller FROM: Department of Experimental Psychiatry SUBJECT: 1957. 1956 to April 1, September of Departmental Activities, Report Experimental of the Department of the of activities following report since the period covering of’Dr. Miller, the submitted request at Psychiatry is The September 1956. A. Progress in Ongoing Projects: the evaluate The signifito control study Evaluation: 1. Electroshock be com1956, will on April 1, instituted electroshock therapy, cant elements in been has been have studied. It 1957. Seventy patients pleted by the end of’May the electrointo insights have we and gained significant successful a most group, made 1955-56, in observation, the we original verified shock process. First, dethe is electroshock therapy behavior in in change that the prerequisite for function. brain in and sustained alteration degree velopment of a significant Under the conditions of altered brain function, however, patients respond in electroshock is follows that the improvement In some patients, various ways. the that was opinion our It disappears. rapidly while in others, it sustained, observations. these determinant in instrumental the was patient's personality in the of patients the personality studied have intensively we For this reason standard interview developed tests, this last group. By applying specially have we number of questionnaire tests, and a modifying psychological tests, and of type between personality the number of relationships determined a behavioral the we At predicting are time, the present behavioral response. and during our predictions electroshock to therapy, the of patients response As a result chance. than better been have months significantly the past few include to personality extend study our to we planning are of these observations, G). Section (see results psychotherapy in factors changes the been has perceptual of patients Our second interest in this group to deable have been we control of a By group, virtue induced by electroshock. and those treatment the to related which are changes termine those perceptual im— been have we In these observations, which are related to practice effects. and their the of the patients personality close interrelation.bf the pressed by two so behavior of is The these of aspects interrelation perceptual processes. in differences individual of undertake study a decided have to we close, that under the behavior eventual to such differences and to relate hope perception 0). Section (see function brain of altered special conditions Our which electroshock therapy of concept a to have led develop us studies Electrotreatment unit. of this management the in has been of significant help which function brain in induces changes treatment. It shock is a non-specific Under these two months. than less of usually time, persist for varying lengths depending environment different in ways to his the responds patient conditions, his he to better 'With relates certain a personality, upon his personality. �-2The and better that he relates to to other his patients. family, therapist, other people the less reason is there-for him to become tense, anxious or 6nce the feeling of well-being is set into motion, it is sustained depressed. by the patient's better ability to function with others. Electroshock therapy is not a specific treatment for a specific fbrm of mental illness. 2. Biochemical Changes in Electroshock: In the course of these studies of electroshock, we noted that other investigators had reported that there were and the one report fluid after in trauma, in Spinal changes enzymes specific noted similar changes after electroshock. Dr. Goldenberg and I undertook a study of these enzymes in order to verify the previous reports and to clarify our own picture of the electroshock process. To date, we have collected 30 spinal fluids. I anticipate that this phase of the work will continue until the end of 1957. 3. Communication Studies: Our interest in communication problems has led to two types of studies. In one, Dr. J. Jaffe has developed a technique for the analysis of recorded interviews which provides us with an objective index of change in behavior. Support for this phase of the work has been obtained from the Foundations' Fund for Research in Psychiatry. At present, he is analyzing the recordings of interviews with electroshock patients made earlier in the year, and his findings are correlating very well with the clinical results. we antiand the in of language changes to an technique analysis this applying cipate behavior that occur in ps;chotherapeutic interviews. analysis of the structured amytal test intero views according to changes in syntax and content. The original findings of this study were presented to the AmeriCan Psychopathological Association in June. Since then, all our amytal test interviews are being analyzed in like fashion and the original findings have been verified and amplified. ”e have come to understand that the language of our patients tells us readily whether or not changes have occurred in brain function and in behavior. Furthermore, correlations between the personality evaluations and the language changes have shown a direct relationship between high degree language changes and certain personwith other personality types. and changes minimal-to-no language types; ality Language is thus a recordable facet of behavior and we are ODtlmiStiC that a combination of the language analyses developed by Drs. Jaffe and Kahn would be a meaningful index of changes in behavior applicable to any form of psychiatric therapy, including psychotherapy. h. Egrebral Reactivity: As described in the previous report, our interest in the question of individual variability in cerebral reactivity has been stimulated by our electroshock studies. One part of this study is the A second is the study of the biochemical in changes fluid. of spinal study rate of development of electroencephalographic change induced by electroshock. Dr. Green has begun this phase of the work and since September has surveyed all EEG basic of their by records, and their an electroshock analysis our patients been has Mcgimide to the cerebral to Also, response hyperventilation. reSponse A second study is a language assessed and this phase of the work completed (see Section B). Beginning in May, the admissions new hOSpital the to that will screen is laboratory anticipated it and that various activation procedures will be tested, so that the definitive study can be undertaken in the Fall. Concurrently, Dr. Green has assessed the relationship between the electroshock seizure threshhold and cranial resistance as factors influencing the development of electroencephalographic abnormality. This study is in progress. �.3This study, under the direction of Dr. Sidney TaraNew York have and been before the the observations continued has presented chow, Neurological Society in January. The observations have been summarized in a reand A.M.A. Archives of which Neurology the in Psychiatry. will shortly appear port S. B. Ambivalence: Completed Projects: 1. Chlorpromazine-Insulin Coma: Control Study: An interim report on the results of this control study was submitted to the Research Committee of the Medical Board on January 31, 1957. In this study, 59 patients referred for insulin coma were divided into two groups - one-half receiving insulin coma and the other half receiving chlorpromazine therapy. It was our conclusion that chlorpromazine is as effective in modifying psychotic behavior patterns as insulin coma therapy. There was a tendency for the discharge ratings to be better for the chlorpromazine ,we to concluded insulin in comparison coma the than for insulin that, group. group coma therapy, chlorpromazine was safer, easier to administer, more controllable in had Tb evidence concluded had no also and that fewer side effects. apits effects, peared in the fifteen months of the study that either therapy had altered the basic schizophrenic process, nor did we feel that either form of therapy had a greater specificity for schizophrenic illnesses. At the conclusion of the study, the Medical Director placed chlorpromazine in the formulary and permitted its use by the Resident staff. Insulin Coma 2. Megimide Evaluation: During this period, Dr. Green has evaluated a new agent in electroencephalography, megimide, for its ability to bring out defects in brain function. The report of his findings Twere presented at the midwinter meeting of the Eastern Association of Electroencephalographers. 0. Projected Studies It is . 1957-58: in progress in the Department will The electroshock evaluation study will be completed this Spring and the next few months will be spent in correlating the information obtained and writing the reports. As indicated in the ongoing and have of studies these out number of developments grown it a progress notes, is anticipated that these will be incorporated in the_active research program. anticipated that the work continue for the remainder of the year. now A Behavioral Reapgggg: protocol has been 1. £ndividual_Differences in developed by Dr. Max Pollack, which incorporates the problem of personality affecting individual responsivity to electroshock. By determining the subject's patterns of perception in specially developed orientation and visual tasks, we hope to demonstrate a relationship between these patterns and the behavioral response, both under the special condition of altered brain function, and the general condition of hospitalization and psychotherapy. Such a study has bearing on the problems of the personality aspects of resistance to change in behavior under stressful conditions (as in forceful indoctrination, isolation, starvation); as well as the definition of suitable candidates for various psychiatric therapies. 2. Personality Factors in Doctor and Patient Affecting Choice of Thera : Our experiences with electroshock have led us to a unmber of hypotheses which relate personality factors in the patient and the therapist affecting the choice of treatment. We are in the process of developing our ideas into a workable hypothesis. We anticipate undertaking such a study by the end of the year. �D. Changes in rersonnelz- Since the last re\ort, this section has been redesignated as the Department the of time the at the to personnel In addition listed of Experimental Psychiatry. Max Research Dr. as Pollack, a have on we part-time basis, appointed, last report, New York from who University has his_Ph.D. Dr. Pollack, Assistant in Psychology. and mount the Sinai Hospital the at research been has psychologist a in 1955, He is experienced the six for Research Child past years. Ittleson Foundation for he that is anticipated research. in and It perceptual aspects in both personality A the indito study July on program basis a full-time be on lst. appointed will and the on perceptual personemphasis with behavior specific vidual differences in made various been has to and him been application by developed ality aspects has foundations for support. Technical a the be to Department, appointed will there Effective April let, FFRP (see Section Grant Under the of terms the analyses. Assistant for linguistic E) funds were made available for a technical assistant to carry out the language measurements devised by Dr. Jaffe. E. Funds: Foundations' Fund for Research in Psychiatry has granted Dr. Jaffe continuation overhead for h5,700 a26,000 of sum plus two the in years support for the been has developed during which past year. Dyad" the of "Languahe the of study FFRP The Kaufmann Foundation. grant will exthe This work had been supported by tend from April 1, 1957 to March 31, 1959. Health Mental fbr of National made Institute the been to have Applications subthe Green. Dr. protocol Also, work by undertaken of support for the program of Division and Development Research the to been has sent Pollack mitted by Dr. FoundaMalina and the to Army, States United the of the Surgeon-General's Office The tion. F. Publications and rresentations: In November, a summary of our studies on electroshock was presented at the Montreal a in Association in report American the Psychiatric of Meeting Divisional FollowChange Behavioral to Function Brain Altered entitled "Relation of Tests of "Electroencephalothe Green Dr. report December, presented Electroshock". In ing Electroenceh of Association Eastern the Negimide" at of Lffects and Clinical graphic studies during the of electroencephalographic In a summary February phalographers. Differences in "Individual entitled a two in was report presented the past years EEG Besponsivity" before the Metropolitan EEG Society. The Department has submitted a number of reports to various societies for the the at for been have presentation accepted Summer Papers and meetings. Spring the Psychiatry, of Biological Society the Research Association, Electroshock International Congress of Psychology and the International Congress for Psychiatry. American the Psysymposia at in to been have invited participate In addition, we These meetings. for Psychiatry International Congress and chiatric Association Department of this the experiences considerable detail summarize in reports will and to electroshock to with regard and two one-half specific the years, past over methods of the language anato have we present an opportunity also will drugs. to as some of our speculations well as presenting Dr. as devised by Jaffe, lysis the role and mode of action of the newer drug therapies in psychiatry. �G. Educationi_ Various members of this Department are continuing their education by formal courses. Dr. H. Korin has been enrolled in courses at the Graduate School of New York University with specific emphasis on statistics. Dr. J. Jaffe is completing the formal training requirements at the William Alanson White Institute of Psychoanalysis. Dr. Robert L. Kahn has been accepted for training in psychoanalysis at the William Alanson White Institute. H. Other Activities: 1. Israel Strauss November 1953. and Members Volume: The Israel Strauss Volume appeared in of this Department were active in the development fulfillment of that volume. 2. Resident Training: Since September 1956, two Residents have worked H. Esecover has been studying the problem of Dr. the in Department. actively psychotherapy with electroshock patients. In this study he has been supervised He made. has have been number conclusions and of a members the Deiartment of by demonstrated that patients differ considerably during the electroshock process and that no single type of psychotherapy is meaningful. Certain supportive and He is now in the process of have value. definite may approaches interpretive describing his observations. Dr. S. Friedman has contributed considerably to the ambivalence study. this work he was supervised by Dr. Tarachow. In During the period September to February, members of the Department participated in a weekly lecture series for the Resident staff on the subjects of research methodology and newer trends in psychiatry. Respectfully submitted, Max MFzgw Department of Experimental l’sychiatry _ flillside Hospital Glen Oaks, New York Fink, M.D . �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH JOSEPH S. A. MILLER, 75-59 263m: M. D. STREET. GLEN OAKS. NEw YORK FIELD STONE Medical Director LEON $7500 Lowwsrm Honorary Chairman Board of Directors SIMON KWALWASSER, M. D. ROY FOSTER Assoc. Medical Director Chairman Board Of Directors MAURICE BACHRACE Administrator E. COLEMAN President ALVIN Dear Sir : basis for the discussion of the research activities at the meeting of the Medical Affairs Committee on Monday, April 8th, I am herewith enclosing the following memoranda= As a 1. Report of Dr. Fink for the Department of Experimental Psychiatry. 2. Research activities in the Department of Biochemistry, by Dr. Harry Goldenberg. 3. Research in the Department of Medicine, by Dr. Arnold G. Blumberg Aside from the regular Medical Board members of the Medical Affairs Coxmnittee, there will also be present Dr. H. L. Rachlin, Chairman of the Research Comittee of the Medical Board and Dr. Max Fink, Director of the Department of Experimental t’sychia’cry. Yours sincerely, f4,WIM, Joseph S.A.Miller, M.D. JSJALI: 11b Medical Director encl. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �April 1, 1957. MEMORANDUM TO: Medical Affairs Committee FOR: Dr. Joseph S. A. Miller FROM: Department of Experimental Psychiatry SUBJECT: Report of Departmental Activities, September 1956 to April 1, 1957. Experimental of the Department of the activities of following report since the period ofHDr. covering Miller, the request Psychiatry is submitted at The September 1956. A. Proggess in Ongoing Projects: the evaluate The signifito control study Evaluation: 1. Electroshock be com1956, will on April 1, instituted electroshock therapy, cant elements in been has studied. been have It pleted by the end ofTMay 1957. Seventy patients the electrointo insights have we and significant gained a most successful group, made 1955-56, in observation, the we original verified shock process. First, the deis electroshock therapy behavior in in change that the prerequisite for function. brain in and sustained alteration velopment of a significant degree Under the conditions of altered brain function, however, patients respond in electroshock is follows that improvement the In some patients, various ways. that the was opinion our It disappears. rapidly while in others, it sustained, observations. these in determinant instrumental the was patient's personality in the of patients the personality For this reason we have studied intensively standard interview developed tests, this last group. By applying specially have we number of questionnaire tests, a and modifying psychological tests, and of type between personality the number of relationships determined a behavioral the we predicting are At the present time, behavioral response. and during our predictions electroshock therapy, to reSponse of the patients As a result chance. than better been have significantly the past few months include to personality extend study our to we planning are of these Observations, G). Section (see results factors in psychotherapy changes the been perceptual has of patients Our second interest in this group deto able been have we control a group, induced by electroshock. By virtue of and those treatment the to which related are termine those perceptual changes imbeen have we In these observations, which are related to practice effects. and their the of patients the personality interrelation.of close the pressed by so behavior two is of The of these aspects interrelation perceptual processes. in differences individual of undertake study a decided to close, that we have under the behavior eventual to such differences and to relate hope perception G). Section (see function brain special conditions of altered which electroshock therapy of a concept to develop have led us Our studies Electrotreatment unit. this of management the in has been of significant help which function brain in changes induces shock is a non-specific treatment. It Under these two months. than less of usually time, persist for varying lengths depending environment different ways in his to responds the patient conditions, his to he better relates With certain a personality, upon his personality. �-2— family, his therapist, and to other patients. The better that he relates to other people, the less reason is there for him to become tense, anxious or depressed. Once the feeling of well-being is set into motion, it is sustained by the patient's better ability to function with others. Electroshock therapy is not a specific treatment for a specific form of mental illness. 2. Biochemical Changes in Electroshock: In the course of these studies of electroshock, we noted that other investigators had reported that there were Specific changes in enzymes in the spinal fluid after trauma, and one report noted similar changes after electroshock. Dr. Goldenberg and I undertook a study of these enzymes in order to verify the previous reports and to clarify our own picture of the electroshock process. To date, we have collected 30 spinal fluids. I anticipate that this phase of the work will continue until the end of 1957. Communication Studies: interest in communication problems has led to two types of studies. Tn one, Dr. J. Jaffe has developed a technique for the analysis of recorded interviews which provides us with an objective index of change in behavior. Support for this phase of the work has been obtained from the Foundations' Fund for Research in Psychiatry. At present, he is analyzing 3. Our the recordings of interviews with electroshock patients made earlier in the year, and his findings are correlating very well with the clinical results. we antiand the in of language changes to an technique analysis this applying cipate behavior that occur in pa chotherapeutic interviews. analysis of the structured amytal test interviews according to changes in syntax and content. The original findings of this study were presented to the American Psychopathological Association in June. Since then, all our amytal test interviews are being analyzed in like fashion and the original findings have been verified and amplified. We have come to understand that the language of our patients tells us readily whether or not changes have occurred in brain function and in behavior. Furthermore, correlations between the personality evaluations and the language changes have shown a direct relationship between high degree language changes and certain personality types; and minimalvto-no language changes with other personality types. Language is thus a recordable facet of behavior and we are optimistic that a combination of the language analyses developed by Drs. Jaffe and Iahn would be a meaningful index of changes in behavior applicable to any form of psychiatric therapy, including psychotherapy. h. Egrebral Reactivity: As described in the previous report, our interest in the question of individual variability in cerebral reactivity has been stimulated by our electroshock studies. One part of this study is the A second is the study of the biochemical in of changes spinal fluid. study rate of development of electroencephalographic change induced by electroshock. Dr. Green has begun this phase of the work and since September has surveyed all our electroshock patients by an analysis of their basic EEG records, and their reSponse to hyperventilation. Also, the cerebral response to Mcgimide has been assessed and this phase of the work completed (see Section B). Beginning in May, is anticipated that the laboratory will screen new admissions to the hospital it and that various activation procedures will be tested, so that the definitive study can be undertaken in the Fall. A second study is a language Concurrently, Dr. Green has assessed the relationship between the electroshock seizure threshhold and cranial resistance as factors influencing the development of electroencephalographic abnormality. This study is in progress. �.3’ 5. Ambivalence: This study, under the direction of Dr. Sidney TaraNew York have before been and the the observations presented chow, has continued Neurological Society in January. The observations have been summarized in a report which will appear shortly in the A.M.A. Archives of Neurology and Psychiatry. B. Completed Progects: 1. Chlorpromazine-Insulin Coma: Control Study: An interim report on the results of this control study was submitted to the Research Committee of the Medical Board on January 31, 1957. In this study, 59 patients referred for insulin coma were divided into two groups - one-half receiving insulin coma and the other half receiving chlorpromazine therapy. It was our conclusion that chlorpromazine is as effective in modifying psychotic behavior patterns as insulin coma therapy. There was a tendency for the discharge ratings to be better fer the chlorprcmazine we concluded that, in comparison to insulin coma the than for insulin group. group coma therapy, chlorpromazine was safer, easier to administer, more controllable in had evidence concluded had no ‘b that also fewer and side apeffects. its effects, peared in the fifteen months of the study that either therapy had altered the basic schizophrenic process, nor did we feel that either form of therapy had a greater specificity for schizophrenic illnesses. At the conclusion of the study, the Medical Director placed chlorpromazine in the formulary and permitted its use by the Resident staff. Insulin Coma 2. Megimide Evaluation: During this period, Dr. Green has evaluated a new agent in electroencephalography, megimide, for its ability to bring out demidTJere the The of his findinas at presented function. brain in report fects winter meeting of the Eastern.Association of Electroencephalographers. C. Projected Studies 7 l9§7~§8: the work now in the in Department will that progress anticipated is It continue for the remainder of the year. The electroshock evaluation study will be completed this Spring and the next few months will be spent in correlating the information obtained and writing the reports. As indicated in the ongoing and have of studies these out number of developments grown it a progress notes, is anticipated that these will be incorporated in the active research program. A i“Response: Behavioral protocol has been 1. lgdividual Differences in IVia}: Dr. Pollack, which incorporates the problem of personality affectdeveloped by ing individual responsivity to electroshock. By determining the subject's patterns of perception in specially developed orientation and visual tasks, we hOpe to demonstrate a relationship between these patterns and the behavioral response, both under the special condition of altered brain function, and the general condition of hospitalization and psychotherapy. Such a study has bearing on the problems of the personality aspects of resistance to change in behavior under stressful conditions (as in forceful indoctrination, isolation, starvation); as well as the definition of suitable candidates for various psychiatric therapies. 2. Personality Factors in Doctor and Patient Affecting Choice of Therapy: Our experiences with electroshock have led us to a number of hypotheses which relate personality factors in the patient and the therapist affecting the choice of treatment. We are in the process of developing our ideas into a workable hypothesis. We anticipate undertaking such a study by the end of the year. 17 , 914.4 f 3 f 1 b Va. 1,5 _. �D. Changes in Fersonnel: the Department been as has redesignated section this Since the last re ort, the time of the at listed the personnel to In addition of Experimental Psychiatry. Max Research as Dr. Pollack, a basis, last report, we have appointed, on part-time New York University from Ph.D. who has Dr. Pollack, his Assistant in Psychologr. and the mount Sinai Hospital the at in 1955, has been a research psychologist He is experienced six the Research for past years. Ittleson Foundation for Child he that anticipated is It in both personality and perceptual aspects in research. A program to study the indiJuly on basis lst. on the perceptual and personwill be appointed on a full-time vidual differences in behavior with Specific emphasis made various been to has and him by application been developed ality aspects has foundations for support. Technical a the Department, to be appointed will there Effective April lst, FFRP Section (see Grant of the Under terms the Assistant for linguistic analyses. the language out to assistant technical a carry made for available E) fUnds were measurements devised by Dr. Jaffe. 3- £211.42: Dr. Jaffe has granted Fund Research Psychiatry Foundations' in for The continuation overhead for $5,700 u26,000 of plus sum the two years in support for the been during past developed has which year. Dyad" the of "Languace the of study FFRP The will Fbundation. exKaufmann grant the by been had work supported This tend from April 1, 1957 to March 31, 1959. Health Mental for of National made Institute the to been Applications have subthe Green. protocol Dr. Also, by work undertaken support for the program of of Division and Development Research the to been sent mitted by Dr. Pollack has FoundaMalino and the to Army, States United the Surgeon-General's Office of the tion. F. Publications and Presentations: the at was presented electroshock on studies of our In November, a summary Montreal a in Association report in American Psychiatric the of Meeting Divisional FollowChange Behavioral to Function Brain entitled "Relation of Tests of Altered "Electroencephalothe Green report Dr. presented December, Electroshock". In ing Electroenceb of Association Eastern the Megimide" of at graphic and Clinical Lffects during studies electroencephalographic the of In a February summary phalographers. Differences in "Individual entitled a in report two was presented the past years EEG Besponsivity" before the Metropolitan EEG Society. the for societies various to number of submitted a reports The Department has the at for been have presentation accepted Summer meetings. Papers Spring and the Psychiatry, Biological of Society the Research Association, Electroshock for Congress Psychiatry. International and the Psychology of Congress International Psy— American the symposia at in In addition, we have been invited to participate These meetings. for Psychiatry International Congress and chiatric Association Department of this the experiences detail considerable summarize in reports will and to electroshock to regard with and one-half specific two years, over the past methods of anathe language to present have we an opportunity also will drugs. to as some of our speculations well as presenting lysis devised by Dr. Jaffe, as in psychiatry. therapies the newer drug of mode and of action the role �-5G. Education: Various members of this Department are continuing their education by formal courses. Dr. H. Korin has been enrolled in courses at the Graduate School of New York University with specific emphasis on statistics. Dr. J. Jaffe is completing the formal training requirements at the William Alanson White Institute of Psychoanalysis. Dr. Robert L. Kahn has been accepted for training in psychoanalysis at the William Alanson White Institute. H. Other Activities: 1. Israel Strauss Volume: November 1955. and Members The Israel Strauss Volume appeared in of this Department were active in the development fulfillment of that volume. 2. Resident Training: Since September 1956, two Residents have worked H. Dr. Esecover has been studying the problem of the in Departnent. actively psychotherapy with electroshock patients. In this study he has been supervised He has made. have been number and conclusions of a members of the Department by demonstrated that patients differ considerably during the electroshock process and that no single type of psychotherapy is meaningful. Certain supportive and He of the now have in value. is definite process may approaches interpretive describing his observations. Dr. S. Friedman has contributed considerably to the ambivalence study. this yprk he was supervised by Dr. Tarachow. In During the period September to February, members of the Department participated in a weekly lecture series for the Resident staff on the subjects of research methodology and newer trends in psychiatry. Respectfully submitted, Max MFzgw Department of Experimental i"sychiatry > hillside Hospital Glen Oaks, New York Fink, M.D. �April 1, 1957 Medical Affairs Cummittee TO: For: Dr. Joseph S.A.Miller From: Department of Biochemistry Subject: Report of Departmental Activities, July 1956 to March 31, 1957. Steroid Studies Studies were continued on the steroid hormones because of their importance in the physiological response to stress. Experiments with rats showed that the liver converts neutral and sex hormones to their sulfate conjugates which are subsequently voided in the urine. Female rat~ liver was far more active than male preparations in conjugating the steroids, particularly the male hormones. These findings indicate that the liver plays a major role in the maintaining hormonal balance, femalssbeing endowed with a regulatory device to dispose of excess male hormones produced in their bodies. Urinary steroid sulfate excretion studies on human subjects were carried out The and total chromatographic techniques. complexation with our newly developed sulfate output was found to be related to both sex and age. Interesting results were obtained with urine from schizophrenics, the level of one fraction (dehydronumber of cases. elevated sulfate) in a being epiandrosterone Drugs and Alkaloids New colorimetric, chromatographic electrophoretic techniques were establipsychothenpeutic drugs. These were recently and for both the psychotomimetic and presented at the American Chemical Society shed Meeting (Brooklyn, February 15, 1957). findings are now being applied to determining the role of trace urinary alkaloids in schizophrenia. our earlier chlorpromazine studies, which were dropped for lack of suitable instrumentation, are again under way with financial help from the National Institutes much throws because The of interest it light on Health. is ver great of subject from the be which cannot gained (microsome action gross liver function liver function tests in currentuse. we find the chlorpromazine molecule is in many ways The from information gleaned to some in isotopes. ways ideal superior an tracer, this study would also throw light on the Akerfeldt "six~minute blood test for from whether suffer a decide schizophrenics should to and us help schizophrenia" defect in oxidative metabolism leading to the in vivo production of hailucinogens. The Electroshock Lavels Therapy. in gholinesterase Earlier investi ations by Tower and others have indicated demonstrable changes in acetylcholine, acetylcholinesterase, and pseudocholinesterase in spinal fluid following electroshock therapy as well as other forms of head trauma. AccordingEEG of have to correlate undertaken Fink patients and Ur. patterns associates ly, EST values cholinesterase in concurrent and with alterations after during before, of spinal fluid. Simultaneous serum cholinesterase determinations on these patients blood red to extend these studies and cell we to carried plan also being out, are (true)cholinesterase. The specific enzyme methods in use were developed at Hillside Hospital and have recently been presented at the American Chemical Society Meeting in Brooklyn. Further reference is made to Dr. Fink's progress report for findings to date. Future plans: More of the same. Harry Goldenberg, Ph.D. �April 1, 1957. Medical Affairs Committee TO For: Dr. Joseph S.A.Miller From: Department of'Medicine subject: Report of Departmental Activities, July 1956 to March 31, 1957. to of An the patients of psychiatric Test: response l. Mecholylof mecholyl analysis between correlation a revealed has striking subcutaneously injections electroshock to and therapy. and diagnosis response age, response have machine blood recording automatic of an studies pressure 2. Preliminary machine for and of this the evaluate practicability to out accuracy been carried now seems As these of result a studies, the work mecholyl it test. on further of the evaluate to used be reproducibility machine usefully can likely that this the mecholyl test. 3. Drug evaluation studies on meprobamate are being carried out. h. Chemical studies with the laboratory department are being conducted on possible hepato-toxic effects of chlorpromazine in our patients. Proposed Research for the coming year: 1. Evaluation of meprobamate in psychiatric patients. three months). 2. (to be completed within Evaluation of reproducibility of mecholyl test employing a recording sphygmo- mamometer. by chromatographic with therapy chlorpromazine alterations of Evaluation 3. protein techniques. h. Evaluation of or Trilafon. a substitute fbr chlorpromazine. This will be either Spafiine Arnold Blumberg, M.D. �HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH JOSEPH S. A. MILLER, 75-59 263RD M. D. STREET. GLEN OAKS. NEw YORK FIELDSTONE Medical Director LEON LOWENSTEIN 3-7800 Honorary Chairman Board of Directors M. D. Assoc. Medical Director SIMON KWALWASSER, ROY FOSTER Chairman Board of Directors MAURICE BACHRACH E. COLEMAN President Administrator ALVIN A Proposed Study for the Behavioral Max From Assay of New Drugs Fink M.D. the Department of Experimental PBychiatny October 30, 1957. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �AProposed Study for theBehavi9ralwg§§ay of New Dm mgs MaxFi‘nk M.D. * 1 . Problem: is little disagreement that the newer psychopharmamode of these drugs of action the behavior, alter cological agents and factors in the marked individual variability in response are unresolved problems. Difficulty in resolving these problems lies, While there in part, in the lack of a theoretic framework subject to operational the is assay perplexing and Particularly experimentation. analysis of new, i;g., clinically untested agents capable of altering behavior. Many the because reports are to assess studies difficult are present and classifications nosologic defined; the poorly population subjective; are unsatisfactory. Based on our previous studies, we have expressed the hypothesis that the efficacy of psychopharmacological agents in psychotic states measurable changes induce to persistent to their related ability is in cerebral function (1). Such alteration in cerebral function provides the milieu for changes in adaptation of the patient in his environmento In this view, alterations in cerebral function following drug administration are not "complications," or "untoward but the sing SEE 293 of the mode effects," of action of these therapies. Changes condition not sufficient but a a cerebral are physiology in necessary, for improvement. * Director, Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. �,2This hypothesis is a direct outgrowth of four years of experimental investigations of electrcconvulsive, insulin coma and various drug therapies in use at Hillside Hospital. These studies are summarized in the appended report (1). we have used a wide t variety of measures of brain function (2, 3, h, 10, 12). Most successful have been changes in the frequency spectrum of the EEG, patterns of language and perceptual tasks. In our experiences with electroshock, slowing of most EEG frequencies has been helpful (2). In drug studies, however, this is less prominent, although fundamental; Language and perceptual tests, however, have given us clues as to ways of measuring brain changes, more subtle than present electroencephalographic techniques. It is this study to logic agents according to their effects the purpose of patterns and on perceptual tasks. to test the following: The compare various psychopharmacoon the study EEG, on language is specifically designed I (a) Can the extent of behavioral change in psychopharmacologic agents be related to the degree of (b) To EEG spectrum changes? what extent can visual discrimination measures of changes in language be tests, and refined to provide reliable, predictablezueasures of changes in clinical behavior? (c) To what extent can such measures predict the clinical usefulness of psychopharmacologic agents? �II. Method: 1. Subjects: All subjects are drawn from the adult impatient service of the Hillside Hospital. In general, these patients are erative, well educated good physical health. intelligent. All are and alert, coopT ambulatory and in 2. Procedure: Two methods of drug assay are in progress. (a) Acutg_Experiments: In the laboratory setting, with simultaneous EEG and language recording in process, single intravenous or oral doses of drugs are administered. the period of drug Patients are under constant observation for activity. (b) Clinical Experiments: Patients are referred by their therapist to the super- vising psychiatrist for treatment with psychopharmacologic agents. Prior to drug administration, EEG and language recording interviews are held. Perceptual tasks are completed. Drug administration then until toxicity is manifest, and drug reduced to a maintenance dose. Testing is repeated, and be- proceeds dosage at a rapid increment havioral observations made, at frequent, defined intervals. in previousstudies, subjects are randomly divided into As groups - an experimental and a control. The experimental group receives the medication, the control group placebo medication. two �3. measurements: (a) 33.29. is Recording with an 8 channel Medcraft instrument in progress. Records have been visually analyzed for changes in frequency, voltage, symmetry and rhythmicity (2). Activation by hyperventilation is routine. validity of other activating and photic hypoglycemia megimide (6), intravenous as procedures The stimulation is being assessed. (b) Perceptual. Within the past decade certain perceptual procedures have been shown to be (11, 12, 13). sensitive measures of cerebral dysfunction Such techniques as critical flicker fusion (OFF), and "embedded" of figures polychromatic the tachistoscopic recognition in a These visual background are being assessed (10, 12, 13). measures have the adVantage of giving a reliable quantitative complex measure of pretreatment functioning in terms of a continuous variable, rather than the qualitative dichotomy of "normal" versus "abnormal;" imposing no undue stress on the patient; and the apparatus and pro- relatively inexpensive. 1) Critical flicker fusion SCFFZ: As the rate of the that the illusion there develops of increased, flicker light is point this at of The the light flickering frequency steady. is light cedure are simple, convenient and is the CFF. The CFF threshold is measured using a Sylvania glow ratio is brightness is varied to robtain thresholds at different tube pulsed by an electronic power supply. The light—dark fixed, and �-5- levels. The psychophysical method of is descending steps limits using ascending and employed. 2) Tachistoscopic recognition of pseudoisochromatic gigures: The H—R-R pseudoisochromatic plates (American Optical Company) con~ sisting of a series of cards with numerous small circles of various sizesare used. The circles vary in color, and form outlines of various geometric patterns, as ring, cross and triangle. These patterns form a "figure" on a constant background. The "neutral" plates are recognized by all subjects - blind." These plates have been photographed and projection slides. initial normal and "color- mounted as 2" x 2" of exposure which permits accurate The speed identification of the figure is the index used. (0) Eggggggg. Interviews with patients are recorded. Both unstructare The records analyzed included. and ured structured periods are for diversity (7) of the dyadic speech. been found useful in analysis of changes in for changes in syntax (9), These methods have and behavior with other therapies. (d) Evaluation of clinical changes. Psychiatric evaluations are made at fixed intervals as to type and degree of changes in behavior, and a rating of "improvement" and is made. in "improvement" are The methods now of rating both change in behavior under study. Present ratings have been based on the Malamud-Sands Rating Scales and have been of limited usefulness. The present descriptive statements of the evaluator, �-6following an outline of specific areas of behavior combined with a review of the nurses' and resident therapist's notes is being continued. h. Pharmacologic Agents: Previous experience with amobarbital (8), megimide (6), reserpine (IA) and chlorpromazine (5) provides the background for the selection of new agents. At present, acute study of diethazine (SKF 1026-A) is in progress. Clinical studies of meprobamate, perphenazine and chlorpromazine are under investigation. have been formulated reaponse. to test other agents, with different spectral Available: The Department of Experimental Psychiatry was established at the Hillside Hospital in l95h. clinical duties. EEG . - III. Facilities Plans of the department have no Members They devote their full at the institution to time the research prognmns. Eight rooms of laboratories and offices in the principle medical building of the hospital are provided. These include: a) EEG Laboratory - equipped with Medcraft encephalograph and Grass photic-stimulator. on a A 8 channel Electro- technician is employed full-time research basis. b) Psychophysical Laboratory - Two Grass stimulators, Dumont oscilloscope and step-up transformer power supply in a rack-mounted assembly. This equipment has been used for the past three years to study threshold and after for simultaneous tactile stimuli of patients before induced states of altered cerebral function. �.37.- A tachistoscopic assembly consisting of two projectors, solenoidaactivated shutters, and opal glass screen is in use. c) Psxcholinggistic Laboratogz: A third laboratory has been established for the recording of interviews. a Magnecord tape recorder, two It is equipped with and mixer. microphones, Electrovoice auxilliary recorders for transcription are available. The available for study. All patients in the hospital are research programs have been well integrated into the hospital Two milieu so that manipulation of experimental variables are readily accomplished. �and Reggrts: Iv. Publications l. 2. of Physiodynamic Action of the Unified Theory Fink, Therapies, J. Hillside Hosp. (in press). M. : A and Kahn, R.L.:' Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. and Pachiat. (in press). 3. h. m: Diffuse of Effects and H.: Korin, , Altered Brain Function in Perception. Read at XV Int'l Congress of Paychology, Brussels, 1957. , : , Relation of Tests of Altered Brain Function to Behavioral Change Following mectroshock. Read at the A.P.A. Divisional Meeting, Montreal, November, 1956. 5. and Coleman, F.S.: Coma and Insulin of Chlorpromazine Comparative Study in the Therapy of Psychosis, J. Amer. Med. Assoc. , Shaw, R., Cross, 6., (in press). 6. Green, Fink, M.: Megimide, EEG. 7. Jaffe, J.: Clinical Effects of W M.A. and An EEG and Clin. Neuromvsiolu g: 180-181, 1957. Objective Study of Communication in Psychiatric Interviews, J. Hillside Hosp. (in press). 8. Kahn, R.L., Fink, M. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electro8c Psvchiat. 1956. 23-29, Meurol. A.M.A. Arch. lé: shock, 9. 10. ll. Durinf-j Ele ctroLanguage Changes in , of Cormnunication, shock Therapy, in P cho tholo Ein press). Crune and Stratton : Em‘oedded Figures After of Perception , Induced Altered Brain Function, Am. Psychol” 1.3: 361 (Abst.) 1957. : Effects of Visual, Vestibular and Somatosensorimotor Deficit on Autokinetic Perception, J. @332. §_2_: 398~LLlO, 1956 (with Battersby, 11.3., Pszchol., Pollack, Mr: Kahn, R.L. and Bender, 15.8.) �0-9- 12. Pollack, M.: Tachistoscopic Identification of Contour in Patients with Brain Damage, J, Cam . Ph 101. szchol., 50: 220-227, 1957, {with Battersby,‘W.S. and Bender, M.B.) 13. Visual Deficit After Brain Damage in Man as Measured with Rapidly Exposed Chematic Stimuli, Amer. Peyphol., 12: h68,(Abst.) (with Battersby,‘w.s. : and Bender, M.B{7: 1h. WachSpress, M., Blumberg, A.G., Fink, M. and Miller,J.S.A.: Evaluation of High Dose Reserpine Therapy for Relief of Anxiety, J. Hillside HOSE. 5: 67-77, 1956. �.10V. Financial Support: Support for the ongoing programsof the Department of Experimental ' Psychiatry is provided by U.S, Public Health M-927, (Altered Brain Function Following Electroshock), the Foundations' Fund for Research in Psychiatry grant 56-151 (Language of the Dyed), and the Board of Directors' Research Fund. The proper development of the specific aspects of this protocol require support for the following, for a two year period. 19 8 Dr. M. P01130k, PhoD. Senior Research Asst. Psychology EEG $ _ Technician - Hrs. Hannah Hosquera 12§9 8,250 $ ‘ 8,750 3,720 3,8u0 2,000 2,000 50 th 50 th 200 300 Equipment: (Over 2 year period). Analyzer (Edin) Flicker Fusion Apparatus EEG Projector, Slides Calculator (h,000) (800) (100) (880) hDO hOO Travel: ) (Amer. Psychol. Assoc. (Amer. Psychiatric ASSOC.) $ 15,060 Overhead (15%) TOTAL $ d 15,h80 2,26h 2,327 17,32h n 17,807 ' �\ KILLSIIE mSPITAL Glen Oaks, NOYO January 27, 1958. MORAN!!! '10: Medical Affairs Committee FOR: Joseph FRCM: Merimental Psychiatry 1958. January 1957 1, to 1, Report of Activities, April Miller, M.D. Deparhxent of SUBJECT: I. 30 A. -~.—-- INTROIIJCTION: achieved has professional work Department the of the nine months, In the past various of understanding We our reflecting have presented reports recognition. and these and international societies, national before physiodynamic therapies October the in work were presented of Five our aspects have been well received. psychiatric by been leading have accepted and other Journal reports the of issue Journals and will appear in 1958-59. convulmode of of action the of Our studies have given us a clear picture confidence to has us given information ibis coma and therapies. insulin sive to these in therapies which were fruitful and techniques extend the hypotheses behavioral concerning a ideas in protocols have expressed our drug therapy. We Psychothe both by received been well These having new ideas, of drugs. assay comand various pharmaceutical U.S.P.H.S. the of Center Research pharmacology 1958. for studies new the in been implemented have panies, . , . therapy, we were , . . number a. of ancillary led to electroshock In evaluating The value for psychiatry. have which basic significance broad, investigations found and assessed were change behavioral of indices of language measures as While a studied. "improvement" was The of defining problem satisfactory. been has approach operational an accomplished, not was satisfactory resolution which the criteria Also, studies. recent defined which was successful in our has an to led Hillside at various the therapies for determine patient referral of choice therapy. factors and affecting psychologic the sociologic evaluation of In addition, the ability of this department personnel to work together has been have the in hospital and Our relationships roles been amply demonstrated. hosthe from at staffs all cooperation excellent defined and we have received pital. II. PROGRESS IN (A) ONGOING PROJECTS: Therapy Evaluations: l. Flectroshock. We electroshock therapy. Our studies have defined the process of physiology; brain in induced changes the to behavioral the have related response behavioral of the type affect that and factors sociologic described personality and clinical behavioral between response the and defined relationship response; of various the types to relate us These studies permit ratings of improvement. PM 1090), electroshock and its varieties, (metrazol 3, convulsive therapy as drug "convulsive there. of concept (Indoklon) meaningful into a and lately, inhalant , pies '. �-2Based on these studies, reasonable criteria for the type of patient "do well" with convulsive therapy can be defined. Continuing studies will behavioral the in of role the personality amplify designed.to in this area are non-electroshock referbetween'out-patient differences the define to response; convulsive inhalant of and evaluation an (IIIc) rals and in~patient populations ' who therapy (111a). 2. . £235 Therapy. control coma-chlorpromazine insulin of conclusion our the Following 1958. and .A.M.A. in early will appear study, our report was accepted by he J the experimental program.for have developed a we months, six the During past which begun was (see IIIb), agents psychopharmacological new of evaluation 3. Selection of therapies: of the based on type generally is of therapy While the selection the Such as aspects decisions. such affect factors mental disorder, other and cultural education his communicate verbally, to facility of the patient have we and been have studied, "authoritarianism” background, and the degree of rebear significant a and aspects psychologic such historical reported that These services. for ancillary lationship to the choice of therapy or referral of the in factors these of results studies have led to an interest in the role socioof role the evaluate further to therapy, and we have designed a study (see IIIc). and therapy outpatient of inpatient psychologic factors in results (B) Language as measurable behavior: one. complex "in is a 'improvement psychiatry of definition and change behavioral of In evaluation of various therapies, the definition have sought we adequate, are While descriptions clinical improvement is crucial. Two methods of our behavior patients. the language in guides more objective for interviews of structured analysis of analyses have been developed - a syntactic and a dyadic of unstructured. The non-convulsive and convulsive induced by changes have described the do clinical reflect patterns these language therapy, and find that changes in to these techniques of the have application to led Our experiences evaluation. We the drug evaluation studies. effort in an in are of progress language other analyses In addition, methods. the of present the broaden applicability to (C) Neurophysiology of Behavior: the between relationship the noted we In the electroshock studies We concluded behavioral response. the and change neurophysiologic of degree and behavior in change to a essential was physiology cerebral in change that a coma therapy. insulin for conclusion We same the come had to to "improvement". chlorpromazine in treatment the response between Since we had observed a similarity was mode action of same the that seemed plausible therapy and insulin coma, it drugs. newer tranquilizing the for operative �-3review of the literature and some preliminary experiments supported the to potent are agents psychopharmacologic newer the that this hypothesis We have function. brain and affect predictably extent that they measurably and in of Psychiatry Congress International the at hypothesis this expressed new undertaken have we As a a Hillside the Hospital. result, the Journal of (see IIIb). various drugs therapies evaluating project .A Concomitantly, our interest has continued in the biochemistry of convulsive therapy. we have observed that diethazine, a potent anticholinergic demonstrated has a Further analysis electroshock effect. the drug, reverses These observadiethazine. LSDHZS to and mescaline between marked similarity as system cholinesterase-acetylcholine the of confirm the significance tions which behavior of psychotic the type a basic mechanism for psychotic behavior may be affected by convulsive therapy. Percgption: (D) have change behavioral of index an as studies of perceptual tests continued. We have defined the relationship between the degree of perceptual demonstrated Our have studies function. alteration and the degree of altered brain Our but the response, in perceptual only not type of personality the significance also in the physiologic response, to convulsive therapy. Our studies of tactile perception clarified the role of strength of stimulus and of the type of instructions (set) in the reported reponses. Individual Differences in Behavioral Responses: The program of study of the ways in which individual differences in various to of subjects and affect response physiology the perception, personality of neurophysiologic Green's Dr. studies under well way. is psychiatric therapies Dr. emphasis and Pollack's EEG electroshock, to the response differences affecting of the both phase in are drug to therapies on perceptual aspects as they relate collecting data in consecutive groups of subjects. (E) III. (A) New Pro ects - Pro am.l 8 Inhalant Convulsive Therapz: In the studies of electroshock, we have been puzzled by the significance of the electric current in the treatment response. In the convulsive-subconvulsive was aftreatment the for response seizure the of the control study, significance compound, inhalant an Recently, clear. not was current of the role but firmed, conflescribed simple was as a safe, of ether anesthesia, the to ethyl similar vulsant. We visited the laboratory at Spring Grove State Hospital, Maryland, We and observed the treatment. It was reliable, quick and easy for the patient. have obtained a supply of this compound and are undertaking a study on February of biochemical and effects psychologic of neurophysiologic, the clinical, lst, convulsive therapy using this compound. (B) Mbde of Action of Psychophammaoologic agents: experiences with other forms of therapy have led us to formulate a the In agents. essence, psychopharmacologic (see IIc) regarding hypothesis and kind of effect the degree to related behavior which is affect drugs to degree EEG. Fbr this the purpose,we by measurable in part, brain have on function, they and personnel equipment for special obtained and support have written a protocol from.the U.S.P.H.S. and various pharmaceutical concerns. Our �-l+- In these studies, patients referred for drug therapies, as chlorpromazine, promazine, reserpine, meprobamate, etc. , undergo special tests before and during treatment, which may predict and reflect the treatment response. (0) Psychologic and Sociologic Factors in Out Patient Therapy; result of our studies in inpatients defining certain psychologic sociologic factors as they affect treatment choice and treatment response, As a and we have made predictions regarding the outpatient population. to undertake a sociologic study of outpatients, and extend our studies this Spring. IV. (A) W318 We are planning inpatient AND. I’UBLICATIONS: Eigerimental Psychiatry Issue, Journal of Hillside Hospital: of this Department wrote five articles reflecting various aspects of our study program for the October 1957 issue of the Journal. This encompassed the whole issue. Such an effort is unique in the Journal‘s history. At Dr. Tarachow's (B) invitation, members Publications: In addition to these five articles, our report on the relation between EEG changes and treatment response in electroshock appeared in the Archives of Neurology and Psychiatry. Seven other reports have been accepted for publi cation and two others are in the hands of editors as of January let. (G) Presentations: Reports of our studies have been presented to psyc iatric, neurologic and psychologic societies. Twelve reports were made before National societies in the U.S. and three before International Congresses in Brussels and Zurich during the summer. These reports have been generally well received. V. PERSONNEL: changes in personnel have been made. We have requested, and the Research Committee and Medical Director have approved, a restatement of the titles for staff members from "Research Assistant" and "Senior Research Assistant" to "Research Associate". The present staff consists of nine members including: No Martin A. Green, M. D. Joseph Jaffe, M. D. Robert L. Kahn, Ph.D. Hyman Korin, Ph.D. Max Pollack, Ph.D. Associate (Neurophysiology) - Research " " (Psychiatry) -" " " (Experimental Psychology; " " (Experimental Psychology " " (Ehcperimental Psychology) - and four technical assistants: Mrs. Hannah Mosque'ra (EEG) , Mrs. Jean Kolodw and Mrs. Ann Horowitz(~?sycholinguistics) and Mrs. Janet Bowie (Secretary). �-5VI. (A) TENTfiIIVE BUDGEE PROJECTION: 1228-52. Personnel: In addition to the personnel listed above, we will request the addition of a Research.Associate in Social Psychology; and a redesignation of the halftime neurophysiologist to a full-time status. These items will increase the budget by $9500 above authorized annual increments for ongoing personnel. (B) Supplies. Em ment and Travel: There will be an increase of $l000 in supplies and travel and a specific equipment expense of $5200 for an EEG Analyzer. This instrument will provide greater flexibility in EEG analysis. A supplementary request for this amount has been asked of the U.S.P.H.S. L Total Egpensesz (C) av" . total expenses for 1958-59 1957-58, an increase of $16,98h. The (D) will be $95,796. as against $78,812 k" "u. Income: In the past six months, this Department has been more successful than anticipated in attracting research funds from private and governmental sources. Fbr the current year, we anticipated $33,595 and so far have been advised that we can expect $h3,h31 for 1957-58, an increase of $9,836 over expectations. Fbr 1958-59; we have already been assured of $50,66h which is $7,233 more than 1957-58. It may be of interest that we already have funds for 1959-60 in the amount of $15,297. These grants totalling $115,235 have been made available to the Department for the period April 1, 1957 to December 1960. Max Mszb/b Fink, M. D. A}\ fork¢3”4 We Respectfully submitted, V‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-005 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Letters; Personality factors in behavioral response to electroshock therapy (draft) by Robert L. Kahn and Max Fink; Progress reports of departmental activities; A proposed study for the behavioral assay of new drugs by Fink; Report of activities Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/5fddf7ec4456da255de4e0d4b1d4c29a.pdf e18d9957071a91ab8e65015c0fde8e69 PDF Text Text January 15, 1956 Perceptual Changes Induced M Prorress Report Maximilian Fink, Director of Research M. D. 927 By Drugs and Electroshock (c) September 1, 1954—January 1, 1956 ' Hillside Hospital Glen Oaks, New York aHEMRY: Beginning with a study of perceptual changes induced by electroshock, emphasis has shifted to a study of the mechanism of electroshock therapy. A marked relationship was demonstrated between clinical improve- ment and certain indices of altered cerebral function. Early, persistent and severe changes in amytal tests and the electroencephalograms were ob- served; but no correlation was demonstrated for memory double simultaneous stimulation. tests or tests of clinical improvement did not alvays persist, further studies to elucidate the relationship of premorbid personality to both short and long term improvement were devised. Preliminary data demonstrate a relationship between persistent improvement and a specific character pattern. Since suprathreshold simultaneous tactile stimulation techniques failed to discriminate in terms of clinical response, threshold studies utilizing square—wave electrical stimuli were undertaken. This technique elicits patterns of altered function not clinically apiarent, and the relation of these patterns to clinical improvement is under study. As �PROGREeS REPORT The inception of M~927 in September 1954 permitted an expansion of studies previously undertaken as a Fellow of the National Fbundation for Infantile Paralysis. Three studies were in progress: (a) evaluation of the amytal test(l) in psychiatric subjects; (b) relation between al~ tered cerebral function and tests of simultaneous tactile stimulation; (c) effect of lysergic acid diethylamide, pervitin, and amytal on visual perception. and In the amytal test, the patient is asked questions concerning his illness, orientation, and recall before and immediately after the intravenous administration of amytal to the point of nystagmus and slurred speech. In the original studies at the Nount Sinai Hospital, the development of disorientation and explicit denial of illness was clearly associated with diffuse cerebral dysfunction(1). As a admissions to Hillside Hospital were tested. patients control study, consecutive Of 68 interviews essayed a- not had recent electroshock therapy, 56 were adequately completed. Of these, 51 were "negative" for brain dysfunction; and of the five " positive" results, hree showed other evidence of brain mong damage. who had In addition to further defining the scope of this test as an in- dex of cerebral dysfunction, the study demonstrated other differences from a group of patients with physical disabilities but without brain disease. There was more transient disorientation and denial, more withdrawal and ludic behavior and more changes in the syntactical aspects of language in the psychiatric population.‘ ._____.________________________..____.______________________________________ *Kahn, R.L., Fink, M., & Heinstein, E.A.: The "Amytal Test" in Patients with mental Illness, J. Hillside Hospital flzfi-lj, January 1955. �2. When such tests were applied in patients who had recently under- gone electroshock therapy, "positive" amytal reSponses were elicited. This aberration had previously been reported by Weinstein, Linn, and Kahn(2), and formed the basis for their explanation of the mode of action of electroshock therapy. In a second study, patients undergoing electroshock therapy tested by simultaneous tactile stimulation methods(5). With were increasing amounts of electroshock therapy, patients demonstrated consistent alterations in the perception of the two stimuli. Failure to report one stimulus and mislocalization of one or both stimuli in predictable patterns were demonstrated. These patterns were transient, however. Electroence- phalographic records were also obtained in these subjects at weekly vals. progressive appearance of delta activity, The first inter- as random, low voltage activity, and later as symmetric, high voltage bursts, previously described by numerous authors(4) was confirmed. Attempts at this time to correlate changes in the electroencephalogram tests and the simultaneous tactile unsuccessful. were third group of studies, of the effects of d~lysergic acid die— thylamide and pervitin on visual perception were inconclusive. A variety of ill~defined subjective perceptual alterations which failed of objec— tive verification were observed and the study was discontinued. A The experiences with amytal tests and simultaneous tactile tests formed the background for the studies undertaken since September 1954 un- der H—927. To determine the relationship between various indices of a1- tered brain function (the amytal test, the electroencephalogram, and �5. tactile tests) simultaneous a correlated study was undertaken. Conse— cutive patients referred for electroshock therapy were studied. Treatment was administered three times a week. Electroencephalograms were done weekly on a day following a treatment. tests Simultaneous tactile stimulation tests were done once a week immediately preceding a treatment and 48 hours after a previous treatment. In addition, special tests of memory and recall utilizing the technique of retroactive inhibition were carried out at weekly intervals. and amytal In addition to intercorrelations between these indices, we were anxious to determine the relation between such changes and clinical alteration in behavior. For this purpose a clinical evaluation of improvement at weekly intervals during treatment was made ing therapy. and the These patients and unimproved. showed by the ratings were The symptoms their therapists; and up to one month follow~ were made independently classified as markedly of the other indices, improved, moderately improved, markedly improved patients were those that brought and the who no longer to the hospital; were rated improved them nurses' notes confirmed such aspects as being able to sleep without medication, better appetite and improved capacity to participate in hospital activities. showed no change The unimproved or only transient changes. were those who had some imtrovement in The patients were those who moderately improved patients symptoms, but in whom severe dis- turbances as obsessional thinking, paranoid ideas or somatic preoccupation persisted. A marked correlation was found between clinical improvement and early, persistent and severe changes in both the amytal tests and the �4. electroencephalogramx to occur. No If such changes did not appear, improvement failed such correlations were manifest between improvement and the tests of recall function or changes in simultaneous tactile tests. Thirty patients were essayed in this study, but 24 were success- fully concluded. At one month post-treatment, eleven were classified by the supervising psychiatrist as markedly improved; six as moderately improved; and seven as unimproved. the markedly improved patients, every one had at least one positive amytal test during treatment. Of the 50 tests given to this group, 58 (76%) were positive. In contrast, of the unimproved of the 45 Of patients, five of the seven never showed a positive result, and tests administered to this group, only 6 (15%) were positive. The moderately improved group showed more positive responses than the unimproved patients, but fell far short of the much improved group. In addition, there were consistent'changes in language and non- verbal aspects of behavior indicating alterations in adaptive mechanisms in the much improved group, even in interviews not employing amytal. These alterations were either minimally or only transiently manifest in the unimproved group and then only under the influence of sodium amytal.* Concomitant studies of the electroencephalograms taken on a day preceding the amytal cords were first test indicate M a similar relationship. measured for per-cent time slow wave The 160 re- (delta) activity, frequency of the the duration of burst activity and the amplitude and slowest waves present. The records were then placed in a rank serial order. Presented at the annual meeting of the American Psychiatric Association, May 10, 1955; and submitted to the Archives of Neurology & Psychiatry for * publication. �5. falling in the upoer third were labelled "high abnormality" and those in the lower third as " low abnormality". Of the much improved Those patients, 25% showed a ment; 80% after two weeks and 90% patients, iowever, first after three weeks. The treat- In the unimproved none had a high degree abnormality record during the three weeks and only one had such a record by the fourth treatment. these high degree abnormality after one week of records of the moderately improved patients week fell of between two groupsc* Changes in memory and learning were tested in these subjects by using the principle of retroactive inhibition. recall of three-letter originally learned By the serial testing of words following the interpola- ted learning of nonsense syllables, patterns of decrement in learning and recall ment up elicited. As a group, the patients showed increasing impairto the third week of treatment, and a rapid inorovement after the were cessation of treatment. No relationship, however, could be established between impairment and resnonse to treatment.** The responses of these subjects to simultaneous touch stimuli were also assessed. ability to identify and While an localize the two tactile tests using increasing impairment in the stimuli could be demonstrated with increasing treatment, no relation to improvement was noted. By tent the spring of 1955, and severe changes tal tests it was our conclusion that early, persis- in both the electroencephalogram and in the amy- are a necessary, though not sufficient, pre~requisite for ..___....-—_. m---_—. » Presented at the joint meeting of the Eastern and Southern E1ectroence~ phalographic Societies, Bethesda, September 50, 1955. * Presented before the Electroshock Research Association, May 8, 1955, and awarded their Annual Prize Award and cited for excellence in research design. ** �6. improvement following electroshock therapy. initial part of the This obserVation confirmed the hypothesis of weinstein, Linn and Kahn(2) ascribing the therapeutic results of electroshock to the facilitation of patterns of denial by altered brain function. But was it true that the patient's improvement resulted from denial of illness or denial of other a- More symptoms? daptive mechanisms manifest? Also, within a few months a number of the markedly improved patients had relapsed. At this time, a second Why? electroshock population was studied. First, to confirm our previous observations on the relation between improvement and changes in the amytal tests and the electroencephalogram. if exnlicit denial is a mechanism in improvement, it post—treatment and directly related to improvement. advanced that those patients who showed cit verbal denial" personality Secondly, should be manifest The hypothesis the characteristics of the would be those more was “eXpli— likely to maintain im— provement. Between April and August, were studied. Satisfactory data electroencephalograms and amytal and again d ring the second and thirty consecutive electroshock patients was obtained in twenty-five subjects. The tests were carried out before treatment, third week of treatment. The patients were again independently rated for improvement by a supervising psychiatrist du- ring treatment, and one month following treatment. These patients are also now being seen in six month follow-up visits to assess the " long-term" changes. In addition to these of subjects was tests, the premorbid personality of this group assessed by an interview with family members, psychologic �7. tests and a tachistoscopic study. in independent interviews. to A At least two close relatives were seen standardized questionnaire has been devised den verbal "explicit the of indicative factors characterological elicit this study fifteen characteristics defined as typiSuch in selected. were of absent in this personality tyne or cally present tons include prestige consciousness, sensitivity to criticism, imagination, temper and attitudes to sex and illness. Each patient is rated on a scale nial" personality. of 0 to denial 2 For for each item - the higher score signifying a greater tendency to o l Each patient vas also tested by a standard psychologic evaluation These Thematic and Tests. Rorschach the Apperception including battery tests were assessed for character structure and the usual tynes of defense or adaptation. tional A tachistoscopic study was devised, in which pairs of emo- and non-emotional words were flashed on a screen at 10, 20, 50, 100 patient's ability to identify the words, the reaction time, and the distortions were ascertained. This pre-treat~ nent data is now being studied as to its ability to clarify the patient's and 250 millisecond periods. The usual defense patterns. Only the short term group nine uatients were results of this study are available. Of this rated as showing marked improvement; twelve as mo- derate inprovement; and four as unimproved. Of the physiological indices assessed in these patients, a signi- ficant difference was again noted in the anytal tests and the electroence— phalograms between the markedly improved and unimproved groups. no There was difference between the markedly and moderately improved groups. �8. relation of personality ratings and improvement, an indefinite correlation was manifest in this small group. Lcores expressive of tendency to "oxalicit verbal denial" ranged from O to 25 in a scale of O Asgarding the to 50. The following table describes the natterns of each grouw when "high" and "low" scores are compared. (10 and Below) Low fiarked Improvement (9) Hoderate " " Uninproved High (Above 10) 2 7 (12) 7 5 (4) e 0 Because the scores were unusually low in this group, a sample of consecutive private electroshock estients were studied. lity ratings and clinical evaluations were made. To Similar persona- date, ten patients have this study is continuing. This study is still in progress. The six month follouaup is now being undertaken and further correlations will be done. Kcanwhile, certain conclusions can be entertained. The relationship between alteration in the been studied and physiological tests and improvement It became apvarent that the patients manifesting clinical exolicit denial of illness post-electro— was confirmed. shock did not have the best long—term response. Lesser degrees of adaptive better prognostic value. This observation led to an analysis of the only verbatim recorded data for this series - the language changes changes may have in the amytal interviews. The data is now being analyzed for a variety of adaptive language changes and correlations with clinical assessment are to be made. �9. Chile these studies of the ohenbmena underlying improvement in electroshock therapy have been under investigation, the tual studies have run concurrently. group studied, the lack of In the first (1954) electroshock correlation between simultaneous tactile sti- mulation tests and improvement was nuzsling. The tactile tests tremely gross, hovever, and this might be a factor. a more meaningful was developed. anticipation that be obtained from Previous exteriences with von Frey hairs for such threshold stimulation had convinced mulus In were ex- this index if threshused, equisnent for threshold electrical correlation could old stimulation techniques were stimulation tactile percen- me that the variation in the sti- often exceeded the fluctuations in hreshold, and the studies were inconclusive. Reports by Segal(5) on the perception of square-wave elec- trical stinuli led to our development of similar equipment. 84~B stimulators and isolation units monitored by a deliver independent stimuli. A Dnnont Two Grass oscillograph switch box and l centimeter steel disc e- Difficulties in isolating the stimuli precluded this testing being carried out satisfactorily until septenber. A continuation of the second electroshock group has been in prolectrodes corolete the assembly. gress since September. The same nhysiological tests and personality assess~ patient's responses to simultaneous hreshold electrical stimuli is tested before treatrent and at weekly intervals. To date, 18 patients have been studied. The same phenomena of exments are undertaken. In addition, the tinction, displacenent, nerseveration, and confabulrtion described in patients with organic mental syndrome with suprathreshold stimuli by Fink, 4. �10. Green, and Bender(6) are apparent technique elicits these patterns in these natients during treatment. This clinically manifest. while extinction is also manifest in yrs-treatment testing, displacement and perseveration are related to the extent of treatment. This study is now though they are not in progress. Concomitant with these studies, preliminary observations of a milar nature have been made in patients undergoing insulin coma si— therapy. Recent reports of the value of prolonged come as the basis for improvement by Revitch, Kwalvasse? and Caplan, Sharass and Rowsell, and Yeager gt al<7> have been confirmed in our patients. In reported a direct relationship between altered brain function, altered patand imnrovement.* and behavior terns of adantation in lan mace clinical t: . ' - one unusual case we r R.L., Graubert, D.H. and Fink, N.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy, J. Hillside Hbsnital fl;154v147, 1955. * Kahn, �11‘ Summary of Our Work to Date and Plans for the Future: studies of perceptual changes induced by electroshock are pro- is in elucidating the factors underlying improvement following electroshock therapy: changes in shysiologiccl indices; adaptive changes in language and behavior in resnonse ceeding in two concurrent and related courses. One to altered brain function; and the factor of personality. study of the watterns of threshold tactile perception The second is a under conditions of altered cerebral function; their relation to "inprovenent" following elec— troshock; and the relation to other indices of altered cerebral function. The problems before this study are conylex. The rating of "improve- is primitive and further vork alcnf this line is mandat ry. The delineution of the explicit verbal denial character is a gross anprOfination of this problem. FUrther study of the role of personality and a descrip- went" tion of defensive operations other than denial which may significance is in progress. To clarify in our data the have therapeutic 203 beneficial be which ascribed to "general interest", electroshock can of therany result "spontaneous cure" or "placebo" effect, a control study is being instituted on February 1. Titb the concurrence of the Sedical Board of Hillside Yos- be will electroshock referred for therauy treated, by ranpital, pitients dom selection, by either pentotbal-convulsive electroshock or jentothal— subconvulsive stimulation. The cerebral chmnjcs induced by pentothal- subcenvulsive stimulation are miniwal and result in a minimal inprovenent rate(8) o �M References l. einstein, E.A., Lahn, R.L., Sugarman, L.A., & Linn, L.: Diagnostic Use of Amobarbital sodium in Organic Brain Disease, Am. J. Tsychiat. 112: 889—894, 1955. 2. Heinstein, E.A., Linn, L. & Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to a Theory of Shock Therapy, Am. J. Psychiat. 102:22-26, 1952. 5. Bender, H.B., Fink, H., & Green, N.: Patterns in Perception of Simultaneous Tests of Face and Hand, Arch. Neurol. & Psychiat. §§3555-362, 1951- , ~ 4. Pacella, B.L., Barrera, o.”., a Kalinowsky, L.: Variations in the Electroencephalogram Associated with Electric Shock Therapy of Patients with Mental Disorders, Arch. Neurol. & Psychiat., fll:567~58#, 1942. f‘! 5. Segal, Harry: Prick Threshold stimulation with Square ‘ave Current: A New Heasure of Skin Sensibility, Yale Jour. Biol. & Med., g§:145-154 1955. A 6. Fink, 3., Green, D. & Bender, U.B.: Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Eeurology.g:46-58, 1952. , 7. (a) Revitch, E.: Observations on Organic Brain Damage and Clinical Improvement Folloring rotracted Insulin Coma, Psychiat. auart. gé: 72, 1954. (b) Kualwasser, S. and Caplan, M.: A Case_of Prolonged Insulin Treatment, J. Hillside Hospital 35145, 1952. Coma: (c) Shagass, C. and Rowsell, P.W.: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma, .M.A. Arch. Neurol. & Psychiat. 13:7059 1954. (d) Yeager, C.L. 33 El: glycemic Coma, 8. Ulett, Electroencephalogranhic studies in PosthypoJ. Harv. & Ment. Dis. 118:455, 1955. of Matched Grougs in the Evaluation of Convulsive and Subconvulsive Photoshock, Bull, Kenn. Olin. l§:158, G. A. gt_al: The Use �m 30, 1956 mama Ammm m mm m - 3.955 FollwingthsamflmdfinfiamtheMamm,msmstyw mrked by integratim at um. 38mm with ongoing 15h. mdnpamimotthsntaff. Maddifimlgrantsm wise rewind its first prize award. Wk left Ht. 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' 1wmmm.m195§.wuamwupotpatmumemu mmmmwmmatMuatmmmmmm his mmumsm‘sgmwmsmmammuuamm appumummbyumlam. flfl.mmmps,mthommt stMmmmmwmamunu-ammmw :mwmnwm,mdmnrmwuobmmmmfimm themflfiergm. mmw,rmmeMmmdu-m,bymu"mm «wmxmmdwuam mmnawmm fermdbyplvaicima otherthmpsycmmtu. £130,312 Immammnmmmmm. “Wham; . ���y‘fi-WWWAMV'VUM amp" Husky, 1min: from in “night and Roasttlmt‘ by H. 3.8nw “3%; 3.3.3.3.c.o., 6.4. MAL, Imam, Shit!” 5. The Childm, ' Putter, Mm sown. Gsoop Hark st. Killuidn Haunt-1, Amer. at 151.161.19553mw Glam; lam,1955. W, J. WM Hosp. g: Orbhopaychiatric Ame... �I April 2, 1956 Corrected Copy RESEARCH ACTIVITIES ANNUAL REPORT SAME AS ORIGINAL - 1955 �IDENTICAI. UP TO END OF PARAGRAPH 1. Research Programs were actively carried out by the Research Service, resident and attending psychiatrists, and by departments at the hospital. (a) Research Service: With the two additions to the expand staff, Dr. Fink was able to continue and his studies of the changes in behavior'widch fallowed electroshock therapy. These studies were directed to understanding the effects of the treatment on the brain, as well as trying to understand the changes in the patients behavior, language,and memory which might result from such changes in brain function. There were three different tests that were used. The changes that occured in the brain patterns (electroencephalogram) were studied and it was shown that it was necessary to have some changes in the brain wave patterns before patients be- wave came better from electroshock. Secondly, by giving the patients injections of who have that patients it changes in brain function show certain specific changes in language after the drug. Thirdly, by special tests of the ability of the patients to perceive two touches simultaneously applied to different body parts, it is possible to get a seditive drug (sodium amytal) is possible to show another index of brain function. These three indices, together, form the best way available today to demonstrate changes in brain function. One way of showing changes in a patient is to study his language. We have continued our studies of language following the administration of sodium amytal. In addition, Dr. Jaffe has begun a study of the changes in language which follow changes in the doctors attitude to the patient. For this purpose interviews between himself and the patient during which he changes is recording his own attitude he to the patient and then measures and examines the type of responses the patient has to this change. �-3- interest has Much been aroused in the newer drugs in psychiatry. A pre- vious study at Iflllside Hospital had shown that small doses of reserpine had very little effect on our controlled study and the patients. When purified reserpine was undertaken by one of internist, Dr. was made available, a the resident physicians, Dr. Wachspress Blumberg, to determine whether high doses of reserpine eleviate anxiety in our patients. It was the impression of the observers that the reserpine failed to relieve anxiety symptoms regardless of dosage and, would that it increased the depressive symptoms. These observations will reported in a forthcoming issue of the Journal of the Hillside Heepital. moreover, be In the biochemical program, under the direction of Dr. Harry Goldenberg, three projects were undertaken. In one study of the effects of chlorpromazine, Dr. Goldenberé carried out fundamental studies azine to under-Stand where and how this on drug might the metabolism of chlorprcm- act. In this study he was us- ing special techniques that he had developed. In a study of the effect of some new drugs in inducing disturbed behavior like schizophrenia, Dr. Goldenberg had studied a variety of alkaloids for their ability to affect a special enzyme system (serum cholinesterase) he reported that the most powerful of the new compounds (hallucinogens) known as which looks to be a very potent enzyme inhibitor as well. the development of a very refined technique so that he can lysergic acid diethylamide Most remarkable was measure very minute was quantities of drugs in the body. Thirdly, fundamental studies on the function of the liver in the he made some metabolism of hormones. (b) Psychiatric Staff : (1) Ambivalence Study: This study was continued by Dr. 3. Tarachow, H. Karin and 5. Freidman. In this study, an effort is patients develop the kind of neurosis that they do. psychologic measured. tests as well as made to understnad Emphasis is made by why some special clinical interview, the degree of ambivalence is This study attempts to prove a hypothesis that there is a relation bea �tween the loss of a parent early in life and the type or neurosis that developes in adulthood. (2) Subculture 5tugy: Under the directian of Dr. R. Navarre, supervising Graubert D. Dr. of (resident therapist), psychiatrist, an interdisciplinary staff Dr. H. Korin (psychology), Mr; A. Lurie (social service) and.Miss Z. Putter (group activities) have studied the hospital environment as a therapeutic agent. They are emphasizing the fact that just coming to a hospital has therapeutic value. Also, that there are many agencies at the hospital which affect a patients change, besides the specific psychiatric treatment that they are receiving from the phy- sicians. In a pilot study, they demonstrated the value of a diary of patients activities in clarifying the communications between patient and therapist, and also to explain unusual changes in patients behavior. The staff has devoted a good part of its time to understanding some of the aspects in thenhospital which motivate changes in the patient. In September, following our preliminary exper- (3) Chlogprcmazine Study: iences with chlorpromazine, one of the newer psychiatric drugs, two of the res- ident psychiatrists Drs. a potential substitute for insulin coma coma undertook a study of are divided into two groups in a randem fashion insulin It is this drug as therapy. Patients referred for insulin R. Shaw and G. Gross, coma hoped - one receiving routine therapy; and the other receiving chlorpromazine for three months. that this study will make a little bit clearer the usefulness of this new drug. (h) Prognostic creteria in Electroshock Therapy: PARAGRAPH REMAINS UNCHANGED �-5(0) Departmental Research Programs: In addition to the cooperation between various hospital services, the following projects were in progress or jndere taken during 1955. (1) Medical Demrtment: In addition to the medical and physiologic observations of the patients undergoing treatment with the newer drugs, reserb pine and chlorpromazine, Dr. A. Blumberg has investigated a new test-the test has Funkenstein Test. This been described as being able to a patient will improve following electroshock or insulin coma tell whether treatment. There- fore, to find out whether this is true at Hillside Hospital, Dr. Blumberg has been seeing all the patients prior to physical treatments. The test is harms less and so far, the results are not available. Dr. Blumberg also studied the possibility that insulin a number of hours. He dosage could be made smaller showed, both by clinical if it were and laboratory divided over studies, that divided doses were not as good as single large dosages of insulin. (2) Social Service: Student affiliates in Social Service have been studying the inter-relations of various factors in patient care. For the most part these studies relate the length of hospital stay, discharge evaluation, fee paying, and.a follow-up of patients who were unsuitable for Hillside HOSpital. These studies show great promise because they help us understand the social factors in mental illness. �Department of Biochemistry .............................. April 30, 1956 Progress Report, MarchpApril 1256 A. Active Projects 1. Steroid Sulfate Conjugates It that high speed liver supernates catalyze sulfate conjugation with the following sterols: deso corticosterone, androsterone, and cholesterol, as well as dehydroisoandrosterone, estrone, and testosterone. The underlined sterols conjugate most readily. Considering the various positions in which the hydroxyl functions are located in these molecules, it may be concluded that the conjugase(s) is nonspecific and can act at C 17, 21, 3a, 38, has been established and on phenolic compounds. least four steroid sulfates have been separated from urine using paper chromatography. The major conjugate has been identified as dehydroisoandroster— one sulfate. The other conjugates are under investigation. At 2. Chlogpromazine Study of a hitherto unidentified metabolite of chlorpromazine have been isolated from 9 liters of a pooled urine collected on the wards. The compound crystallizes in beautiful colorless needles, m.p. 190°C. It has been sent out for an element analysis. We suspect it is chlorpromazine mercapturic acid; the analysis will reveal whether our hunch is correct. Another metabolite has been separated electrophoretically and is believed to be an hydroxy derivative. 270 mg. B. Projects Planned to study the metabolism of mescaline this Summer, provided funds are forthcoming from the Dazian Foundation (see below). The investigation would throw light on the mode of detoxication of hallucinogens in the body and facilitate follow~up work dealing with trace endogenous alkaloid excretion in mental disease. We C hope . Funds grant application was submitted to the Dazian Foundation fer personnel support and for the purchase of a spectrofluorometer. We were infonned that funds are not available for instrumentation, but that personnel coverage may be forthcoming. Further information is not available at this time. A — cc. to: Dr. Fink Dr. Jos. S.A. Miller Max H. Goldenberg, Ph.D. �HILLSIDE HOSPITAL GLEN OAKS, N.Y. geptember h, 1956. Mr. George W. Galinger 170 East 79 Street New York, New York Dear fir. Galinger: is Facilities". a copy of the "Recommendations for Expansion of Research Space and This data has been compiled by Dr. Max Fink, who prepared an original outline on the basis of the needs of the Department of Neurophysiology and Neuropsychiatry, and on the basis also of a discussion with myself and with the heads of the Departments of medicine and Biochemistry. The present draft also was discussed in some detail at a special meeting of the Research Committee held on Tuesday, August 28th. Enclosed I understand that will refer these outlines, which include the main functional uses to which thisnnew building will be put, to the architect. The current plans are based on three floors of space (a basement and two floors) with an approximate area of hO' x 100‘ for each floar. The data includes the expected expansion during the next few years of the current projects of the Department of Neurophysiology, the set-up and inclusion of a clinical laboratory, projected space for dynamic and psychological research. The building plan should include the possibility of establishing 12-20 interviewing or psychotherapy rooms which would be housed on the first floor, either at the beginning of construction or sometime later. Such space would be valuable in offering a replacement for the present psychotherapy rooms used for in-patient psychotherapy and housed currently on you the second floor of the Elizabeth Sloman Lowenstein Clinic Building. where Our it present plans are to leave the research and biochemistry department presently is located, but to move the clinical laboratory into the new research facilities. If there is any other data or clarification that you would 11g; from.n§; the Research Committee or Dr. Fink, please feel free to communicate With me.~ Yours JSAl-‘I:1b encl. sincerely, Joseph S.A.Miller, M.D. Medical Director �TO: DR. 1v .. 8-31-56 J.S.A.Miller gear-1: Max Fink, q§UBJECT: RECOMMENDfiTIONS F R EXPANSIOT OF RESEARCB;§?ACE. M.D. “u.- following recommendations for the development of facilities for research summarize the consensus of meetings held by me with my staff; Dr. Miller, Dr. ReCohen and the to Blumberg; Dr. Mr. as presented Dr. Bachrach, Goldenberg, search Committee of the Medical Board, at its meeting August 28, 1956, and apBoard of Directors. the committees of the them to for appropriate referral by proved The I, INTRODUCTION: A.) Eggatiggi - The major share of the work in the recommended facilities who and are in the acute be with patients the chiefly population, will in-patient services. For this reason, the research building should be in close proximity, recommended Lowenstein for consideraBuilding. Sites Morris the to attached or a3 LowenThe Morris between the include order area the in ofusefulness, tion, stein Building and 76th Avenue;.b) The smaller area lying between the Morris Loqenstein and Elizabeth Sloman Lowenstein Buildings, the connecting tunnel and 76th Avenue; and c) The field east of the Morris Lowenstein Building, and north of the Israel Strauss Pavilion. W 3.) Facilities: 1.) In the development of the Research Service, during the past two Anamet have been various by measures. temporary the space.requirements years, needs the for reasonable well work expansion as the as of present program, lysis next five years, has resulted in the following recommendations. The character of the research program, at present, is along the lines of experimental psychiatry and neurophysiology. Such a program requires neurophysiology laboratory space, sound recording rooms, and special laboratory equipment as the first objective. logical expansion of the research program.as outlined by the Research Committee, by the development of a section in Clinical Psychodynamic Psychiatry, the next need is for facilities for interviewing patients and relatives; offices for staff members; and space for the observation of the psychoflierapeutic interview. The latter should be capable both for the observation of single patients and, also, groups. 3.) For the cooperation of staff members, conference rooms are needed. These should be so placed and equipped that much of the interaction between staff members will occur in that area. b.) Another need lies in facilities for the 2h-hour physiologic observation of patients. A four-bed unit, next to the thSiOlogy laboratories, will serve both as a recovery room for physiologic studies, as well as an observation unit for physiologic and biochemical studies. 2.) Keeping in mind the 5.) Another recommendation is with regard to the potential growth and utilization of the medical library. During the past few months, in which we have had a librarian on a full-time basis, space in the library has beCome �-2 '9 overtaxed. A major portion of the librarian's time is devoted to work in conjunction with the Research Service. It would be advisable that pro— vision be made in the same area of research expansion for the medical library. Facilities for an adequate reprint file, and facilities for microfilm reading are recommended. 6.) For time, the present separation of the Medical Clinic (in.Morris Lowenstein Building), the X—ray laboratories (in the Littauer Building), and the @linical Chemistry Laboratories (in the Sloman Lowenstein Building), has made adequate service cumbersome. It is recommended that the Clinical Chemistry Laboratory be relocated in the Research Building, in close proximity to the physiologic observation ward. some With the moving of the present neurophysiology offices from their present position, on the first floor of the Morris Lowenstein Building to the Research Building, three rooms adjacent to the present Medical Clinic will be vacated. It is recommended that these rooms be converted to the x-ray, fluoroscopy and radio~isotope laboratories of the Department of Medicine. With the Research Building attached or in proximity to the Morris Lonenstein Building, the present separated facilities will be in close proximity. Relocation of the Clinical Chemistry Laboratory, from the Sloman Lowenstein to the Research Building, will free an additional 300 ft. of laboratory space for the expansion of the Research Biochemistry Laboratories. 7.) In the history of the growth of this hospital, it is ap— parent that the growth rapidly outstrips the projected allowances. In the development of this building, it is recommended that provisions for expansion be provided in the initial designs, by ind.uding a foundation strong enough for the addition of 100% of the Space; space for elevators; and utility resources adequate for this type of expansion. Also storage space rapidly outstrips the needs of the laboratories. For this reason, a recommendation is made that a basement storage, equal to 15% of the initial floor area, be provided. 0.) Name: is inadvisable 'It"Laboratories" to apply to this building or wing the name or "Experimental". To follow the traditions "Research", of the hospital, the name of a benefactor may he applied, or other non- specific designation. D.) Research Beds: item of research need is not recommended. That item is a To ward. research provide facilities for the continual observaspecial tion of a large number of patients, separated, even in name only, from the rest of the hospital group, would dilute to potentialities for the utilization of all other patients, as well as provide a psychologic barrier to the experimental program. For the present, it is inadvisable to admit One patients for "research.". �.3. II. . GENERAL OUTIINE 0F SPACE RELOCATIQE: Taking into account the available fUnds and the potentiality of additional Public Health Service support, a three-story building, approximately of the size 100 ft. x no ft. is projected. A.) Basement: To include space for the following: 1.; 2. 3.) h.) Library stacks. Storage Space. Clinical Chemistry laboratory and offices. Space for expansion of Chemistry Research laboratories. include utilities, enlarged to 5,000 sq. ft.). (To it may be advisable to have the basement area B.) Egret Floor: l.) waiting room - receptionist. 2. Medical library. 3. Large conference room. Small conference room. h.) 5. Offices and interviewing rooms - 12. 6.) Secretaryfs office and filing room. C.) Second Floor: 1.) 2.) 3.) h.) 5.) 6.) III. Neurophysiology laboratories - 2 - and central recording room. Physiology observation ward. Psychophysical laboratory. Psychotherapy experimental laboratories - 2 - and central sound recording room. Four offices. Small conference room. SPECIFICATIOIB: A.)‘.Taboratories: l.) Physiologic and Neurophysiologic Laboratory: Two rooms for the simultaneous observation of two subjects should be placed about a central third room, which will contain the physiologic recording equipment. In such a system, single pieces of recording equipment can serve dual functions. Such rooms should have independent facilities for temperature and humidity control. Initially, the central equipment room will contain a single EEG unit; but space for a second unit and a frequency analyzer should be allowed. The equipment room should contain recording equipment capable of continuous, simultaneous observation of a number of physiologic variables, such as blood pressure, pulse rate, respiratory rate, and galvanic skin reflex. The position of these three rooms should be in close proximity to the physiologic observation ward. a.) Location - Second floor. b.) Approximate size: each experimental sq. ft., the equipment room of 180 sq. ft., with an adjoining smaller repair laboratory of 120 sq. ft. room of 150 �.h. c.) Relationship access to and access: Each experimental room to have the phySiology ward; and to the equipment room. Equipment room to have large glass port into experimental room. Port to slide into wall to allow direct communication between equipment and experimental rooms. d.) Special construction: (1) Individual temperature and humidity control for experimental rooms. (2) Sliding port. (3) Double walls and ceiling for sound-proofing. (h) water piping and sink in each experimental room. 2.) - Physiological Observation War ‘ Attached to the physiological laboratory, there should be a four-bed observation unit. Such a unit should be equipped for the 2b hour study of patients for biochemical and hormonal studies. A nursing unit should be provided, as well as storage space for the medical equipment needed to protect patients who are under investigation. a.) Location: second floor. 800 sq. ft. Size: b.) c. Relationship and access: access from the main hall and offices; as well as the two physiology laboratories. d.) Special construction: (1) Two two-bed units. (2) Two lavatcries and one shower. (3) opace for storage of clothes of patients; and nursing equipment. (h) Nurses station of desk, storage space, reirigerator and 3 1m 0 (5) Doors wide enough for stretchers or bed. 3.) - Esychophysical Laboratory: This laboratory should be equipped for visual and tactile studies. he room should have windows with built-in light- proof shutters, and the doors should be such that complete darkness can be achieved. For a visual laboratory, the length should be at least 2h to 26 feet. This room should have individual temperature and humidity control. a.) Location: second floor. 250 Size: Length sq. ft. b.) and c. Relationship should be 2h access: access to the logy equipment room and an office. d.) Special construction: El) Light-proof shutters ft. hall, the and doors. 2) Individual temperature and humidity control. physio— �-5h. Psychotherapy Experimental Laboratory: Sound Recording Unit. For the proper observation of patient and therapist, two experimental rooms about a central observation equipment room, should be provided. These rooms should be sound-proof and isolated, preferably at the end of a hall, away from traffic . Lighting should be provided in experimental rooms so that filming of the procedure can be done without additional lights. The central equipment room should contain sound recording equipment which can be controlled either remotely from inside the observation room or from the equipment room itself. A port should be provided from the equipment room into each of the experimental rooms for filming. It would be advisable that at least one of the two experimental rooms be of sufficient size to permit a group of six or eight patients to be under continuous observation. Observation will go on from the central equipment room through one-way vision.windows. should be possible to accommodate a large By adjustable, one-nay vision mirrors, group of observers in the large experimental room, to study the procedures in the smaller experimental room, while recording is accomplished for the separate recording it room. a.) Location‘ second floor (this facility may be placed the first floor in exchange for officeS.) b.) Size: three rooms: (1) Experimental room, large - ZhO sq. ft. on (é) Experimental room, small - 100 sq. ft. (3) Recording-observation room 150 sq. ft. 0.) Relationship and Access: (1) Both experimental rooms are to have one-way ports from the recording room. (2) The large experimental room should have a one-way port into the small experimental room. (3) Access to hall from each experimental room and recording ' room. (h) Access from recording room into large experimental room. d.) Special Construction: (1) Double walls, ceiling for soundproofing. (2) One-way mirrors as in (c) each into filming Special room. experimental port (3; (A Cable connections from each experimental room to recording room. (5) Loudspeaker connections from small experimental room to large. (6) Microphone location and outlets placed in original wall brackets and fixtures. 5, Clinical Laboratory: Relocation of the Laboratories for Clinical Chemistry in close proximity to the physiology ward is advisable. The Clinical Laboratories should heprovided with adequate benches for routine and special test procedures. In View of the space recommendation for Research Biochemical Laboratories, it is advisable to locate the Chemical Laboratories in the basement, with access bv open stairway to the first floor reception room. a.) Location: basement near stairwell. b.) Size: 750 sq. ft. c.) Access: from hallway in basement; to first floor reception room and second floor laboratories through stairwell and elevator. �u6u d.) Special construction: (1) High ceiling to allow for hanging pipes and "false" ceiling. (2)'work benches, sinks, electrical, compressed air, hot and cold water, gas outlets according to detailed specifications of biochemist. 6. Allowance for Expansion of Research Biochemistry: 1500-2000 recommended that is allowances of the this In building, it expansion. biochemistry future be for basement incomplete, of left area sq. ft. Such area should have higher than average ceiling to allow for the installation of necessary piping. B. foice Space: Individual work space for each of the members of the research service inpsychiatry in experimental The requirement staff be present should provided. and two provision psychologists, clfiles two psychiatrists, a neurophysiologist, and additional psychologist. an of a physiologist addition the by for expansion into would requirements I space picture Clinical Psychiatry, In the section for (anthropologist scientist social two a psychologists, clude three psychiatrists, of staff makes This professional a total worker. and a social or sociologist), One three persons. 1h. In addition, the secretarial services will require in she act also receptionist as a can such that be in a position secretary should secretarial Additional of offices. section the of entrance the a waiting room at adv In be where records will kept. section and filing help should be in an office pre-docresearch fellows, for be aside set two additional officesashould dition, research the with who become associated medical students may toral psychologists or nrqgram. be the on to first floor, largely is office Location: space a.) with some on the second. b.) Size: 1.) Offices of 2.) 3.) c.) Access 1.) 2.) 3.) ft. are recommended. Sixteen are required for the fourteen provisional personnel and two additions. A waiting roomplSO sq. ft. A large secretarial office for two secretaries and filing space - 150 sq. ft. and Relationship: Twelve offices on the first floor, each with access to. two of sets leave advisable be to may a hallway. It offices with an inter-connecting door for the administration heads of the two psychiatric sections. The reception room should be at the entrance to the and staircommand the hallway through and access unit case with the basement, second floor and all offices. The 10x12 or 120 sq. secretarial office should be located close to the reception room. d.) §pggial construction: Double walls and ceiling to establish privacy for the patients under observation. �C.) - Conference Room: important element in any research unit is a place where various A conference room so and discuss activities. their workers can get together This would be workers most the of be would for ideal. central placed that it would prevent the use of one office, the lihary or a laboratory for group disand slides films; blackThere be for should projecting provisions cussions. boards for discussions; and space for exhibits of projects under study. An A second small conference room should be provided for similar purpose on the second floor. a.) Location: first floor for large small. room; second floor for 180 sq. ft. and 120 sq. ft. Access and Relationship} (1) The large room should have access from the b.)Size: c.) library. (2) The small room needs access only from the hall and hall. centrally located on floor. d.) Special construction: facilities for slide-projection, blackboards, and exhibition space allocated on two walls Both should be of the room. D.) - Medical Library! present Medical Library contains one thousand volumes. In Committee has been aware that the library the the Library assessing collection, be obtained during volumes thousand will that one approximately by deficient is the next two years. In addition, considering the number of journals now in subadded and texts are that number neurologic of and the psychiatric scription, hundred hundred four to of three the rate at of a the expansion library annually, volumes per year is anticipated. In addition, the Library Committee anticipates For and these micro-cards. micro-film both the use recommending that library removed of the is location library the the that present well fact as reasons, as from the main activities of both the resident and research staffs, it is recommended that space for the library be provided; the Space to be divided into a main reading room; small librarian’s work room; and library stacks. The a.) Location: 1.) The main reading room to be on the first floor, The preferably near the entrance to the building. librarian's work room to be off the main reading room. 2.) Library stacks to be in the basement, preferably under the main library. b.) Size: c.) Main reading room Librarian work room Basement stacks: 900 sq. 100 sq. 750 sq. ft. ft. ft. Access and Relationship: The main reading room to have access from the hall and from the large conference room. The work room is to come off the main.reading room. The stacks to have access from the basement hallway. �.8d.) Special construction: In the main reading room, bookcases for current books, journal racks for current journals; special equipment for microfilm reading. Also a mechanical dumb-waiter to connect library and the stacks. E.) -;§nimal Laboratories: Present studies on steroid metabolism, the role of cholinesterase and acetylcholine, and the need for some experimental work on the threshholds of convulsions,hsve made me feel that facilities for animal studies diould be provided. The space presently allocated in the Sloman Lowenstein Building is satisfactory; and part of the funds allocated for this expansion should be utilized to equip that space. F.) ~ Storage Space: Storage space for patient records, laboratory data and equipment, should be provided. Such space should be considered in the basement. Minimal allocation of 500 sq. ft. for the laboratories is suggested. G.) - Egpansion: ._ Allowance should be made in the planning of this building, for the addition of a third and fourth floors. For this reason, an elevator well should be included in the original designs, as well as boiler and other facilities with expansion possibilities to accommodate doubling the original floor space. an Furthermore, to accommodate laboratories on the basement floor, extra-high ceiling is recommended. Also, construction of the foundation and supporting structures should be such as to accommodate the increase in floor space. �ham”. nus-an 1. \ um. um. ”a. “it. W 1.. Ida. nun. mu m u: hm, mm. may M. 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Miller Subject: Report of Research Service, Second Year - To September 1, 1956 At the request of the Medical Affairs Committee Chairman, I am sub. mitting this report of the Research Service, describing its activity during its second year. During this year, the staff has increased; we renewed our grants with the U.5.J.H.S. and through the efforts of members of the Board of Directors, received grants from the Kaufmann and Dazian Fbundations; and we were encouraged by the results in our electroshock evaluation, reserpine and chlorpromazineinsulin, and anbivalence studies. distressing feature of the year was the denigratration of the Research Service to separate services without a Director. As of September 1, 1956, the Research Service is divided into a Section of Experimental Peychiatry (under my direction); a Section of Clinical (Psychodynamic) Psychiatry, to be created; a section of Biochemistry headed by Dr. H. Geldenberg; and a section of Internal Medicine unfer Dr. Cohen's direction. 'Uhile there is some theoretical justification for such a development in a large institution, the development here has led to a diapersicn of activities and a lack of adequate supervision of ongoing One activities. high note at the end of this year has been the recommendation by the Board of Directors that the Ford Foundation funds be allocated to relieving the space problems of the Research tervice. Following this recommendation, and after discussion with interested members of the hospital staff, I drew up a basic program for the Research Building. This program was approved by the Research Committee of the Medical Board at its meeting on August 28, 1956, and is now in the hands of the hospital architect. A A. PROGREjs l§*9HGOING PROJECTS l. Electroshock.Evaluation.Proaec : We have completed Electroshock Project # 3 which demonstrated the dependence of the rating of improvement following electroshock on the patient‘s personality; as well as elicited definite measures of language changes which were correlated with improvement. result of these studies, we instituted a "control" study, designed to validate our hypotheses. we are new in the midst of this study, which will continue until spring, 1957. As a believe that we now understand the neurophysiologic, personality and psychologic factors in electroshock therapy. Our data has both prognostic and theoretical significance; and I plan to present a definitive report before the American Psychiatric Association in may,.1957. We presented the language changes in electroshock to the American Psychopathological Association; the EEG changes to the Eastern LEG Society; and will present a report entitled "Relation of Tests of Altered Brain Function we have �92- to Behavioral Change lolloning Electroshock" to the Divisional A.P.A. meeting in November, 1956. Reports of the memory changes, amobarbital test and EEG changes in electroshock have already appeared in press. T? Meanwhile, as part of the resident training program, we have encouraged a senior resident, Dr. Harold Esecover, to undertake a study of the type of psychotherapy which is best suited to different types of electroshock patients. Furthermore, as a consequence of data presented at the American ELG Society in June, I have devoted considerable time to an elucidation of the biochemical changes underlying electroshock. Such reading has led me to elaborate a theory of the relationship of acetylcholine and cholinesterase in blood and spinal fluid to electroshock results. nith the cooperation of Dr. Goldenberg, this study will be added to the ongoing control electroshock study. (a) Thorazine - Insulin: The control study instituted a year ago has continued with dramatic results. To date hS patients have been studied, 22 on Thorazine and 23 on insulin. All were insulin coma condidates. The thorazine group has demonstrated a higher improvement rate, and a lower refusal and complication rate than the insulin patients. we are impressed by this data and plan to complete the study by the end of the year, for presentation to the staff. 2. Drug Evaluation fifudies: (b) Reserpine: See "com. pleted projects." (c) Anectine- Electroshock: Continuing our studies of paralytic agents in electroshock, we utilized a technic for administration of anectine devised by ur. William Karliner of the Attend. ing staff. ’Ue found it most useful and safe and the results prompted us to recommend the adoption of this technic for our unit.‘ This study, undertaken by Dr. Tarachow, has been successful in defining enmivalence in operational terms, i.e., by the tests used to measure A summary of the two years work is being presented to the staff on Octit. ober 7th. 3. émhiyalence Study: In addition to Dr. Tarachow, Dr. H. Korin has beenzactive in this project; and recently, under the resident training program, a senior resident, Dr. Stanley Friedman, has been assigned to the project. h. Commlication Studies: Aided by the grant from the Foundation, Dr. J. Jaffe has devoted this year to developing ways of measuring the verbal interaction between doctor and patient. To do this, he records his interviews with patient before and after periods in which he modifies his attitude to the patient. At one time he says little, later he may re-enforce the patient's positive (or negative) comments. By noting changes in language, rate of speech and in mood, Dr. Jaffe has developed an index of communication change. Kaufmann �-3... present, he is testing the validity of his scoring methods, and plans to apply them to doctor-patient interviews in the near future. At In addition, with Dr. Kahn, 3r; Jaffe has explored the possibility of other technics, as sentence completion tests and the reading of'a standard parab graph under conditions of immediate feed-back as measures of changes in commun- ication patterns. 5. Autonomic Reactivity: In his initial studies, Dr. Blum» berg demonstrated that the class; ification of patients according to their blood pressure response to mecholyl was meaningful for our population. He then applied the test to the patients on the reserpine study, and noted a consistent and persistent lowering of blood pressure 11th an a-.. increase in the mecholyl response Iuring the period of reserpine action. w“. Host significant, however, has been his studies of the electroshock He has studied 100 patients, and established celrelations of their mechgroup. olyl reactivity with age, diagnosis, and therapeutic result. He concluded that the mecholyl responsivity is directly related to age - and that this is the determining factor, more than the primary illness. He is describing his observations in the forthcoming Israel Strauss Volume of the Journals a consequence of these studies, he has recommended, and the Research Committee has approved, a study of better ways of measuring blood pressure; and a collaborative biochemical venture (with Goldenberg) inDC the chanes As . r. in adrenalinenoradrenalin in the blood. 6. Biochemistgy: (a) Steroid Sulfate Coniugates: As indicated earlier, the steroid studies were undertaken because these hormones are known to be implicated both in the physiological response to stress as well as in the sexual processes. Three impartand observations have been made in the Hillside Hospital Laboratory. First, has been noted that the steroids, which are manufactured by the adrenal and it sex glands, are converted in the liver to water-soluble steroid sulfate conjugu ates. Since this is one of the major forms whereby the sex hormones are elim» inated from the body (via urine), the liver evidently plays an important role in maintaining hormonal balance. A second discovery in this area was made by comparin“ male and female rat liver activity. Female rat liver was found to be remarkably active in conjugating the steroids, particularly the male hormnnes. This means that the female animal possess- a regulatory device whereby she maintains her ielaleness by preierentic.lly excreting the male hormone which, incidentally, are present in both senes. s Finally, in the first group of 18 normal human observed that urinary steroid sulfate output is a) so::-linked, being tnice as high in males as b) appears to be low in value for calm people, whoare innately tense, excitable, prone to controls it has been in females, and but rises in subjects anxiety. (b) Psvchotomimetic and szchotherapeutic Dru;s“ : Thesecond preject in the laboratory involves a study of the possible role of hallucinogens in the development of mental disease. It has been hypothesized that indole-like compounds, comparable to LSD, acrenochrome, or a.crenolutine may be formed in vivo as a result of faulty metabolism and give rise to the $3.rmptoms commonly.associated with the psychoses. Initial studies in Our laboratory have failed to detect these alkalw , �.u. oidal products in patient's urine. Ebssibly this is due to a poor choice of patients, since none were actively hallucinating. it of the the most proportion that greater likely appears suSpected alkaloids would be excreted in changed form, and very likely via the feces. r‘his is suggested by metabolic studies which we have carried out to is administered in known quantity. determine shat happens to mescaline when unaccounted The 5% the rest is urine. in unchanged comes about through Only carbon diobe A as of expired course carbon residues might of the portion for. LSD the isotope the drug. in would account not nitrogen for xide, but this hence excretion the of in drug accumulation gut, this indicate studios in Jurope studies For subsequent these reasons our here. seems also feces the likely in However, it will involve isotopically—labelled hallucinogens to determine their ultimate decould more then we intelligently these at our facts disposal, Having fate. termine the excretion of related compounds by psychotics. (c) 92lorpromazine project; Studies on the metabolism of chlorpromazine by psychotics were reported earlier, at which time chlorpromazine, chlorpromazine were derivative alkaloidal and unidentified an chromogen, the purple sulf Xide, demonstrated in urine. A sufficient quantity of the last compound could not be and the project conventional methods, by identification from for urine isolated was held up in April pending receipt of a continuous flow electrophoresis unit. This item has been on order for h months but has not yet come in. 7. Tactile Perception: Following the technics devised by Dr, Bender, Dr. Green and myself, we have, with U.S.P.H.S. support, set up studies of tactile perception using simultaneous threshold electrical stimuli. Patients have been studied before and during electroshock. To date, the data amply demonstrates that the phenom! ena of extinction, displacement and confabulation, noted clinically in childin all elicited readily are cerebral with dysfunction, and organic ren patients induced the organ— with electroshock, Furthermore, threshold levels. at subjects ic cerebral changes exaggerate the perceptual errors in identifiable patterns. This study is continuing and it is planned to present the data before the appropriate neurologic societies. ' 8. Prognostic EngiCatorg g: glectrgshgggg This study, designed by Dr. Karliner to elucidate the relation between presenting symptoms and the results of electroshock therapy, is continuing. Forty-five patients have been studied, and it is anticipated that the results will be determined in the coming weeks. �.5. B. COMPLETED PROJECTS: collaborative study of the urinary steroid pattern changes with electroshock has been discontinued. The initial findings demonstrated a significant alteration in the steroid patterns after electroshock in improved patients. After studying these results, Dr. Hellman of the SKI and I prepared a protocol of experimental drug administration designed to clarify these findings. 1. Sloan Ketterinr Study: The presentation of this protocol to the Research Committee, it was their recommendation that, despite the merits of the research design, it not be approved for this hospital. The chief criticism was one of the risk to the pat. Upon ient of the procedure. these studies could not be meaningfully carried out at the hospital, the program.has been transferred to Creedmcor State Hospital, where the cooperation of the Medical Director and the Commissioner of Mental Hygiene of New York has been assured. As 2. subculture: project has been discontinued following the initial reports of the study group. hour observation of a patient, islaeing prepared The primary study, that of a 2h for the Research Committee by Dr. R. Navarre. The 3. Reserpine Egalyation: The high-dose reserpine evaluation study was completed in harsh. The results demonstrated a limited usefulness of this drug in our population. Hhile it occasionally controlled overactivity, it did not reduce the symptom of anxiety; and did increase existing feelings and states of depression. The results were reported in the April issue of the Journal and summarized for the administrator and staff in memoranda and meetings in April. As a result, reserpine was made part of the hospital formulary, with specific recommendations for its limited use. C . PROJECTS Fulfil-ED: 0*.“ 1. Cerebral Reactivity: In the course of our studies cf electroshock, we have been imp pressed by the differences in brain responsivity to electroshock. Some patients show a quick and intense change in behavior and on our tests; while others require more frequent treatments, higher voltages, etc. to induce any change. u developed a series of hypotheses which ascribe the differences in reactivity to (a) biochemical differences in acetylcholine-cholinesterase metabolism; (b) personality differences; and (c) generalized hypo-responsivity to all stresses. For this purpose, we are now elaborating protocols to test these hypotheses. As developed, they will be submitted to appropriate granting agencies for support. we have 2. Autonomic Reactivity: See "Ongoing ProjectS." �3. Digghemistrv: Following the present studies it is planned to continue the studies of bio- chemical changes in mental steroifs sulfate excretion illness along the following lines. end a) Comprehensive survey of urinary its relation to anxiety. b) Circulating steroid sulfate levels in blood and spinal fluid. c) Enzymic and fluorometric evaluation of alkaloids excreted in feces, with particular reference to patients who are hallucinating. Cholinesterase and acetylcholine levels in spinal fluid of patients undergoing electroshock therapy (as part of the electroshock evaluation study). d) D. STAFF CHANGES essential change during this period has been the reorganization of the hospital‘s research activities. As of SepteMber, 1956, the Section of Experimental Psychiatry, which is one of the surviving sections of the Research Service, consists of the following: The Dr. N. Fink D?, - J, Jaffe Dr. R. Kahn Dr. H. Karin Dr. H. Green Research Associate Research Assistant~Psychiatry Sr. Research Assistant-Psychology Research Assistantufsychology Research Assistant-Neurophysiology and a full (Mrs. H. Hosquera). time secretary (Miss Gayle Iankel) and 2/5 - time EEG technician chief addition has been the addition of the EEG technician and the part time appointment of Dr. M. Green. For the present, and until December 1957 As of January somatic the 1, Green filerapies. Dr. 1956, supervising is 31, he will devote all his time at Hillside to experimental work. The E. FUNDS: for 1956-57 have been received from the U.S.P.H.S. From the National Institute of Mental Health, support for Dre. Kahn and Karin, in the electroshock evaluation study, and for biochemical studies in the relation of alkaloids to mental disease. Also, from the National Institute of Arthritis, funds for the study of steroid sulphates, now used to support one research Grants chemist (Hrs. Ruth Foley). Also, a small grant from the Dazian Foundation supported the summer employment of a chemist; while the Kaufmann Foundation has been supporting the studies of Dr. J. Jaffe. �I are planning to submit an application for support of the studies in cerebral reactivity; while Hrs. Blumberg and Miller are submitting one for their studies in autonomic reactivity. Both reAt present, Dr. H. Green and quests are to go to the U.S.P.H.S. before F. OTHER November 1, 1956. ACTIVITIES l. hedical Library: In mic-1955, the hospital obtaineo the services of a part-time 1110(l0a1 librarian. By the year's end, it was apparent that the acecuate utilization of our library required a full time librarian, anc as of March 1956, miss Rosalind Lazarus was apppointed. I was appointed chairman of the Library Committee, and through our joint efiorts, the medical library was activated. A definitive budget was prepareC and approved; rules for library use established; and more recently, a 2000 volume addition to the library was recommended to bring this library up to the standard as the most complete psychiatric library in the North Shore area. of the Journal of the Hillsidee“ 2. Israel gtreufig_folune S ervice Research* m<.1d3ers o;t of the the By active aith Dr. cooperation HosEital: S. Tarachov 3 the volume was orranized and editec. It is new in the hence of the printer and fill appear in November, 1956. 3 3. Isreal Strauss hemorial Lecture: The appointment of the second lecturer, Dr. Hilliam Halamud, an” the detailed arrangements for the lecture were made by the Committee headed by Dr. Bender, with the active cooperation of members of the Research Service. Research Builcing: Following the recommendation of the Board of Directors, the members of the Research Service were most active in planninf the new structure; describA. The and the for architect. relationships descriptive ing its uses; establishing first blueprints were submitted and after considerable discussion, were returned with corrections. Continued liason with the architect is planned. 5. Resident Training: During the past year, members of the Research Service gave bimonthly seminars on recent advances in psychiatric research. Two special lectures were arranged; and the local Research Conference of the Nassau Heuropsychiatric Society'nas held at Hillside Hospital. Respectfully submitted, Mffigw Fink, M.D. Research Associate (bxperimental Psychiatry) Max �fi— - Methods New Reports .For Evaluating Electroshock Hosfipifali W . . thropies, is engaged in a number of investigations into the basic causes and treatment of mental ailments. Dr. Maximilian Fink, research associate at Hillside, said that electroshock actual1y Fan change the way the braln functions, and that these Changes can be observed and measured by electroencePhalography. The change' in the brain also, shows itself in the response to dru es, M s cholo gical testin e and the weakening of unpleasant memories. The Hillside researchers report new and definite methods for measuring the extent of these changes. In the successfully treated electroshock patient, these brain changes enable the person to maintain better control over his emotions and behave more like a normal person. An' important clue to how'to identify patients less likely electric shock therapy affects to benefit from electroshock the human brain has been un- so that they can be treated covered by researchers at Hill- earlier by other methods. side Hospital, Glen Oaks, it The electrOShock developwas announced today. ment was described in the Hillisannual report side Hospital is It expected that this discovery will increase the ability sued todayvto select patients most likely Hillside, a non-profit mental to benefit from electroshock. hospital affiliated with the This development also will help Federation of Jewish Philan‘ ll llIlllllllllllllllllllllllllllllllllllllllllllllllllllll . For Free. 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SP'“*" 8" Pr°°£ ‘ i V ‘ 3 QUARTS—‘l 1.75 0 CASE or 12—4650 . r nolh§§§£§§ZXt°£atlt°2§§§i§ 31;: HEAR-OLD "MITCHELL" MARYLAND RYE patient to benefit more readily from psychotherapy administered during and after the . tcourse of electroshock. .tElectroshock therapy will continue to be used in the treatment of depressions occurring in patients in the 30 -to 60-year age groups, and also in younger schezophrenics showing mainly excitement or stupor as symptoms. In issuing the report, Dr. Joseph s. A. Miller, medical director, also presented the following data about the year’s activities at the hospital. Among 575 patients treated during the year, the average length of hospitalization was 176 days. Of_ these, 32 patients were admittfld t0 the Israel Strauss Adolescent Pavilion, a facility for adolescent girls; which was founded in October, 1954. The out-patient service treated 224 patients. ‘ ——~— �. following day- BERNETHY—Elnia 1... on October 30, 1956. wife of the late Richard 3.. beloved mother at Gertrude Tobias and 1Estelie Abcrnethy. ervices Thursday, November lst. 8:30 P. M. at the Clarence F. Simonson Funeral gall-[EL 1119-04 Hillside avenue. Richmond ntermeni‘ Friday. 1]. A. M. Maple Grove Cemetery.lALICCHlO—Raifaele, on October 30. 1956. of 101-28 99 stret, Ozone Park, beloved husband of Marianna, dear father of .Vincent and Florence. dear brother of Carmine. also survived by eight grand— l children. Leposmg at the Cassese .Funeral‘ Home, Inc.. 101-07 101 avenue, Ozone Park. Funeral Saturday, 9:15 A. M. Solemn requiem high mass St. Mary Gate of Heaven aterment St. John’s Cemetery. IHRISTENSEN—Chauncy J., on October 30, 1956, after a long illness, belov‘ed husband of Amelia.‘ devoted father of the late Dorothea C. Herold. loving grandfather of Barbara and Richard Herold. ‘uneral from the Walter B. Cooke Funeral Home. 158-14‘ Northern boulevard. Flushing L. 1. Friday, 3 P. M. nterment Cedar Grove Cemetery. URClo—Lena. on October 28. 1956, of 73-11 Metropolitan avenue. Middle Village. devoted wile of Carl. loving mother oi Salvatore and Joseph. Leposing at the Phillips Funeral Home. 79-02 Metropolitan avenue. Middle Village. Funeral Friday at 10 A. M. Solemu mass of requiem at st. Margaret's R. C. Church at 10:30 A. M. nterment st. John's Cemetery. “NAN—Elizabeth. on October 29. 1956. beloved wife of William. mother oi Lulu Harrington and Mary Mattoe; also survived by two great-grandchildren. teposing at the Walsh Funerar Home. 94-08 118th street. Richmond Hill. Services Friday. 1 P. M. nterment Mount Olivet Cemetery. HEDGE—Catherine V.. of 585 Seneca avenue. Ridgewood. on October 30. 1956.-age 66 years, beloved mother of Walter. Joseph, Madeline, Frances Connell, Mary Jo. (Dolly) Connell. devoted sister of Ellen O'Loughlin, also survived by four grandchildren. ’uneral Saturday. 9 A. M. from Charles Morton Funeral Home. 578 Onderdonk avenue, Ridgewood. Solemn requiem mass St. Brigid’s R. C. Church. 9:30 A. M. e nterment St. John’s Cemetery. lAY—Laurance X, Staff Sgt. U.S.A.F.. suddenly at Carlisle. Mass. on Saturday. October 27, 1956. beloved husband of Patricia A. (nee Joerger). devoted father of Donna Patricia. Laurance and Kevin Gay, dear son of Lorraine and Margaret ,Gay. loving brother of James. Jere. Patricia Papscun. Marguerite Clay. Jeanne-Marie Dalessandro. and the late Lorraine Edwina Gay. uneral from the Gleason Funeral Home. 10-25 150th street. Whitestone. N. Y. on Friday. November 2nd. at 10:30 A. M. Solemn requiem mass st. Luke’s R. C. Church at 11 A. M. utennent United States National Cemetery, Pinelawn. L. I. lATCH—Helen Frances. on October 29. 1956. beloved wife of the late Lewis. devoted mother of Ruth E. ervices at Walter B. Cooke Mineral Home. goaOSrgdena avenue. Brooklyn, Wednesday, ' , . ' , :iterment Walkill Valley Cemetery. Walden. New York. lAVERLY—Joseph. of 60-27 78 avenue. Ridgewood. on October 28. 1956. age 76 years. beloved father of Joseph. Jr.. Henry and Robert Haverly. Catherine Anastasia. Lucy Corrado. Lillian Caverler. Marie Roethel: also survived by 28 grandchildren and nine great-grandchildren. uneral Friday. 9:30 A. M. from Charles Morton Funeral Home. 578 Onderddnk avenue. Ridgewood. Solemn requiem mass. 10 A. M at st. Matthias R. C: Church. nterment St. Charles Cemetery. Pinelawn. Long Island. sum": non Until 5:39 in «m... or I. IL Satori-y llliib‘S—Mai‘ie (nee Gademann). on Octoher 30, 1956. beloved wife of Edward Heiss. devoted mother of Carol Elizabeth. Nancy Edwina and Bruce Edward G. Heiss..deai sister of Frances. of Regen— burg, Germany, loving daughter of Reinhold and Francisca Koob of Munich. Reposing at the Leo F. Kearns Funeral Home. 61-40 Woodhaven boulevard at Dry Harbor road, Rego Park. Funeral Friday, 9:30 A. M. Solemn requiem mass at our Lady of Perpetual Help R. C. Church. Richmond Hill, 10 A. M. Interment St. Charles Cemetery. Please omit flowers. ., .. , HOFFMAN—Augusta E., on October 29, 1956. beloved mother of Fhillip Pflug, dear grandmother of William Pflug, sister of Anna Uphoff and William Warnke. Services. at the Stutzmann Funeral'Home, 224-39 Jamaica avenue. Queens Village, L. I., on Thursday. 8 P. M. Funeral Friday, 1:30 P. M. Interment Lutheran Cemetery. Jun—Wilhelmina M.. on October 30. 1956. Beloved wife of Ernest. dear mother of Jr.. and grandmother of Leona Ergest u . SerVices at the Stutzmann Funeral Home. 224-39 Jamaica avenue. Queens Village. L.‘ 1.. on Thursday. 8:30 PM. Funeral a,_ ~ Friday. 10 AM. BAECH’I‘OLD—Emil Albert.‘on October 30. 1956. beloved husband of Anna '1‘. (nee Pfei er). dear father of Mrs. Ruth H. Will and Elmer A. Baechtold. brother 01 Christian A. and Walter 0. Baechotld. also survived by two grandchildren. Reposing ,at the Floral Park Chapel of Thomas F. Dalton. 29 Atlantic avenue. Religious serVices Thursday. 8 P. M. followed by Masonic services, Eureka Lodge No. 243, F. a. A. M.. Machinists Lodge, F. 8: A. M'., Interment Friday, 2 P. M._ Lutheran Cemetery. . BURNS—Samuel J., of 84 New York avenue. Baldwin. formerly of Brooklyn, on October 29, 1956, son of the late George J: Alice O’Keefe Burns; dear brother of. Belle Burns. Reposing at the Fullerton Funeral Home, 131 Merrick road. Baldwm. Solemn R. C. Eeguiegl Firiiiaiss €5.00C1Arilatopher'l urc r ay : . . 2312 Third Street. KOLLlNS—John S., of East Meadow, L. I.. suddenly, on Monday, October 29 1956 in his 45th Year. beloved husband of Angela. devoted ratherr of Adrienne. dear brother of Mrs. Bertha Bowers, Stanley and Tony Kollins. R'posing at‘ the Catholic Chapel. 2100 3e11more avenue, Bellmore. L. I. Notice of funeral later. Under direction of John J. Mlchalek. ' Interment Maple Grove Memorial Park. KENNEDY—Thomas F.. 116-30 221 street, FUNERAL HOME. BELMORE Cambria Heights, L. .I. Beloved husband of Ethel (nee Huxley), father of Eileen CAROW—Edward, of Malverne. suddenly Devlin. Kathleen Wilson.» Ethel Albert. October 30. 1956. beloved brother of Loretta McGivney. Adeline on Tuesday. of Rayhusband of Jennie. dear father Doyle.. Ethel Casey. Seven grandchildren. ' of Dorothy Koenig and Reposing at the Funeral Home of Lawrence mond. brother survived by four grand" Eldred. also D. Rouse Inc. 191.02 Linden boulevard, children, St. Albans. L. I. Solemn requiem mass. Reposing at the Flinch a. Bruns Funeral .Friday. 10 A.M.. Sacred Heart R.C. Home. 34 Hempstead avenue. Lynbrook. Church. Cambria Heights. L. I. Interment st. John's Cemetery. Middle The family will receive friends between the hours of 3 to 5 P. M. 8: 7:30 to Village. L. I. 10 P. ,M. Masonic services on Thursday. [ALLY—Philip E., on October 27. 156. 8:30 P. M. Religious services on Friday. dea; uncle of William F. Lawkins. 10 A. M. Funeral from the Queens Village Chapel Interment Knolls Memorial Park. Nassau at Thomas M. Quinn a Sons, 214-65 Port Washington. Jamaica. avenue. Queens Village. L. I..‘ on Friday, 9:30 A. M. Solemn requiem FLORENCE—John W.. on October 30. 1956. fies: Olfi Lady of Lourdes R. C. Church, of 315 Locust avenue. Unlondale. Beloved husband of Frances. and loving father Interment St. John’s Cemetery. of John W. Jr.. Jeanne and Diane. SurLOMBARDO—Teresa vived by one brother and two sisters. (Rommanelli) , on October 29, 1956, beloved wife of Angelo Reposing at the Martin Funeral Home. 412 Willis avenue. ,Williston Park. Solemn Lombardo, devoted mother of Mary requiem mass at St. Martha R.C. Church Strollo, Anne Carro, Sue Cremona, John Frank and Edmund Lombardo, dear sis- on Friday. 10 A.M. ter of Rafiaela Genovese and Carmela Interment Holy.,Rood Cemetery. Impci'ato, also survived by seven grand~ children. KOLLINS—John S.. of 2312 {rm (1 street. Reposing at the Leo F. Kearns Funeral East Meadow, L.I.. suddenly n MonHome, 103-33 Lefierts boulevard near day, October 29, 1956. in his 45th year. Liberty avenue. Richmond Hil Funeral Beloved husband of Angela. devoted Thursday. 10 A. M. Seryice at the father of Mrs. Sophie Kincinski AdriChristian Pentacostal Church 'of God, enne, dear brother of Mrs. Bertha Bowers. Mrs. Ann Mankowskl. Stanley and Tony 10:30 A. M. Also surviving are two Interment “The Evergreensz” Kalirdohlisllgi en. ran c ._ Regiaosing 1956. 29 BellOctober 2100 BeMAYER—Bertha. on Catholic Chapel. the at loved wrfe of Otto Mayer, active member Bellmore. L. 1. Salem avenue. more ‘ of Ridgewood Heights Maenner Cbor. high requiem mass on Friday Noyember Memorial services at Buss-Avenius Funeral 2 at 11:15 A.M. at St. Rap leis R.C. Home. 63-32 Forest avenue. gewood. Newbrldge road. East Meadow. Church. L. 1.. Wednesday. 8:30 P. Funeral L. I. Thursday, 11 AM. Mt. Calvary Cemetery, Linden. Inger-merit Cremation Fresh Pond. ew ersey. Under direction of John J. Michalek MEYER—George F., on Tuesday. October l BELLMORE FUNERAL HOME 30. 1956. of 111~21 198 street. st. Albana. L. I. Beloved husband of Florence Meyer. 149 w. Stanton of E. and devoted father of Mrs. Florence McCRAI Victoria Combes. grandfather of Dorothy Combes. ,avenueltulaaldwin, on Monday. October 29. SerVices at the Fairchild Chapel, 220-05 1956. beloved wife of Morton C. McHillside avenue. Queens Village on FriGraime; devoted mother of Douglaomnd Kenneth: dear daughter of Eugenie and _day at 8 PM. Victor Fernandez. NIGRl—Lucia. beloved mother of Edmund Reposlng Funeral Brother: Weigand at oi” the ngl‘l Nigrl Furniture House. Home. 24 South Grand avenue, Baldwin. Orstehnydia Mancino: in Italy. Gaetano. Services Wednesday. 8:30 P.M. Elena. Dorotea, Teresna and Nicoletta. Interment Thursday. Milford Cemetery. Reposmg at Robert Giordano Funeral Milford Connecticut. Home. 2346 Pacific street. Brooklyn un-. til Friday, 9:30 A. M. solemn requiem QUAGLIATo—Anita Hill). on October (nee Our of Lady Loretta Church. 29. 1956. of 678 Franklin avenue. Massaf0“: alt/I pequa. L. I. beloved wife of Ferdinando: Interment St. John's Cemetery. devoted mother of Mrs. Lucille Rubusto. oasrfitLE—Aiwma. on-October 28, 1956. Mrs. Blanche Burns, Richard, Joseph. Services Wednesday. October Slst. at and Ferdinand Quagliato; dear sister of 8 P. M. at the Clarence F. Simonson Mrs. Rose Brandt. Mrs. Isabelle Snediker Funeral Iflome, 119-04 Hillside and William Hill; also: survived h- “-1-“ ‘ ___.__,_______———. - - _ . . . ‘ �Wham”. ”mi”: mashing”. mm”; ' WW W W W wmummwmmmw,w WWatt-bMMufi-mtdw ww.nmmmumwm¢t:wum mammwmm (W)M murmugmmmdmmam wwummawmmm mamam'mmmwmnmu Whuumumwmmu mam “anmmmmthWu-m «mama-ammuuwmmuworbw WW‘OM . manuumnbuwm. ramming-ma. mamammaum.mmmm~p mmmwummww m mummmcmpmwum. 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Wu..m.h¢~mx.mmsu.mmmm H. m) I mum mumamnmumm.m. 396. 3.956. 15) (um mummy. m a. . «Whammwm‘mmnmma.mmm Wpiifl'flgm �,v .7. vie .._.,.._..,-,_ "W ’3"“W". m. .. a":r-x—z var Afiv DCK TERA?! or one administered third in electroshock therapy we in previous years the adult patients. For the meet pert, it was prescribed for peuente in the As forties and fifties who electroshock was used manifested depressive symptoms. (21: To a lesser extent, patients) in schisophrenic patients to modify ms- active, essenltin er delusional behavior. the studies the of earlier results of that was in this group pstients It Psychietry were applied and extended. Patients of the Departmnt or W received series a the electroshock psychiatrist by supervising for mmmded encberbital test These included electroencepmlogren, of neurophysiologic tests. for organic brain disease, and pemeptusl tests, tactile. During per week, the tests were both visual and the course of treatmentfihieh ms adminstered three times periodically repeated. with clinical Based upon changes "alustiens in these mumplwsiologic tests ceabined psMiatx-ist, the extent «amines; In these instances in which the neuro- by the resident and supervising of electroshock tmmpy was treatment bed been not behavior obtrdned, in alteration for basis physiologie intensively. week and acre occasionally times modified five to per regimes were Ch this basis, the usual com-es of tmmnt m the patients meshing between 6 me lo batsmen 11 and 19 with m percent of the patients received more than 20 of mtients rescind less an incomplete series. Twenty-five treehnen’os .. The number of tmtnnnts tmtmsnts. than 5 treatments, which in each instmee 10% Four and to reference with diswosie therapy results at in chart is condition at time at discharge is seen in chart #9. The original studies relating the alteration in brain function indueed by electroshock to the short term clinical results, were confirmed in this series amounts-sud of and his Fink staff Dr. where study. of patients in a predictive shown #10 and the I that only these patients in when alteration in the electroencephalogram and �#2 mbarbikl taste had bean to warrant the rating of a umber 031‘ reports have mud, had mm D. clung. in behavior sufficient uprated or momma. A: a Insult. of these studies, been presented before nation]. psychiatric societies. much �#3 During 1953 there had been considerable experience at the hospital with of the newer chemotherapeutic agents, chlorprousine and reserpine. It decided to evaluate ohlorpronasim as a potential substitute for insulin tVo was em therapy. The use of chlorpronnzine we suggested by the many reports thst mlcrpronasinc had been successful in schisophrenio psychoses. Also, the specie; report of the Medical Board noting the course of patients disohnrged roam dmonstnted that the poorest long tom results were found in the insulin cone population. For this reason, a control study was instituted. Beginning Septenber, 1955, and continuing until Deomber 31, 1956, :11 patients in 1950 had referred for insulin coma therapy by the supervising psychintriste were divided into tee groups: one group received insulin coma therapy in the established doses received in and second therapy the urge chlorprmsine group newer; over a four month period. Insulin coma therapy was given for a course of 50 comes in most instances. treatedlcsees. The results Chart #llxoflects the number of cones in insulin of insulin some therapy is noted in Chart #12 and it is seen that of the 15 much of inproved or recovered. were a four rating given patients ,. In the patients who were given chlorpronesine, dosage ranged betueen daily with a 800 600 of milligrams. to mge Treatment was oontimed for a period or shut four months. In this group 200 and 3600 tailligrsms of patients, who were median unselected except for having been candidates for insulin of the insulin to that were of improvement equivalent the ratings moment, cone population. 01' 21: patients discharged during 1956, one was discharged as riftem miinprored. and much as improved, as em recovered, three as inpmd, some Guptring the complication rates of both treatments, it was noted that prolonged of nine tones and in were insulin resis cmplications reactions ledondary ems, the insulin some patients. Wtansion airfioient to cause fainting and severe demtitis were complications in five of the chlorpronasine group. Agitation �#h and penis, seizures and numbers It refusal of further therapy were seen in muivalent of patients in both groups. was the opinion of the numbers of the Deparhuent of peydtiatry ami Manual the resident physicians, Doétora Robert Shaw, George Gross Mean for this study, that in to insulin coma therapy, chlorpromasine was safer, easier to ldminater, more controllable in its effects, and had fewer aid: effects. It was their recommendation that chlorpmmine therapy would be warranted as the initial and Fred Coleman, who had hem responsible treatment for patients in the younger age group who were suffering with schizophrenic disorders. In such cmditions, they anticipated that chlorpromuino would be most behavior. effective in modifying overactive, as saultive and delusional �#5 cogg sagx rmmr 01' the fifteen patients treated by insulin com therapy, the modification of behavior was inadequate in five, loading to a be combined with insulin come. nemudntion that. electroshock of these, four patients were suffering fm a schizophrenic disorder and one from a manic-depressive not one of the patients were mach improved illness. In each instance, or recovered after combined mutant. Similarly, there were four patients or the insulin com group who had had metroshock therapy either prior to the insulin com or subsequent to the insulin con moment. Here too, the mtinga or immemnt were in the lower 4 two categories. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-004 Date A point or period of time associated with an event in the lifecycle of the resource 1956 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1954-1965 Relation A related resource The Max Fink Collection Description An account of the resource Perceptual Changes Induced by Drugs and Electroshock - Progress Report; Research Activities - Annual report; Letters; Annual Reports - Department of Experimental Psychiatry; Newspaper clipping, Hospital reports new methods for evaluating electroshock, Long Island Daily Press, 1956-11-31; Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/4b34d77a93adfdf543aae63a1ead5831.pdf 9a3d77013a79d7057f02f224ed583aa6 PDF Text Text 42.5.3. gm Standin- of tho ‘ alteration in mum the focus or muffins 1 laboratory for olmtmnmphllompm studying A or the Dona-“mm. of Manley during eh. ambuahod, and ”min manta]. oyndma m. introduced. grasp Band», dapreuivu m mm ammmud with unplug“ illmaua, men-u, man-hm. We: m method- for on, The tha change in pal-cerium in and following alactrocomulaivo therapy. “fact. at barbiturate”, ”mun um um intentiuly studied. “new of the Wan. put you. invents;pmimWe“ 51113393“ to alwltmm stimulation buts, hogan at tinted study gationa or the raspame of by Dr. w with changu in brain funeum wan and 1.780er acid (181345) on such The mammal latter part or the year, a corn-3.1M in brain function during data-woman“. thump: m In tho m psychologists. Dr. march assistants to the Imam Robert him and In; R. Karin worn uppointod «Mt, tad Dr. in: link a fellow of the fiatiml for Infmtiln Fanlyain mu appoinm to mum” the laboratory work. oi: Databa- 1, 1953 am charmmloganQ laboratory was cmbliahod with a Man. 8 clam}. instrumnt. In the mum. mm month. 65 mount. are taken. 01' than 19 um emulation muons m M in the ovum of th. integrated study an altered bran functian. [mung tn. year. 55 consultation mum matured. figure than half of mania mental am.» “mated with amt-"sin 111m“, were far or mhtod to duotmnhook thonw‘ 301m awn». neuritic types of pain, 1nd abnoml involunm menu and. up the bulk of mum. 81.: patients with «ism «11:0er um mum and controlled with anaemia to the neurologiml service of mi. Sinai amen. Thu. patient. are fie-pita?! m further ima’oiauogu for nmlogim conditions chums»! at tho m mum: We mm haapi talc �~2- m pmodural chm m introdum by an dmflunfi. u an Ad to evaluating thu uremic mum sum, tn. «ma “but” no introduood m Ivar round tbu 1m thin m1: «as worming an m put yaw, mum. ' folio-“mg the am of ehktrolhm mutant” and the In part of the in maid». mu m at mmimlmholim inugrltod study an olectrwhaoh in (month) A: In Want chlorich new“ mmmm mum; as mutated. and at «Iv m tho no! emu)“ m1- want. 1: mm «amnion: in indumn; roux-Man mum cum mining agent: 50mm. 121 Mates! m: or thetroflmck wanmu. 3.. at 4:1: The damn“ an at maharhiul ”dim in Mam” m. Jaw. Psych. zommm. (Jump) 1953. Eu- 31131108.» (1953) Mr. 11.8.! Kit.“ of link, I!" Harm, 9.3., Bath-awn, I. and on Perception, Trans. Amer. Hm. used... Jun- 1953. m, it" Green, )1- and Binder, Simultaneous 3.3.x Perception of & Malta, am. mm mu. m». mm» 5: A ma a. sum-um. study m: a fink. Tmhw, w mummy Jour. 31mm. Hosp. 236%71 (Ha-ch) 1953. 117th34¢9 m I thtu M11. um.) emu 1953. momma mamas, �October h , 195“ Interin Report Dear Dr. Miller, requested I wish to report that the following projects have been in progress this summer in this department. 1. Effect of electroshock on memory func» tion tests. Twenty-four patients are now fully studied; the data is beingA collected; and a report is planned for the 1955 A P meetings. 2. Effect of Lysergic Acid on perceptual functions, including Rorschach; and on blood chemistry. These experiments are now in progress and will be completed by the end of the year. ‘E3iy Under the terms of the U.S.P.H.S. grant a continuing study of perceptual changes in insuli n, and EST patients is now in planning. a. A psychiatric rating scale, modified after Malamud, is in use. As soon as it is standardized in this population, it will be presented to the Research Eonmittee. £5. The Funkenstein test (Hecholyl) in EST and insulin therapy is being checked in our pop— As you ulation. Sincerely, HF33RB �Obtober Projects in Progress as. 1954 / ,2-\ Relation of mental changes to behavior f‘ 1' (1) Effect of organic mental syndrOme on results of EST. (3) Changes in perception with I92. \ (3) Can ACTH. cortisone alter brain function and thereby (a) l ; i results of (b) EC! or ICT? \ \ Psychophysical measurements of Psychiatric terms - an operational approach to terms of diagnosis. (1) Denial: Relation to improvement in electroshock Relation of premorbid character to change in behavior in electroshock. (2) Ambivalence: Is it possible to measure ambivalence by psychophysicel menad and relate to the past history of the patient in choice of neurosis? Relation of chemical agents to psychoses. psychological. (o) biochemical and behavioral aspects. (d) 9 Rating Scale' �October 1?, 195b Dear Dr. Rachlin, requested I wish to report the following projects have been i n progress this summer. (1) Effect of electroshock on memory f unction, FRO, Amytal tests and nerceptual tests. Twenty four patients have been fully shielded. The first revert on the relation between the response to treatment and the occonotal test is being submitted to the A E A. The observat ion support As you the thesis that there is a relation between t development of an organ. he Mental syndrome and improvement. Effect of lysergiv acid on perce ptual functions. Rorschack and blood chemistry. The psychiatric and psychologic tests are being prepared for presentetnion at the American Psychopathological Association. (3) Under the terms of the U.S.P.H.S. gr ant a continuing study of perceptual changes in insulin and EST patient a is now i n planning. (3) A psychiatric re.ing scale, modified after Halemud, is i n use. As soon as it is standardized in this population, it will be presented to the (2) Research Committee. (5) The Punkenetein test (neohom) in EST and __ �nsulin the rapy population. 1 18 being checked Since rely, 1 n our � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-001 Date A point or period of time associated with an event in the lifecycle of the resource 1953-1954 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Annual report - department of neurology; Interim report to Dr. Miller; Progress Report; Letter to Dr. Rachlin; Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/6d5d109f552158de5a99360da32ba4a2.pdf cbe6f09f352080376a08471f0e47212a PDF Text Text HILLSIDE HOSPITAL FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263RD GLEN OAKS. N. Y. STREET FIELDSTONE 3-7300 JOSEPH S. A. MILLER. M. D. MAURICE BACHRACH MEDICAL DIRECTOR ADMINISTRATOR SIMON KWALWASSER. M. D. Assoc. June 27’ 1955 MEDICAL DIR. Dear Dr. Fink: This is to I sure that there acknowledge, with thanks, the receipt of $100 for the Research Fund, from yourself and your Associates, Hyman Karin and Simon Kwalwasser. no need am for us to tell you is of the importance of our research program. The Directors are appreciative of the sentiment underlying your gift of this $100. to Hillside Hospital. Very sincerely yours Maurice Bachrach MBzhm cc: Dr. Kwalwasser Dr. Miller Mr. Korin AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �June 30, 1955 Somatic Therapy'fbsearch Program 1955-57 From the Research Service of the Hillside Hospital mode of action the to investigate A. AIMS: It is the purpose of this study We do by this to plan mental illness. of somatic therapies in and personality behavioral of physiological, the systematic investigation factors which B. may be involved. mechanism conc‘eming the therapeutic Although many theories BACKGROUND: been have they advanced, been have of the somatic therapies cannot validity their that either empirically disproved, or, are so vague be and hypothesis, meaningful more of a development the More recently, tested. new methods of study have provided the opportunity ion. In l952,'fleinstein and Kahn (Amer. for a fruitful investigat- Journal Psychiatry l923 22-26) sug- of milieu a creating by improvement to gested that the somatic therapies lead Some could of denial operate. anisms mec in.which function brain altered support for this hypothesis has been found in the literature. Carter (Am. earlier work of Janis, unpleasant life memories after the of some confirmed 1953) has §5 330, Psychologist of selective forgetting there is showing that electroshock. non—emotional and emotional of Using tachistoscopic presentation demonstrated 1953) hhS, §5 (Am. Psychologist words, Teicher that of repression" to emotional stimuli occur in the post-shock state. For the past year and a half preliminary studies "mechanisms investigating this done been have hypothesis at these laboratories at Hillside Hospital. results to date striking. have been patients were followed.with serial taneous tactile Twenty—four The consecutive electroshock electroencephalograms and amytal, simul- perceptual and memory tests. A marked correlation between �.02. improvement and early, persistent alogram, and in the amytal tests was observed. appear, improvement did not occur. sistent and severe changes on the electroenceph- It is If such changes did not our conclusion that early and per- sufficient, prepossible to predict changes in these indices are a necessary, though not make These observations improvement. for it requisite the short term response to therapy during the second and third week of treat- ment. A report on the amytal test results was presented at the recent meet- ing of the American Psychiatric Association (May 1955) and submitted fer public- Electroshock the At of of meeting American Journal a Psychiatry. the to ation Research Association on May 8th, a report of the changes in memory and learn- This was treatment presented. electroshock of the course ing occurring during he Award citation Association. the of Annual Prize awarded the was report noted the methodology as exemplary, and offering a fruitful method of study- ing electroshock. Concomitant with these studies,t7e have followed patients on insulin therapy. Recent reports onthe value of prolonged coma as the basis for improvement (Kwalwasser and Caplan: J. Hillside Hospital l; 1&5, 1952; Revitch, coma E. : Neurol. Arch A.M.A. Rowsell: and 195h; shagass 72, Quart. fig; Psychiat. and Psychiat. 225 705, l95h; and Yeager 195h) In one gt 3;; J. Nerv. & Ment. Dis. llgg h35, 2 the over studies past in years. in our patients unusual case report the direct relationship between altered brain fun- have been confirmed (Delusional demonstrated Reduplication been has and improvement denial ction, of Parts of the Body After Insulin Coma Therapy, J. Hillside Hospital, 1955, in press). C. METHOD: 1. we plan to verify and amplify our preliminary observations on the relation of changes in behavior to altered brain function after somatic treatment. �-3” E.A. and Kahn, sease, Am. electroshock will be given amytal tests (heinstein, DiBrain Sodium In Organic Use Amobarbital of Diagnostic Patients (a) 3.: on J. Psychiatlggf Test" for Brain Disease: 889—89h, 1953; Its Serial Administration of the "Amytal Arch A.M.A. Value, and Prognostic Diagnostic and before and electroencephalograms l95h) Neurol. and Psychiat. 1;; 217-226, treatment. make be a used to This will data preat stated intervals during diction of the short term response to treatment. (b) Double simultaneous tactile perceptual tests will using threshold electrical stimulation. be carried out Using two Grass Sh-B stimulators, to be his for tested ability the will patient monitored by an oscillograph, of his body. different parts to simultaneously two stimuli applied perceive shown to been previously has stimulation simultaneous double of technique hé-SB, g} Neurology, (Fink function 3}, be a good index of altered brain at The January, 1952). By applying this highly refined technique it is hoped that elicited. be will patients tests, changes in brain function which are not otherwise apparent will be and amytal of electroencephalognmn the case in tested before and at stated intervals during treatment. As 2. Other Physiological procedures will be carried out in con- junction with the tests above. (a) Each patient will be given the mecholyl-epinephrine cribed by Funkenstein and associates The results will (J. Nerv. (b) sulin coma as des- Ment. Dis. Egg: h09, Nov. 19h8). be compared with the work of previous as with the results of our other physiological test investigators as well tests. and electroshock of undergoing Biochemical testing patients treatment have been in progress for some time in- in these laboratories. In this series of patients, estimates of urinary ketosteroid excretionxates Simultaneously esexcretion rate. be post-treatment to compared their will timates of steroid sulphates; phosphatase; and blood levels of steroid sulphate, �«hphosphorus, phosphatase and total alkaloid will be done. of many that investigation 3. It has been evident in our preliminary months. within six treatment somatic relapse the patients tm.t improve after imp of duration the to involved in regard The critical problem of the factors provement is also to be studied. One hypothesis now under investigation is related to the premorbid personality. denial" verbal of the "explicit characteristics the with patients Specifically, Denial Factors in Personality R.L.: and Kahn, personality (Mainstein, E.A. that sustained improvement may be 1953) March, 1-13, fig: Psychiat. Illness, A.H.A. Arch. Neurol. more likely to maintain improvement, than patients & of who do will be not have this pre- morbid personality makeup. (a) two with interviews by personality of premorbid the Evaluation close relatives will airre will be used to be made elicit dictive value such as need to for each patient. A standardized question- characterological factors, which be at least may have pre- right, prestige-consciousness, sensitivity toczfiticismand compulsive drive. words: and of pictures (b) Tachistoscopic presentation The threshold material be compared.with will illness to related levels of subject matter characterological for be evaluated data This will of more indifferent nature. assessed be as quantwill in response alterations In addition, indications. itative indices of denial. (c) and be Rorschach given will and the Test The Thematic Appereeption evaluated for the same factors as the personality interviews. to of response predictions material, the of personality (d) the basis of treatment the to start Prior made at different periods.. treatment will be 1) those unthree to possibilities: according be classified patients will On and temporarily; moderately or to improve 2) those likely to improve; likely 3) those improvement and sustained marked maintain to likely (for at least 6 �.5. Prediction will also be months). made during the course of treatment (the third weekfbr the electroshock patients) taking into account the physiological At the of factors. the premorbid personality well analysis indices as as conclusion of treatment patients will be evaluated for actual immediate response to the treatment. Those who showed some improvement ified again according to whether or not improvement will will then be be class- sustained. h. Evaluation of the change in behavior of patients undergoing treatment will Such ratings will be be made on the basis of a modification of the made independently of all Malamud the other rating scales. test results by a supervising psychiatrist. D. FACILITIES AVAILABLE: l. Hillside Hospital is a 200 bed voluntary hospital for psychiatric care. All patients subjected to phy— siological therapies are available for study. Periods of hospitalization.are 2-8 months; and a h-6 week observation period is generally available prior to the institution A of physical therapy. Research Service has been established, with a full time professional staff of a Director (neuropsychiatrist); assistant in psychiatry; biochemist EEG and technician (Ph.D.) research and assistant chemist; neurophysiologist and secretary. A full time psychologist and two chemists are associated on a project basis. Laboratory a Medcraft D-8, two S—hB 8 facilities include: (a) Electroencephalographic unit with channel instrument; (b) Neurophysiological laboratory with Grass stimulators, Du Mont # 3&0 R oscillograph; two synchronized tach- Biochemical (0) laband equipment; electronic auxiliary projectors istoscopic the followwith and of equipped 1000 with feet laboratory space square oratory ing major items: Beckman spectrophotometer,'Warburg respirator, Coleman Spect- rophotometer, and radioisotope unit following the basic specifications of the A.E.C. �2. Personnel: (a) Dr. Max Fink, M.D., Director of Research: After undergrad- uate studies at the University College of his D-A. New York University where he received cunllaude with Honors in Biology in l9h2, he attended the New York University College of Medicine, graduating in 19h5. After a rotating interneship he served in the U.SL Army, where he attended the School of Military Neuropsychiatry. training Formal neurologic York (19h8-l9h9) and was received at Montefiore Hospital in at Bellevue Hospital ( l9h9-1951). Formal psychiatric training received at Bellevue Psychiatric HOSpital (6 Hillside Hospital (1952). and During 1951, again in 1953, New at months 1950) and then he was a research fellow of the Nat- ional Foundation for Infantile Paralysis, first at of Medicine and then at Mount Sinai Hospital in New New York University College York. Both periods of study were under the supervision of Dr. Iorris B. Bender. In 1952 he was certified in Neurology by the Amer. Board of Psychiatry and Neurology, and was granted complementary May certification in Psychiatry in l95h. Simultaneously he attended and.gsunnfindfrom the William Alanson Institute of Psychoanalysis, Psychiatry Certificate for Physicians in January 1953. White and Psychology, receiving (b) Dr. Jeseph Jeffe, M.D., Assistant in Psychiatry: undergraduate studies at their Following Columbia College (B.A., l9hh), Dr. Jaffe attended the New York University College of Medicine, and was granted was elected to Alpha Omega Alpha. He was an interne his M.D. in 19h7. He at the Morrisania City Hospital, and then began three years intensive study at the Bellevue Psychiatric Hospital. First as a resident in psychiatry, theniizneurology, and he com» pleted his studies as a U.S.P.H.3. post-doctoral research fellow under the supervision of Dr. Morris B. Bender. �~7— From 1951 to 1953 he was in the United States Air Force. He graduated from the School of Aviation Medicine and was Chief Psychiatrist at the Mitchell Air Force Base Hospital. Since discharge from the military service he has been in the private practice of psychiatry. He was certified in psychiatry by the American Board of Psychiatry and Neurology in 1953. Since 19h? he has been a candidate in White Psyof Psychoanalysis, Alanson Institute William the at psychoanalysis in Research Assistant two and the and for past years Peychology; chiatry Neurology at the Mount Sinai Hospital of (0) New York. Dr. Robert L. Kahn, Fh.D.: Assistant in Neurophysiology: After graduation from Brooklyn College Columbia University which was United States Army. in l9h0, he started graduate interrupted by work at four years of service in the In the army he went to Clinical Psychology School and served as psychologist in various hOSpitals within this country and overseas. On leaving the army he became a Research Psychologist in the Department of Neurology of the Mount Sinai Hospital in the supervision of Dr. time. To date, M. B. New York, where he has worked under Bender and Dr. E. A. Weinstein up to the present he has been an author of more than twenty co-author of the monograph. "Denial of Illness: ASpects" which was published in Symbolic and Physiological May, 1955. received his Ph. D. from the He publications, and is New York University School of Graduate Arts and Sciences in 1953, and was an instructor of psychology and Hunter Colleges sultant to the New for York at Brooklyn For the past two years he has been a con- years. State Department of Mental Hygiene and has conducted two training programs in several of thé mental hospitals. (d) Chemist: A Dr. Harry Goldenberg, Ph.D.: Director of Laboratories and Chief Trethe of he where was a C.C.N.Y. l9hh, of recipient in graduate maine Scholarship and graduated cum laude, Dr. Goldenberg received his Ph.D. in �~8l9h9 from the Polytechnic Institute of Brooklyn. (who-ll?) Institute the Polytechnic at biochemistry He (1951 to date).' In l9h7-h9 National Institute U.S.P.H.S. project he was a Research Fellow an been has and in instructor in at Brooklyn College enzymology of the of Health, and from 1950 to 1952 he was a chemist to a at Jewish Hospital of Broeklyn studying enzyme methods in clinical chemistry. (e) Mr. Hyman Korin, Research Assistant (Psychology): Following four College of the City of military service, he matriculated at and received his B.S. in 19h? and his M.S. in 1950. During years of New York 1951-52 he was Ph.D. his for and matriculated Sinai Hospital psychology interns at the in Research Assistant been 1953 has he June Since New York University. at thesis doctoral his completed and has recently Psychology at Hillside Hospital Mount on "The Effects of Electroshock on Retroactive Inhibaticn." 3. Publications: Recent publications of the Research Service include: The Amytal Test in Patients with Mental Illness, 1955. 3-13, ii: Hospital, Hillside J. Electroshock, in Improvement and to Memory Learning of in Changes Relation press). Conf. Neurologica, 1955 (In Delusional reduplication of Parts of the Body After Insulin J. Hillside Hospital, 1955 ( Therapy, In press). Relation Between Altered Brain Function and Denial Amer. Coma in Electroshock Therapy, J. Psychiatry (submitted). Rectification of Nonlinear Beer's Law Plots, Anal. Chem. gé: 690, l9Sh. Bioand Biochem. Arch Curves, Enzyme Non-Linear Activity Rectification on phys., fig; 288, l95h. �July 1, 1955 BUDGET l. -. RESEARCH SERVICE, PERSOM'EL 1955-56 EFF—ES. Director of Research 15,000 - BD OF DIRECTORS 15,000 in Psychiatry 7,200 Research Assistant in Neurophys. 7,500 Chief Chemist 8,200 Assistant Chemist 2,800 Research Assistant in Psychology h,000 h,000 - Assistant Chemist h,000 h,000 ~ Assistant Chemist 1,800 1,800 - 2,520 960 150 150 3,810 2,1uo 1,670 1,000 200 800 $ 57,980 $20,750 $37,230 Research Assistant Secretary - EEG Technician 2. EQUIPMENT 3. CONSUMABLE )4. TMWBL-CONFERENCES TOTAL SUPPLIES 7,200 7,500 - 8,200 2,800 1,560 ��your grant for the biochemm and neuroplvsiologiul approved. A mpplamuzy grunt request fer $7992.00 apprum! by the Public Health Serum for the 24—927 pmaeem This may will amt thsalary or Dr. R. him. 6. grants were A. , 3 The ascend In sdditionk protoccla were submitted thmgh Hr. medatim. m Calm ta the Hofheimr �Department of Biochemistry ................................. RESEARCH PROGRESS REPORT, JULY-AUGUST A. Major work Dr. H. Goldenberg 1955 in Progress 1. Determination of Chlorpromazine in Blood and Urine procedure for the colorimetric estimation of chlorpromazine and related alkaloids, described in the June 1955 progress report, has been further refined to permit detection of the extremely small amounts of drug circulating in blood. The method is based on two new features: (1) The finding that drugs can be quantitatively extracted from biological fluids with a single portion of an ethylene dichloride-ether solvent mixture, and (2) The use of a three—phase solvent dye partition system of analysis. The Clinical data are also being obtained on bound as well as free circulating promazine, based on the use of hot acid to liberate the conjugated drug. 2. Inhibition of Cholinesterase by Hallucinogens These studies are being continued as indicated in the prior report. 3. Steroid Sulfate Conjugates All but one of the major problems involved in the assay of steroid sulfate metabolism.in mental disease have now been solved. A novel device has been introduced for eliminating the interference with our test due to phenol sulfates in blood and urine. A two-phase system incorporating dicyclohexylamine (DCHA) as a complexing agent effectively separates the steroid from the phenol sulfates, permitting their unequivocal determination. The procedure for serum is now as follows: is treated with alkali to release the hormone conjugates. b. A lipid solvent is added to precipitate the proteins and simultaneously extract the hormones. DCHA The and between to brought is dryness supernate partitioned c. lipid a. Serum and chloroform. free steroid sulfates are released by shaking the chloroform extracts with acidic resin. e. Final assay of the sulfate conjugates is effected by adding dye and reading the color. d. The considerable amount of clinical data have already been obtained on normal people and on patients selected for independent studies by the Sloan-Kettering Institute. An immediate correlation has been established in our laboratory between urinary conjugate levels and sex, males excreting about twice as much conjugate as females. This ties in well with what is known of steroid metabolism A �and tends to confirm the validity of the method. Attention is now being devoted to fractionation of the steroid hormones in conjugate form. Paper electrophoresis has proven inadequate for the purpose. Paper chromatography is more successful and is under continuing study. B. Papers, Lectures and Conferences following papers are in preparation: (1) "Colorimetric Determination of Alkaloids, with Particular Reference to Chlorpromazine", and (2) "Steroid Sulfate Conjugates. II. Colorimetric Microestimation". The C. Funds and Personnel Changes 1. Research Grant #A-675 from the National Institutes of Health the fiscal period Sept. 1955 - Aug. 1956. 2. Messrs. Michael Miller and Spencer Parness terminated in the laboratory at the end of August. cc. to: Dr. Fink Dr. Miller their was renewed for summer employment �Department of Biochemistry ................................. RESEARCH PROGRESS REPORTI SEPTEMBER - A. Major werk Dr. H. Goldenberg 12§§ in Progress 1. Determination of Chlorpromazine in Biological Fluids As a result of repeated analyses of blood drawn from patients receiving chlorpromazine, the circulating blood level has been established as less than 1 microgram per ml. serum. The three-phase solvent dye partition scheme of analysis mentioned in the previous report has therefore been adopted as the only method capable of detecting the extremely minute amounts of drug in peripheral blood. A new shaking machine has just been obtained from the A.H. Thomas 60., Philadelphia, to permit application of the method on a broad scale. question naturally arises as to the metabolic fate of chlorpromazine in humans. We have recently detected in patients! urine an ether-soluble carboxylic acid which reacts with ferric chloride and appears to be an oxidative byhproduct of chlorpromazine metabolism. The 2. Inhibition of Cholinesterase by Hallucinogens three-phase system mentioned above has been found applicable to the analysis of LSD 25 as well as chlorpromazine and serpasil. By combining this observation with the earlier discovery of the inhibitory effect of LSD 25 on human serum cholinesterase, it is now possible to relate the enzyme inhibitory action to the alkaloid concentration in "unknown" samples of fluid and so deter— mine the specific molar inhibitory action at the 0.1 microgram level. This amounts, in effectI to the first sensitive chemical test ever reported for the detection of LSD 25 and related hallucinogens. The 3. Steroid Sulfate Conjugates work progressing cc. to: Dr. essentially as described in JulyhAugust report. Fink Dr. Joe. S.A. Miller M. �TJ'M‘ W10,” kW!“ mmMume mmfimmmam.mu¢wmtbmmmm dfiltfldmfiord’pfiififid‘fl. 7 mauummm �WW Wmmtmmmunmmngmpm. 3.) nmmmm Wamwmm‘m M.anummt.mk mmmwmmummmm.w. mmrpmhmmmmdmdt “Wumm Mnuwhmwmmmmmmmunm �.3. «W. wammnwunm-Wmum. 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Dr. mmnuuudatwrmnummmmmhmmm �mum-mu. n.) nun-rum WWII-luminous mummmnmummmwmm. mum Wummmmomumsnnamw-m www.mum.mmummmma: ’mmuem‘mwmrvwgm W m&% 11.:an . �\fl October 20, 1955 MEMORAEDUM TO: Dr. Joseph S. A. Miller mom: Max Fink, 14.1). SUBJECT: Six Months Report of Research Activities at Hillside Hospital At the request of the Chairman of the Medical Affairs Committee, I am submitting this six month report of the activities of the Research Service and associated research activities at the hospital. During this period, numerous projects have been under investigation, our staff has expanded, and our space requirements were met. Two projects are being completed, and one project has just been instituted. A. PROGRESS l. hmw2: In ONGOIfiG PROJECTS: ELECT§9§§QQK # Our second electroshock project was undertaken in March project had clearly demon- in September. Our first strated that cerebral changes were essential to improvement and that these 1955, and completed could be measured by the electroencephalogram and by amytal tests. 'Ue also concluded that memory tests were a poor index of improvement and believed that there were specific psychological patterns indicative of denial which were more prominent in the improved group than in the unimproved. Following this study, the second project was undertaken and was designed to demonstrate the reliability of the electroencephalogram and the amytal tests for prognostic purposes; and to ascertain the characterological as‘fle term be term the short which and in results. long factors might pects have studied.twenty-seven patients to date. The data of this project is now being processed, and will be available following our six month follow up period, (which is from November to January). data from the first study was pres nted at various meetings, including the American Psychiatric Association, the Electroshock Research Association, and the Eastern Association of Electroencephalographers. The memory data, presented by Mr. Korin at the Electroshocx Research Association The in May, was awarded The their annual prize. electroshock project # 3 is below), and will be instituted November 15. now in the planning stage (see This project, which has been undertaken with Dr. Sidney Tarachow of the Medical Board, has accomplished a considerable amount of its basic work. Three approaches to the problem of measuring ambivalence have been accepted. These include an interview evaluation; the thematic apperception test, and tachistoscopic presentation of pictures. During this period of evaluating methods, twenty-three patients have been studied. Dr. Tarachow has been attending to this work, and the testing has been undertaken by dr. Korin. 2. AMBIVALcNCE: ‘ �~2- Serpasil evaluation study, undertaken at the end of last year, is com~ double blind a by been have studied intensively Seventeen patients pleted. Blumberg Drs. andeachspress. evaluated by The now data being is technique. To date, the clinical results are disappointing. Patients who were depressed, who were over-active Patients symptom. of this manifested an efiag ration disturbed/EnogIIeviation of this activity but the psychotic ideation genand of secondary induced a The variety intramuscular dosages erally persisted. complaints. In the evaluation of'the mecholyl responses following serpasil, The blood in pressure response all subjects. effect consistent was a there of this presentation considering Dr. and Blumberg is lower was significantly data at the next meeting of the American Psychosomatic Society. 3. SQRPASLL: The } Preliminary studies by Dr. Laderman in 20 patients in a series of clinical not was but significant this alterations and behavioral showed symptom studies of Shaw evaluation undertook an Dr. In mid-September, in the doses used. A protocol coma therapy. Thorazine as a possible substitute for insulin French and Kline submitted Smith, to was The Research Committee, approved by and approved, assuring us of adequate supplies for the duration of our proof 8,to a medication for period receive will In this study, patients ject. 12 weeks, comparable to the insulin coma period. During this time, very have been To be used. patients eight date, will thorazine of doses large The obser3600 1500 initial from to The daily. mg. dosages range studied. three had clinical response; a show significant three the patients vations h. THORAZINE: and one symptoms, toxic developed one minimal had patient changes; patients medthe of Cohen and Blumberg Drs. medication. the patient has just begun our using to permit controls the have contributed necessary ical department such large doses of this potent drug. Since June, Drs. Goldenberg and Royce have been coopof a in study Sloan—Kettering Institute the chemists the at with erating the possible alteration in the keto-steroid excretion patterns in our patSince June. Committee Research in by our This was approved study ients. then five patients have been under investigation. The initial data is not in Dr. Goldenberg by studied Each of being the is patients available. yet his laboratory as well as by the chemists at the Institute. 5. SLOAN KETTERIDG STUDY: Dr. Goldenberg has been occupied in studies measurand acid of devising the effects lysergic estimating ing chlorpromazine, methods to measure steroid sulphate conjugates. This basic research is to which to we apply measurement plan of methods the to provide necessary our patients. (a) Chlorpromazine: An ultra~sensitive technics has been of amounts this drug. microgram) minute (0.1 which measure can developed Golden— Dr. Thorazine, of number By applying this to a patients receiving bloodstream. the amounts in small appear demonstrated only that has very berg LSD has been by cholinesterase The LSD: of serum (b) inhibition A compounds. demonstrated, and this test applied to other hallucinogenic correlation between hallucinogenic activity and cholestestcrase inhibition was found. 6. BIOCHEMICAL RESEARCH: �*3“ a (c) Steroid Sulphate Conjugates: ‘Nith the grant support from the USIHS, methods to estimate these compounds have been devised. By studying hormone demonstrated sulphates are synthat Dr. Goldenberg liver slices, of the level in difference and a there sex is that the thesized by liver, steroid excretion. Both these observations are of fundamental significance, and will be presented to various societies this winter. In the Department of Medicine, hrs. Cohen and Blumberg have continued Durand the electroshock of the patients. serpasil studies their Mocholyl and than more been have studied to additional an patients this period ing half have had more than one such evaluation. The serpasil group demonstrated a significant alteration in their blood pressure patterns following this done be and been will has The correlated not data electroshock yet drug. as soon .8 our electroshock # 2 data is available. 7. MECHOLYL: Following the approval of this project by the Research Committee last spring, Drs. Navarre and Graubert had a number of meetings with members of the Medical Board. Following these discussions, they have begun a pilot study of one patient, and intend to evaluate those factors in the hospital environment which may be contributory to the patient's improvement. This satisfactory pilot study was udertaken in an effort to clarify a protocol to the Ibsearch Conmittee and of sufficient quality to be submitted for 8. SUBCULTURE: To some extent, this project outside to organizations. financial support was hampered by the multiple duties of members of the committee and by the resignation of Dr. Gurvitz. Since September, however, the committee has been working very actively and it is anticipated that a satisfactory protocol will be available by the end of the year. In June, following some discussions concerning the Laderman and Drs. coma of insulin doses for insulin treatment, correct doses between the multiple relation into undertook an Blumberg investigation 05 insulin and the blood glucose level. lt was anticipated that multiple small doses of insulin might reduce blood sugar significantly earlier and large dose. It was quickly determined, for longer periods than a single .) however, that multiple small doses, even if the sum total was equal to a This and of depth. coma degree a not did satisfactory produce dose, single project is now being prepared for publication. 9. B. DIVERE' I SULIN D SE8: PROJECTS PLANI‘IED: November # the third Electroshock 3: Beginning let, l. electroshock project will be undertaken. This study is designed to extend our experience with the factors which may be relevant in both the long and short term clinical reSponses following electroshock. Also, in this study specific emphasis is placed on the psychiatric and language changes which follow electroshock treatment and which we have been accustomed to calling "improvement." Dr. Joseph Jaffe has prepared a number of specific studies, including detailed interviews with patients prior to and during treatment, in which specific aspects of behavior and language will be assessed. �a... In this study, also, a basic problem in the perception of multiple simultaneous tacti e stimuli will be undertaken. Under our original grant from the United States Public Health Service, we were given funds to study the problem of Satisfactorily delivering single and multiple independent and The completed was designed equipment wave impulses. electrical square in Septemler and for the past few weeks has been undergoing rigorous clindur« be and will applied found been has satisfactory highly ical tests. It between changes the of relation the with question specific ing this project the in and in behavior, changes stimulation tests simultaneous double in electroencephalogram and in amytal tests following electroshock. 2. EIOC ‘thAL APPLICATION OF HEM TESTS: ’ Dr. Golden— berg has completed.the pilot studies necessary to devise measures of Specific compounds. He believes these should be applied to our clinical population over the next year. A specific protocol for this application is being prepared. 3. For more than a year, has been interested in form- EEQQNOSTIC IdDIGATQE§flIfl ELECTROSHOCK: ' ‘ Dr. Karliner of the attending psychiatric staff electroshock. would be in which helpful factors some prognostic ulating Discussions were held in June and at the suggestion of Dr. Miller, Dr. Karlbe This scale will evaluate scale to prognosis. iner prepared a special months. next the six and Committee assessed over Research the to presented C. STAFF CHANGES: Dr. Joseph daffe, a practicing peychoanalyst, was and in research psychiatry, assistant Service Research as appointed to the behavioral the in is Dr. interest Jaffe's work on September began lst. induced altered brain function and the by and language changes which are relation between such changes and premorbid personality. were resolved effectively Lowenstein of the floor the on the of first extension the laboratory by The reduced. been tachistoscopic have also Our problems equipment building. be able now to works and well. are into alignment was brought equipment During this period our space problem simultaneously. two or individually pictures tachistoscopically present The electric stimulatorsale functioning satisfactoraly so that we are now able to produce isolated simultaneous square wave stimuli with the ability to vary any of the essential parameters. D. FUNDS: In May, we submitted an application to the United Sept— In of Dr. Jaffe's Service Health program. for support Public States an in the and staff interviewed the Frank Jerome came to hospital Dr. ember, USPHS the from in we anticipate a response evaluation of our program. mid—December. In June, we also submitted the necessary forms for second renewals and both and Dr. Goldenberg myself, both renewal for grants year the these both renewals, note for that to were approved. It is important overhead allowances were increased to 15%. At the suggestion of Mr. Coleman, specific protocols of our re» search program were submitted to the Kaufman, hoffheimer, and lttleson Foundations during this period. �-5the been for has Service writing Research the which The protocol of Committee Research the submitted to was Ford Foundation grant pr gram was the protocol that the consensus was the Medical Board in September. It suggestions, their Following be submitted. not and that it unsatisfactory of Drs. the with cooperation Service Research made the by changes are being Lenzer and Luttrell. another submit application to am planning I present time, re— March for meetings their to the USth in January for consideration at to an application am contemplating also I newal of our present program. ambivalence study, the for for Fund support for Psychiatry Foundation the as soon as the basic work is completed. At the E. Q?HER.ACTIJITIES: l. ISRAEL 5T3§p?§nF9§E§Ei9F THE JOURNLL QEWEELEEERE HOSPITAL: Following diScussion with Dr. Tarachow, the Research Service has undertaken the Tarachow issuin Dr. work in and ssisting editorial necessary secretarial Journal. Volume of Hillside the Commemorative the special ing 2. ISRAEL STRAUSS LECTURE: Consideration is being given by members of the at Discussion is next the lecture. Committee for Lecture Strauss Israel should decision and a final candidates of number present centered about a be available by the end of November. Respectfully submitted, . i "’ -," ’- 4 H7 ”.51 ‘ ‘) {I 1 «I g.“ ,--‘or ,. ‘ j . If ‘f‘ \ Fink, M.D. Director of Research Max . . �Department of Biochemistry ................................. Research Pro ress Re Major werk l. rt, Dr. H. Goldenberg November l9§§ in Pregress Chlorpromazine Studies previous work has been summarized in the report for the 6 month period ending Oct. 1955. We have subsequently learned from two representatives of the Smith, Kline and French Laboratories that Drs. Salzman and Brodie, working at the National Institutes_of Health, have identified chlorpromazine sulfoxide in the urine of dogs and men after treatment with chlorpromazine. A sample of the sulfoxide was requested from Smith, Kline and French and arrived the end of Nov. Our ultraviolet absorption spectrum of the sulfoxide was determined in aqueous solution and compared to the Spectrum obtained with extracts from patients! urine. A remarkable similarity was noted. On the basis of this and other data accumulated in our lab., there can be no doubt but that urine from mental patients receiving chlorpromazine contains: (1) chlorpromazine, (2) the sulfoxide, (3) one or two other alkaloids of related structure, and (A) at least one break-down product which yields a violet color with sulfuric acid, as contrasted to the pink colors typical of chlorpromazine and its sulfoxide. The Using our dye—partition scheme, the sulfoxide yields a color which is roughly 1/5 the value given by chlorpromazine in equimolar concentrations. Hence our dye scheme is not applicable as such to the analysis of fluids con~ taining both derivatives, unless some additional information is available on the relative amounts present.‘ Fortunately the relative proportions can be estimated from the extent to which the color is depressed by the addition of ether. Nonetheless, we are withholding a manuscript dealing with chlorpromazine analysis until this question is completely resolved. Ultraviolet and chromatographic studies are to be undertaken soon to establish the various chlorpromazine derivatives in urine and their clinical significance. 2. Role of Toxic Agents in Mental Diseas : An Enzyme Test for LSD first draft of a manuscript entitled "Inhibition of Serum Cholinesterase by Lysergic Acid Derivatives. Submicro Detection of LSD 25" has been completed. Copies are to be forwarded to the Research Committee on Dec. 8th. The 3. Steroid Hormone Conjugates Little progress has been made in this area in the last 6 weeks because of a delay in construction of our chromatography cabinet and unavailability of electrical parts needed for the circuit. This situation should be remedied by the middle of December. cc. to: Dr. M. Fink Dr. Jos. S.A. Miller �ELECTROSHOCK THERAPY EVALUATION PROGRAM from the Research Service of the Hillside Hospital Glen Oaks, New York December 20, 1955 Alvin E. Coleman, President Joseph S.A. Miller, M. D. Iiedical Director �Electroshock Therapy Evaluation Program em I. Aim II. Background III. Previous Studies Development and Progress in Studies IV. Tests of Altered Brain Function Premorbid Personality of Adaptation Patterns NonAVerbal Verbal, Evaluation of Improvement Steroid Excretion Studies Autonomic Studies V. Program Summary Method Significance VI. Facilities Available Laboratories Personnel VII. Budget Present Budget Requested Support VIII. Appendix References Bibliography of Personnel Page �I. E: During the past few decades there has been an of various new somatic intensified development therapies for mental illness. Jhile some have even- been an has established as electroshock therapy into fallen disrepute, tually important and successful method for both immediate and long term results (1). Despite its empirical usefulness, the many theories concerning the mechanism of this therapy have been either disproven or are so vague that their validity tested. In a comprehensive review, Kalinowsky and Koch (2) emphasize the lack of information in this regard stating: ".......the theoretical cannot be aspects of the various somatic treatments in the case of the shock treatments, still ..... are poorly understood, or, as entirely obscure in their mode of action." The aim of this program is to study the therapeutic mechanisms in electro- convulsive therapy by the systematic investigation of behavioral, personality, physiological and biochemical factors. Thile the program has electroconvulsive therapy as its focus, considerable theoretical and experimental information can be derived to relate the phenomena observed in this therapy to other somatic treatments such as lobotomy, electronarcosis and insulin coma. �II. BACKGROUND: of abundance has stimulated an electroconvulsive therapy of use and the Both kind theories of the much and research. exper(3) hypotheses The of interest the reflect however, particular undertaken, imental investigations the origin frame reference of regarding and theoretical his the investigator of mental disorders. Thus, each has been usually limited to one aspect of the problem. In general, these theories may be differentiated between those that emphasize physiological, biochemical, or psychological constructs. A who classical physiological construct is exemplified suggests that the various by Gellhorn (h) forms of shock therapy "act on the centers of the autonomic system, produce intensive and prolonged sympathetico-adrenal mental activity, hypothalamic-cortical augmented and alter, through discharges processes and behavior." psychogalvanic reflex, The varying responses of blood pressure, heart rate, and other physiological indices to chemical stresses are obtained been has data huch of sympathetic reactivity. interpreted as indices to and Show autonomic reactivity, in this induces change a electroshock therapy that (5) coaworkers and support this his Funkenstein by studies recent conclusion. Much illness and biochemical study has been devoted to the relation between mental steroid metabolism. between ketosteroid excretion Numerous rates instances (6) in which a relation and change in mental state following electroshock therapy are reported, but the clinical difficulties in the measurement of steroids have left this issue unresolved. Kore recent studies excretion to the total steroids between individual the relationship exploring rate (7) utilize elaborate chromatographic separation technics. �In a good review of the biochemical and neurophysiological hypotheses, mode the view the that evidence to justify Ashby (8) presents experimental of action of electroconvulsive therapy is through effects on the adrenal cortex mediated by direct stimulation of the hypothysis. Psychologic constructs generally fall into three designs - studies of the psychic significance of the loss of consciousness; the relative importance of ities memory loss; and an estimate of the subject's re-integrating abil- the Numerous unemphasize studies of confusion. following a period conscious significance of the treatment as a “rebirth which eliminates reand exneed punishment for of a satisfaction narcissism" a (9); or gressed piation for committed sins (10). Amnesic effects are a common concomitant of treatment but most studies of these The significance of impairment. the nature emphasize the temporary defects for therapeutic results is emphasized by numerous authors. Data is the on emotional charge patreduces the treatment that presented to emotionallyfor of induces familiarity loss a associations (ll), ient's show toned associations (12), or a selective forgetting of unpleasant life memories (13). These constructs are further elaborated by authors who believe that the as behavioral responses confusionalemate including of an organic induction im» electroshock the for basis is over-reacting euphoria, impulsiveness or provement (1h). A more umerated by Weinstein & recent elaboration of this explanation is that enKahn (15), described subsequently. �-h- adaptive in changes proregard explanations of psychologic Another group describe (16) and Frosch Impastato mechanism. cesses as the basic therapeutic on a which then re-integrates the of ego electroshock as causing a dissolution suggestopinion similar has a Alexander of adaptation. previous or higher level ing that defensive operations. enhances active and electroshock arouses For this in'whii1 conditions those in effective such is therapy that he asserts reason conp in ineffective but are low ebb, as in depressions, such operations are at a (17). alerted highly already ditions in which defensive operations are most two in.which Kahn (15) and Another hypothesis was developed by weinstein were the process of therapeutic aspects related. They asserted that the thera- of altered milieu of a creation the in convulsions lay induced of action peutic is of problems his expression symbolic brain function in which the patient's Their them. studies, denying of form the explicitly altered, particularly in cerebral with with patients documented by an extensive neurologic experience behavior. in adaptive of changes a function, amply demonstrate great variety dys— attention (l9), orientation (18), They describe altered patterns in language manifestations (21) as defect of and awareness (15b) (20), sexual behavior the patient's constitute mechanisms these conclude that and of adaptive behavior attempt to deny his illness or striking and enduring in those its meanings. patients Such who had most were denial at attempts habitually used the defenses with their of coping means a as and rationalization of verbal denial of indicative these patterns that problems (22). They also demonstrated administraintravenous the following interview "denial" could be elicited in an interview the clinical manifest in not when were they tion of sodium amytal (23)-* followdenial and explicit disorientation of * This appearance of patterns with associated so clearly sodium is amytal ing the administration of authors these by described been has diffuse cerebral dysfunction, that it test." named "amytal the been has This (23). as a test for such dysfunction �-5of denial between a patient's noted direct relationship a they cere— of the of and signs the electroshock appearance therapy pain following test) of mechanism the that suggested they amytal bral dysfunction (positive Thus, when electroshock therapy may be the facilitation of patterns of denial by altered brain function (15). and psychophysiological at integrating This hypothesis is an attempt which terms in View it of the and As operational in such, factors. logical have which studies base our theoretical upon a has provided is stated, it been elaborated. �III PREVIOUS STUDIES: of altered manifestations studies investigating For the past three years, cerebral function in psychiatric patients, have been in progress at Hillside Hospital. In 1952, the application of the amytal was asseSSed (2h). test to psychiatric subjects Positive responses were found only in patients who had had electroshock therapy or had other indications of organic brain disease. in order to test the relationship between altered brain referred consecutive patients electroshock to therapy, and the function response electroencephalograms, with serial intervals weekly at tested treatment were for During 1953-195h% amytal tests, simultaneous tactile perception%% tests, and tests of recall function. A marked correlation was found between improvement therapy and early, persistent the electroencephalograms. following electroshock and severe changes in both the amytal If no such tests such changes did not appear, improvement and failed correlations were manifest between improvement to occur. In contrast, and tests of recall function or changes in simultaneous tactile tests. WM TWenty—four subjects were tested in this first study, and were classified improved markedly as psychiatrist the supervising by independently ately improved (6) and unimproved (7) at the (ll), moder- end of one month post-treatment. Paralysis Infantile for Foundation National from the Aided Fellowship a by * (Dr. Fink, 1953) and Grant K—927, National Institute of Fental Health, National Institutes of Health lQSh-Sé. stimuli two simultaneous tactile of the of perception as Previous studies one localize to or of perceive failure demonstrated characteristic patterns of the stimuli in patients with diffuse cerebral dysfunction (25). �-7Of the markedly improved patients, every one had at least one positive amytal reaction during treatment. Of the 50 tests given to this group, 38 (765) were positive. In contrast, of the unimproved patients, five of the seven never showed a positive result, positive. 6 (13%) were and of the The LS tests administered to this group, only moderately improved group showed more positive re- sponses than the unimproved patients, but fell far short of the much improved group. In addition, there were consistent changes in language and non-verbal as- pects of behavior indicating alterations in adaptive mechanisms in the in interviews not employing amytal. These alterations improved group, even were much either minimally or only transiently manifest in the unimproved group and then only under the influence of sodium amytal.* Concomitant studies of the electroencephalograms taken on a day pre- ceding the amytal first measured test indicate for per~cent time a similar 31 w wave relationship. The 160 records were (delta) activity, the extent of burst activity and the amplitude and frequency of the slowest waves present. They were then placed in a rank serial order. Those falling in the upper third were labelled "high abnormality" abnormality." ality after Of the and those in the lower much improved patients, one week of treatment; 80% after 25% showed third as "low a high degree abnormp two weeks and over 90% after three In the unimproved patients, however, none had a high degree abnormality record during the first three weeks and only one had such a record by the fourth weeks. week of treatment. The records of the moderately improved patients fell between these two groups.*% * Presented at the Annual Meeting of the American Psychiatric Association, Kay 10, 1955. ** Presented at the joint meeting of the Eastern and Southern Electroencephalographic Societies, Bethesda, September 30, 1955. �Changes in memory and learning were tested in these subjects by using the principle of retroactive inhibition. 3-letter originally learned By the serial testing of recall of words following the interpolated learning of nonsense syllables, patterns of decrement in learning and recall were elicited. As a week of treatthe showed to third impairment the increasing up patients group, ment, and a rapid improvement after the cessation of treatment. No relation- ship, however, could be established between impairment and reSponse to treatment.* The responses of these subjects to simultaneous tactile tests using touch stimuli were also assessed. While an increasing impairment in the ability to be two demonstrated with increasing could and stimuli the localize identify treatment, no relation to improvement was noted. however, and in anticipation that more meaningful The tests were extremely gross, correlation for this index of altered brain function could be obtained, a study using threshold electrical stimuli has been undertaken (pg. 10). As ent and result of these studies, it was our conclusion that early, persistsevere changes in both the electroencephalogram and in the amytal tests a are a necessary, though not sufficient pre—requisite for improvement following electroshock therapy. These observations make it possible to predict the short term response to electroshock, and such a study was undertaken earlier this year (pg.ll). Concomitant with these studies, we have made some preliminary observations in patients undergoing insulin coma therapy. Recent reports of the value of prolonged coma as the basis for improvement (26) have been confirmed in our patients. In one unusual case report we noted a direct relationship between * Presented before the Electroshock Research Association,1;ay 8, 1955 and awarded their Annual Prize award for excellence in research design. �altered brain function, altered patterns of adaptation in language and behavior, clinical and improvement (27). Concurrent with these psychologic investigations, basic studies have been done in in biochemistry. 1950* with an The initial biochemical research laboratory was established program of study of the relationship between steroid excretion patterns and states of mental illness. studies, utilizing alumina column chromatography, demonstrated atypical The number excretion of a levels in psychotic ketosteroid patients. urinary The of B—steroids (particularly dehydroisoandrosterone) was found to be elevated, and the etiocholanolone was depressed (7a). The ll-ketoetiocholanolone values appeared to be sex-dependent: male patients excreted the steroid metabolite in normal amounts, while the several female patients studied had markedly elevated values. During the past year, a collaborative study was chemical department of the Sloan-Lettering initiated with the Institute of new York. bio~ Similar steroid excretion pattern studies were undertaken utilizing paper chromatographic technics. In the first phase of the study recently completed, the elevated excretion of ll-ketoetiocholanolone was confirmed, with a severe reduction in the excretion of this when compound prior to discharge, at a time the patient had shown considerable improvement from her * Supported by grants from the Dazian Foundation illness. for Hedical Research. �.10... IV. §EUDIES IN PROGRESS 1. Relation 2f AND Tests IN DEVEILEEENT: Improvement: Function Brain 33 Altered 3; altered between relationship direct Our earlier studies this that however, apparent, is treatment. It to and function response brain and not only function brain altered of indices certain holds for relationship and elabconfirm to undertaken been has for others. Further study, therefore, have shown a methods of measuring orate these findings, as well as to investigate improvement. clinical to related function which are more reliably a. cerebral Amytal Test and Electroencephalogram: Amytal tests and electroencephalograms are done and second the and during subjects before, third in all weeks of electroshock treat— make a used predicto data is the findings ment. On the basis of our earlier those that predicted is treatment. It to term short response the of tion and with positive abnormality electroencephalographic patients with a high degree amytal test findings will be most likely to show improvement; while those with amytal and with negative abnormality a low degree electroencephalographic results are considered unlikely to improve. b. Tactile Perceptual Tests: perceptual tactile simultaneous the As described before, was planned inconclusive. It were of test results in our first series patients conditions under stimulation, electrical to repeat this study using threshold terms Under controlled. be could rigidly wherein the various stimulus parameters two of consisting assembly instrument (M—927) an USPHS grant of an existing dewhich can devised was oscillograph monitored by an Grass Sh-B stimulators the assembly, this Using stimuli. electrical wave independent square liver stimuli applied simul- to perceive their ability for tested patients are technique refined this By applying body. taneously to different parts of the two �.11be may otherwise not apparent function brain in it is anticipated that changes and of improvement the be to degree compared will observations These elicited. to our other test~results. As in the case of the electroencephalogram and the and intervals during stated before at tested are amytal tests, patients course of treatment. c. Hemory Tests: imp and loss of memory of relation the Numerous theories provement have been described. Our own data to date shows no significant re- and words and simple nonsense syllables for lationship forselective a there is evidence that considerable But there is improvement. For memories. and situations of life significant getting, during treatment, between the memory loss a record this purpose, may be is made of events during the preceding six months which of emotional significance to the patient. During treatment, inquiries records verbatim of these events, recollection patient's are and these compared to the pre-treatment reports. made of the 2. Relation gf’Premorbid Personality to Duration 3; made, Response: has also been apparent that the relationship between altered It brain function and clinical response is valid only for the short term response When six followed a for treatment. weeks several after to treatment, ite., return a had showing relapsed, the of improved several patients period, of their former symptoms, and in some instances requiring further hospital- month ization. thesis To account for the varying duration of was advanced that the difference personality patterns. Specifically, it was clinical response, the hypo- related to differences in premorbid was suggested that patients who showed would (22) denial verbal personality" the of "explicit the characteristics likely to maintain improvement. premorbid personality of each patient is assessed be those more The an interview with family members, psychologic and psychiatric interviews. by four procedures tests, tachistoscopic tests - �a. Family Interviews: At least two close relatives are seen in independent interviews. A standardized questionnaire has been devised to elicit characterological factors indicative of the "explicit verbal denial" personality. For this study fifteen characteristics defined as typically present or absent in conscious— Such include items prestige selected. were of this type personality and and to sex attitudes temper to imagination, criticism, ness, sensitivity illness. Each patient is rated on a scale of 0 to 2 for each item - the higher score signifying a greater tendency to denial. b. Psychologic Tests: Each patient is tested on a standard psychologic eval- uation battery including the Rorschach and Thematic Apperception TEStS. These adap— defense of and usual or types structure character assessed for tests are tation. Such tests are repeated at the termination of the treatment program and again prior to discharge, to obtain additional information as to changes in behavior in the course of treatment. - c. Tachistoscopic Tests: tachistoscopic study has been devised; in which pairs of emotional and non-emotional words are flashed on a screen at 10, 20, 50, 100, and 250 millisecond periods. The patient's ability to identify the words, A the reaction time, and the distortions are ascertained. This pre-treatment data is now being explored as to defense patterns. The its ability to clarify the patient's usual tests are repeated at the end of greatment and again prior to discharge for the possibility that characteristic changes in perception develop with altered modes of adaptation.. �-13.. d. Psychiatric Interviews: In the course of estimating changes in behavior, patients are seen prior to treatment, and at intervals during treatment. In a clinical interview setting, an assessment is made of the patient's symptoms, and usual of adaptation. Changes in symptoms, behavior, language and modes of adap- modes tation are noted. By interviews with the patient's therapist, judgment as to the significance of such changes and bral states can ment their relation to treatment, or altered cere- be made. On the basis of the data in a-d above a prediction of response to is made. treat- Prior to the start of treatment the patients are classified as: 1) those unlikely to improve; 2) those likely to improve moderately or temporarily; 3) those likely to maintain marked and sustained improvement (for at least six months). During the third week of treatment, (after the patients have had ments), a second prediction of the short term response change is made 7—9 treat- according to the in the physiological indices. 3. Altered Patterns g£.Adaptation Kanifested in‘Verbal and NonéVerbal Behavior: In the earlier study on the amytal test it had been noted that specific changes in language and behavior indicative of altered adaptive responses occurred in the improved patients to a significantly greater degree than in the unimproved patients. Further experimental procedures were necessary to clarify the nature and significance of these changes. deemed �alb- a. The is a highly structured interview of the patterns of language. made ients who show language will in émytgl Tests: amytal test procedure is recorded. This Language Changes Induced situation, The and systematic observations are hypothesis tested is that those pat- consistent, increasing use of the following types of adaptive be more likely improve: 1) The use of the second or to third person. In such instances the patient reports his main trouble as "the Doctors say I'm depressed", or state the wish that "my family should be well." 2) The selective response to questions, as answering readily questions about date and location but failing to answer, illness. tive mumbling or using neologisms when asked about 3) The use of conditional or qualifying expressions, or the subjunc- mood which has the effect of vitiating the patientis committment to the is I feel kind of dBpressed", in w hich "sometimes" qualifies the temporal degree of illness, and "feel" and "kind of" statement. An example "sometimes ‘qualify the intensity of the illness. Committment would be indicated by the direct, unconditional statement of "I am depressed". h) or stereotyped expressions in discussing illness, as "to or "well, in a manner of speaking..." or "I didn't keep wheel". 5) Language antic statements. 6) problems. tell my The use of cliches you the shoulder to the filled with nonpsequiturs, circumlocution, ornate The use or pedp of humor when talking about their illness or other 7) The use of metonymy or paraphasia, as Dr. as a "recorder". 8 )The various forms of ulation about the main problem truth..." referring to the examining explicit denial including confab- and temporal displacement. 9) changing the sym- bolic frame of reference in response to questions, as replying to the question, feel?", by stating, "with my hands." 10) The use of hyperbole, as "you're the best Dr. in the whole eastern Atlantic seaboard area." "how do you �.15- State: Confusional the PostaShock b. Language Changes in Each orientation for tested is patient and awareness of treatment. a following immediately awakening of the period in his main problem such At intervals. weekly and then at treatment the initial done after @his is most severe, and a defects are cerebral neurologic the times, These of language appear. tive changes in the pattern variety of may be comparable adap— to the records are and the situations, interview other the in noted changes language and changes language the later to both as indications assessed for prognostic the degree of improvement. Study: Sentence Completion 0. in language in and changes A way of studying the patterns technique. completion sentence a devised using been has fashion a quantitative accordstructured been have which complete, to sentences to given The patient is the in first been have put sentences the of Ten different patterns. ing to four when....", criticized am "I Wish that......", such "I as unconditional, person, the in expressed are they that except meaning in identical Ten others are etc. sometimes "people as aspect, qualifying or conditional third person and with a the In reetc. When.....," criticized wish that.....", "people are usually these of senten In indicated. maining twenty items no person is specifically or occurrence exact an to refers or direct is sentence the tences, however, event as "every time....", ”when the doctor comes in.....", etc. The remainp "at times....", as aspect, indefinite or qualifying conditional, have a ten ing etc. when.....", better "things usually seem a little for analyzed not in sentences The response of patients to the incomplete rated is each response Instead, manner. psychologic content in the traditional �16 the whether include ratings for its grammatical or syntactical structure. or conditional, direct or is second third person, or response is in the first, The 1h). (page above described of language manifests aspects 1) assumptions: following the on This study is based begins in the to most obviously applicable a manner A sentence which patient (e.g., first person, adaptive reto elicit likely unconditional) creates conditional is or the third in person A sentence which is expressed 2) sponses. and least minimal is stress creates is less applicable to the patient. It complete used to The 3) person syntactical likely to elicit adaptive responses. maximum stress and is most of indicative is to person in regard indeterminate is whose beginning sentence a shows less of the person first the use the degree of stress experienced (e.g., third second or the of the use defensiveness, person shows greater defensive— ness). d. Attitude Interviews: In this part of the study an attempt the of mechanisms ego. adaptive the tionally Two is made to define opera— structured interviews followed. The attitude of the questionnaire is interone In next. the to interview from one examiner, however, is reversed and the in concerned, view the examiner is empathetic, pessimistic, minimize to and tends insensitive non-empathetic, he brusque, is other interview are held, in which the the patient's same difficulties. In general, the first attitude produces good a in grossly results latter the while rapport with these disturbed patients, each asked in are non-communicative situation. Although the same questions to be appropriate to the examiner‘s attitude. interview, the wording is altered "YOu must today?", poorly "feeling as such he questions asks In one interview worse?.“ been getting "has and it consider your condition pretty serious?", don't "you today?", well While in another interview he asks, "feeling pretty consider your condition serious, do you?" and "have you been improving?". �.11.: The two structured.interviews are performed just prior to electroshock interviews All are treatment. of treatment and repeated following the course of the patient's 1) alteration the study: in recorded. There are two variables The four attitude. examiner's the in behavior by treatment, and 2) alteration recordings are studied for and changes. language vocal changes, content, The it defensive mechanisms of the patient both out be carried can that transactions of the of terms range in ationally, and any changes in can be defined, oper- be commmay patient depressed For a example, very treatment. and after before he whereas interview, empathetic concerned, the in treatment before unicative jovial, mood is the when latter examiner's the in will be unable to participate of one is treatment to his response However, if and minimizing. bantering becomes he sustreatment Following reversed. be euphoria, the situation may and empathetic, concerned examiner is when the anxious or hostile, picious, Thus the interview. the optimistic in stressful less communication is whereas terms, objective in be stated the defensive system of the patient can change i.e., in of interpersonal standardized range to a in terms of his reactions uations. in sit- M h. Clinical Ratings 2: "Improvement": changes evaluating of methods and test These various experimental ratthe psychiatric in significance further have may and behavior language considerable experienced we studies revious In our : rovement." "im of P ing Or, be guide? the to relief symptomatic Is our patients. difficulty in rating to recovery Is be the goal?. to improvement" "social recovery" or is a "social relief? Agreement by symptomatic well as as of insight be judged by the degree "unimproved" and improved" "much "recovered", of definition the in psychiatrists is not available, investigations, to further crucial is issue and yet, this We �they terms as these of assessing task further the undertaken have therefore apply to the electroshock population. of incapacity and type the degree are Central to this problem of evaluation and the the of therapist, the goal personality, of the patient, his premorbid capacity events, intercurrent as Other aspects, therapy. to attitudes patient's environmental the patient's of therapy, suitability of the therapist, temporal present. at encompassed not but are assessment, to important also assets are To are studies evaluation following the "improvement", of meaning clarify the in progress. Evaluation: Pre-treatment a. the by therapy electroshock Patients are referred for and resident therapist. supervising psychiatrist evaluation is made by the research psychiatrist. An Two independent psychiatric aspects are specifically decompensation of signs clinical encompassed in this study: of sympdegree for and rated mental status descriptive a recorded in which are of the patient‘s estimate 2) an (28); scale tomatology on a Kalamrd rating 1) the symptoms and operations. defensive usual his of with description a develOpment of ego level Relationship: Therapist—Patient the in Changes b. to held prior therapist resident the with interviews In and the therapist between relationship the therapy, electroshock of the onset recomp the for the reason on emphasis with specific explored the patient are and the patient's treatment, the of the goals mendation for this form of therapy, mental of treatment of method Since the primary attitude to the treatment. electroshock for recommendation the disorders at this hospital is psychotherapy, the between patient communication that assumption the with carries it generally deis the exploration For this reason, meaningful. no longer was and therapist and recommendation, the led to that relationship the in voted to those changes �19 and symptoms that it is behavior of of those aspects statement a definitive We the in interested also therapist's affect. treatment are may the anticipated attitude to this may form of treatment, and attempt to assess the role this attitude play in the eventual results. of the the results theories relating numerous there are Furthermore, made being are attempts and in our inquiries, therapy to its punitive aspects, to assess the significance of this factor in the outcome. During the interviews with the resident therapist and with the patient, the patient's attitude behavior) and against (both language defensive operations to the treatment, his his in and alterations the electroshock represents, the reality threat that attitude during the weeks of treatment are studied. Further information regard— of our the in course be ascertained will of factor this ing the significance control study (page 21). c. Follow—up Study: Crucial to the evaluation of "improvement" is the oppor— treatment of the period following various periods tunity to repeat evaluations at from hosthis discharged of the patients follow—up report Recently, a four-year between customary the disparity indicated and (1) this pital was made available of inthis the In course illness. discharge ratings at out carried being observers is same the vestigation, repeat evaluations by As check a treatment. months after and six various times during hospitalization and eventual course of the and the physiological of the personality basis the on the predictions two—week the for recorded factors studied, specific follow—up evaluations are (long-term months period and the result) six post-treatment period (short-term made on ther— the resident of the to ratings result). These evaluations are compared each In instance, medical director. and the apist, supervising psychiatrist and the of terms projected formulated in the ratings made in this study are and interpersonal language of behavior, those noted aspects in actual changes �Excretion 23 Improvement: 5. Relation of Steroid and their reof steroids excretion patterns of The studies of the More recently continuing. is 9, on described page mental to states, lation of measurement the for of techniques development the on been has emphasis colorimetric and * new separative steroid conjugates. During the past year sulfate steroid measure to (29) devised techniques have been these for patterns excretion blood and urine. Daily urinary compounds in compounds are and prior again electroshock of the course assayed prior to treatment, during resolve to is of this program The object selected patients. in to discharge individual total the with values these and compare bound steroids, the sulfate excretion hormone between relationship the elucidating Besides hormone levels. which to extent the indicate of mental illness, such studies and rates states hormones. steroid of metabolism the the liver (30) participates in Electroshock Therapy: Results Functions of on 6. Effect of Autonomic behas studies, it electroencephalographic of our In the course alterations the typical fail of number patients that a apparent come to also fail These patients treatment. extensive in cerebral rhythms despite and frequently tactile tests, in the amytal tests, simultaneous to show show changes reactivity the studies, these with Simultaneous periods. confusional evince no mecholyl of administration the to rate and the pulse blood of the pressure to done was prior too, This, out. carried been have "Funkenstein—test") (the Marked ended. had treatment of the course after immediately treatment and two test these found in were medication this to variations in the responses the of earlier the reports way general a in followed observations These periods. between relationship the of exploration the undertaking workers, but we are now tests. physiological and these function brain altered of tests in the alteration * Aided by a grant (A-6YSC) Public Health Service. States United Health, of from the National Institutes �v. THE PROJECTED PROGRAM: SUMMARY 1. 3 21 - Method: the along and development continuation The projected program is a Our ultimate of this two report. sections lines indicated in the preceding the systematic by therapy electroshock of mechanism goal is to clarify the of behavioral, inter-relationship the of and integrated investigation biochemical factors. and physiological sonality, This program is per— rev interdisciplinary full-time a by undertaken being neurophysiolpgist, psychoanalyst, of psychiatrists, search staff consisting help. technical and allied biochemist physiologist, experimental psychologist, Some in scope clear already are the in program of the specific studies and new continues the program as become apparent Others will and outline. Two new basic develop. leads promising further or problems appear critical decided been upon. already have methodological aspects date work to our in 1. Control group:0ne of the major deficiencies starting Accordingly, control group. has been the absence of an adequate two into divided be will electroshock for referred January 1, 1956, patients of conusual course the receive will One group fashion. random a in groups treatments. sub-convulsive be given vulsive therapy; the other group will Ulett of study instructive recommendation follows the recently reported This et a1. (31). In other respects the two groups will be treated in the same will each group in are patients who will The only person fashion. of The purpose treatments. the administering be the supervising psychiatrist in— of the effects physiological the differentiate to is such a control group know which outcome. therapeutic the affecting Some duced convulsions from other factors disease process, the of particular 1) nature the of these factors might include 2) the attitude and symbolic etc.; depression, involutional or as schizophrenia of a large attention 3) the special the patient; to treatment of the meaning �~22: numbers of observers h) the incident to being placed on the treatment program; attitude of the patient's therapist toward the patient and toward electroshock therapy, including the expected goals in each case; and S) the relative effectiveness of other forms of therapy provided for these patients in the hospital milieu. The use of a control group will also clarify the nature of "Spontaneous recovery" and may aid in the understanding of "atypical" results in the patients actually receiving convulsive therapy. 2. Insulin Coma: It is planned to extend the present methods of study to an investigation of those patients receiving insulin coma therapy. �~23.- 2. Significance This program of study has both applied and theoretical significance. there since electroshock of therapy use clinical It can lead to the improved be mechanism. will It the of therapeutic will be a greater understanding to who better improve, will those patients more skillfully select to possible and to predict the involved therapeutic in process, factors other manipulate more accurately future management problems. of the psychounderstanding to a greater however, also This study leads, pathology of mental picture which illness. Through the various methods of study a clearer will be obtained meaningful criteria for of the mechanism of defense and modes of communication may contribute more operationally accurate and "improvement". of determination the for diagnostic classification techtherapeutic other on throw light may Finally, the investigation and and obserthe function cerebral in niques. The studies of the alteration have signifi— damage and cerebral behavior between vations on the relationship also is It electrocoagulation. and cerebral cance for the studies in Ibbotomy modes of and in language the changes into here gained the insights that likely of psychotherapy. study eventual significant make an possible adaptation may �VI. FACILITIES AVAILABLE: 1. Hillside Hespital is a 200 bed non-profit psychiatric hospital. All admissions are voluntary, with periods of hospitalization varying from h-lZ months. All patients are available for study. The hospital was established in 1927, for the purpose of treating ulatory psychiatric patients. A amb- residency training program.was instituted earxy, under the supervision of an active staff of psychoanalytic psychiatrists. In 1950 the research biochemical laboratory was established, to be followed in 1953 by the neurophysiological research laboratory. In 19Sh these laboratories were combined and expanded, and a Research Service established as a:full-time operation of the hospital. Research Director was appointed to integrate program. At this time, the staff consists all A full-time the studies into a basic of the Director, research assis— tants in psychiatry and psychology, biochemist and assistant biochemist, siologist, and EEG technician. In addition, a psychologist and phyb two chemists are associated on a project basis. Laboratory Medcraft D-8, two S-hB Grass 8 facilities include: (a) Electroencephalographic unit with a channel instrument; (b) Neurophysiological laboratory with stimulators, tachistoscopic projectors ical laboratory with Du Mont # 3&0 R and feet of laboratory space Beckman Coleman Spectrophotometer, and ifications of the A.E.C. two synchronized auxiliary electronic equipment; (c) 1000 square the following major items: oscillograph; Biochemp and equipped with Spectrophotometer,'Warburg respirator, radioisotope unit following the basic spec- �£2 5.. fl 2. Personnel:* studies Undergraduate Research: of (a) Dr. Max Fink, H.D., Director the and degree New Yorn College University, of Universitv were undertaken at the {e the attended l9h2. in was granted of B.A. cum laude with Honors in Biology New l9h5. in graduating of Hedicine, York University College interneship he served in School of the from he where graduated U.S. Army, the Military Heuropsychiatry in Knox After a rotating 19h7, and was Chief of the Psychiatric Section, Fort Station Hospital during 1947. Formal neurologic training was received at hontefiore Hospital in York New Formal psychiatric (l9h9«1951). Hosoital Bellevue Dsychiatric and at (l9h8-l9h9) and than (1950) at Hospital Bellevue ?svchiatric undertaken at training was Hillside Hoscital (1952). During 1951, and again in 1953, he and then at Mount In 1952, he was American Board of first at Sinai Hospital in a research fellow of the Hational Both periods of study were under the Foundation for Infantile Paralysis. ection of Ur. horris 3. Bender, Was flew York dir- University College of fledicine flew York. the by in l95h, and Psychiatry, in Feurology, in certified ‘sychiatry and Neurology. Simultaneously he attended and gradof Psychoanalysis, Psychiatry and Institute 1953. In January, in Physicians for Psychology, receiving their Certificate Mental of Institute National the of June, l9Sh, he was granted a research grant uated from the ”illiam Alanson Fhite Health for a 2-vear study of electroshock processes. In September, l95h, he was Fink Dr. Hillside Hospital. Service at Research appointed Director of the is 33, married and has one son. _____._.__.___.___________.___.____________.._._____._______._____________.______. 38. apaended, page of is personnel * Bibliography �7-20Collowing Psvcuiatry: in Assistant (b) Dr. Joseph Jaffe, h.D., the attended Jaffe Dr. l9hh), (B.A., Columbia College at studies undergraduate Then 19b7. M.D. in his and.was granted of hedicine, College New vorlr. University he began interneship, rotating a he was elected to Alpha Omega Alpha. Followinr resident a as First Hospital. DelleVue Psychiatric the at of study three years U.S.P.H.S. posta as studies his he completed in psychiatry, then in neurology, lender. 3. Morris Dr. of doctoral research fellow under the supervision from graduating Air Force, States United the in he was 1953, From 1951, to Air Eitchell the at Psychiatrist Chief He was fiedicine. Aviation the School of Force Base Hospital. prac— the private been in has he service Since discharge from the military of Board American the by psychiatry in He certified was tice of psychiatry. psychoin candidate been he a has Since l9h9, 1953. in and Neurology Psychiatry Psychiatry Psychoanalysis, of Institute 'hite Alanson analysis at the William the at Assistant Research been has a two years the and past for and Psychology in position present to his He was appointed Mount Sinai Hospital of New York. September, 1955. Chemist: Chief Ph.D., Goldenberg, (0) Dr. Harry A graduate of the Tremaine of a recipient York New in of the City of College D. in ”h. his received Goldenberg Dr. Scholarship and graduated cum laude. in instructor He been has an Brooklyn. of Institute from ‘olytechnic the l9h9 l9hh, he was the College Brooklyn and at (l9h6-h7) biochemistry at the Dolytechnic Institute Natthe of enzymology Fellow in Research he l9h7~h9 was a In (1951 to date). ional Institute of Health, and from 1950 the to chemist he was a 1952, to methods enzyme studying of Brooklyn Hospital Jewish the at U.S.D.H.S. project in clinical chemistry. �...27.. Dr. Robert L. Iahn, Ph.D., Assistant in Psychology: (d) After graduation from Brooklyn College in l9h0, he undertook graduate studies at Columbia University. These studies were interrupted by four years of service and School Dsyc‘hology went he Clinical to where United Army, States in the On and overseas. country in this various hospitals served as psychologist in of Neurology the Department in Research T’syc‘iologist became he the army leaving of the Mount of Dr. horris Sinai Hospital in New York, where he wormed under the supervision B. Bender and Dr. E. A. "einstein until January, 1955. is He of monograph, the and co-author is studies, experimental of numerous the author "Denial of Illness: He Symbolic and Physiological Aspects" published received his Ph.D. from the New in May, 1955. York University School of Graduate Arts instructor of psychology at Brooklyn and Huntto been he a.consultant has two two For the past fbr years years. er Colleges conducted and has training proMental of Hygiene New York Department State the and Sciences in 1953, and was an he been has 1955, a Since January, mental the of several hospitals. in grams member of this staff. (e) Dr. Hyman years of military service, received his 3.8. in ogy interns at York four Following Psychology: in Assistant Ph.D., Korin, he matriculated l9h9, and at College of the City of his H.S. in 1950. During 1951-52 he the Hount Sinai Hospital and University. New was York and psychol- matriculated for his Ph.D. at New Since June, 1953, he has been Research Assistant in Psychology at Hillside Hospital. He recently completed his doctoral thesis on "The Effects of filectroshock on Retroactive Inhibition," and received his Ph.D. in October, 1955. his'L. F. (f) Dr. Arnold Blumberg, H.D., Internist: Dr. Blumberg received from the University of Pennsylvania in l9h2, for studies in physiology, and in l9h5, received his E.D. from the Mew York University College of Medicine. continued he two of and service, military years interneship Following a rotating 1952. l9h8 First from to Memorial Goldwater Hospital at his residency training �-28he completed Fellow Medicine, in then a as as a resident in neuropsychiatry, He has 1950-1952. Division Research the his studies as a Research Fellow in been a Fellow in Medicine at the New York University College of Medicine, 1951-Sh. He was is an certified Internal Medicine in l95h and of Physicians. He is the associate by the American Board of associate of the American Attending Internist at Hillside Academy Hospital and has'been directly responsible fa' of coordinator well as as Research Service, the physiological studies of the the biochemical programs. 3. Function of Research Service: the Research Service, the of research programs In addition to the with actively They cooperate functions. staff is active in two additional research who on part-time carrying are those members of the hospital staff In such instances, aid nature. of clinical a chiefly projects, the planning of goals, project clarification the is given in and design of programs, and is needed. and during in is progress, program Secondly, an active resident training independon an to opportunity carry an given is the third year, each resident been have two service projects of this ent project. Since the development such technical assistance as the include projects completed, and three are testosterone of and the use states anxiety in of reserpine clinical evaluation include resident At projects present, coma therapy. insulin to adjuvant an as now active. The completed a factor, therapeutic milieu a as the of hospital a study clinical evaluation and clinical, coma therapy insulin for substitute a of chlorpromazine as aMbivalence. of measures and tachistoscopic psychologic �-29In May, 1955, the Research Service established a. liason with the Sloan- York of steroid New out study to cooperative a of Institute carry Kettering excretion rates in psychotic patients, with emphasis on the patterns altered during and following electroshock thefapy. �-30.. VII, M PRESENT BUDGET AND REQUESTED SUPYOR : Budget and Present Support: 1. Present anus—“u The following is the full budget of the Research Service for the fiscal year l9SSmS6. The major Share of the program is supported by the Board of Directors, supplemented by grants of the United States Public Health Service. Under Grant M—927 of the National Institute of Mental Health, $1h,807 of direct costs and $2221 of overhead costs was granted for the year September 1, 1955 to August 31, 1956. This grant is the second year of a 2-year grant for neurophysiological studies including the present Electroshock Evaluation Study. awarded $6500 The National Institute of Arthritis has for the second year of a twoayear grant for biochemical studies. �~31- 1. w.- ' Board of Directors U.S.P.H.S. 15,000‘ 15,000 -——- Psychiatry* 7,200 7,200 --— Research Assistant in Psychology 8,000 -——-— 8,000 Research Assistant in Psychology 5,000 -—-—- 5,000 2,520 2,520 -———— Chief Chemist 8,600 8,600 -—-—- Assistant Chemist h,000 __—- h,000 Assistant Chemist 2,800 2,800 -——- Assistant in Chemistry 1,800 -——- 1,800 h50 -—-— h50 3,810 2,253 1,557 1,200 1,000 200 Personnel Director of Research Psychiatgz: Research Assistant in 7E0 Technician - Secretary Biochemistgz: 2. Equipment 3. Consumable supplies h. Travel - Conferences Total Overhead TOTAL * 3/5 time to September 1956. 60,380 39,373 21,007 2,521 ______ 2,521 62,901 39,373 23,528 �.32.. 2. Requestegjg‘udgetagr Support: A. include requirements of the Electroshock Therapy Evaluation Project The two two of other modification the to professional staff, additions specific allocations of equipment funds. (1) Psychiatrist: The cooperation of an additional full time psycoma insulin include of to the study the needed to enlarge scope chiatrist is positions, and of evaluations the in to assist control the study; therapy; to supervise diange in patients and carry out follow-up studies. For this position, an- alytic experience is essential. (2) Physiologist or Heurophysiologist: Present physiological studies of Further physiostudy and the Internist. Director the out by carried are by full-time a of studies these coordination the changes requires logical physiologist, (3) M.D. or Ph.D. Equipment: and physiology. For Present needs are focused in two areas - biochemistry further refined studies of the steroid sulfate patterns mechanical and a Beckman.Spectrophotometer the attachment for a recording carry out the anticipated physiological studies modifications and attachments to the electroencephalograph are shaker (Dubnoff) are requested. To suggested. following budget is one suggested to continue the present proneeded completo the of 1956 personnel addition the with July 1, gnmn after ment the present staff. The budget is divided into three categories, followB. The Research Serthe coordinated in which divisions are the three laboratory ing and five period, a for the for year Estimates listed first year, are vice. including projected salary increments. �M First 1. Psvchiatqz: a. Director Secretary Conferences 13 Year Five Year Total (20,-25,000) 20,000 112,500 (2,6-3,100) 2,600 1,200 11,220 (15,-18,000) (15,-18,000) 15,000 15,000 9,000 5,500 82,500 82,500 52,500 35,000 1,200 3,600 . Personnel 1. Psychiatrist 2. Psychiatrist 3. Eeychologist 13.. Psychologist c. Supplies Subtotal - & ( 9"12:OOO) (5’5' 8,500) Equipment 388,820 69,500 Psychiatry 2. Neurophysiologx: a. Personnel 9,000 3,600 52,500 12,000 b. Equipment 1,000 1,000 c. Supplies 1,200 6,000 1. Physiologist 2. Technician (9,-12,000) (3 : 641-31400) 71,500 10,800 Subtotal - Neurophysiology 3. Biochemistry: a. Personnel Chief Chemist (9,-11,000) 9,000 6,000 0,000 1,800 36,000 25,000 11,200 b . Equipment 7,000 7,000 0. Supplies 1,500 7,500 1. 2. 3. h. Chemist Chemist issistant Subtotal - Biochemistry (6,-8,h00) (bu-6,000) (1,8—2,600) 29,300 137,700 �Total First - All Programs .. All Programs 113,600 598,020 17,0h0 89,700 130,6h0 687,720 Overhead Allowance\(15%) TOTAL Five Year Total Year C. Budget Reconciliation: 1. Salaries: The salary range for each item is consistent with pre- sent positions established at the hospital, or for new positions, with neighbor- for supervising psychiatrists is $12,-15,000, with a projected revision to the stated scale in 1956. ing institutions. Present salary 2. Equipment: ment expenditure ance range For psychiatry, the initial year includes the equip- for tape recording system (#600) and an annual for expenses. The $600 allow— physiological equipment expense (51000) is to allow modification of present electroencephalographic equipment to record other physiological indices. The expenditure for supplies includes allowances for consumable items and the provision for the building of specialIized equipment. In biochemistry, the a recording attachment for the Beckman intiial expenditure includes $7,200 for spectrophotometer and 9800 for a Dubnoff shaker. 3. Conferences: Present budgetary items include this of the Director or members of the sum for the use staff to attend appropriate scientific meet- ings. h. Overhead: Consistent with hospital policy and recent administrative changes in other grants, a 15% allowance is requested. This amount includes hospital allocations for Social Security coverage; and for such contingencies in the expenses of the program as not reg iring a significant alteration in the budget. 5. Subtotals and Total: The budget is presented in three sections, representing natural subdivisions of the program, thereby allowing for modifications in support. �VII. APPENDIX A. REFERENCES: from Discharged 317 Patients of Study Follow-up H.L. RACHLIN, 2E.§i: 1. in Hosp., Hillside press. l?50, J. in Hillside Hospital and other Psychosurgery Shock Treatment, 2. KALINOWSKY, L.B. and HOCH, P.H.: New York, Grune Stratton, (2nd a ed.), Somatic Treatment in Psychiatry 1952. 19h8. 397, Mil. Surg. $92: Theories, Shock Therapy Fifth GORDON, H.L.: 3. and Dsvchiatry, Neurology of Foundations h. GELLHORN, E.' Physiological 1953. Minneopblis, Hinnesota Press, University of Nervous Autonomic H.C.: S.a FNNKENSTEIN, D.H., Ment. 3 Nerv. J. Shock Treatment, System Changes Following Electric GREENBLATT, M. Dis. 329%.: 2109, and SOLOMON, 19,480 Which PreA Test H.C.: 5.b FUNKENSTEIN, D.H., GREENBLATT, M., Schizophrenic on Treatment Shock Electric of dicts the Clinical Effects 1950. 889, Am. 199: Psychiat. J. Patients, AND SOLOMON, 5.0. Autonomic Changes H.C.: SOLOMON, and M., FUNKENSTEIN, D.H., & Nerv. J. Patients, in Mentally Changes Psychologic Paralleling GREENBLATT, Ment. Dis. 6.a. 11;: 1, 1951. Ill Exthe and in HOAGLAND, H. et al: Changes in the Electroencephalogram of AgitTherapy Electro-shock Accompanying cretion of T7-Ketosteroids 19h6. Med. §32h6, Psychosom. ated Depression, Excretion on Treatment of Effect B.H.: 6.b. ALTSCHULE, N.D. and & Neurol. Arch. Mental Disease, with Patients in of l7-Ketosteroids 1950. 516, éfi: Psychiat. Cortins of Excretion the on Convulsive Therapy 6.c. ASHBY,‘W. 1.: Effects of 19h9. 275, Ment. Sci. 23: and Ketosteroids, J. PARKHURST, Excretl7-Ketosteroid the of Studies Chromatographic H. WERBIN, 7.a. gt El: Hosp., Hillside Normal J. Individuals, and ion Datterns of Psychotic 195,40 2011, 2: l7~ Neutral of Urinary The Fractionation S. R.: M. STITCH, and REISS, 7.b. Ment. $99: Sci., J. Male Schizophrenics, Chronic from Ketosteroids 7011, 195,40 8. ASHBY, W. R.: Mode 22: 202, 1952. of Action of Electro-Convulsive Therapy, J. Ment. Sci. �.36... 9. Shock Therapy, Hypoglycemic and JELLIFFE, S. E.: Discussion on Insulin 1937. 200, & 2Q: Psychiat. Arch. Neurol. of Aspects Psychologic Certain 0n E. MOSSE, 9.: and J.A.B. 10. MILLETT, l9hh. 226, Med. 6: Electroshock Therapy, Psychosom. Shock Electric with Treated Patients in Functioning Memory ZUBIN, J.: lla. l9h8. 33, Dersonality Therapy, J. ll: on Therapy Convulsive Electric of Effect S.E.: BARRERA, and ZUBIN, 11b. J., 596, l9hl. fig: Biol. Soc. Exper. Hemory, Proc. Assoword the on Performance on Shock Therapy of : Effects ZEAEAN, J. 12, 19h7. Association, Psychological Eastern the at Presented ciation Test. J. Treatments, Convulsive Electric Following Loss Memory JANIS, I.L.: 13. 191.18. Personality 1.1: 29, der mit Erfabrungen Psychopathologische GROBE,’W.: and W. BAEYER, von, lha. l9h7. 163, Psychiat. $12: Elektrokrampfmethode, Arch. f. after Patients Mental on Observations E. STAINBROOK, J.: H. and LOWENBACH, lhbg l9h2. 828, Am. 2g: Psychiat. J. Electroshock, Post—Convulsive of Immediate Description Rorschach STAINBROOK, E.J.: Ibo. 19AM. 302, & Personality'lg: Mental Function, Char. Electroshock During Psychosis KAHN, and R.L.: LIEN, L., WEIWSTFIN, E.A., 15a. Am. Psychiat. J. Shock Therapy, of the Theory to Relation Its Therapy: 1952. 22, $92: and PhysioSymbolic of Illness: Denial KAI-1H, R.L.: 15b. mnrsmm, F..A and 1955. Illinois, C. Springfield, Thomas, Charles Aspects, logical Ego, the on Treatment Shock of Effects D.: IMPASTATO, and FROSCH, J. 16. Psychoan. Quart. I]; 226, l9h8. l7. 18. 19. 20. Recent Under "Normal" Person of Electroshock on a L.: Effect 1953. 696, Am. J. Psychiat. $92: Stress, in (Paraphasia) Misnaming Non—aphasic UEINSTEIN, E.A. and KAHN, R.L.: 1959. 72, 61: a Psychiat. Neurol. Arch. A.M.A. Brain Disease, Organic Organic in Disorientation of Patterns KAHN, R.L.: WEINSTEIN, E. A. and 1951. 21h, & Neurol. I: Brain Disease, J. Neuropath. Clin. "47.1%.: 7-iithdrawal, Inattention, 310133, and mms'mm, E.A., ram-I, R.L., 1955. 235, & IA: Psychiat. and Pain Asymbolia, A.M.A. Arch. Neurol. ALEXANDER, �-3721. T‘JEII‘YST‘EIN, & E. nsychiat. A. _6_L_l: and mm, 772, 1950. D. Neurol. Arch. Anosognosia, of L.: Syndrome " of Denial Illness, in Factors Personality R.L.: MEN, and 22. IEINSTEIN, E.A. 1953. §_9_: 355, & T.‘Ieurol. Psychiat. 11.14.11. Arch. 23. L.A. and LINN, R.L., SUGABI'JIAN, Brain Disease, Sodium Organic in Amobarbital of “IEINS'I'Em, 33.11., MEN, Am. Use Diagnostic 1.: J. Psychiat. 112: 889, 1953. 21;. Test" "Amytal E.A.: H. and vmmsmm, KAI-1N, R.L., PINK, 1955. 3, Hosp. 3: Hillside Mental Illness, J. in Patients with Differential the in Tests Perceptual NJ: Tactile 25a. DEF-HER, MB. and 1952. 21, Hosp., Hillside 1: J. Disorders, Psvchiatric of Diagnosis Sign 8. Diagnostic Test as Face-Hand 1.1.3.: 25b. PINK, M. GREEN, M. and BINDER, 1952. h6, 2: Neurology, of Organic Mental Syndrome, ImproveClinical and Damage Brain 26a. REVITCE-I, 13.: Observations on Organic 195h. §_8_: 72, Quart. ment Following Protracted Insulin Coma, Psychiat. Coma: TreatInsulin A Prolonged Case of M.: 26b. IC-“IALEJASSER, S. and CAPLAN, 1952. 1115, Hosp. 1: ment, J. Hillside and ClinicElectroencephalographic 26c. SHAGASS, C. and ROFSML, P."T.: Serial & Neurol. A.Z"T.A. Arch. Coma, Insulin Prolonged of Case al Studies in a 195b,. 705, Psychiat. 12.: Posthypoglycemic in Studies 26d. TRACER, C.L. at £1: Electroencephalographic 19530 1135, 1.32%: Dis. l‘ient. Coma, Jo NerV. Parts of 1-5.: Reduplication Delusional and N. FINE, 27. KAHN, R. L., GRAUBTE’ET, D. 1955. 13h, Hosp. g: Hillside Coma Therapy, J. Insulin After 1Jody the of Scale, Rating the A Psychiatric of Revision 28. MALAI‘EUD, 'T. and SANDS, S.L.: Am. J. Psychiat. _l_9_l_l: 231, ram. Colorimetric Quantitative the for Dyes Basic Use of 29. GOLDENBERG, H.: Chemical Society American Conjugates, Sulfate Estimation of Steroid 1955. 'Iarch 31, 200, Abstract, Highspeed by Synthesis Sulfate Steriod : T4.. REIL’IANN, J. and 30. GOLDEHBERG, Chem. Soc. in Am. press. J. , Liver Supernates, Convulof Evaluation the in Matched Groups Use The of G. A. 313 31.: 31. ULE'IT, 195h. 128.: 138, July, Menn. Clin. Bull. Photoshock, Subconvulsive and sive F11 K, (31‘. �B. Publications of Personnel: Dr. N l. x Fink: Subdural Hematoma Developing during Hospitalization, Amer. J. Psychiat., 191: 381-383, 1950 (with Dr. M. Green). 2. Patterns in Perception of Simultaneous Tests of Face and Hand, Trans. Amer. Neurol. Assoc., 22; 250, 1950 (with Drs. M.B. Bender and M. ..., Green). ibid, Arch. Neurol. & Psychiat., éé: 355-362, 1951. Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology, 2: hé-58, 1952 (with Drs. M. B. Bender and M. Green). The Face-Hand Tactile Perceptual Tests in the Differential IJiagnosis of Psychiatric Disorders, J. Hillside Hosp., 1; 21—31, 1952 (with Dr. M. B. Bender). A Clinical Evaluation of Carotid Angiography, Conf. Neurol., 13: Exosomesthesia, or Displacement of Cutaneous Sensation into Extrapersonal Space, Trans. Amer. Neurol. Assoc., lg; 1952 (with Drs. M. F. Shapiro and M. B. Bender). .... ibid, Arch. Neurol. & Psychiat., éfi: h8l-h90 1952. 9. Order of Dominance in Cutaneous Perception, Trans. Amer. Neurol. Assoc. 2E3 238~h0, 1952 (with Drs. M.B. Bender and M. Green). 10. Development of Perception of Simultaneous Tactile Stimuli in Normal Uhildren, Neurology, 2; 27-3h, 1953 (with Dr. M. B. Bender). 11. Perception of Simultaneous Tactile Stimuli by Mentally Retarded Adults, J. Nerv. Ment. Dis. 111; h3-h9, 1953 (with Drs. M. B. Bender and M. Green). l2. Spinal Fluid Findings 2: 137, 1953 (I-rit‘n Dr. 13. Following Cerebral Angiography, Neurology, M. Stein). Statistical Study of a Psychoanalytic Hypothesis; Absence of a Parent as a Specific Factor Determining Choice of Neurosis, J. Hillside Hospital, a; 67-71, 1953 (with Dr. S. Tarachow). A Effects of Barbiturates 15: 1953 (with Drs. on Perception, Trans. Amer. M. B. Bender, P. Bergman and M. Neurol. Assoc., Nathanson). Homosexuality with Panic and Paranoid States (Case Report) Hillside Hosp., _2_: 16h-9o, 1953. J. 16. Standardization of the Face-Hand Test, Neurology a; 211-217, 195h (with Dr. M. Green). �.3917. Patterns of Perceptual Organization with Simultaneous Stimuli, Arch. Neurol. & Psychiat., 12: 233-255, 195A (with Drs. M. B. Bender and H. Green). 18. The Amytal Test in Patients with Mental Illness, J. Hillside Hospital, g; 3-13, 1955 (with R. L. Kahn and E. A. Heinstein). l9. Delusional Reduplication of Parts of Body After Insulin Coma Therapy, Dr. Joseeh Jafiig: 1. Perceptual Patterns During Recovery From General Anesthesia, Jour. of Neurol. Neurosurg. & Psychiat., 1%; 316-321, 195l (with M. B. Bender). 2. Factor of Symmetry in Tests of Double Simultaneous Stimulation, Brain, 15: 167-176, 1952 (with M.B. Bender). Dr. Rdbert Kahn: 1. Toxicity of Quinacrine (atabrine) for Central Nervous System: Experimental & Human Neurol. Arch. on Psychiat., 5g: 28h—299, l9h6 Study Subjects, (with Dr. T. Lidz). 2. After-Imagery in Defective Fields of Vision, J. Neurol., Neurosurg. and Psychiat., lg: 196-20h, l9h9 (with Dr. M. B. Bender). 3. A Hereditary Syndrome Characterized by Mirror Movements, Left Handedness and Organic Mental Defect, Trans. Am. Neurol. A., ZS? 22h—226, 1919 (with Drs. I. Freiman and L. Michaels). Tumors and Vascular 15: 277-278, 1950 (with h. Correlation of Clinical and EEG-Abnormalities in Disease of the Brain, Trans. Am. Neurol. A., Drs. E. A. ieinstein and H. Strauss). 5. Syndrome of Anosognosia, Arch. Neurol. (with Dr. E. A. Heinstein). & Psychiat., ég: 772-791, 1950 6. Patterns of Disorientation in Organic Brain Bisease, J. Neuropath. Clin. Neurol. 1; 21h-226, 1951 (with Dr. E. A. heinstein) & 7. Nonaphasic Misnaming (Paraphasia) in Organic Brain Disease, A.M.A. Arch. Neurol. & Psychiat., él: 72-79, 1952 (with Dr. E. A. Neinstein). 8. Preoperative and Postoperative Personality Changes Accompanying Frontal Lobe Heningioma, B. Schlesinger). 9. J. Nerv. & Hent. Bis., llh; h92-510, 1952 (with Dr. Phenomena of Reduplication, A.M.A. Arch. Neurol. & Psychiat., 81h, 1952 (with Drs. E. A.'Heinstein and L. A. Sugarman). él: 808- �uhO- Shock Therapy, Am. J. Psychiat., heinstein and L. Linn). Its Relation to the Theory of 222; 22-26, 1952 (with Drs. E. A. 10. IBychosis During Electroshock Therhpy: ' Brain Sodium") Sodium ("Amytal Organic in Amobarbital of Diagnostic Disease, Am. J. Psychiat., 109: 12, 889-89h, 1953 (with Drs. E. A. Ueinstein, L. A. Sugarman and L. Linn). Use Neurol. Arch. of Denial Factors in Illness, Personality Q2: 355—367, 1953 (with E. A. Heinstein, M.D.). & Psychiat., Behavior Disturbances Following Cataract Extraction, Am. J. Psychiat., and L. Linn). E. 1953 A.‘ einstein (with Drs. 281—289, 219} Delusional Reduplication of Parts of the Body, Brain, 7?: h5-60, l95h (with Drs. s. A. deinstein, s. Halitz, and J. hozanshiT: Serial Administration of the "Amytal Test" for Brain Disease: Its Diag195h & 217-226, Neurol. Arch. and Psychiat., Value, Prognostic nostic ll: (with Drs. E. A. Heinstein and S. Malitz). 16. Ludic Behavior in Patients with :rain Disease, J. Hillside Hospital, A. Sugarman). and L. B. A.'Heinstein l95h (with Drs. 98-106, 2: 17. Test in Mental Illness, J. Hillsifie Hospital., (with Drs. M. Fink and E. A. fleinstein). The Amytal Q; 3-13, 1955 Amer. "Irritative" Lesions, in of Functioning Intellectual Patterns 18. PSychologist, 25 h02, l95h (with Dr. E. A. Meinstein). 19. "Spatial inattention" in Patients with Localized Lesions of the CereN. S. l95h (with 327-328, Drs. Psychologist, 2: Pollack and M. B. Bender). brum, Amer. M. Batteery, 20. The Adaptive Role of Behavior Accompanying Brain Disease as Exemplified by the Phenomena of Reduplication, Amer. Peychologist, 2; h90, l95h (with Dr. E. A. ieinstein). 21. Denial of Illness: Symbolic and Physiological ASpects, Springfield, I11., Charles C. Thomas, 1955 (with Dr. E. A. ;einstein). 22. Coma Therapy, Insulin Body After of of Parts the Jelusional [@dnplication M. and Fink). D. Graubert 1955 (with lBh—lh7, Drs. J. Hillside Hosp., g: and Pain Asymbolia, A.M.A. Arch. Neurol. 23. ’kithdrawal, Inattention, Psychiat., 1h: 235—2h8, 1955 (with Drs. s. A. neinstein ana'h. H. & Slote). Spatial Inattention in Focal Cerebral Lesions, Brain, in press (with Drs. C. S. Battersby, M. B. Bender and.M. Pollack). �25. Autokinetic Movement in Patients with Sensory and.Motor Disturbances, J. M. M. and B. Pollack S. (with Drs. H. Battersby, Exp. Psychol., in press Bender). 26. Relation Between Altered Brain thction and Denial in Electroshock Ther& Peychiat., in press (with Drs. M. Fink and A.M.A. Meurol. Arch. apy, E. A. heinstein). 27. Mount Sinai of J. With Picture Schizophrenia, Clinical a Encephalitis Hosp., a1; 1955 (with Drs. E. A. Heinstein and L. Linn). Korin: Dr. .1. The New Effects of Electroshock York University, 1955. on Retroactive Inhibition, Ph.D. Thesis, Dr. Hargz Goldenberg: and of Amino Acid Esterase Trypsin Activities of the 1. Chymotrypsin, Arch. Biochem., 22; 15h, 1950 (with V. Goldenberg). pH Depenfience 2. Several Derivatives of Acetyl-dl-phenylalanine, J. 5317, 1950 (with V. Goldenberg and A. McLaren). Am. Chem. Soc., lg: 3. Effect of Ultraviolet Light on the Specific Activity of Chymotrypsin and Trypsin, J. Am. Chem. Soc., 72: 1131, 1951 (with A. D. McLaren). h. An Ester Leucine of Ethyl Hydrolysis the Enzyme-Catalyzed Into Inquiry Gold1951 V. (with Biochem. 110, Acta, Biophys. 1; et Chymotrypsin, by enberg and A. D. McLaren). 5. Report D-12, April 1, l9h6; cf. pp. 117-119, concerning 8-Hydroxyquinoline Method (Alcohol Extraction), in C.J. Rodden's "Analytical Chemistry of the Manhattan Project", (with J. Greenspan, M. J. Sohuler, D. Taub, and A. S. Carlson). 6. Calcification. V. Influence of Fluoride and Cyanide Ions in the Presence and Absence of Magnesium, Proc. Soc. Exp. A. L. Sobel). Biol., 19: 719, 1951 (with kaline Earths on Survival of the Calcify1952 (with A. E. Sobel). 695, Exp. Soc. Proc. g1: Mechanism, Biol., ing 7. Calcification. IX.Inf1uence of A 8. Calcification. IV. Influence of Strontium and Magnesium Ions on Calcification in vitro, Proc. Soc. Exp. Biol., IQ: 716, 1951 (with A. E. Sobel and A. Hanok5. 9. Calcification. XI. Studies of the Incorporation of Citrate in Calcification in vitro J. Dent. Res., 3;: L97, 19Sh (with A. E. Sobel and E. Schmeriler). �~h2§ Ions and Cyanide Fluride by Inhibition 10. Calcification. XII. Cation-Linked & Hed., éé: 27S, Biol. Soc. Exp. Proc. in B-GlycerophOSphate Medium, l9Sh (with A. E. Sobel). 19Sh. 26: 690, Chem., Anal. Plots, ll. Rectification of Nonlinear Beer's 12. Curves. Nonlinear Activity of Rectification Biochem. & Biophys., ég; 288, 195h. Enzyme Law I. Preliminary, Arch. �Studs.“ '1 tho room. L 01‘ 91‘ the “mum Width. 01‘ tn: 1:: Win A man}: Wm Wtm «mum, 01’ khanm tar claatraoncophflampw W! «mum “W studying 01-min manta]. with WW in brain during tin mmmd. m and Wm M wt yaw. W method. for YMMMW mmmmno at Madam ta stimulation mm W m,mmmmuhhmmmmmmmmpumm thew. m Wu. Mitmun. mental W «mum int-mm: um M m huts, ham gatima or tho hymn dam-uni" affect: of inn-ms, and human um cum-a. tannin; haloahraaanmkin acid (mp-was) an anal: and In tho mm- 5: yaw, a my at tho was in brain function during mmmuw mm «I Mpmholamu. Dre WWW”. Kmmlwomm and the Pink to Dr. fellow of tha a «mm. m mum «mm. Mutilation tar Inna“): Win an imam to sup-mu that kbonhary work. “W. Ha rm on with a Main: 1. W 1953 In a alumni ultimatum immut- In tbs Ané’t‘tmwmu aluminum tantalum tho integrator! “My an laboratory was «unnamed mam than math! Wamhéin 11W brain mum. the 1mm ammo: 65 m W of {w with maul mania 111mm, dwmatu ”mum 3W m mm mum to mmm mime. Mam dim, mun WI ef pain; mwnwmmmmumwmmotmmmmm» mtkm; with «13m (litmus-I m tuna-Id ma amtralkd with anal-put: drugs. may ammu- m ta m mammal mm a: am: 1m1uuoha During tho yaw, $5 mutton tum-Ind. More than half. aw 85.1: mm}. hospi'alk m- mmr M m mammal «mum at... am an. an. �4-» mmmaohmmmmwmwmmmm ”mutate ermg than thflu Ina 1mm yum, ”we“. macaw «:1th at mum. mmmwmnmmsunmmmmumm :Mz‘mmwmmmmnwdwumfloftb W. «ammufimmnsmmmmmmmuuumma mm m In addition. tan on m at mammalian!!- mmmmm McMithmmmmmmngnmm_ mmammmomrmmmammmmmammm uttkflhoapim. . wmmm, s. A. at .1: The mm, M. am PM o: mama: mm in m damn IWtSMfls (Jam) Bibltofl (1953) 1953:» m. mm. m. tau-m, 9.5.. Ramon. n. m mm on Pmopum, Mm... Jam 1953. il'ink. K... m m, M; m. u. and Bond», 11.3.: remap-um a: w man-11y mm: m mm at mm.“- 51mm mm. Stimuli Now. a m. nu. mam-w (Jar-u) 1953. am. mm, 3. m: m, m A sumac-1 away ’or a mummm mom-m, am. swam no». 2167*?! (March) 1953. rm, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title 2/2). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-003 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Letter to Fink; Somatic Therapy Research Program; Monthly report; Research Progress reports - Department of Biochemistry; Letters to Dr. Miller; Electroshock Therapy Evaluation Program; Annual Report - Department of Neurology; Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/e5d103cbe3dc9cd93159ddec488b3ecc.pdf 022eaace568b7d0816980adc5ccaa74c PDF Text Text �nau- mmmmtmw.mumntwmsm Mmammmmawmatmmmummm mmmwmmawmmwmmmamuwum uwmmummmmmm. mammmmipwh umummonm. mwwumwamm vamwwmhym.mmm. mmuummmmmmmmww mmmmmmwmmuormmmm 1. Wanna-m mmmummwummwtw wommwmmmumzmmmmmm mamawaum. itmhmmummum wm.mmm1mmmwm.mm,mmmm Wm W W M as th- an M: to» Manama. at Bra. 13.311.313.31, a «mud mam-1. m mgm.mmmmmmmfiam.mmmruuw u1wmmmamwmmmtmmmm. M mmwmmmgmmwummmuzmw. m W‘M‘MWMWmmwMWMMdm msMMMmMmm-cmaammm.m 1mm». smu‘mmmmuwmmmmmm umwmmmwmdmmwwnmmm mwumwmuwmwmamummuum. ' mmummmmmmmwuammmm ammmmam~mummdummum mwummnmmmm. �03¢ unmmmumswummmammau wthmquduWMuMdehu-W atmwmummthummmu-mum flat “mm. ”mum, mum... 'm man-om. mm: mmmummmmmmpmnymm and a; W13M.Wfl a. WWW mimnmmtmmmatfimmm W(mm)maamum. Wmmmmm minituamtmfltmmlymmsum. mmmmmmmmmtmmanm M 1(th m.w.muammmmammuumm flaw. maem,nnmmwgmnhmtmnmu Madmanhdtnmmmm. nmmmm,mm Mmtmm)mmlwwm.nm,mmmnum nu mm“ m madam ( mm mm. 31WCW319511}. in. thWWWMtWWthqu man up man. um), mum m by the (at... P. mm um), WMWWW‘WuM): Wmmmtzmm mfimleohtaM (mu. 3» a.» scam mum (in. A. mm) m: mm mm mm m affirm! 1*» the mama about»: mlmumtomammumwmmmm mmmuwmmumdmm mommamm mwmmmmammmm �ah- m.nmmmmtm.amahmummm mammwmmwmmumarmmmwnmwmm ww-wwmmumzwmmmmdm- mummmmmmm Ammaomwmt . mumermmmmmmd. mammalian ”wind to: m :mm mm, W Wm m1 momma-g. Wammmmormmmw mmmmmmmuma,mmmm wuunmmu.m«smmormum. mummm monarwmm,wmm9r£mgmtmrormwa Wcmmummmuamumwm. nmmuumymawwwmm W..1tmwmtm‘uitr1nhmdmhm mmmammmm. Mmmmemdin mommmum. num-mmmummmu immiwflmmmmg nmwmmm.m.mmmwwm mmwmmmotmummmmmmmm PM!» mmmmimhfimotuMMiflthmhm wmmummmwmmmmnww wwwmmtawmummwmwm. Pu WW hammmwmamummmaaw WWhmamfiSfimmmnu-ammnh «ma-W'mmmwmmhnmmmwmm hmuuaummumMmmwrm-um unmmmm,m.m,wmmummm ��.fi‘ V mum mum. mm am-ammummmrmmmam ummmmmmmnmw hr mum iii. W mumt WM AM}. 1955. www.mmmmarumwanm mnmwmmmwmmumummuw mmmu‘mummm‘ WW. 8. mMMMMWWWhNWW‘ mu m in nan-mm m :15 7.» WW Mmemm 3» mm .mumwmummmwbmmmmwm «mmgmumflormwmwmmwu mummuuwotmmumm 9'9me”. mammmmdmuuatmummmmum murwmwmuwuwmmmnr ammmxmysa. ��Dr. Fink January 18, 1955 To: All Department Heads 'Re: Annual Report Please prepare Report all - l95h of your data for the 195h Annual at the earliest possible date. All tables and other information should be turned in to Mrs. Bailey, Office Manager, on or before February 10. uith your statistical data, Dr. Miller requests that in addition to any tables or general statistics which you will furnish, that you write a succinct out— line of the'work of your department for the calendar which comments in appeared the to similar l9Sh, year Along the last Annual Report for your department. Please submit all data in three copies. I think that will be Report in.March of this With everyone's cooperation, able to publish the Annual year. a report of I vities of the hospital similar to the would like you to Janua RY 19 meeting. make all research'acti— one given Maurice Bachrach Administrator. Mled at the �(33L Biochemical Research Material assistance was offered the laboratories during 1954 in the form of enlarged quarters, and by the award of a two-year grant from the National Institutes of Health. The program initiated the previous year by Dr. Harry Goldenberg, Director of Laboratories, was continued along the following lines: Clinical Methodoloww It has become abundantly clear that the clinical laboratory can no longer cope with the special problems of mental disease using ther standard chemical tests carried out in general hospitals. Consequently increased attention has been directed towards providing the clinical laboratory with procedures for testing adrenal and carbohydrate metabolic function as well as for determining the course of drug and shock therapy. Reference has previously been made to ketosteroid and corticoid analyses. A new direct colorimetric test for hormone conjugates is nearing completion. Rapid micromethods have alib been perfected for two standard analyses, viz. blood phosphorus and which have hitherto been subject to large experimental phosphatase, A simple technique is also being investigated for following errors. the course of chlorpromazine excretion in urine. Metabolism of Steroid Sulfate Conjugates Impetus to our earlier studies on the metabolism of sulfuric acid—bound steroid hormones has been furnished by an InStitute of Health Grant which makes provision for much needed equipment and simple personnel. At the outset of the grant period a remarkably method was discovered for the colorimetric assay of steroid sulfates, based on the use of basic dyes. Further inquiry shows that, aside from its use in enzyme research, the method offers great promise for the assay of bound steroids in blood and urine as an index of these lines. Studies along continuing are stress. physiological Mechanism of Action of Lysergic Acid Diethylamide and from drawn have been vitro conclusions inc preliminary ig which induces LSD mode 25, a of of drug action on the vivo studies in a—transient psychotic state: (l) LSD 25 is a powerful inhibitor of human serum cholinesterase. (2) Parallel with a definitive response by the individual receiving LSD 25 there is a rise 11),..38rum alpha keto acids. Hormone Assay with Enzyme Systems There appears to be little doubt but that hormones are implicated The in establishing deterrent prime mental aberrations. and emotional in of for of assay suitable procedures this relationship is the lack . �function. Were such procedures available it should be possible to catalog mental illness on a chemical basis and suggest corrective action as an adjunct to the psychiatric services. Since the effect of hormones on various organs is mediated via enzyme systems, an extended study has been undertaken into the The hormone for systems isolated enzyme of‘using assay. possibilitywould involve incubating the test fluid with the appropriate procedure enzyme system in a test tube, and then determining the degree to which the enzymes are altered by the hormone in question by measuring conditions the release of a colored product. To determine the choice of makuxx been necessary to for carrying out these measurements it has The on two mathematical studies. papers out detailed first carry in Several manuScripts are more been have published. this'subject of preparation. various stages hormone Bibliography Goldenberg, Harry "Rectification of Nonlinear Beer's 690 (1954). Goldenberg, Harry Law Plots”, Anal. Chem., gg, "Rectification of Nonlinear Enzyme Activity Curves. Arch. Ricchem. and Biophys., §§, 288 (1954). I. Preliminary" �.; and Research of the of Publications Department Psychology ;/ Research in the Department of Psychology was oriented around several themes including: Refinement of psychological tests, the persis— tent problem of schizophrenia, and the effect of maturation and agang as measured by objective criteria. Certain aspects of the Rorschach test were dealt with more objectively by a series of papers by Dr. Gurvitz and Mr. Eichler and Mr. Feinberg. These set up for the first time objective adult standards for evaluating many Rorschach criteria which were not available previously. Further data was made available to experimenters illustrating the normal process of aging and maturation to further extend the cancept that if people grow older there are decrements in intellectual functioning and personality ingegration. In two new papers to be presented at the Eastern Psychological Association meeting, further progress was made in diagnosing schizophrenia by teens of psychological tests. The past and current research in psychology at Hillside has continued to attract attention both in terms of the acceptability of papers in both scientific meetings and professional journals, and also in terms of the many hundreds of requests for reprints sent in by psychiatrists, psychologists and social workers. These papers and research projects have also served as a training medium for psychological internes in the Department of Psychology and the past year was noteworthy for the fact that each one of the psychological internes or staff members presented at least once at a psychological convention or participated in some published research.project. ��RESEARCH During the calendar year l9Sh two projects were in process. their families pay for hospitalization a) Study of rates which patients and as correlated with time Spent in the hospital. b) The adjustment of applicants referred by psychiatrists found unsuitable for admission to Hillside Hospital during period 1951/1953. This latter study is a series of studies which is being done to determine the adjustments in the community and the use of community resources for applicants who have applied for admission to Hillside HOSpital but were found unsuitable. It is planned to continue this series during the year 1955. In addition, the joint project with the Jewish Community Services of long Island concerning the placement of discharged patients in private residence continues. W3 research project is being set up at the Altro'work Shop to which patients discharged from Hillside Hespital go in order to learn work habits. A Publications: )/ <3'“>( '21” ,~ 63‘” 7 s====r ;) Vocational Adjustment for the Emotionally Disturbed Authors: Roland Baxt, Abraham.Lurie, and Joseph .A. Miller, . - M.D. Presentations at conferences: a) [pulse Pinsky presented a paper at the National Conference of Jewish Communal Service in May, 1951;, called, "The Impact of Medical Crisis on the Family". b) AL:hd ‘ Abraham Lurie Spoke at the National Conference of Social‘Wbrk in may, 195h, "The Implications for Psychiatric Social‘work of Team‘work Relationship Between Social'workers and Psychologists". �MEMORANDUM FROM THE CREATIVE THERAPY DEPARTMENT WWW 1955 Study on the constructive and/or destructive use of passive and active aggression as a differential test for determining schizophrenic responses. Data for this research project had been gathered for the past three years. Their sifting and clinical evaluation is planned in the near future. The test is carried out within the C.T. program and consists of 16 specific proand number of jects EZ/r #290 a sub-tests. “a 707 Ernest Zierer �Fsbmary 2, 1955 Memorandum from: Dr. To: Subject: Fink M. Bondsr, M. D. 24.1). Anmsl Report of Hillsids Hospitals and medical services with other Coordination md cooperation with the psydxiatrio staff past you. With in. slsotmoncsphalogmm, for the of laboratory sstsblishnsnt tho crossed use of this facility and of the consultation faoilitin m was incrsssed during the: ands by members of the resident and attsndim staff. the answered attending by 19 consultations ssrs the yes“: hiring neurology oer-vies, and 1:0 consultations in addition vsrs anmrsd by the rssidaxt neurologist. In the slootrosnoophahgramio laboratory 111:8 this nun":- 75 constituted consultstion taken rsoords wars the 0! records. maindsr, follow-up ”cords vars taken. rsqnssts and 01' in tho oourss of two invsstigations - one in tho effects of electro- shosk on brain function; and the second on the relationship between treatinsulin the of and the rssults can function brain in changes mt. Evaluation of the organic mental mamas provided the major with three Thurs were patients consultations. nourologio Icons for the clinic. followed in sud who controlled wars disordsrs leisurs Four logic nonrafurther for another institution to transfsrod sore pstiants work—up and troatmnt. when direction another in The neurologic service nto consultation prior for aimissions olinis nods tbs tron qussts ms was extended hospital admission. your and Sm such oomltstions were dons during the svnlustion butts:for s an upper-unity ssrvioo providsd this �of the patients problems before autumn“. introduced to you in 1953 to evaluate organic m natal The " mail test" which was mm richly used during the put year, syndmmlg . �Fobmary 15', 1955 modem Annual Report of Wt of Neurology, 11111:“. Hospital — moperation with the psychiatric star! and other mdical gen-ion by when of the neurology was increased during the year. 63th Fortyunino «nomination: by the attending neurologists, and «agitation: 1:0 additionfl were answered by the supervising neuropaychiatriut. the eiootroenmphalographie laboratory 111:8 ream-ch mm m. In this 01' lumber, 75 constim‘bod consultation requests and follow-up rewards. Evaluation of the organic mantel syndrome provided the major focus for ammlog‘io consultations. more were three patients with mime disorders who were controlled and followed in the patients mm tranatemd to work-up and treatment. Hillsido in 1953 was The «3111116. Four guard hospitals for further nonmlogie «um»; first“ which to: introduced at mm widely used to evaluate organic mental and» must. {the mmlogic service uni also extended when rogue“; worn man from the admissions clinic for consultation prior to hospital admission. such consultations were answer-ad during the your and Sm this service provided boron admission. Under tom an opporhnity for a batter evaluation of patients of a U.S.P.H.S. grant, the electroencephalographic laboratory was swarmed for taohirboscopy, and a number of basic nouns. physiological problems were smdiod. f ’13:“ ��_ my}- 1955 Neurology hmommmwumammmwumh mes in the visiting a... was noon almond by mm. Wynn». tndmtharrfi m supervising mailman In th. metro-n mphdographic laboratory, 210 mom an am, of which 7!; war; consultaticn "quests. For the most put, the consultations in!" on)» momentum (6); pain syndma (3) and axiom cum tit-onion (7); men-1 wt: >nenrnlng1c mum (10). 'th wk). test for organic bran dim” Wmtinflpt’dnnu. activities mar-aura: ”sued mm... «momma-mt uflmofuorganicmtalayfimflfl ingpmmo. mmormmmmommsmemzm “Wmtmmmum var. mammotmmpaum fonmddnringthairtmmtflth aerial Wanndawmtem. numfltamsoam.tunmnn¢mdnmmm ammunmummmmmmmmamm mummifiufornm �"... u. p.-.. “N... . . N, ~ mm .mu—mww." wwmmw’mwm. ., W, .vnx— “‘Wn" .7 m as: u.- momma! Dr. H1110? TO: Dr. H. Fink RESEARCH SERVICE, smcrmmmya-pm-m. Dummmtharmmhthemmamanumwmume . in organizing an mom nhctmshook 2mm, the and the mam, the mm m Scrpuil project. Considerable mm electron-Museum laboratczy, and sum Public Health Bunion for adds! lamb Grant “97. penis“ w mm in project with Dr. spout in letting up WMar by the equipment mud thu no , Fonoving discussion with Dr. Embers and Dr. known, Dr. LnQuor Wimudtoviaitiflllgidumdmmmm..Dr.LIQm15mchup of the Luann unit at Grandma: State Hospital. a: March 9th, Dr's. numbers, mum and melt mum cm:- to as Dr. hQuor'I mam unit. m intended in his that. Vinita, the use or split mm mm: to induce com. mm. This '11]. be mm RobertluhnandnvaeuvisiudDr. hulfloehandnr. thhtric Imtituto chitin-$133M. Wflaittonr. WWW Dr. undue for the nut Following Med research emanate. at. Dr. Blmbarga suggestion din- mud a similar project ban, and the protocol was prumtod at the nut numb can-dun mating. nth» w. purponoracqmmuthmmaentnumh with Dr. Ismail m most helpful as m. second Our b. has had dmidunbla experience in psychoplvaicq. tachniquu. SW8 ut his ham and dime.“ withhmthemdforimmudmndsforthocmmm. Iupmssodtohiu (h March 17th I Visited Dr. Ismail thodllinbflityofhlvingmummeo that Dr. filmmldbo thoDuunPoundntionorthoPnaidcntamifm Public mppomw ‘19de that ��mm: Glon om, no: Ia-k KEPITAI. April 28, 1955 to, Dr. Josoph S.A.Hillor,llodioal Dix-sates M8 Dr. Kl! Pink 8i: subJoot: ' hospital, Honth Promos Ropu-t and Room-noun". Atthsondstthofirstsixnouthsasbirootorotnosoomhatth 1 should libs to dosoribo tho prosont stoto of our rosoaroh program, thhnsfathofluturo,anitonkowonoouasndationsforsrosm asparagus. I: Prosoat m dotinitivo report of tho rosooroh aotivitioo of tho dspsrtnsnts of tho hospital was prooontod to tho nsdioal Board on April It, 1955. by tho chairman of tho Itososroh Omittoo. A tho prosont tins, tho staff assisting tho Dirootor inoludos two it psychologists and a part-tins sscrotary ( supportod by norm and Dausn Foundation grants); and o half-tins no toohnioian. Port-tins roooorch ootivitios aro cox-riot! out in tho various sorvicod sports-onto. In tho Doportuont at Ioborotorios, two toohnioians oro assisting Dr.Goldonborg, undo:- tho tons of a noon-oh grant of tho USPRS. Of tho psychiatric staff, two supss‘visim psyohiatrists and two rosidonts aro ootivoly oncogod in part-tins rosoaroh. Of tho ottonding staff, tour labors of tho Hodicol Board as in diroct collaboration with hospital psrsonnol in spocitio projects. is octivo in tho following projootst a. Following on tho sumoay of tho 1951; proJoot on thorolotion of altsrod brain mnotion to following olootroohook thorapy, a oooond projoot has boon undsrtoksn to asaosa tho chorootomlogioal and bioehonioal factors in impromnt. b. An snluotion of sorposil so a thoropoutio ogont hao boon undortakon as an intomopsrtaontal projsot, with tho sotivo oooporotion of tho .diool dopu-tmnt, onporvisim psychiatrist and a rosidont psychiatrist. has Dinotor imam. o. dosslopuont of moan-so of abivolonoo, both as a chorootonologiosl factor and a symptom of psychiatric choc-ponsation. “his study is in conjunction with a lambs: of tho Hodiool Board. d. and taoMstoooopio ”physiological of tho new, is now noaring oonplotian. Dnfiont Tho 'l'ho laboratory, built with funds Tho hm m'ass stimlata's, nocosoary for tachis- mt. mublod. oscilloooops, and roloy and lons tosoopy havo boon dolivorsd, on?! are being boon outlinoo and will begin by slid-Mu. Projects hovs �4-2Bimltonoomly with thou motto, I havo boon participant in a nunbor of tho dopartnontol projocto at the hoopitalp oooporatod with tho fibcultun Study Omittoo in tho dmlop-ont of its protocol; and havo mlnatod throo protocola which uoro oubnittod to tho Roaoaroh Conittoo from outoido loot-coo, and out. opooifio roommdationa on oooh. now mum problou of mohiatry involvo all aopooto of tho moo, oonroo, for thoo'pocitio tonic tron-int and provontion of tho Nor poyohoooo. an! innmatory poychoooo, nothing is known of tho otioloy of ochioophronia, involutional paycheck or antic-domain illnooo. Itch duoription of tho oouroo of thooo illnooooo io availablo, but thio haa boon of littlo bola": in troatnont or promotion moot in ioolatod inotonooo. mutant io omit-idol; and W at boot, poi-ital". ' " control roam for hospitalisation in loot pationto in tho dmlomontvo! owning tonsion and anxiow, and pmhotio thoughto. lutorporoonal rolaticnohipo havo boom diotortod, culmination blurrod, and otfootivo activity oo to throotod oolf-prooorvation. rho vat-1m porchiotric thorapioo oo availablo today attack difforont aopoota of thooo problouo. A prion-y goal io tho doovoaoo in tonoion and musty, and tho ovum-o of mohotio idoation. hob offal-t in «pound ot chaining intorporoonalxolatimohipo and oodoo of omnioation; and nontual ”education and oupport d tho pationt in dirootim his ootivitioo along «room ohannolo that lood to on! meiot- prooorvotim. Tho m1 alto 0'thMom. “ti-toot“: intho njority or ma‘ont nothoda portion.- in at loaot town-11y atomim tho poyohotio rollovine tonnion and indnoim a roturn to non offoctivo In this prooooo, tho following nothodo are pennant at tho hoopitoln Ont 1. W. By 2. By 3. By hoopitolilation, thoe pationt ' is ”poo-om pm, and ioolatod ' tron bio » .diootion, barbitnratoo, oorpooil, and chlorpronaoino, and by olootz-oohook and ubnlatory insulin trootnonto, ton-ion and anxioty are roduood. dmg W oo olootroohock, olootz-onaroooio and inmlin cola thorapy pontwtio idoation in omod by altoring brain function. It. 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Aututunt 1n Puyohiutxy: For Inch mohiutdutu who hm bud thruu thuoppu» ormnyuuruoIIMpuyohmmonMt mtmmm, for on. team on: and Ruuuurcthmypz-widuthuau~ Mt: ormuywu for maturation in renewal: uluo prom the dimtor with flu mutton uuiutuneu at pcuomul 1n buwuunthu ruuidunt ma flu Memo Mute Thu “shunt. 1n puyuluutry uuu uuawu mpommnty for tho auction ' "0001‘“. �{a &1.th 7- W torthovmm prom; mum chuguinb-hmvuh and of tho int—Ewan“ “as. in tutor. mom mm” «.111 the want Wear of th- p-thnt; Tho "spanninw um fa. than aspects “W offlmbhummu‘auonumiuhmhu Hoflllufihumhrm,~mmmuueh mmwwmam. mmttmummutwwm kmlnhmchm,hmm¢h mm'mummmdmnmmwmmuMufmhapimummduuw-fl' aux-y nap-nuns nap mm. W. ’ neopo, ' ' 06.000 to 10,000. on twmpuyeholoyuflanm mammal. mmwamm,mummmpommwrortu nothoda and smut-hum at thbut Newt. smart. duign ' with tho soul- of thy . ‘ 'thryrumn-Sfifioommhwo «Wotan. ”mam Mat-311W W, build can. mmuw “Wham cm; with tho parallel-exist inc m maul-d) mat: MW ”Wham cup-rd..in ohmic“ magnum" mum m. b. mum: a); 1ft!» hbontcry u asp-aloe to m. manna-n whatnot-chain studio’s. Wlmmmmtdflummool con-urn. Salary to 30,900. mg. Mtg ",3‘ an an -, o :7 . sup-n13. abducts-Inna; Ia and: null-1 than“ 1‘0 and Wm a- 85,200 W 1mm wWad cum W We m, um ”hum 1M www.mmupmdmwmmw mum mm: rem um mm mm Wwamn‘tarofthu “hm; wtocmmmumumhmungmmm unioapnjocum toba-Iunhyflu ”Mummhmm; alum d. And-mt - Social WI 3.5. (Seaman-k) with yum work. on use-sing funny nhtiennhipu. Pinon-1 ambit: 11' pmiou mun-ch «pox-hm. with or mum-nu it should be Mufly might-d. Aid-tut. u to napouihdhty for on binary tad to obtain {tantalum ad to the only you. of durum] to with tho mm of f1” 1- in amusing mum, m1 new mammal Ihichhcwmoorgwuththnpm «mammal-am follow up contact. undo. For :11 fellow-up touting an! thc 1:111 like tin mos-cry contact- tad arrangunufor Hindu-actor. “0mm Tho wot-hr to th- aws-Itch amo- I111. 11‘ t1.- 13 mm]... cooperate with the Dix-actor 3350:3111 8mm. in flint prawn 5% WtuWNIIMMWtMDMrMMIWO. aim-Monongooor WmomMmuwW-innm �hme-mlmm,aw0uommmwm anuslupus. alum; m “not. In. "can!”mum «a! £11m; “parts WM mmmegaMnmmp—m. ”00 I;thMtum-mhmmutbm. ‘9 ”‘mo “’m‘ 1 .“ ”m m1. PM W, 2. Gallop M00, WW1. m.mehw. huststthubmmm” uthmmmnngarmm mamwmmusimmmm.mmmmwnm «.memgmummmmmormgwmua mmmpamgmw,mnmmm1mm. mrmdwmmmmmuémm. fimmmfimgmmmw 81 1'' m.ummumniymowu‘mumma bmmamtimingfumtimmdukolomm mum-norm. plmning haiblo, it is mud-d 0h“ W stummmormmmmmuwaecmmm of . nun-buds» of 060,000 870,000; and with . 3 luau-uh 1955-56 by Ommhfll] flat 836.100. mmnwwmmmbmm-ufl, lab-1M. Wily We!” lam, 3.0. I955. �HILLSIDE HOSPITAL Glen Oaks, New York April 28, 1955 Tb: Dr. Joseph S.A. Miller, Medical Director From: Dr. Max Fink Six Month Progress Report and Recommendations. Subject: At the end of the first six months as Director of Research at the hospital, I should like to describe the present state of our research program, our plans for the future, and to make specific recommendations for a research department. I: Present 'A Proggam definitive report of the research activities of the departments of the hospital was presented to the Medical Board on April h, 1955, by the chairman of the Research Committee. At the present time, the staff assisting the Director includes two psychologists and a part-time secretary (supported by USPHS and Dazian Foundation grants); and a half~time EEG technician. Part-time research activities are carried out in the various service departments. In the Department of Laboratories, two technicians are assisting Dr. Goldenberg, under the terms of a research grant of the USPHS. Of the psychiatric staff, two supervising psychiatrists and two residents are actively engaged in part-time research. Of the attending staff, four members of the medical Board are in direct collaboration with hospital personnel in Specific projects. The Director is active in the following projects: a. Following on the summary of the l95h project on the relation of altered brain function to improvement following electroshock therapy, a second project has been undertaken to assess the characterological and biochemical factors in improvement. evaluation of serpasil as a therapeutic agent has been undertaken as an interdepartmental project, with the active cooperation of the medical department, supervising psychiatrist and a resident psychiatrist. b. An c. development of measures of ambivalence, both as a characterological factor and a symptom of psychiatric decompensation. This study is in conjunction with a member of the Medical Board. d. neurophysiological and-tachistoscopic laboratory, built with funds of the USPHS, is now nearing completion. The two Grass stimulators, DuMont oscilloscope, and relay and lens systems necessary for tachistoscopy have been delivered, and are being assembled. Projects have been outlined and will begin by mid-May. The The v' / �-2... Simultaneously with these efforts, I have been a participant in a number of the departmental projects at the hospital; cooperated with the Subculture Study Committee in the development of its protocol; and have evaluated three protocols which were submitted to the Research Committee from outside sources, and made specific recommendations on each. II. Future Programs Present problems of psychiatry involve all aspects of the cause, course, treatment and prevention of the major psychoses. Except for the specific toxic and inflammatory psychoses, nothing is known of the etiology of schizophrenia, involutional psychosis or manic-depressive illness. Much description of the course of these illnesses is available, but this has been of little help in treatment or prevention except in isolated instances. Treatment is empirical, and at best, primitive. central reason for hospitalization in most patients is the devel~ opment of overwhelming tension and anxiety, and psychotic thoughts. Interpersonal relationships have become distorted, communication blurred, and effective activity so minimal as to threaten self-preservation. The various psychiatric therapies available today attack different aspects of these problems. A primary goal is the decrease in tension and anxiety, and the erasure of psychotic ideation. Much effort is expended at clarifying interpersonal relationships and modes of communication; and eventual reeducation and support of the patient in directing his activities along effective channels that lead to self- and social- preservation. The present methods are apparently satisfactory in the majority of patients in at least temporarily stemming the psychotic process, relieving tension and inducing a return to more effective functioning. In this process, the following methods are prominent at the hospital: Our 1. By hospitalization, the patient is separated environment. and isolated from his 2. By drug medication, as barbiturates, serpasil, and chlorpromaline, and by electroshock and ambulatory insulin treatments, tension and anxiety symptoms are reduced. 3. By electroshock, electronarcosis and insulin coma therapy psychotic ideation is erased by altering brain function. b. By group and 5. By social activities, environment, better and group therapy communication is fostered. in a permissive individual psychotherapy interpersonal relationships are fostered along realistic lines. 6. By environmental manipulation, job reeducation, and help, effective functioning is strengthened. Our social service research program is devoted to studying these processes. A. To Understand the'flay Therapy'Horks: disciplines are constructively applied at the hospital, the effectiveness of any has not been sufficiently assessed, nor has the mode While these �.3mode of of the lhe study evaluated.r present been adequately of operation has Electroshock of our interest. example an electroshock of is operation By assessing in many from patients. depression psychotic resulted in improvement be works will electroshock the various possibilities it understood. If this is accomplished, then some ideas about the mental and The understanding of become clear. may in depression physiological processes A plan for a of service. research the electroshock treatment is the first goal similar study of insulin coma therapy is now in preparation; and others at the environment as a therapeutic of the hospital a study planning hospital are is hoped that the way mechanism. B. Relationship of Character Structure to Diagnosis: child— of the the demonstrate importance to devoted been study has hood environment in the development of character, behaviour patterns under stress conditions and the neuroses. Other investigators are actively involved in assess— of adult in the variety result that childhood relationships the in the factors ing behaviour patterns. It is not possible to carry out such studies at Hillside, but the important relationship between character and the type of mental illness of behavioural to of the character patterns the relation the patient shows; change which we call 'improvement'; and the aspects of character that resist treatment methods can be assessed. A prototype of such studies is now in progresselectroshock in therapy. improvement to basic of character the in aspects much C. Biochemical and Physiological Factors in Mental Illness: ill for long periods, appear to take on a stereoPersons who have been and chemistry in their reflected which is ultimately typed behaviour pattern, by neurologic, 'non—reactor' and patterns such of 'reactor' Study physiology. the failures in assessing methods important and are drug biochemical physiologic, and physical illness between psychiatric the relations of present therapies; Such and a improvement. between therapies 'organic' and the relation illness; to drugs EST and reaction where second project, the in incorporated study is and of long short terms in be assessed will electroencephalogram changes in the term improvement rates. (Follow—up): Results Treatment of D. Continuing Evaluations suffer treatment of generally of present the results studies Follow-up of the evaluation done an without are only; one therapy because they assess control to standard and compared not are improvement; for subject‘s potentialities followcontinuing a be to organize possible With may active support, it groups. evaluated on admission; assessed are the in hospital which patients up program, in followed a and over then methods at discharge; and psychiatric by psychologic number of years with an evaluation as to sustained change and reasons for failure. much would have at discharge, the to predictions Such an evaluation, if compared base—line for and a provide of choice therapies, present merit in assessing the the evaluation of any future therapeutic methods. III. Recommendation of problems the methods in attacking of suggested In this outline the treatment best; as one made to specific specify no effort have I psychiatry, is that fragmentary so it knowledge is Present the specific. or one etiology as of psychoses. the major to the eticlogy make as only a to poor guess possible A multidisciplinary approach with full freedom to follow many leads is the best of a establishment recommend the would For I be this offered. reason, that can �- u - Research Service, with full-time personnel devoted to such studies. I would suggest that such a service have "research" as its function; that it be independent of the service departments of the hospital; and that it have a basic budget which would assure continuation regardless of the availability of outside research funds. A. The Research Service should have the following organization: 1. Director of Research -- Responsible to the Medical Director. 2. Research Associates in Psychiatry and Psychology. 3. Research Assistants: a. b. c. d. Psychology Neurophysiology Psychiatry Social Service h. Secretarial and clinical personnel. 5. Technicians. B. Annual Budget recommendations for the Research Service: 1. Director 2. Associate in Psychiatry " in Psychology b. Assistant in Psychiatry " 5. in Psychology “ 6. in Neurophysiology " 7. in Social Service 8. Secretary 9. Technician n 10. - Lab EEG (1/2 time) $20,000 12,000 8,000 6,000 5,200 5,200 h,000 2,760 h,000 1,300 Equipment: As warranted Consumable Supplies Travel Overhead: As decided by Administrator. - $25,000. - 20,000. - 10,000. - 10,000. — - - 8,h00. 10,000. 6,000. 3,300. 6,000. 1,800. 2,h00. 1,000. available as a continuing commitment to the Medical Director for long range planning of the Research Service. These funds should be made For the budget year 1955-1956. I should like to make the specific recommendation that the following are the minimum requirements: 1. 2. 3. h. 5. Director Research Assistant " " Secretary Consumable Supplies 6. Travel 7. Overhead 8. EEG - Psychiatry - Psychology & Equipment Technician (in Operating budget) $15,000. 7,500. 7,200. 3,000. 2,h00. 1,0000 - $36,100. 1,600. $37,700. �0. Space: Problems of space at the hospital are acute, and will provide an increasing measure of difficulty as the service is developed. It is suggested that in the next capital outlay by the hospital for construction, some allowances be made. for the Research Service ‘ D. Relation with Other Departments: activities of the Research Service are to be those designated by the Director. Interdepartmental projects will be carried out by the Research Service, or in those instances where approval of the Research Committee is obtained, by the departments involved. Supervision of such interdepartmental projects will lie with the Research Director. The Interdepartmental projects are to be fostered by the Director. Prior approval by the Research Committee and the Medical Director is required. Such projects as are consistent with the service functions of the departments involved W111 be fostered. Presentations and reports are to be approved by the Research Committee prior to publication. E. Job Description: 1. Director of Research: objectives of the Director of Research will be to: (l) Organize and maintain an active program of research and a Research Service; (2) Promote, supervise and integrate research activities at the Hospital; (3) Educate hospital personnel in research methods and progress; and (h) Administer research funds. The The director of research will: a. Organize a central project or series of projects appropriate to the unique character of the Hospital and integrate this into the activities (therapeutic) of the Hospital. Progress reports will be submitted to the Medical Director and to each meeting of the Research Committee of the Medical Board; and such data as is approved for presentation will be submitted by the Director or his delegate at the appropriate scientific society. all staff to plan and carry out individual research projects. Third year residents in psychiatry are to be specifically encouraged to undertake research projects under his direct supervision, or that of an attending psychiatrist. For these residents, and any other professional members of the staff, the director of research is to assist in the planning of b. Encourage members of the the project; in its integration into the hospital program; and in both technically and financially. its support 0. Carry on such educational activities as the supervision of third year residents in research; monthly seminars in research problems and progress; and periodical reports of important psychiatric meetings. The director will maintain a calendar of meetings and lectures; stimulate attendance thereto; and foster the He such of is also to invite such meetings. at Hospital activities presentation guest lecturers and seminar leaders as are available. d. Administer all research funds with the approval of the Medical Director. This includes the stimulation of fund sources; the application for funds; and their allocation to hospital projects. �2. Research Associate: Director in all projects at the hospital; to assume responsibility for specified projects; and to carry on such independent investigations as his training and experience dictate. Tb work with the Associate in Psychiatry is to be a qualified diplomats in psychiatry, with extensive experience both in psychoanalytic psychiatry and in descriptive psychiatry. By training or experience, the associate should have teaching qualifications; and some training in research methods. A. Such an assume responsibility for that portion of the functions of the service assigned to him by the director; assume responsibility in the director's absence; attend conferences, meetings and assume teaching functions as recommended by the director. He range — will Salary to be determined by qualification and experience. Probable $12,000 to 20,000. B. Such an Associate in Psychology is to be a qualified psychologist with at least 10 years experience. Psychoanalytic experience is preferable. The equivalent in academic standing of Associate Professor is the guide line. research associate in psychology is to assume responsibility for those functions of the Research Service assigned to him by the director. An evaluation of testing methods. statistical evaluation of results. and a of the research of of aspects contr0l the.functioning procedure in all rigorous service are his responsibility. The research associate in psychology may be chosen from the research assistants. Salary range - $8,000 to 10,000. The will: organize and supervise projects in the department; supervise projects of the resident psychiatric staff; assist such department heads as request aid in organizing departmental projects; advise the director of new research possibilities; attend conferences, write reports and papers, and carry on such administrative activities as the Director may require. Both Research Associates Board at Appointments to Research Associate are to be made by the Medical the recommendation of the Medical Director and the Director of Research. 3. Research Assistants: assist the director in his research activities and carry on the work of the department. Each assistant is to be responsible to the director, and will carry on such tests, procedures, write such reports, and present those To papers designated by the Director. Assistants are to be qualified by training and experience for the specified jobs named. They are to be appointed by the Medical Director at the nomination of the Director of Research. a. Assistant in Psychiatry: For such psychiatristswho have had three or more years of formal psychiatric training but not yet certified, the opportunity to work for one or more years on a Research Service may provide the stimulation for continuation in research and also provide the director with the assistance of personnel intermediate in experience between the resident and the associate. The assistant in psychiatry can assume responsibility for the selection �-7of the patients for the various projects; evaluate changes in behaviour with treatment; assess the importance of intrapsychic and environmental factors in the present behaviour of the patient. the assistant.vill assume responsibility for those aspects of the problems under investigation as are within his scope, and assigned by the director. He will write such reports, papers and make such presentations as the director may suggest. He will make such tests, learn such technics and work with those members of the research service or the service departments of the hospital as his projects permit. Salary is dependent on experience. Probable range $6,000 to 1C,000. b. Assistant in Psychology: Graduate in psychology with a minimum of doctorate. Preferable experience in research methods and publication experience with some specialization in laboratory methods. Equivalent academic status of assistant professor. The assistant in psychology is to carry on such psychologic and laboratory tests, and make such statistical and methodological evaluations as the projects of the service require; and to make such reports and presentations as the director may suggest. He is to direct the laboratory technicians, organize their work and assume responsibility for the maintenance of all testing equipment and materials. In the design of projects, he is to assume responsibility for the application of the best methods and design commensurate with the goals of the project. Salary range ~ $5,200 to 8,h00. c. Assistant in Neurophysiology: M.D. or Ph.D., with a minimum of three years experience in electroencephalography or neurophysiology. To supervise and coordinate all neurophysiological studies, now being organized; develop and build electrophysiological equipment; assume responsibility fer such animal studies as are organized; cooperate with the psychologist in coordinated neuropsychological investigations; and supervise technicians in electrical methods. This position can be filled only if the laboratory is expanded to include more basic studies. Personnel can then be recruited from medical school training centers. Salary range - $5,200 to 10,000. d. Assistant ~ Social Service: B.S. (Soc. Work) with minimum of five years experience in field or administrative work. Emphasis on interviewing technics and assessing family relationships. Personal analysis recommended. If previous research experience with psychiatrists or psychiatric clinics is noted, it should be heavily weighted. Assistant is to assume responsibility for interviewing relatives of patients and develop technics of assessing premorbid characteristics based on history and interview; to obtain histories from relatives and patient relevant to the early years of development; to cooperate with the psychologist in assessing the personality of the subjects; and to coordinate research testing in the various projects. Patients seen during their hospitalization in any of the research service projects are to be seen by the social worker prior to discharge, and eVery effort at follow up contact made. For all follOWbup testing and evaluation, the assistant will make the necessary contacts and arrangements for the director. The social worker assigned to the research service will, if time is available, cooperate with the Director of Social Service in those interdepartmental projects which he may have organized with the approval of the director of research. Assistant is to be selected by the Director of Social Service. Salary range proportionate to experience in research. Range - $h,000 to 6,000. �e. Technicians: EEG -~ High l. fundamentals school graduate, although two years college preferred. To learn the of electroencephalography; make the necessary measurements and place electrodes; obtain artefact free records; maintain card files; type reports; keep records in systematic way; and maintain equipment. Technician is to be responsible to the assistant in neurophysiology or the director. Salary -- if untrained, $52,600; if trained, $33,060 to 353,600. 2. Lab. Technicianp-Neurophysiology. College graduate, preferably with some engineering or physics experience. To assist the assistant in neurophysiology and/or the assistant in psychology, in the development and maintenance of electrical equipment; to assist in the handling of animals; to cooperate in the experimental procedures; to build, adjust and design special equipment. Salary range dependent on training-- Rangefi .000 to 6,000. IV. Summary: Research Director is actively involved in a number of studies of the mechanism of treatment. To maintain a continuing function and make long term planning feasible, it is recommended that a Research Service be established; that be an integral part of hospital organization with a continuing annual budget. it A proposed organization is included in this report, with a projected annual budget of $60,000 ~ $70,000; and with a minimum budget 1955-56 of $36,100. The This report approved by the Research Committee April 27, 1955. Respectfully submitted, Max Fink, MoDo Director of Research �HILLSIDE HOSPITAL Glen Oaks, New York April 28, 1955 Th: Dr. Joseph S.A. Miller, Medical Director From: Dr. Max subject: Six Fink Month Progress Report and Recommendations. first six months as Director of Research at the hospital, I should like to describe the present state of our research program, our plans for the future, and to make specific recommendations for a research At the end of the department. I: Present A Program definitive report of the research activities of the departments of the hospital was presented to the Medical Board on April 5, 1955, by the chairman of the Research Committee. At the present time, the staff assisting the Director includes two psychologists and a part-time secretary (supported by USPHS and Dazian Foundation grants); and a half-time EEG technician. Part-time research activities are carried out in the various service departments. In the Department of Laboratories, two technicians are assisting Dr. Goldenberg, under the terms of a research grant of the USPHS. Of the psychiatric staff, two supervising psychiatrists and two residents are actively engaged in part—time research. Of the attending staff, four members of the l"ledical Board are in direct collaboration with hospital personnel in specific projects. The Director is active in the following projects: a. Following on the summary of the l9Sh project on the relation of altered brain function to improvement following electroshock therapy, a second project has been undertaken to assess the characterological and biochemical factors in improvement. b. evaluation of serpasil as a therapeutic agent has been undertaken as an interdepartmental project, with the active cooperation of the medical department, supervising psychiatrist and a resident psychiatrist. c. development of measures of ambivalence, both as a characterological factor and a symptom of psychiatric decompensation. This study is in Dmedical member of the with Board. a conjunction d. neurophysiological and tachistoscopic laboratory, built with funds of the USPHS, is now nearing completion. The two Grass stimulators, DuMont oscilloscope, and relay and lens systems necessary for tachistoscopy have been delivered, and are being assembled. Projects have been outlined and will begin by mid-May. An The The �-2... Simultaneously with these efforts, I have been a participant in a number of the departmental projects at the hospital; cooperated with the Subculture Study Committee in the development of its protocol; and have evaluated three protocols which were submitted to the Research Committee from outside sources, and made specific recommendations on each. II. Future Programs Present problems of psychiatry involve all aspects of the cause, course, treatment and prevention of the major psychoses. Except for the specific toxic and inflammatory psychoses, nothing is known of the etiology of schizophrenia, involutional psychosis or manic-depressive illness. Much description of the course of these illnesses is available, but this has been of little help in treatment or prevention except in isolated instances. Treatment is empirical, and at best, primitive. The central reason for hospitalization in most patients is the devel- opment of overwhelming tension and anxiety, and psychotic thoughts. Interpersonal relationships have become distorted, communication blurred, and effective activity so minimal as to threaten self-preservation. The various psychiatric therapies available today attack different aspects of these problems. A primary goal is the decrease in tension and anxiety, and the erasure of psychotic ideation. Much effort is expended at clarifying interpersonal relationships and modes of commun— ication; and eventual reeducation and support of the patient in directing his activities along effective channels that lead to self- and social- preservation. present methods are apparently satisfactory in the majority of patients in at least temporarily stemming the psychotic process, relieving tension and inducing a return to more effective functioning. In this process, the following methods are prominent at the hospital: Our 1. By hOSpitalization, the patient is separated and isolated from his environment. 2. By drug medication, as barbiturates, serpasil, and chlorpromaaine, and by electroshock and ambulatory insulin treatments, tension and anxiety symptoms are reduced. ' 3. By electroshock, electronarcosis and insulin coma therapy psychotic ideation is erased by altering brain function. ' b. By group and social activities, and group therapy in a permissive environment, better communication is fostered. 5. By individual psychotherapy interpersonal relationships are fostered along realistic lines. 6. By environmental manipulation, job reeducation, and social service help, effective functioning is strengthened. Our A. To research program is devoted to studying these processes. Understand the Hay Therapy Vorks: disciplines are constructively applied at the hospital, the effectiveness of any has not been sufficiently assessed; nor has the mode While these �.3mode of of The the study evaluated. present been adequately of operation has Electroshock of interest. our example an electroshock of is operation By assessing in many from patients. depression psychotic improvement resulted in be works will electroshock the way that hoped is the various possibilities and mental about the ideas some then accomplished, understood. If this is it The of become understanding clear. may in depression physiological processes A plan for a of service. the research electroshock treatment is the first goal similar study of insulin coma therapy is now in preparation; and others at the environment as a therapeutic of the hospital study a planning hospital are mechanism. B. Relationship of Character Structure to Diagnosis: study has been devoted to demonstrate the importance of the childhood environment in the development of character, behaviour patterns under stress involved in assessOther actively are and investigators the neuroses. conditions of adult the in variety result that childhood relationships the in factors the ing behaviour patterns. It is not pOSSible to carry out such studies at Hillside, mental of illness and the between type character the but important relationship of behavioural to of the patterns character the relation shows; the patient of character that resist and the aspects 'improvement‘; we which call change A be prototype of such studies is now in progressmethods assessed. can treatment electroshock therapy. in improvement to basic of character the in aspects Much C. Biochemical and Physiological Factors in Mental Illness: ill for long periods, appear to take on a stereoPersons who have been and chemistry in their reflected which is ultimately typed behaviour pattern, by 'non—reactor‘ neurologic, and patterns of such 'reactor' Study physiology. the failures in assessing methods important and are drug biochemical physiologic, and physical illness between psychiatric the relations of present therapies; Such a and improvement. between therapies 'organic' and the relation illness; and to drugs EST reaction where second project, study is incorporated in the and of long short terms in be assessed will electroencephalogram the changes in term improvement rates. D. Continuing Evaluations of Treatment Results (Follow~up): suffer treatment generally of of present the results studies Follow-up of the evaluation done an without because they assess one therapy only; are control standard to compared and not are improvement; subject's potentialities for followa continuing be to organize possible may With active support, it groups. evaluated on admission; assessed the are in which hospital patients up program, in followed a and over then methods at discharge; and psychiatric by psychologic number of years with an evaluation as to sustained change and reasons for failure. much would have at discharge, Such an evaluation, if compared to the predictions for base-line and a provide of therapies, choice present merit in assessing the the evaluation of any future therapeutic methods. III. Recommendation of problems the methods in attacking of suggested In this outline the treatment best; as one made to specific specify no effort have I psychiatry, is that fragmentary so it knowledge is Present the specific. or one etiology as of the psychoses. major to the etiology make as only a to guess poor possible A multidisciplinary approach with full freedom to follow many leads is the best of a establishment recommend the would For I this reason, that can be offered. �- h - Research Service, with full-time personnel devoted to such studies. I would be indesuggest that such a service have "research" as its function; that have a basic pendent of the service departments of the hospital; and that budget which would assure continuation regardless of the availability of outside it it research funds. A. The Research Service should have the following organization: 1. Director of Research -- Responsible to the Medical Director. 2. Research Associates in Psychiatry and Psychology. 3. Research Assistants: a. Psychology b. Neurophysiology c. Psychiatry d. Social Service h. Secretarial and clinical personnel. 5. Technicians. B. Annual Budget recommendations for the Research Service: 1. Director 2. Associate in Psychiatry " 3. in Psychology b. Assistant in Psychiatry " 5. in Psychology " 6. in Neurophysiology " 7. in Social Service 8. Secretary 9. Technician " 10. — Lab EEG $20,000 - $25,000. 12,000 - 20,000. 8,000 - 10,000. 6,000 - 10,000. 5,200 - 8,h00. 5,200 - 10,000. h,000 - 6,000. 2,760 - 3,300. h,000 - 6,000. 1,300 - 1,800. (1/2 time) warranted Consumable Supplies Travel Overhead: As decided by Administrator. Equipment: As 2,h00. 1,000. available as a continuing commitment to the Medical Director for long range planning of the Research Service. For the budget year 1955-1956. I should like to make the specific These funds should be made recommendation 1. 2. 3. h. 5. 6. that the following are the Director Research Assistant " " Secretary Consumable Supplies Travel minimum - Psychiatry Psychology ~ & Equipment 7. Overhead 8. EEG Technician (in Operating budget) requirements: $15,000. 7,500. 7,200. 3,000. 2,h00. 1,000. - $36,100. 1,600. $37,700. �C. Space: Problems of space at the hospital are acute, and will provide an increasing measure of difficulty as the service is developed. It is suggested that in the next capital outlay by the hospital for construction, some allowances be made. for the Research Service ' D. Relation with Other Departments: activities of the Research Service are to be those designated by the Director. Interdepartmental projects will be carried out by the Research Service, or in those instances where approval of the Research Committee is obtained, by the departments involved. Supervision of such interdepartmental projects will lie with the Research Director. The Interdepartmental projects are to be fostered by the Director. Prior approval by the Research Committee and the Medical Director is required. Such projects as are consistent with the service functions of the departments involved will be fostered. Presentations and reports are to be approved by the Research Committee prior to publication. E. Job Description: 1. Director of Research: objectives of the Director of Research will be to: (l) Organize and maintain an active program of research and a Research Service; (2) Promote, supervise and integrate research activities at the Hospital; (3) Educate hospital personnel in research methods and progress; and (h) Administer research funds. The The director of research will: a. Organize a central project or series of projects appropriate to the unique character of the Hospital and integrate this into the activities (therapeutic) of the Hospital. Progress reports will be submitted to the Medical Director and to each meeting of the Research Committee of the Medical Board; and such data as is approved for presentation will be submitted by the Director or his delegate at the appropriate scientific society. staff to plan and carry out individual research projects. Third year residents in psychiatry are to be specifically encouraged to undertake research projects under his direct supervision, or that of an attending psychiatrist. For these residents, and any other professional members of the staff, the director of research is to assist in the planning of b. Encourage all members of the the project; in its integration into the hospital program; and in both technically and financially. its support c. Carry on such educational activities as the supervision of third year residents in research; monthly seminars in research problems and progress; and The director will maintain of meetings. important psychiatric periodical reports a calendar of meetings and lectures; stimulate attendance thereto; and foster the He such of is also to invite such meetings. at Hospital activities presentation guest lecturers and seminar leaders as are available. d. Administer all research funds with the approval of the Medical Director. This includes the stimulation of fund sources; the application for funds; and their allocation to hospital projects. �2. Research Associate: Director in all projects at the hospital; to assume responsibility for specified projects; and to carry on such independent investigations as his training and experience dictate. Tb work with the Associate in Psychiatry is to be a qualified diplomats in psychiatry, with extensive experience both in psychoanalytic psychiatry and in descriptive psychiatry. By training or experience, the associate should have teaching qualifications; and some training in research methods. A. Such an assume responsibility for that portion of the functions of the service assigned to him by the director; assume responsibility in the director‘s absence; attend conferences, meetings and assume teaching functions as recommended by the director. will He Salary to be determined by qualification and experience. Probable range - $12,000 to 20,000. ‘ B. Such an Associate in Psychology is to be a qualified psychologist with at least 10 years experience. Psychoanalytic experience is preferable. The equivalent in academic standing of Associate Professor is the guide line. research associate in psychology is to assume responsibility for those functions of the Research Service assigned to him by the director. An evaluation of testing methods, statistical evaluation of results. and a rigorous control of procedure in all aspects of the functioning of the research service are his responsibility. The research associate in psychology may be chosen from the research assistants. Salary range - b8,000 to 10,000. The will: organize and supervise projects in the department; supervise projects of the resident psychiatric staff; assist such department heads as request aid in organizing departmental projects; advise the director of new research possibilities; attend conferences, write reports and papers, and carry on such administrative activities as the Director may require. Both Research Associates Board at Appointments to Research Associate are to be made by the Medical the recommendation of the Medical Director and the Director of Research. 3. Research Assistants: assist the director in his research activities and carry on the work of the department. Each assistant is to be responsible to the director, and will carry on such tests, procedures, write such reports, and present those To papers designated by the Director. Assistants are to be qualified by training and experience for the specified jobs named. They are to be appointed by the Medical Director at the nomination of the Director of Research. a. Assistant in Psychiatry: For such psychiatristswho have had three or more years of formal psychiatric training but not yet certified, the opportunity to work for one or more years on a Research Service may provide the stimulation for continuation in research and also provide the director with the assistance of personnel intermediate in experience between the resident and the associate. The assistant in psychiatry can assume responsibility for the selection �-7of the patients for the various projects; evaluate changes in behaviour with treatment; assess the importance of intrapsychic and environmental factors in the present behaviour of the patient. the assistant will assume responsibility for those aspects of the problems under investigation as are within his scope, and assigned by the director. He will write such reports, papers and make such presentations as the director may suggest. He will make such tests, learn such technics and work with those members of the research service or the service departments of the hospital as his projects permit. Salary is dependent on experience. Probable range $6,000 to 10,000. b. Assistant in Psychology: Graduate in psychology with a minimum of doctorate. Preferable experience in research methods and publication experience with some specialization in laboratory methods. Equivalent academic status of assistant professor. The assistant in psychology is to carry on such psychologic and laboratory tests, and make such statistical and methodological evaluations as the projects of the service require; and to make such reports and presentations as the director may suggest. He is to direct the laboratory technicians, organize their work and assume responsibility for the maintenance of all testing equipment and materials. In the design of projects, he is to assume responsibility for the application of the best methods and design commensurate with the goals of the project. Salary range - $5,200 to 8,hOO. minimum M.D. of with a Ph.D., or Assistant in Neurophvsiology: c. three years experience in electroencephalography or neurophysiology. To supervise and coordinate all neurophysiological studies, now being organized; develop and build electrophysiological equipment; assume responsibility for such animal studies as are organized; cooperate with the psychologist in coordinated neuropsychological investigations; and supervise technicians in electrical methods. This position can be filled only if the laboratory is expanded to include more basic studies. Personnel can then be recruited from medical school training centers. Salary range - $5,200 to 10,000. d. Assistant - Social Service: B.S. (Soc. Work) with minimum of five years experience in field or administrative work. Emphasis on interviewing technics and assessing family relationships. Personal analysis recommended. If previous research experience with psychiatrists or psychiatric clinics is noted, it should be heavily weighted. Assistant is to assume reaponsibility for interviewing relatives of patients and develop technics of assessing premorbid characteristics based on history and interview; to obtain histories from relatives and patient relevant to the early years of development; to cooparate with the psychologist in assessing the personality of the subjects; and to coordinate research testing in the various projects, Patients seen during their hospitalization in any of the research service projects are to be seen by the social worker prior to discharge, and every effort at follow up contact made. For all followbup testing and evaluation, the assistant will make the necessary contacts and arrangements for the director. The social worker assigned to the research service will, if time is available, cooperate with the Director of Social Service in those interdepartmental projects which he may have organized with the approval of the director of research. Assistant is to be selected by the Director of Social Service. Salary range proportionate to experience in research. Range - th,000 to 6,000. �e. Technicians: l. EEG -- High school graduate, although two years college preferred. learn the fundamentals of electroencephalography; make the necessary measure— ments and place electrodes; obtain artefact free records; maintain card files; type reports; keep records in systematic way; and maintain equipment. Technician is to be responsible to the assistant in neurophysiology or the director. To Salary -- if untrained, $2,600; if trained, $3,000 to $3,600. 2. Lab. Technician--Neurophysiology. College graduate, preferably with some engineering or physics experience. To assist the assistant in neurophysiology and/or the assistant in psychology, in the development and maintenance of electrical equipment; to assist in the handling of animals; to cooperate in the experimental procedures; to build, adjust and design special equipment. Salary range dependent on training-~ Range$h,000 to 6,000. IV. Summary: Research Director is actively involved in a number of studies of the mechanism of treatment. To maintain a continuing function and make long term planning feasible, it is recommended that a Research Service be established; that be an integral part of hospital organization with a continuing annual budget. it A proposed organization is included in this report, with a projected annual budget of 3,560,000 - $570,000; and with a minimum budget 1955—56 of $536,100. The This report approved by the Research Committee April 27, 1955. Respectfully submitted, Max Fink, M.D. Director of Research �Viva—v Wu'I-v-r “IV 11; 1955 mom DR. M. FINE SUBJECT: MOW REPORT, RESEARCH SERVICE «- APRIL 1. My louder ectiviw this month has been the planning and preeentim to the Director, the Research Committee end to the Medical Affairs a plan for a research department. This was discussed at length at the hoepdtel. and then presented to the Research Omittee, April 27th and approved. It was later presented on May 3rd to the Medical Affairs Oomittee. 2. Research pro cots underm: a. BM 2: theetndy ienowinmllewingendueam followingconoeoutive patients with all our indiciee of change. (30th " b. Ambivilence: Our equipment for techietoecopy hue been set up. Correlations between clinical evaluations between embivilunce made by Dr. Tmohow and tween, and the laboratory studies using the techietoecope and the TAT test, are new in pmgmee. \ electrouetimuletore and oscilloscope have been coordineted and preliminary measurements are being made in the alteration in tactile perception in electnoehock patients. (I. Serpaeil project continues despite some difficulties in the choice of patients. c. The ' e. Subculture: This comittee has continued ite work despite a number of hwering developments. This eppointment of Dr. Navarro to the adolescent pavilion hue limited the amount or time available for this project. Simlteneouely, Dr. Outwits announced that because of the pressure of other activities, he would be unable to devote the mountfl‘ time previously outin- eted to the project. For the meanwhile, the committee elucidating a protocol. is continuing and in Projects begun: Dr's Ledemn end Emberg have begun a study or the use of divided insulin doses and their effect on come levels. 3‘. attended: Dr. Knhn attended the Eastern Psychological Asediction nee e in Philedelphin, Ind participated in a panel and presented a paper based npm his work at the hunt Sinai Hoepital. I attended the April meeting of the New York Neurologic Society. 1;. ' p 3 " 5. Pipers published: In the Joumel or the Hillside Hospital, the ”th1 Test in Mental Petientc' by Dr. Kuhn, Weinetein and myself. . �MEMORANDUM Dr. Joseph so A. Miller, Mono FROM: Dr. Max Fink SUBJECT; Monthly report, Reaearoh Service T08 1. Activities of - Boy of the Research Service during the month have been attendance at various psychiatric matings; the presentation of papers; and tho continuation of ongoing projects. members 2. Papers Presented: (c) The paper entitled "RelatiOn of want in Eleotroshockfl was read, ~ Kwalwasser. To . and Learning to Improve» the Electroahcck Rosearoh Association Changes in Memory hy title, by Mr. Karin, Dr. Fink, and Dr. This paper received the Annual Prize Award of the association. (b) To the American Psychiatric Association, the paper entitled "Relationship Betucon Altered Brain Function and Denial in Electroshook Therapy“ was presented by Dr. Kahn and Dr. ?ink. ‘(c) the resident's meeting of tho New York Neurologic Socioty, Dr. Grnubert road the paper 'Daluaional Rodnplication of Parts of the Body After Insulin Coma Thorapygfi To final manuscripts of these three paperc Committee, at the end of the month. The 3. Meetings uttendod: were sent to the Resoarch or the Research Service attended the following meetings: Amorican Psychosomatic Society, American Psychiatric Association, Electroshock Ecuooroh Association - all at Atlantic City. Also the Nowhers York Neurologic Society and the American Psychopathological Association in New York City. ‘ How h. Notes regarding ongoing projects: a. Further data has been con llected for the two projects - EST # 2 and Ambivalence. b. Serposil: Some difficulties in the selection were cleared in conferences with Dr. Loderman and Dr; Blumberg. Later on in the month Dr. Laderman requcsted that he be relieved of working on this project except in the aupervisony role since he has to many other activities. The project will continue with Dr; chhspress assuming the major psychiatric role. 0. Subculture: Furthor work in preparing a protocol has continued during the month despite the hampering difficulty of the nooignaticn of Dr. Gurvito and the increased activities of Dr. Navarre. It is my anticipaticn that a satisfactony protocol may be available by the and of the month. up �S. New Projects: Following an initial meeting with Dr. Loon Helium: of the Sloan Kettering Institute on April 25th further dismsions were held at the hospital between Dr. Goldenberg and myself and a second visit to the institute was made on May 23rd. With the elucidation of their program, our own protocol is being prepared and will be submitted to the Research Committee and Medical Dimctor within the next few days. ‘ The Annual Prim Award of $100.00 was donated to the the Electmshock Research urea]. Strauss Research Fund, Association for also renewal mquest for tho grant. of the 0.3. Public Health Service were submitted on May 3rd. 6. Funds: 7. Papers Published: None. �DOW 0! 310011-131.” eeeeeeseeeeeeeeeeeeeeeeeeeeeeee Dr. 8. mm MW 1. PROGRESS mom, m Gold“ 19” WtionctchlorpromeineendSeryuilinSem,Urineend embroepdnel Fluid. Wire inthodhesbemdevelopedrorthe detemiutionor drugesnd rented elheloidel compounds in blood end urine. The procedure involves extinction orthe buiriedi‘luidwith heptsneendreextraetionottheecupoundfromthe heptsne leyer with hydrochloric acid. an mixing the acid solution with methyl orange e complex is formed which dissolved in ethyl.” dichloride to give I: soln. whose color in directly proportionel to the amount of chlorpromssine, eerpcsil, or other elkeloid origindqureeent intheteettluid. Adeteiled etudyhes eleo bean nude or the specificity of the melytiecl method. Prelim-:7 results obtained with serum of petiente indicate an «trench rapid rate of dieeppesrsnee or the mister-ed meterinl. Studies are being mderteken to determine whether this 1e due to repid elimination, detonticetion, or both, and whether the degree or retention of the drugs can be correlated in em we: with their clinical effectiveneee. 2. Inhibition of Sena Cholinestereee by Hallucinogen» stub wee reemd or en intereeting observation that had been made in our lobe. lest Sept... 195:. but not subsequmtly followed up became of leek of personnel. it that time it was noted that LSD 25 is e potmt inhibitor of mm 11;. The cholinesterese. question eroee as to whether thie phenomenon correlates in may we; with the echisogenic ection of LSD 25, end whether hallucinogenic in general have 1 eimer effect on cholineetereee from serum, cells, end brain. serum Prelilinery results with serum cholineetereee indicate a perelleliem between hallucinogenic eetivity of the 3 druge teeted, listed in the order or decreasing activity, '13., lysergic acid diethylenide > lyeergie seid monoethylamide > mecsline, end their ability to inhibit the anyone. 3. Steroid 3mm. Conjugate Studies. einple method hec been found for eliminating the protein and alkaloid interference with steroid sulfate cnelyeis or biological fluids. Procedure involves eddition of alkali to diesoeiete steroid sulfate bound to protein, followed by extraction with lipid oolvente end treatment with e eulronie eeid resin to remove excess bees as well a: tree alkaloid. Progreee along theee lines has been extremely rapid and fruitful. It hes also been discovered that the home sulfates ere synthesized by the liver. Chromtomphic end paper electrophoretio methods are being adopted ee companion tools to our dye teehnie in order to establish the identity or the component hormone conjugates. A �mm .1..qu MW “mm.o 1. Papa of biological fluids to Maniac tho 1nd alkaloidol drugo, prosciu- in mm... Italics “mid on 2. Preparation for following out. to ho conduct-d on blood and urino or tor urinary “mid studios hy Slow-Kauai.“ mend opp-oval): steroid sum». uhloido, phosphorus, plating ' fum- W151" chemo-two, ma poooihly total War; of 1W Wm. W, 2.xuuam1cmmmmmmummnmidmum; 1. K. Board with! ham Education “pm to orients." July lot, 1955. mmwflmfial 3mm}: Mo. Hmoido sponsorship by tho �mm mm: 199N955 Themuumhmfiufloaatthohoammm for-1mm uiththeappdnhamtofflr.mnnkuninctoreffiomm0¢tomg mdmop‘muwuybytheostamahnntdnnmhurumbym Humans-a. what. mmmmmmmamm mud sum mm m the grunts Health Service and wmmmmmmrerhmmwmmmud mmmmmrormumubymmunmm. mummcemmamwlymmdmamr otwwmgmlmwotfulds.whhstyeuamw«fthe dehwkmmdam.mefimtstwmmd mmntyotWMhWnMMmtanmmtefarm Wtfommtmfimnt. Thamsultaofthiaam mummmmttmmwmmfimmwmpm mumedtotmmamhockhmhsmmmdmu wmmrmmmmmmhdem. Mummtha um of am toineludofurflmr thanpym cumming; and lave becnhroadamd upcflnftheWsinfiwedbyinsMasmuu 0W.mammal studio! m the effects at 11:11am: Wymlfiudhsmmrpdmmdchlmmmgmd anwamw «mm museum“! � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Progress and annual reports; research activities (folder title 1/2). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Annual report - research; Biochemical research; Research and pUblications of the Department of Psychology; Annual Report of Department of Neurology, Hillside Hospital; Letters to Dr. Miller (Budget); Research Progress Report Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/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. 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 Prognostic value of Rorschach criteria in clinical response to convulsive therapy. J Neuropsychiatr. 1960 May-Jun; 1:242-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-48-014 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; <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 Journal of Neuropsychiatry, Vol. I, No. 5, May—June, 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/2c170ecde2c5784e8f07a062c10eb68d.pdf 5609f5c2406d7b6449fb5af08c8f4105 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, Basle 1960 From the Discussion to the First Symposium: THE PROBLEM OF ANTAGONISTS TO PSYCHOTROPIC DRUGS MAX FINK Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. (U.S.A.) ’ It has been a privilege and a pleasure to read and to listen to the reports by Drs. and DENBER. These authors have approached the problem of antagonists to psychotropic drugs from different vantage points: Dr. GADDUM that of the pharma— cologist — theoretician, assessing general issues; and Dr. DENBER, the experimental clinician with a specific problem exemplifying a theoretic principle. Dr. GADDUM essayed a broad classification of drug antagonisms emphasizing c0mpetitive inhibition. While studies of this concept have a likelihood of clarifying our GADDUM References p. 32. �DISCUSSION 31 knowledge of drug action, there was little that could be specified at present. This View, founded on extensive experience, suggests that a critical appraisal is necessary of the and of relation theories serotonin, fanciful the 5—hydroxytryptophan recent on many amine oxidases, amongst others, to human psychoses. If I interpret Dr. GADDUM’s review correctly, he is describing basic postulates which must be satisfied before drug antagonisms are established, and such establishment is requisite to the determination of the site of action of such interactions. Dr. GADDUM notes, that for the determination of competitive inhibition, four considerations must be fulfilled, i.e.: I. control drugs are not inhibited; 2. antagonistic actions are demonstrable at several sites or systems; 3. dose relationships are systematic; and 4. agents have a common chemical grouping. To these I would also add, that for such determinations of competitive inhibition to have significance for human psycho—pharmacology, the antagonisms should not be based on work limited to a single animal species, but should be demonstrated in man. Dr. DENBER has approached the problem from a specific experiment — the meas— urement of changes in various blood chemical elements and gross clinical behavior in chronic relapsing psychotic subjects. These patients were studied before and after intravenous mescaline followed by a variety of phenothiazine agents administered as “antagonists”. Dr. DENBER confirmed his earlier studies that various phenothiazine derivatives, excepting diethazine, are effective in modifying mescaline clinical affects; and that such effects are related to the halogenation of the chemical ring structure. Parenthetically, we can confirm the observation that diethazine is not an antagonist for hallucinogens, for in our studies diethazine induced illusory states and EEG desynchronization in psychiatric patients, similar to mescalinel. The biochemical data indicates the wide range of behaviors altered by these broad acting agents. Like his earlier studies on the changes in the EEG, and the observations from others of the blocking of induced psychotomimetic effects as measured in frame— theoretic from be this data must a analyzed etc., mood, perception, language, work of the relevance, or imputed causal relations, of such observations to clinical behavior. No such framework is given and the assumed connection between these blood changes and clinical behavior is obscure. Indeed, Dr. DENBER concludes that: “In all probability, the reactions observed represent part of a total body response to a stress-. . Assuming this conclusion is a reasonable working hypothesis, we are taxed by the problem of critical experiments to elucidate the body response to psychotomimetic and psychotropic agents. In this task we are faced by a number of monumental problems, and it is here that Dr. GADDUM’S principles and Dr. DENBER’S experiments approach a common base, albeit tenuous. For what Dr. GADDUM fails to indicate in his principles are the significant behaviors to be studied; while Dr. DENBER selects be— interactive clinical of and —~that blood of behavior global chemistry two aspects havior — as dependent variables. It is the selection of significant experimental variables and their quantification that represents a central problem of human psychopharmacologic research today. Assuming that the laws of human interpersonal behavior are the goals of our studies, and that psychopharmacology represents one aspect of the modification of human References 12. 32. �FIRST SYMPOSIUM 32 interpersonal behavior, what evidence is there that any single aspect of task behavior is correlated with changes in interpersonal behavior induced by drugs? I am troubled by the fact that innumerable investigations have selected a single or few variables on the biochemical level and correlated these with a single or few variables on the behavioral level, the selection of which is not designed to elucidate a theoretic framework but rather based on a vague personal notion. Thus, investigator after investigator selects pole climbing, bar pressing, conditioned avoidance, jiggle cage movement, etc. as single variables in a wide range of animal studies; and rating scales, self—ratings, psychomotor tasks, EEG, blood pressure, and many others in human studies as single significant variables. Few studies assess the relevance of these tasks for the prediction of the direction or efficacy of drug effects on interpersonal behavior. Other significant problems include that of generalizing from non—psychopathic populations to our understanding of disordered human behavior. A sub—aspect of this problem is the generalization from one psychopathic population to another without fully taking into account such population factors as genetic predisposition, early organic traumata, varying acculturation processess and sociologic status upon population characteristics. These aspects may so alter the observations obtained with a specific pharmacologic agent as to give varying, and occasionally opposite results when similar studies are done in different settings. Some years ago, Dr. ABRAHAM WIKLER outlined the problem facing experimental psychopharmacologistsZ. In assessing the relation of psychopharmacology to experimental psychiatry, he recommended: “In psychiatry we need more properly controlled studies on the comparative effects of a variety of drugs, on the behavior of varied, but selected, homogeneous groups of subjects, under varied but standardized experimental conditions, and with varied but specified activities of the observer.” In this I concur and commend it to the Collegium as the most logical beginning to the resolution of the problems of antagonists to psychotropic agents. REFERENCES 1 2 M. FINK, Effect of anticholinergic agent, Diethazine on EEG and behavior: significance for theory of convulsive therapy. A .M.A. Arch. Neurol. Psychiat, 80 (1958) 380. A. WIKLER, The Relation of Psychiatry to Pharmacology, Williams & Wilkins, Baltimore, Md., I957- Printed in‘ The Netherlands �‘ w33;; érn‘msmfi‘ ’1angmgemam: $§i~wgfl .91»: ~' ‘iWMem 423d mmhm: maximmmvmfi .: {Err thwxsfisw 9mm: fim téfim, , . . 1 . Mamiew. > �D First I I S C U 3 8 Synponiun TH! PROBLBH'OF ANTAGOHISTS lax 713k, ~ 0 l 0.1.H.P. TO PSYCKOTROPIC DRUGS H.D. Pro. tho Depart-ant o! Bxporinontal Psychintry, Billlido Hoapitnl, clan Oaks l.!. July hth, 1960, 3:310, Switaorland �It listen has been a privilege and a pleasure to read and to to the reports by Drs. Gaddun and Denber. These authors have approached the problem or antagonists to psychotropic drugs from different vantage points Dr. Gaddna that or the pharmacologist - theoretician, assess~ ing general issues; and Dr. Denber, the experimental-clinician with a specific problen exeaplitying a theoretic principle. — Dr. Gaddnn essayed a breed classification of drug antagonisns emphasising conpetitive inhibition. While studies of this concept have a likelihood of clarifying our knowledge of drug action, there was little that could be specified at present. This view, founded on extensive experience, suggests that a critical appraisal is necessary d’the nany recent fanciful theories on the relation of serotonin, S—hydroxytryptephan and anine oxidases, alongst others, to huaan psychoses. It I interpret Dr. Gaddun's review correctly, he is describing basic postulates which must be satisfied before drug antagonisns are established, and such establishnent is requisite to the deternination of the site of action or such interactions. Dr. Oaddna notes, that for the determination of competitive inhibition, four considerations nuet be fulfilled: i.e.: (1) control drugs are not inhibited; (2) antagonistic actions sre demonstrable at several sites or systems; �To (3) dose rslaticnships are systoaaticg and (h) agonts hsvs a con-on cboaical grouping. that would for ouch dotorsinatioos of thoss I also add, coapotitivo inhibition to have significance for huaan psycho~ pharmacology, tho antagodsus should not be basod on work bo doaonstrablo should but aniacl a to spacios, single liaitod in san. Dr. Donbor has approacbad tho probloa Iron a spocitic oxpariaont - tho aoasursaont of changoa in various blood ohsaical closonta and gross clinical behavior in chronic rolapsiog psychotic and intravonous botoro Thoso studiod attor scro patioots subjects. aoscalino followed by a varicty of phonothiasino agonts adaioistorod so *antsgonists'. Dr. Donbor contirsod his oarlior studios that various phonothiosino dorivativos, oxcspting diothasino, aro ottoctivo in soditying aoscalins clinical atrocts; and that such ottocts arc rolatod to tho halogonation of tho choaical ring structuro. Paronthotically, so can contira tho cbsorvation that diothasino is not an antagonist for hallucinogons, for in our studios diotbasino iodacod illusory stats: and EEG dosynchronisatioc in psychiatric potiouts, aioilar to aoscalino (1). Tbs biochoaicsl data indicatos tho aids songs of bohaviors altorod by thoso broad acting scouts. Liko his oarlior studios? on tho changos in tho EEG, and tho cbsorvations from othors of tho blocking of indccod psychctoaiaotic ottocts as Ioascrod in bo snot data analysod this languago, aood, porcopticc, otc., �-3Iron a theoretic fraaevork of the relevance, or iapcted cancel relatione, of anch obeervationa to clinical behaviour. No Inch fraaevork ia given and the aeauaed connection between these blood changee and clinical behavior in ebecnre. Indeed, Dr. Denber that: "In all probability, the reactione obaerved repreeent part or a total body reaponee to a atreaa- ...' leenaing thie conclnaion ie a reaeonable working hypo-» theeie, we are taxed by the problea of critical experiaente concludee to elucidate the body reeponee to peyohotoaiaetic and paychetropic agent. In thia teak we are faced by a nnaber of aonnaental probleae, and it ie here that Dr. Gaddna'e principlee and Dr. Denber’a experiaenta approach a coaeon baae, albeit tennoce. For what Dr. Gaddna taile to indicate in hie principlee are the eignificant behaviore to be atodied; while Dr. Denber eelecte two aapecta of behavior - that of blood cheaietry and global clinical interactive behavior - aa dependent variables. It in the eelection or significant experiaental variablee and their quantification that repreeente a central problea o: hnaan peyohopharaacologic reeearch today. ieanaing that the lava o: hnaan interpereonal behavior are the goale or our etndiee, and that paychopharnacology repreeenta one aepect of the aodification or hnaan interperaonal behavior, what evidence ie there that any single aepect of teak behavior is correlated with ehangee in interpereonal behavior induced by drugs? �-1... I on troubled by the tent thet innnnereble investicetione heve eelected e eingle or ten veriehlee on the bieeheeioel level end correleted theee with e eincle or ten verieblee on the behevierel level, the eelectien or which ie not deeigncd to elncidete e theoretic freeeeork but rether beeed on e vogue pereenel notion. Thne, inveetigetor efter inveetigetor eelecte pole cliebing, her preeeing, conditioned evoidence, Jigcle cege leveeent, etc. ee eingle veriehlee in e wide reuse of enieel etndiee; end retina ecelec, eelt-retinge, peyohoeotor teeke, EEO, blood preeenre, end eeny othere in hneen etndiee ee single eixnificent verieblee. rev etndiee eeeeee the relevence of these teeke tor the prediction of the direction or etficecy o8 drug ettecte on interpereonel behevior. Other eigniticent prohleee include thet o: generelieing tree non-peyohopethio populetione to our underetending of dieordered hneen behevior. e eobaeepect of this problee is the generelieetien free one peychopethic populetion to enother without ench eccount into populetion rectore ee genetic teking telly prediepoeition, eerly orgenic tredeete, verying eccnlturetion proceeeee end eociologio etetne upon popnletion cherecterietice.» Theee eepeote eey eo elter the oheervetione chteined with e epecifio phereeoologic egeet ee to give verying, end oceeeionelly opposite reenlte when eieiler etndiee ere done in different settings. �-5Solo yoara ago, Dr. Ahrahaa Hiklor ootlinod tho prohloa In aoooooiog (2). paychopharacologiato oxporiaontal facing tho relation of poyohopharoacology to oxporioontal psychiatry, ho roconaondods 'Iu poychiatry Io nood noro properly controllod otndioo on tho oooparativo ottocto of a variety of drogo, on tho behavior of variod, hot ooloctod, hologonoooo groups or ouhaooto, undor variod hot otandardiaod oxporiaontal conditiono, and with variod but opocitiod activitioa of tho oboorvor.’ In this I concur, and connond it to tho collogiuo an the aoot logical hoaiuning to tho roaolution of tho prohloao of antagoniota to psychotropic agonto. �1. link, n: Effect at Antieholinergic Agent, Dietheeine3on EEG end Behavior: Significance fer Theory of Convaleive Therapy. .§_o_ 2. "‘ AHA Arch. figural. a Pezehiet. 380‘387, 1958. Hitler, A: The Relation of Pezphiatrz to Phernecologzl In. Wilkins, Beltinere, 1957. � Dublin Core The Dublin Core metadata element set is common to 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 Problems of antagonists to psychotropic drugs, 30-2 (Discussion, Neuropsychologic response patterns of some psychotropic drugs). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-51-017 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from: E.ROTHLIN (Editor), Neuro-Psychopharmacology, Vol. 2 (1961), Proceedings of the 2nd International Meeting of the Collegium Internationale Neuro-Psychopharmacologicum, Basle 1960 From the Discussion to the First Symposium: THE PROBLEM OF ANTAGONISTS TO PSYCHOTROPIC DRUGS 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/dcb2d198f268393b586365e8e34503d8.pdf f1412cf3717181597ffc25684c3fe518 PDF Text Text PREDICTION OF INDIVIDUAL PATIENT RESPONSE TO CONVULSIVE'THERAPY 1/ e i - i e ' . <-- Max Fink, M. D. l - E -ku'xs‘b The prediction of response to treatment is a necessary daily task of medical practitioners, who, after a process of clustering the symptoms and signs of illness of a patient, select a treatment regimen most likely to effect a salutary change in the patient. Where the classification of the disease is established by definitive criteria in syphilis. diabeas tes or malaria - the physician's problem is simplified. Where classification is not based on definitive criteria, as in heart disease, or mental disease - the physician's is problem complex. for he must resort to the recognition of pattern based on his individual experiSuch classification is not readily validated, and in the absence of specified external ence. criteria, errors in grouping for therapeutic purposes are frequent. ' wv'h"'" ‘ ' In the instanCes where remedies are established by their effectiveness. as in syphilis, or bacterial infections, or avitaminosis - treatment selection is readily defined. Where remedies are non-specific, as in the treatment of mental illness by environmental manipulation, psychotherapy and various physiodynamic therapies, the problem is complicatcd, not only by the non-specificity of treatment but by the probability that potentially effective therapies are applied to potentially responding and potentially nonresponding pop- -...-....'..-.-....-..—”.y—--—- ,.. ulations. The problem is further complicated b y a lack of evaluative criteria of salutary Various change. approximations are in use, as symptom rating scales, social adaptational measures, patient self-ratings, and changes in target symptoms. These indices are gencrally too broad, too inclusive and too non-specific to be useful. For example, in the target symptom approach, the assumption that anxiety in neurotic phobic, neurotic depressed, or paranoid schizophrenic subjects are equivalent processes is not valid. in Depression various subjects is no more the same phenomenon than is the fever in t mania or lung abscess. c . ' There are, therefore, three aspects to the problem of predicting individual patient response to therapy: the specification of populations (patient selection); the selection of therapy; and the specification and evaluation of behavioral change. These will be aspects described with reference to the convulsive therapy evaluation of the Hillside programs Hospital as studied during .the past seven years. Hillside Hospital is a voluntary, nonprofit, community supported institution in New York City. In these studies, the patients were referred specifically for convulsive therapy by staff psychiatrists to the special somatic treatment unit which was responsible for all somatic treatments at the hospital. .. ' I I mvvv’ ! . ' ; ~<~u .‘-~v- “tn“ a. ' ,,..~..‘..-.... i Observing the usual mixed group of subjects referred for convulsive thera py, we recorded a variety of behavioral adaptive patterns at the times when subjects had received the number of treatments sufficient to i nduce neurophysiological The changes. patterns ineluded euphoria, hypomania, denial, and minimization; loss and increased memory complaining; increased fearfulness, agitation and excitement; and withdrawal, paranoid and delusional ideation. In assessing these patterns, that of euphoria, denial hypomania. and minimization was prominently associated with clinical ratings of much improved and recovered. We termed this adaptive mode "euphoric-hypomanic" and set this as the criteria for the behavioral change which we would like to predict (l). \r I N. Y. ..~: “ Since treatment selection was defined by the institution, our studies focused initially the definition of parameters of change. 1/ From the De partment of Experimental ‘- aw.- 'V.¢§“-.~ Methods on ...._.-.,-..-,',.-»--—s.- Psychiatry, Hillside Hospital, Glen Oaks, L.I a. Aided, in part, by grants M-927 and MY¥Z715 of the National Institute of Mental Health, U.S. Public Health Service. 317 __W_ -_.. ”_.u' ‘U .—:r.. U..- ‘ �(and be therefore this show adaptive pattern to To determine the population prone terms usual diagnostic or the eschewed symp. we recovered) and rated as much improved these studies behavior. During of We measurable aspects more and sought tom check list. the termed which we neuroconvulsive-therapy process the of had develOped a concept a device to as convulsions seen are repeated view. In this (2). view physiologic-adaptive behavioral function brain adap. altered of such conditions the Under alter brain function. attitudinal and factors. sociocultural Thus, individual personality, based on tations emerge indices. attitude and predictive as personality we sought measures of pre-treatment defined that the we studies these had completed we after it was For the most part, of "much clinical ratings the earlier tables these on that "euphoric-denial" pattern, so with this be to equated be. View. in and our reported are, improved" and "recovered" are havioral pattern. Results Earlier of language patterns. was assessment Our first 3. Lan ua e measures. with brain dysfunction that patients demonstrated had (3) Kah and n Weinstein studies by after confabulation and intra. disorientation of denial, changes had characteristic language language these that same observed we study electroshock In one venous amobarbital. those that noted We patient. also of treatments. numbers with increasing changes occurred those not while recovered, evaluated as the ones showing these language changes were content A analysis linguistic unimproved. rated as generally exhibiting the changes were disminimization. denial. be to explicit the in study showed the language patterns rated of tense, of change third use comments, person, cryptic cliches, evasion, placement, (4). with question a and responding withdrawal, qualification, elecafter showed these who patterns language the subjects It seemed probable that treatment before such to . using patterns who have propensity a the be ones troshock would tested therefore. We. test. provocative some by changes if we could elicit the language adinterview, structured short in a questions each patient before electroshock by asking then and repeated and nystagmus. slurred speech until was there amobarbital ministered after amoof changes number language the for the We scored answers the questions (3). barbital (4). We noted a relation between the number of pretreatment language pattern changesthe during manifested clinically of changes number language the to following amobarbital between, also relationship a there was 1'). Furthermore. (Table of treatment week fourth imof much clinical ratings and term short changes the number of pre-treatment language proved and recovered (Table 2). TABLE 1 TO RESPONSE LANGUAGE PRETREATMENT BETWEEN RELATION AND CHANGES CLINICAL AND SODIUM AMOBARBITAL WITHDRAWAL DURING TREATMENT Three or more clinical language patterns“. Pretreatment response to amobarbital sodium pretreatment response to amobarbital sodium No *x2 +x2 318 4. 26; p< . 05. 6. as; p< . 01. Withdrawal reactions to amobarbital sodium: The scorn denial sc< We 1 cal rating score and �TABLE 2 “""“ RELATION OF PRETREATMENT LANGUAGE CHANGES WITH AMOBARBITAL SODIUM TO EVENTUAL CLINICAL RESPONSE V: «vs Change with amobarbital sodium‘I Much Improved 19 -~..-,..’. 68% .-.~.e. .. Moderately Improved _,_ ‘91- _ Unimproved *x2- 10. 30; P < .01 y-a-M-...‘;N -——vr-- b. Famil Interviews. Our second assessment was a denial personality As inventory. patients were referred for convulsive therapy, we interviewed a relative in an unstruc- exploratory interview. The questions were designed to determine the degree to which the patient approximated the explicit verbal described personality type Weinstein by and Kahn (3). On fifteen items, patients were scored on three a scale of l point and 2. 0, The scores were ranked and divided in half - those in the half termed were upper "high denial score" and those in the lower half, as "low denial score" (5). tured, vvvu—n- .vw- . . w».- w— v .AW observed a significant relationship between the denial score and short term clinical ratings (Table 3), In addition. there was a significant between relationship the denial score and the number of clinical language changes during treatment (Table 4). We . -pv TABLE .- 3 ..1..—. RELATION OF DENIAL PERSONALITY TO CLINICAL RESPONSE TO ELECTROSHOCK 'Much Improved Personality Score - ,ewv. .w-vv- Moderately Improved ,V, l4 s 7 u-....r.»-v 21 T,-..,'.«..fl_~. —.s.-—.— .--.-.. TABLE 4 RELATION OF DENIAL PERSONALITY SCORES TO CLINICAL LANGUAGE CHANGES DURING TREATMENT Personality Scores 11-25 (2.0) 0-10 (20) Number Language Changes 8 l7 ‘ 12 3 * . 319 �We the did Rorschach. was task Another not essayed Determinants. Rorschach c. look upon this test in the usual interpretive manner. but scored the number and patterns of Rorschach determinants following the schemata of Klopfcr and Kelley (6). It was observed that ratings of much improved and recovered were associated with the following Rorschach criteria; absent human movement (M). absent form color (PC). few responses, high form percentage (F ). presence of color (C) and color form (GP) or absence of all color. and low shading response. One schedule is reproduced in Figure l (7)- FIGURE 1 RELATION OF RORSCHACH PATTERN TO CLINICAL RESPONSE TO EST °/° NO M, no c M,CF AND [3 MUCH IMPROVED NO M, a\ MODERATELY IMPROVED AND no M,.cF/c M, NO c F6 AND M, FC UNIMPROVED. d. California F Scale. Still another attitudinal task is the California F Scale. This is the which to 10 subject statements of global of uncritical,’ series consists a task simple asked to express the extent of his agreement or disagreement. High scores reflect high agreement, and low scores, high disagreement (8). There was a significant correlation between high F scores and favorable clinical and (9,10) studies factors social out realso carried In we addition, 5). (Table ratings ported that favorable outcome was associated with few years of education. foreign'birth. and older age. ' » TABLE 5 RELATION OF SOCIAL FACTORS TO DISCHARGE RATINGS IN CONVULSIVE THERAPY . Recovered Much Improved Improved and Unimproved 320 Mean F Score 53.1 Mean Age Mean Years Education 7- 50 9. 4 / 10.6 12. 3 Foreign Born ‘ 35 17 �Conclusion summary, we have observed that a variety of pre-treatment measurable aspects of behavior, usually described as personality variables, are associated with the develop— ment of the euphoric-hypomanic adaptive pattern in convulsive therapy and are rated as much improved or recovered in our setting. These variables have been defined in language patterns, denial scores on family interviews, perceptual style reflected in the Rorschach. California F Scale measure of attitude, and the social variables of age, educational level, and birthplace. These personality and social variables provide the perceptual and attitudinal bases for the adaptive changes which occur under the conditions of altered brain function induced by repeated convulsions. Absence of these personality traits, in the presence ,of equivalent degrees of brain function leads to other adaptive patterns, usually rated as "improved" or "unimproved. " and not to the euphoric-hypomanic mode. In The same theoretical model of the neurophysiologic - adaptive interactional hypothesis is applicable to drug therapy (2, ll). We would suggest that different agents are psychopharmaceutically useful to the extent that brain function is altered systematically. These can be measured by the electroencephalogram, although not exclusively. Under the conditions of persistent altered brain function, changes in adaptation will occur, dependent on pre-treatment personality variables. These can be specified, and studies now in progress at Hillside Hospital are assessing this model for various psychotropic agents. References (1) Pink. M. and Kahn, R. L. : Patterns of Behavioral Change and Improvement in Convulsive Therapy. AMA Arch. Gen. Psychiat. (in press). (2) Fink, M. : A Unified Theory of the Action of Physiodynamic Therapies". J. Hillside (3) Weinstein, E.A. and Kahn, R. L. : Denial of Illness: Smbolic and Physiological Aspects, Springfield, Ill. C. C. Thomas, 1955. (4) Kahn, R. L. and Fink. M.: Changes in Language During Electroshock Therapy. Psycho atholo of Communication, Ed. Hoch. P. and Zubin. J., Grune & Stratton 1958, pp. l26-139. (5) Kahn, R. L. and Fink, M. : Personality Factors in Behavioral Response to Electroshock Therapy. J. Neuropsych. 545-49. 1959. (6) Klopfer. (7) Kahn, R. L. and Fink, M. : Prognostic Value of Rorschach Criteria in Clinical Response to Convulsive Therapy. J. Neuropsych. _1_: 242-245, 1960. (8) Kahn, R. L. , Pollack, M. , and Fink, M. : Social Attitude (California F Scale) and Convulsive Therapy. Jour. Nerv. Ment. Dis. L351: 187-192, 1960. (9) Kahn, R. L. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp. 2: Zl6-228. I957. (10) 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. AMA Arch. Gen. Psychia . l_: 565-574. 1959. 1942. (ll) Fink, B._ and Kelley, D.: The Rorschach Technique. New York, World Book Co. . EEG and Behavioral Effects of Psychopharmacologic Agents. NeuroPsychopharmacology. ed. Bradley. P. . Elsevier, Amsterdam, 441-446. 1960. M. : DR. LASKY: .,- Thank you Dr. Fink. Do members of the panel have any questions or comments? 'r~ r- ”‘5 | 321 ”.“wnpm‘. �DR. KLERMAN: I Max, you presented with a fair amount of specificity, the personality and social fac. tors which characterize the patient. Iwas disappointed in that the other half of your neuro-adaptive scheme was left unspecified. Namely, is there any specificity in the alter. ation of brain function that is as predictive as these specific social and persouality factors? ‘ . patien1 adapta to tree will nc brain are co convul nnl, tt that hi . DR. PINK: answer to that is that we do have considerable specificity for the various treatments that we use. If I might have Figure 2. This Figure will show that we did use electroencephalographic measures. We were rating the EEG changes according to criteria which we called high degree-slow wave activity. This index could be specified and quantified. After determining which records were "high degree" slow wave activity, we were able to go back and look at the patients who had shown the much improved category, the moderately improved and the unimproved. It is apparent that of the patients who were in the much improved group, about 90% of the records of that group had shown high degrees of EEG change during the third. and fourth weeks of treatment. It is also clear that the pa. tient's who were "unimproved" did not show the high degrees of EEG change. We interpret these data to indicate that unless a patient has a high degree of EEG change he will not .show behavioral change. It is necessary to have changes in brain function and it is under the conditions of the brain change that adaptive change will ocdur. The type of adaptive change depends on these personality variables. In drug therapy we have other EEG patterns which can also be specified. I think the change 'shock. - DR ' L I schalk comm much crude with tl ' DR. F FIGURE 2 I . h. r . >‘ ,._ o—MUCH IMPROVED (u) E ..... moo IMPRovsom g S 3O ‘ - DR. 7 _ umumoveom (3 spe cif tional being . ‘ has s‘c UJ LL] as 0 0 $ DR. F LL! I reflec know \ “I": atric 6 5 u these more our e1 ber of E: we do much eupho: being: 2% if ‘ ' 4'6 7'9 “242 NUMBER OF TREATMENTS statin: . behavj which . . DR. KLERMAN. Is one difference between this kind of physiologic measure and the other measures in that they occupy different type predictive factor? Would you say here that unless the patient has this characteristic, EEG changes, he will not subsequently develop behavior and adaptive changes but can you predict before the treatment in any physiologic way whether or not a given patient will manifest these characteristic delta wave changes 7 In other words there is a difference between a predictive variable that you described as existing or .. characteristic with the patient prior to his exposure to the treatment and a predictive variable that says he must experience a certain kind of change under the influence of the so- matic therapy. 322 : ‘ - this a‘ $323: - ation This i ‘ :fifhfi hospit e ducai �PINK: I think what you are asking is whether we can predict the physiologic response of the patient. I think we can, although this is much more difficult than predicting the behavioral adaptation. We still do not know what the determinants are or how to measure them prior to treatment, to predict whether a person will or will not show a drug response or will or will not show a physiologic response. The question is not one of a sequence, where altered brain function comes first and then the subjects involuntarily adapt to it. These processess arc concurrent. At the time that brain function is changing under the influence of repeated convulsions or under the influence of repeated doses of drugs, the perceptual, the attitudinal, the conceptual and all the other aspects of patient behavior are undergoing change so that his whole view of life and his response to his environment is changed. The kind of change he shows depends on his pretreatment propensities, as we tried to show on electroshock. DR. ‘\ x v w -« ~ .rv-w--. "a... mv‘vo—‘w “ o...— DR. LASKY: 01-- - Dr. Fink, we'll ask another question or two. They are short ones. think Dr. Gottschalk and I have something rather similar in mind. Now, the one I had was--Could you comment On your criterion. You used a three level over-all clinical rating of recovery, much improved and improved. Now the question that comes to my mind is why use such a crude criterion when you are using rather quantitative measures as predicters and ties in with that, of course, what (ices this criterion mean that a man is "improved" 7 I DR. ”on mu w-wfinwvr'Vb-‘M FINK: Dr. Gottschalk, do you want to ask something ? w-vfimnmm DR. GOTTSCHALK: Well, I had a somewhat similar question, but I have focused on something a bit more specific than that--As whether Dr. Fink had any idea why those people with lower educational levels tended to have more improvement, was this possibly because of the goals being less as compared say to persons with higher educational levels, then of course this has some relationship to the question about the criterion for improvement. 'r-v-q—vruwm.“ - ‘ a ‘ Wm DR. ‘w FINK: .5 we‘rv .. think that both these questions are crucial ones.. I tried to indicate that our slides reflect early aspects of our studies. At the time that we did these first studies, we did not know what we were using as the eventual criterion of behavioral change. We used psychiatric ratings much as everybody else. This criterion was fairly effective. In the course of these studies, we learned that there were different behavioral modes, and these seem a more meaningful criterion. We are now in the process of assessing patients going through our electroshock program, trying to predict these various modes. Unfortunately, the number of patients referred for electroshock in 1960-61 has dropped off precipitously, so that we do not have a large enough sample. But, the statement of the slides on recovered and much improved reflects, ‘as we look back in our data, those patients who showed the euphoric-hypomanic adaptation. That adaptation can be characterized by a feeling of wellbeing; an attitude on the ward of being fine; dressing up, and participating; and on inquiry stating they are no longer sick or depressed and that there is nothing wrong with me. Such" behavioral changes are the ones that psychiatrists rate as much improved. In our hospital, which is psychodynamically oriented, there are a number of psychiatrists who have seen this adaptation and have said that this is not improvement, but explicit denial is a psy— chotic adaptation. There is, therefore, a problem of evaluating what we mean by much improvedor unimproved. The question about educational level is also related. The evaluation of "much improved" is dependent on the psychiatrist's or the evaluater's attitude. This is one of the reasons why the use of much improved characterizations across hospitals is almost impossible. We tried to show this yesterday in Dr. Pollack's report of our tri-hospital study where discharge ratings did not have the same meaning in the various hospitals. The educational level is important because. there is something about being well educated in the American culture which does not lend itself to the use of the, gross denial I , r‘tV‘W‘WW' mq— v'fT'V-a run-"Vera nrw— m. u~—WWWW—w—wm~n» l—"r'" le‘fp ”r" «- -m .» 1‘ i l t i l i V ‘323 i i i i �\Q institution is this in and reour them, we see as cultures ive The more primit response. who have and in may Europe who born were flected in the people in the older age group the adaptation use or such can people that in Europe, life sustained their early processes American Our younger. intelligent, denial. more verbal do use the adaptation of explicit born girls and boys just don't use gross denial. the for I on use apologize must and. is poor very The use of improved categorization The next studies. started our the we is that way the slides, but Ihad to use it because reflect will but an have not will that. two hence, series of slides, hopefully a year or that have teased think we which we predictors the" hope we Then adaptive mode typology. differences. those in demonstrating effective be will out using improving categories in ap procedure by investi; In or pharmacol lucidly, tc jsctive es; of familia: able dosa; 'age level not associ experimer pipradr‘ol tect: 47 ju : DR. LASKY: who A. 'Gottschalk. Louis Dr. is next Our speaker Fink. Thank you very much, Dr. Cinof Psychiatry. the Department at Coordinator Research and is Associate Professor to Individual Pay. Response is "Measuring his of title The paper cinnati General Hospital. Free-Associative) Behavior (or Verbal and Method a Introspective an choactive Drugs by Method. " Dr. Gottschalk. Fron the indivic a seconda: by pipradz themselve able to wo one thing themselve duced stin 1 AN BY DRUGS PSYCHOACTIVE TO RESPONSES INDIVIDUAL MEASURING INTROSPECTIVE METHOD AND A VERBAL BEHAVIOR (0R F REE-ASSOCIATIVE) METHOD 1] of accomp] , ‘ Louis A. Gottschalk, M. D. Introduction is a redrugs to psychoactive and individual idiosyncratic responses the Measuring of study and The systematic serious search area of increasing interest to investigators. the fact that the collective effect of such phenomena is made difficult and compounded by and the unique that time the at same the psychoactive drug has to be accurately measured for accounted plausibly whenever possible, and, observed individual effect is being validly at some level of organization. individual the for and accounting of measuring, Approaches to this problem detecting, and methof the Some principal ingenious. been have many drugs to psychoactive response different with major of to of patients a drug administration groups The ods have been: l) suband of behavioral different for patterns psychiatric nosological syndromes and looking psychoneuroschizophrenia, the , category, to diagnostic e.g. jective reactions according 1929; 1953; Bensheim, and 1952 and Pennes, sis, etc., (Beringer, 1927; Hoch, Cattell, of of the relationship Z) determination The 1960). Weinstein, 1953 and 1954; Kornetsky, beor profiles with different personality associated to a drug varying individual reSponses by measured etc. --as hysteria, depression, extraversion, havioral patterns--such as, and (Kornetsky evaluations clinical psychiatric various psychologic inventories or tests or individof the The 3) 1958). assessment a1. 1955; Laverty. , Humphries, 1957; Lasagna, et of defear such a conflict, as, with psychodynamic a ual reactions to a drug associated different The investigation'of 4) 1957). pendence (Gottschalk, et a1. , 1956; Sarwer-Foner, Kurland. 1955; and 1950 1956; et a1., Wolf, and 1955 a1. et . reactions to placebos (Beecher, the hence and effect placebo sometime of powerful the 1960), which provide an indication individual placebo component of the reaction to a drug. of Medicine. of College Cincinnati, of University the Department Psychiatry. 1/ From from (MY-1055) research in grant a by These investigations have been supported part and Welfare. Education of Health. Mental of Health, Department the National Institute 324 The i the individ about the i very devia ple and 1e: tive drugs character cannot, ho rically we] drug addic individual major psy¢ The pharmacol I assessing 1960, 1961‘ measuring perimenta situation subject to 1 investigatl The verba the only 1': of ‘speech The relia’: the scales eral or ty: been devel s chizophr ‘ �lfifilt$1ll at Indxvtiaaz Pattau$ nutpunua $0 etuvuzntvu rhnrtpy Ill! Flak, Rafi. .: Impurinuntnl Payuhattry, fvun tho nlylr§ncnfi #10! MC. ‘31., 'gta tad-i, 1: port, Hillttan Ibupitnl. 0: tin luttcuul Ilnl%h aurvict. by graafin uaytv nai 31.:115 Instittfio of Haiti} Icalth. v.3. PuBISa Proaoatnd gt ti: 6%; annual V.A. lcuoaroh atatcrtutc, 1': 8/13/61 �rouponio 1n n nonalu fivtatuunt to prudxutlaa o; it: IOdIOIl yrsctatxynorn, at». 31%.: a vary «£517 ttak arupttat ind stuns o: illnoua o: grants. 0: alxnfiurtug :: ti. a putatut, atlact I trtttuon‘ raglan: moat likely $0 otttcfi was». tho tho in ‘8ango clanuitlcttioa unlutnry pntiunt. : of it: ‘13.... :- estabISshcd by antlnitavc 091%.r1a an in typhtlis, 61:50:03 or malaria th¢=phyutotua'u vrohlcn in usnplitatd. whit. clacnttiaa‘taa 1: not b!!!‘ on definittvu . ~ disoutc Inutul thGlittil, tr phynictun's yrobluu 1. uonvlex, tar ha aunt raaovt tn the raeocaittca or pattcrn bssod on his 1361114311 cxyurtanao. Inch olunutrteu‘lon 1. act readily *alldntcd, and in the thuunc- at apccttlsd axtorunl oritoria, 09?!!! in grouwinu to: thsrtpcutta pnrpoaon urc trcqncut. In it. anatanoon Ihlfi rI-caion at. iatubliahod by thuir artistIVInoal, a: in nyphtllo, at hscturzgl tntnottoaa, 0r nvttuasaontu - £rnutncnt 0.100%10n 1: ro&4117 tortacd. what. raunélun up! una~:poottta; n: in the tralCanat if uantnl 311:... by .nvirulnnuttl nuntpulttiun, pnyuhcthurnpy nae vnrlcun phyvluayuuntc thcrapioo, ta. problan 1: Gain placntod, an: only by tun unwoupoattlctty Qt trcntnnufi Eat 37 the probability that pntuutiilly'urtccttvo thornpiou and to mapltsd pct¢at13113 nun. ratpaufillg petuntltlly Ir. r.upond£ag populttiouo. the problnu :- further ocuylioutcd by a Ina! or cvaltatavc crasorsu or aslutnrr «bingo. Variou- uppromintu $1.». 33¢ in a... nu uyuptan tutti: uculni. 3001.1 ari‘«r£s, an 1: heart �.m, Idtp‘ltttnil atannrnt, putiant ¢¢It~rntiu¢a, sud ihtfifll! in strait nynptonu. $31.: 13d1¢¢5 art :cnurllly tlu b?ill. to. incluntvt Out to. non-nyueitzo t; h. utctil. for CIIIDIO, in it. tar¢1t I’lptdn apprauoh, tn; anaunp‘lun that anxiety 1n noarofilt phattc, ufiuro£1n daprcscod, a: paranoid naiinoyhruuiu lthtItfl at. ugutvnloat arousaaOI 1: nit valid. napvtasinn In various «ataoota a: nu I02¢ tan tuna phanoncnuu thug a. ‘3. first in fiukcratlonis, ynluuoatt tr its: drastic. nipacto to tin protlou this! nra. thuruttrc, flirt. of proiitilu: inltvadafil pattant rtuponac to thcrt’yg it. upocsttctttun it purulgtxlu- (pataoat '01-.tAcu); tan talotttuu at fihnrayyy and tho Ipuuartaatioa and cvgllatiua o: bohnvlurul :Inugo. That. guy-etc Itll bu actortbod with rttarcaua in the cauvulalvu thavuyy tvnlnation prvcrtun a! fit. tillaldt laivitdl an ctudtid during thc pnu$ IUVUI gusts. 111131;. Ritalin: it a thgntary, nonwprutxt. eon-natty anppcrtod 1ac$1tatzon 1n luv flirt 63". In that. tuanatomy "no Mum mu gum. a. nun» vulutvu thirty: by afint! pnythsstrtuts to the 19001.1 nu-nfito trastnnat :318 tits) at; roapaanthlu tor all tauntic sysataaut: at tic httpstul. mm: 513:. trantntnt coluctsca our cfimdaou or changn. initially tbcgacq III it datinod by thy Incitinttou. fit. dofiuttilm at ynvunatnvc �n53.» antarctic 5h: tunul atatd group a! Iuhstétu rcfttrfifi um tOOIrdId a itriuty at iuhiriaral ounvnlntvo tharnpy, it: udapttva pgtturnu 3t tho ‘tnnn when nuhsacto had roeoivtd .thc 383509 of troltnnntu Initiatont t0 induct naurtphyiiolocicul antagoa. 1h. pattarun 13011614 cughnriu, hypauuuit. X00. and tauranuad couwltiaw lnfi scumry aiuiniaatsan; atrial, 1am; inoraAI-d tourtulncuo, ugitutian and clattancnt; and withdrawn}, ptranatd and dnluntuual iauattau. In nsnassing than: unitarul, that at nuphartt. hyvonuuat. dupini and 3131315551.» van aroniutntly agitaatiod 81th clinical rattan: 01 Inch inprtvnd uni rnoovcrud. Ha tarnnd this snaptavo and. 'Ilphnriauhapouunxc' as! not fits. as $8. arifioraa (or tic hohtviornl Ihlnli thick at until 11:. ‘0 prodlat (I). in fiatarnino ‘hc p¢pultfitln 9:03. to that thin tdqptlvc puttura (and thorotura by ritad II 3:33 iuprcvui and r'covurcd) an uaahauud fin; Ic‘ul dingaantnu torn: or taught unrc honourabla anyocta at activiuw. Duran; thou. utuaica v. had dcvtlupad a stucopt or in. convultlvu-thornpy'praaist think an tarnnd tin nouruphrsiaiocismudapttva vita (a). In thin vicu, rnpoatad «intuitions urn lCfin a: u dgvtat to alto: brain truatiuug Undur it. atadttann: or tank llifirifi brush taxation h¢hsv1tva1 uasptttionn nuwtga tuned on indivtautl partuntltty, lactacultural and attitudtuul rin$pra. raga. an tomcat unalarna at prcatruasnnut pavnannltty «a: attitndn an pradtttlvu symptoa chock tadiait. liut, mad �.4... It: fit: unit part, It ran nttnr u. ind uolpldtud this. siuasot tint um cosine! tau ‘U‘Qhfitifihltfilil’ pgttaru. :0 ihtfi on than. tahlnu fit: ourltnr «lininal ratings 0: 'umuh auyrwvoafi and *rwcvvared' urn 20903104 and cit. in car vicw, it b: tqnztnd witk than bohmvtnrcl gust-ru- I a ; u: A. Ina-11w Langfiaga nannuran at: tarst gurus-nan! was of imaging. patt‘rnu. and“: by minute» and mm (3) m cum-tuna that pl‘tlfl‘l with basin dyml‘acttQI had churaatortatit lancuucu chanson u: tout-1. diaovtuntttlun and cuatnbulntsou it‘.’ iatruvuacnn an OhOOrVIO tint tnnbnrblfiax. In an. c1¢¢Qr9Ihntk study thcnu a... ltuculcc chtngns uacurrna It‘s 1302.531»; nuubnr3 at fiata‘luu‘a. Ho Ill. fitted tint that. ya‘toatu ohiuttgl‘hosc luncu;go chanson war. in. and. ovalultci an vucovnrtd, title than. nut annihitlag the .chnlgta tutu guncrully tutti an unimprovaa. A lingutnttc soatalt‘iathatu ahavud tbs languagu pntfiarna rntca in :3. Iiifly in he uxpllett £03131, Ianilisn£t¢u, dtuplacuutnfi, CVttiuu, clichcu, crypttu ocuanutc, II. of ttlrd purcun, lhlnxt or tonne, withdrtuul. qunlltiaatiun, :nd roupondxug with 3 citation (h). Xi aaauct probahzu that $3: Iuhsuotc It. august thin. Inusutcu puttcrnc utter aluo‘rcchuok vuuld be the fill any but! u prnpauatty to I‘tflg itch 9I$itlil burst. truatHOQt �.5g' II tait. 12 00:13 olacit sh. laacuago «haunt. by nous prcvcau£1vo no, uhurgtovo. tou‘od 0:0h putanut tutors ulnafircshank by acting qncstloan in t abort a‘rtttnrla intOtvtiu, Idntaiafiartd unohnrbtfial uu‘xl that: In: Ilnrr-d apo¢ah lad ayatngnnn, and #305 rtpuated tho quca‘iout (3). we luarcd tbs Innunrn {pr tho u‘ubur at luagulgc chanson altar mu»! alficd 0:). at u rolatlln butv.uu the ntnbgr or pru~ $I¢utuuai language puttnru chi-go: following :noharbttul ta £hn mutate a: luugnnao chtngcs Ianttuu£ad 311310311: during tn. fourth rock 0: tran‘nout (Tunic I). Furtharnnro, that. can :13. $ rolationohxp httfllfln tn. nuibcr or protrottlout linguoco chanson and about torn clinics: rating: find rtcovorod (tabla 11). or Inch ingrowcd fi‘-‘ .. O“ 40“ ‘ rabltu I, I! 3. ltully Iatorvituw : dautnl p¢raoa31tty rotorrcd it: touvulttvo thnrnpy, Our accond aunnolnnat at; savvniory. In patients worn no tltnrvinuod a ruxttlvu an an uanructurod, caploratorr £n$orvicu. fun qunatton: var! 60313306 ta actarline the vhtci 303:3. to tic pat10u% .pariualutcd tbs axpllost vvrbul plrsonnlity typc duccribol I7 “biacttin Ind tab» (3). an titties itnna, patients were t£09¢4 on & throa point tall. at o, 1 ‘nd 2. 1h. IIOFDI nur- rgnkod and �.75. dividcd in half . thlil in tho app»: htlt cur. taruod 'hxzh Junta: tact.“ and thtst an ‘3. lava: h:1!, us '10! innit! it!!!“ (5). aigaittulut rulutleulhip butauon tin short torn eliutcul rating: (table 111). no abacrvoa a dcnial ntoru and In afidation. chart was a siguztiuuut rulntsonshiy untrue» ‘hn «tutu! IOOIO and it. illhlr or clinical langunso GICIIOI daring £routunu$ (tabla It). D--“m““--‘ 215190 121, IV ..¢..~........ c. lartchnah nutcruanuntu Anothur task cunnyue In: in: lornchtch. 80 did u.% look uyou that tout in thc It!!! inturprctivo nuancr, hat scarce tho IIIbCf and pattcrnt a: Iorlchloh eatcruauv unfit following in. unhonstn 0! 110990: find tollty (6). It III Obaorvcd fihnt vstinga or tank improvud and rucovurad wort tauoain£od with the tailoring Inraohaoh crituric; thaini lunan havonunt (I), ubuuat for: 001.: (re), tut raupauuua. high for: ptroautnco (30), proscuco at atlor (6) Ind 0010: turn (or) if «haunt. a: .11 oolnr, 10' thufliug rulpcntt. can Iahudulo 1: rugrodtco‘ Inblo 1 {7).’ and fihlo V -Wd 1n �.7. a. culitoruia I aetistill anoint! attitudinal tint in tho caiitoruin r 80.1.. this ailpln tank eon-int: at n 0:21.: at 10 unoriiiaai, global sintonnntc to which in. Inbaoct in Ilkod to otprocl the cairn: of his agrcoaont or dinnarcosemi. list .3090. rotioct high tarocnnnt, and low amoroa, hick iiungrtclant (a). that. VII I liguiticuni curt-iniita hair... high r snort. and taverahio clinical rutinga (tail. '1). In addiiion, u. .1:- curriod out toainl factor. Italian (9.10) and roperiod ihai tavorahlo antenna val aaaociuicd with for yuaro or adiaution. tor-inn birth, und .16.: ago. -‘....” Tfiblt VI GQlCEVSIOls In Cilllfy, no but. oboorvcd this a varinty of pr.trottnaat lauuurabia aspect: at b-havior, unually douoribod .3 porooanlitw varinfiina, it. nauociniad with tho devoIOpr nant at tho ouphorieahypolnnio aduptivo pittcrn in unavainivo ihcrnpy and Ir. rated in luck inprcvod u: r-oovorod in our uniting. in... variuklou havo boon auxin-d in language pittorna, Gemini 30.9.. on 2:311: int-trio's, puroapiuni styl- rotlooicd in the nor-chuck, culitorain Sonia nannurn or nttitudc, and in. social variabiao 0: :30, educational 10701, and hirihvluca. r �“as this: permanality and utoitl vurtuhlnu yravtdu tha ptrauptutl and attitudinal bacon tar tug tdnptiva cunngon whiwh oaaur undur thn unufittitag a: Alcarsd Evita function induced a7 rnpcttnd canvulqtoan. tsunami of that. paracn~ alt$y truits. in th. pvncwuua a: aqu£V§lont duct... at Evita lunettun Illdl to 0th.: udtpsivn yu‘turna. attally an to m “mm-4'«ass-9W», a» am a. maman ’ hypluunic luau. the Inn. tha0r0£1oil natal a! tin acurnphyuialouic ¢ IdlpttVI znt¢ra¢tinnn1 hypcahc-is 1: nppliauqu ‘0 drug Gillan-at ig'n‘l ihcrnpy (2.11). "b woula sugguut at. yaynhupharnucnatsaally~1:0!!! tn tho extant that brain tuucslon In Il‘trfid ayataunttenklr. Yucca can bu nonsurud By tin olnatraanoaphulogrnn. althangh ant axalautvqu. Ulnar eh. eundttaouu at pcrnlntent n1£arn¢ hrgia run¢£1ou, ohtugua in aiuptntauu V111 ficaur, dcycnauut 0n prnutruutnwut tht pgrioanltty vurinhlus. 3!... «an h. apouttiaa, tad attitaa piogrunt law in ut lilllidt.‘0.vti¢1 av: nanotling thin nodal :0: variant ya:who$ropio Iz¢ntu. �1a iiuk; l. and tab». 3.3.2 rattcruu at iwhuvturtl nhnsun and Improvunous in auavu111Vt fhnrlpy. 5g; arch. 633: _!gzgg;gt. (in prnsu). a. tint, 5.: 1 Iaitsod fhnory at tho fiction 0! thytisdynnnta $303351... 2. la;§¢§da gang. g; 197*206, 1957. J. Unina£¢$a, 3.1. Ind Kuhn, 1.x.u 9593:; at ;;;ngtug 8M..; 4,“, ¢.c. rkants, 1955. laka, 3.5. and link, n.v' Ghatgct in » - ‘ s . l. A ; Satanic“, In. $nngungc During llocirauhuck Ihavtpy. r Ed. au¢n, 9. an: zubgn, a., Eran. s acrnttaa 1955, pp. 126-139. Ital, 3.1. tut rink. 3.: ruraouniity ructora 1a Behavinrtl laupnnio to Exactruahock Ikurayy. 3. xtnrgggzgh. 53 . &5«u9, 1959. tlnytar, a. raahtnh itchns nu. It! Ibrk, khrld Beak $6., lfiha. labs, B.L. and Fink, n.: Prsgnautit 731:: at Rartehnuh aritarAa in altuical lacyumau t0 cruvulsiwc thorapy. and £01101, 9.3. 2524“, 196a. $d§1fl1 an‘ Attattdo Pallusk, 2.: link, 3.1., u., Illa, {Bularornsu r sail.) ané euavultivv fhcrupy; gaggz_gggzg n¢n3, 23;, 329; xsr~191, late. 3.? una Social raatnra in lain, I.&., rilluck, x. rant, galactiua at Therapy in u Vtiuu‘nry lcnttl lbtpttll. a, :zzxsasg 5352, g; 21£~2¢a, 1957. 1, trauma”. 9» -ho 8 0 A: �13.. mm. 3.3... Mink, “put: 0: Psychiatric huugs and amt.» n. Mutton a: 91mm“. 565-515., 195’. In as an mu “on”. flak, 8.: Boominholuie tht banana“... it. and rank. is: a m alumina). Arch. “In-nun mm Mums. M: g mthat, y taut; a: antenna”. $3me Slum”, mum, mama, 1960. Mnualuz, «I. 11% . III-why, h, �153;! 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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 Prediction of individual patient response to convulsive therapy. VA Cooperative Chemotherapy Studies in Psychiatry, 6:317-24. 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Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/cd19f1b46d47e649344f387e918358a2.pdf 402d7d717080af9c10d773a24db00fb9 PDF Text Text Reprinted from Journal of Neuropsychiatry, Vol. I, No. 1, Sept-Oct. 1959. Personality Factors in Behavioral Response to Electroshock Therapy ROBERT L. KAHN, PH.D., and MAX FINK, M.D. In previous studies”,7 we found that patients who were most likely to improve from electroshock treatment exhibited persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital test for brain disease.10 We reported, furthermore,7 that patients who improved with electroshock treatment had developed a language pattern similar to- that previously described by Weinstein and Kahn}3 in their studies of neurological patients with cerebral dysfunction. Weinstein and Kahn described a language pattern which they called “language of denial” and demonstrated the relationship of this language pattern to the premorbid personality of the patient. On the basis of these observations, we assumed that the patients most likely to benefit from electroshock treatment would be those who most closely approximated the “explicit verbal denial” personality.11 To test this hypothesis, we studied 63 consecutive patients referred for electroshock therapy. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. Thepatients ranged in age from 20 to 66, with a mean of 47, and included 21 men and 42 women. Prior to and during treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient’s family. At the opening of the interview, the relative was asked to describe, in his own words, the patient’s usual interests and attitudes. The relatives were encouraged to talk about any aspect they wished, and the interviewer followed the trend of their talk, rather than proceedFrom the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented at a meeting of Electroshock Research Association, Chicago, 1957. ing in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the “explicit verbal denial” personality. The number and; type of questions required'with each relative varied according to the degree of spontaneous production and the informant’s capacity to comprehend and communicate. The informant was encouraged to give concrete: examples of all statements. The patients were evaluated as to the pres ence and extent of the following character istics: whether they (1) stressed verbal symbols such as resolutions, homilies, cliches-and rationalization; (2) were prestige and; security conscious, and did not enjoy the in; trinsic benefits of health, work, leisure money and property; (3) regarded illnéSs: as an imperfection or disgrace, keeping it an; , secret from family and neighbors, and were reluctant to seek medical care; (4) tended) to “shake off” their own troubles and to be) regarded as practical persons who advise, others; (5) possessed much drive and coma pulsive energy and felt guilty or uneasy if not occupied; (6) were conscientious, with a high sense of duty and responsibility; (7) were sensitive to criticism, regarding it as an attack on their integrity; (8) were proud and tended to avoid help from others; (9) were reserved rather than openly affectionate or emotional; (10) emphasized being correct; (11) lacked imaginativeness and creativity; (12) were not considered by their relatives as dependent; (13) did not discuss sex openly; (14) did not have temper outbursts; and (15) were not “ludic”—a term taken from Piaget8 and used by Weinstein” and Kahn12 to denote comic, tragic or melodramatic behavior. After the interview, each item was rated on a scale of O, 1 or 2. A score of O was given if the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked ,» . , ' ' �' presence of the pattern. The scores for each item were added and, the resultant score termed the “denial personality score.” 2. Clinical Evaluation: Each patient was interviewed prior to treatment and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient’s behavior in the few weeks following the end of the course of treatment, and was based on the evaluation of the patient’s therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: much improved, moderately improved, or unimproved, following the criteria outlined previouslyf‘ 3. Language Study: In addition to. the clinical interviews, each patient was examined with a standardized series of questions directed at determining his attitude toward his illness. Two of the questions asked were “What is your main trouble?” and “If you had one wish, what would you wish for?” The patients were tested before and during treatment, and the verbatim responses were analyzed for changes in language, according to the method previously described.7 Treatment for all patients consisted of grand mal electroshock, using a Reiter elec— trostimulator or a Medcraft alternating-current instrument, on a schedule of three treatments per week. Of the 63 patients, we were able to- interview the relatives of 47; and the present study refers to this group. The denial personality scores ranged from 0 to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the “high denial” group, while those with scores from 0 to 10 were classed as low in denial tendencies. Personality Score and Clinical Response: Patients with high denial personality scores in these family interviews were most likely to be rated as much improved, and only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as unimproved. ') .« TABLE I Relation of Denial Personality Scores to Clinical Response to Electroshoclc Denial Much Personality Improved Score 11 - 25 0 - 25 14 Total Moderately Improved Unimproved Total 7 9 9 1 7 24 23 21 18 8 47 The difference in the denial scores between the much and moderately improved patients, when compared to the unimproved patients, is statistically significant (at 1% level of confidence by Mann-Whitney U Test). Although the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative Observations: Although there is a relationship between high personality scores and the clinical rating, 30 per cent of the patients with low denial scores were also evaluated as showing a marked improvement. While the group of seven patients is a small one, certain common characteristics can be described. Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or others’ feelings. They relate to the environment primarily by nonverbal forms of communication. They are described by their families as laughing or crying excessively and as showing anger by muteness— “going into a shell,” “walking out of the room in a huff”——or by violent tempers with table-pounding, throwing objects or direct physical assault. Personality Score and Changes in Language: By means of the technique of language analysis described in a previous study,7 the changes in language in clinical interviews ~were compared with the denial personality scores. Nine patterns of language change, such as explicit denial of illness or symptoms, displacement, qualification, etc., have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether �. qr nothe showed three or more explicit language changes. Patients with high denial personality scores showed a greater number of language changes than those with low denial personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is +.71, significant at better than the 1% level of confidence. TABLE II Relation of Denial Personality Scores to Clinical Language Changes Daring Treatment Denial Personality Scores 11 - 25 (20) 0 - 10 (20) N 0. Language Changes 0 — 2 3 or more .................................. 8 .................................. 17 12 Total ........................................ 25 15 3 Illustrative Cases Case 1. High Denial Personality Score: A 61-yearold housewife was admitted to the hospital with a 15—month history of insomnia, abdominal. pain and fear of cancer. On admission she was depressed, retarded and seclusive, evincing little interest in her surroundings and wandering aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with much integrity. She had no hobbies or outside interests, and was unable to relax; as a consequence, she busied herself with chores at home. She was “mortally afraid” of doctors, minimized her illnesses and concealed ailments even from her husband. Very restrained, she showed no affection or emotion, never discussed sex and rarely lost her temper. She had “a long memory for little things if she felt that she was wronged,” a “streak of stubbornness,” and would “just as soon hold another person responsible for her mistakes.” She was proud and would “rather go- without food” than borrow or take money from others. According to the denial criteria, her score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a “model” patient who, “while reluctant to discuss her personal feelings, asserted that she had no difficulties at home, had a wonderful husband who was very good to her, considered herself lucky and eagerly anticipated her discharge.” She was discharged with a rating of “much improved.” Case 2. Low Dental Personality Score: A 41year-old housewife was admitted to the hospital with a two-year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission it was noted that the patient paid little attention to her personal appearance, cried readily, showed psychomotor retardation and was circumstantial in speech. The patient was described by her husband as a “negative personality” with whom it was not easy to get along because she was opinionated and argumentative. He regarded her as “completely impractical, with no common sense.” She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. An excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, however, she Would become either completely mute or “very nasty, implying you just don’t know any better.” Although considered a “cold” person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was “naive” and “unrealistic,” believing, for example, that she had a flair for writing although others considered her amateurish. Her personality score was rated as 4. The patient received 18 electroshock treatments, which were terminated at her own insistence because she was too frightened to take any more. At the time of her discharge her doctor noted her as “quite depressed,” but felt it was doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for continued psychotherapy. Discussion The structured family interview was designed to test the Specific hypothesis derived from earlier observations that patients with the “explicit verbal denial” personality are most likely, with electroshock therapy, to show both the language and behavioral changes which are rated as much improved by the examiner. The data support this hypothesis and are also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952.9 They suggest tha “. . . the therapeutic eflicacy of electroconvulsive therapy . . . derives from the production of a. state of brain function in which the mechanism of denial is facilitated in characterologically disposed individuals.” The degree of explicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. On the basis of the present data and methods of analysis, a broader View of’ personality patterns in relation to improvement with EST is now possible. Those patients who are rated as clinically improved are character- ' �8va — _ ,r-Pff-‘wu ‘:_‘_":':'*'r‘-n-€"L ,V"-~.' -: < ,2 ized as: (a) nonempathic—unable to think critically or sensitively about the needs, feelings or communications of others; (b) nonintrospective—unable to think critically about their own feelings or needs, or to achieve insight even with the collaboration of others in the psychotherapeutic relationship; (0) relying heavily on nonverbal communication—even when they are talkative there is little referential communication, the words being clichéd, stereotyped or representative of feelings and emotions rather than transmitters of information; and (d) highly conventional—without imaginative or creative capacity, and with few resources to deal with stressful or new situations. With this pattern as the common background, two classes of patients who respond to treatment can be defined: the driving, conscientious, independent, successful, emotionally controlled person who can be characterized as the “explicit verbal denial” personality type; and the chronically inadequate, affectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short-term response to electroshock, preliminary followup observations indicate that the “explicit verbal denial” personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change shown with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms, and are rated as improved. Others develop paranoid agitated states, become withdrawn or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality factors in those cases whose behavioral response was rated as improved. We have not considered the patients who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information 4.: in this regard is minimal, as this problem has not been approached with a specific hy-“ pothesis. These observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic premorbid personality. Abraham1 noted that states of depression occur in obsessional persons. Arnot2 described depressed patients as being overconscientious and perfectionistic. Hamilton and Mann,5 reporting various aspects of the personality in involutional depression, included such features as “followed a rigid pattern of behavior . . . displayed a lack of imagination . . . narrow range of interest . . . thorough, conscientious, meticulous devotion to duty . . . lack of feeling for point of view of others . . . hard, uncompromising drivers . . . oversensitive . . reserved.” Cohen et al.,3 in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having little capacity for communicative interchange; and unaware of other persons’ feelings toward them or of their feelings toward others. They emphasized the patients’ inability to communicate verbally and suggested that the therapeutic relationship should be in nonverbal terms rather than emphasizing the intellectual content of the exchange, These studies of the personality background of depression show a pattern that is most similar to those personality aspects which have been described as the “explicit verbal denial” personality. The factor of personality could thus explain the fact that depression is the condition that responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to nonverbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism and prestige consciousness which produce a cat- ' > �.' respOnse in the individual faced astrophic 7 With the loss, of a partner, job, business or u'loiv‘ed one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed “improved” by the family and the therapist. Summary and Conclusions To summarize, we believe that our results show that aspects of personality can be differentiated, which are significantly related to the response to treatment. The basic personality pattern of the patients Who respond best to electroshock treatment can be characterized as (a) nonempathic, (b) nonintrospective, (c) communicating nonverbally and ((1) highly conventional and stereotyped, with little imaginative or creative capacity. Within the context of this common care, there are two main subdivisions of improved patients. One group is comparable with the “explicit verbal denial” personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to be chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are affectively labile and ludic. The same personality factors which contribute to a depressive reaction contribute to a behavioral change, under the conditions of altered brain function following electroshock therapy, which is evaluated as improvement. . . . REFERENCES Abraham, K.: Selected Papers on Psychoanalysis. (The Hogarth Press Ltd., London, 1949.) Arnot, R.: The Predepressed Personality. Arch. Neural. (G Psychiat, 76:617-618 (1956). Cohen, M. B., et al.: An Intensive Study of Twelve Cases of Manic—Depressive Psychosis. Psychiatry, 17 :103-137 (1954). Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock. Arch. Neural. c6 Psychiat, 78:516-525, 1957. 10. 11. 12. 13. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Hoch, P., and Zubin, J. (eds.), Depression, pp. 199-209 (Grune d2 Strattan, New York, 1954). Kahn, R. L., Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neural. c6 Psychiat., 76:23-29 (1956). Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Hoch, P., and Zubin, J. (eds), Psychopathology of Communication, pp. 126. Piaget, J .: Play, Dreams and Imitation in Childhood (W. W. N ortau, New York, 1951). Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109:22-26 (1952). Weinstein, E. A., et al.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112:889-894 (1953). Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol. (Q Psychiat, 69:355-367 (1953). Weinstein, E. A., Kahn, R. L., and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease. J. Hillside H08p., 3:98-106 (1954). Weinstein, E. A., and Kahn, R. L.: Denial of Illness: Symbolic and Physiological Aspects. (Charles 0'. Thomas, Springfield, Ill., 1955.) ' ��March 1957 £471.“. Personality Factors in Behavioral Response to ElectroShock Therapy Robert L. Kahn, Ph. D. and.Max Fink, From New WW. M. D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, York. Aided by M—92? of the National Institute of Mental Health, National of Health, United States Public Health Service. grant Institutes Presented to the Electroshock Research Association, Chicago, l. , l, , , gnu-H‘SVAmh-fiy, May 1957. �INTRODUCTION The behavioral response of patients receiving electroshock therapy variable. noted In previous studies of the factors related to that patients who showed is this variability early, persistent and relatively we marked degrees of altered brain function, as meaSured by the electroencephalogram and the amobarbital test for brain disease (10), were most response which was rated as improved (h) (6) (7). likely to The show a clinical present study is an investigation of the role of personality in the behavioral response. explicit hypothesis concerning this relationship has been derived An from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), patients patterns as explicit denial of illness; who develop such language we reported that personal, Spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) studies of neurological patients with cerebral dysfunction. in their They characteru ized this behavior as the "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "ex- plicit verbal denial" personality (11). the hypothesis was advanced On the basis of these Observations, that those patients this "explicit verbal denial" personality type the behavioral changes The purpose after EST who most closely approximated would be more likely to Show which are rated as improved. of the present study, therefore, was to determine: 1) whether personality characteristics related to the behavioral reSponse to electroshock therapy can be differentiated; and 2) whether patients with greater "denial" tendencies are more likeLy to show proved. behavioral changes after electroshock therapy which are rated as imp �~2~ POPULATION Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: 1. Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was asked to describe, in his interests and attitudes.. The relatives patient's usual encouraged to talk about any own were words, the aSpect they wished, and the interviewer followed the trend of rather than proceeding in a serial fashion. The their talk, interviewer asked questions, however, to obtain information in 15 Specific areas which have been described as characteristic of the "explicit verbal denial" personality. and type of questions required with each The number relative varied according to the de- gree of spontaneous production and the informant's capacity to comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence features: 1) stress verbal symbols such as rationalization; 2) are prestige and and extent of each of the following resolutions, homilies, cliches security conscious, intrinsic benefits of health, work, leisure, money and it a and and do not enjoy the property; 3) regard secret from family and neighbors,-and are reluctant to seek medical care; h) "shake off" their own illness as an imperfection or disgrace, keeping �-3troubles and are considered practical persons who advise others; 5) have drive and compulsive energy, and are guilty or uneasy if not much occupied; 6) are conscientious with a high sense of duty and responsibility; 7) are sensitive it to criticism, regarding as an attack on their integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly affectionate or emotional; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; 13) do not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25) After the interview, each item was rated score of O was given if on a scale of O, 1 or 2. A the aspect was noted to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the each item were added and the resultant score pattern. The scores for is termed the "denial personal- ity score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The evaluation was determined by clinical the patient's behavior in the few weeks follow- ing the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist's supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. Patients were classed into three groups: proved, following the much improved, moderately improved, or unimp criteria outlined previously (6). 3. lgnguagg §t_gy: In addition to the clinical interviews, each patient was examined toward his with a standardized series of questions determining his attitude illness. Two of the questions asked were, "What is your main trouble?" and ”If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim reSponses were anal- ized for changes in language according to the method previously described (7). �V «hRESULTS The relatives of scores ranged from h? patients were interviewed. to 25, with a O O denial personality statistical comparison Patients with scores ranging from 25 were consiRered the "high denial" group, while those with scores from to to For median of 11. the patients were divided into two groups. 11 The 10 were classed as low in denial tendencies. Patients with high denial 1. Personality score and clinical reSponse: personality scores in these family interviews were most likely to be as much improved, and only one case was considered unimproved (Table patients with a chance 30% I). In clinical reSponse rating occurred low scores, however, the basis, with rated on of the patients being regarded as unimproved. I TAJLE Relation of Denial Personality Scores to Clinical Response to Electroshock Moderately Much Unimproved Total 9 1 2h 9 7 23 18 8 h? Improved Improved Personality Score - 25 1h 0 ~ 10 7 11 Total . 21 The proved difference in the cenial scores between the patients, significant. % when compared to the unimproved much and moderately im- patients is statistically Although the much improves patients have a higher mean score than the moderately improved group, this Jifference is not significant. 2. Qualitative observations: Although there is a relationship between high denial personality scores she the clinical rating, low denial scores * Significant at ‘1 30% of patients with were also evaluated as showing a marked improvement. 'Hhile 1% .0 ' level of coniidence by HannAWhitney U Test. �-5the group of seven patients be described. and security is a small one, certain common characteristics can Although these Subjects lack the competitive drive, prestige ne ds of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings» They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or bv violent tempers with table-pounding, throwing objects or direct physical assault. patients are "ludic," - a term used These by Heinstein and Kahn (12) to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were compared with the denial personality scores. patterns of language change, such as explicit denial of illness or Nine symptoms, displacement, qualification, 323' have been described as characteristically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial personality scores showed a greater ality scores ality scores number of language changes, than those with low (Table II). The denial persen- coefficient of correlation between the person- and the number of language Chan es is + .71, significant at better than the 15 level of confidence. * This terizwas taken from Piaget behavior of young children (8). who pplied it to the play and imitative �-6- II TABLE Relation of Denial Personality Dcores to Clinical Language Changes During Treatment Number Language Changes - 0 2 3 or more Personality Scores 11-25 (20) 8 12 0-10 (20) 17 3 Total 25 15 h. Illustrative Cases: Case 1. A month High Denial Personality Score: élayear-old houswife was history of insomnia, abdominal nain admitted to the hospital with a 15 and fear of cancer. she was depressed, retarded, and seclusive, evincing On admission little interest in her surroundin s, and uaneering aimlessly about the ward. The patient was described responsible person with and was unable to home. She was much relax. by her husband as a conscientious, dependable, integrity. She had no As a conseguence, she hobbies, outside interests, busiee herself with chores at "mortallv afraid" of doctors, minimized her illnesses and con- cealed ailments, even from her husband. Very restrained, she onenly showed no affection or emotion, never 6iscusse€ sex had "a long memory for little "streak of stubborness," sible for her mistakes." than borrow or take things and would if she and felt that According to the denial She she was wronged," a "just as soon hold another person She was proud ane would money from rarely lost her temper. "rather go reSponu without food" others. criteria, hrr score was 20. After 20 electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor �-7called her a "model" patient feelings, asserted that band who was very good her discharge." who, "while reluctant to discuss her personal difficulties at home, had a wonderful husto her, considered herself lucky and eagerly anticipated she had no She was discharged with a Case 2. Low "much improved." Denial Personality Score: hl-year-old housewife A rating of was admitted to the hOSpital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social activities, found it increasingly difficult to take care of her baby and had suicidal thoughts. On admission the patient was showed attention to her personal appearance, cried readily, psychomotor retardation and was circumstantial in speech. The whom He little noted to pay patient it was was described by her husband as a "negative personality" with not easy to get along because she was opinionated and argumentative. regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would ative person, she liked to sations. When put herself out for others. engage An excessively talk- in long, intellectual, pretentious converu angry, however, she would become either completely mute, or "very nasty, implying you just don‘t "cold" person, she was able to know any better." Although considered a talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "un- realistic," believing, for example, that she had a flair for writing although others considered her amateurish. rated as h. Her personality score The patient received eighteen electroshock treatments, which were term» inated at her was frightened to take any more,, At the time of her discharge her doctor noted her as "quite depressed," but felt that ital. it was own insistence because she was too doubtful that she could benefit from further treatment at the hosp- She was discharged with the recommendation for continued psychotherapy. �-8- . DISCUSSION The structured family interview was designed to test the specific hypo— thesis derived from earlier observations that patients with the "explicit verbal denial" personality are most likely to havioral Changes the examiner. show both the language and be- to electroshock therapy which are rated as The data supports this hypothesis and much improved by is also consistent with the theory of the mode of action of electroshock therapy advanced by'Weinstein, that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain Linn and Kahn in 1952 (9). They suggest function in which the mechanism of denial is facilitated in characterologically disposed individuals." The degree of explicit verbal denial is, however, only aspect affecting the behavioral reaponse to treatment. one personality the basis of the On present data and methods of analysis a broader view of personality patterns in relation to improvement with rated as clinically empathic - ~ improved are unable to think EST is now possible. Those own who are characterized by such features as: 1) non- critically or sensitively about the needs, ings, or communications of others; 2) non-intrOSpective critically about their patients - — feel- unable to think feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic relationship; 3) rely heavily on nondverbal Communication little referential -- even.when they are communication, the words being cliched, stereotyped, or .representative of feelings and emotions action and h) highly conventional .. .. rather than transmitters of informp withoutimaginative or creativecapacity, y'and,with few resources to deal with stressful or With talkative there is this pattern as the common new situations. background, two classes of patients who "‘respond to treatment can.be-defined: a) the driving,.conscientious, independent, �.9can be successful, emotionally-controlled person who plicit verbal denial" personality type; b) the chronically inadequate, coming from an impoverished ively labile and ludic, dependent person, cultural background. characterized as the "ex- 'While both types are rated as improved affectsocio- in their short term reSponse to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical reSponse, while the ludic group is likely to relapse quickly. Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change'with electroshock therapy. The kinds of behavioral change shown with however, vary marcedly in different patients. denial or diSplacement of symptoms and paranoid agitated states, become withdrawn, altered brain function, Some show mood changes and are rated as improved. Others develop or show ory complaints, and are rated as unimproved. In additional somatic or memp this study we have stressed the personality factors in those cases whose behavioral reSponse was rated as improved. We have not considered the patients who were rated as only moder- ately improved or unimproved. If the basic hypothesis is correct, we should also find a relationship between personality and the behavioral response in patients who are rated as unimproved. Present information in this regard is minimal, as These this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic predepressed personality. Abraham (1) noted of depression occurred in obsessional persons. Arnot (2) describes that states depressions as being overly Conscientious and perfectionistic. Hamilton and Mann (5), reporting various aSpects of the personality in involutional depress- ion, include such features as "followed a rigid pattern of behavior....dis~ played a lack of imagination...narrou range of interestS..thorough, conscientious, �.10.. meticulous devotion to duty...1ack of feeling for point of view of others... hard, uncompromising drivers...oversensitive...reserved." Cohen, §t_§l'(3) in an intensive study of manic-depressive psychosis, reported their patients as being highly prestige-conscious; little concerned with problems of interpersonal relatedness; stereotyped; conventional; having communicative interchange; and unaware of self or of his feelings toward others. to be little capacity for other persons' feelings toward him- They emphasized the patients' inability that the therapeutic relationship should in non-verbal terms rather than emphasizing the intellectual contents of communicate verbally and Suggested the exchange. studies of the personality background of depression Show a pattern that is most similar to those personality aspects whidh have been described These as the "explicit verbal denial" personality. The factor of personality could thus explain the fact that depression is the condition which responds best to electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are those which make him responsive to non-verbal forms of therapy. These factors enable him to reSpond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, convention- ality, perfectionism, and prestige-consciousness, which produce a catastrophic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �.11SUMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for e1ectro~ shock therapy were studied by means of a structured family interview. 2. which are 3. be The results show that aspects of personality can be differentiated significantly related to the reaponse to treatment. The basic personality pattern of the patients who respond characterized as a) non-empathic, b) non-introspective, c) non-verbally, and d) highly conventional and stereotyped, with best can communicate little imagin- ative or creative capacity. h. ‘Within the context of of improved personality, patients. One showing such and emotional control. ically inadequate grounds, uho are this group is core, there are two main subdivisions comparable to the "explicit verbal denial" common features as drive, conscientiousness, independence The oflaer group and dependent, coming consists of persons apt to be chron— from deprived Socio-cultural back- effectively labile and ludic. 5. The relationship between these personality patterns and descriptions of the personality of depressed perSOns is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of which altered brain function following electroshock therapy is evaluated as improvement. �.12.. FERENCES 1. Abraham, K.: Selected Papers on Psychoanalysis. London: Press Ltd., 19h9. Arnot, R.: The chiat., 3. Cohen, h. Fink, Predepressed Personality, Zé: 617—618, 1956. A.M.A. Arch. The Hogarth Neurol. & Psy- B., Baker, G., Cohen, R. A., FrommpReichmann, F. and Ueigert, An Intensive Study of Twelve Cases of Manic-Depressive Psychosis, Psychiat., 11: 103-137, l95h. H. E. V.: M. and Kahn, R. L.: Quantitative Studies of Slow wave Activity EEG Clin. Neurophysiol., Q; 158, 1956. Following Electroshock, Hamilton, D. M. and Mann, W. A.: The Hospital Treatment of Involutional Psychosos, in Depression (Hoch, P. and Zubin, J., eds.), New York: Grune & Stratton, 199-209, 1952. L., Fink, M. and weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Kahn, R. 7. Language During Electroshock Communication (Hock, P. and Zubin, Psychopathology of Kahn, R. L. and Fink, M.: Therapy, in Changes in Eds.) in press. Piaget, J.: Play, Norton, 19 51. Dreams and Imitation in Childhood. New J., York: N. W. 9. Weinstein, E. A., Linn, L. and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, Am. J. Pey- chiat., 193; 22-26, 1952. 10. ‘Weinstein, E. A., Kahn, R. L., Sugarman, L. A. and Linn, L.: Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain Disease, Am. J. Psychiat., 11g} 889-89h, 1953. 11. E. A. and Kahn, R. L.: Arch. Neurol. & A.M.A. ness, neinstein, Personality Factors in Denizl of Psychiat., éfi: 355-367, 1953. Ill- 12. Ueinstein, E. A., Kahn, R. L. and Sugarman, L. A.: Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp., 2; 98-106, l95h. 13. Ueinstein, E. A. and Kahn, R. L.: Denial of siological Aspects. Springfield, Ill.: Illness: Symbolic and Phy- Charles C. Thomas, 1955. �--.f\ ._ Personality Factors in Behavioral Response to Electroshock Therapy Robert L. Kahn, Ph.D. and From Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. Aided by grant M-927 of the National Institute of Mental Health, National Institutes of Health, United States Public Health Service. Presented to the Electroshock Research Association, Chicago, May 5/59 195”. �INTRODUCTION .The behavioral response of patients receiving electro— shock therapy is variable. In previous studies of the factors related to this variability we noted that patients who showed early, persistent and relatively marked degrees of altered brain function, as measured by the electroencephalogram and the amobarbital most likely to show a test for brain disease (10), clinical response were rated as investigation which was present study is an of the role of personality in the behavioral response. An eXplicit hypothesis concerning this relationship has been derived from previous studies of the patterns of behavioral change occurring with EST. In an analysis of language changes after electroshock (7), we reported that improved (h) (6) (7). The develop such language patterns as explicit denial of illness; personal, spatial and temporal displacement of symptoms; and qualification, evasion and minimization are rated as improved. These language patterns are similar to those previously described by Weinstein and Kahn (13) in their studies of neurological patients with cerebral dysfunction. They characterized this behavior as the patients who "language of denial" and demonstrated a relationship to personality. In particular they described the characteristics of the "explicit verbal denial" personality (11). On the basis of these observations, the hypothesis was advanced that �-2- closely approximated this "explicit verbal denial" personality type would be more likely to those patients show who most the behavioral changes after EST which are rated as improved. purpose of the present study, therefore, was to determine: The - 1) whether personality characteristics related to the behavioral response to electroshock therapy can be differ- entiated; and 2) whether patients with greater "denial" tendencies are more likely to show behavioral changes after electroshock therapy which are rated as improved. EQPULATION: Sixty-three consecutive patients referred for electroshock therapy were studied. The selection of patients for treatment was made by the psychiatric staff, independent of the judgment of the authors. The patients ranged in age from 20 to 66 with a mean of h7, and included 21 men and h2 women. METHOD Prior to treatment each patient was evaluated according to the following methods: Structured Family Interviews: Personality was evaluated in interviews with members of the patient's family. At the opening of the interview, the relative was 1. �-3asked to describe, in his interests and attitudes. own words, the The relatives patient's usual were encouraged to aspect they wished, and the interviewer followed the trend of their talk, rather than proceeding in a serial fashion. The interviewer asked questions, however, to obtain information in 15 specific areas which have been described as characteristic of the "eXplicit verbal denial" personality. The number and type of questions required with each relative varied according to the degree of spontaneous production and the informant's capacity to talk about any comprehend and communicate. The informant was encouraged to give concrete examples of all statements. The basic items included the presence and extent of 1) stress verbal symbols each of the following features: resolutions, homilies, cliches and rationalization; 2) are prestige and security conscious, and do not enjoy the intrinsic benefits of health, work, leisure, money and such as regard illness as an imperfection or disgrace, keeping it a secret from family and neighbors, and are reluctant to seek medical care; h) "shake off" their own troubles and are considered practical persons who advise 5) have much drive and compulsive energy,.and are others; guilty or uneasy if not occupied; 6) are conscientious property; 3) with a high sense of duty and responsibility; 7) are sensitive to criticism, regarding it as an attack on their �-u- integrity; 8) are proud and avoid help from others; 9) are reserved rather than openly.af£ectionate or emotuonal; 10) emphasize being correct; 11) are not imaginative or creative; 12) are not seen as dependent by their relatives; not discuss sex openly; 1h) do not have temper outbursts; 15) and are not ludic (25). After the interview, each item was rated on a scale of 0, 1 or 2. A score of O was given if the aspect was noted 13) do to a minimal degree; a score of 1 indicated that the characteristic was moderately present; while a score of 2 indicated the definite and marked presence of the pattern. The scores for each item were added and the resultant scoretns termed the "denial personality score". 2. Clinical Evaluation: Each patient was interviewed prior to and at weekly intervals during and following the course of treatment. The clinical evaluation was determined by the patient's behavior in the few weeks following the end of the course of treatment and was based on the evaluation of the patient's therapist, the therapist’s supervising psychiatrist and the supervising psychiatrist in charge of the electroshock treatment unit. into three groups: much improved, unimproved, following the Patients were classed moderately improved, or criteria outlined previously (6). Study; In addition to the clinical inter~ views, each patient was examined with a standardized series 3. Language �-5of questions determining his attitude toward his illness. Two of the questions asked were, "What is your main trouble?" "If you had one wish, what would you wish for?" The patients were tested before and during treatment and the verbatim responses were analyzed for changes in language and according to the method previously described (7). �-6RESULTS relatives of interviewed. The denial personality scores ranged from O to 25, with a median of 11. For statistical comparison the patients were divided into two groups. Patients with scores ranging from 11 to 25 were considered the "high denial" group, while those with scores from O to 10 were classed as low in denial tendencies. 1. Personality score and clinical response: Patients with high denial personality scores in these family interviews The likely to were most patients h? rated as be were only one case was considered unimproved (Table I). In patients with low scores, however, the clinical response rating occurred on a chance basis, with 30% of the patients being regarded as much improved, and unimproved. TABLE I Relation of Denial Personality to Clinical Response to Electroshock Much Moderately 25 1h 9 1 2h to 10 Total 7 9 7 23 21 18 8 h? Improved Improved Total Unimproved Personality Score 11 0 to The difference in the denial scores between the and moderately improved unimproved * patients, when compared much to the patients is statistically significant.* Although Significant at 1% level of confidence by Mann-Whitney U Test. �-7the much improved patients have a higher mean score than the moderately improved group, this difference is not significant. Qualitative observations: Although there is a relationship between high denial personality scores and the clinical rating, 30% of patients with low denial scores were also evaluated as showing a marked improvement. While the 2. group of seven patients is characteristics a small one, can be described. certain common Although these subjects lack the competitive drive, prestige and security needs of the high denial subjects, they show a similar lack of creative or imaginative capacity or ability to think critically of their own or other's feelings. They relate to the environment primarily by non-verbal forms of communication. They are described by their families as laughing or crying excessively; and as showing anger by muteness, "go into a shell," "walk out of the room in a huff," or by violent tempers with table—pounding, throwing objects or direct physical assault. These patients are "ludic," - by Weinstein and Kahn (12) a term used to denote comic, tragic, or melodramatic behavior.* 3. Personality score and changes in language: Applying the technic of language analysis described in a previous study (7), the changes in language in clinical interviews were the denial personality scores. Nine patterns of language change, such as explicit denial of illness or compared with * This and term was taken from Piaget imitative behavior of young applied it to the play children (8). who �-8displacement, qualification, 323. have been described as characterically occurring after electroshock. As in the previous study, each patient was classified according to the dichotomy of whether or not he showed three or more explicit language changes. Patients with high denial symptoms, personality scores showed a greater number of language changes, personality scores (Table II). The coefficient of correlation between the personality scores and the number of language changes is + .71, significant at better than the 1% level of confidence. than those with low denial TABLE II Relation of Denial Personality Scores to Clinical Language Changes During Treatment Number Language Changes 0 - 2 Personality Scores 11-25 0-10 (20) (20) ' Total h. Illustrative 3 or more 8 12 1? 3 25 15 Cases: gigh Denial Personality Score; A 61-year-old housewife was admitted to the hospital with a 15 month history of insomnia, abdominal pain and fear of cancer. On admission she was depressed, retarded, and seclusive, evincing little interest in her surroundings, Case 1. aimlessly about the ward. The patient was described by her husband as a conscientious, dependable, responsible person with and wandering much �-9- integrity. hobbies, outside interests, and was a consequence, she busied herself with She had no unable to relax. As chores at home. She was “mortally afraid" of doctors, minimized her illnesses and concealed ailments, even from her husband. Very restrained, she openly showed no affection rarely lost her temper. She had "a long memory for little things if she felt that she was wronged," a "streak of stubborness," and would "just as soon hold or emotion, never discussed sex and another person reaponsible for her mistakes." She was proud and would "rather go without food" than borrow or take money from others. According to the denial criteria, her score was 20. electroshock treatments, she became euphoric, took an interest in her personal appearance and participated in hospital activities. Her doctor called her a "model" patient who, "while reluctant to discuss her personal feelings, asserted After that she 20 had no difficulties at home, had a wonderful husband very good to her, considered herself lucky and eagerly anticipated her discharge." She was discharged with a rating who was of "much improved." Denial Personality Score: A hl-year—old housewife was admitted to the hospital with a two year history of depression following the birth of her fourth child. She cried frequently, lost interest in social aetivities, found it increasingly difficult to take care of her Case 2. Low suicidal thoughts. On admission the patient was noted to pay little attention to her personal appearance, cried baby and had �readily, showed psychomotor retardation and was circumstantial in speech. patient was described by her husband as a "negative personality" with whom it was not easy to get along because The she was opinionated and argumentative. He regarded her as "completely impractical, with no common sense." She was a poor housekeeper, constantly demanding help from other people, although not the kind of person who would put herself out for others. excessively talkative person, she liked to engage in long, intellectual, pretentious conversations. When angry, An either completely mute, or "very Just don't know any better." Although however, she would become nasty, implying you considered a "cold" person, she was able to talk freely about sex. She frequently complained of physical ailments and went to physicians readily. She was "naive" and "unrealistic," believing, for example, that she had a flair for writing although others considered her amateurish. personality score was rated as h. The patient received eighteen electroshock treatments, which were terminated at her own insistence because she was Her too frightened to take any more. At the time of her discharge her doctor noted her as "quite depressed," but felt that it doubtful that she could benefit from further treatment at the hospital. She was discharged with the recommendation for was continued psychotherapy. �-11- Elialfiilgli structured family interview was designed to test the specific hypothesis derived from earlier observations that patients with the "explicit verbal denial" personality The are most likely to show both the language and behavioral changeswfiflxelectroshock therapy which are rated as much data supports this hypothesis and is also consistent with the theory of the mode of action of electroshock therapy advanced by Weinstein, Linn and Kahn in 1952 (9). They suggest that "....the therapeutic efficacy of electroconvulsive therapy....derives from the production of a state of brain function in which the mechanism of denial improved by the examiner. The is facilitated in characterologically disposed individuals." degree of eXplicit verbal denial is, however, only one personality aspect affecting the behavioral response to treatment. 0n the basis of the present data and methods The of analysis a broader view of personality patterns in relation to improvement with EST is now possible. These patients who are rated as clinically improved are characterized by such features as: l) non-empathic - - unable to think critically or sensitively about the needs, feelings, or communications of others; 2) non-introspective ~ - unable to think critically about their own feelings or needs; unable to achieve insight even with the collaboration of others in the psychotherapeutic rely heavily on non-verbal communication they are talkative there is little referential relationship; even when 3) - �-12communication, the words being cliched, stereotyped, or representative of feelings and emotions rather than transmitters of information and h) highly conventional - - without imaginative or creative capacity, and with few resources to deal with stressful or With new situations. this pattern as the common background, two classes patients who respond to treatment can be defined: a) the driving, conscientious, independent, successful, emotionallycontrolled person who can be characterized as the "explicit verbal denial" personality type; b) the chronically inadequate, effectively labile and ludic, dependent person, coming from an impoverished sociocultural background. While both types are rated as improved in their short term response to electroshock, preliminary follow-up observations indicate that the "explicit verbal denial" personality type is more likely to sustain the clinical response, while the ludic group is likely to relapse quickly. of Consistent with our previous studies we have found that altered brain function is a necessary condition for behavioral change with electroshock therapy. The kinds of behavioral change slacwn with altered brain function, however, vary markedly in different patients. Some show mood changes and denial or displacement of symptoms and are rated as improved. Others develop paranoid agitated states, withdrawn, or show additional somatic or memory complaints, and are rated as unimproved. In this study we have stressed the personality become �-13- factors in those cases as improved. We whose behavioral response have not considered the patients was rated who were rated as only moderately improved or unimproved. If the basic hypothesis is correct, we should also find a relation~ ship between personality and the behavioral reSponse in patients who are rated as unimproved. Present information in this regard is minimal, as this problem has not been approached with a specific hypothesis. observations raise questions concerning the relation of personality to type of mental illness and choice of therapy. Clinical observations support the concept of a characteristic These predepressed personality. Abraham (I) noted that states of depression occurred in obsessional persons. Arnot (2) describes depressions as being overly conscientious and perfectionistic. Hamilton and Mann (5), reporting various aspects of the personality in involutional depression, include such features as "followed a rigid pattern of behavior.... diaplayed a lack of imagination... narrow range of interests.. thorough, conscientious, meticulous devotion to duty...lack of feeling for point of view of others...hard, uncompromising drivers... intensive study of manic-depressive psychosis, reported their patients oversensitive...reserved." Cohen, sflngg (3) in an as being highly prestige-conscious; problems of little concerned with interpersonal relatedness; stereotyped; conventional; little capacity for communicative interchange; and unaware of other persons’ feelings toward himself or of his having �~1h- feelings toward others; They emphasized the inability to verbally communicate therapeutic relationship should be patients' that the in non-verbal terms rather and suggested than emphasizing the intellectual contents of the exchange. These studies of the personality background of depression show a pattern that is most similar to those personality "explicit verbal personality. The factor of personality could thus the fact that depression is the condition which responds electroshock treatment. The same personality factors which make a person susceptible to a depressive reaction are aspects denial" explain best to which have been described as the those which make him responsive to non-verbal forms of therapy. These factors enable him to respond, under the conditions of altered brain function, with those language and other behavioral changes which are evaluated as improved. Thus, the same stereotypy, conventionality, perfectionism, and prestigeconsciousness, which produce a catastrOphic response in the individual faced by the loss of a partner, job, business, or loved one permit the development of denial, minimization and displacement under the conditions of altered brain function and are deemed "improved" by the family and the therapist. �-15SQMMARY AND CONCLUSIONS 1. Personality factors in 63 consecutive patients referred for electroshock therapy were studied by means of a structured family interview. 2. The results show that aspects of personality can be differentiated which are significantly related to the reSponse . to treatment. basic personality pattern of the patients who respond best can be characterized as a) non-empathic, b) non-introspective, c) communicate non-verbally, and d) highly conventional and stereotyped, with little imaginative or creative capacity. h. Within the context of this common core, there are two main subdivisions of improved patients. One group is comparable to the Wkplicit verbal denial" personality, showing such features as drive, conscientiousness, independence and emotional control. The other group consists of persons apt to 3. The chronically inadequate and dependent, coming from deprived sociocultural backgrounds, who are effectively labile and Indie. 5. The relationship between these personality patterns and descriptions of the personality of depressed persons is noted. The same personality factors which contribute to a depressive reaction, contribute to a behavioral change under the conditions of altered brain function following electroshock therapy which is evaluated as improvement. be �116REFERENCES 1. Abraham, K.: SelecteguPafiers on The Hogarth Press Ltd.,‘l9h9. 2. Arnot, R.: The Predepressed Personality, A.M.A. Arch. Neurol. and Psychiat., 1g: 617f618, 1956. Cohen, M.B., Baker, 6., Cohen, R.A., Fromm-Reichmann, F. and Weigert, E.V.: Antintensive Study of Twelve Cases Psychosis, Psychiat., 11: 103-137, 1ofsfianic-Depressive 9 3. Psychoanalysis. London: 5 o R.L.: Quantitative Studies of Slow Wave Activity Following Elastroshock, EEG Clin. Neurophysiol., g: 158, 1956. Fink, M. Hamilton, and Kahn, The_Hospita1 Treatment of D.M. and Mann, W.A.: Involutional Ps choseg, in Depression (Hash, J., 6. 933.5, New Stratton, FT and Zubin, 199-209, 1952. and Weinstein, E.A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, Kahn, R.L., Fink, A.M.A. Arch. 7. York: Grune E M. Neurol. & Egychiat., lé‘ 23-29, 1956. Kahn, R.L. and Fink, M.: Changes in Language During Electro— shock Therapy, in Psychopathology of Communication (Hoch, Zubin, J., eds.) New York: Grune & Stratton, 1958, P.6and 12 ~139. fi J.: Play) York: W.W. Piaget, 9. Norton, l9Sl. Imitation in Childhood. New Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy, 10. Dreams and Am. J. Psychiat., 109: 22-26, 1952. Weinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.: Diagnostic Use of Amobarbitai Sodium ("Amytal Sodium") Am. inSOrganic Brain Disease, ""‘ J. Psychiat., 112: 889-89h, 19 3. 11; Weinstein, E.A. and Kahn, R.L.:’Personality Factors in Denial of Illness, A.M.A. ArCh. Neurol. & Psychiat., £2: 355-367, 1953. 12: Weinstein, E.A., Kahn, R.L. and Sugarman, L.A.* Ludic Behavior in Patients with Brain Disease, J. Hillside Hosp. 2: 98-106, 195h. Weinstein, E.A. and Kahn, R.L.: Denial of Illness: Symbolic and Physiological Aspects. Springfiél’, 111.: Charles i 13. UT Thomas, 1955. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Personality factors in behavioral response to electroshock therapy. J Neuropsychiatr. 1959 Sep-Oct; 1:45-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-41-007 Date A point or period of time associated with an event in the lifecycle of the resource 1959 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Two [preprints] and one reprint. Reprint fromJournal of Neuropsychiatry, Vol.I, No.1, Sept-Oct. 1959 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/a1c70b872beb13c5b56dba9ecef3099b.pdf de32dee2acdbbfa2e67eb3cd0c31e52d PDF Text Text Simultaneous of Perception Tactile Stimuli in Normal Children Max Fin/z, M.D. and Morris B. Bender, M.D. Normal adults readily identify and localize tactile stimuli applied simultaneously to the face and the hand (the “face-hand test”).1 While half the subjects perceive stimuli incorrectly on the initial trial, all are accurate by the tenth trial of the test. Young children, however, find the task of identification and localization of two skin stimulations difficult. They report only one of the two stimuli, or, if they report the two, frequently mislocalize one of them. The omission or mislocalization of stimuli is not haphazard but follows a consistent pattern in which stimuli to the face are readily appreciated (“most dominant”) while those to the hand are not (“least dominant”). In order to determine the pattern of “dominance” in children and the age at which such tactile perceptual tasks are correctly performed, a study of normal children was undertaken. The responses of children to the face-hand test and to simultaneous tactile tests of other body parts were ascertained. SUBJECTS AND METHOD Three hundred normal children between the ages of three and 15 were examined. They were from a neighborhood child care center, from the wards and clinics of Bellevue Hospital, and children of neighbors and friends. They were without manifest disorder of the nervous system. A few children at two and a half years of age were included in the three year age group, but younger children were generally not able to comprehend the test. The subjects were examined individually, but there were many who were examined in a day-room in full view of other children. The child was engaged in play and when toys were available they were used to gain his confidence and interest. At some time during play, the face-hand test was introduced. From the department of neurology and psychiatry, New York University College of Medicine and the Bellevue Hospital, New York City. This work was aided in part by a fellowship grant from the National Foundation for In- fantile Paralysis, and by a grant-in—aid from the Coordinating Council for Cerebral Palsy in New York City, Inc. Read at the fourth annual meeting of the American Academy of Neurology, Louisville, Kentucky, April 24, 1952. 27 Reprinted from NEUROLOGY, Minneapolis, January, 1953, Vol. 3, No. 1 �28 NE UROLOGY For the face—hand test, the child was told: “I (examiner) am going to touch you,” and he was to “touch the same place I touch.” He was asked to close his eyes. The examiner, with the fingers, then touched simultaneously a cheek and the dorsum of the contralateral hand of the subject. The child was asked what he felt, and to point to the sites stimulated. After this response, the child was asked to close his eyes again, and now the opposite cheek and hand were similarly stimulated and the report recorded. If only one response was given to this trial, the child was asked if there had been another stimulus anywhere else. Following these two trials, the cheek and hand on the same side of the body were tested in a similar fashion. The fifth and sixth trials were not of asymmetric body parts but simultaneous stimulation of both cheeks or both hands. The following various types of stimulation were used: heterologous stimula— tion of asymmetric body parts on opposite sides, as right cheek and left hand; homolateral stimulation of asymmetric body parts on the same side of the body, as right cheek and right hand; and homologous stimulation of symmetric body parts, as both cheeks or both hands. Such tests were repeated in each child until at least ten trials were recorded. Subsequent tests of other body parts, performed in a similar fashion, were introduced until at least 20 consecutive trials were observed in each subject. A number of modifications had to be introduced for young children. Many would not play the game with eyes closed, but insisted on keeping their eyes open. In such cases the tests were applied with eyes open. Also, a large number of three and four year old children insisted on pointing to the examiner’s hands and face on the initial trials. For these children, a few trials of single touch stimuli applied to the thigh, chest or hand were introduced, until they grasped the concept of pointing to their own bodies after the stimulation. These single trials were carried out with eyes open. After the series of double simultaneous stimulation tests were completed, single stimuli were applied to various body parts to exclude from the normal focal difficulties. with subjects any sensory group The children were asked what they had felt and to point to the places stimulated. Verbal reports of the locus of stimulation were not accepted. It was occasionally noted that children would correctly name the parts stimulated, i. e., the cheek and hand, but then point to both cheeks, or to two places on one cheek. It seemed as if naming the locus yielded more accurate responses than did pointing. These tactile tests were repeated on consecutive days, or subsequently after a lapse of a few days or weeks in some children. At such times, cutaneous stimuli other than light touch were added to the testing. These included repetitive touch (rubbing), single pin prick, and repetitive pin pricks. RESULTS Incidence of errors: Young children made many errors on face-hand tests. Eighty per cent of children under the age of six failed to localize both stimuli �PERCEPTION OF TACTILE STIMULI IN CHILDREN I00 m 2, E ,_ 9 II m p. k no: m at “J ,— uzJ u o: to u. 100 90 (“C9, ‘ 80 85 70 L2 so 2 | 4 5 6 7 8 9 IO I2 ll .‘N‘K ‘ . '\ x. _ __ “t“ c: In a. 3 '_ ‘~~. \._x_x_‘. - \K 3 0 \,\,. -----------.‘ I‘. E 20 ‘ \ LA— 30 ‘. .- 8 so c: 0 4o o 30 40 ‘- 60 o. 50 -------------- 70 Z 60 \ ' 90 r: ~-.. a . ,_\.-___..‘ 29 _ 3 ......... . YEARS 5 YEARS 7 YEA S .----I ~~~~~ o .......... 9 YEARS L345 NUMBER OF TRIAL AGE Graph 1. Graph 2. during the initial ten trials of the face—hand test; many of these even with eyes open. In the older children the number of failures fell sharply (graph 1) so that only 2 per cent of children in the 11 to 15 year age groups continued to make errors after the initial ten trials. Apparently the ability to identify two simultaneously applied tactile stimuli was directly related to the age of the child. This ability was also related to the number of previous trials of the face-hand test. In table 1 the trial of the test after which the child was consistently correct is recorded. The last column of the table includes all the subjects who made errors in the first ten trials, and on many trials of the test beyond the tenth. Graph 2 illustrates this relation for selected age groups. Type of testing: In these studies homolateral and heterologous stimulations were carried out at random. Errors were made by subjects of all age groups in tests of either type. Homologous tests, such as both cheeks, or both hands, randomly interspersed in the testing after the fourth trial, elicited correct reof this served clue While all the older to in as a some cases. nearly sponses TABLE 1 NUMBER OF TRIALS OF THE FACE-HAND TEST NECESSARY FOR PERSISTENT CORRECT RESPONSES ( Age 3 4 5 6 7 8 9 10 ll 12 13—15 Total Number of Subjects 39 34 37 36 26 22 23 20 21 24 29 Touch Stimuli) 1 2 — — — — — 2 — —— l 4 2 2 6 8 6 2 6 8 3 7 4 10 Trial Correct 3 4 5 6 7 l l 1 l 6 3 4 5 2 4 6 — —— 3 2 2 — 5 4 l 6 4 l 8 9 — 2 1 — 2 — l — — —- — 2 2 5 4 — — 1 2 2 1 — 2 2 2 — 1 — — — — 1 — — — — l 2 1 — -- — — — l 2 l l — 1 — —— — 2 Errors Beyond 10 Trials 34 28 28 22 10 4 3 2 0 2 0 �30 NE UROLOGY children that two stimuli were being applied, it did not seem to alter the results in the younger children. In these subjects subsequent trials of the face-hand test were incorrectly reported, even though the responses to the symmetric stimuli had been correct. The perception of symmetric stimuli was much better than asymmetric stimuli. Subsequent testing: Of the total group of children studied, face—hand tests were repeated at varying intervals subsequent to the initial testing in 40 children. Of the children under the age of six, subsequent testing elicited the same difficulties with face—hand tests as was evident on the initial examination. In a few children over six years of age, who seemed to have grasped the concept of two stimulations in the initial testing, errors were manifest on subsequent days. It was as if many trials were necessary for successful learning of the task, and then, even though the task was successfully completed, the learning was temporary. These observations are in contrast to those made in normal adults, in whom subsequent testing did not elicit the errors of the initial test.1 Type and pattern of responses: The errors (table 1) made by children on repeated trials of the face-hand test were of six types: (a) a touch on the cheek only, implying no perception in the hand; (b) a touch on each cheek, implying a mislocalization of the stimulus applied to the hand; (0) a touch on the cheek, and a second touch on the shoulder, neck or elbow, implying a partial mislocalization of the stimulus applied to the hand; (d) a touch on the hand only, implying no perception in the cheek; (e) a touch on each hand implying a mislocalization of the cheek stimulus to the hand; and (f) one or two touches on the examiner’s body, implying a mislocalization away from the child’s body. Face dominance (responses (I, b, c) was apparent in all age groups. It was most manifest as extinction“ of the stimulus to the hand (response a), and was seen in 62 per cent of the errors. Mislocalization of the hand stimulus to the cheek (displacement) was observed in 31 per cent of the errors. While most of the displacements were observed in tests involving cheek and hand on opposite sides of the body, 7 per cent of the errors were displacements from the hand to the cheek in the simultaneous stimulation of homolateral body parts, e. g., right cheek and right hand. At such times the child pointed to the cheek once, saying “a touch here,” and then, moving his fingers 2 to 3 centimeters lower on the cheek, saying “and here.” Other types of displacement were infrequent. There were partial displacements from the hand to the shoulder or neck. Mislocalization of a stimulus across the midline of the body, known as allesthesia,3 was occasionally apparent in the stimulus to the hand on heterologous testing. Furthermore, children *The failure to report one of two simultaneous stimulations has been called “extinction” of a stimulus? The mislocalization of a percept to the homologous body part of the second stimulus is called “displacement.” The mislocalization of a percept in the direction of the second stimulus is called “partial displacement.” In each instance, the stimulus which is correctly reported is said to be “dominant.” �PERCEPTION OF TACTILE STIMULI IN CHILDREN 31 under five years of age frequently mislocalized the initial stimulation away from their body to parts of the examiner’s body or into space (response 7‘). This phenomenon, known as exosomesthesia,4 persisted in some children despite repeated stimulations with the child’s eyes open, and despite the examiner’s insistence that it was the child who had been touched. Another phenomenon was seen during homolateral testing. The child reported only the stimulus applied to the cheek. If the examiner asked insistently, “Did you feel another touch anywhere else?”, a number of children hesitatingly pointed to the symmetrical point in the Cheek on the opposite side of the body. In order to determine whether this was a unique or a systematic phenomenon, tests of other body parts were carried out. In homolateral tests of foot and hand, shoulder and hand, and cheek and foot, the same phenomenon was observed. The child first reported only the foot, the shoulder or the cheek—and then, when the examiner insisted on a second locus, pointed to the opposite foot, shoulder or side of the face. Furthermore, in some young children the phenomenon appeared on single stimulation. Single stimuli applied to any body part were localized correctly. If the examiner then insisted that there had been a second stimulus, the child pointed hesitatingly to the symmetric part on the opposite side of the body. As already indicated, hand dominance (responses d and e) was infrequent. It was observed in 7 per cent of the errors on face-hand tests. In all subjects in whom it was apparent, subsequent trials of the face-hand test manifested the pattern of face dominance. Relation of hand and foot: In tests of parts of the body other than the face and hand, the hand was always least dominant and the cheek the most. Simultaneous tests of foot and hand, the foot-hand test, were introduced after the initial ten trials of the face-hand test in most children. In the foot-hand test, foot dominance was apparent in 51 per cent of the responses (see table 2). It was demonstrated by hand extinction, by displacement of hand stimuli to the foot, and by partial displacement to the thigh, knee and leg. TABLE 2 FOOT-HAND TEST ( Touch Stimulation Bilateral Ipsilateral Stimuli) Total Trials 53 48 Responses Correct 21 23 Foot 17 16 Hand 1 3 F oot— Foot 10 3 Partial F t.—F t. 2 3 HandHand 2 O Other stimuli: A small group of children who made errors in tests repeated at varying intervals were examined with other cutaneous stimuli. Extinction and displacement phenomena were present in face-hand tests using pin prick, repetitive pin prick and repetitive touch (rubbing) stimulations. While the number of errors with these stimuli were fewer than with touch stimuli, the �32 NE UROLOGY still extinction hand of and dominance face was apparent. pattern DISCUSSION The ability to identify and localize simultaneous stimuli separated from each other at some distance is a complex function which gradually develops during the first decade of life. It is a relatively unstable ability, for many Focal discriminations. such disturb of the the in state can organism changes cerebral disease as in hemiplegia5 or parietal lobe lesions,2 spinal cord lesions,2 and diffuse brain diseases such as toxic states, senility and inflammatory conditions6 can so alter tactile discrimination that the phenomena of extinction and displacement become prominent. Errors in simultaneous tactile tests are the of the trials few initial the test—during adults normal in during apparent period of learning.1 Persons subjected to large doses of barbiturates,6 electroshock therapy6 or anesthesia7 also manifest such inability. A prominent feature in all groups is the uniformity of face dominance. When discrimination of simultaneous stimuli is interfered with, for whatever stimuli the in hand and the stimuli not the made to in the are errors reason, to the face. The corollary of “face dominance” is “hand extinction.” It, too, is apparent in all subjects and under the variety of conditions studied. Furthermore, in an “order of dominance” other body parts are between these two limits. Studies in patients with hemiplegia5 and patients with severe mental of dominance order revealed have disease6 of brain result an a as changes of face-shoulder—trunk-thigh-foot and hand. Insofar as these other body parts were studied in these children, a similar order was observed. Since dominance is evident in young children, it appears that the pattern of dominance is an inherent function of the organism. This childlike way of responding to simultaneous tactile stimuli is exposed and exaggerated in adults under a variety of pathologic conditions. these of dominance rostral to explain has Cohn a theory suggested Recently observations.8 Our observations are not in accord with such a theory. The dominance of the foot to the hand in children, as well as the dominance of with of series hand in the two foot and to patients large buttock, thigh penis, diffuse brain dysfunctionfv9 make such an explanation untenable. with in with children normal in findings patients of findings Comparison those with children in the On mental findings comparing syndrome: organic previously reported in patients with severe mental changes due to brain dysfunction,6 a close similarity in performance is observed. In both groups the ability to discriminate simultaneous stimuli is limited. On non-homologous tactile tests, such as the face—hand test, errors are made on initial and subdisis the of stimulus most While extinction frequent trials. error, a sequent with a and children both In errors is occur patients, common. placement done be stimuli. of Furthermore, frequently testing cutaneous may variety with eyes open, and in many instances with repeated verbal clues that there is of factor The not prommade. still and learning are stimuli, errors two are inent Since testing on subsequent days will elicit the previous patterned errors. �PERCEPTION OF TACTILE STIMULI IN CHILDREN 83 In Gestalt terms, patients with organic mental defects and children have diffi— culty in extracting a complex sensory “figure” from the “background” of the total sensory “field.” Significantly in each group there is no difficulty in identifying simultaneous stimuli if the stimuli are applied in symmetric regions of the body, such as each hand or both sides of the face. Here, each stimulus figure has a common background in terms of body image, namely the hand.10 Face dominance is apparent in both groups. It is manifest not only on tests of face and hand but also on tests of face and other body parts. Also, insofar as it was tested, the order of dominance for other body parts is similar. While extinction and displacement are the most frequent types of error, other phenomena are elicited in both children and patients. Partial displacements, e. g., the mislocalization of the percept from the hand to the shoulder or neck on the face-hand test, are occasionally observed. The phenomena of allesthesia and exosomesthesia are seen in the more severely affected patients and in the youngest children; both are frequently associated in the same subjects. In allesthesia, the subjects usually localize the cheek stimulus correctly but mislocalize the hand stimulus to the opposite hand or elbow, In exo— somesthesia, the stimuli are mislocalized either to space in front of the subject or to the examiner’s body. This phenomenon was frequent in the youngest children, and despite the examiner’s urging that the child point to its own body, the child persisted in such mislocalizations until a trial of the face-hand test was performed with eyes open. In addition to these phenomena which appear spontaneously, patients with organic mental syndrome also manifest another response to simultaneous stimulation first noted in children, i. e., on homolateral testing only one stimulus (the cheek) is spontaneously reported; but when the examiner insists, the second is mislocalized to the opposite cheek. Since the patients show so many similarities to young children in their responses, it was predicted that they would also show this phenomenon. In a series of patients with severe mental changes, homolateral tests of the cheek, hand, foot, shoulder and thigh were applied. When only one stimulus was reported, the examiner asked for the locus of the second stimulus. Responses were obtained in 20 per cent of the patients, and in each one the second stimulus was mislocalized to the symmetric body part. Furthermore, in some subjects the same phenomenon was observed with single stimulation. This phenomenon appears to be similar to the completion phenomenon described in Gestalt literature as “closure” and “good continuation.” These are usually described for other sensory modalities. When a circle is tachistoscopically exposed in the visual field so that half falls on a hemianopic field, or if a cross is exposed so that the center falls in the blind spot, many subjects report a complete circle or cross. This “completion” occurs for “good” figures. In simultaneous tactile studies, symmetric figures appear to be the “good” or “strong” figures. �NE UROLOGY 34 CONCLUSIONS Ability to identify and localize asymmetric simultaneous tactile stimuli develops gradually during the first decade of life, and is present in 80 per cent of normal children by the age of eight. Symmetric stimuli are more readily localized and this ability is well developed in normal three year old children. 2. The errors on asymmetric (bilateral and ipsilateral) stimulation involve either extinction (only one of the two stimuli is reported), or displacement (one or both stimuli are mislocalized). Whenever extinction and displacement occur, stimuli to the face tend to be correctly reported. This face dominance is found at all age levels tested. 8. One can conclude that extinction and displacement of tactile stimuli, as well as face dominance, constitute a normal and consistent pattern of rechilin these addition In children. observe, in to one can responses sponse dren under six years of age, the phenomena of allesthesia, exosomesthesia and partial displacement as normal reactions to simultaneous tactile stimulation. 4. The difficulties in recognition of simultaneous tactile stimuli, as shown by young children, reappear in the same fashion in adult patients With focal or diffuse dysfunction of the brain. The abilities of tactile discrimination acquired by the child during growth are lost by the adult who develops mental changes as a result of cerebral damage. 1. REFERENCES M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests 0f face and hand, Th Am. Neurol. A- 751 250, 1950; BENDER, M. B.; FINK, M., and GREEN, M.: Patterns in perception on simultaneous tests of face and hand, Arch. Neurol. 5‘ P sychiat. 661355, 195.12. BENDER, M. B.: Extinction and prec1p1tation of cutaneous sensations, Arch. Neurol. 8c Psychiat. 54:1, 1945; KOLB, L.: Observations on the somatic sensory extinction phenomenon and the bOdY sch—eme after unilateral resection of the posterior central gyrus, Tr. Am. Neurol. A' 75: 1950' 3- BENDER’ M' 3'; WORTH, 5' B" and CRAMER’ J“: Organic mental syndrome w‘th phenomena of extinction and allesthesia, Arch. Neurol. & Psychiat. 59:273, 1948. 4' SHAMRO’ M . F .'’ FINK’ M. ’ and B ENDER ’ M. B.: Exosomesthesra, or the phenomenon 1c e ment of sensation into extra p er o f di spa 8‘ Psychiat. 68:481’ Neurol. Arch. space, $109221 717, 1949. 1. BENDER, _ 5' _ _ M. F and Extinction phenomenon in FELL , A . W, .. hemiplegia, Arch. Neurol. 8c Psychiat. 62: BEND-ER M B . SHAPIRO SCHAP- M. 3,; The face-hand test as a diagnostic sign of organic mental syndrome, Neurology 2:46, 6. PINK, M_; GREEN, M" and BENDER, 1952, J” and M. B.: Perceptual patterns during recovery from general anesthesia, J_ Neurol., Neurosurg. & Psychiat. 14:316, 1951_ 8 . COHN, R., and RAJNES, G. N.: On certain aspects of the sensory organization of the human brain: A study in rostral dominance as determined by ipsilateral simultaneous stimulation Tr Am Neurol A '74'162 1949. COHN, R.: On certain aspects of the human brain: sensory organization of the . . .1 f A Ch‘d‘en’ II Neurolsggljylfllgastlrgsfiommancem 7_ JAFFE, BENDER, 1 9. GREEN, M., FINK, M., and BENDER, M. B.: . . . Order 0 f dominance in cutaneous perception. Tr. Am. Neurol. A. In press. 10. JAFFE, J., and BENDER, M. B.: The factor of symmetry in the perception of two simultaneous cutaneous stimuli, Brain 75: part 2, 167-176’ 1952’ �All, [:w.,¢ffl (f P Aflu‘ f 1 \. 3/“5 ”a...” «w 0' V -—« ‘ "1“" ‘3'". :’ I ‘1 - momswammanual I! W swam new m cm h I“ m, I.B.*’ ' and MM! 3. Bind”. Id). mun-11:16:11.0. ’0 «mum»: 11» 3.11m mama, 1m: 1m: mum tar mama. 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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/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/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/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/348b7ac617e184efef2c6c30c847fca6.pdf 36100719e5c813fdabfca556caa0ba68 PDF Text Text Reprinted from TRANSACTIONS OF THE AMERICAN NEUROLOGICAL ASSOCIATION 1950 PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER MAX FINK AND MARTIN GREEN NEW YORK In previous studies we found that the method of double simultaneous stimulation showed defects in sensation (extinction) which were not apparent on routine single stimulation. In testing two different regions of the body and various combinations it was found that extinction was apt to occur most often in the hand and least in the face. Conversely, “dominance” was greatest in the face and least in the hand. In the present communication we wish to report the results obtained on simultaneous stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syn— drome; 4) schizophrenia; 5) no disease of the brain (normal adults) and 6) normal children between the ages of four to ten years. Patients in groups 2 and 3 showed severe memory defects, confusion, poor orientation, difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched Simultaneously. Care was taken to make the two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked to report what he felt, and following this, where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first examination: a) a touch on the face only (face dominance), implying no Sensation in the hand (extinction) ; b) a touch on both sides of the face (there being “displacement” from the hand to the ipsilateral face) ; or c) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that on subsequent tests he was expectant of more than one stimulus. In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislocalization was towards the face it appeared as if the face determined the direc250 �251 Perception in al.——Patterns Bender, et of type a this was that therefore, said, be might It than tion of the displacement. common less was displacement, or (b), Response dominance. face the patients in often most seen was (b) Response extinction. or (a) testing. response repeated despite persisted and with the organic mental syndrome, comment. special needs no and normal expected the was face The (c) response ipsilateral the when noted werealso Extinction and displacement including tested, subjects the all In tested. sides and hand were simultaneously left and right the between difference no was there aphasia, with those - ' of the body. the in shown is various groups the in obtained results Analysis of the following table: Hand ;/,’// Group Face Response Extinction or Displacement Number of Subjects 2 ‘4 22 20 5 53 ' 3 20 . 0 14 24 , 19 ‘ 0 6 20 ' Response _ 9 12 15 12 1 Face and Head Response ‘ 2 6 28 0 ' ‘ - 0 0 0 . j . l l of is dominance there whenever that obvious is it; foregoing the From. the hand in Dominance face. the in is it apparent another over sensation the in one "uniformly almost found was dominance Face once. notedonly did was patients These 2 and 3).. (groups changes mentalwithsevere in. _ subjects few a In repeated'testing. after hand even the not report sensation in were or stimuli, two were there told the were patients after even stances, percept one only reported they stimuli, of the of asked to watch the application sides both of stimulation simultaneous cases Inthese one. displaced these that or objection the excluding thus correctly, the face was reported once. things at _. two perceive do or able to not were those in and patients with aphasia subjects in dominance face of The'incidence, in .. patients 1 and 4) was less. In contrastto with schizophrenia (groups correctly sensations both 1 4 reported and in those groups 2» and 3, the hrst groups done not had soon if they trials, fourth third or second, the domiface on of. incidence the 5) adults (group normal of the In group the trial. on found only it was though even significant, still but least, dominance nance was face of incidence the. children normal of series In trial. a dominance first face children 3. In 2 and young in groups as the same almost was examination. first the after trials several tested was present even hand were the than other body of the When theface and parts The apparent. still was dominance face 3, 2 and in" groups calf, simultaneously thigh, penis, (breast), trunk shoulder, face, was dominance order of hand. and foot, arm . . _ �252 Weights (IL—Discrimination of Bender, et CONCLUSION In a wide variety of subjects the phenomena of extinction and displace- consistent A demonstrated. stimulation simultaneous were ment on double dominant most face the which in was established of pattern perception was and abnormal the in both noted These findings were and the hand the least. the normal subjects. In the abnormal subjects with severe mental changes, be that consistent they may extinction were so face dominance and hand used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, be to brain diffuse disease, with in appear patients which are so prominent exaggerations of the patterns found in the normal subjects, especially children. �um II mama! 0' MES 0! I‘M! w 3mm my- A! Harris 3. Bender, ILD. Pink, IL». m and lax-tin anon, LB. of lumbar fipi‘ffinfi '75; Buivenity cones. of Mieinc, 555 Sinai City. tort lelpiul, In m lupin ' 101E law c fiy Edi-y,1 and that Haunt 3.11m. from the mum; grant a ”starch by part) (in This work was aided a. by grant and part) (in service Public With of math, Institutes Inc York . city. in Cmbral of In council his: Coordinating the I‘m �1.' Previously it was shown thst exsnihstioh of the cutaneous uodelitiec by the method or double siuultsneous etisnlstion elicited defects in perception which were not sppsrent on single “extinctiont” ”obscuration,” The ss defects, desctihed etihhlstion. "displacement” and "eliesthesis'.were observed in groups of or the centrsi nervous disesse diffuse with localixed or patients systen (1) (a) (3). In esch group the defects in cutaneous per» most were stimulation double sismitsneous obtsined on ception of the rhe fece. hand the sud object in the lesst in appsrent or the was responses determine to patterns investigation present in nonnsi subjects, sduits and children,to simultaneous stisu1s~ Yarns "fece~hs.nd” observe~ head and teat the face of the tion tions in this nonnsl group were then cospsred to sole extent with the responses of pstients with orgshic mental syndrases, sphssis sud cchisophrenis. IAEIR£égc the ”non-s1“ subjects were children and sdulte. These there. subjects were persons attending hcspitsl clinics, in was no evidence or disesce or the brsin; and school children, start of disorder manifest who: no was there sud in students, personnel been had Hone of then previously system; the central nervous exslined by the nethod or double sisultsneous stimulation. the to according sge: three into groups classified were subjects 12 “adults” end 6 over end years. 7 to 3 children or to it years, For comparison with the noml goup we studied patients on 'There were three Bellevue wards of Psychiatric the iospitsl. the sod lo attempt sphssis. psychoses ~ organic schizophrenia, group: whom �2. .uno and. to separately study each or the clinionl typo: of schisophronil. float of tho puticntu ours or the paranoza, mixed or iinplc vurietiel of Iohixophrenin. the patient: uith organic montnl changes showed doreota 1n nonorw, orient¢t1on and onloulution, a: wall In other signs and symptom: oharuoteriltio or dxtruoo dileIIO of tho brain. Tho clinical diagnoael in loot of,those onuou was Althoincr'n dilt&§c, urtorionolcrotio onoop~ haloputhy, severe oorobrll ordain, brain tumor or toxic ano¢p~ who with thou mm uphuu. lubjootl mommy. ohnrnotcriltio difficultiob in columnioation. Theta who had a oonoolitant hmnipnroail or I huuiscnlory aorta? noticeable on single Itilnlation war. not inorudod in thin Curios. m '3th maroon: 2h: subject val instruotcd to‘olouo tho cyan. When thia 1p3111tcéll (chock) and tho oontrav done or either tho-root it: our. hand ninnltnnooully on. (any hand digit.) at or part lateral touohcd or stroked with tho examiner‘s ringorl. the subject: whoa two sonsntionn; only one percept one or either reported no: reported tho subject was naked 1: than. at: 3:111 unothor, and 1: no, to indiooto its loontion and quality. Following the initial trial, in each subject, tho opposite chuck Ind hand aura stimulatod 1n the 1.80 nunnor. Those tout: poquepoatod and tho result: reoordod, until tho subject: oon~ who those In both auhjootl otinnli correctly. nistontly roportod toiled to localize tho two Itinuli oorruotly otter at: or eight word an touted t1oo~ttoc,'hand~ body the of 0th.: part: triala, room-hand tho with uumung ma, “mama, penis-hand, em, tout. �otinuleé eerie! ot.stndies pin prick tions sere used in s sinilsr fsshion.w In both series, cere use taken to apply the stimuli at the me time and with the em thst'snhdects who‘nede consistentt was spherent intensity. It he would correct as soon es the stinuli were errors in reporting rsther thsn sinnltsneoutly, even if the spplied consecutively tine leg betseen stinuli was that or one or two nonente. It was slso necesssry to use neive norssl subjects, since sthects previously tested did not show the.petterns noted below. In e second sepsrste 8 ones; lhe responses obtained on the tnce~hsnd test fell into four groups: (s) s touch on the face and the hsnd, indicstins the correct end expected perception; (h) e touch on the fees only, in the head; (c) I touch on both sides or implying no eensstion the tees: and (d) s touch on the bend only, implying none on the race. flhen only one stimulus III reported the subject use ssked if there uss any other sensstion. the oocesionsl reply sue that there use snother percept, and the sthsct correctly pointed to the second locus. lhny hdhaects, however, reported thst they hsd not perceived snother stimulus, neuslly sdding the state-cut: ”In use not paying sttention - do it seein' or, ”I'm not sure - Isvhe of here" end somewhere the the was direction in over pointing it side of the body or the poorly felt stimulus. In some instances, second while correctly locslising the percept, they Iinnteered the ststenent: "It use not es strong es the other one,“ or "It doesn't seen as sharp.” Before we proceed with the results we rust define the connnnicstions other the failure or the need. In special terns �#. luhjoet to report ohm or two ninnltnnmaunly applied stimuli ha: of been called “tbs phhnhnenon gunnery extinction“ hr ”extinction“ 1n utid wharu stinmlu; tho poreeived or body the (1). the part Ill uxnultanuhulh to he "danihnnt” ta the part of thh body where thn Itinnlun nun net perceived, or parceivcd faintly. the latter aensatieh was terncd ”obnouration.' or a the diminution in quality whah tho uuhject ruparted tun nonnatiehn, hut ninloenlilod one or thun, the "ditplhccncnt' a: a peroapt in .315 to hire oeeurrea (2). ndsplaccnentu Ir. ununlxy 1n the direction or tht daninnnt ’ntinnxup and as: he puttinl hr eqnpxgte. rhe‘dilplaccucnts nttcd man» chock the side. of hand.to th1§.ner1gp tn. were :ran.the in Rarely did the displscahehts cedar to the hack or thauldor. tram the nthhdpoint {hm snalyuod result; \Ih1t1h1‘2r1hxs uqrt of initial and nuhluqnont thee¢hnnd test with touch trilla. en Ithhlltion tn. initill trial or the Inhjcetn, taco deninnnec uuu appurant 1h :11 use granny. 'lhrc_thnn half or such and none in thc race the in the schnation udulta rcported nonntl hand. lhrno Cubdoetn ninlaehlisod tho lentation 1n the hand to thn £160. In thn green: of hon-n1 children 90! under the use of hand the percept hiuloealizcd thee the or hereopt :1: reported only tha {teeddhinhnoe in a: also 1: seen face. the Ibis pattern to children tram 7~12 years of age hat.th a 10:30: extent. hand the adults‘reportod or the ham-ll suhjaotl, five indtidl or example dinplaeenont In thn an trial. only Ittnulus noted. hand was tram race to by hand extinction or by daninanee face or Ill pattern the more apparent was tune even th hind percopt of.the dinplncclant 1n nornnl �in thn patients aznninad. Xt uun.noat evident in patients with arggnic gantal chanset, 935 or when did not repert bath stimuli corrnctly. In callinntion. or uchixqphrunio lub:ectn and patinntu with aphnail runponneu lililnr to thnse of thc annual adult were observed on tum intill trial. land doninnnoe was accllionllii seen in the patient and vital: in tn. net-:1 Iahjpat. In «use. of hand dominance the race' not the reported the but percent; It was seen manual I in the initial trial on m five different net-11 Malta .. In the” instano§3. tun nubaoct ropnrtod both.ttanu11 carrectiy oh nubaoauunt tinting. In the patidntt with organic mental changes hand dauinnnee III In inconntant rtupanto and rcpeated touting the sale day or on unbloquant dawn danonntrated thy amt! usual poruiutunt pattern or dominanco. "" ' rm 1 stilulttion ,Rolponso on initini roueh 19ml Adult lam]. «mm, low emu. Totalicorrcot Pace Only luaowraae land Only 160 77 15 3 5 3-6 564 m 23 18 a 7.12 76 33 27 9 2 7: 26 n5 1 2 syndrome 120 9 9n n 3 o o Schisoyhranin (“malt-niried) mute luau: trill . i Apmu Submgguont I 23 Erialla or the 12 83 11 narnti adult. uh» nude errata initial trial, #3 were correct on the uecond and 12 on the third triul. In a to! sub: '“Vffliaur. five at Ii: trill! var. the nucOIsary berare the tun stimuli Into corructly localised. than. on �6.‘ ta be annual, althuugh complete psychologiaal (tennion during that noted VII anxiety It the with to'ploaae) interfered desire strong callinltton,er.n annual :11 aubaeetl, In rncognition the of ntiauli.v torruct early aubjoets ware Inlunnd tent. wcro.not dune. the IIB correct once those rosponae with anxiety, including abtn1npd (oven all fitter an was iith elicited error.) it trials number warn or if n¢cncd a an tritll It many aubnequont_teut1ns.: ”aét“ axmnlnntion, the at the into neoenuary_ror tn. anbaect'ta set evon cccurutoly, trtcr the ha ntinnli riported the once in tad set, of any WI; ”9,10.an in that was apparent child annual wanna th: it In testing inst canon Inn: tail: war. nocolsnry.h¢£ore the correct rotpanse was «enlistently elicited. Alta, tan child at. not tlltya dayu. many over tasting lopeutcd tubaugunnt touting. an correct of Ibis tuna daninlncc, in: shin tbs patterns hauever, olicittd natod in 36 of tho 56 childrtn tottqd, ‘In a number of instances than and reportcd tho stimuli appz1¢nttan can o; Intchcd en. child was thy But repeated an test noon corroetly. percept1onn tbs t; stimulus. on. repertod child tho «my with tm «you acted. min or “int” the tn» in: not into could tho get ehild evident that It oxtninntion, even with viaunl anal. 311 In children. in not wag apparunt vary thin diffieulty t6 the 76 give the failed 17 at anly (age: 7-12) the older group correct renponse utter th; inititl tau trials. 1.: at the nae-hand on the reports obtained repeated. A: relieved connintent s pattern. test: in mgr-:1 nubjecta also tubsocti. on tbs initial trial, face daninnncc was trivalent in all or or‘ obsmatien (a) extinction by It was: unite,” uthor " tr: m �8. or the autumn te displacement fees, or er me atmii ”.in aevertl insteneea the displacement we. in a direction tantra (1)) by O3 ' em taco. In contrast to normal adults, patient; with organic mental change: were unuhie te regert the two stimuli earreetly even utter many triele. When_the yetient reported the pereept in ane teet eorreetly, he frequently failed on tubuequent testing; It was tine Ipperent that touting en subsequent‘daye etiii elicited in and er stimuli. extinction dieeinemt m: u ntrang who made seldom unmet: to tn error apparently subject: centreet on subsequent tritiu, day: after the initial examination. the responses obteined in this group demanetrated the pattern: at tee. teetffl deninnnee in meet or the niepiaeenent of the hind percept to the tune was frequent. In tame instances dieplneement or extinctien was preeent deepite the {get that the putiont watched the applitutiea of the etinnii to the fete and hand. Extinetien was very taxman en hencieterni or heterologoun teeting while ~ fine apparent dilpieoenent neatly on heterolegeun teats. 514; the and nyhneie patient: the uehisephrenie reports gayb which were «1:111: te normal adulte. After the first tie trial: the pertentnge of errer in hand sensation was slightly higher than in the normal greup. reraietent bistrre reepoaeee were elicited from a number or the schizophrenic Inbdeetl. lheee reperte inelufied multiple responses to mingle or daubie stimuli, pereietent displacement: to one area from any other body area, ineonsittent verve end 'mimrreveruls or localiutien. day: As normal the to free with an day examinetien_and eating consecutive an the aphasia subject Iehixephrenie touting or idnlt, M �days roiled to elicit extinction phenonehe once the been eccorltely reported before. test hen ‘ comparison of the reeponeee or each or theoe groove to nultiple teeting in chain in fig. 1. A firfi 54’” Pin Phick Btiuuietioh: It in known thet the type or etinuiue epplied influence: the result: in perception. To denonetrete the importance or thie rector einiier groups of subject: were tested ueing two pin prick ineteed or two touch etilnletione. With pin prick etinnieticn ct tece end hencflfece dominance wee egein uehiteet in all the groupe. however, the incidence of error in perception of the pin prick in the head III lower than with e touch etinnloe. Ihe reeulte are recorded in IhhflcIIt Elna! II :1 ' afizaiififmfi’fim lttei tor-ll Adult correct Pace only Feccqrece Hind an}: 68 51 15 2 c flannel child, 3~6 yearn #5 lorlml Child,7~12 your! 39 50 Schizophrenin 16 26 2 1 25 1h 0 0 36 13 9 1 arsenic lentei syndrome #7 9 33 3 2 Repeated testing with two pine in the nccnfii adult subject: elicited the correct reeponeee in the initiel three trieie. Fever at the chiloren figificd to report the teat eccuroteiy after the initiel trials. ~It we: poeeibie ih_e hunter or instance: to alternate touch and pin prick etieuietiohe, end demonstrate extinction to touch, but correct localization to pin prick. loreover, with �m. abre intehae pih prick atianlatieh, extinction and diaplaeeaant were lean frequently ebaerved. vzheae phendaena, haaely extinction and diaplaeeaent were eveh.nbre apparent in the patiehta with erzahie mental ayadreaea. Bdaplaeeaeht or touch ltd-311 eauld be alternated with oerreet Idealiaatibn of pin brick atzaulatiah. A ddubihatxon or touch tb the fade had pin prick te the hand evinced the edubinetibn at displacement and obaenratioh, an the patient reported “a teach an the fade, and a dull the en the other aide {or the face).' Pin prick to the eheak and teach to the hand raaulted 1n extinction hand the pareept; be, oeeaaiehally, the rephrt or a pin prick of both an the cheek and hand. rhe aehizephrenie aubaeete were able to loealiae the pin prick accurately after the initial ten trials, an had the aerial mule: . Blflaflbazfll: mains the nethbd er dabble ainnltaneoua atinulatibn in teuta or the face and the hand a eenaiateht pattern bf reapeneea baa been observed in a variety hr aubaeota. the atinnlua to the m.’ 1: non readily perbeived than the one 1:: the me. «never, the pareept in the race influences the due in the hand, frequently canning the displacement of aehaatibh. 1h1a pattern a: reapbhaee haa been repeatedly deaehatrated in bath the annual and abnormal eubJeeta, and 1a aahireet 1h extinetibn, obaeuratibn and diablaeeaant. Extinction 1: abet and diaplaeeaeht :- leaet frequent. In eatinetien, the race pereept 1a correetly reperted aa te quality and leans, but the hand attanlua 1a not perceived at all; In all hf the rereading teat: or patient or abrnaz aubJeeta§*uhether By �11; ' tha reaponaaa were aaeurate tr not, it uaa notod that tbs stiuuius yointad to the face tirat. aubjaet almost invariably pattoived and 1a ourrectly hand perecpt tha Octaaianally iooaliaed, but anamnea a qualitative differonce, always of diaifintion. In displaeunant tha percent in the hand 1: 113* such an the or rage, tho it direttitn the face, or localiscd tn to tan ahauldor er nuak. In aunt instance: if tha taco cud tho hand at the lama aid: are stimulated, tho lubaeet occasionally 1a thaae phnnancna of 1n lane the taco. raporta tut paroapta ah: or these un1eh one with the rrtquancy haphaaard. nail. varia« druga, be attention, observed affected by may erraeta 1: tion in atilnli, ate., it: pattern 1: eonaiatent. Thea. raaponaaa to tha face-hand teat arc undifiad by nan: (b) attenttan. factor] arc flame influnnning of tbs fa) factora. or atinnlna, (a) type of stimuli, (0) simultanaity d: subject, aga (o) atrensth a: stilnlua, (t) locua of atilnlation and (3) internal with tha fragment, Etna; alter fatter! lax atate or organiaa. afipeur do change net but and that displaccnaut which Ixtinetien tbs pattern or face dalinanso. 1a in factor of tha teat a.na:or Iuardnaaa the aubaact'a 80th attention extinntiun. a: thy phannncnon of tho appearance ’)( awarenaai€£)1n.a and priviona axpnrionoa tun bring stimuli to two to were informed who Itinnli that unra adulta atria: or twanty Baoauaa proviaua of applied abouad extinction parcepta. be non. tan abet-nary rcaerd ta uaa intluensa.a response it experience in.ha1ve flatbed aw this aubjccta. tha.f1ndinga on initial trial At the Ian» wan aintniacd. experience or previoua en. tactar number the ”alert" for he the on tine tbs aubjcct was not apt to ' �of stimuli he an: ta reeeive. cannequently ene night nay thet the reason the subject perceived only one Itinulul or perceived ene and diupleeed the the other at he atinnluu in that pefifypt 4 was not peying ettentlen. this aritieinn may be valid but the Iiznifieant fact it 9 //¢w » % that the error III always aide in the hand and net in_the‘teee. I: it were mere inattention one utula expect 50! or the single response: ta dauble einultaneeue stimulation ta be in the hand end 50% in.the flee. But this type or ehance enter was not ebterved. it the single reepenaes ta double lilultaneeul Iti-nluticn 95% were at the fete percent and 5% at the hand pereept. Iain pettern of race daninnnee or hand extinction examinetionl. further during subsequent eitublilhed Ill lereovee, when dinplneenent II. seen in normal aubJeetn, it was to the race and not ta the hand. ihin pattern at face daninnnee to deuble tinultnneaul stimulation was fauna to be exnggereted in nan-.1 young children, when 83$ deuanetrated either 33nd.extinetion or displeoenent at er the hand pereept to the face an the initial triel. loreover, this high percentage of face duuinnet reiponnet peruisted on eubuequent trielE. In the elder children ulna tece delineate we: consistently demonstrable. It It: noted that the younger the ahild, the more distinct In: thie puttern of race daninnnee. awn extinetion night he Ittributed to an mummy to perceive two ltflluli at once. Ehiu particulir detect has been noted in patient: with severe until change? (“Zlf'fifievm in patient: with severe lentel changed or in young children itinuli epplied to both cheek: or both hands or.eny other two hanglegonn body even: were correctly reported as tee uenentione. Ihere it: _ �neither extinetion nor displacement. aaldstein'eKohuervatien, therafere, cannot be used an an explnnetion for hand extinetion. what matter daninanne in noted apparent flee that at It is types or etimnlltion was used. Simulteheoun pin prick stimulation: revealed the pattern of face daninenee, elthaugh with e leaner frequency than touch etinhiltiona. ether duteneeua utinuletion such :1 two tuning forks, hot and cold telperature tuhel, rtpetitive rubbing and repetitive pin prick Itianletian were Ipplied and neniteet regardless of the cuteneeun utilnletiun race daninence is flied. inphrtmee of the ainulteneity or the ”man. has nlrudy been alluded to. In eubJeetn in when extinctidn In: persistent, consecutive epplieetion or the stimuli invariably resulted in the permeption or two stimuli. In actual Idultn consecutive the nun-L1 the on the even of two trial, we ma. etiluletion extihetioa. never resulted in -euuni thin thy nerd ntinuli intensity. at these ethdien In aux-aux, the for in inn-pom: the in pattern mum eliciting ”I. stimuli here teemingly mare readily perceived than equal etiuuli. After the first few trials the etheet was able to perdeive the two stimuli, even it one we: pnintul and the other not. In and diaextinction mental hhuevee, with chnhses, organic patient: quality, the wide dinorepency in pleeenent were manifest despite a of the stimuli. aw Altering the etrength a! the Itinhli, it ran hand the at the tram extinction response pdlaihle to alternate th teak) the' ta diepleaenent were hand the stieuli percept (if .gheek (if the head stimuli were utrang). The sneeze than extinhtien ulst the the at by quality elidited altering run displacement to The ' ‘ �13. touch the to ,Ievertheleac, frna prick. pin that ia atiunli, a at. a,ua oe'aaa the part: of the body being aianltanecnaly atianlated are have patterna. theae I! etudying consideration in another already alluded to the fact that extinction ie anat cannon in the hand and leaat in the face. In teating other body areaa the incidence of extinction and diaplaceaent ia leaa than in teating and ahcnlder thigh nay hand. and the testing the face Ithat is, not elicit extinction or cbacnraticn,where the faceehand teat will. Alec, in patients with leaicnn or the brain or apinal cord, the pattern or relationahip cf the body parts tc aiaultaneoua atinnlaticn.nay be altered in a characteriatic haniaenaery or ”level leaicn' ayndreae. Aa fer the aignificance cf the pattern be can the leaning before prayer further atndiea are neceaaary would be time purely thin deducticn.aade Any at interpreted. that by gained atating ia nothing For inatance, speculative. dcainance (7). of inpliea order aenccry rcatral a daninance face Such hypetheaia ia ccntradicted by at leaat one tact, naaely the ‘chaervaticn that when the hand and fact are atimlated eimltanecualy data are hand. after'ncre Perhapa the dcninatea over the fact accumulated a aatiafactcry theory night he obtained. , QUIIIRI: hand haa and race the cf teata in pattern in perception method cf the abnaraal and anh:ecta.hy been elicited in actual dcnble simultaneous atianlaticn of cutanacua uhdalitiea. hand the of percent extinction by Face delinance, aaniteat an a in seen the hand to race, the or percent or dicplaceaent the~ and in non-a1 the adulte, in naniteatcd normal phancaencn, aeriea. the exasined in and anhaaie cchiacphrenia with patienta A �15. with in m in menu:It 1: mcntod young «mum and what ,of ditpnouont the «unfit.» bran in an...” mitten: utter may}. mun . . um. m 1: at run or unite“ denim” usual.” pattern m: 1n the a only clung. {chucking the autumn- nodanw team, a! 11th in type “mum. .cxtincuoa' at rmugnay am. ‘ �m, mm W :m. In,” Wtifll m t ‘4; “1,5151 m m m «some. mm m.“ 1.!” Id. “.3. mo mm. m, 19”.Mum-sic 3.: (I) cum... mm m mm. m, at unusual than. ”pm ma. a; M ammo 3.1.: Aug-mu m m ' Mm m mummy Mmkwém Datum 81mm!“ 11W. m. mnnmuumumumwmm mum. £1. Pittm‘03.; I. w m mum m; m. u-mmmuormmomm -.-.m: 1. (I) W 3.3. 1‘ “ ‘3) 2. (a) 3. I ‘ if... .5 . --... 08 , and - ...., 610: «.5 an .LL. -. > , ' and 813-191, 5 . 1 am. 1.1. 11.3.;and in 11.: @1162!!! 5. mwflw W mm. mmm In fit an 6. . W Warm. to mom chum- as «W 1M6 61m 72: 5 nth m to frontal am “so. «poets of m may W Auwmmmm 5mm mm manna-mm. cm, R. and m max. mam... at 1956. tn “1. 1959. and 501.515. ,5 -. ‘0 117.121., _ ‘ 8.3. ILL! (o) 50 phonon-manor 1n 5......- 1'. 9: 3.1.: 9:135:19: wholes“ 1 ”“33; of pm1p1uuea m and 11014: 11.8.: (h) m1 mm mum. an 6.1.: w by 191111101111 166-1685 19195 tuna-Mon. �PATTERNS IN PERCEPTION By: ‘I 0—m— ON SIMULTANEOUS TESTS OF FACE AND HAND Morris B. Bender, M.D., Max Fink, M.D., and Martin Green, In previous studies we found that the method of double M.D. simultaneous stimulation showed defects in sensation (extinction) testing In which routine were not apparent on single stimulation. ; the two of body and various combinations it was different regions \, found that extinction was apt to occur most often in the hand and least in the face. Conversely, "dominance" was greatest in the face and least in the hand. In the present commuhication we wish to report simultaneous on obtained the results stimulation of the face and the hand (the face-hand test) in groups of subjects with the following conditions: 1) aphasia without hemiparesis or hemisensory syndrome; 2) aphasia with severe mental changes; 3) organic mental syndrome; disease 5) of the no 4) schizophrenia; ,‘ brain (normal adults) and 6) four of between normal children the ages to ten years. 'Patients in 5 2 showed and severe memory defects, confusion, poor orientation, groups difficulties in calculation and other symptoms characteristic of diffuse disease of the brain. Method: The subject was instructed to close his eyes. When this was done his face (cheek) and contralateral hand (any part of the hand or fingers) were touched simultaneously. Care was taken to make two stimulations of equal intensity. As soon as the stimuli were applied the subject was asked tox°eport what he felt, and following this, Where he felt the sensation. Identical tests were carried out with light rubbing and pin prick stimulations. Results: Under these conditions the subject gave either of the following responses on the first-examination: a) a touch on the face only (face dominance), implying no sensation in the hand (extinction); . $1.1mMuTfizA kfiWJqM 5.4.1:. �2. b) a touch on both sides of the face (there being "displacement" from the hand to the ipsilateral face); 0r 0) a touch on the face and contralateral hand. In the (a) response the subject was asked whether he felt still another stimulus. The reply was either in the negative, or there was uncertainty or vague approximation. This question suggested to the subject that there were two stimulations so that than one stimulus. on subsequent tests he was expectant of more In the (b) type of response the subject mislocalized or displaced the sensation evoked in the hand toward the ipsilateral face. Since the mislobalization was towards the face it appeared as if the face determined the direction of the displacement. It might be said, therefore, that this was a type of face dominance. Response (b), or diaplacement, was less common than response (a) or extinction. Response (b) was seen most often in the patients with the organic mental syndrome, and persisted despite repeated testing. The (c) responSe was the expected normal and needs no special comment. Extinction and displacement were also noted the ipsilateral face and hand were simultaneously tested. In all the subjects tested, including those with aphasia, there was no difference between the right and left sides of the body. Analysis of the results obtained in the various groups is shown in the following table: when �3. Group of Subjects Number 1 15 2 12 3 Face Response Extinction or Face and Hand‘ Hand Response Response ~ Displacement 9 6 O 12 O O 22 20 2 O 4 20 14 6 O 5 55 24 28 6 20 l l From - p . 19 o it is obvious that whenever there is sensation over another it is apparent in the face. the foregoing dominance of one p Dominance in the hand was noted only once. dominance Face was found almOSt uniformly in the subjects with.severe mental changes (groups 2 and 5.) These patients did not report sensation in the hand even after repeated testing. In a few instances, even after the patients were told there were two stimuli, or were asked towratch the application of the stimuli, they reported only one percept or displaced one. In these cases simultaneous stimulation of both sides of the face was reported correctly, thus excluding the objection that these patients were not able to<io or perceive two things at once. The incidence of face dominance in subjects with aphasia and those in with schizophrenia (groups 1 and 4) was less. In contrast to patients in groups 2 and 5, those in groups 1 and 4 reported both sensations correctly on the second, third or fourth trials, if they had not done so on the first trial.‘ In the group of normal adults (group 5) the incidence of face dominance was least, but still ' significant, a even though it was found only on the first trial. series of normal children the incidence of face dominance was In �In young children face dominance was present even several trials after the first examina- almost the same as in groups 2 and 5. tion. the face and parts of the body other than the hand were tested simultaneously in groups 2 and 3, face dominance was‘ The order of dominance was face, shoulder, grunk apparent. still When (breast), penis, thigh, calf, foot, arm and hand. In Conclusion: a wide variety of subjects the phenomena of extinction and displacement on double simultaneous stimulation were demonstrated. A consistent pattern of perception was established in which the face was most dominant and the hand the least. These findings were noted in both the abnormal and the normal subjects. -In the abnormal subjects withseVere mental changes, face dominance and hand extinction were so consistent that they may be used as a sign of diffuse disease of the brain, but only when found to persist after repeated examinations. The pattern of dominance, as well as the phenomenon of extinction, which are so prominent in patients with diffuse brain disease, appear to be exaggerations of the pattern found in the normal subjects, especially children. I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. Trans Am Neurol Assoc. 1950;51:250-2. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2a-003 Date A point or period of time associated with an event in the lifecycle of the resource 1950 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Two preprints] and a reprint. Reprint from Transactions of the American Neurol Assoc. 1950;51:250-2. (abstract). Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a>; Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/abb942c109b57ff8986a7757e43563c2.pdf 23a7bbd876571d7517224c266ad15ea2 PDF Text Text Patterns in Perception on Simultaneous Tests of Face and Hand _ N...”- —-. MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK Reprinted from the Archives of Neurology and Psychiatry Septmnber 1951, Vol. 66, pp. 355-362 COPYRIGHT, 1951, .‘BY AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO 10, ILL. Printed and Published in the United States of America �Reprinted from the A. M. A. Archives of Neurology and Psychiatry September 1951, Vol. 66, pp. 355-362 Copyright, 1951, by American. Medical Association PATTERNS IN PERCEPTION ON SIMULTANEOUS TESTS OF FACE AND HAND MORRIS B. BENDER, M.D. MAX FINK, MD. AND MARTIN GREEN, M.D. NEW YORK it PREVIOUSLY was shown that examination of the cutaneous modalities by the method of double simultaneous stimulation elicited defects in perception which were not apparent on single stimulation. The defects, described as “extinction,” “obscuration,” “displacement,” and “allesthesia,” were observed in groups of patients with localized or diffuse disease of the central nervous system.1 In each group the defects in cutaneous perception obtained on double simultaneous stimula— tion were most apparent in the hand and least in the face. The object of the present investigation was to determine the patterns of in normal subjects, adults responses and children to simultaneous stimulation of the face and hand—the “face—hand” test.2 The observations on this normal were then compared to some extent group with the responses of patients with organic mental syndromes, aphasia, and schizophrenia. MATERIAL The “normal” subjects were children and adults. These subjects were persons attending hospital clinics in whom there was no evidence of disease of the brain, and school children, staff personnel, and students, in whom there was no manifest disorder of the central nervous system. None of them had been examined previously by the method of double simultaneous stimulation. From the Department of Neurology and Psychiatry, New York University College of Medicine; Bellevue Hospital, and the Mount Sinai Hospital. This work was aided (in part) by a research grant from the National Institutes of Health, United States Public Health Service, and (in part) by a grant from the Coordinating Council of Cerebral Palsy in New York City, Inc. 1. (a) Bender, M. B., and F'urlow, L. T.: Phenomenon of Visual Extinction in Homonymous Fields and Psychologic Principles Involved, Arch. Neurol. & Psychiat. 53:29—33 (Jan) 1945. (b) Bender, M. B.: Extinction and Precipitation of Cutaneous Sensations, ibid. 54:1—9 (July) 1945; (c) The Phenomenon of Sensory Displacement, ibid. 65:607-621 1951. (May) (d) Bender, M. B.; Shapiro, M. F and Schappell, A. W.: ., Extinction Phenomena in Hemiplegia, ibid. 62:717-724 (Dec.) 1949. (e) Bender, M. B. ; Wortis, S. B., and Cramer, J.: Organic Mental Syndrome with Phenomena of Extinction and Allesthesia, ibid. 59:273-291 (March) 1948. (f) Bender, M. B.; Shapiro, M. F., and Teuber, H. L.: Allesthesia and Disturbance of Body Scheme, ibid. 62:222-231 (Aug) 1949. (g) Bender, M. B., and Nathanson, M.: Patterns in Allesthesia and Their Relation to Disorder of Body Scheme and Other Sensory Phenomena, ibid. 64:501—515 (Oct) 1950. 2. Bender, M. B.; Fink, M., and Green, M.: Patterns in Perception on Simultaneous Tests of the Face and Hand, Tr. Am. Neurol. A. 75:250—252, 1950. �2 The subjects were divided into three groups according to age: children of 3 to 6, and 7 to 12 yr., and “adults” over 12 yr. of age. For comparison with the normal group, we studied patients in the wards of the Bellevue Psychiatric Hospital. They were divided into three groups on the basis of their disease— schizophrenia, organic psychoses, and aphasia. No attempt was made to study separately the clinical types of schizophrenia. Most of the patients had the paranoid, mixed, or simple variety of schizophrenia. The patients with organic mental changes showed defects in memory, orientation, andcalculation, as well as other signs and symptoms. characteristic of diffuse disease of the brain. The clinical diagnoses for most of thesegpatients was Alzheimer’s’ disease, arteriosclerotic encephalopathy, severe cerebral trauma, brain tumor, or toxic encephalopathy. The subjects with aphasia were those who showed characteristic difficulties in communication. Those who had concomitant hemiparesis or ‘a hemisensory defect noticeable on single stimulation were not included in this series. MET HOD The subject was instructed to close the eyes. When this was done, the face (cheek) and either the ipsilateral or the contralateral hand (any part of the hand or digits) were simultaneously touched or stroked with the examiner’s fingers. The subjects reported either one or two sensations. When only one percept was reported, the subject was asked if there was still another and, if so, to indicate its location and quality. After the initial trial, in each subject, the opposite cheek and hand were stimulated in the same manner. These tests were repeated and the results recorded, until the subjects consistently reported both stimuli correctly. In those subjects who failed to localize the two stimuli correctly ‘after six or eight trials, other parts of the body were tested in such combinations as face-face, hand-hand, face-breast, or penis-hand, these stimulations alternating with the facehand test. In a second, separate series of studies, pinprick stimuli were used in a similar fashion. In both series, care was taken to app-1y the stimuli at the same time and with the same intensity. It was apparent that subjects who made consistent errors in reporting would be correct as soon as the stimuli were applied consecutively rather than simultaneously, even if the time lag between stimuli was that of one or two moments. It was also necessary to use naive normal subjects, since subjects previously tested did not show the patterns noted below. RESULTS The responses obtained on the face-hand test fell into four groups: (a) a touch sensation on the face and the hand, indicating the correct and expected perception; (b) a touch sensation on the face only, implying no sensation in the hand; (6) a touch sensation on both sides of the face, and (d) a touch sensation on the hand only, implying none on the face. When only one stimulus was reported, the subject was asked if: there was any other sensation. The occasional reply was that there was another percept, and the subject correctly pointed to the second locus. Many subjects, however, reported that they had not perceived another stimulus, usually adding the statement: “I was not paying attention; do it again,” or, “I’m not sure; maybe it was somewhere over here,” and pointing in the direction of the side of the body of the poorly felt stimulus. In some instances, while correctly localizing the second percept, they volunteered the statement: “It was not as strong as the other one,” or “It doesn’t seem as sharp.” Before we proceed with the results, we must define the special terms used. In other communications the failure of the subject to report one of two simultaneously applied stimuli has been called “the phenomenon of sensory extinction,” or “extinction.” 1”“ b The part of the body where the stimulus was perceived is said to be “dominant” to the part of the body where the simultaneous stimulus was not per— ceived, or perceived faintly. The latter diminution in the quality of a sensation was ' �3. termed “obscuration.” When the subject reported two sensations, but mislocalized one of them, the “displacement” of a percept is said to have occurred.1c Displacements are usually in the direction of the dominant stimulus and may be partial or complete. The displacements noted in this series were from the hand to the cheek of the same side. Rarely did the displacements occur to the neck or shoulder. Initial Trial—The results were analyzed from the standpoint of initial and subsequent trials. On the initial trial of the face-hand test with touch stimulation in normal subjects, face dominance was apparent in all age groups. More than half of such normal adults reported the sensation in the face and none in the hand. Three subjects mislocalized the sensation in the hand to the face. In the groups of normal children, 90% under the age of 6 yr. reported only the face percept or mislocalized the hand percept to the face. This pattern of face dominance is also seen in the children from 7 to 12 yr. of age, but to a less extent. Of the normal subjects, five adults reported the hand stimulation only on the initial trial. N 0 example of displacement from face to hand was noted. This pattern of face dominance by hand extinction or by displacement of the hand percept to the face was even more apparent in the patients examined. It was most evident in patients with organic mental changes, 93% of whom did not report TABLE l.—Response to Touch Stimulation on Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia (unclassified) ............ Organic mental syndrome ............... Aphasia ................................. Total 160 56 76 74 120 23 Correct Responses 77 10 38 26 9 12 Face Only 75 28 27 45 94 11 Face-Face Hand Only 3 18 9 5 0 1 2 14 3 O O 2 both stimuli correctly. In examinations of schizophrenic subjects and patients with aphasia, responses similar to those of the normal adult were observed in the initial trial. Hand dominance was occasionally seen in the patient and rarely in the normal subject. In cases of hand dominance the subject reported the hand, but not the face, percept. It was seen in the initial trial in five normal adults. These subjects reported both stimuli correctly on subsequent testing. In the patients with organic mental changes hand dominance was an inconstant response, and repeated testing the same day, or on subsequent days, demonstrated the more usual persistent pattern of face dominance. Subsequent Thain—Of the 83 normal adults who made errors on the initial trial, 43 made correct responses on the second trial and 12 on the third trial. In a few subjects, four, five, or six trials were necessary before the two stimuli were correctly localized. These subjects were assumed to be normal, although complete psychological tests were not made. It was noted that anxiety (tension during examination or a strong desire to please) interfered with the early correct recog— nition of the stimuli. In all normal subjects, including those with anxiety, once the correct response was obtained (even after many trials with errors), it was elicited on all subsequent testing. It seemed as though a number of trials was necessary for �4 the subject to get into the “set” of the examination, and that, once in the set, he reported the stimuli accurately, even after the lapse of many days. In testing the normal young child, it was apparent that in most cases many trials were necessary before the correct response was consistently elicited. Also, the child did not always give a correct response on subsequent testing. Repeated testing over many days, however, elicited the same patterns of face dominance. .This was noted in 36 of the 56 children tested. In a number of instances the child watched the application of the stimuli and thus reported the perceptions correctly. But as soon as the test was repeated with the eyes closed, the child again reported only one stimulus. It was evident that the child could not get into the “set” of the examination, even with visual cues. This difficulty was not very apparent in all children. In the older (ages group 7 to 12 yr.) only 17 of the 76 failed to give the correct response after the initial few trials. A\\A A\4*A\ ‘~ 90 ‘___-c\‘ ~ ‘c____ .¢—————-—._—_——__———-—c 89 Responses 70 60 Dominant Face 50 Organic Mental Syndrome c--c Children, age 5 to 6 o——o Schizophrenic Adult Normal Adult 40 % 50 20 10 1 2 3 4 5 6 10 Responses to face~hand test on initial and subsequent trials. The responses obtained on repeated trials of the face-hand tests in normal sub— jects also followed a consistent pattern. As on the initial trial, face dominance was prevalent in all subjects. It was manifest either by (a) extinction or obscuration of hand stimuli or (b) displacement of hand stimuli to the face, or, in several instances, in a direction toward the face. In contrast to normal adults, patients with organic mental changes were unable to report the two stimuli correctly, even after many trials. When the patient reported the percept in one test correctly, he frequently failed on subsequent testing. It was also apparent that testing on subsequent days still elicited displacement and extinction of stimuli. This is in strong contrast to the responses of apparently normal subjects, who seldom made an error on subsequent trials, days after the initial examination. The responses obtained in this group demonstrated the patterns of face dominance in most of the tests. Displacement of the hand percept to �5 the face was frequent. In some instances displacement or extinction was present despite the fact that the patient watched the application of the stimuli to the face and hand. Extinction was very common on homolateral or heterologous testing, while displacement was apparent mostly on heterologous testing. The schizophrenic and the aphasic patients gave reports which were similar to those of normal adults. After the first two trials percentage of error in hand sensation was slightly higher than in the normal group. Persistent bizarre responses were elicited from a number of the schizophrenic subjects. These reports included mul— tiple responses to single or double stimuli, persistent displacements to one area from any other body area, and mirror reversals of localization. These were inconsistent during an examination and from day to day. As with the normal adults, testing the schizophrenic or aphasic subject on consecutive days failed to elicit extinction phenomena once the test had accurately been reported before. A comparison of the responses of each of these groups to multiple testing is shown in the accompanying chart. Pinprick Stimulation—It is known that the type of stimulus applied influences the results in perception. To demonstrate the importance of this factor, similar groups of subjects were tested using two pinprick stimuli instead of two touch M TABLE 2,—Respoinse to Pinprick Stimulation an Initial Trial Normal adult ........................... Normal child, 3-6 yr ..................... Normal child, 7-12 yr .................... Schizophrenia ........................... Organic mental syndrome ............... Correct Total Responses Face Only 68 45 39 50 49 51 16 25 15 26 14 36 9 ' 13 33 Face-Face Hand Only 2 0 2 1 0 0 3 0 1 2 stimuli. With pinprick stimulation of the face and hand, face dominance was again manifest in all the groups. However, the incidence of error in perception of the pinprick in the hand was lower than that with a touch stimulus. The results are recorded in Table 2. Repeated testing with two pins in the'normal adult subjects elicited the correct responses in the intial three trials. Fewer of the children failed to report the test accurately after the initial trials. It was possible in a number of instances to alternate touch and pinprick stimulations and to demonstrate extinction to touch, but correct localization to pinprick. Moreover, with more intense pinprick stimulation, extinction and displacement were less frequently observed. These phenomena, namely, extinction and displacement, were even more apparent in the patients with organic mental syndromes. Displacement of touch stimu— lation could be alternated with correct localization of pinprick stimulation. A combination of touch to the face and pinprick to the hand evinced the combination of displacement and obscuration, as the patient reported “a touch on the face, and a dull one on the other side (of the face).” Pinprick to the cheek and touch to the hand resulted in extinction of the hand percept. or, occasionally, the report of a pinprick on both the cheek and the hand. The schizophrenic subjects were able to localize the pinprick stimulus accurately after the initial few trials, as had the normal adults. �6 COMMENT By using the method of double simultaneous stimulation in tests of the face and the hand, a consistent pattern of responses has been observed in a variety of sub— jects. The stimulus to the face is more readily perceived than the one to the hand. Moreover, the face percept influences the hand percept, frequently causing the displacement of sensation. This pattern of responses has been repeatedly demonstrated in both the normal and the abnormal subjects and is manifest in extinction, obscuration, and displacement. Extinction is most, and displacement is least, frequent. In extinction, the face percept is correctly reported as to quality and locus, but the hand stimulus is not perceived at all. In all the foregoing tests of patient or normal subjects, whether the responses were accurate or not, it was noted that the subject almost invariably pointed to the faceixsti‘mulus first. Occasionally the hand percept was perceived and correctly localized, but assumed a qualitative difference, always of diminution. In displacement the stimulus to the hand was mislocalized to the face, or in the direction of the face, e. g., to the shoulder or neck. In some instances if the face and the hand of the same side were stimulated, the subject occasionally reported two sensations in the face. None of these phenomena was haphazard. While the frequency with which any one of these effects was observed might be affected by attention, drugs, or variation in stimuli, its pattern was consistent. These responses to the face-hand test are modified by many factors. Some of the influencing factors are (a) attention, (b) age of subject, (c) simultaneity of stimuli, (d) type of stimulus, (e) strength of stimulus, (f) locus of stimulation, and (9) internal state of organism. These factors may alter the frequency with which extinc— tion and displacement appear, but they do not change the pattern of face dominance. The subject’s awareness of the test is a major factor in the appearance of the phenomenon of extinction. Both attention and previous experience can bring stimuli to awareness. In a series of 20 adults who were informed that two stimuli were to be applied, none showed extinction of percepts. Because previous experience can influence a response, it was necessary to record the findings on initial trial in naive subjects. By this method the factor of previous experience was minimized. At the same time, the subject was not apt to be on the “alert” for the number of stimuli he was to receive. Consequently, one might say that the reason the subject perceived only one stimulus, or perceived one stimulus and displaced the percept of the other, is that he was not paying attentio‘n.3 This criticism may be valid, but the significant fact is that the error was always made in the hand and not in the face. If it were mere inattention, one would expect 50% of the single responses to double simultaneous stimulation to be in the hand and 50% in the face. But this type of chance error was not observed. Of the single responses to double simultaneous stimulation, 95% were of the face percept and 5% of the hand percept. This pattern of face dominance or hand extinction was further established during subsequent examinations. Moreover, when displacement was seen in normal subjects, it was to the face and not to the hand. This pattern of face dominance to double simultaneous stimulation was found to be exaggerated in normal young children, of whom 83% demonstrated either hand extinction or displacement of the hand percept to the face on the initial trial. Critchley, M.: The Phenomenon of Tactile Inattention with Special Reference to Parietal Lesions, Brain 72:538—561, 1949. 3. �7 Moreover, this high percentage of responses of face dominance persisted on sub— sequent trials. In the older children, also, face dominance was consistently demon— strable. It was noted that the younger the child, the more distinct was this pattern of face dominance. Hand extinction might be attributed to an inability to perceive two stimuli at once. This particular defect has been noted in patients with severe mental changes by Goldstein.4 However, in patients with severe mental changes or in chil— young dren stimuli applied to both cheeks, or both hands, or any other two homologous body areas were correctly reported as two sensations. There was neither extinction nor displacement. Goldstein’s observation, therefore, cannot be used as an explana— tion of hand extinction. It is noted that face dominance was apparent no matter what type of stimula— tion was used. Simultaneous pinprick stimulations revealed the pattern of face dominance, although with a lower frequency than touch stimulations. Other cutaneous stimulation, such as application of two tuning forks or hot and cold tubes, repetitive rubbing, and repetitive pinprick stimulation, was used, and face dominance was manifest regardless of the cutaneous stimulation employed. The importance of the simultaneity of the stimuli has already been alluded to. In subjects in whom extinction was persistent, consecutive application of the stimuli invariably resulted in the perception of two stimuli. In normal adults consecutive stimulatiOn of the face and the hand, even on the initial trial, never resulted in extinction. In these studies the stimuli were of equal intensity. This factor was important in eliciting the pattern in the normal subject, for unequal stimuli were seemingly more readily perceived than equal stimuli. After the first few trials the subject was able to perceive the two stimuli, even if one was painful and the other not. In patients with organic mental changes, however, extinction and displacement were manifest despite a wide discrepancy in the quality of the stimuli. By altering the strength of the stimuli, it was possible to alter the response from extinction of the hand percept (if the hand stimulus was weak) to displacement to the cheek (if the hand stimulus was strong). The change from extinction to displacement was also elicited by altering the quality of the stimuli, that is, from touch to'pinprick. Nevertheless, the pattern of face dominance was always apparent. The parts of the body being simultaneously stimulated is another consideration in studying these patterns. We have already alluded to the fact that extinction is commonest in the hand and least in the face. In testing other body areas, the incidence of extinction and displacement is less than in testing the face and the hand. That is, testing shoulder and thigh may not elicit extinction or obscuration, whereas the face-hand test may. Also, in patients with lesions of the brain or spinal cord, the pattern of relation of the body parts to simultaneous stimulation may be altered in a characteristic hemisensory or “level-lesion” syndrome. Further studies are necessary before the significance of the pattern can be interpreted. Any deduction made at this time would be purely speculative. For instance, nothing is gained by stating that face dominance implies a rostral order of sensory dominance.5 Such a 4. Goldstein, K.:: The Mental Changes Due to Frontal Lobe Damage, J. Psychol. 17:187, 1944. 5. Cohn, R., and Raines, G. N.: On Certain Aspects of the Sensory Organization of the Human Brain: A Study in Rostral Dominance ‘as Determined by Ipsilateral Simultaneous Stimulation, Tr. Am. Neurol. A. 74:162-168, 1949. �8 hypothesis is contradicted by at least one fact, namely, the observation that when the hand and foot are stimulated simultaneously the foot dominates over the hand. Perhaps after more data are accumulated a satisfactory theory may be obtained. SUMMARY _. “awn—a, elicited in normal and abnormal subjects by the method of double simultaneous stimulation of cutaneous modalities. Face dominance, manifest by extinction of the hand percept or by dlsplacement 0f the handmpercept to the face, is seen as a normal phenomenon, manifested1n the normal adults andin the patients with schizophrenia and aphasia examined in the series. It is exaggerated in young children and in patients with diffuse disease of the brain, in whom extinction and displacement are persistent after multiple trials. This pattern of face dominance is manifest regardless of the cutaneous modality tested, there being a change only in the frequency of extinction with change in type of stimulus. j Printed and Published in the United States of America / f / r: L/nAJ/C’ ..... . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Patterns in perception on simultaneous tests of face and hand. AMA Arch Neurol Psychiatry. 1951 Sep; 66(3): 355-62. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-2b-004 Date A point or period of time associated with an event in the lifecycle of the resource 1951 Creator An entity primarily responsible for making the resource Bender, Morris B.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Green, Martin Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from the Archives of Neurology and Psychiatry September 1951, vol. 66, pp. 355-362. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/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/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/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/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/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). 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Title A name given to the resource Max Fink, ship surgeon, American Export Line, 1948 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-009 Date A point or period of time associated with an event in the lifecycle of the resource 1948 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/9bde6be6bc795aa367e0ff3ce1a1cf46.jpg d63c5320d960711e3a969b3b25f295ab Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Max Fink, research director at Hillside Hospital, 1955 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-010 Date A point or period of time associated with an event in the lifecycle of the resource 1955 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/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/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). 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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). 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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). 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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). 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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/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/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/34ffc14c69353beb28205e3d083f74c1.jpg 15d767820d5675ff4b8227daac69b607 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Max Fink (second, right), Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-025 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/f44d0c2625f1389edfd0c676eea438c3.jpg 207003d989abb5a29d50b834f258c445 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Max Fink (right), Taylor Manor Hospital Award, 1983 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-026 Date A point or period of time associated with an event in the lifecycle of the resource 1983 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/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/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/9bec4d07db9cc7bbdca592d03c5631f1.jpg e27ee77bdf6e164226f11d4601b974de Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Max Fink (right) and Jules Angst, 2005 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-028 Date A point or period of time associated with an event in the lifecycle of the resource 2005 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/8fb21cedddcd09ee293085e8ddd43092.jpg 4ccc01813c057ee2539defeddfe0f394 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Max Fink (right) and George Kirov, Edinburgh, Scotland, 2010 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-029 Date A point or period of time associated with an event in the lifecycle of the resource 2010 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/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/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/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/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/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/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/73f23282cc67af28739fea856ee770e8.pdf e300a093a9da17b1283d89c0561639fc PDF Text Text Reprinted from ”Electroencephalography and Clinical NeurOphysiology Iournal" Vol. 10, No. 1, February 1958. LATERAL GAZE NYSTAGMUS AS AN INDEX OF THE SEDATION THRESHOLD 1 MAx FINK, M.D. With the technical assistance of HANNAH MOSQUERA Department 0] Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. (Received for publication: October 17, 1957) On reading the report of Thorpe and Barker (1957) in the recent issue of the Archives, we were moved to assess our own experiences with the sedation threshold, and to report a clinical guide to the “inflection point” that we have found useful. Following the initial description of the technique by Shagass (1954), we modified our tests which included the administration of the amobarbital test for brain dysfunction (Weinstein et al. 1953) to obtain a measurement of the sedation threshold as well. Our technique was identical to that of Shagass, with the addition of the measurement of nystagmus on lateral gaze which the latter test required. The change in beta amplitude in the EEG was measured visually in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to identify the onset of slurred speech with consistency. Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction of sleep. As we were also obtaining a record of the induction of nystagmus on lateral gaze, we became aware that this index was reliably agreed upon by the two observers, and a correlation with the sedation threshold was sought. We, therefore, omitted the instructions regarding counting and substituted the following instructions. Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged tion period. The administration of barbiturates con— tinued until nystagmus was observed, and then an additional 2 cc. were given. RESULTS To date, we have 91 measurements. The following table notes the difference between the number of milli- grams of amobarbital per kilogram body weight for the EEG measure (the sedation threshold) and for the onset of nystagmus. Differences greater than one unit did not occur in this series. The two measurements are seen to be reliably related by a unit of 0.5 or less in more than 90 per cent of the observations. M TABLE I Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg. amobarbital/kg. body weight) No. Tests (91) 1 47 12 +0.5 +1.0 27 4 Test-Retest Reliability: During these studies we have also had the opportunity to repeat the sedation threshold measurement three to five times in the same patient at weekly intervals. These measurements were done in randomly selected patients receiving subconvulsive doses of elec- TABLE II Absolute Range of ST. Values Range 0 0.5 1.0 1.5 2.0 No. Subjects (16) 0 2 6 2 4 fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. Such observation was repeated after each injection of 1 cc. of amobarbital solution, between the 25th and 40th sec. of the injecSupported by the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 1 2 tric current under barbiturate premedication as part of a study of convulsive-subconvulsive electroshock. The behavioral changes in this group were small 14 of the 16 were referred for grand mal electroshock within 4 weeks after the subconvulsive treatment -—— period. The range of sedation threshold measurements under these conditions is noted in table II. [162] �LATERAL GAZE NYSTAGMUS OF THE SEDATION THRESHOLD Being unable to ascribe greater validity to one reading than to any other, we determined the mean sedation threshold for each subject, and the range of variability about the mean. In table III we have listed the subjects in each range of variability about the individual mean value. Thus, the intra-patient inter-test variability for this test in this series is considerable. The test reliability of nystagmus as an index of the electroencephalographic change is well within the retest variability of the test in these subjects. 163 lographique mesuré chez ces malades et dont la validité a été démontrée. Il est recommandé d’utiliser cette méthode en remplacement de celle qui est basée sur l’apparence de troubles dysarthriques. ZUSAMMENFASSUNG Das Auftreten von Nystagmus mit lateralem Blick ist ein klinisches Mass fiir die Sedationsschwelle, welche gut mit dem gemessenen EEG-Index iibereinstimmt und dessen Verlasslichkeit nachgewiesen werden konnte. Gebrauch dieser Methode wird daher TABLE III Range of ST. Values from the Mean Range No. Subjects (16) 0.1—— 0.6—— 0 0.5 1.0 0 6 4 CONCLUSION The appearance of nystagmus on lateral gaze is a clinical guide to the sedation threshold, with a variability from the measured EEG index well within the test-retest reliability of the test itself. It is recommended as a substitute, therefore, for the onset of slurred speech. Further studies of the retest reliability of the sedation threshold are necessary. RESUME L’apparition d’un nystagmus dans le regard latéral est une mesure clinique de la sedation qui montre une bonne correlation avec l’index electroencepha- 1.1— 1.6— 2.0 >2.0 4 1 1 1.5 empfohlen als Ersatz fiir diejenige basiert auf dem Auftreten von verwischter Sprache. REFERENCES The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 1954, 6: 221-233. THORPE, J. G. and BARKER, J. C. Objectivity of the sedation threshold. A.M.A. Arch. Neurol. Psychiat, 1957, 78: 194-196. WEINSTEIN, E. A., KAHN, R. L., SUGARMAN, L. and LINN, L. The diagnostic use of amobarbital sodium (“Amytal Sodium”) in brain disease. Amer. J. Psychiat, 1953, 109: 889-895. SHAGASS, C. threshold. sedation the of index M. Lateral as an FINK, nystagmus Reference: gaze physiol, 1958, 10: 162-163. EEG Olin. Neuro- 63:3 �‘ “W 9.13.5? W W ma w Mai mm 0 �mmmmtwmwmmmmmeum MWW,wmnwummmmflm-uwm amummm,mmmauammmmumfimaummv Wtwmfmm. wmvmpumwmmmwmmtz), Wm ”memmwzmmmmumdmmml *mt Warm. {fiwo‘hWtWt 92mm“ wwwmxmmmwmtamm.nw mmumwmetummmummmm fifiwmmm. mmmmwnmmmmmww mmawmmmumm,mmwawmwwm WW: hwqmmefiMgMWWWth mmmmawmeapmmmmm. MW“ aim “Wamflmdmuaf mammmmotdw. uwmduobmmtmmdw fiWmumlmgwmmmtthm numwummmmmmwnWMvmmmm ‘ V “.mm,mimmmmmummmmm MW m 3mm mmmfi mm um um am it mom mummymmummmwmmmawwmnmw mramquWWamrmWWflanummu. 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Roy W mum. 0mm. 7 of ‘ ‘\ \ 16,, Dear Dr. Grimmer: W Inmadmzhoramtmmloafmmdmrmm pmblem. undead short 45an my am vb» m nth-mung an ”gamut of tho «mum tgnsumtofl this that. cmMahala," we are md to “(nativity at w M15192: than 111th this tout, u an as our solution to pufllol mama “the be of help to note W this note is I: the taunt. at pinned to follow your momma. would be for the Archives, I m Fink, 1w. K3563 �PUBLICATION OFFICE AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO IO. ILLINOIS AUSTIN SMITH, EDITOR, A. M A. SCIENTIFIC PUBLICATIONS A. M. A. ArChives Of NEUROLOGY and PSYCHIATRY GILBERT s. COOPER, MANAGING EDITOR A. M. A. SPECIALTY JOURNALS SECTION ON PSYCHIATRY DR. EDITORIAL BOARD RCY R. GRINKER $R., M.D. CHIEF EDITOR. CHICAGO STANLEY COBB, M.D.. BOSTON GEORGE E. GARDNER, M.D.. BOSTON ““353?st JOHN WHITEHORN, M.D., BALTIMORE Institute for Psychosomatic and Psychiatric Research 29th Street and Ellis Avenue, Chicago 16 September 20, 1957 Max Fink, M.D. Department of Experimental Psychiatry Hillside HOSpital 75-59 263rd Street Glen Oaks, New York Dear Doctor Fink: it will not be possible to publish and we like to backlog, large have a wide selection of papers on many subjects and feel that we have published already all that seems important on the sedation threshold test as devised by Shagass.. I the in your paper am very sorry, but ARCHIVES. We have a Regretfully yours, Roy R. Grin er, M.D. Editor~in-Chief for Psychiatry RRszm enclosure �3.er Dr. Mort 3. Sam, General Putnamtu Boa: (7&3 {’4’ BOWEN, ah. 1957. Hospital, Mt Du:- Dr. Scarab: In vnading : recent. article on the ”mmuvity of the Station Threshold" in the Archives or Barclay and Paychntx-y, we were mud to parallel «panama with we test, as well as our 301an to the problm. I would appreciate your enumeration of this short clinical not» for the Section of 61mm. uni laboratory Notes of the mm m EEG hum]... Simon]: you", mm, 130th HE‘BJB or menu-m1 Paychutry; “on. �3-8200 EXT. 380 TEL. LAFAYETTE ROBERT s. SCHWAB. M.D. MASSACHUSETTS GENERAL HOSPITAL BOSTON 14 September 27, 1957 Dr. Max Fink 75-59 263rd Street Hillside Hospital Glen Oaks, New York _ C.N. #61 Dear Dr. Fink: received and I would like to conditionally accept for Clinical Notes in the EEG Journal as it stands subject to the approval Your manuscript has been it of the Bditor—in—Chief, Herbert Jasper. MW Yours very RSS:mc sincerely, Robert S. Schwab, M.D. �1g 33 ‘12, McGILL UNIVERSITY MONTREAL Department of Electrophysiology Allan Memorial Institute, 1025 Pine Avenue'West, Montreal. September 30 1957 Dr.Max Fink, Hillside Hospital, 75-59 263rd Street, Glen Oaks, New York. Dear Max, to see you for your note on the nystagmus. It was nice at Zurich, and I hope that we shall be able to meet Thank you again soon. My best regards. Sincerely, Cw CS/ef % , C. Shagass, M.D. �12/3/58 Discussion: Dr. Shagass Dr. H. Fink - Hillside HOSpital Dr. Thompson, Members and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass.‘ This study, like its predecessors, relates neurophysiologic indices to behavioral measures this area of psychiatry, reflects a welcome application science to clinical problems. a and in of basic appropriate to examine this report in the perspective of recent concepts in experimental psychiatry. During the 1930's, when electroencephalography was a new science considerable effort It seems in relating EEG patterns to "personality types" or ”diagnoses,” without success. With more refined instrumentation, there have been sporadic re-assessments without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he was expended related the amount of barbiturate necessary, under standard conditions of rate of administration and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG and behavior but between a measure of reactivity or responsivity of clinical behavior. We may carry this description a bit-further. The electroencephalogram is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure of the reactivity, or reSponsivity, or bufibring the EEG and �of the biochemical enzymatic systems flat make up the nervOus system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety of phrenotrOpic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafle adaptability. One application of these technics highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,who reported their ihitial observations on the significant relationships between schizophrenic behavior was and the reactivity of insulin. These of the glucose-enzyme systems to the authors carefully noted that there stress was no relationship between the initial levels of their biochemical measures and behavior. Dr. Shagass' earlier studies of the sedation threshold - end-point - are clearly within this tradition. His report today is also in this general tradition, but instead of a neurophysiologic index of clear definition has utilized a clinical index ~ lack of a verbal motor response to a verbal command - as the end-point. In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as "sleep") with the affective state of the individual at the time of the experiment. He has observed that the more fearful,disturbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce using an EEG �-3- quieter, more indifferent, inactive and retarded patient is, the less barbiturate is necessary for sleep. He sleep. a Ehe titration is thus achieving a biochemical titratinn, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatim, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, some of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships I have noted two puzzling relationships. Increasing sleep thresholds are associated, on the one hand, with excitement, worry, restlessness and anger; but also, with clinical improvement in a course of convulsive therapy. Also, in one are somewhat cloudy. patient, transient induced psychosis sharp drop in threshold, while in the same a LSD is associated with patient, fear of a treatment, restlessness and increased tension are associated with rising thresholds. I would snapect that these apparent discrepancies arise frOm the non-Specific nature of behavioral reaponse to neuro— physiologic change and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronization; or such psychologig indices of brain function as the perception of embedded figures or OFF; or such behavioral indices as dyadic or syntactic linguistic �-hanalyses. Alternatively, more precise,— operational measures of the behaviorll subsumed under "anger," restlessness,¥ "worry” may proiido, again, the relationships indicated earlier by the sedation threshold studies. Lest these comments be misconstrued, let me say, in closing, that Dr. Shagass is to be warmly congratulated in these studies basis for the developing neurOphysiologicadaptive hypothesis of behavior. His demonstrations of central neurophysiologic reactivity in the sedation threshold are in the best exPerimental traditions. We are eagerly looking forward to further experimental neurophysiologic studies from his new which are providing a firm laboratories in Iowa. �12/3/58 Discussion: Dr. Shagass Dr. H. rink — Hillside Hospital Dr. Thompson, Henbers and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass. This study, like its predecessors, relates neurophysiologic indices to behavioral measures and in /‘this area of psychiatry, reflects a welcone application or basic science to clinical problems. It seaas appropriate to examine this report in the perspective — of recent concepts in experimental psychiatry. During the 1930's, electroencephalography was a new science considerable effort was expended in relating EEG patterns to ”personality types" or "diagnoses," without success. With more refined instrumentation, there have been sporadic re-assessnents without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he related the amount of barbiturate necessary, under standard conditions or rate of administration-and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG when and behavior but between a measure of reactivity or resphnsivity of clinical behavior. The e1ectro~ We may carry this description a bit further. encephalogran is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure or the reactivity, or responsivity, or buflhring the EEG and �«2e- of the_biochenica1 ensynatic systems fiat make up the nervous system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety or phrenotropic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafls adaptability. One application or these technics was highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,vho reported their initial observations the significant refationships between schizophrenic behavior and the reactivity of the glucose-enzyme systems to the stress of insulin. These authors carefully noted that there was no on relationship between the initial levels of their biochemical measures and behavior. earlier studies of the sedation threshold using an EEG endspoint ~ are clearly within this tradition. Bis report today is also in this general tradition, but instead or a neurophysiologic index of clear definition has utilized a clinical index - lack of a verbal notor response to a verbal Dr. Shagass' - as the endnpoint.' In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as asleep“) with the affective state or the individual at the tins of the experiment. He has command observed that the more feartn1,distnrbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce �-3sleep. the quieter, gore indifferent, inactive and retarded a patient is, the last barbiturate is necessary for sleep. He titration is/thna achieving a biochemicat titration, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatin, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, eons of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships are somewhat cloudy. I have noted two finssling relationships. Increasing sleep thresholds are associated, on the one hand, with excitenent, worry, restlessness also, with clinical improvement in a course of convulsive therapy. also, in one patient, a transient LSD induced psychosis is associated with a sharp drop in threshold, while in the sane patient, tear of treatment, restlessness and increased tension are associated with rising thresholds. I would suspect that these apparent discrepancies and anger; but arise from the nonnspecific nature of behavioral response to neuro~ physiologic changa and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronisation; or such-psychologtg indices of brain function as the perception of embedded figures or 61?; or such behavioral indicee as dyadic or syntactic linguistic �l-h‘ analyses. Alternatively, more precise,~ ofierstionsl measures of the behavioral subsumed under ”anger,“ restlessness,1 “worry" hey provide, again, the relationships indiohted esrlier by the sedation threshold studies. Lest these comments he misconstrued, let me say, in closing, that Dr. Shegsss is to be warmly congratulated in those studies which are providing o firm basis for the developing neurophysiologica adsptive hypothesis of behavior. his demonstrations of central neurophysiologio reactivity in the sedation threshold are in the best experimental traditions. we are eagerly looking forward to further experimental neurophysiologic studies from his new laboratories in Iowa. �qt- I ZIN’EIQAL. 614245 ' ‘ QM r r; m Marlyn»; #ng /% 4n Z/{[ 5/ ’f/e. /3~f7 Ska/177m Amt gnaw; E u, . . 7:va E Wu” E :1va E I . m,“ 1W 1W" ‘ quwr—rrw—nw—v /M /W flaw @524: // M" am/ZEWW/éwu Lb 7%“ @43’ W WM &%M/w/’ Aruéda 54% E E E E M7424 - . �W we moved reading the report of Thorpe and ' in the to assess our own W5 /Q1(LLAAjr Barke%ajm issue of the Archives, we were experiences with the sedation threshold, and to (2 report anether clinical guide to the "inflection point" that useful. ' ‘ ’“ n U Following the initial description the adninistration of the amobarbital W / )1 "# WWW Our ’ ' / ' “‘ '* have found, we ,, I _ / " fir of the technique by Shagass we modified flat: is: iifi— our seaside which included test for brain dysfunction (-Weéna-teim, to obtain a measurement of the sedation threshold as well. technique was identical to that of Shagass, with the addition of the measurement of nystagmus on 775: lateral q change gaze which the latter test required. 7h4¢4ww¢16f EEG was done- visually ‘ ‘ in beta amplitude in the in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to the onset of slurred speech with consistency. identify Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction �-2l?!‘ sleep. gaze, As we were also We, ML. Wis-of :_ reliably that this index was we became aware observers, and w/umd 9/ obtaining /“45“¢’7"" nystagmus on ?/ lateral agreed upon by the slur-e W..a.correla.tion withthe sedation thresholdwv W/{Z‘ therefore, omitted the instructions. regarding counting stituted the following instructions. Subjects intervals they would one side and then be requested to were their open and sub- told that at periodic eyes and to look first to the other at pre-arranged fixation points. This to was repeated twice in each direction, usually within ten seconds, while the observer noted the development of Sustained regular nystagmus gaze. Such observation was repeated after The injection of lateral 1 cc of amo— N, ~: ‘ . “42" barbital solution, each on between the 25 and ho seconds of the injection period. administration of barbiturates continued until nystagmus was observed, and. MW ’00 (Lou and then ?WU°: ——————-—_ To more were given. date, we have 91 measurements. ,, difference between the number of thes926an threshold and W W . MW) not!“ the : milligramkl (/19 m7... of ambbarbitaljfo/r Mafia,” for the Onset of nystagmus, reflects-enemi- Differences greater than one unit did not occur in this series. The two measurements 7,2 79/1; following table 4 The arenreliably related by a unit of 0.5 or lessxw Wamflm~ Z... ‘ ' �-3I TABLE Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg Amobarbital/Kilogram Body Weight) No. Tests .100 .005 0 +0.5 +1.0 l 12 h? 27 h \ ?// ; Test-Retest Reliability: During these studies all» we ' havenhad the opportunity to repeat the sedation threshold measurement three to five times in the intervals.- weekly These measurements were done patient at same in randomly selected patients receiving subconvulsive doses of electrnc current under barbiturate premedicationqi as part of a study of convulsive-subconvulsive electroshock. changes in this group were small - fourteen of the sixteen The were behavioral referred for /z~n/¢‘¢A{4”~*¢¢ég«~0 ' grand mal electroshock within four weeksye7/ngr . ‘ (fl/$4,224. The range of sedation threshold meaSurement?under these conditions noted in Table II. TABLE II Absolute Range of S.T. Values' Range My, Subjects (/4) 0 0.5 1.0 1.5 2.0 o 2 6 2 h >2.S 2 ff’a./§L»«# is �-hBeing unable to ascribe greater é validity . the we determined we have mean sedation threshold for each subject, subjects in the-m mdmadud MM. value. the listed WE: W W one reading than fies any each range of M basis variability ’ mean III TABLE Range Range /o. fiubjects (/5) other, of S.T. Values from the e 0.10.5 0.61.0 o 6 h 1.6- 101'- 1.5 ’ “N‘r‘m-wrv .,.m 52.0 2.0 7 h J Mi."- Mean 1 1 , . ., K.,.fim’WhfiW-am~w-.w:122-w 7 Wat, {is mus-patient;inter-test variability for this test in this series is considerable. test reliability of The electroencephalograpmzhc change is well within the retest variability of test in these subjects. Qéz: the adapted the appearance of nystagmus on m a ; / J1/ J 1/}, C- i ’ / A A f" is / / /z€—— "/5 I I , [KI-A ,5 - ,v clinical guide to a ‘4’; my: M , fl» gray 1.47! /’L! CW/m4‘4flt (331’; fi{ I, ;’(f fl ,Cy «a, ' M; gaze WWK .ma- Asa/2w ,Aaé .4 // My 4 Wfiffeéé: fr!» WI mat?» lateral WRfi—WW the sedation threshold, a; nystagmus as an index of the AA“: iséwtu/MA‘I (2: 7! /)/”/»£¢A/L.( M #63“e/ Ca” we '1’ .11“ fl¢»%flw//L{u¢{304?“:{3’ a? / ,. 3 if '4" ”17’2“" r , _.;__.‘ 4’ "I; a: A" {fi’flg‘t . ,, ,4? Ayifi ”(:4'5‘ Alt—‘3 / A’Jik �, ..‘ )- I *’ Wv .1. C . ya $407M Mann}; 4 M4, /:7 a4“!!- C . 74V galvauE/Zw/ I £44373; 59:7. Z—f: M4. 41% ’7sz /f4/A/75, (”fif) W77er?“ ' #1 %@‘*’5‘“ g CL .‘ «9-9/-'.?33, ‘ /7f¥, M . ‘ / $42M” ~ i ) fltm NA /‘J3, /flf: ff7~ff~c '/ $4,441,, V . flu d {7 . /% (1;.1'5 7. �THE LONG ISLAND JEWISH HOSPITAL 270-05 76th AVENUE Department of MEDICINE 0 NEW HYDE PARK, LONG ISLAND, N. Y. - TELEPHONE: Fleldstone 3-6700 �Suptonbar 21, 1961 ntrtin H. rats, Ph.n. Reiuurch Piyuholosint Paychophurnnaoloxy surviuc Cantu: o: nautnl Bonita lation:1 Institutg Md. Buthnldn 1h, Dcar _ flirtin, tour lattqr regarding 1 r0110! o: it: Iodaiitn thrcihold attack a oynpsthcsia chord, and I an caconr:god to share my Vitus with rat, Buvavcr, tin probla: in acuu plax tad perhaps no as: not anido tan. tin. in Huntington fur a dutuiled diacunuion. Hy interest in tho sedation thronhaid van cooulionnd onrlicr intarout in tho at. 0: intravoaonn snibirhitll an a fast tar brain dynrunation. Hoinltciu and Ichni Donitl at Illa-an c c. ThOIIl, 19 S) In tn. court. of ofcoifiucfioci 05:310., we curriod out many out13¢tau at tho 8.2. .36 can. to it. eontlalion taut sh. inst was phyliylogically and itchnically Hound. Finding dylgrthriu I difficult ondnpoiut, I lubntitnicd nyutccnuu; but in raulity, thin can b: dilponlod wish, ninco tn. acnlurod and-puini in to. EEO tbs 3.3995: by ny aarpud nhoui drunrthrin, corroct ll tar an int: hlvo (out, but thin dittiauliy intr.not inlnrunuBStblo, uni boar: no aigaitiaing rolgtion to the valet at $8. tout. the critic: who have The quantiann It inane trot II it. tlli stunt. in in: can. individual .v-rtiuo? 2. In thuro a charteturiltio tcapanao which boar: a oiguir10§nt1y high corroliticn with n bchnvioral Vlriibli - ntnnly, sh. oililifiottion by psychiatriltl a! tangent: iuia uolclogic (racy-9 1. �0-2- 3. Thirdlr, your quclhiou, “it true, it (8.1.) ahvioualy can b. very alarm! in trtttnaut firodiotion nhndicl'. 1. Out Inn uxp.richou indiohtUI that : high intrh~ individual variabiliir; a limited ran 0 at vuluon tar thc halt (tvclvc point. from 1-6 in half than. and an oqnivocnl EEG 0nd»point in 10-20! a: test: lit?! to nuko tha rnlihbla duturu ainntion if tho 8.!. difficult.’ that. vurinblcn soon inhurout in th. taut danish, and Ira not, in :1 opinion, I luck or know-haw by uh. ohlurvcrl. 2. no. Hy nogahiva unuwar to thin question is partly hhoad on (1); Ind partly on tho uuucl dittioaltios at nonology. in somewhat limplowmiadod to uspuat a high corrolntion It betwocn a 'uinplt’ phyiinloxic rotativity naulurc had a “90:91.3” hypnthctie clhatrnat with '0 Inch inhtront unhigui» 3 hy Ind variability. in: 3.2. may hat bu rnlutcd in diagnosis; aha the 3.T. h. unoful in truttacnt prediction? I think it uh: ha, ~~ not for hhc losicul raglan: anuuily IiVOI, but blcinll of the value of tha tout an I .anctivity” nth-urn. In the pulh tow ybnrn variouu indict: huvo blln nhaua to huar IOll rolatiou to trontnont or to diacnnlis ~hnd ouch influx it halt huh-ulna under tho hgru or a 'ruautivio influx”. HO utatod hhht pationth vhe chowod two or nor. tr laughing «hangs. utter intrtvonoun uncharhitnl war. nor. likely to thaw curly EEO ehnnsun httnr uloetrouhock, had to 3. Evan ihough aha: gruntor dncrucn or hohnviortl church and iuprovonnnt of Cenaunieatign, 126 - 139, 1958). Goldntn pantothnl burnt. tr. 010' ’3'; a o thin in uppchrsaoo in achiIOphronic nnhjocta, and ht! unod tout protnouticclly. Siuilhr mittencutl hart bath midi, in £36 Ctt‘uli nor. quantitttivo Itudinu, by Itil (Erlungun) (Milan), why havu rclntod thn changod EEO putt-run to corehrnl ltrophy on pucnnaoneophulozrtphy. In hnothcr type of studios, tho bland prolhnro rcupan-au to nocholyl and to harshnlin have bath roptahcdly Incgnutod an a dilflnflltic had prognontic 136.3. A cannon bhaiu in thcnc Ithdiou in that u link of reactivity or a alow ranchivihy in zanornlly taunted vith schiloyhruni: 0» brain atrophy ~~ a poor proxnoutic high to: the artillhlo thsrtpiol; whil. high rtnotivity in aquutnd with écprcauivc syndronon ~~10w: [and tauntivprognostic sign with awnilhblh thnrapitu. Than, invoked indux or but hi an high any your prtgnoling a: it: ruaahivity will bchr A high wurrulation with hshhvioral chaugu, had a varinhlo In. with inprOthont rutinzs. (3.0 �.3our views of beteviorel change and inpreveuent ratings, Arch. Gen. Feloniet. g; 259, end 5; 30, 1961) Thus, there is much merit in Shannen 8.1. -- not, in .my View as e diegnoetic index (for age is much more relieble and easier to ascertain), but ea one guide to neurophyeielegic reeetivity -- e eubaect that needs {nether study as e preg- noetic and as]: noeelogicel teal! I trust this in reeponeive to your inquiry. I would 16-1? ?) like to disease it acre fully in doWashington (October the 8.1., in end wenld recommend that if yen get interested on veriene reactivity that you consider 3 eeriee or aeetinge ueeeuree in plyehietry .. the neehelyl test, the 8.2. end the coldnen ee exemplee at the more explicit. My regerde. sincerely yours, Hrcdte ex n , “.5. �I1 I. I. I $5 I [3 EE P1 (3 55 F’ I'T'l\ I. FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263RD A. MILLER, M. D. , , Medical Director JOSEPH S. SIMON KWALWASSER, FIELDSTONE LEON LOWENSTEIN 8-7800 Department Of Experimental Psychiatry M. D. Assoc. Medical Director MAURICE STREET. GLEN OAKS. NEw YORK BACHRACH Honorary Chairman Board of Directors ROY .FOSTER Chairman Board Of DWWOH ALVIN E. COLEMAN Administrator President September 12, 1957. Dr. Roy Grinker, Editor, Section of Psychiatry, A.M.A. Archives Neurology & Psychiatry, 29th Street & Ellis Avenue, Chicago, 16, Illinois. Dear Br. Grinker: In reading the report of issue of the Archives, the sedation threshold, Thorpe and Barker in the latest (August) to assess our own experiences with and to report another clinical guide to the we were moved "inflection point" that we have found useful. During the past two years we have included a measurement of the sedation threshold in our tests of brain function. we initially followed the technique described by Shagass (EEG Clin. Neurophysiol. é: 221-233, l95h). Measurement of the beta amplitude reaponse is done visually in several samples of record using the additive ruler described by Shagass. initial group of patients, two observers were unable to onset of slurred Speech with any consistency. 'We, therefore, the identify omitted this step, and continued drug administration until gradually drowsiness was clearly manifest, combined by a statement by the technician that an increase in beta amplitude in the record had occurred at least 1% In the minutes before. that occasionally amounts of amoreach an inflection point were administered. We, barbital inadequate to therefore, began to note'the onset of nystagmus on lateral gaze as a guide to the sedation threshold. This technique had the drawback Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. The administration of barbiturates continued until nystagmus was observed, and then 2 cc more were given. The EEG records were then measured for the inflection point by the visual method. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �Dr. Roy Grinker (Contd) -2— To date, we have 91 such.measurements. In the following table, the difference between the point of onset of nystagmns (nystagmus index) and the inflection point of beta amplitude change (EEG index) is reported. Difference .100 1 EEG Index s-Nystagmns Index .005 0 +05 +1.0 12 h? 27 h Differences greater than 1.0 unit did not occur. It is apparent that the nystagmus end point for the sedation threshold is reliably related to the EEG end point by a unit of % in more than 90% of the trials. Since the error of the sedation threshold under test - retest conditions is between 0.5 and 1.0 units, this nystagmus index is a satisfactory guide to the sedation threshold, as defined by Shagass. W In our continuing studies of the sedation threshold, we have, therefore, ceased measurement of slurred speech or drowsiness, but have relied on the onset of nystagmns as the clinical guide to this index. I trust that this data may be helpful to other investigators. Sincerely'yours, v ,4 a’V‘wflwc has: MF:JB _ Fink, 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 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 Lateral gaze nystagmus as an index of the sedation threshold. Electroencephalogr Clin Neurophysiol. 1958 Feb;10(1):162-3. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-28-003 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 Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 12 items. 1: [Preprint]. 2: Reprint from Electroencephalography and Clinical Neurophysiology Journal Vol.10, No.1, February 1958. 3: Letter to Dr. Roy Grinker form Fink. 4: Letter from Grinker to Fink. 5: Letter to Dr. Robert S. Schwab from Fink. 6: Letter to Fink from Schwab. 7: Letter to Fink from C[harlie] Shagass. 8: [preprint] to Dr. Thompson, members and guests discussing Dr. Shagass (2 copies). 9: Handwritten notes. 10: Draft with edits. 11:Letter to Martin M. Katz from Fink. 12: Letter to Roy Grinker from Fink. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). 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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/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/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? Firthilafltfitl‘litiIril prior ‘0. durstu, qr in. tank: attic ironintu‘. Eafipi‘tl dicohtrgt rntzuci at var. cqutvulnn‘. 1! tnduntanl at and. Intuit: II inliulatiuun‘ it it. 110‘s: 1: ‘3. tamrulaiva ‘haruar yruaann. tht nouatpoitttcttr at Inactinausluvulnzaun and ¢ht crottur dzftanulflr or adntaittrutaon §ho that trnutncat. dotorrtnfiu altnannl ‘0 at it. It. inpwovuuant . ’ruu $39 Dupnrinuat at Zapariaonsul Plrahit‘tr, Hill-ta: nbcpttnl. “1" MI; L010’ '3!- tor publication in 16/69. it. An; tvoh1v¢u a: Pursuintry �atsatrtennca o: tuhnlnnt Inflaeud Ocuvnlniqml :0: Qatar: «1 the convulg£vi thaws»: Frugal. In: r333, 3.3., unstrt L. Kain, ti. ra.n. Htrtil A. arocn, 3.9. 1.3., tad leary'J. Lark-vitl, 5.9. Bria tarp. B.A., flax rallnck, Ph.9., isrrc A133, Iran tho Dupartunnt a: lqurtlna‘nl Pcyuhtntty, 31111140 lonptttl, 61“ MC, 3...!” ”or. Aided by grant» nr»aoya and fl~921 a: th- ll‘10BQI Ianitfiuto at lon‘nl Baulfih, U... riblto inclth Barvseu. xx: 10/60 �Signitiatncu ct Inhtlnnt Induccd convulsion. tar $3!hoory if in. canvulltvo thurupy Prtcoas ct tnvaa%1¢¢t£an at ‘3. cathlaavo thnrapy pronoun, thnra 1. ntt11.:u¢h can‘t-v.91: eouuurniua tho importanco o: $ho 3.11.30 1%:011. 300% t‘!‘$!l haw. coacludca that thc coavnlnicu :- I ntcnlunry index a: it. coruhral outta. 01131031 bohnvintnl absuga (9,19,15,33,:9). 80:. ta illtlttil involttun‘ora, navurthaluli, have unlisted Itcntttcauau not it tho hufi inch matting tactarn pnynh§logtou1 aatilra t; it ti. 0: tan trtatlnnt to tho put303t. 2&311330 at tact. and tn. :0— ycntad I’ll at con-stouunnal (3.3.28). 30-91%. 13.1 ynurt tho-curly i‘ldltl it lultnivaky.3345;&, (2h) lid Paonllu ind algctroumtphtc «ltulcul (30), butt da-anntrntln; g;_3.. dittortnnoo butane: grand 3:1 and pcttt :31 fittntuontu, inflicutad tun Ittnttifl‘nt r01. 0: tin acxturo. 2h. Vitiflil. 3tudann acuparinc convuluirt with oibeouvulsivo trc‘tncat Sanctutr§God that ‘iGhlifiiO. eumnlnu‘ing in a couvulntou warn anttarlly associttud wl‘h utuawrublu flagrant or neuraphyutologic una bohnvaoral chtuco, whilo auboonvulntvu toehntquon ugro nit (15,27,25,39.h0). In racon$ Itiéiul tram that laberticrr. sisalnr ditttrouaou 1n the tug trcttuaat typos war. abunrv.d tor ouch aspacic at bohtvanr nu BIO :10» :11. actavt‘r (8,10), IAIIII‘O changto titlt anoblrbt‘nl (19,20,21) and paraaptnul talk! (13.22.25). �can. littal aspcat ta tbs prtblau at unaorataadtaa enuvulnivo thcrgpy aincgrnl ‘ho rolttsun It tho ntthod fit tudualn: tho fictsara t. tho thorupoutla ouficann. 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/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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Uhtt 6.A.andm 3. mmmdwwimmlmwmn thl Many mama we. 1952. 115: urn-sea. 3m, “1. mm. mm York. 1353. Haw s Wihy Sons. 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/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/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. C9 Aird, R9 139, Striit’ L A9, Pace, of electrically induced convulsions finch. Neel/1.0L effects Neurophys1ologg§§ (1959. )19: 371— 378 ”WW I Aktivnost kholinesterasy 99999 Alpern, D90 i kholinergicheskaya reaktsiya krovi pri shizofrenii9 [Cholinesterase activity and choliner 10 reaction of the blood in schizophrenia ”J; Fizzéoh 2%{719575 .57 87- Pg\ 9 3%; J 1/9 .9 Vitamins, enzyme systems, and trace elements9 Bodéfly Phyzsiofiogy in Mental. and Emotional Duoadefvs) Grune 8 Stratton, New York, It 1953! .1 Altschule, ‘ W M9 W Augustinsson, V D9 New 913$“. f\ M for cholinesterases9 In WGlick 05 Biochemical Ana/Emu) Interscience Publishers, 3‘,We 5’ 1‘1” [103 Presence and action of acetylcholine in experimental 5% Method/s Bornstein, M9 D9 brain trauma9 J; NewLophyAwL, Wig: J 399— 399 Merritt, H9 H9 Effect of certain choline derivatives ctrical acti ity of the cortex. Aach9 Neww£9 PAychia/t. 99: 382 395, Brenner, 91942. #4.. ' Assay methods K9-B9 York, 1957, f” ________ Augustinsson K '-B9 The normal variation of human blood cholinesterase activity9 A1199 PhyALOL Scand9,\l955 \3__5_: 90——52}/ '/ arr” C9 and ' ‘ M physiological significance of acetylcholine9 In K9 A9 C9 Elliot, I9 H9 Page and J9 H Quastel)116(/y) Thomas, Springfield, 4-1-12, 1955],) NeuaochenuADLy) jam-939911 27s“. M99949», 309 my, and acetyl;2 Chatfield, P909 and Dempsey, E9 W9~ Effects of prostig%ne choline on cortical potentials, (Ame/L9 .79 PhyAzéofw', 1992 135: 633-6M0. )9] Burgen, Cone, ., 9 ,1 99, W9 A9 S9 V9 and MacIntosh, F9 C9 The W V9, Toner, D9 B9 and McEachern, D9 Acetylcholine and neuronal {j activity in epilepsy9 (.79A9 M9A9,119u8 73: 59 63 A9 and Merrick, Crossland, The effect of anaesthesia on the acetylcholine content of the brain9 .79 Phybioh ,\¥l95lt.9125 56- 66 9,! .11 1. (/JJ’j) Dale, H9 H9 The action of certain esters and ethers of choline, and their relation to muscarine. 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. 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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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Effect of anticholinergic compounds on post convulsive electroencephalogram and behavior of psychiatric patients. Electroenceph. Clin. Neurophysiol., 21. 22. 12 (2): 359-369, 1960. of action of convulsive therapy: the neurophysiologicadaptive view. J. Neumpsyclfiat. , 3: 231-233, Pink, Pink,- M. M. The mode 1962. and Kahn, R. L. Quantitative studies of slow wave activity following electroshock. Electroenceph. Clin. Neurophysiol. , s: 153, 1956. 23. Alan, B, and beflcowits, H. J. Inhalant-induced convulsions. Arch. Gen. Psychiat. (Chicago), 4: 259-266, 1961. �2“. Freedman, A. M., Bales, P. D., Experimental production of Amer. 25. J. Physiol., mstem’ Do Ho Willis, electrical major convulsiVe patterns. 156: 117-1214, 19%. . Gr‘eenblatt, J. New. mnto Dis. , [08: mnkenstein, changes J. 27. D. Rmkenstein, D. nervous system Autonomc shock treatment. M. and Solomon, H. C. in mentally Autonomic ill patients. 114: 1-18, 1951. H., Greenblatt, M. and Solomon, H. C. Autonomic test of prognostic significance in relation to electroshocktreatment. 28. electric psyChOIOgic changes Dis., Nerv. Ment. 301011011, H. C. HOQ-HZZ, 19.48. H., Greenblatt, paralleling and Mn nervous system changes following 26. A. and Hinwich, H. E. Psychosom. Med., 14: 3147-362, 1952. Cholinesterase activity of whole blood from healthy and schizophrenic individuals. Nature (London), 198: 1118-1119, Gal, E. M. . 1963. 29. Giannan, M. J. acetylcholine. 30. and Pepeu, G. Drug-induced changes Brit. J. Pharmacol., in brain 19: 226-2314, 1962. Significance of individual variability in EEG response to electroshock. J. Hillside Hosp. (Glen Oaks), Green, M. A. 6: 229-2H0, 1957. 31. Hampson, J. L., Essig, C. F., McCauley, A. and Himwich, H. E. Effects of di-isopropyl flnomphosphate (DFP) on electroencephalogram and cholinesterase activity. Electroenceph. Clin. Neurophysiol. , 2: ui-us, 1950. �32. E., Essig, Hinwich, H. Freedman, A. M. F., C. Hampson, J. L., Bales, P. 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/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/bf0b6905f6c2b44054f0b8c530666cd5.pdf b11f5eee6a69d331f4c3c98cd7961516 PDF Text Text Reprinted from the :1. M. :1. Archives of Neurology May 1960, Vol. 2, pp. 547—551 Copyright 1960, by Aerircm Medical Association F igure-Ground Discrimination After Induced Altered Brain Function ROBERT l.. KAHN, Ph.D.; MAX POLLACK, Ph.D., and Studies of complex visual perception with altered brain function in man have not always yielded clear or consistent results. The disagreements may be due to many factors, such as differences in population studied, types of procedures employed, and difficulties in evaluating the degree of alteration in brain function. Electroconvulsive therapy (ECT), however, provides a unique op portunity for studying the effects of cere— bral dysfunction in that more accurate control can be maintained over the degree of induced cerebral dysfunction and its measurement. While most investigations of brain—injured populations have focused on the role of the locus of the lesion on behavior, current studies of ECT have emphasized individual differences. Marked variability has been shown for perceptual}2 behavorial,7 and physiologic 5'8 responses to ECT. Various personality 6'11 and social factors 9'10 have also been related to differences in response to treatment. In the course of an investigation of the perceptual and behavorial changes with ECT, a convulsive—subconvulsive control study was undertaken. In this report, the performance on complex visual tasks is pre— sented. Specifically, the aim was to deter— mine whether perceptual change induced by ECT is related to the degree of altered brain function and clinical behavioral ‘ Accepted for publication Jan. 18, 1960. From The Department of Experimental Psy— chiatry, Hillside Hospital. Presented at the American Psychological Association, New York, August, 1957. Aided by Grants M-927 and MY-2092 of the National Institute of Mental Health, National Institutes of Health, US. Public Health Service. MAX FINK, M.D., Glen Oaks, New York change, and Whether the pretreatment perceptual pattern is related to physiologic changes with treatment. The method used in the study was the perception of embedded geometric figures—— a technique which has been employed in recent years in studies of perceptual change in head trauma and brain tumor pa- tients.1'“"'14 Method Population—Fifty-three consecutive patients referred for ECT were studied. These included 16 men and 37 women, the ages ranging from 22 to 66 years, with a median of 49 years. The patients were divided at random into two groups. A convulsive group, of 29 patients, received grand mal electrotherapy with thiopental (Pentothal) premedication three times a week, using either a Medcraft alternating-current instrument or a. Reiter C-47 electrostimulator. A minimum of 12 treatments was given. The total number of treat— 1. ments was determined by the supervising psychia— trist in charge of the treatment unit on the basis of clinical criteria. A subconvulsive group, of 24 patients, was treated in similar fashion except that only subconvulsive stimulation was given after the thiopental. Fourteen of the subjects in the 'subconvulsive group were subsequently given a regular course of convulsive therapy. 2. Perceptual Task—In the week prior to treat— ment and on the day following the 12th treatment each patient was tested with a modification of the Gottschaldt hidden—figure test developed by Bat— tersby et al.1 The subject is presented with a page containing two forms—a simple geometric figure, and below it a complex figure in which the simple figure is embedded (Figure). The patient is asked to trace a specific geometric figure from the background by outlining it with a colored pencil. The discriminations range in complexity from relatively simple to more complex. There are 25 such discriminations. A maximum of two minutes is allowed for each. Performance is scored in terms of total number of errors. To minimize a practice effect, two equivalent forms of the test were used. The forms were alternated with 77/547 �A.M.A. ARCHIVES OF NEUROLOGY Comparisons for Number of Errorr Before and During EC T TABLE 1.———Intragr0up Type of Treatment Subconvulsivo Convulsive Before No. 24 43 ECT During Differ— ECT once 1’ 7.7 11.8 ~2.3 +2.3 <0.02 10.0 9.5 * (0.02 Intragroup analyses in this and in subsequent tables are based on Wilcoxon’s method of paired replicates. * Results \VAVI ‘7"7V 'AL A AL‘ Figures in hidden-figures test. The preliminary sample used to acquaint the subjects with the task is shown in a; b and c are examples of test figures. In (1 the task is complicated by having the subject determine which of the two single figures can be found in the complex figure. successive patients in pretreatment testing. During treatment the patient was reexamined with the form different from that given initially. 3. Evaluation of Physiologic Change. Two measures of brain function——the electroencephalo— gram and the amobarbital test15—were given to each patient prio1 to and at weekly intervals during treatment. The electroencephalogram was evaluated as to the degree of induced slow-wave activity according to criteria previously published.5 The amobarbital test was noted as positive or negative for brain dysfunction according to standardized criteria}5 The results of these tests during the second, third, and fourth weeks of treatment furnished the criteria for physiologic change. A combined physiologic index was obtained by ascribing to each high—degree slow—wave EEG record and each positive amobarbital test a score of one. The range of physiologic altera— tion thus ranged from 0 to 6. 4. Behavior Ratings.—Each patient’s behavior was evaluated at weekly intervals. After the 12th treatment, a rating for the degree of behavioral change was made according to four classes: marked, moderate, minimal, or none. These ratings of change were not value judgments as to the quality of change but, rather, quantitative estimates of differences in behavior patterns under similar conditions of observation. Thus, such behavior patterns as euphoria, paranoia, and withdrawal might all be rated as equivalent for degree of quantitative change, although the implications of. each for the qualitative evaluation of improvement may be difi'erent. 78/548 The pretreatment and treatment scores and the mean change in the number of er— rors with treatment are shown for each group in Table 1. Intragroup analysis shows that the subconvulsive group made signifi— cantly fewer errors during treatment, whereas the convulsive patients made sig— nificantly more. Prior to treatment, subconvulsive patients made approximately the same number of errors as those in the convulsive group, a mean difference of 0.5 error. During treatment, however, the difference between these bet— at significant (4.1 errors) was groups ter than the 1'% level of confidence. When the data are analyzed with respect to physiologic change, significant increases in errors are found only for those patients with great— er degrees of physiologic change. This re— lationship is present in the analysis of the amobarbital test and the EEG as separate 2,—1ntragroup Comparisons for Number of Errors Before and After EC T in Relation to Degree of Physiologic Change TABLE 3 Mean Difference in No. of Errors During Treatment Physiological Index N Amobarbital Test None or one positive 13 —0.2 Two or three positive Electroencephalogram None or one high delta 28 +3.7 23 +1.7 Two or three high delta Combined Physiologic 0 t0 3 18 +3.3 21 +1.0 20 +3.9 4 to 6 1’ Not significant <0.01 Not significant <0.05 Not significant <0.01 V 01. 2, May, 1960 �FIGURE-GROUND DISCRIMINATION 3,—Intragronp Comparisons for Number of Errors Before and During ECT in Relation to Degree of Behavioral Change 4.—Relation of Pretreatment Errors to Eventnal Degree of Physiologic Change TABLE Degree of Behavioral Change Marked Moderate Minimal or none N Treatment 14 5 ——0.4 Physiologic Change 1’ 0 3 5 <0.01 Not significant Not significant indices, and when the two tests are bined (Table 2). to 2 and N 16 4 and 6 19 8 Mean N o. of Errors Pretreatment 7.9 11.2 13.3 logic change had frequent difficulty following instructions. They would trace the lines com— The relationship between the degree of behavioral change and the change in num— ber of errors during treatment is shown in Table 3. Those patients with minimal or moderate behavior changes did not show an appreciable difference in number of er— rors. Those with marked behavior changes, however, made significantly more errors during treatment. Analysis of the pretreatment error scores in relation to the degree of physiologic change is shown in Table 4. A significant relationship is shown between the pretreatment error scores and the degree of physio— logic change during treatment. Patients with minimal physiologic change during convulsive therapy had a mean pretreat— ment score of 7.9 errors, while those who developed marked physiologic effects had a mean pretreatment score of 13.2. The triserial correlation of pretreatment score and physiologic change is +0.34, significant at the 0.05 level of confidence. Qualitative Data—Alterations in size of figure or in minor aspects of form were common types of error during both testing periods. Certain qualitative patterns were frequently noted during treatment, which occurred only rarely in the pretreatment period. It was common for patients to make no attempt to trace the more complex figures. This failure was often associated with a generalized withdrawal reaction in which theipatient was unresponsive to any stimulus or procedure. Others became hos— tile and negativistic toward the testing. Patients with the greatest amount of physio— Kalm ,et al. During Treatment Mean Difference for Number of Errors During +3.6 +1.0 24 TABLE indiscriminately, without regard for the specific figure to be traced, repeat a previous figure despite changes in the test figure, draw lines where none actually existed, and attempt to trace the stimulus figure while ignoring the more complex test figure. Such patients were likely to respond quickly and impulsively, and showed little concern about making an error even when spontaneously commenting, “I know that’s not right.” Comment This study demonstrates a relationship between the degree of cerebral dysfunction and the degree of perceptual alteration as measured by errors on the embedded-figures test. Patients with subconvulsive stimulation made fewer errors on retesting. Patients receiving convulsive therapy, in whom only minimal physiologic changes were recorded, manifested slight increase or no change in errors. The convulsive patients, however, with the more marked physiologic altera— tions, showed a significant increase in ‘ errors. This interrelationship of brain func— tion and perception may be related both to the perceptual patterns with neurologic dis— orders and t0 the mode of action of con— vulsive therapy. It is evident that perceptual responses systematically vary with the degree of dif— fuse cerebral dysfunction. In relating these patterns to concepts of localized pathology, the role of generalized, nonspecific cerebral dysfunction must be considered. For ex— ample, unilateral spatial “inattention,” fre— quently attributed to parietal lobe lesions alone?!4 has been reported with a variety 79/ 549 �AM. A. ARCHIVES OF NEUROLOGY of lesions provided there was a somato— sensory defect and an associated generalized mental impairment."""16 Teuber and Wein— stein 1“ found that performance on an em— bedded—figures test was unrelated to locus of lesion in cases with penetrating brain wounds, but that aphasic patients made significantly more errors than a nonaphasic group. Pollack et al.,13 using a test identical with that in this study, reported no rela— tionship between errors and the location of lesion in tumor patients. They noted, instead, that the number of errors was related to the severity of general mental changes, manifested as disorientation for time and place. The present observation that perception of embedded figures is re— lated to the degree of diffuse brain dys— function is in accord with these studies of patients with head injuries and brain tu— mors. In previous investigations of the mode of action of convulsive therapy, we have shown that clinical behavioral change is related to the degree of altered brain func— tion.5'7'8 The present study reinforces this observation, the objective criterion of per— ceptual errors being used as an index of behavioral change. As a group, the patients who showed the greatest increase in errors with treatment were those who also showed the most pronounced change in clinical behavior, as assessed by conventional psychiatric evaluation. There appeared to be considerable comparability in the type, as well as the degree, of clinical behavioral change and the quali— tative aspects of performance on the em— bedded-figures test. Failure to attempt the task characteristically accompanied with— drawal or paranoid hostility. A lack of con— cern in correcting errors was associated with clinical euphoria or hypomania. From these behavioral observations, the increases in errors may be attributed to a change in attitude toward the task or examiner, as well as to a specific defect. The altered brain function modified the total pattern of interaction with the environment, of which 80/550 the performance on a complex perceptual task is just one aspect. Previous studies have shown that there is a relationship between the clinical response to convulsive therapy and aspects of personality, defined as the habitual or characteristic modes of response and adaptation.“v1°'11 In this study it has been shown that the pretreatment perceptual performance is related to the physiological response during treatment. This finding suggests that the indi— vidual differences in the development of physiologic change may also be related, in part, to personality factors. Summary and Conclusion Fifty—three consecutive patients referred for electrotherapy were studied before and after treatment on their ability to perceive embedded geometric figures. An experimental group of 29 patients received a course of grand mal therapy with thiopental (Pentothal) premedication. A control group of 24 patients received submnvulsive stimu— lation with thiopental premedication only. The experimental group made significant— ly more errors after treatment than did the controls. Within the experimental group there was considerable variability. Increase in errors was significantly related to the degree of altered brain function and to the degree of behavioral change. Qualitative aspects of perceptual behavior mirrored the pattern of behavioral change observed clinically. Pretreatment error scores were signifi— cantly related to the degree of altered brain function developed during treatment. The significance of this observation in terms of personality factors is indicated. Department of Experimental Psychiatry, Hillside Hospital. REFERENCES l. Battersby, W. S.; Krieger, H. P.; Pollack, M., and Bender, M. B.: Figure-Ground Discrimi— nation and the Abstract Attitude in Patients with Cerebral Neoplasms, A.M.A. Arch. Neurol. & Psychiat. 76 2369, 1956. Vol. 2, May, 1960 �FIGURE-GROUND DISCRIMINA TION Battersby, W. S.; Bender, M. B.; Pollack, M., and Kahn, R. L.: Unilateral Spatial Agnosia (Inattention) in Patients with Cerebral Lesions, Brain 79:68, 1956. 3. Critchley, MacD.: The Parietal Lobes, Baltimore, Williams & Wilkins Company, 1953. 4. Cobb, S.: Amnesia for the Left Limbs De— veloping into Anosognosia, Bull. Los Angeles Neurol. Soc. 12:48, 1947. 5. Fink, M., and Kahn, R. L.: Relation of Electroencephalographic Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 2. 78:516, 1957. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Affecting Individual Differ— ences in Behavioral Response to Convulsive Therapy, J. Nerv. & Ment. Dis. 1282243, 1959. 7. Fink, M.; Kahn, R. L., and Green, M. A.: Experimental Studies of the Electroshock Process, Dis. Nerv. System 19:1, 1958. 8. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improve— ment in Electroshock, A.M.A. Arch. Neurol. & Psychiat. 76:23, 1956. 9. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside Hosp. 6: 6. 216, 1957. Kalm cl 0]. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital, A.M.A. Arch. Gen. Psychiat. 1:565, 1959. 11. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. Neuropsychiat. 1:45, 1959. 12. Landis, C.; Dillon, D., and Leopold, 8.: Changes in Flicker-Fusion Threshold and in Choice Reaction Time Induced by Electroconvul— sive Therapy, J. Psychol. 41:61, 1956. 13. Pollack, M.; Battersby, W. S., and Bender, M. B.: Figure—Ground Discrimination in Patients with Cerebral Tumor, read at Eastern Psychological Association, 1957. 14. Teuber, H. L., and Weinstein, 5.: Ability to Discover Hidden Figures After Cerebral Lesions, A.M.A. Arch. Neurol. & Psychiat. 76: 10. 369, 1956. Weinstein, E. A.; Kahn, R. L.; Sugarman, L. A., and Linn, L.: Diagnostic Use of Amo— barbital Sodium (“Amytal Sodium”) in Brain Disease, Am. J. Psychiat. 112 2889. 1953. 16. Weinstein, E. A.; Kahn, R. L., and Slote, W. H.: Withdrawal, Inattention, and Pain Asymbolia, A.M.A. Arch. Neurol. & Psychiat. 74:235, 15. 1955. rrmccu’ and l’ublinhed in the United State: 0] America 81/551 ��liguruwaruuua ntncrtainn‘aau Artur Induaod Alsorud Irwin luuat£an "M‘ In ”I. than. m ,“1333' "on. II‘ “‘3 'Ilk Kc”. $ at Savorinnuinl Payuhaitry. Islanido Ilqpitul. tron ti. ‘3... 0th, 31$. '0!ttdod I: (933‘! 3‘91? and uz-noya .8 1h: rattanal Igs¢tiutn at lialfih ’ublta v.3. 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"by 9.: Wk mug-ma um m an.“ u 3. n g m an: m tn um» Hm. «I: u “I“ an at“ m was “we. W m �«1 3a References I. Inttarahy, w.s.. traccnr. x.r., reliant, n. and nundlr. 3.3.: figuruogrcmnd ¢£unr£uannt1nu and the abatrtut uttitncn 1n putatuta with narchrax neayltnna. 5,555, ‘4 xi, '_'_, gaig.~;k;w., 19; 369, 195$. 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/b574305356446714449f347eaa71e515.pdf 4bf163bfe85fee82b5e7d9be3ad5c243 PDF Text Text Experimental Studies of the Electroshock Process MAX FINK, M.D., ROBERT L. KAHN, In the last seven years, increasing study by various authors“5 of the neurophysiologic alterations occurring in electroshock has resulted in a re-assessment of the mode of action of this form of therapy. The present neurophysiologic-adaptive hypothesisly2 states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in the continuing evaluation of the electroshock process in this laboratory. These include: The relation of changes in neurophysiolog‘ic indices to behavioral change; 2. Types of psychologic response expressed and factors in the evaluation of “improvement;” 1. 3. and The role of personality in the behavioral response. and Method: The studies have been carried out in groups of consecutive, unselected electroshock referrals. The subjects are voluntary patients in an open ward psychiatric hospital. All patients are treated by resident psychiatrists, who make the referral to the elec— troshock therapy unit. The duration and type of therapy, however, are determined by the supervising psychiatrists in charge of the treatment unit. Patients varied in age from 20 to 66, and have been diagnosed as suffering from depressive and schiz0phrenic I. Subjects illnesses. (a) Tests of Brain Function: Two indices of cerebral function have been stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,6 and changes in orientation and aware— ness of illness after amobarbital sodium.7 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Aided, in part, by grant M-927, National Institute of Mental Health, National Institutes of Health, U.S. Public Health Service. Read at the Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N. J ., June, 1957. PH.D., and MARTIN A. GREEN, M.D. 1) EEG: Electroencephalograms were done weekly prior to treatment, and on a day following a treatment. Bipolar recording was used, and selected leads were measured fOr the degree of delta activity. The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and slowest frequency of delta, and, the longest duration of bursts were the measures utilized in the classification of the recOrds into “high degree]? "‘mod— erate degree” and “low degree delta activity.”6 Amobarbital Test: This is a structured interview, in which the patient is asked a standard set of questions pertaining to ori— entation and awareness of illness. Amobarbital is then administered intravenously, in a concentration based upon body weight, at a rate of 1 cc to every 40 seconds, until nystagmus and slurred speech are induced. In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold} the procedure was modified to allow for weight differences of subjects. The same questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called “positive” and are indicative of states of altered cerebral function.7 Tests were carried out before electroshock, and at weekly intervals during elestroshock on the day following treatment. (b) Evaluation of Behavior: In addition to the notes of the patient’s therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and 2-4 weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these descriptions. Ratings of improvement 'Were based on the behavioral response two to three weeks after the last treatment, and reflect a short term clinical rating. The patients were divided into three groups: much improved, moderately improved and unimproved, based on criteria 2)_ described.2 Reprinted from Diseases of the Nervous System, Vol. XIX, No. 3, March 1958. �(0) Evaluation of Personality .' The initial method of personality assessment employed has been a structured family interview. In their original observations, Weinstein and Kahn described the characteristics of the maintenance of high degree delta activity and short term clinical ratings.6 Of the pa— tients who were rated much improved, 90% had high degree delta EEG records in the 3rd and 4th weeks of treatment, While of the unimproved patients, only 20% had such records. The relationship between delta activity and clinical ratings is seen in Figure 1. “explicit verbal denial personality.”9 To determine the significance of this personality type for behavioral response, a structured questionnaire was developed. In interviews OO .— MUCH IMPROVED (u) with two members of the family, the patient’s usual attitudes and interests in 15 90 .-—— moo. IMPROVENG) UNIMPROVEDW) .-.— characEach specific areas were explored. 80 teristic was rated as being absent, moderately present or markedly present. Scores 7O of 0, 1 and 2, respectively, were assigned, '60 and added—the resulting score being termed 50 the “denial personality score.”1° (d) Treatment: Electroshock was admin- 4o istered on a schedule of three treatments 3. 30 12 week. A minimum of treatments was given, except in a few cases where a. severe 20 confusional state appeared earlier. The course of treatment was determined by the supervising psychiatrist in charge of the lO-lZ electroshock unit, based upon clinical criteria. Treatments were grand mal, using either a Medcraft alternating current instruobservations In these series, subsequent ment or a Reiter C-47 electrostimulator. Pain Based extended predictive were study. a tients were generally premedicated with inthe earlier it on was suggested observations, travenous Pentothal prior to the treatment. those the much that were improved patients In the past year, a subconvulsive therapy been in had whom delta high activity degree group was instituted. Randomly selected induced in and the of treatment course early electroshock referrals received 12-42 suband Records second sustained. the during convulsive treatments, under Pentothal preweeks of third treatment, therefore, were medication. These patients were subjected in 54 consecutive The results assessed. pato the same test procedures and the same bein Table Of I. the noted tients patients are therevaluations mal havioral as the grand delta who degree developed activity high makthe Neither psychiatrist apy subjects. weeks of third second the and treatduring ing the evaluation, the patient’s therapist, while much rated 67% improved, were ment, nor the patient was cognizant of which pawithout the such of 30% aconly patients tients received which form of therapy. The rated. so were tivity data for this series of patients is now being evaluated, and reference will be made only TABLE I to the general observations. Patients With High Delta Activity During II. Observations: Second, Third Weeks of Treatment RATING CLINICAL in Cerebral Role Function of Altered (a) '8 >. Behavior: i’ 75w: a: Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and a 1. .c: EEG Delta Both High (18) One High (16) None High (20) S E to. E 5 8 a 5 12 (67%) 4 (25%) 6 (30%) a; 8 ’5‘ Q sE (22%) 8 (50%) 7 (35%) 4 a D 2 4 7 (11%) (25%) (35%) . �Amobarbital Test In the initial series of 24 patients, ‘previ: ously reported,‘-’ eleven patients were rated as much improved,,andall had positive aniobarbital test reactions after 7 to 9 treatments and sustained this response. Of the unimproved patients, 15% had positive amobarbital responses in the third week and 28% in the fourth week, but these were not Sustained. A comparison of both the EEG observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. In 77 patients tested to date, observations during the second and third weeks of treatment were examined for the presence of high degree delta activity and positive amobarbital test results. Of the much improved patients, 75% had both positive amobarbital tests and high EEG delta activity during this period. Of the unimproved patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is the cluster of negative amobarbital tests, low and moderate EEG delta activity and clinical rating of unimproved. TABLE II EEG and Amobarbital Test Results During Second, Third Weeks of Treatmenfit 2. :, .c: 8 2 8 Total .................................................... 33 .01 E 3 8 E e s E Both Positive Amobarbital and High EEG Delta Activity ........................ 25 Either Positive Amobarbital or High EEG Delta Activity .......................... 8 Neither Positive Amobarbital nor High EEG Delta Activity .............. O *Significant at better than 2 2 Q E sD 10 3 12 5 3 11 25 19 level of confidence. (b) Clinical Patterns of Behavior: In these patients, we have observed varied responses to electroshock including the absence of noticeable symptoms with a return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic com.plaints and pre-occupations, states of in— creased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of’behavioral change is seen to be related to the degree of alter'a} tion in the neurophysiologic indices. During electroshock, with the gradual induction of states of altered brain function, and their restitution in the weeks following cessation of therapy, behavior shows characteristic patterns. The following are but a few of the gross patterns that are observed during the period of increasing and waning states of altered brain function. An early change in behavior in retarded subjects, for example, may be a change in the degree of participation in ward activities and increased neatness and interest in personal care. This is succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial of illness, and insistence upon going home. At this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest in the future becomes prominent. Premorbid patterns of behavior are in evidence, and the EEG returns to normal and the amobarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed during treatment, withdraw from participation in hospital activities, and complain increasingly of memory loss, physical distress and insomnia. Amobarbital tests and electroencephalograms may show the same degree of change as in the first group. With cessation of treatment, there is either a return to the depressed state, or a persistent emphasis on the memory loss and physical complaints of the treatment. Another pattern, seen in hostile, negativistic and withdrawn patients, is the development of hyperactive, hypomanic, and impulsive behavior. Memory loss is marked, and clinical disorientation and confusion may be noted at the height of neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional for.3 �mation become prominent, to be followed by withdrawal and mutism. (c) Efiect of Subconvulsive Therapy: The interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by obser— vations in the subconvulsive group. TWentyseven subjects received subconvulsive therapy instead of grand mal. Minimal changes in the electroencephalogram and in amobarbital tests were induced, and the changes in clinical behavior were limited. The electroencephalograms demonstrated either no delta or a minimal amount of such activity. In no patient were moderate or high degree delta activity records observed. In the amobarbital tests, only three patients had positive tests during treatment, and in each instance it occurred only once. No change in symptoms or behavior was noted in twenty—three. Nineteen were referred for a second course of treatment. Grand mal electroshock in— duced changes in brain function of high de— gree delta activity and/or repeated positive amobarbital tests in fourteen of these. All fourteen showed significant changes in behavior; While of the five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. (d) Role of Personality in the Adaptive Respouse: Another variable in the adaptive response of the patients is the personality—the habitual attitudes, patterns of perception and behavior and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients showing denial mechanisms to the clinical result. The relatives of 47 patients were interviewed, and denial personality scores assessed. Scores ranged from 0 to 25, with a median of 11. The scores were divided into two groups: scores from 11 to 25 were classed as the “high denial group” and those from 0-10 as the “low denial group.” Of the patients with high denial personality scores (Table III), 58% were in the much improved group, and only one patient (4%) was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random—'4 about one third appearing in each rating category. TABLE III Relation of Denial Personality Scores to Clinical Response to Electroshock Personality Score 11-25 0-10 Total Much Improved 14 Moderately Unimproved Improved 7 9 9 1 7 21 18 8 Total 24 23 47 The difference in the denial scores between the much or the moderately improved patients, when compared to the unimproved patients, is statistically significant. That the personality ratings were indeed reflective of the patients’ adaptive response under the conditions of altered brain function is noted in the correlation of these scores with actual changes in language patterns which had been described11 as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether he showed three or more explicit language changes. The group of patients With high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The coefficient of correlation is +.71, which is significant at better than the 1% level of confidence. Discussion: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn,1 and again by Kahn, Fink and Weinstein,2 and the observations of Roth,3 Aird,4 and Ulett.5av Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. We have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital as indices of altered brain function. Other measures, applied in the same serial fashion, will, we believe, demonstrate the same relation to changes in behavior or alteration in brain function. Under the conditions of the induced 111. ‘0 �change in brain function, altered patterns of adaptation are expressed.» The type of adaptation varies, apparently dependent upon the personality organization. In these studies we have noted the relationship of an “explicit verbal denial” personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews.11 We have observed that patients with high denial scores are those who are more likely to be evaluated as “much improved” (Table III). The type of adaptation is varied, however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a means of inducing change in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. We have emphasized “change in behavior” in this report. In previous studies, we related our observation to “improvement.” “Improvement” is a derivative evaluation of the induced behavioral change, which is dependent upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, who had been withdrawn, crying, and had expressed suicidal thoughts, no longer is seclusive, and is jovial, friendly and euphoric, denies his prob— lems and sees his previous thoughts of suicide as “silly,” a rating of “much improved” is made. To the extent that a schizophrenic patient is perceived as less delusional, less excited, and less Withdrawn, he is rated as “improved.” When, however, the induced behavior is one of increased anxiety and fear— fulness, or persistent complaints about memory loss, pain or other physical symptoms, or excitement and delusional thoughts, a rating of “unimproved” will be made. These studies amplify the present neurophysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquilizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. IV. Summary and Conclusions: 1. This report summarizes continuing experimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an alteration in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The pattern of behavioral alteration is shown to vary markedly, depending upon the degree of induced cerebral dysfunction, the personality of the subject and the environmental situation. 4. “Improvement” ratings are seen as a special case of behavioral change dependent upon the type of adaptation elicited, the expectation of the therapist, administrator and family, and the tolerance of the milieu. 5. The extension of this neurophysiologicadaptive hypothesis of electroshock action to other forms of somatic therapies is suggested. 1. REFERENCES Weinstein, E. A., Linn, L., and Kahn, R. L.: Psychosis During Electroshock Therapy: Its Relation to the Theory of Shock Therapy. Am. J. Psychiat, 109: 22-26, 1952. 2. Kahn, R. L., Fink, M., and Weinstein, E. A.: Re- lation of Amobarbital Test to Clinical Improvement in Electroshock. Arch. Neurol. and Psychiat., 76: 23-29, 1956. 3. Roth, M.: Changes in the EEG Under Barbiturate Anesthesia Produced by Electro—Convulsive Treatment and Their Significance for the Theory of EST Action. EEG 01m. Neurophysiol., 3: 261-280, 1951. 4. Aird, R. N., Strait, L. A., Pace, J. W., Hernoff, M. K., and Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. Arch. Neurol. and Psychiat, 75: 371-378, 1956. 5 a. Ulett, G. A., Smith, K., and Glesser, G. C.: Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group. Am. J. Psychiat, 112: 795-802, 1956. 5 b. Ulett, G. A., Glesser, G. C., Caldwell, B. M., and Smith, K.: The Use of Matched Groups in the Evaluation of Convulsive and Subconvulsive Photoshock. Bull. Merm. Olin, 18: 138-146, 1954. 6 a. Fink, M., and Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Olin. Neurophysiol., 8: 158 (Abst.) 1956. �6’ b. . . Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. Arch. Neurol. and P31chiat, 78: 516-525, 1957. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L.: Diagnostic Use of Amobarbital Sodium (“Amytal Sodium”) in Organic Brain Disease. Am. J. Psychiat, 112: 889-894, 1953. Shagass, C.: The Sedation Threshold. A Method for Estimating Tension in Psychiatric Patients. EEG Clin. Neurophysiol., 6: 221-233, 1954. : . Weinstein, E. A., and Kahn, R. L.: Personality Factors in Denial of Illness. Arch. Neurol.» and Psychiat, 69: 355-367, 1953. . Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock. Therapy. Conf. Neural. (In Press.) 11. Kahn, ;R. L., "and Fink, M.: Changes in Language During Electroshock Therapy in Psycho~ pathology of Communication (Hoch, P., and Zubin, J ., Eds.). Grune and Stratton, N. Y., 1957. (In press.) 10. _ ��.thv- AyiAuu. .gypZZILu Experimental Studies of the Electrcshock Process Max Fink, 14.13., Robert L. Kahn, 31.1). and Martin A. Green, M.D. From the Department of Experimental Psychiatry, Hillside HOSpital, Glen Oaks, N.Yo of Mental Health, part, by grant M—927, National Institute Service. Health Public U.S. of Health, National Institutes Aided, in Twelfth Annual Convention, Society of Biological Psychiatry, Atlantic City, N.J., June, 1957. Read Vo at the 6‘27-S7 �-2Experimental Studies of the Electroshock Process In the last seven years, increasing study by various authors (1-5) of the neurophysiologic alterations occurring in electroshock has re- sulted in a re-assessment of the The mode of action of this fcnm of therapy. present neurophysiologic-adaptive hypothesis (1,2) states that an induced change in brain function provides the milieu in which behavioral changes can occur, depending upon the characterologic predisposition of the subject. This report summarizes the data of three groups of studies which have been completed in this laboratory. in the continuing evaluation of the electroshock process These include: relation of changes in neurophysiologic indices in behavioral change; 1) The 2) types of psychologic response expressed and evaluation of "improvement;" and 3) the role of personality factors in the in the behavioral response. �II. -3“ Subjects and Method: studies have been carried out in groups of consecutive, unselected The electroshock referrals. ward subjects are voluntary patients in an The open psychiatric hospital. All patients are treated. by resident psychiatrists, who make the referral to the electroshock therapy unit. type of therapy, however, are determined by the supervising unit. Patients varied in age from charge of the treatment have been diagnosed as sufferina from depressive (a) Tests of Brain Function: have been Two duration and The psychiatrist in 20 to 66, and and schizophrenic illnesses. indices of the cerebral function stressed: Quantitative measures of the degree of induced delta activity in the electroencephalogram,(6) and changes in orientation awareness of illness after amobarbital sodium (7). 1) Egg: Electroencephalograms were done.weekly ment, and on a day following a treatment. selected leads were measured and prior to treat- Bipolar recording was for the degree of delta activity. used, and The average percent time delta for each of these selected leads, the highest delta index in any one lead, the highest amplitude and Slowest frequency of delta, and the longest duration of bursts were the measares utilized in the class- ification of the records into "high degree," "moderate degree" and "low degree delta activity" (7). 2) Amobarbital Test: This the patient is and awareness asked a standard set of questions pertaining to orientation of illness. Amobarbital is then administered intravenously, in a concentration based seconds,% is a structured interview, in which upon body weight, until nystagmus and at a rate of 1 cc slurred speech are induced. to every ho The same 1"“.% In the initial series, a 5% solution of amobarbital was administered at the rate of 1 cc per minute. Recently, to permit simultaneous estimates of the sedation threshold (8), the procedure was modified to allow for weight differences of subjects. �~12.- questions are repeated, and persistent changes in orientation, denial of illness, confabulation, and reduplication are called "positive" and are indicative of states of altered cerebral ftnction (7). Tests were carried at weekly intervals during.electroshock out before electrodiock, and day on a after a treatment. (b) Evaluation of Behavior: In addition to the notes of the patient's therapist and supervising psychiatrist, all patients were seen by the research psychiatrist at weekly intervals during treatment and Z-h weeks after the last treatment. Evaluation of changes in behavior induced by electroshock were based on these on descriptions. Ratings of the behavioral response reflect a short term groups: much improved, described ( two to three clinical rating. weeks The improvement were based after the last treatment, patients were divided and into three moderately improved and unimproved, based on criteria ). (c) Evaluation of Personality: The initial method of personality assessnent employed has been a structured family interview. In their orig- inal observations, Weinstein and Kahn described the characteristics of the "explicit verbal denial personality" (9). To determine the significance of this personality type for behavioral reSponse, a structured questionnaire was developed. In interviews with two members of the family, the patient’s usual attitudes and interests in 15 Specific areas were explored. Each characteristic was rated as being absent, moderately present or markedly present. Scores of 0, l and 2, reapectively, were assigned, and added - the resulting score being termed the "denial personality score" (10). (d) Treatment: Electroshock was administered on a schedule of three treatments a week. A minimum of 12 treatments was given, except in a few �cases where a severe confusional state appeared ment was determined by earlier. The course of treat- the supervising psychiatrist in charge of the electro- unit, based upon clinical criteria. Treatments were grandznal, using either a Medcraft alternating current instrument or a Reiter C-h? electro- shock stimulator. Patients were generally premedicated with.intravenous pentothal prior to the treatment. In the past year, a subconvulsive therapy group was instituted. Randemxy selected electroshock referrals received 12-h2 subconvulsive treatthe ments, under pentothal premedication. These patients were subjected to same test procedures and the same behavioral evaluations as the grand mal therapy subjects. Neither the psychiatrist making the evaluation, the patient's therapist, nor the patient was cognizant of which patients received which.form of therapy. The data for this series of‘patients being evaluated, and reference will be made only is now to the general observations. �III. Observations: A. Role of Altered Cerebral Function in Behavior: 1. Electroencephalogram: In these studies, we have emphasized the degree of delta activity. In the initial series of patients a direct relationship was noted between the early development and maintenance of high degree delta activity much and short term clinical ratings (6). or the patients who were rated weeks of improved, 90$ had high degree delta EEG records in the 3rd and hth treatment, while of the unimproved patients, only relationship between delta activity and 20% had such records. The clinical ratings is seen in Figure 1. In subsequent series, these observations were extended in a predictive much study. Based on the earlier Observations, it was suggested that the improved patients were those in high degree whom delta activity had been in the course of treatment and sustained. Records during the ant third weeks of treatment, therefore, were assessed. The results induced early second in Sh consecutive patients are noted in Table 1. veloped high degree delta ment, such 67% rated were activity were activity during the second much improved, so while only EEG High Delta and who de- third weeks of treat- of the patients without I Activity During Second, Third‘weeks of Treatment. Clinical Rating Much Imgroved Delta 30% the patients rated. TABLE Patients with Of Mbderately'lrunnved Unimproved (11%) Both High (18) 12 (67%) h (22%) 2 (16) u (25%) 8 (50%) h (25% None High (20) 6 (30%) 7 (35%) 7 One High (35%) �a7; 2. AmObarbital Test: In the of 2h patients, preViouSly reported (2), initial series eleven patients were rated as testreactions after 7 to much improved, and all 9 treatments and sustained had positive amObarbital this response. 0f the positive amobarbital reaponses in the third week and 28% in the fourth week, but these were not sustained. A comparison of'both the EEG Observations and the amobarbital test data, as related to the eventual clinical rating is seen in Table II. unimproved In 77 patients, 15% had patients tested to date, observations during the second weeks of treatment were examined activity 75% and had both and third for the presence of high degree delta positive amobarbital test results. positive amobarbital tests Of the much improved and high EEG patients, delta activity during patients, however, 57% had neither positive amobarbital tests nor high EEG delta activity. It is apparent that the cluster of positive amobarbital tests, high EEG delta activity and much improved clinical ratings is a significant one; and equally significant is this period. Of the unimproved the cluster of negative amobarbital activity and tests, low and moderate EEG clinical rating of unimproved. delta �9 ..—-- m TABLE EEG II and Amobarbital Test Results During Second, Third Weeks of Treatment.* Much Mbderately Improved gnimprovsd Improved Both Pbsitive Amobarbital and High EEG Delta Activity 25 10 3 Either Positive Amcbarbital or High EEG Delta Activity 8 12 5 _£L_ L (25) Neither Positive Amdbarbital nor High EEG Delta Activity (33) (Total) B. 1.1 (19) Clinical Patterns of Behavior: In these patients, we have observed including the absence of noticeable varied responses to electroshock symptoms with a return of yrs-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations, states of increased panic, excitement and agitation and varying degrees of withdrawal, and seclusiveness. The degree of behavioral change is seen to alteration in the neurophysiologic indices. brain During electroshock, with the gradual induction of states of altered function, and their restitution in the weeks following cessation of therapy, be related to the degree of behavior Shows characteristic patterns. The following are but a few of the are observed during the period of increasing and waning gross patterns that states of altered brain.function. Anearly change in behavior in retarded subjects, for example, rO-‘fi’lt. * Significant at hotter than .01 level of confidence. x»,-~-n---.' ~rmw-n. may it...“ �be a change in the degree of neatness and participation in interest in personal care. This ward is activities and increased succeeded by a phase of minimizing symptoms and displacement of complaints, mild euphoria, denial this time, the EEG shows the greatest degree of delta activity and amobarbital tests are positive. With the cessation of treatment, the overactivity diminishes, and interest of illness, and in the future insistence upon going home. becomes prominent. Pre-morbid evidence, and the EEG returns to normal At patterns of behavior are in and the amdbarbital test becomes negative. Other depressed subjects, however, become increasingly disturbed and during treatment, withdraw from.participation in heapital activities, Amocomplain increasingly oi memory loss, physical distress and insomnia. barbital tests and electroencephalograms may show the same degree of change as in the first group. with cessation of treatment, there is either a return to the depressed state, or a persistent emphasis physical complaints of the treatment. Another pattern, seen is the loss is on the memory loss and in hostile, negativistic and withdrawn patients, development of hyperactive, hypomanic, and impulsive behavior. Memory marked, and clinical disorientation and confusion may be noted at thelieight o£1neurophysiologic change. After treatment is ended, ideas of reference, negativism and delusional formation become prominent, to be followed by withdrawal and mutism. C. Effect of Subconvulsive Therapy: interdependence of these adaptive patterns with the state of altered brain function is more clearly demonstrated by observations in the subconvulsive group. Twenty-seven subjects received subconvulsive The �~10; electroencephalogram therapy instead of grand mal. Minimal changes in the behavior and in smobarbital tests were induced, and the changes in clinical limited. The electroencephalograms demonstrated either no delta or were a minimal amount of such activity. In patient no were moderate or high activity records observed. In the amobarbital tests, only each instance three patients had positive tests during, treatment, and in it occurred only once . No change in symptoms or behavior was noted in degree delta treatment. twenty-times. Nineteen were referred for a second course of degree Grand mal electroshock induced changes in brain function of high delta activity and/or repeated positive amobarbital tests in fourteen of while of the these. All fourteen showed significant changes in behavior; five patients in whom the physiologic indices showed only minor changes, only two patients showed a definite behavioral change. of Personalitywin the Adaptiverg‘e‘spggg: the Another variable in the adaptive response of the patient is and behavior - the habitual attitudes, patterns of perception 1). Role personalitw and defenses of the patient. The initial study of the role of personality related the characterological disposition of patients mechanisms to the clinical result. The showing denial relatives of h? patients were inter- Scores ranged from viewed, and denial, personality scores assessed. O to 25, scores were divided into two groups: scores from and those from O - 10 as 11 to 25 were classes as the "high denial group" with a median of 11. the “low denial The gar-mp." 0f the ,.latients with high denial personality scores (Table 58%; were in the much improved group, and. only one patient (1%) was III), in �911- the unimproved group. The ratings of for the patients with - about one third appearing in improvement low denial personality scores were random i each rating category. lean; Relation of Denial Personality Scores to Clinical Response to Electroshock Much Improved Moderately Improved Unimpmved Total M9&1}EI., §9ar£ 11 — 25 1h 9 1 2h 0 - 10 7 9 7 23 21 18 8 h? Total The difference in the denial scores between the improved patients, when compared to the unimproved much or the moderately patients, is statistically significant. That the personality ratings were indeed reflective of the patients' adaptive reaponse under the conditions of altered. brain function is noted. in the correlation of these scores with actual changes in language patterns which had *een described (11) as indicative of denial responses. As in that study, changes in language in structured interviews with the patient were studied. Each patient was classified according to whether or not he shone 6. three or more explicit language changes . The group of patients with high denial personality scores showed a significantly greater number of language changes than patients with low personality scores. The co- efficient of correlation is +.7l, which is significant at better than the 1% level of confidence. �IV. Discussign: These studies of the neurophysiologic and psychologic aspects of electroshock support and amplify the hypothesis of electroshock action initially expressed by Weinstein, Linn and Kahn (l) , and again by Kahn, (3), Aird (’4), and Ulett (5a, b). Alteration in brain function is the central effect of electroshock therapy, and is a pre-requisite to behavioral change. He have emphasized delta activity in the electroencephalogram and the patterns of disorientation, confabulation, and denial of illness after amobarbital Fink and 'E-i‘einstein (2), and the observations of Roth as indices of altered brain function. Other measures, applied in the serial fashion, will, we believe, demonstrate the in behavior or alteration in brain function. Under the conditions of the induced change same same relation to changes in brain function, The type of adaptation altered patterns of adaptation are expressed. these varies, apparently dependent upon the personality organization. In studies we have noted the relationship of an "explicit verbal denial" personality type with the development and maintenance of clinical language patterns of denial, displacement, and minimization in structured interviews (11) . We have observed that patients with high denial scores are those are more likely to who The type of adaptation be evaluated as is varied, "much improved" (Table III). however, as we have described here. In this context, therefore, the conclusion is affirmed that electroshock is a in cerebral function in which altered patterns of adaptive-interpersonal behavior can be sustained. means of inducing: change We have emphasized " change in behavior" vious studies, we in this report. In pre- related our observation to "improvement." "Improvement" �:13- derivitive evaluation of the induced behavioral change, which is dependend upon the expectations of the therapist, the family, or the administrator, in the milieu in which the behavior is observed. When a depressed patient, is a who had been withdrawn, is seclusive, and crying, and had expressed suicidal thoughts, no longer is jovial, frienc‘ly and euphoric, denies his problems and sees his previous thoughts of suicide as is made. To "silly," a rating of "Inuch improved" the extent that a schizophrenic patient delusional, less excited, and less however, the induced behavior one is perceived as less rated as "improved." When, of increased anxiety and fearmlness, or loss, pain or other physical symptoms, or delusional thoughts, a rating of "unimproved" will be made. persistent complaints about excitement and is t-Iithdrawn, he is memory studies amplify the present neumphysiologic-adaptive hypothesis of electroshock action. Further studies, defining the significant aspects of personality and of the expectations of the environment on the patterns of These behavior which are observed under the condition of altered brain function are suggested. Application of this hypothesis to the effect of newer tranquillizing agents is in progress. Finally, studies of individual differences in the neurophysiologic response to equivalent amounts of cerebral trauma warrants exploration. �V. gunnery and. Conclusions: 1. This report sumarizes continuing esperimental studies of the mode of action of electroshock therapy. 2. Behavioral change in electroshock is dependent upon an altera- tion in brain function as evidenced by serial changes in delta activity in the electroencephalogram and disorientation and confabulation with intravenous amobarbital. 3. The depending upon the subject 1;. pattern of behavioral alteration is shown to vary markedly, the degree of induced cerebral dysfunction, the personality of and. the environmental situation. "Improvement" ratings are seen as a Special case of behavioral the type of adantation elicited, the expectation of the therapist , adninistrator and family, and the tolerance of the milieu. change dependent upon this neurophysiologic-adaptive hypothesis of electmshocl: action to other forms of somatic therapies is suggested. S. The extension of �m REFEIUQI‘ICES l. Juno‘s—t Weinstein, E.A., Linn, L. and Kahn, R.L.: Psychosis During Electroshock Therapy: Its relation to the Theory of Shock Therapy, Am. J. Psychiat” 109: 22-26, 1952. of Amobarbital 1. and Weinstein, E.A.: RelationA.I—-I.A. Arch. Neurol. Electroshock, in Test to Clinical Improvement 1956. and Psychiat., IQ: 23-29, Roth, 1-1.: Changes in the EEG under Barbiturate Anesthesia Proclucec‘v by Electro-Convulsive Treatment and their Significance for the Theory of EST Action, EEG. Clin. Neurophysiol., _3.: 261-280, 1951. Kahn, R.L., Fink, 3. h. Pace, J.EI., Hernaff, M.K. and Bowditch, 5.0.: Neurophysiologic Effects of lectrically Induced Convulsions, A.:-I.A. Arch. Neurol. and Psychiat., 15: 371-378, 1956. Aird, Ran, Strait, L.A., . G.A., Smith, K. 5a. Ulett, Subconvulsive Shock and Gleeser, G.C.: Evaluation of Convulsive and Therapies Utilizing a Control Group, Am. J. Psychiat., 112: 795-802, 1956. 5b. Glasser, G.C., Caldtrell, B.M., and Smith, K.: The Use of I'iatched Groups in the Evaluation of Convulsive and Subcommlsive Biotoshock, Bull. Mann. 015.11., 6a. 6b. _1__8_: 138-1h6, 1951.. H. and Kahn, R.L.: Quantitative Studies of Slow Wave Followi.n:_; Electroshock, EEG Clin. Neurophysiol” _8_: 158 Fink, Activity (Abst.) 1956. EEG Delta Activity to Behavioral and ___: Relation of Response in hilactroshock: Quantitative Serial Studies, A.itI.A. Arch. Eleurol. and Psychiat. (in press). 7. E-Jeinstein, E.A., Kahn, R.L., Sugarman, L.A. and Linn, L.:Diagnostic Use of Amobarbital Sodium ("Amytal Sodium") in Organic Brain F‘lisease, Am. J. Psychiatu .133: 889-89h, 1953. 8. Shagass, C. : The Sedation Threshold. 9. Weinstein, E.A. and Kahn, R.L.: Personality Factors in Denial of illness, in Psychiatric Patients, A.1-I.A. Arch. Neurol. and EEG A Method for Estimating Tension Clin. Neurophysiol., Psychiat., _6_: 221-233, 1951;. 99;: 355-367, 1953. Parsonality Factors in Behavioral to Electroshock Therapy, Coni‘. Neurol., (in press) Response 10 . Kahn, R.L. and Fink, 14.: 11. Kahn, R.L. and Fink, 141.: Changes in languAge During Té‘lectroshock Therapy, in P cho tholo g; Comunication (Hoch, P. and Zubin, J., 13623.), Grune and tratton, N.Y., 1957. (in press). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental studies of the electroshock process. Dis Nerv Syst. 1958 Mar;19(3):113-8. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-30-007 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L.; Green, Martin A. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Diseases of the Nervous System, Vol.XIX, No.3, March 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/549693df019a0cabd2aa7cfa90ad3ced.pdf 62db1d0b502fce82996214e0276f034a PDF Text Text ’i' WM 3mm; lacunae Whammy mum. a: convulsive ma Ems in 1:33,“;ant W Mhim Fth mm m 1-. 0-. A. 3.1% of mmm mmm, m the mam. mm m, 34.1., $1”. W Hakim}. W? of the Unfiml Wfim%_ a! Manta Insti‘MkaWWith, mm fiflm mm: mm 80m“. He: 33.113169 -' Aldus! 3.33.1513, 01' a Se Wolagiaal W an arm mmg, Howof1m 3mmandm- ammal Psychiatry, Kw Yam assuming mum may, of 10-613mm, flu: Kerk, 13., 1953:. Promtud a mama: . » ‘ 5.. #- sky and Mb �II: 3-1148 Experiment-3. 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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 . 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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 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/07a3d1b2eec1cf62891da3ff4c4049c8.pdf f5bf70eb575371f639319602e2837d97 PDF Text Text EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, M.D. Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume X ° Nos. 3-4 ° July-Oct. 1961 �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, MD. The dedication of Hillside Hospital as a Research Institute has been a dream of many of its students—a dream that may achieve realization in this decade. Dr. Tarachow was an early proponent of this view; and both in his sponsorship of the Journal, and in his encouragement of research studies, he presaged this development. He was also the inadvertent sire of the research studies in experimental psychiatry. While I was a resident in psychiatry in 1952, we collaborated in a study of the relation of the early separation of child from a parent to the adult choice of neurosis. Reviewing the hospital records of five previous years we concluded that there was, indeed, a relation—— neurotic patients with obsessional neuroses had a significantly, greater incidence of separation than patients with hysterical neuroses (2). This report was the beginning of the patient population studies described here. Since 1954 the various programs in experimental psychiatry have been devoted to an understanding of the mode of action of the psy- chiatric therapies of the hospital. The techniques have been adapted from descriptive and dynamic psychiatry, neuropsychology, electroencephalography, linguistics, pharmacology, and sociology. This report reviews these studies and presents support for the creation of a Research Institute at Hillside. PAST STUDIES In our early studies of convulsive therapy, instituted with the 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. The studies reported here have been aided by the Board of Directors Research Fund; the National Institute of Mental Health (Grants M-927; MY-2092,-27l5, -4798; MF-12,033); Foundations Fund for Research in Psychiatry (FFRP 56-151); Kaufmann, and Dazian Foundations; and numerous pharmaceutical concerns including Geigy, Bristol, Wyeth and Smith, Kline 8c French Laboratories. 159 �160 MAX FINK aid of a grant award of the National Institute of Mental Health, evaluations of patient improvement were shown to be dependent both on changes in brain function and on psychological factors. As our understanding of convulsive therapy developed, a general neurophysiologic-adaptive view of somatic therapies emerged (6). A change in brain function was seen as a necessary condition for behavioral change, with the type of change varying, depending upon psychological and sociological characteristics of the subject (22, 25). Thus, the mode of action was not seen as either “organic” or “psychological” but rather as the interaction of neurophysiological changes and individual patterns of response and behavior. This hypothesis was sustained in studies of convulsive and in sulin coma therapies (21, 22); and the mode of action of the new psychotropic agents was expressed within this hypothesis. It was suggested that psychotropic drugs would be effective to the extent that persistent changes in brain function were induced; and that the type of behavioral response would be related to the type of brain change, and to individual premorbid psychologic (personality) patterns (6, 28, 40). Convulsive Therapy Process: Seeking a measure of altered neurophysiological change that was sensitive and suitable for repeated retests, various measures were studied including changes in the face-hand test (1, 10, 13, 35), memory tests (17, 35), amount of slow-wave activity in the EEG (16, 23) and confabulatory and denial language patterns after amobarbital (3, 15). The latter two, EEG and amobarbital tests, were the most sensitive indices of change in convulsive therapy subjects. In one experiment, clinical ratings of improvement were correlated with high degrees of change in these indices (15, 16). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to either convulsive or subconvulsive therapy. High degrees of electrographic slow-wave activity and positive amobarbital tests were observed only in the convulsive group; improvement rates were significantly higher in this group, and when subconvulsive subjects were retreated by convulsive applications, the improvement rate was similar to the convulsive group (22). In subconvulsive applications, considerable electric current passes between the electrodes. It was postulated that the therapeutic agent was not the total electrical current per se, but the “all or none” quality manifested by the grand-ma] seizure (9, 23, 42). The signifi1. �EXPERIMENTAL PSYCHIATRIC RESEARCH 16] cance of the grand-mal seizure was examined in a comparative study of the inhalant convulsant, hexafluorodiethylether (Indoklon), and electrically induced seizures. Similar degrees of electrographic change, improvement rates, types of behavioral adaptations, and changes in neuropsychological task behavior were observed in both the inhalant and in the electrically treated groups (49). However, not all subjects manifesting high degrees of physiological change were evaluated as “improved.” In a descriptive typologic study, five adaptive modes were described, empirically termed “eu— phoric,” “hypomanic,” “somatization,” “paranoid-withdrawal," and “panic.” While the first two patterns were rated as “much improved,” the latter two were seen as “unimproved" or “worse” (50). In studies of psychological variables, it was reported that patients rated “much improved” and “recovered” frequently manifested personality patterns akin to the explicit verbal denial personality type (37). These patients expressed the “language of denial” more frequently than unimproved subjects, exhibiting such aspects as explicit. denial, minimization, displacement and clichés (27). Other psychological indices also related to favorable outcome included high F Scale score (42), Rorschach determinants of color, absent movement and absent form-color (30, 45), and low educational achievement and foreign birth (31). 2. Anticholinergz'c Compounds and Convulsive Therapy: Seek-ing a way to augment the degree of postconvulsive EEG slow-waveactivity, an anticholinergic compound diethazine, was given intravenously at various stages of the convulsive therapy process (20, 24).. Unexpectedly, diethazine caused an immediate and sustained de-crease in EEG slowing, which was associated with marked changes. in language and mood. In patients with denial language patterns. (27), these could no longer be elicited. Instead of euphoria and wellbeing, the subjects became irritable, anxious, and complaining. In‘ subjects prior to convulsive or drug therapy, diethazine induced, ex-citement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds" and sympathomimetic hallucinogens showed behavior and electrographic patterns similar to diethazine. These observations led to the suggestion that an increase in the cholinergic activity of the central nervous system was the biochemical basis for the convulsive therapy process (38). Psychotropic Drugs and EEG: Following these studies, the: neurophysiological changes induced by drugs were testedwithinan. 3. �162 MAX FINK acute experimental-EEG setting. It was observed that phenothiazines induced EEG synchronization and a shifting of the frequency spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of the spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (18, 26, 28, 40). Imipramine induced desynchronization with a shift of frequencies to the slow bands (33, 34). Each active psychotropic compound was thus shown to have a characteristic frequency pattern. Various other experimental compounds were also tested, and for these no consistent electrographic pattern was recorded. These compounds have since been shown to have either no or very limited clinical psychotropic activity. The absence of behavioral change with these compounds lent further support to the assumption that brain change is a necessary condition for the action of psychotropic drugs. These observations suggested that psychopharmacological agents provide a means for eliciting various types of altered brain function in contrast to the single pattern following convulsive therapy. Furthermore, the type of neurophysiological alteration, as reflected in EEG synchrony and frequency patterns, was found to be related to specified types of behavioral adaptation. The advantage of EEG techniques for the assay of new psychotropic agents and the technical merits of electronic frequency analysis were assayed and described (47, 52). 4. Insulin Coma Therapy: In our insulin coma studies we con- firmed earlier observations that persistent alterations of brain function were related to prolonged coma and spontaneous seizures; and saw in this relationship support for a neurophysiologic-adaptive hypothesis. With the availability of the new psychotropic agent chlorpromazine, a controlled chlorpromazine-insulin coma study was undertaken in September, 1955. As patients were referred for insulin coma they were randomly assigned to courses of either oral chlorpromazine for at least three months in doses adjusted to fall short of toxicity; or insulin coma, induced by a standard technique at least fifty times in each patient. While a number of minor differences were noted in comparing the two therapies, the results at time of discharge showed no statistical difference in the effectiveness of both treatments. Neither treatment seemed to affect the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management (21). Concurrently, following the suggestion by the Creedmoor workers that �EXPERIMENTAL PSYCHIATRIC RESEARCH 163 divided insulin doses were superior to single insulin doses, Blumberg and Laderman (39) essayed this problem and demonstrated no significant merit to the multiple-dose technique. (In 1958, following the general confirmation of these observations, insulin coma therapy was discontinued at Hillside). 5. Neuropsychology: Various psychophysical tests were adapted from neuropsychology, where their significance in brain-damaged subjects had been demonstrated. The early studies assessed these tasks as indices of altered brain function (35), and measured the range of performances of psychiatric patients, who are generally assumed not to be brain-damaged. Thus, memory function was assessed on immediate recall, after various interpolated learning tasks (17, 35), as well as during convulsive therapy (17). Tactile perceptual tasks were first examined in the clinical population (1). Later, with more sensitive electrical tactile stimuli, Korin (10) observed the range of thresholds in different body parts, the changes with altered brain function (10), and the influence of set (instruction) on performance (36). We also studied the perception of embedded geometric figures (43), tachistoscopic presentation of embedded color figures (55), perception of the visual upright (55), critical flicker frequency (49), and interference in reading time by delayed auditory feedback (55). For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher—a betterment of performance ascribed to practice effect. Concurrently, assessment of various psychological measures as indices predictive of behavioral change during convulsive and drug therapies led to studies of the Rorschach determinants (30, 45), California F Scale scores (30, 42), language patterns after amobarbital (27), denial scores on interview (37), and the perception of the visual upright and auditory feedback (55). 6. Psycholinguistics: Concurrent with the syntactic language studies (27), analyses of other language patterns were undertaken, both in a search for more objective indices of behavioral change and to gain experience in the technical problems of tape analysis for psychotherapy research. An index of variability in the vocabulary of speech, the type-token ratio (TTR) of consecutive samples of dyadic speech, was extensively studied (7,41, 44, 46, 56, 57). In convulsive therapy patients, significant changes in TTR mean �164 MAX FINK and standard deviations were related both to the degree of induced EEG slow-wave activity and to syntactic language patterns obtained in independent structured interviews. It was noted that speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (41). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents which produced predominant synchronization patterns on the EEG were related to a decrease in mean TTR and an increase in the standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns and decrease in variability of consecutive scores (44). Other language measures studied included distress-relief quotients, self-reference, and alterations in tense and person. It was suggested that these psycholinguistic measures are useful techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents (44, 46). 7. Brain Damage and Schizophrenia: Following his studies at Ittleson Center, Pollack reviewed the relationship between age of hospitalization, intellectual functioning and prognosis in schizophrenic children and adults. He noted that initial hospitalization in childhood and adolescence was related to I. Q. scores in the subnor— mal range, deviant performance on psychomotor tasks, and more frequent ratings of “unimproved” at hospital discharge than was initial hospitalization as an adult. The early and insidious onset of the behavioral syndrome “schizophrenia” was thus related to brain dysfunction (54). Findings suggest that different subgroups of schizophrenia may be classified on the basis of neuropsychological deviancy. 8. Sociological Studies: Considerable interest in the family organization to which discharged patients were returning, the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to treatment referral patterns led to a series of population studies. In one study (8), education, age, place of birth, and score on the California F Scale were significantly related to the type of therapy received and the utilization of adjunctive hospital services. In a second study (3]), duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors, while in a study of patient refusal of ECT, similar relationships were observed (51). These observations suggested a comparative interinstitution study, and among three hospitals the relationships between social class and other demographic variables (age, sex, education) to the clinical �EXPERIMENTAL PSYCHIATRIC RESEARCH 165 variables of patient classification (diagnosis), duration of hospitalization, selection of therapy, and discharge evaluation have been assessed. Three teaching institutions were selected in which all therapies are equally available to all patients—Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lowerclass, Catholic), and Hillside Hospital (middle-class, Jewish). In such a comparison we have found the differences in designations of treatment, diagnosis, and discharge evaluation so marked as to make comparisons difficult. While many relationships between social variables and clinical variables were observed in each hospital, no social variable was found related to the clinical variables in every hospital (53). In an outpatient department study, sex, age, and marital status were found to be related to the acceptance and rejection of patients and failure to complete the application process (55). These observations in population samples led to concurrent studies of staff attitudes in the selection of therapy (ll, 12). In a series of ward observation studies, Kaplan and Lefkowits indicated the significant role of staff attitudes (especially nursing personnel) in the referral for subjects for somatic therapies, and in the transfer of patients from one ward to another. (To study the influence of stafi attitude on patient selection for drug therapy, we requested one ward be designated as a “no-movement” unit. This was adopted in September, 1959 and shortly thereafter by the whole hospital.) PRESENT STUDIES During the period of the convulsive therapy studies, many new psychotropic compounds were assessed clinically (5, 21), electrographically (34, 40, 48), and psychophysically (48). The present psychopharmacology evaluation program, based on these studies, was designed to answer the following questions: 1. Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? 2. Are there pretreatment clusters of psychiatric, physiological, and psychological variables which are related to the type of behavioral adaptation? 3. Are such clusters related to the type and degree of physiologi- cal change? As an initial approximation, a double-blind, fixed dosage, ran- �166 MAX FINK dom assignment drug study was undertaken. Based on our clinical experiences three types of compounds were selected on the basis of their EEG patterns. In this study, 203 subjects were referred, and 149 have completed the testing program, from October, 1959 to July, 1961. l. Behavioral Change: In a survey of the behavioral adaptations of patients receiving various psychotropic compounds during 195859, a behavioral typology based on the treatment response and on pretreatment psychiatric profiles was developed (55). In the present study, the typologies are being tested, and various measures of behavioral change studied, including therapist ratings, self-ratings, and various ward observation scales. 2. Neuropsychology: Psychological tasks have been viewed both as indices of behavioral change and as predictive guides in convulsive therapy. Each of these tasks and a selected group of motor tasks are now being assessed for both their capacity to reveal change with various drugs and their capacity to predict change with the drugs in. this program (48). 3. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (16). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques (48), and electronic frequency analysis was introduced in August, 1959. By measurement of the pen deflection for various frequencies from 3 to 33 cps in ten-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are obtained (52). Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure response to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. 4. Data Analysis: To analyze the data generated in this study, we have sought the aid of complex statistical methods and computational facilities. Analyses of covariance, correlation matrices, factor analyses, and discriminant function analyses are computations now in progress with these data at the NIMH Psychopharmacology Service Center’s Biometric Laboratory in Washington. THE NEXT STEPS Favored by a national research climate and a cooperative hospital staff, these studies have proceeded vigorously. The assets for research in this setting have been great—a selected, intelligent patient popula- �EXPERIMENTAL PSYCHIATRIC RESEARCH 167 tion resident from six to twelve months, without individual economic limitation of hospital stay; a sophisticated administration tolerant of controlled studies; and approval of a Board of Directors who desire “research” as an institutional function. As Dr. Lewis Robbins noted in his first hospital report in 1959, a specialty hospital can make little impact on the mental illness problems of the community by treatment alone. The successful treatment of 350 patients a year is but little comfort to the 40,000 resident patients in the state hospitals of Long Island. Nor will the annual training of twenty or thirty physicians in the arts of psychotherapy do much to help these unfortunates or the many thousands of ambulatory mentally ill resident in the nation. No, a therapeutic goal alone is salutary but inadequate to our needs. As he proposed, the answer may lie in the dedication of a “research hospital,” as it is here that a specialty hospital can truly excel. The charter has been written in the Board’s assertion of research as a hospital goal. With the assets of an exemplary therapeutic facility, such rededication can provide the stimulus for the continuous study of the cause of mental illness and of methods of therapy. Such dedication would provide the stimulus for comparative and controlled assessments of different therapeutic techniques. Continued study is urgently required of the selection of patients for various therapies; the application and mode of action of the therapies; and the role of social and milieu factors in supporting the effects of our ther- apies. Assessments require a meaningful classification of subjects. The behavioral variables alone, which are the basis of our present diagnostic schemata, are unsatisfactory. Study is urgently required of the applicability of social and demographic variables; psychological task performance profiles; typologies based on behavioral response to defined stresses or drugs; and physiological reactivity measures. Such classifications are also essential for any biochemical, physiological, or evaluative study to provide homogeneous samples and comparable controls. Assessments also require meaningful indices of evaluating change. Present global “improvement” ratings and socialization measures are inadequate. Whether the intervening variable be milieu therapy, psychotherapy, drug therapy, or time, the criteria of behavioral change require definition. The applicability of rating scales, language tasks, self-ratings, psychophysical change scores, family assessments, etc., require study and evaluation. Recent studies of psychotic subjects have provided the suggestion �MAX FINK 168 that there is a neurologic factor in a group of the schizophrenias. The high incidence of electrographic and neurologic dysfunction, the lack of behavioral response to all therapies, and the relentless course of the illness suggest an “organic” involvement in this cluster. Such a substrate must be clearly sought by the application of biochemical, neurophysiological, and epidemiological techniques to various clus- ters of young psychotic subjects. These are broader views of some of the questions studied in the programs in experimental psychiatry of the past seven years. These programs, and the contemporary projects in biochemistry and in medicine, provide models of bootstrap studies undertaken with limited support. A dedication of Hillside Hospital as a Research Institute will provide the needed focus and impetus for the scientific and humanitarian forces of the community to join in a common endeavor to resolve the problems of the mentally ill. Acknowledgment: Participants in these programs include the present members of the Department of Experimental Psychiatry: Ira Belmont, Martin A. Green, Abraham Kaplan, Eric Karp, Donald F. Klein, John C. Kramer, Max Pollack, and Arthur Willner. Former associates included Karl Andermann, Joseph Jaffe, Robert L. Kahn, Hyman Korin, George Krauthamer, Nathaniel Siegel; and Research Fellows Barre Alan, Fred Coleman, Harold Esecover, Stanley Friedman, Henry J. Lefkowits, and Robert Shaw. The cooperation of Arnold G. Blumberg of the Department of Medicine in the present program is gratefully acknowledged. The reports listed here are the result of the collaboration of these workers and the professional staffs of the hospital who gave unstintingly of their time and their good-will. REFERENCES' (1) This Journal, 1:21, 1952; (2) ibid., 2:67, 1953; (3) ibid., 4:3, 1955; (4) ibid., 4:134, 1955; (5) ibid., 5:67, 1956; (6) ibid., 6:197, 1957; (7) ibid., 6:207, 1957; (8) ibid., 6:216, 1957; (9) ibid., 6:229, 1957; (10) ibid., 6:241, 1957. This Journal, 10:84, 1961; (12) ibid., 10:97, 1961; (13) Neurology, 4:211, 1954; (14) Arch. Neurol., Psychiat., 72:233, 1954; (15) ibid., 76:23, 1956; (16) ibid.‘, 78:516, 1957; (17) Conf. Neurol., 16:88, 1956; (18) EEG Clin. Neurophysiol.,9:180, 1957; (19) ibid., 10:162. 1958; (20) ibid., 10:207, 1958. (21) J. Am. Med. Assn., 166:1846, 1958; (22) Dis. Nero. Sys., 19:113, 1958; (23) ibid., 19:227, 1958; (24) Arch. Neurol., Psychiat., 80:380, 1958; (25) ibid., 80:73, 1958; (26) Neurology, 8:682, 1958; (27) Psychopathology of Commum'cation, New York: Grune 8c Stratton, 126, 1958; (28) Psychopharmacology Frontiers, New York: Little, Brown, 325, 1959; (29) Proc. XV Int. Cong. Psychol., North Holland Publ., 238, 1959; (30) J. Nerv. Ment. Dis., 1281243, (11) 1959. (31) Arch. Gen. Psychiat., 1:565, 1959; (32) EEG Clin. Neurophysiol., 11:398, �EXPERIMENTAL PSYCHIATRIC RESEARCH (41) (51) 169 1959; (33) ibid., 12:243, 1960; (34) Canad. Psychiat. Assn. 1., 4:166S, 1959; (35) Proc. Int. Cong. Neurol. Sci., Pergamon, 613, 1959; (36) Am. J. Psychol., 72:384. 1959; (37) J. Neuropsychiat., 1:45, 1959; (38) EEG Clin. Neurophysiol., 12:359, 1960; (39) Am. J. Psychiat., 116:839, 1960; (40) Neuro-Psychopharmacol., 1:441, Elsevier, 1960. J. Nerv. Ment. Dis, 130:235, 1960; (42) ibid., 130:187, 1960; (43) Arch. Neurol., 2:547, 1960; (44) Dynamics of Psychiatric Drug Therapy, Springfield: Thomas, 29, 1960; (45) ]. Neuropsychiat., 1:242, 1960; (46) Am. J. Psychother., 15:46, 1961; (47) Neuro-Psychopharmacol., 2:30, Elsevier, 1961 ; (48) ibid., 2:381, 1961; (49) Arch. Gen. Psychiat., 4:259, 1961; (50) ibid., 5:30, 1961. J. New. Ment. Dis., 132:153, 1961 ; (52) Medicina Experimentalis (in press); (54) Arch. Gen. Psychiat., (53) VA Conf. Psychopharmacology (in press); 2:652, 1960; (55) Unpublished manuscript; (56) Psychiatry, 21:249, 1958; (57) Comparative Psycholinguistic Analysis of Two Psychotherapeutic Interviews. New York: Int. Univ. Press, 1961. ' Due to the length of this Bibliography, it is presented in an abbreviated form. ��IIPRIIIBIIAL PBIGIIATEIO 13831303 A! IILLBIBI noiiow and Proapoct HI: Pink, 3.9. Iron tho Dopsriuont of Export-cutnl Psychin$ry, 31113160 Hospittl, clan Oaks, L.I., 1.!. 2h. Itud1fil roportod hart hi1. baa: ntdud hr tho Board Dir-ctoro Research Fund; thc lttiannl Instituto or I: Honttl nutlth (Grants l-927; I!-2092,-2715,-h7983 nr~12,033); POIndationl Fund for honoureh 1: Psychiatry (373? 56-151); xuutnan§, tad Dalian fantastical; and lustrou- pharnao ooutionl cost-rap tncIudinx 60131, Briatbl, Wrath and Snith, K1130 a Iroach Lnboratorioa. 1': 10/1/61 �Exporinontol Poyohtotrio Rooooroh ot Htlloido lovtov ood Proopoot tho dodtoottou of 3111-14. Boopttol oo o Rooooreh Inotttoto boo boon o drooo o! nony or 1to otudooto - o drool that nay oohiovo rooliootion in thin dooodo.< Dr. 3. toroohov woo on oorly propoooot of thio vtow, ood both in hto oponoorohip of tho Joorool, ond to his onooorozonont or rooooreh otldtoo, ho prooosod thio dovolopuoot. no woo oloo tho toodvortoot oiro at tho rooooroh otodtoo 1n oxporioontol poyohtotry. “halo 1 woo o rootdoot 1n poyohtotry to 1952, no oolloborotod in o otudy or tho ro~ lotion of tho oorlr ooporotsoo of child tron o ohotoo tho poroot to odolt of uoorooto. notion13¢ tho hoopttol rooordo o: ttvo proviomoyyooro no oonolodod thot thoro woo, todood, o rolotioo nourotto pottooto with otooooionol oouroooo hod oigoitxoootly xrootor tooxdoooo o: ooporotioo thou potiooto with hyotoriool oonroooo (a). rhto roport woo tho boctooinc of tho potioot popolottoo otodxoo dooorabod horo. stnoo 19Sh tho vortooo progrooo 1o exportoontol poyohiotry hooo boon dovotod to on ondorotoodtog of tho undo o: o U �.2.- antioo of tho poyehiatric thoropioo of tho hoopitol. rho tochniquoo hovo boon odoptod tron doooriptivo ood dylooio payohiotry, oouropoyoholou, olootroonoopholonophy, linguiotiuo, phoroooology, ood sociology. Ihio roport roviowo thooo otudioo ond prooooto support for tho erootion or o nooooroh lootitoto ot lilloido. PIS! SIFDIBS In our early ttudioo or oonvoloivo thoropy, inotitotod with tho oid o: o grout oword of tho Iotionol Institoto o: nontoi Roolth, ovoluotioal o: potioot iaprovonont woro ohown to to dopoodont both on choocoo in broio function ond on poyoholociool tootoro. AI our Indorotondioz of oonvoloivo thoropy dovolopod, o gonorol nooropnyoioloxio~ odoptivo viow'o: ooIotio thoropioo ooorgod (6). i cholgo in brain function woo oooo oo o noooooory condition for hohoviorol ohonuo, with tho typo or chooco, houovor, voryiu; dogoadin; upon poyoholocicol oud oooio— logiool chorooto'iotioo ox tho outjoot (22,25). thou, tho oodo o: ootioo woo not too: oo oithor “orgooie' or ”prlyoholouinl' but rotbor oo tho iotoroction or non-ophyoiologiool chooaoo nod individual pottoroo o: rooponoo oud bohovior. fhio hynothooio ' woo oootoiood in otodioo or convulsivo old insulin oono thoropioo (21,22); and tho oodo or action of tho now psychotropic oconto woo ozprooood within thin �.3. payohoiropic'drugn that It would bu urinativo to tho uxtnn‘ thu‘ pcrllutcnt ehgugon k.— fiypo or tho tad induncd; that brain Inuation ugro in hnvtoral reopens. would bu rolntcd to tn. iypo o: br¢1a hypothosta. wan unggun‘od chnnga, and to individual pro-norb1d psychologie (par-caulitr) vtttnrns (6,28,ho). consu1;1v3 thcrngz Draco-s: Soaking a noncaro of gltorcd nourOphgstoleglogl «hangs that w:- annuitivo 1. tnitnblo for rcpol#od rutolta, various nan-urns wort studigd inpludinx chanson in tho ts¢o~hand tout (1,10,13,35), nanory tout; (17,35), anoant .1 slow utvn activity 1» tit :30 (16,23) tld contnbulatory and duaial languago pfit‘Orll attur nuebarbitul (3,15). an. llttor two, EBB und unubnrbittl touts, Hit. tbs nest oonlttlvo indie.- o: chaulc 1a convulnivo thgrtpy subjects. In on. uxpcrincnt, clinical rating: a: taprcvcfiont var. carrolatod wi‘h high 6.320.! of chungo in than. indicol (15,16). 2)... oblcrvutlon: wore touted 1n n doublo-bltnd study in which p;titntl tutorrod tor oloctroahock worn rindauly ‘3313306 to oithor convulsivo cr anhconvnlsivu and . therapy. nigh dour-on o£_oltetrogrnphic Ilcw wave :otivity and pastfiivg nnfibarbttnl tout: warn obsorvod only 13 the convulaivc group3~1nprovcutnt titan were algntticuntly highQr in this group, and whnn subconvn1I1Vt aubjccto var. retransod by convulnsvo applications, (he tnprovogout rat. way 31:31.: to tho ooarulstvo ureup (22). �.3. In sibeonvuluivo applications, nousidornblo oloatric current pgaau: botwugn the cleatrudou. It wan pontulntod that tho ihcrapoustc tguut was nut tin $Otl1 olootrt¢:1 current, r so, but_thu ":11 or nonn' quali$7 llhiftl‘td by tho crana 331 Ittluro (9,23,h2). 2h. Itcniriounao o: tut [rand 3:1 .oisuro was «an-$306 in n ounparuttv. study of sh. 13ha1:nt oonvulutut, lnxaflnnrodiothylathnr (Indckloa), :nd clnotrtotlly inducad soituroa. 81:11:: dour... ct olcatrtcrnphao chango, improvuuunt rat‘s, typo. or bohnviornl ndtptntionn, Ind ohnnxcn in Inuropcychnltgiotl talk hchavior war. ohocrvod 1n bush tho inhalant And in tho alcctraa;117 tronfiod crouy: (k9). Kuvonr, not ‘11 Iibaootl auntie-ting high dccroo: or phyttolbgiaal thugs. var. avnluttcd .3 “improved“. I: n doncrtp‘tvo typologia Ifindy,_£1vo .dnptivn aldol war. dusoribod, cupirxcslly torund “ouphorto', ”hypunnaic‘, "nmuuuon', 'mmnld-wtthdravnl', Vial. ‘h. strut tun pattcrnn ltttcr worn ratcd and ”pan“ . an 'uuoh inprovnd', var. loan as 'undnpruvod' or “war-0' (So). In utudloa at plynholoaicnl varinblou, it was ruportod that pationtn ratod “much inpravcd’ $36 'rocovorod' troquently nanitultnd parloatlttw pattern: :kin t. tho explicit vurbal dcntnl parnonnlity type (37). 2h... pattoutn cxproslod tho ”innauago a: 6.3151“ nor. troguontly than uninprov‘d aubjoctl, antibiting such asp-oil a: tho two �-5- explicit deeiel, einieieetiee, dieyleeeeeet eed oliehee (27). Other perchelexieel indieee else releted te fevereble eeteeee included high I fleele eeere (ha). nereeheeh deternieente ex eeler, ebeent eeveeeet eed ebeeet rereneier (30,h5), eed lee edueetieael eehieveeent eed rereice birth (31). 2. Aetiohelieer ie cenmeuede end Geeveleive There seeking e we: te enceeet the degree at peet-eeevuleive EEG e10? were eetivity, en eetiehelieergie deepened dietheeine, wee given intreveueeely e. verioue etegee or the ceavuleive therepy preeeee (20,2h)Q Unexpectedly, dietheeiee eeeeed en ieeediete end eeeteined deareeee in EEG elewiec, ehieh wee eeeeeieted with eerked cheagee in lengeeae end need. In petieete with deeiel leeteege petterne (21), theee oeuid no longer be elicited. Ineteed e! eupherie eed well 'heing, the subjects beoeee'irriteble, enxieus end coepleiuinn. In eebjeote prior to convulsive or drug therepy, dietheeine induced exeiteeent, teeeiee, eexidty end illeeery eeeeetieee. Subeeqeeet-etediee with ether centrel entiehelinergie cenpeeede end eyepethenieetie helleeieegeee ehewed behevier end electregrephic petteree eieiler to dietheeiee. the-e ebeervetieee led te the eeaxeetien thet ee ieereeee ie the ehelieergic eetivity at the eentrel eerveee eyetee wee the bieoheeieel beeie to: the eenveleive therepy preceee (38). �-6Iad‘filat Fallowing thtli Itudiou, tn. neurophyliolosic‘l august: induond by drugwar! touted within a. acito oxporiadnt.1 EEG Iotttng. It run obitrvod Butt phnuothinuianu induced BIG synchronxuuticn and a Ihittlnc at tun Iroqunncy spectrum to tbs slew Iroqunuotons taprobannfic and barbituratoa, tn agar-1:04 lynchruatagsgon ;nd a ahttt of thy spectrum to tact troquaauiau; rosorptnu, an iuaruatod slowing with uynohrcn3. ?a tutttoa at chair: is ,r law dontgua, gnd doqynohronitasion IIVOII (18,26,28,ho). at hiahur Iazprnliao induced douynchronination with a sun .1 trauma to the now bud: (33,310. Each ‘otivu psychotrnpia compound wgu #hu: about to ant. a charactnriatic trnqnoacy patturn. Vtriouo 9th.: axpcrtncafisl coipounda wort also tantad and tar than.. no noafiistcnt ulcotrogruphic pattart was rooordod. In... ounpuinds bl?! Gino. boon nhawa to have dittor no ¢r vary limitad clinical psychotropic :ctivity. rho .bIOflei of bahaviurul chins. with than. coupoundo loot turthor uupport Sc tho anlunptton that 32.1: chnnco is a accosstry condition far the nefiion of puyehntrOptc drugs. 2h... obncrvnfisons auccoattd thnt psychophgrnncou 10310.1 tannin provide a noun: icr niioitin; vnriou- typgs or altarod brain function in coltrnst to tho $13319 pattcrn following canvalniva tharupy. furthermora, tn. type a: luurophrliolocionl altorution, an rallcotod in EEG Iyuohrcay �.1and traqucncy patfiorns, val round rcln‘cd to 0’0011106 a: bohnvicrul adaptation. 2h: ndvnntazu 0: £80 toohnancs to: tho ‘Icay at new psychotrOpic taunt. sad types fihy toohntcnl tarts: or aloo‘rontu Iroquanoy tally-t- «or. unnarcd and dolcrihod (£7.52). h. Insulin can: fhnragz: In our inluliu can: studies we ocuttrnod anrlaor observations that porutntout alfiorntiona or brain tunottom were taint-d to prolonsud «one and upcntanaonu nuilnrou; and tau in this rolntioanhtp suppert for n nitroplyltologtc~ndapttvo hwpothontl. With thc grailnbtlitr 01 ‘h. ncv psychotropic asant chlnrprunasinn, a ountrollod?chlorprunaltao Insult: can; atudy was undartnkon in Sop‘anbgr 1955‘ AI patiaata war. rotorrod for insulin aim: tun: get: rundonly unsignod fin couraos or nithor oral chlorprcualino for at IQlIt 3 months in dosoa adJuIt-d #0 1111 short of toxicity; or'tnnultn cans, induoud by s uuhmd «chateau at last» so was 1: «ch pattont. Vh110 a uI-bur or ulnar distoroncou worn noted in comparing the two thgrnpigs, thn results at tile or dicohtrac chewed no stutilfitonl ditrorcnco in tho offsettVQBQnI at both traatncntl. loithnr troutunat £00.06 to affect tn. bantc nonsquhrcnto procons, but chlorpro-asino had tn. advantagot boing 3:202, tacit: to adniniator, lad hotter suited so long torn unnnzunont (21). concurrontly, following the 0“goutton by £ha Or-odnoqr worker. thtt dividod insulin �.3. doooa woro aofiorior to olaglo insulin doooo, Bloabor; and Ladoroao oooayod thin probloo and donorotratod no significant oorit to tho oulttplo dooo toohoiquo (19). (lo 1958. £91 ral courtroa too at hooo oboorvotiono tho a , 5. floor woro adaptod oho :' Various poychaphyoloal tooto tron oooropoyoholozy, whoro thoir signitioaooo to brain da-agod onbdocto had boon dononotratod. 1h. oarly otodioo aooooood thooo took: on lodlcoo a: altorod brain rotation (35), aod ooaaurod tho ranzo of portornaocoo or poyohtotrlc patiooto, who oro conorally aooonad not to to brolo dana‘od. Into, looory function woo aooooood on inoodiato roooll, artor vorlouo tutorpolatod loorninc tooko (11,35), aa roll ao aorta: coorulolvo thorapy (1?). rootilo porooptoal tooko voro tirot oxaninod to tho clioioal population (1). Lator, with ooro oonoitivo eloctrioal tootilo otlaoli, Karin oboorvod tho raafio o1 throoholdo 1a dittoroot body parto (10), tho ohaogoo with altorod . brain function (10) and tho inflooooo or oot (inotrootloo) on porforaanoo (36). Ho also studied tho porooption o: ooboddod gooootrio figuroo (h3), toohiotoooopio prooootatloo o1 ooboddod color rigoroo (55), porooptloo of tho vzoual oprlsht (55). orltlool illokor froqaoocr (h?) and 1ntor~ toroooo 1n roadtag tioo by dolayod auditory toodbaok (55). For oooh took, tho dogroo of dooroaoat 1» took portoroaooo �-9- gastttvaly oarralatad with tha anoint at 386 aldwtas. Folluuina troatnoat couplattan, with an. rota»: at partialoatoal tadtaaa ta pre-traatlaat lavala, partaraauoa in thaaa paychalagioal tanks also rataraad to prautraataant lavala, or tight: -.a battaraanfi a: partoraaaoa aacribad to practiaa afract. waa found $0 be concurrautly, aaaaaanant or varioua payoholaxtcal aaaauraa an indicaa pradictiva or behavioral «hang. daring convulsive and drug tharaptaa lad to studiaa of the Rorschach datarninanta (30,h5). calitornia F Seala nonra(30;h2), languaco pattern. attar atobarbital (21), daatal acarae an antarviaw (3:) and tha paroapttan of tho visual upright and auditory taadback (55). 6. razehalég‘uiattoa: concurrant with an: syntactic studio: languaua (27), analyaaa of othar languaga pattaraa warn andartakan, boat 1: a aaarch tor aura objective xadiaaa a: bahavtaral chaaua and to gain oxparianca in the taehnioal pwablana of tapa aaalyaia tar payahatharapy research. La . influx of variability in the vocabulary of apaaoh, tha typo- tokaa-ratio (if!) of eonaacufiavo Iaaplaa of dyadic apaaoh, wu “unholy atudiod (1,h1,hh.h6,56). In convulsiv. aharapy patxanta, aigaiftoant chanson 1n TIE naan hué standard daviationa war. ralatnd bofih to the dagraa or iadaaad 280 slow wave activity and to ayniactic �~10- lcnlicsc puitarnl abicincd in indcpcndcnt tircotnrcd intnrvicvn. It was cocoa that uptick bola-o norrepetitive (lav-rod not: III) an! acre varinblo in colaocntiVb cunplc: (kl). In intnrviowl infur- nnd cttor tho intravenous administration or ccntrclly active agents. ainiIcr chanson war. ohlcrvcd. input: which produced prcdo-iaact synchronisation pattorun on tho EEO ware rclctod to a docrctso in «can 1!! cad an incronno in flu: smdcrd duration or ...m. while «synchronising ccapcuada clicitod groatcr variability in cpccch pcticruc and dccrocnc in variabilifir at consecutivu acorn: (hh). 0thcr 1:33:53. Iltlflrlfl atndicd included diatrclc~rclict quoticntc, colt-rotoroncc, and altar:ticnc in till. cad patina. It VIC snag-ntod that than. paychcliuguictic accsuro- arc usctnl techniqnoc for thc operational caclyscl c: phyniolcgical and psychological uttcctc or psychopharnncclcgiccl cgcnta (hh,h6). 7. ling; B‘llli gud Schinaghrcgil: rollcwiug his ' Itudicl at Ittlsccn Ccntnr, PoIlnck ruvicwod th. rclcticnu chip bctwcon can 9! hospitaliscfiicn, intollcctucl tunationils and prognosis in cchincphrcnic childron ind nttad that initiil bagpitalilltica cdclta. H: in childhood cad Idoloaccncc was rclatcd to I.Q. secret in tko cubncrncl tango, dcvicnt pcrxcrnancc on psychanctcr ttlkfl, and nor. �.11; troqasat ratings or 'uaiaprsvsd” ai hospital discharge than was initial haspihaliaaiioa as as adult. rho aarly sad insidious sasst st iha hahsvisral syndrsss “sohissphrsaia‘ was ihas rslatsd to brain dysfunction (5?). Findings saggsai that say ha olsssitiod on davianoy. diffsrsat suhrroaoo s: aohisophrsoia tho basis at asarspsyohslogioal in Considarahlo iotorssi Studios: aooiols‘ioal tho family organisation to vhioh disohargsd patisnhs ohoios‘ wars rotsraing, tho ralatioa a: social factors to sad rssults o: pevohiatrio irsaiaaat, and ihs spaoifio prohlaa of tho ralatioa at thasa factors to irsatasot rorsrral paiisras lad to a ssrisa of population studios. Ia oas study (8), soaoatiao, ago, plaoa at birth and soars on tho California I seals wars significantly rslaisd to tho hypo or thorapy rsasirsd ass tho utilisation of adaaaotivs hospiial ssrviosa. In a ascend study (31), darstioa or hospitalisation, dischargs avaluaiioo and diagnosis wars rslatsd to tho sans social factors, whila in a study of patisht rafuaal of BOT, sitilar relationships wars ohsarvad (51). Thass ohssrvations suggastad a_conparativs and tho three among hospitals study, min-institution batwssn othsr demographic social class and rslationahips 8. ‘ variables (ago, sax, sdooatioo) to tho clinical variablos �.12. at patanat cltulixtcttscn (ataanonal), auruttoa o: inapttuln tuttton. soloctiqn or thornpy and dtuohnrgu uvaluntion 5.1. 3.0: unlocuod. Into. touching tuntttuttolu were :11 thortptcc arc oqaa11y avatlnblo to I11 pntiontl, - nonnincor Foundation Hospital (uppor-clusc, .Protoctant), uttsaohuontta ncntnl lualth Contor (loverclnll, Cathnlic) ind £111.16. Boaptttl (niddlo-claul, Jow1ah). In hack a canytrtton w. turn round tho dittorcaoul 1n duotgnntiona of trontnnnt, diagnoliu tad dtuehargo cvnluatton so dafforbnt an to ugh. nonpartnean difficult. Vhtla III: rolttionnhtpu tatvton Iodill varinblon 1nd 91131c31 Virilbltl var. oblarvad in each heapitnl, to 1001.1 variablo was fauna rclstcd to thc clinical variablo. 1- "01-7 hospital (53?. In an Out-Pattont Departnont utndy, sex, 8‘. 3nd narttallatata: var. found to ho rc1atod to tho acceptancand roawetion at patttuts tad fuilnr. to couplcto tho upplionttuu pIOGOII (5h), that. abatrvnt1¢nl 1; population Ianploa 10d ta coa— current Itmdios or start attituia: 1: tin Iolootion at thorapy (11,12). In a aortas o: ward obnorvation studiol; Kaplun and Lotkawttn indientsd tho significant :01. or otntt attitudes (oupocta11y turning porcannol) in thc rerorrgl tor lubaostn for lunatic thtrcp1on, and in tho tranutcr at pztiontl tron out ward to unothur. It stud. Icloctod ' 1n whaen �-13. fit. tn£1u ca .1 :finxt attitndo t1§n$ soloattoa for drag thorngz, w. g33u03$nd can ward be dontgagtnd an a "ago-avnusas' unit. 2):! van ndagtad in 8:233:34: 1259 and an shor‘lz fihornuttqr 3: the whole hangatul.) mum 8E1“ buriug *ho parioa at the convullivc thsrupy studios, man: nun psychotropic 00:90:36: were attained clinically (5,21) alootrographzgally (3h,h0,h8) ‘fid psychophrttcnllr .(aa). rho pro-ant payehophntuncology cvaluattoa progrta, b;sod on ‘hoao u§udion, was designed in gnaw-r tbs follow- ing'qunltions: I 1. fiber. ; rclntion botvooa COIII9I§XI &lt.rlttga in brcin function tad bahaviurnl Chtflflfl with psychotrOpic drug: on circuic :d-intstrntton? Ar. that. prb-troatnoat cluttcrl of plyohtatric, phy1101031ca1 and psycho- logiotl variablnl which are rolatod to ‘ho flypc at bohnvtoral adaptation? Arc ouch olultcro rclntad to thy typo and dogroo or physiolextcll chango? LI an iatt1;1 upprqxin&t19n, a doubln-blznd, fixed detach, vandal aunt‘s-ant drug study was undartakcn. Blood on our c1131ca1 cxporicaenl throo tIpCI a: compound: var. �Du. oolootod on tho boots o: thotr EEO pottoroo. 1: thin otody, 293 onhjooto woro rotoirod old 1&9 hovo oonplotod tho touting progron, tron ootohor 1959 to July 1951. 1. lohoviorol Chog‘oa In o ourvoy of tho bohoviorol Adoptotioao o: potiouto roooivin; voraoao poyohotropto compounds during 1958-59, o bohoviorol typology boood on tho arootnont rooponoo one on pro-trootnont poyohiotrto protiloo dovolopod (55). In tho pro-out otndy,tho typoloatoo oro botng tootod, old various oooouroo of bohoviorol choogo otodtod, inolnd1n‘ thoropiot ratings, coll-ratingo old various word ohoorvotaoo oooloo. woo 2. ggnr o cholo : Psychological tooko hnvo boon viovod both on indiooo of bohoviorol chonuo and on prodietivo goidoo to convulntvo thoropy. Koch o: thooo tooko and o oolootod group or uotor tooko oro now bozo; oooooood for both thoir oopoaity to rovool ohongo with voriouo drug: ood thotr oopooity to prodiot ohongo with tho drugs to this -pro.ron (hB). 3. Blootrooooogholg‘goggln In tho ooovuloivo thoropy ' otodiot, tho dogroo of slowing woo loooorod by counting tho oonoooutivo wovoo in oolootod oonploo (16). whoa tho noro oubtlo ohongoo or drug ottooto are studied, 1a noooooory to opplr loot todiouo tochniquoo (ha), ond EEG it olootronio froquonoy ontlyoio woo introdocod in August, 1959. I: nooourouont of tho pon dotlootioo for voriouo �.15- ' sooosd is_ton opoois, ropid trsqssssiss tron to nosslrsnsat or oppsrsstly sssll ohsncss is total activity and trout-soy upsets: or. sttsisod.(52). ethos physiological vsristlos stadiod in this 3 33 bps yrogron include tho rooponso of 830 to istrsvsnoos chloru ~pro-suns, blood prosaoro rospouso to nooholyl, tho EKG, radioactive iodine optsko, and saslysss or various blood tad urine olsnsnta. h. hots Ansgzgisx rs onslrso tho dots goosrotsd in this otndy, as hsvs sovxtt tho aid or complex ststisti- colon-thud: and computational tsuilitios. Analyses or notorious, osaj‘rslstioo ”trio", factor analyses and disorisintst function onslrsoo ore connotations new in prouross with this dots at tho III? Psychophsrnsoology aortic. contsr's Biolstris Laboratory in Washington. Ill-l!!! STEPS Favorsd by s notional rososroh ' clissto and s ooopor- stivo hospital staff, thsso studio; hows proooodod vigorously. Rho ssssts for rososroh is.this sotting hi7. toss arsst ~— s solsctsd, intslligont pstisst popnlstiou rssinsnt from six to twolvo months, without individual economic linitstios of hospital stay; a sophistiostsd sdninistrstioa tolorsst or controlled studios; sud spprovsl o: s 30:26 or Birootors who dosirs 'rssosroh' as on institutional function. �~16- eeted 1n hie tiret heepitel repert 1a 1959, e epeetelty heepitel eee eeke little tepeet en the eeetel illeeee prehieee er the seeeehtty by treet— eent elehe. the eeeeeeetel treeteent e: 350 petteate e contort to the h0,000 reeident petteete in but little yeer 1n the etrte heepzltele a: La; Ieleed. I» will the eeeeel treieie. or twenty er thirty phveieieee in the erte e: peyehetherepy do exeh to help theee untertnnetee or the reeident 111 theeeende of in the mentally enbnletery nee: eetiee. he, e therepeetle [eel eleee 1e eelutfiry bet teedeqeete to ear neede. he he prepeeed, the eeewer eey lie in the deeieetiee or 'reeeereh heepttel”, ee it 1e here thet e epeeielty heepttel eee truly excel. the eherter hee been written in the neerd'e eeeertlee er reeeereh ee e heepttel ceel. with the eeeete or en exeeplery therepeette teeility, each rededteetlee eee previde the etieelee tor the centieeeue ether 9! the eeeeee er mental zlheeee end at eethode e1 therepy. Seek dedicatiee ueeld provide the etteulee tor cenperetive and controlled eeeeeeeeete e: dittereet therepeette teehniquee. Centteeed etudy 1e urgently required of the eeleettee e: petseete ter verieee therepiee; the epplieeteee end eede er eetlee e: the therepiee; end the role of eeetel end ntltee :eetere in euppertte; the exteete Le Dr. Levin hehhtee & �.17- o: oar tharaptol. tubjoctl. the hohavioral Vtrtnblou OIOII, which are tin halt: a: on: profiont ditcznltso Ichtnstn, arc taunts-raotcry. at:dy is urgtntly requirod at tho upyltonbtlltr a! aootnl tad dulnarnphtc i:riab1¢a; paybholoutcal t:§k pcrfornancu protilun; twpologinc bnaod ca b-havxoral response to dozinnd Itroaaun or drug.; and physiologicall roactivity measures. such olaantticatioan arc also oniéntial for any biochemical, phyainlogioal or tvnlunttvo study to pravado ha-nzonous 33:91.! and campgrablo outrun. ‘ Alloa§nantu tlnd requsro moaningtul indtcoo of evaluating 05833.. Pros-at global 'tnpro.uncnt“ rating: tad loeaalitttton noctur-n arfi inadequate. Whathor tho 'iatorvuuing variablo bu nilihn thnrnpy, psychothnrapy, sino,‘§héleri£irii at bohhvioril chant. max... «anti-.1»; in.” 3592;131:1511”: a: rung-«1n, drug therapy 0r ' ladguaao #:028, idlt€r££1n3n,wpsyohéphyatéal"ch:n¢cVaéufca. . family CUIOIIIO§$I5I2E2- raqniru study :33 cviilatién; Roount attains of p¢y§hottc hubjoeta has proiidcdv tho succession thit thfirs in a notrolosic factor 1a.: group a: eh: ichisophroainn. The h1¢h tacidoneo er citatro"graphic and aauroloxie éysiunetian, the 153k or behavioral Vidnficulc to all thoripiol, and tut rclontlcna course a: �-18 o illncts nascent: involvontut in thin clustcr. Such a substrate aunt bo-olourly sought by tho app11egt19n of biochemical, nourophyniolegioal and opia daiiologionl toehuiquu to Vitus elation or you; pcyohutio hubgccta. 5: Eh. quontiona broador or 110:. than. arc son. Ittdiud in thc prosrtlz in cxyurimontul psychiatry ot-tho pant aovan yéura. than. programs, and the cantonporury projaots-in hiaahuniatry and in medicino, providc nod-1s It hootuatrgp studios andor;lkon with linitod uupport. ‘A dodieltion at lilllidOIHinitll as a ncaonrch Institutc I111 providc tho neodca £96“. and impetus for tha Iciontltia and hunnnitcriun forces at the oonnnntty to Join in a connea endeavor to roaclva the problems or the tantally £11. fiho 1n “orznn1¢* �LGRROUIOG‘OIIi‘ Participanfil in than. procraua inalndo thprouont ac-bcru a: fih- Dopartnnnt or Expnrtnoutnl tuyohiatry: Its lalnoat, acrtln A. Orton, thrthna Iaplnu, Brio Karp, Beunld 1. £1.13, Joha 0. truncr. an: Pollack and Arthur 33113.3. turner associntad includod Kurl tuner-nun, Joseph 4:230, lobart L. Kahn, Hyman Koran, Goircu Kruathunor, ln£h3n101 81.3.1; and angry J. Lorkauats, untold Intonvur, lid ntrrc Alan. It. couporn$1on 0! Arnold a. Blunborc ot~ Bopartaont of Hodictnn in the protont program in srqtntully the ropor‘s liltod horn are the roault at tun collnboratian of this. tartar. and fit. prutoastonll atQtta a: $h| h0upita1.vha an?! unnttnttnxly or tuttr tin. acknuwlodgnd. and that: nooduw111. �W J. innum- mug. 3:21, 1. was, 67, 1956; 6. 1953; 3. 3. 1955; ha 1952; 93.59201, My 1951; 10. £535.21.» aggmh, man, 53339229, 33539216. 7. 1957; 9. 1951; wgaév. 2. 1951; 1955; 5. 19575 gnu“ 12. 1961; and 35;: 33:81:, J. gag. 13. ”surfing, £3211, 195k; 1!... Arch. Home)... 16. 1956; 15. 195!“ 33311923, 353 3:233, 11. 91, 1961: and. ”an“. 13.516, 1951; can. gut. . 33:88, 11. human-.101. 3:180. 1957! 19. 10:207, 1958; 21. 22. 91!. 21;. Arch. and. Im. haul. 733, 19583 ' Jon. “or. M Ann. 1956; 18. no 011:. 32:162. 1953; 20.3113 }_6_§:18h6, 1958; 23. 3333.21221, 1958; 25. 1958; and £9: £33380, . cg ’E‘L‘E 26. Iowa. 33682, 1958; 21. Pazohoutholqz 323. 323113. 1958; w. at Gal-Inna», Brno & Suntan, 126, 1958; 28. PatchesGo. 1959; 325, a Iron Luna, , zbnrnuohg nation, 29. Pros. xv 139. can. Pulp»)... lath fioluud Pthln 238, 1959: 30. 3921.3, 1959. 31. Arch. 00:. PI:«but. $3565, 1959; 32. Egg cm. lam-gm“ . M 531668. 1959: 35- Pros. 33:398. 1959; 33. 6256. Porch. Luna. .1. 0.3.. Install. 501., Forum, 613, 31;. Plzchn . 133381;, 19595 31. J. 1959; 300911011. 35.2w. 36. 1960.: I“. nor. J. 11155, 1959-; �38. Ila 3113. "‘£32Ez.1.13 $30359, 1969; 39. Aunt. J. Plzdhzut. ;;§t839, 19601 ho. lonro~rozghgzhurnneologzll: n(‘) kl. Jeur. Harv. Rant. 31-. $§91235, 1960; ha. ibid $293187, 1960) h}. Arch. H.353 . 3.5h7. 1960; bk. nganien or Puyuhintrio Brag rhorugl, $9, 0.8. rhonnl, 19603 £5. 3. retrogjzoh. $3252, 1960; hé. 130:. J. Pazchuthor. $3; h7. Intro-tszghaghuguncolagz‘gc30, Elsovicr, 19613 hB. than 3:381, 1961: M9. Azeh Gan. rqzuhil . 5:259, 1961; 50. thid 2130, 1961. 56, 19611 ' orv. Rant. 91.. £2gn153, 19613 52. 535:, taint Eggorinontalcs (in prosl)£ 53. '5 can :wggvahogharuneo » (1n 5h. 890111 pro-I): 2‘; Inn‘s; (in prose); SS. Bupub~ lishoa §anulcript3 56. Pszohiltrz 3;:2h9, IQSB; 5?. Arch Gen. Paychiat. 23652, 1960. 51. Jour. � Dublin Core The Dublin Core metadata element set is common to 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 psychiatric research at Hillside: review and prospect. J Hillside Hosp. 10:15969. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-57-023 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprint from JOURNAL OF THE HILLSIDE HOSPITAL Volume X Nos. 3-4 July-Oct. 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/2f72d717289d05cb684207e823cb7f30.pdf 566433f2c3abf4221015fe305a951903 PDF Text Text Psychopharmacology erVicc Center ulletin N IMH-Sponsored Collaborative Study of Phenothiazine Treatment of Acute Schizophrenic Psychoses, p. 1 January 1961 NIMH Grant Support for Early Clinical Drug Evaluation Units, p. 3 NIMH—PSC Outpatient Study of Drug-Set Interaction, p. 4 Research Conference on Drugs and Community Care, p. 7 Conference on Information Needs of Psychopharmacologists, p. 13 The Psychopharmacology Research Unit at the Downstate Medical Center, Brooklyn, N.Y., p. 15 Experimental Psychiatric Programs at Hillside Hospital, ' p. 18 Coca-Leaf Chewing in the Andes, p. 22 Publications, p. 25 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE - Public Health Service �Inquiries about the Psychopharmacology Service Center’s program are invited. Please write to: Dr. Jonathan 0. Cole Chief, Psychopharmacology Service Center National Institute of Mental Health Bethesda 14, Md. Correspondence regarding the Psychopharmacology Service Center Bulletin should be sent to: Dr. Lorraine Bouthilet Head, Scientific Information Unit Psychopharmacology Service Center National Institute of Mental Health Bethesda 14-, Md. The Psychopharmacology Service Center Bulletin is distributed at irregular intervals by the Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. It is issued for information purposes to investigators interested in psychopharmacology. It is requested that the Bulletin not be considered part of the scientific literature, and not be cited, abstracted, or reprinted. �NIMH-Spemered Collaborative Study of P/eemtbz'drz'ne Treatment of Acute Se/ez'gopbrem'e Pylcboyef The National Institute of Mental Health, through its Psychopharmacology Service Center, is sponsoring a collaborative study of phenothiazine treatment of acute schizophrenic psychoses. The comparative efficacy of thioridazine (Mellaril) , fluphenazine (Permitil, Prolixin), and chlorpromazine (Thorazine) in the treatment of a large group of hospitalized acute schizophrenic patients will be evaluated at nine psychiatric institutions. Investigators at the collaborating hospitals applied for, and have now received, N IMH research grants which will support their participation in the study, which is expected to begin in February 1961 and to continue for 2 years. The grants were awarded to the following investigators and institutions on the basis of their interest and research experience, the availability of patients, and the geographical location and type of hospital organization: Principal Investigators Edwin M. Davidson Melvin M. Kayce Institutions Boston State Hospital Dorchester, Mass. Richard Steinbach Bernard Levy Georgetown University and D.C. General Hospital, Washington, D.C. Robert R. Knowles Edgar A. Moles Kentucky State Hospital, Danville, Ky. Kathleen Smith Washington University and Malcolm Bliss Mental Health Center, St. Louis, Mo. James H. Ewing Harold H. Morris University of Pennsylvania and Mercy-Douglass Hospital, Philadelphia, Pa. Frederic F. Flach Charles I. Celian Cornell University and Payne Whitney Clinic, New York, N.Y. Guy M. Walters Christopher F. Terrence Rochester State Hospital, Rochester, N.Y. Springfield State Hospital, SykesVille, Md. George A. Ulett Martin Gross Irene L. Hitchman John Donnelly Francis J. Braceland Bernard C. Glueck, Jr. The Institute of Living, Hartford, Conn. The study is under the overall supervision of Jonathan O. Cole, Chief of the Psychopharmacology Service Center. Gerald L. Klerrnan, PSC Research Psychiatrist, *Prepared by Gerald L. Klerman, Research Psychiatrist, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. will serve as project coordinator. Other members of the PSC staff who are involved in the study are Eva Y. Deykin, Research Social Worker, Martin M. Katz, Research Psychologist, and C. Jellefl' Carr, Chief of PSC’s Pharmacology Unit. The Planning Committee, composed of the principal investigators in the collaborating hospitals and the participating members of the PSC staff, provides for the coordination and execution of the specific projects. Because of the parallels with the Veterans Administration Cooperative Studies of Chemotherapy in Psychiatry, the committee maintains close liaison with the VA Central Neuro-Psychiatric Research Laboratory at Perry Point, Md. The Committee on Clinical Psychopharmacology, a group of outside consultants appointed by the NIMH, serves as the advisory and consultative body to NIMH on this project, as Well as on other aspects of the Center’s clinical program. Members of this committee are Henry Brill (Chairman), Deputy Commissioner of the New York Department of Mental Hygiene, Albany, N .Y. ; Sol L. Garfield, Professor of Medical Psychology, Nebraska Psychiatric Institute, Omaha, Nebr. ; Goldine Gleser, Associate Professor of Psychology, Department of Psychiatry, University of Cincinnati, Cincinnati, Ohio; Leo E. Hollister, Chief, Medical Service, Veterans Administration Hospital, Palo Alto, Calif.; and George D. Ulett, Associate Professor, Department of Psychiatry, Washington University Medical School, St. Louis. Mo. DEVELOPMENT AND DESIGN OF THE STUDY The Committee on Clinical Psychopharmacology and the PSC stafl' designed this research project during the spring of 1960. Following general approval by the National Advisory Mental Health Council of the principles of the study, the Center staff discussed it with a number of clinical investigators who had previously expressed interest in such a project. In June 1960, representatives from more than a dozen institutions met to plan and clarify the research methods and aims of the study. A number of the investigators who attended the meeting subsequently submitted applications for an NIMH research grant to support their participation in the study. Thus the final design and methodology of the study resulted from the combined efforts of the Committee on Clinical Psychopharmacology, members of the PSC staff, 1 �In psychiatry, cooperative research has been slower to and the principal investigators. The staff of the Biometric Laboratory of George Washington University, which operates under contract to the NIMH, will provide ongoing consultation on matters of research design and statistical techniques and will analyze the data from the study. The primary aim of the project is to evaluate the effects of two new phenothiazine derivatives, thioridazine (Mellaril) and fluphenazine (Permitil, Prolixin) on schizophrenic symptoms and behavior by comparing them with the effects of chlorpromazine (Thorazine). Each of the 9 hospitals will study 40 patients (10 in each of the 4 treatment groups) . Newly admitted schizophrenic if the for selected will be 16 study 40 to aged patients they present two or more of the following types of symptoms or behavior: Thinking and speech disturbances, catatonic motor behavior, paranoid ideation, hallucinations, delusional thinking, disturbed affect and emotion, and disturbances of social behavior and interpersonal relations. The patients will be on the prescribed research treatment regimen for 6 weeks. A double-blind procedure will be used throughout. Improvement during the hospitalization phase will be assessed by the Lorr Inpatient Multidimensional Psychiatric Scale, the Burdock Ward Behavior Rating Scale, the Clyde Mood Scale, and clinical judgments. In addition to the primary aim, evaluating the efficacy of the drugs, the study will also allow for the followup of 2 least for of at cohort patients schizophrenic a large made will be assessments 6-month At intervals, years. of the patients’ discharge status, psychopathology, social performance and adjustment, and treatment program. Social workers will interview family members for their perceptions of the patients’ progress, home conditions, and attitudes toward treatment. COLLABORATIVE AND COOPERATIVE RESEARCH Since World War II, collaborative and cooperative research, in which a number of institutions follow a common research design, has been successful in many areas of medicine. The trials of antimalarial drugs during World War II, the extensive studies of antituberculous drugs now in their 17th year, and the British-United States research on cortisone and aspirin in acute rheumatic fever are some examples. NIH experience with cooperative research includes the current extensive cancer chemotherapy program of the National Cancer Institute and the Collaborative Study of Cerebral Palsy, Mental Retardation, and Other Neurological and Sensory Disorders of Infancy and Childhood being conducted by the National Institute of Neurological Diseases and Blindness. 2 _ in of studies extensive penicillin the although develop, CNS syphilis during the 1940’s stands out as a notable AdministraVeterans the effort. In recent early years tion has developed its Cooperative Studies of Chemodemonhave studies VA now The in Psychiatry. therapy strated the value of cooperative studies as a means of clarifying important issues in psychopharmacology. From the scientific point of view, there are two major reasons for collaborative studies of psychiatric drug therapy. First, such studies allow one to increase the generalizability of findings. If the only question being asked is whether drug X is better than placebo, then the 40 of 20 with to obtained be often pagroups answer can tients. However, much larger groups of patients are discriminarefined make wishes to if (a) one necessary tions between compounds which are closely related chemically and pharmacologically, such as the phenothiazines; (b) to increase knowledge of predictors of drug response; whom for of a the patients define specific types to (c) or particular drug is best suited. Multihospital studies allow for comparisons among institutions. In the mental health field there has been much discussion of the possible differences in the effectiveness of drugs given in varying hospital and clinical settings. A multihospital study provides both the number of hospitals and the number of patients needed to clarify these complex drug-environment interactions. The pros and cons of conducting large-scale, multihospital cooperative studies of psychopharmacological its and NIMH by been have weighed carefully agents advisory groups during the 4 years of the Institute’s proPSC. the administered by in psychopharmacology, gram The NIMH first developed a wide program of basic and clinical studies in psychopharmacology, and has until now centered its major efforts upon the stimulation and support of individual research projects. While this program has resulted in a great deal of clinical drug research, it has not met the need for large-scale evaluation of widely prescribed psychiatric drugs. The several Cooperative Studies of Chemotherapy in Psychiatry which have been developed by the Veterans Administration in recent years have provided a great deal of useful information about some of the newer psychiatric drugs. The generalizability of these findings has, however, been limited by the special characteristics of the clinical material available to the Veterans Administration. The NIMH Collaborative Study of Phenothiazine Treatment of Acute Schizophrenic Psychoses has been designed to provide information on the effectiveness of new drugs in a population which will include female patients. The patients will, in general, be more acutely ill and will be treated in a wider range of hospital milieus than could be the case within the Veterans Administration. In addition, the study is designed specifically to explore possible interactions between hospital milieu and has than in systematic manner more a drug response �been possible in the earlier studies conducted by the Veterans Administration. The success of the Collaborative Study, a complex research endeavor, will depend upon close and continuing cooperation and collaboration between the research teams in the participating hospitals, the staff of the Psychopharmacology Service Center, and the advisory bodies of the National Institute of Mental Health. As this project develops, it is hoped that the participating groups will undertake a continuing series of investigations of the treatment of acute schizophrenic psychoses. NIMH Grant Support for Early Clinical Evaluation Unity Drag In November 1960, the National Institute of Mental Health announced the establishment of special grants for early clinical investigations of psychiatric drugs. The primary purpose of the grants is to broaden the present scope of early clinical trials of promising new compounds and to make it possible to screen more new drugs for effectiveness in the treatment of psychiatric disorders. The grants will be awarded to a limited number of carefully selected clinical units to support trials of promising compounds in patients to determine the safety, appropriate dose ranges, and side effects of the drugs, preliminary studies of their clinical effectiveness in the treatment of particular symptoms or syndromes, and small controlled comparisons of new drugs with known standard drugs or placebo. Because of the need for flexibility in tailoring a clinical research design to fit the types of drugs and types of patients under study, an attempt will be made to achieve an adequate balance between careful observational studies and small-scale comparative and controlled studies. This particular area was chosen for expansion because NIMH considered it to be more seriously in need of further support than either of the other two major stages of new drug development; i.e., (a) preliminary screening of new drugs in animals to determine safety and pharmacological activity, which is being adequately supported by the drug industry and by National Institutes of Health grants for basic research, and (b) definitive clinical drug research (controlled clinical trials and hypothesis-oriented clinical investigations), which is amply provided for by the existing NIMH research grant program in psychopharmacology. Expansion of support for early clinical drug evaluation was therefore recommended by the Advisory Committee on Psychopharmacology and by the National Advisory Mental Health Council, and the Congress subsequently provided funds for the establishment of special grants in this area. The program will be administered by the Psychopharmacology Service Center. �NIMH-PSC Outpatient Study The National Institute of Mental Health has recently awarded research grants to Karl Rickels, of the University of Pennsylvania, Philadelphia, Pa., and E. H. Uhlenhuth, of the Johns Hopkins University, Baltimore, Md., to support their participation in a special research project initiated by the Psychopharmacology Service Center. The study is a double-blind, placebo-controlled investigation of the effects of an active psychopharmacological agent (meprobamate) and physicians’ attitudes on a carefully defined sample of neurotic outpatients. It is one of the first known attempts to control experimentally the communication of differential attitudes by physicians when administering medication. The project is to be conducted at three clinics simultaneously, the Henry Phipps Psychiatric Clinic of the Johns Hopkins University, the Functional Clinic of the Hospital of the University of Pennsylvania, and the Neuropsychiatric Clinic of the Philadelphia General Hospital. The study was designed by the staff of PSC’s Special Studies Unit in collaboration with the two principal investigators, Drs. Rickels and Uhlenhuth, and was approved by the Committee on Clinical Psychopharmacology and the Advisory Committee on Psychopharmacology, both of which are appointed groups of consultants who serve the National Institute of Mental Health in an advisory capacity. The two principal investigators subsequently applied for and received, on recommendation of the National Advisory Mental Health Council, research grants to carry out the study. Coordination of the project will be handled by the Center’s Special Studies Unit, whose members are Seymour Fisher, Seymour H. Baron, Mitchell B. Balter, and Elizabeth Hackett. Under contract with the National Institute of Mental Health, the Biometric Laboratory of George Washington University, Washington, D.C., will assist in the analysis of the data. RESEARCH DESIGN AND METHODS The Outpatient Study of Drug-Set Interaction is part of a larger special program which is concerned with the effects of psychological set and social interaction upon drug response in both patients and normal subjects. The study has three main purposes: *Prepared by Seymour Fisher, Chief, Special Studies Unit, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda 14, Md. 4 of Drug-Set Interaction“ To determine whether meprobamate, administered for a 6-week period at a fixed dosage, is more effective than an inert placebo in the treatment of neurotic outpatients. (See Laties and Weiss, 1958.) 2. To determine whether patients’ expectations or set (as induced by contrasting behavioral roles by the doctors participating in the project) have a significant effect upon treatment course. Set will be varied by training one group of doctors (the “T” group) to maintain a positive, consistent, enthusiastic, “therapeutic” approach to their patients; another group (the “E” group) will be trained to manifest a more aloof, uncertain, “experimental” approach in relating to their patients. The “T” therapists will attempt to convey the belief that they are treating the patient with a known, efficacious agent; the “E” therapists will attempt to convey the belief that they are evaluating the agent. 3. To determine whether a significant drug-set interaction exists; i.e., to test the hypothesis that a “T” set will potentiate response to the active drug. Following a pilot study of 24- patients, a total of 200 patients will be treated for a 6-week period, 50 patients being assigned to each of the following 4 treatments: Meprobamate combined with “therapeutic” set; mepro— bamate combined with “experimental” set; placebo combined with “therapeutic” set; and placebo combined with “experimental” set. The basic research design is in the form of a 2 x 2 factorial analysis, with each of the two independent variables being varied in two ways. Table 1 shows the four-cell design, which permits an exact statistical test (by analysis of covariance) of the three 1. hypotheses. Patients will be seen biweekly for 6 weeks. In order to rule out the effects of the personality characteristics of the doctors in the study, a total of 12 physicians will participate, 4 psychiatric residents at each of the 3 clinics. Thus, interclinic‘ comparisons will be possible. An attempt will also be made to validate the role behaviors in the doctors. TABLE 1.—-Researc}z Design Medication (N=200 patients) Set Meprobamate ......... ........ “Therapeutic” “Experimental” 50 patients 50 patients ....... ....... Placebo 50 patients. 50 patients. �The dependent variables are ratings—patients’ selfratings as well as doctors’ ratings—on a symptom-distress checklist, on the Clyde Mood Scale, and of overall change. Dropout rate will also be considered. BACKGROUND OF THE STUDY The impetus for this study stems from the Psychopharmacology Service Center’s interest in various methodological problems involved in the clinical evaluation of psychiatric drugs, in particular the problem of attitudinal variables and their effect upon drug response. The basic thinking underlying this approach was presented in a draft paper prepared some months ago (Fisher, 1960). That paper also pointed out the kinds of specific research designs which would test for any unique interactive effects between medication and set (i.e., attitudes and expectations) . A review of the literature has revealed much clinical suspicion that patients’ expectations may interact with medication to produce differential clinical effects, but supporting evidence for such speculations is rather tenuous. Sabshin and Ramot (1956) note that: “Often the patient may interpret a change in his internal milieu in the context of being a change in the expected direction. It is thus possible for a subtle type of communication to take place . . . and this may potentiate the drug effects. Hence a relatively specific effect can be geometrically increased.” However, the investigators do not present empirical evidence. That a particular drug can have one effect under one psychological condition and a quite different effect under another psychological condition is well documented experimentally. This holds for animals (e.g., Brown, 1958; Chance, 1946; Gunn and Gurd, 1940) and for humans. In an elegantly designed experiment, Hill, Belleville, and Wikler (1957) clearly demonstrated a significant interaction between incentive conditions and drug response in human subjects. Nowlis and Nowlis (1956) and Starkweather (1959), in studies of normals, report complex interactions between drug response and the subject’s perception of other subjects’ behavior. In the clinical setting, Feldman’s paper (1956) indicated that the physician’s attitude toward medication is reflected in his report of degree of improvement in psychiatric patients. However, that is not conclusive evidence for an interaction effect, since placebos were not employed for comparison, and evaluation of the patients was badly contaminated by the fact that each of the participating physicians made his own overall estimate of change The latter comment also applies to a clinical study reported by Kast and Loesch (1959), who similarly argue that the action of a psychopharrnacological agent can be made disproportionately more effective than an inactive placebo when the medication is administered within the context of a positive set (i.e., a given set can potentiate drug response). While their theoretical formulation is quite ingenious and heuristic, their experimental design does not afford a valid test of their hypothesis. A more dramatic study concerned with potentiation was published by Uhlenhuth et al. (1959). In a doubleblind, cross-over design using meprobamate, phenobarbital, and placebo, two physicians obtained significantly different rates of drug-related improvement in their patients. One physician (who was “therapeutic” and enthusiastic) obtained significant differences between the active drugs and placebo, while the other physician (who was more skeptical and “experimental”) found no significant differences among the three agents. The results of this study are certainly suggestive, but they are difficult to interpret since one cannot state definitively what the effective differentiating characteristic(s) between the two physicians was (i.e., in addition to “attitude,” they obviously differed in an infinite number of ways), and because of the complication introduced by using a three-way cross-over of drugs. In March 1960, Irvin S. Wolf, of Denison University, and PSC’s Special Studies Unit tested the interaction‘ hypothesis on normal subjects who were given dextroamphetamine and placebo under three different attitudinal sets (consistent, uncertain, and inconsistent expectations). Analysis of covariance for a 3 x 2 factorial design on subjective and psychomotor dependent variables revealed a number of significant or near-significant trends (all in the anticipated direction) suggesting a drug-set interaction. The significance of this research approach is perhaps revealed in the following considerations. When reference is made to a “place-b0 response,” it is evident that the concept is a complex one. In a placebo-controlled experiment, not only is there a general set of expectations associated with the symbolic value of receiving medication from a prestige authority, but there are also undoubtedly specific expectations about the nature, purpose, and action of the medication. These different kinds of expectations have been discussed elsewhere (Fisher, 1960), but one important implication is worth repeating here. The most frequently used model in controlled evaluations of drugs assumes that the “placebo response” (i.e., the amount of change attributed to nonpharmacological factors) is a type of “error” involved in assessing the pharmacological effects of the active drug: If one can accurately measure the degree of placebo response, that effect can be subtracted from the total effect, thus giving the pharmacological component. This assumes that the psychological (i.e., general and specific expectations) and the pharmacological components are additive in nature. As shown in figure 1, specific expectations 5 �CLINICAL IMPROVEMENT SET A FIGURE 1. SET B Hypothetical Data Illustrating Additive Model. (sets A and B) do affect the response, but essentially equally for subjects who receive the active drug and for those who receive placebo. Irrespective of the set under which the drug is evaluated, the conclusion is the same—— the drug is X units more effective than placebo. CLINICAL IMPROVEMENT PLACEBO\ SET A FIGURE 2. \\\ O SET B Hypothetical Data Illustrating Interactive Model. A quite different possible model, however, can be built on the‘ assumption that the pharmacological and psychological components are interactive. As shown in figure 2, the specific expectations in set A potentiate the drug response, and one cannot generalize the effect of the drug without taking into account the set under which it was administered. Note in figure 2 that if the drug were evaluated in an experiment in which only set B was operative, one would conclude that the drug was no more effective than placebo—a conclusion which, though 6 correct, would have to be limited to the conditions of the experiment. Figure 2 also shows, however, that under set A the drug was obviously superior to the placebo— an equally correct conclusion for the given conditions. Thus, if it were established that the interactive model is more appropriate for certain kinds of clinical evaluation, one would run the risk of rejecting as ineffective a treatment which really does have an effect (type II error) whenever the clinical trial is conducted under inappropriate conditions of set. A great deal has been written about the need for controls in clinical research. It has often been noted that new forms of therapy are enthusiastically received on the basis of early uncontrolled clinical impressions, only to be laid to rest by subsequent controlled evaluation (Cornell Conference, 1954) . Recent papers by Foulds ( 1958) and Astin and Ross (1960) show that a significantly greater number of uncontrolled studies in psychopharmacology yield positive results than do controlled experiments. Undoubtedly, this difference can be partly attributed to such factors as lack of controls, faulty or biased measurement, faulty design, etc., in the uncontrolled studies, or to insufficient dosage or duration of medication, or sampling bias, in the controlled experiments. On the other hand, it is possible that this difference is not all due to various kinds of “error.” If some genuine interaction effect should exist between physicianmilieu and drug action, that would go a long way in accounting for many of the apparent discrepancies between the findings of hardheaded researchers and those of equally hardheaded clinicians. In uncontrolled clinical trials, the patients may be exposed to a quite different “attitudinal” atmosphere: They more often see themselves as being “treated” rather than “researched,” and that might provide a quite different setting for drug action. In many controlled experiments, the patients are definitely aware that they are participating in a research project (implying “Let’s see if the drugs will help you”), and such a perception is probably reinforced whenever patients find themselves periodically being observed, tested, and probed. The overall aim of the Outpatient Study of Drug-Set Interaction is to attempt to create experimentally these two contrasting attitudinal sets within the context of a controlled clinical evaluation. REFERENCES Astin, A. W., and Ross, S. Glutamic acid and human intelligence. Psychological Bulletin, 1960, 57, 429—434. Brown, B. Influence of inter-animal and environmental stimulation on action of central nervous system drugs. Proceedings of the Western Pharmacological Society, San Francisco, January 27—28, 1958. Chance, M. R. A. Aggregation as a factor influencing the toxicity of sympathomimetic amines in mice. Journal of Pharmacology and Experimental Therapeutics, 1946, 87, 214—219. �Cornell Conference on Therapy. How to evaluate a new drug. American Journal of Medicine, 1954-, 17, 722—727. Feldman, P. E. The personal element in psychiatric research. American Journal of Psychiatry, 1956, 113, 52—54. Fisher, S. Milieu controls in psychopharmacology. Manuscript, 1960. Foulds, G. A. Clinical research in psychiatry. Journal of Mental Science, 1958, 104-, 259—265. Gunn, J. A., and Gurd, M. R. The action of some amines related to adrenaline. Cyclohexylalkylamines. Journal of Physiology, 1940, 97, 453—470. Hill, H. E., Belleville, R. E., and Wilder, A. Motivational determinants in modification of behavior by morphine and pentobarbital. A.M.A. Archives of Neurology and Psychiatry, 1957, 77, 28—35. Kast, E. C., and Loesch, J. A contribution to the methodology of clinical appraisal of drug action. Psychosomatic Medicine, 1959, 21, 228—234. Laties, V. G., and Weiss, B. A critical review of the efficacy of meprobamate (Miltown, Equanil) in the treatment of anxiety. Journal of Chronic Diseases, 1958, 7, 500—519. Nowlis, V., and Nowlis, Helen H. The description and analysis of mood. Annals of the New York Academy of Sciences, 1956, 65, 345—355. Sabshin, M., and Ramot, J. Pharrnacotherapeutic evaluation and the psychiatric setting. A.M.A. Archives of Neurology and Psychiatry, 1956, 75, 362—370. Uhlenhuth, E. H., Canter, A., Neustadt, J. 0., and Payson, H. E. The symptomatic relief of anxiety with meprobamate, phenobarbital and placebo. American Journal of Psychiatry, 1959, 115, 905-910. Research Conference on Drugs and Community Care“ In September, the Psychopharmacology Service Center sponsored a “Research Conference on Drugs and Community Care” to bring a number of investigators together to discuss problems of research on the use of drug therapy in the care of psychiatric patients living in the community. The conference, held in Washington, D.C., dealt with studies of both acute and chronic patients, evaluations of home-treatment or day-hospital care, maintenance therapy, treatment specifically designed to prevent relapse in previously hospitalized patients or to treat relapsed patients in the community, and followup studies. The primary objectives of the conference were (a) to permit investigators whose research in this area is supported by NIMH to discuss problems and to exchange ideas and experiences related to solutions to problems; (b) to provide the Center, its consultants, and the participating research investigators with an overview of the nature of the research now being supported; (c) to determine what has been learned from these studies about the role of drugs in the community care of psychotics; and (d) to assess progress in dealing with the technical aspects of these kinds of research; e.g., the establishment of criteria and the development of methods for classifying patients and for evaluating change and adjustment. In addition to NIMH grantees conducting research on drug therapy in the community, the participants included investigators whose interests and experience were compatible with the aims of the conference and several who are just entering research related to this general field. The conference was organized by Martin M. Katz, PSC research psychologist. The formal participants *Prepared by Martin M. Katz, Research Psychologist, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda l4, Md. were Dean J. Clyde, Washington, D.C.; Jonathan 0. Cole, PSC; Joel J. Elkes, Bethesda, Md.; David M. Engelhardt, Brooklyn, N.Y.; Leon Epstein, Sacramento, Calif; Seymour Fisher, Houston, Tex.; Norbert F reedman, Brooklyn, N.Y.; Sol L. Garfield, Omaha, Nebr.; Goldine Gleser, Cincinnati, Ohio; Bernard Glueck, Hartford, Conn.; Milton Greenblatt, Boston, Mass.; Martin Gross, Sykesville, Md.; Leo E. Hollister, Palo Alto, Calif. ; Martin M. Katz, PSC; Else B. Kris, New York, N .Y.; Jordan Lawrence, Sykesville, Md.; Mark Lefton, Columbus, Ohio; Samuel B. Lyerly, Washington, D.C.; David Mann, Brooklyn, N.Y.; Richard D. Morgan, Sacramento, Calif.; Benjamin Pasamanick, Columbus, Ohio; Leonard Pearlin, Bethesda, Md.; Seymour Perlin, New York, N.Y. ; George A. Ulett, St. Louis, Mo. ; and Joseph Zubin, New York, N.Y. The first half of the program was devoted to reports on six research projects, each of which was related to some aspect of drugs and community care. The papers reporting the projects emphasized aims and general research design, methodological and operational problems, and plans for future work. The second half of the conference was devoted to theoretical and practical problems of methodology. In many cases, new methods and methodological problems mentioned briefly in the research reports were presented in greater detail and discussed more fully during the second half of the meeting. Some of the points made in each paper are summarized in the following paragraphs. These summaries do not, of course, cover all of the points covered by the speakers, but it is hoped that they will provide at least enough information to convey some impression of the overall content of the meeting and of the major issues which were considered. �SIX RESEARCH PROJECTS Home Versus Hospital Care for Schizophrenics. Presented by Benjamin Pasamanick, Department of Psychiatry, Ohio State University Medical School, Columbus, Ohio. This study is designed to test the hypothesis that acute schizophrenic patients can be treated at home when proper public health care is combined with appropriate drug therapy. All first-admission schizophrenic patients referred to the Columbus Psychiatric Institute are to be considered for the study. Those who are suicidal, homicidal, or so violently disturbed that it would be impossible to keep them in the home will be dropped from further consideration. The remaining patients will then be randomly assigned to one of the following three treatment groups: (a) A group treated at home with drugs plus frequent visits by a public health nurse; ( b) a group treated at home with placebo plus frequent visits by a public health nurse; and (c) a hospitalized group treated with the usual methods of the hospital. The three groups are to be evaluated before treatment, after 1 year, and after 2 years by psychiatric and psychological examinations, and by reports and ratings from nurses and social workers (including interview data from patients and their families). Quality of housing and general home environment of all three groups will also be rated. A public health nurse, working in consultation with the psychiatrist and social worker, will frequently visit each home-care patient to give nursing guidance and counsel to the patient and his family. Patients in the home-care groups will be hospitalized when that is recommended, on the basis of previously established criteria, by a diagnostic council from the Institute. The hospitalized group and the home-treatment groups are to be compared for total length of hospitalization, psychiatric condition, and family reaction and receptivity. The two home-care groups—one on placebo, one on drug—will be compared for rate of hospital admission. Discussion of this study was devoted to such matters as control of medication in the home-care groups, degree of comparability of the hospitalized and home-treatment groups, and problems related to hospitalization of patients assigned to home treatment. Later in the conference, Lefton, also from the Columbus Psychiatric Institute, presented a detailed discussion of the interview schedules which will be used in the study. A Study of Ataractics in Outpatient Schizophrenia. Presented by David M. Englehardt and Norbert Freedman, State University of New York, Downstate Medical Center, Brooklyn, NY. This project was described as a longitudinal study of the effects of tranquilizers on the community adaptation of schizophrenic outpatients. Questions of interest in the study are whether continuation of medication after an initial gain will prevent relapse, whether further improvement is noted when med8 ication is continued, and, when there has been no initial gain, whether improvement will occur after prolonged administration of drug. Changes in symptomatology and in social behavior associated with drug therapy will be assessed after a brief time and after sustained administration of drug. The following criteria of outpatient adaptation are being used: Maintenance of outpatient status (i.e., avoidance of hospitalization), reduction in psychopathology, freedom from functional decrement, reduction in social dysfunctioning, concordance between social adaptation and psychopathological changes, and stability of clinic course during a prolonged period (up to 24 months) of continuous treatment with drug or placebo. Baseline psychiatric and psychological data are obtained during the first week. The patient is then placed on promazine, chlorpromazine, or placebo. Dosage levels are flexible and medication is administered doubleblind. Supportive psychotherapy is given, but the emphasis is on medication. Patients are seen in the clinic at frequent intervals. Detailed re-evaluations are conducted after 3 months and at the end of 1 year. Preliminary findings reported by Engelhardt show that the rehospitalization rate is significantly lower in the drug groups than in the placebo group. Also, the number of patients showing clinical improvement at 6 months is much higher in. the drug groups than in patients on placebo, as is the rate of improvement of a group of patients who demonstrate severe thought disturbance on initial evaluation. Further, the amount of social dysfunctioning as reported by the relative has been found to be greater in the placebo group than in the patients on chlorpromazine. A detailed report on the accumulation and analysis of the data on social behavior was presented later in the meeting by Mann and Freedman, participating investigators in the study. Freedman also discussed the problem of dropout, which has been one of the major difficulties thus far. Attempts to distinguish clear-cut differences in personality or psychopathological features in the patients who drop out have not been successful, though the speculation is that there may be a complex interaction between the patient’s expectation concerning treatment and what he actually experiences in the clinic. Discussion of this project centered around the specific kinds of information obtained from the patient’s relatives, the handling of such data, problems of following up patients who drop out of the study, possible reasons for dropping out, side effects (which have not been a problem), the ethics of using placebos, and the possible relation between degree of social dysfunction and level of drug dosage. Drug Therapy in a Daycare Facility for Relapse Control. Presented by Else B. Kris, Manhattan Aftercare Clinic, New York, NY. The aims of this project are to evaluate �day hospital care plus drug therapy as a means of controlling relapse and preventing rehospitalization of formerly hospitalized psychotics, primarily schizophrenics. Acutely disturbed (relapsed) patients who would ordinarily be rehospitalized are randomly assigned to one of two treatments: (a) Rehospitalization and usual hospital care, or (b) drug therapy in a special day hospital affiliated with the Research Unit of the Manhattan Aftercare Clinic. At the time of assignment to a treatment group, the psychotic condition of each patient is determined by use of the Wittenborn Psychiatric Rating Scales. Patients assigned to the day hospital are immediately started on intensive pharmacotherapy, with drug dosage individualized according to patients’ needs. Length of time between onset of relapse and subsequent remission in the two treatment groups, and community adaptation following remission, are being compared. After patients are released from either the hospital or the day hospital, the investigators will study the patients further to determine whether remission achieved in the day hospital is temporary or lasting. Community adaptation is being measured by a set of scales developed by Katz, who described them more fully later in the conference. Kris reported that the most remarkable finding thus far has been the rapid achievement of remission in the day hospital patients, who return to their jobs far sooner than patients who were rehospitalized. She also noted that treatment in the day hospital seems to promote better community adjustment and that patients seen in the day hospital seem to have learned that they can discuss recurrence of symptoms without fear of being rehospitalized. Questions about the details of handling patients at the day hospital were discussed, along with comments about the liaison betwen the day hospital and employment agencies or vocational rehabilitation centers, possibilities of using the center as a training facility for physicians and psychiatrists in private practice, criteria for admission to the study, and the staffing and physical layout of the day hospital. Termination of Treatment With Ataractic Drugs. Presented by Martin Gross, Springfield State Hospital, Sykcsville, Md. This project, begun in 1958, investigated the importance of continuing chronic psychotic patients on medication after their release from the hospital. All patients in the study were first stabilized on one of six drugs and then randomly assigned to either (a) a control group which was continued on active medication, or (b) an experimental group which was gradually transferred from drug to placebo under double-blind conditions. Patients who relapsed were removed from the study and placed on medication if they had been receiving placebo or were rehospitalized. The criterion for relapse was the clinical judgment of the treating psychiatrist. A rating scale developed to permit objective determination of the ' psychiatric condition and social adjustment of the patients was described by Lawrence during the second half of the conference. During the preliminary phase of the study, and at intervals thereafter, patients were evaluated by psychological tests, and their families or the people with whom they were living were interviewed by the social workers. Frequency of relapse while on active medication was compared with that which occurred while patients were on placebo. Summarizing some of the findings from the study, Gross reported that relapse occurred significantly more frequently during the withdrawal or placebo period, the relapse rate being approximately three times as high during the placebo period as during the period on medication. He also noted that three-fourths of the patients who relapsed while on placebo did not require rehospitalization but were able to regain stability after medication was resumed. Among the problems of methodology and design which Gross enumerated were the difficulties experienced in dealing with six different drugs rather than with a single drug. He noted also that the generalizability of the findings was limited in that patients in the project—— chronic psychotics who were free from alcoholism and organic brain damage and who were able to attend the clinic regularly—could not be considered representative of the general outpatient clinic population. In reply to a question, Gross stated that he felt the low incidence of dropout was due to the personal contact between the patients and the social worker and physician. Other points discussed were the difficulties of maintaining double-blind conditions and of objectively determining the point of relapse, procedures for determining whether the patients took their medication, and techniques for switching patients from drug to placebo. Drugs and Social Therapy in Chronic Schizophrenia. Presented by Milton Greenblatt, Massachusetts Mental Health Center, Boston, Mass. This study was initiated to determine (a) how much of drug effectiveness is due to the drug per se and how much to other causes, and (b) whether there are significant social and environmental differences between hospitals which may account for the differences between drug effects in one setting and another. Sixty chronic schizophrenics were transferred from a State hospital to an intensive treatment center (the Massachusetts Mental Health Center), where 33 received drug in addition to other therapy and 27 were not given drug. Comparison groups were composed of 55 patients remaining at the State hospital, of whom 25 were assigned to drug treatment and 20 were not. In neither setting were the patients assigned to “research wards.” The criteria on which patients in the four groups were compared were clinical improvement and discharge rate. �Findings reported by Greenblatt showed only slight differences between the State hospital groups and the MMHC groups after 6 months. At 18 months, however, there were differences which suggested the possibility of a beneficial carryover of milieu effects in patients who had originally been transferred to the MMHC. In commenting on discharge rate, Greenblatt indicated that the State hospital criteria for discharge are much more stringent than those of the MMHC. He also noted that discharge rate was affected by the availability of a family or a transitional facility to which the patients could be released. Among other special problems which he discussed were the difficulties of incorporating chronic schizophrenic patients into MMHC treatment routines without changing the environment of the Center, the reasons for having decided not to attempt double-blind administration of drugs, and the possible significance of any effects of “transfer trauma” in patients moved from one setting to another. The Efleet of Ataractie Drugs on Hospital Release Rates. Presented by Richard D. Morgan and Leon Epstein, California State Department of Mental Hygiene, Sacramento, Calif. This project is one aspect of a much broader study of population movement in the California State mental hospitals. Morgan’s paper was devoted to the overall study, and Epstein’s to the parts of it which are specifically concerned with drug therapy. Morgan first briefly explained the system of cohort followup analysis which is being used, noting that it is essentially the application of individual followup analysis techniques to a group of patients who have one or more characteristics in common—cg, age, year of admission, sex, diagnosis, etc. Having set July 1948 as the beginning point for the collection of data, the California State Department of Mental Hygiene is now systematically coding and punching onto IBM cards detailed information on all first-admission patients in the State’s 11hospital system. The records are not restricted to the period of first admission, but cover residence during subsequent readmissions in the same hospital or in a different one within the State system. A wealth of information is collected for each patient: Vital statistics, diagnosis and details of treatment, and data covering current hospital entry, previous hospitalizations, leaves, etc. Thus, a patient’s complete record of hospitalization can be examined in great detail at any point during the followup period, and cohorts can be constructed on the basis of any combination of a large number of descriptive characteristics. Morgan observed that this technique permits analysis of the frequency or the likelihood of occurrence of changes in status during any specified interval in the followup. The status of a given cohort of patients can be examined for any period of time. Data being collected in this study are proving valuable in studies of current administrative policies and investigations of the 10 effectiveness of new or expanded programs. This system is also valuable in providing retrospective control data which may be used in lieu of a control group in evaluations of specific programs. Following Morgan’s report, Epstein discussed a particular set of analyses of these data in which the aim is to evaluate the role of tranquilizing drugs in the recent decline in State mental hospital populations, a decline which has occurred in California as well as in other States. For the period from July 1, 1955, through December 31, 1957, additional information (i.e., additional to that routinely obtained for all patients) on details of drug therapy was recorded for each patient in the State system who had received treatment with drugs. Name of the drug, total amount of drug administered, number of days on drug, and the reason for stopping drug treatment were among the additional data recorded. By looking at significant subgroups—for example, first-admission male schizophrenics between the ages of 25 and 4-4—the investigators hope to be able to draw certain conclusions about shortened periods of hospitalization and their association with drug therapy. Data concerning drug usage during the period of the study are now being analyzed. Epstein stated that investigators participating in this study are “painfully aware” that the data involve a variety of physicians, drugs, settings, and timings of drug treatment in relation to admission, as well as a variety of discharge policies among the 11 different hospitals. Despite such problems, the data do provide some reflection of what may be associated with drugs as they are used in a total system. A number of the conference participants were particularly interested in certain specific applications of data being recorded in the California studies or of cohort analysis techniques generally. Others expressed concern about the use of release rates as a criterion in studies such as these, questioned the comparability of present-day schizophrenics with those of a few decades ago, or asked whether the current “decline” in certain hospital populations might not be in part a reflection of the decline in birth rate which occurred during the depression. RESEARCH METHODS The section of the conference which dealt specifically with methods was devoted to technical and theoretical problems which arise in carrying out research on drugs and community care. In accord with evidence that drugs in combination with other psychiatric treatments are contributing significantly toward. maintaining formerly hospitalized patients in the community, investigations have been initiated which are aimed at specifying the nature of these treatments and their effects. For purposes of the conference, the question of specificity was seen as having two major parts. The first was concerned with the problems of specifying the kinds of �patients who are helped by a given treatment, identifying the clinical, personal, and social characteristics of patients which are associated with response to treatment, and identifying the “types” of patients who are most likely to respond to a given treatment. In addition to the question of types of variables which merit study with regard to this problem, the technical problems which arise here, such as coding and the application of multivariate analysis procedures, were also considered in separate papers. The second part of the section on methods was concerned with the problems of specifying the effects of a given treatment, of measuring clinical change and the various aspects of adjustment. Several approaches to these problems were described. Population Specification Three papers were concerned with the search for significant variables in clinical history, sociological characteristics, or personality of the patients. Clinical history was discussed by Bernard Glueck, of the Institute of Living, Hartford, Conn. Although several clinical and social variables have demonstrated some general predictive value in studies of response to treatment, Glueck observed that the search for specific prognostic factors in these areas has not been very successful. He reviewed some of the clinical history variables which have been linked to response to insulin therapy, electroshock, and lobotomy, and commented to the scarcity of such information in relation to treatment with drugs. His major criticism was aimed at the continuing lack of a common language to describe psychiatric conditions. Following a description of Q-sort techniques which he and his associates are applying to this problem, Glueck suggested that Q-sort methods provide a means of standardizing language and making comparable the findings from different clinics or hospitals. Sociological variables were covered by Leonard Pearlin, of the National Institute of Mental Health, Bethesda, Md. Arguing for greater specificity in this area, Pearlin observed that generic variables such as social class, age, and sex role are too global to be of much value in understanding the relations among variables. The need, he maintained, is for greater emphasis on description of the social context—i.e., the family, the community—and a descriptive system in which the “social characteristic in context” is the unit of analysis. The role of personality in the prediction of response to treatment was the topic of the paper by Seymour Fisher, of Baylor Medical School, Houston, Tex. His review of previous work in the personality area and his own experience led him to the opinion that the more simple personality variables have not been very helpful in the past as predictors and are not likely to be too helpful in the 580375—61—2 future. Increased emphasis should, he felt, be placed on theoretically derived configural measures of personality. Several possible conceptual dimensions were described. He acknowledeged, however, that the linking of personality variables to response to treatment is subject to a number of pitfalls, some of which he enumerated. The discussion which followed focused upon the issue of the single variable versus the configural approaches in attempts to relate personality and treatment response, and resulted in some clarification of the roles of each. The issue, however, was not resolved. Methods for dealing with population variables were discussed by Samuel B. Lyerly, of the Society for Investigation of Human Ecology, Washington, D.C., and Dean J. Clyde, of the Biometric Laboratory of George Washington University, Washington, DC. Lyerly, in a paper entitled “Interview Data: Coding, Scaling, and Selection of Potentially Useful Variables,” emphasized the differences in hospital and community situations which affect the collection and analysis of data, the characteristics of information which are essential to statistical analysis of data, and the importance of insuring that information collected is comparable from subject to subject. With regard to coding, he discussed different types of data and classification systems, the role of the pilot study, ways of handling of “free responses,” and the application of simple mathematical procedures to patterning problems. Problems of weighting, suggestions for dealing with “does not apply” responses, and the application of different types of validity models were also considered. Clyde’s paper, “Multivariate Problems: Clustering Variables and Classifying Patients into Types,” focused on the role of multivariate models in drug research. He described the following three approaches and presented examples of the application of each: (a) Analysis of covariance, whose use was exemplified in a study in which control of the pretreatment level of severity of illness was required; (b) factor analysis, which was used, in the example presented, to reduce a large number of items in a rating scale to two independent dimensions and thus served to clarify the composition and meaning of the instrument; and (c) discriminant function, which was applied to a problem of separating out groups of patients on the basis of their differential response to drug treatment. The relevance of the latter procedure to the problem of etiology was also considered. In discussing these papers, Goldine Gleser, of the University of Cincinnati, Cincinnati, Ohio, elaborated upon several approaches to separating subjects into meaningful groups. Three statistical models for accomplishing this kind of separation were described. She stressed that the state of knowledge in the field is not sufficiently advanced to permit the prediction beforehand of the best way of separating groups, but pointed out that study 11 �of the outcome of such empirical separation can yield hypotheses which can then be cross-validated in other studies. Methods for Measuring Improvement Papers presented in this section of the conference described methods which are being used or developed to evaluate the adjustment of the patient and to specify ways in which improvement is manifested. Norbert Freedman and David Mann, of the State University of New York, Downstate Medical Center, Brooklyn, N.Y., described the manner in which they are attempting to measure psychopathology and social behavior. Emphasis within the clinic is on the psychiatric rating scale approach, and in their community studies emphasis is on a “naturalistic” approach. They have, through preliminary analysis of their psychopathology ratings, identified factors which improve with drug treatment and which predict drug response to treatment. In the area of social behavior, development of an extensive interview schedule covering such areas as family history, work history, and social pathology was described by Mann. He also discussed in some detail their coding procedures, the progress of their approach to studying the “typical day in the patient’s life,” and the dimensions of classification which have been derived from the social data and which will contribute toward defining “social remission.” It was pointed out that the definition of social remission is one of the central aims of the project. The details of a rating scale for measuring the improvement of outpatient psychotics treated with drug and placebo were discussed by Jordan Lawrence, formerly of Springfield State Hospital, Sykesville, Md. The scale, which is completed by a psychiatrist or psychologist and a social worker following an interview with the patient, has three sections, one covering major psychopathology, one describing neurotic symptoms, and one concerned with social adjustment. Lawrence reported that the more reliable items in the scale have been factored and have yielded tentative dimensions of “schizophrenia” and “depression.” He also indicated that the three subscores and the total score have been found to discriminate well between pre-relapse and relapse conditions, but noted that further, better controlled validational studies need to be carried out. Progress on the development of a set of inventories designed to assess clinical and social adjustment was reported by Martin M. Katz, of the Psychopharmacology Service Center. He noted that the instruments are based on the need to integrate two points of view, the patient’s and the relative’s, in assessing the adjustment and per- 12 of the patient. The inventories represent atobtain objective estimates of (a) the amount of home and free-time activity in which the involved, and (b) the patient’s and the relative’s level of satisfaction with the patient’s functioning in the clinical, work, social behavior, and free-timeactivity areas. A validity study was described in which relatives were shown to be in very high agreement with psychiatric assessment (based on intensive clinical study of the patient) with regard to the level of psychopathology present and the extent of home, social, and free-time activities of the patient. Several trends in the data were noted: The relative is capable of providing accurate, objective information in certain areas; the sheer quantity of activity as reported by patient and relative reflects the level of adjustment; and the relative’s level of expectations at the time of assessment correlate highly with adjustment. More detailed study of the composition of the instruments and their general applicability is in progress. Mark Lefton, of Ohio State University, Columbus, Ohio, described his implementation of the interviewschedule approach, which had some similarity to others with regard to the areas of functioning sampled. Separate schedules were designed for the patient and the relative. The variables of prime interest in Lefton’s assessment of community adjustment are social participation, work performance, psychological functioning as measured by a relative’s ratings on a list of psychopathological indices, performance as a homemaker, and meas» ures of the relative’s expectations and tolerance of deviation. He reported that several measures have been found to discriminate between patients who were returned to the hospital within 6 months and those who remained in the community, as well as between patients who function well and those who function poorly in the community. During the discussion of these papers, one participant commented on the salutary effect that commitment to a particular approach has in this area, but he cautioned against inflexibility at this early stage in the development of the field. The use of clinical judgment as a criterion‘has its advantages, but it was noted that areas of disagreement among raters can be just as important for understanding the nature of the problem. formance tempts to and kind patient is In an area that has seen only scattered attention in the past, the conference participants agreed that the diversity and extent of efforts now being directed toward assessing the clinical and social effects of various psychiatric treatments are very promising developments. �Conference on Information Needo A conference on scientists’ need for information, sponsored by the Psychopharmacology Service Center under contract wtih the Matrix Corp., of Arlington, Va., was held on November 25 and 26 in Washington, DC. It was a small, invitational conference of scientists active in research in psychopharmacology, documentalists, and other information storage and retrieval specialists. The aims of the conference were several: To learn whether the conference method of face-to-face interchange would reveal more relevant data about scientists’ needs in the field of information and. communication than has hitherto been revealed in questionnaire and interview studies; to learn whether bringing the generators and users of information into direct contact with the experts in documentation would yield information of value to both; to obtain specific information about needs of scientists working in psychopharmacology; and, as a byproduct, to help the PSC’s Scientific Information Unit plan its future activities. The meeting was very informal. There was no prearranged agenda, nor was any attempt made to arrive at specific recommendations. Under the chairmanship of Roger W. Russell, of Indiana University, Bloomington, Ind., three speakers presented papers as starting points for the discussion. Robert J. Hayes, of the Electrada Corp., Los Angeles, Calif., reviewed the whole field of information storage and retrieval, emphasing new methods and machines. He brought out that there are now machines that can be applied to almost any problem or situation in the field of information storage and retrieval. Emphasizing the team approach to the problem, the cooperative efforts of users, operators, and machine experts, he observed that the application of machine methods to information problems is successful only when the machine specialists and documentalists have a clear understanding of the users’ requirements. Daniel X. Freedman, of Yale University, New Haven, Conn., discussed the use of information in his own research, reviewed the development of his research program and the role of information in the program, and mentioned ways in which information could be more useful. Murray E. Jarvik, of Yeshiva University, New York, N.Y., also reviewed the sources of information that he employs, including journals, monographs, books, reprints, review articles, conferences, the public press, science writers, drug company literature, textbooks, and other materials. In addition to these three speakers, several other participants described their uses of information, covering of Pyye/oop/onrmneologz'rtx kinds of information used, how it is used, and ways in which they would like to have it improved. Interspersed among the papers was lively and varied discussion from most of the participants. The following summary attempts to convey some of the ideas presented in the discussions, but it does not cover all the points that were made. Throughout the meeting one recurring theme was concern about the quality of scientific information. Commenting on the many problems of so-called scientific writing, one participant observed that much scientific writing occludes more than it illuminates. Most participants felt that many experiments were poor to begin with and should never have been published. They pointed to the need for editors of scientific journals to evaluate work more carefully and more critically before accepting it for publication. On the other side of the question were emphatic comments that strong efforts in this direction could lead to stultifying and untenable orthodoxy in science. One of the participants maintained that the problem was too much information, and that steps should be taken to cut it off at the source; i.e., to induce the scientist himself to be more selective in reporting his work. Another took the opposite point of view, saying that, as with farm surpluses, the real problem is not that of having too much information but of distributing and using information more effectively. A frequently recurring generalization was that scientists do not make maximal, or even good use of the many sources of information available to them. As each participant mentioned kinds of information he used, others remarked that they did not know of those sources. Similarly, when specific needs were mentioned, other participants often retorted that such needs were now being satisfied and the scientist had only to take advantage of available services. One of the questions raised was whether centralized, or even decentralized, information services could ever serve all the needs of scientists. One participant suggested that much of the seeming dissatisfaction with present information and communication is due to the unrealistic expectations of scientists, who often want answers to research questions that they themselves should submit to research. Information at the forefront of knowledge must be obtained by the scientist; readymade answers do not exist. A related comment was that information needs differ from one stage of research to another. A point that could be generalized from the discussion was that scientists perhaps do not know what they want 13 �in the way of information, and that it is, therefore, the duty of specialists in the information area to provide scientists with a wide variety of information presented in many different forms. If that were done, the scientists could then select what they need from what is offered to them. The usefulness of critical reviews of the literature was discussed in some detail. Although all agreed that critical reviews are valuable, they noted that finding really eminent scientists to write the reviews constitutes a major problem. Handbooks and other compilations of factual information that would be of particular value to the applied scientist were also felt to be of great importance. Many participants cited reprints, rather than journals, as one of the most useful forms of information, and felt that much could be done to make distribution of individual articles more feasible and more effective. In discussions of systems of handling information, it was noted that a scientific discipline is itself an informational system, and that some disciplines are, at different times, much more tightly organized systems than others. Physics and chemistry, for example, are at present rela- 14 tively more “organized” than the biological sciences and, therefore, in a sense, present fewer information and communication problems. This discussion, which occasionally bordered on excursions into the philosophy of science, brought out the paradoxical observation that as a body of knowledge or science develops and overthrows old concepts and formulations, it is in a continuous cycle of creating chaos out of order and then creating order out of chaos. In general, the conference participants agreed that the most important and effective means of disseminating and exchanging new information are by personal contacts at scientific meetings, by the “first” type of scientific communication—the letter—and by visits with other scientists. In discussing the value of this kind of direct, personal interchange, it was suggested that tape recorders, which are now available in most laboratories and university departments, might be used to simplify and speed up the informal exchange of information. The practical value of directories of scientists and of indexed compilations of films and other audiovisual aids was also stressed. �The Pylebep/aarmacolegy Rerearcb Umt State Unevem'ty of New Yer/e Dowmtate Medical Center" The Psychopharmacology Research and Treatment Unit of the Department of Psychiatry, State University of New York, Downstate Medical Center, Brooklyn, N.Y., was established in October 1957. From its inception, the Unit has been concerned with the study of the effects of long-term psychopharmacological treatment on the community adaptation of schizophrenic outpatients. In the selection of ambulatory schizophrenic patients as our study population we were guided by the wide use to which psychopharmacological treatment is put with such patients. By setting community adaptation as the criterion of treatment outcome we hope to emphasize that change in these patients must be defined in terms of performance at home, at work, and in the community, as well as in terms of the usual criteria of psychological and psy— chiatric functioning. By assessing the effects of longterm, sustained drug action (1 to 5 years of continuous drug administration) we expect to determine to what extent such treatment may prevent relapse or lead to further improvement after an initial stabilization has been attained. The Unit thus focuses on the behavioral (i.e., psychological as well as social behavioral) correlates of drug treatment and tries to apply the method of controlled investigation to the clinical setting. Considerable effort is also being extended to the methodology of outpatient drug assessment and to the basic research task of developing objective assessment techniques which will allow for the tracing of changes in the qualities of community adaptation. These overall research objectives are discriminated into the seven specific studies outlined below. The overall project is in part supported by Public Health Service grant MY—1983. In addition to these long-term studies of chronic schizophrenic outpatients, a section of the Research Unit is specifically concerned with the testing of new drugs. In the course of the short-term studies we have an opportunity to test the validity of some of the assessment techniques developed in the longterrn studies. Finally, the staff of the Research Unit also engages in teaching psychopharmacology to undergraduate medical students and psychiatric residents. A *Prepared on request by David M. Engelhardt and Norbert Freedman, Psychopharmacology Research Unit, State University of New York, Downstate Medical Center, Brooklyn, N .Y. research fellowship program is carried out by the Research Unit with second- and third-year medical students who are expected to conduct their own experiments in psychopharmacology. The present staff of the Unit includes David M. Englehardt, Director, Norbert Freedman, Associate Director, Leon D. Hankoff, Research Psychiatrist and Director of the Treatment Unit, David Mann, Research Social Psychologist, and Reuben Margolis, Research Clinical Psychologist. The research design of the principal (long-term) project has the following essential features: (a) A free-clinic population of chronic schizophrenic patients is studied. Some patients come with a history of prolonged hospitalization, some with a history of brief recurrent hospitalization, some without previous hospitalization. The population is ethnically heterogeneous, evenly divided between males and females, and draws upon the lower socioeconomic groups. (b) Patients are given one of three commonly used agents, chlorpromazine, promazine, and placebo, and are seen in a setting which emphasizes a supportive doctor-patient relationship. The drugs are given under double-blind conditions, and drug assignment is made randomly. (6) Assessment of treatment effects is made by psychiatric ratings and psychological tests, as well as by detailed social behavior interviews administered to key relatives of the patient according to a predetermined schedule. Psychopathology and social behavior are thus independently evaluated, the former in the clinic by a psychiatrist and psychologist and the latter by the report of a relative. It is planned to assemble a cohort of 500 patients who have completed 3 months of treatment and a smaller number of patients who have completed 1 to 2 years of treatment under these relatively standard conditions. Study 1: The Role of Ataractio Treatment in the Maintenance of Community Status Treatment may affect both incidence of hospitalization and clinic dropout. Preliminary findings show that drug treatment (chlorpromazine) is associated with lower incidence of hospitalization. Our next goal is to determine the role of drug treatment in preventing hospitalization by separately studying certain criterion groups. 15 �Thus, we hope to define incidence of hospitalization on the basis of diagnosis, socioeconomic status, the relative’s tolerance for the patient, and previous hospitalizations, and to ascertain the probability of hospitalization for each of these criterion groups separately, for drug andplacebo conditions. Clinic attrition for reasons other than hospitalization is also being studied systematically. Analysis of dropout patients relative to patients remaining represents an important methodological task because of the potential bias that early attrition may introduce in the interpretation of results of change. Drug treatment does not appear to affect dropout rate. Instead, dropout appears to be affected by factors in the patient’s motivation toward treatment and certain factors in the treatment situation. Social (group membership) determinants also appear to be implicated. Study 2: The Measurement of Social Behavior and Social Behavior Change Emphasis is placed on the development of quantitative and qualitative indices of community adaptation. The instrument used is a detailed focused interview. This interview elicits from a relative a reportorial description of the patient’s activities at home and at work, covering a specified timespan. These detailed reportorial accounts by the relatives provide measures predictive of change as well as measures denoting changes per se over the course of drug treatment. Preliminary data have shown that the effects of drug treatment can be discriminated by a relative reporting on the patient’s behavior. This preliminary study has involved the use of a simple checklist of social dysfunctioning filled out by the relative. Patients on drug showed greater reductions in dysfunctional social behavior than did the patients receiving a placebo. Relatives having no awareness of the specific treatment the patient was receiving were able to make this discrimination. The meaning of these differential changes must await the detailed coding of qualitative behavioral descriptions. Study 3: Changes in Psychopathology and their Concordance with Social Behavior Changes Changes in psychopathology are evaluated by the coding of the doctors’ clinical judgments (progress notes), a detailed psychiatric rating scale, and certain psychological test performances. Psychological tests are used primarily to elucidate the meaning of changes observed on psychiatric and social behavior indices. A cluster analysis of psychiatric ratings suggests that psychiatric changes may be described in terms of two relatively independent dimensions of change, a cluster called thought disorder and a cluster called change in anxiety and treatment contact. There is a trend for patients on chlor16 promazine to show greater reduction of thought disorder than for patients on placebo. Once the social behavior indices of change are sufficiently developed, we expect to determine the degree to which psychiatric judgment and relatives’ observations concur or diverge. Specifically, we expect to inquire whether relatives and psychiatrists concur on specific aspects of the patient’s behavior (i.e., belligerence) or whether both concur that change has taken place but are in fact referring to different areas of change. Preliminary data so far indicate greater concordance of change on certain specific variables for patients on drug than for patients on placebo. Basically, this study seeks to attack the question of generality of the treatment effect. Is the treatment effect limited to change observed in the doctor’s office, or does it extend to the patient’s functioning in the community as this is perceived by a representative of the community? Implicitly, we are studying variations in the conceptions of mental health and illness as these are held by different observers. Study 4: Freedom from Functional Decrement The possibility that sustained treatment with psychopharmacological agents may bring about a decrement in the effectiveness of the patient’s functioning is especially important for outpatients, on whom the demands for effective performance in a community are greater than for inpatients. Psychiatric ratings and relatives’ reports on such variables as sluggishness, apathy, inertia, etc., are especially relevant here. Equally cogent in determining functional decrement are psychological test performances on measures of inertia and perseveration* and the Porteus Maze Test. Data on about 100 patients treated with drug or placebo for a 3-month period have been analyzed for changes in maze performance; so far we have not been able to substantiate Porteus’ general findings of a decrement with chlorpromazine treatment, but we have observed a decrement in one specific subgroup. The subgroup was characterized by a “more complex” level of cognitive organization. (See the following description of study 5.) Study 5: Prediction of Clinical Course Underlying our studies of the community adaptation of a heterogeneous group of schizophrenic patients being treated with drugs is the assumption that outcome is modified by factors within the patient and within his social mileu. Preliminary data suggest that several parameters other than drug must be considered in predicting clinical outcome: (a) The patient’s motivation toward treatment, (b) his cognitive organization, and (c) the attitude of the family toward the patient’s illness. The patient’s cognitive organization as gleaned from *See Cattell, R. B. On the measurement of perseveration. British Journal of Educational Psychology, 1935, 5, 76-92. �Rorschach responses (based on a scoring derived from Werner’s concepts) has been especially helpful in elucidating a “pattern of drug effects”: the direction of change in response to a given medication depended upon the patient’s cognitive organization. Study 6: Incidental (Nondrug) Treatment Factors In addition to the prognostic indices just enumerated, the role of several nondrug factors within the treatment situation has been observed. We have explored the significance of the initial response to placebo and the doctorpatient relationship as they may affect the patient’s clinic attendance (dropout or hospitalization), as well as qualitative changes observed by the psychiatrist. Scoring procedures for the assessment of both doctor-patient relationship during the initial interview and response to placebo have been devised. These studies have emphasized the importance of nonverbal communication in the psychopharmacological treatment of schizophrenic outpatients. They have also delineated the contributions of the active agents to the treatment effect in some patients, but have suggested that in other patient groups the nondrug factor was prepotent. Study 7: Long-Term Drug Action Patients remaining in treatment for 12 to 24- months under drug and placebo conditions are observed at monthly intervals and their progress is then graphically charted. Our approach to long-term studies has been to select one of the more reliable change indices (psychoticism) and trace the patient’s status at successive intervals. In analyzing the time trends we have found it useful to distinguish two baselines, one at intake and a second after approximately 3 months of treatment. This second baseline permits the comparison of any further improvement or worsening in the patient’s adaptation after allowance for the initial drug effect has been made. It must be emphasized, however, that this study is always limited to patients willing and able to remain in treatment for such a long period of time. We are continually assessing differences between remainers and dropouts, so as to be in a position to detect bias introduced by the selective attrition of the sample. These long-term studies will also be corroborated by intensive case studies. Study 8: New Drug Testing The major efforts of the Unit are devoted to the study of long-term drug responses of chronic schizophrenic outpatients. Three relatively commonly used agents are employed. However, one section of the Unit is concerned with exploring the suitability of newer psycho— pharrnacological agents, specifically as they may be applicable to outpatients. Assessment methods which have proved to be useful in the larger study are also employed with the relatively brief trials of new drugs for outpatient use. With the study of new drugs we also hope to extend our information about the behavioral changes among outpatients in different diagnostic groups such as depressed patients. Studies of the following compounds have been completed or are in progress: fluphenazine (Prolixin), isocarboxazid (Marplan), imipramine (Tofranil) , and pyrbenzindole (IN—461, or 4-(1-benzyl-3-indolylethyl) pyridine hydrochloride) . In the course of conducting these studies we are accumulating a body of information about the methodology of outpatient drug testing; i.e., we are beginning to delineate the relative advantages and limitations of double-blind procedures in long-term assessment, the merits of simultaneous appraisal of an agent by the multiple clinic-community-member criteria, the utility of at least two baselines in the study of long-term trends, and the advantages of a drug spectrum of chemically similar agents which vary in presumed clinical intensity. Future Plans The findings so far support the view that the hospitalization rate tends to be lower for schizophrenic patients on active medication than for those on placebo; that psychotic symptomatology among these patients tends to be reduced by the drug; and that the adequacy of social behavior as judged by the relative appears improved, although we are not able to specify the quality of behavioral changes implicated here. Preliminary data on such variables as “psychotic thinking” also suggest that with prolonged administration of medication there tends to be less relapse with drug than with placebo. F urthermore, the data suggest that significant variations in the effectiveness of drugs depend on the patient’s cognitive organization and his motivation toward treatment. In certain criterion groups, incidence of remission tends to be high regardless of drug treatment. In other criterion groups whose improvement is lower, the remission rate for patients on active drug exceeds the expectancy of improvement attributable to nondrug factors. Our next step in the project is to place these findings on a more solid foundation: We expect to study a sample of 5-00 patients who have received 3 months of treatment; we expect to cross-validate some of the specific predictions drawn from the initial sample; we expect to specify the meaning of the qualities of treatment outcome, particularly in the area of community behavior, through qualitative coding of behavioral descriptions by the relative; we expect to conduct certain control studies on the source of dropout, the patient’s condition after separation from the clinic, and changes in a sample of “isolated” schizophrenic patients, i.e., those not living with relatives. Finally, we hope to describe changes in subjective experiences among those patients judged by 17 �psychiatrists and relatives to be in remission. Thus, we hope to describe improvement from three vantage points, the community’s, the psychiatrist’s, and the patient’s. In most general terms, it is hoped that our Unit can contribute to the knowledge of the effectiveness of psy— chopharmacological treatment of schizophrenic outpatients by developing and delineating criteria of treatment outcome, by specifying expectancies of clinical change for specific patient groups, by indicating the role of the drug and nondrug factors in outcome, and by tracing the long-term consequences of treatment. Once this information has been derived from a large heterogeneous group of schizophrenic patients under relatively standard treatment conditions, it is hoped that newer agents can be tested more effectively; i.e., that the larger sample can be used as a reference group and that inferences can be drawn from smaller patient groups seen over briefer periods of observation. Finally, we hope that the accumulated data will increase our knowledge of the schizophrenic outpatient. Experimental Pay/chiatric Program: at Hillside Hospital, located in Glen Oaks, Long Island, N.Y., is a nonprofit, philanthropically supported psychiatric institution to which patients are admitted voluntarily for extensive psychotherapeutic treatment. Patients are from a predominantly middle-class, urban population, and most have high educational attainment. The programs of the Department of Experimental Psychiatry are a cluster of interrelated studies focused on common population samples. Other research laboratories in biochemistry and in medicine are active, and laboratories in psychodynamic psychiatry are being developed. The programs of the Department of Experimental Psychiatry have developed over 6 years, and are devoted to understanding of the mode of action of psychiatric therapies through studies of brain function. The principal techniques have been adapted from descriptive psychiatry, neuropsychology, electroencephalography, linguistics, pharmacology, and sociology. Members of the staff, representing various disciplines, are Max Fink, Director, Karl Anderrnann, Ira Belmont, Martin A. Green, Abraham A. Kaplan, Eric Karp, Donald F. Klein, George Krauthamer, Joseph Jaffe, John C. Kramer, Max Pollack, and Nathaniel Siegel. Former associates who contributed to these programs are Harold Esecover, Robert L. Kahn, Hyman Korin, and Henry J. Lefkowits. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pretreatment psychological variables. As our understanding of convulsive therapy developed, a general neurophysiological-adaptive view of somatic therapies emerged. In this view, psychiatric treatments are therapeutically effective to the degree that brain function is measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation varies, depending upon pretreatment psychological and sociological characteristics of the subject. Thus, the mode of action is not seen as either “organic” or “psychological,” but rather as the inter18 Hz'ZZJz'de HarpiMF action of diffuse neurophysiological changes and adaptive mechanisms. Further, while behavioral change is related to changes in brain function, and the adaptive characteristics, psychological to pretreatment pattern evaluations of “improvement”—being special types of evaluation of change—are derivative judgments based on staff and family expectations and tolerances. This hypothesis was developed and sustained in a series of studies of convulsive therapy. Concurrent studies of insulin coma indicated that behavioral change here, too, was related to the onset and degree of prolonged coma or repeated seizures, these being the prin— cipal manifestations of prolonged neurophysiological change in this therapy. The mode of action of the new psychotropic agents was also expressed within this hypothesis. It was suggested that these agents would be effective to the degree that they induced persistent changes in brain function, and that the type of behavioral response would be related to the type of brain change and to prernorbid psychological (personality) patterns. The present programs in the Department are designed to study these relationships in detail. Convulsive Therapy Process Of various measures of brain function, the amount of slow wave activity in the electroencephalogram and confabulatory and denial language patterns after amobarbital were the most sensitive indices in convulsive therapy subjects. In one experiment, improvement ratings were correlated with the appearance of high degrees of change in these indices. These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to courses of either convulsive or sub' *Prepared on request by Max Fink, Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, N.Y. �»n-s,ww.- . . E convulsive therapy under thiopental (Pentothal) premedication. High degrees of neurophysiological change were observed only in the convulsive group; improvement rates were significantly higher in this group; and when subconvulsive subjects were re-treated by convulsive applications, the improvement rate was similar to the original convulsive group. In the subjects given subconvulsive treatment considerable amounts of electric current passed between the bitemporal electrodes. It appeared that the therapeutic agent was not the total electrical current per se, but an all-or—none quality manifested by the grand mal seizure. The significance of the grand mal seizure was examined in studies of the inhalant convulsant hexafluorodiethylether (Indoklon). Similar degrees of electrographic change, improvement rates, types of behavioral change, and changes in neuropsychological task behavior were observed in the Indoklon group and in the electrically treated group.- It was soon apparent that not all subjects manifesting high degrees of physiological change were rated as “improved.” In a descriptive typological study, five patterns were described, empirically termed “euphoric,” “hypomanic,” “somatization,” “paranoid-withdrawal,” and “panic.” While the first two of these adaptive modes were rated as “much improved,” the latter two were seen as “unimproved” or “worse.” In studies of psychological variables, it was reported that patients rated as much improved and recovered frequently manifested personality patterns similar to that described by Weinstein and Kahn as the “explicit verbal denial personality.” In language patterns, patients expressed the “language of denial” when diffuse brain change was induced, exhibiting such aspects as explicit denial, minimization, displacement, cliches, etc., more frequently than unimproved subjects. Other indices related to favorable outcome were high scores on the California F Scale, and Rorschach determinants of pure color, absent movement, and absent form-color. In this population, also, favorable outcome was associated with low educational achievement and foreign birth. Anticholinergic Compounds and Convulsive Therapy Seeking a way to augment the degree of postconvulsive EEG slow wave activitiy, an anticholinergic compound, diethazine, was given intravenously at various stages of the convulsive therapy process. Contrary to expectations, diethazine caused an immediate and sustained decrease in EEG slowing. Patients with denial language patterns relinquished them. Instead of feeling euphoric and experiencing a sense of well-being, the subjects became irritable, anxious, and showed symptoms expressive of pretreatment patterns. Prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds—WIN—2299 (2-diethylaminoethyl-a-cyclo- pentyl-a-(Z-thienyl)-glycolate HCl), JB—318 ( l-ethyl3-piperidy1 benzilate HCl), JB—336 (N-methyl-3-piperidyl benzilate) , and benactyzine—showed behavioral and electrographic patterns similar to those of diethazine. Similar desynchronization of postconvulsive EEG slowing was also noted with central sympathomimetic hallucinogens (amphetamine, mescaline, LSD—25), and has been reported for antihistamines (diphenylhydramine). These observations led to the suggestion that an increase in central cholinergic activity was a biochemical basis for the convulsive therapy process. Psychopharmacological Agents and EEG During this period, the mode of action of newer psychopharmacological agents aroused interest. Following the concepts derived from convulsive therapy, the neurophysiological changes induced by drugs were tested within the same acute experimental framework of the EEG setting. It was observed that phenothiazines (chlorpromazine, promazine, triflupromazine) induced EEG synchronization and a shifting of the spectrum to the slow frequencies; meprobamate and barbiturates induced an increased synchronization and a shift of spectrum to fast frequencies; reserpine induced an increased slowing with synchronization at low dosages and desynchronization at higher levels ; and imipramine induced desynchronization with a shift of frequencies to the slow bands. Other experimental compounds tested included BLM188 (which is 4-dimethylamino-3,4,5-trimethoxybenzanilide) and phenyltoloxamine, deanol and its various congeners, WY—214-9 (which is tropin-4-chlorbenzhydryl ether HCl), and azacyclonol. No consistent electrographic pattern was recorded for any of these compounds. It was suggested that psychopharmacological agents provide a means for eliciting a variety of neurophysiological patterns in contrast to the single pattern of induced convulsions. Furthermore, the type of neurophysiological alteration, as reflected in EEG synchrony and frequency patterns, was related to specified types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquilization, sedation, and decreasing agitation, while desynchronization and a shift to fast frequencies were associated with excitement, illusions, and delusional ideation. These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychiatric drugs have already been reported.* Psychopharmacology Evaluation Program The present psychopharmacology program, instituted in October 1959, was based on the studies described in the *See Fink, M. EEG and behavioral effects of psychopharmacological agents. In P. B. Bradley, P. Deniker, and C. RadoucoThomas (Eds), Neuro-psychopharmacology. New York: Elsevier Publishing Co., 1959. Pp. 441—446. 19 �preceding paragraphs. It is designed to answer the following questions: Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? Are there pretreatment clusters of psychiatric physiological and psychological variables related to the type of behavioral adaptation? And, are such clusters related to the type and degree of physiological change? Method. As an initial approximation, a double-blind drug study was undertaken in which subjects were randomly assigned to a fixed-dosage schedule. On the basis of our clinical experiences with various psychotropic compounds from 1954 to 1959, we selected three classes of drugs according to their patterns of EEG response. The agents selected were those with either predominant desynchronizing patterns, synchronizing and slowing, or minimal or no effect. After medical examination and after all other medications have been discontinued, patients referred for drug therapy are randomly assigned to treatment with a compound in one of these three classes. Convulsive and drug therapies are prescribed by staff psychiatrists on referral to the Department of Experimental Psychiatry. All treatment is administered by the Department staff, so that the experimental variables of drug dosage, route of administration, assignment to groups, etc., are readily controlled. All patients in the hospital are available for study. The mean duration of stay for patients is 7 months. After a testing period, all patients receive 40 cc. of liquid medication daily from individually labeled bottles. Dosages are increased in fixed weekly steps until a maximum dosage is achieved at 4‘ weeks. After 2 weeks on maximum dosage, retesting occurs. To date, 140 subjects have been referred, and 110 have completed the study period. Preliminary analyses of the data are now in progress. Behavioral Change. In a survey of the behavioral adaptations of patients receiving various agents during 1958— 59 a number of clusters of behaviors were developed. The typologies were based on the treatment response and on pretreatment psychiatric profiles. In the present study, the typologies are being tested and various measures of behavioral change are being studied. These include therapist referral questionnaires and 6-week evaluations; therapist’s ratings of patients on the Clyde Mood Scale; the Multidimensional Scale for Rating Psychiatric Patients, used for evaluations in interview by two research psychiatrists; the Lorr Psychiatric Behavior Rating Scales for ward behavior (AAMI: Level of Anxiety, Level of Activity, Mental Disorganization and Interpersonal Relationships); and patients’ self-ratings on the Johns Hopkins symptom checklist, the Chicago Attitude 20 Scales (self-perceptual scales devised to elicit attitudes of dependency, fight, flight, and pairing), and the Clyde Mood Scale. Neuropsychology. Psychological tasks have been viewed both as change variables and predictive variables. In convulsive therapy, changes in memory tasks, tactile perception, Wechsler—Bellevue, critical flicker frequency, figure-ground tasks, and tachistoscopic recognition of figures were related to the degree of induced neurophysiological change. For each task, the degree of decrement in task performance was found to be positiVely correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance on these psychological tasks also returned to pretreatment levels or higher, a betterment of performance ascribed to practice effect. Denial scores on interview, Rorschach determinants, F scale scores, language patterns after amobarbital, auditory feedback, and perception of the visual upright have been viewed as predictive indices of the behavioral changes following ECT. Psychopharmacological agents are now being used to assess these various tasks, their capacity to change with various agents, or their capacity to predict change. Electroencephalography. In the studies of convulsive therapy, the degree of EEG slowing was measured by counting the consecutive waves in selected samples. When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques. Electronic frequency analysis was introduced in August 1959. By measuring the pen deflection for various frequencies from 3 to 33 c.p.s. in 10-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are now obtained and applied. Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood-pressure response to Mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. Psycholinguistics Another series of studies in the Department has been devoted to formal language patterns. Following the studies of syntactic language patterns in convulsive therapy, other aspects of language were studied as indices of change in interpersonal behavior. Jaffe, after considerable exploration with various linguistic measures, suggested that type-token-ratios (TTR) of consecutive samples of dyadic speech might be a useful index. While TTR had previously been applied to written texts or to the language samples of individuals, Jaffee indicated that the two-person communication (dyad) was a more significant index of the state of the �interaction than were analyses of separate samples from the participants. Applying this technique to patients receiving convulsive therapy, changes in TTR mean and standard deviations were related both to the degree of induced EEG slow wave activity and to syntactic language patterns obtained in independent structured interviews. Speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (increased standard deviation). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents with a predominant synchronization pattern on the EEG exhibited a decrease in mean TTR and an increase in standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns (increase in TTR mean) and a decrease in variability of consecutive scores (decrease in standard deviation). Other language measures studied included distressrelief quotients, self-reference, and alteration in tense and person. It was suggested that these psycholinguistic measures are potent techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents. Sociological Studies In the course of these psychiatric programs, considerable interest was engendered in the family organization to which patients were returning. Also, the general problem of the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to the referral patterns, led to a series of population studies. In one study, education, age, place of birth, and score on the California F scale were significantly related to the type of therapy received and the utilization of adjunctive hospital services. Thus, patients who were older, poorly educated, had higher F scores, and were foreign born, particularly those born in Eastern Europe, were most likely to be referred for electroshock. These relationships were independent of diagnosis. Within the group of electroshock patients, the time of referral for ECT was also related to these factors. In a second study, duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors. For example, patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign born, and had the higher F scale scores. Younger, native-born, better educated patients who had lower F scale scores were hospitalized the longest. These relationships held true within treatment type and within diagnostic class. On discharge, older patients had the most favorable ratings. In ECT, patients rated as recovered or much improved had the highest F scores, least education, and were most likely to be foreign born. In another study of patient refusal of ECT, similar relationships were observed. These relationships are now under study in the Outpatient Department and in a trihospital comparative study. This study is assessing the populations of three hospitals, each of which has a prevailing patient population which differs from that of the other two. In each of the three hospitals, all therapies are equally available to all patients. The participating hospitals are the Menninger Foundation Hospital, whose population is primarily upper class and Protestant; the Massachusetts Mental Health Center, whose population is primarily lower class and Catholic; and the Hillside Hospital, whose population is predominantly middle class and Jewish. It has been postulated that the relationships mentioned in the preceding paragraphs reflect the influence of social background on psychological processes, such as habitual patterns of communication and modes of expression. The contribution of these factors to the pattern of mental illness and to the patient-therapist interaction are being investigated. Plans for Future Work Further growth and the direction of ensuing studies will depend upon the results of the investigations described here, as well as upon the growing institutional awareness that research is as much an integral part of the hospital’s operation and budgets as are patient treatment and staff training. 21 �Angler" the in Com-Leaf Chewing For many centuries, at least as far back as 1000 B.C., the inhabitants of the highlands in the Andean region have been habituated to the consumption of the leaves of Erythroxilon coca, a shrub growing in the Andean mountainsides at an altitude between 1,500 and 6,000 feet above sea level. At present, the production of coca leaves in Peru is estimated at 10 million kg. per year; approximately 40,000 acres of cultivated land are used, empIOying 25,000 workers (approximately 2 percent of the population devoted to agricultural tasks). The leaves of this shrub may be cropped on the second or third life-year, and the plant continues to produce for 20 years, yielding from three to six crops per year. The leaves are dried in the sun for several hours and then kept in cool, shadowed places until sold for human consumption. Marketing is essentially free, being only under the necessary controls for proper taxation and to avoid illegal exportation. Coca leaves are sold all over Peru, in any requested amount, from a few grams to several th0usand kilograms. Human consumption of the leaves, as such, is unrestricted. Industrial processing for the production of cocaine is forbidden by law, although frequent disclosure of illegal factories and cocaine rings calls for improved. methods of fiscal control. Coca leaves contain 0.60 to 1.80 percent of cocaine and 0.03 to 0.90 percent of ecgonine, according to calculations from different laboratories and varying also with the region and method of cultivation. Mention is also frequently made of the fact that coca leaves contain vitamin B1 (6 to 8 mg. per kg), riboflavin (10 mg. per kg.) and vitamin C (150 to 200 mg. per kg.). The high content of cocaine in the coca leaves becomes more meaningful if one realizes that the Peruvian people consume an estimated 9 million kg. of coca leaves per year, representing an average of 90,000 kg. of cocaine per year. The legally approved medical requirements of all the rest of the world amount only to 2,500 to 3,000 kg. per year. (This does not include the legally approved consumption in the United States. According to official information from Peruvian sources, the Coca-Cola Co. imports from Peru 140,000 kg. of coca leaves per year. These coca leaves are decocainized and the decocainized product is used in the manufacture of the Coca-Cola bevis turned obtained cocaine The as subproduct a erage. over to the proper authorities for legally approved consumption, the surplus being incinerated. The United States, thus, does not import or export cocaine.) The 90,000 kg. of cocaine contained in the 9 million kg. of coca leaves are consumed by approximately 2 million of the total 10 million inhabitants of Peru. These 22 million people represent 90 percent of all adult males in the highlands, 20 percent of all adult women in the highlands, and a large, but undetermined, percentage of male children over 12 years of age in the highlands. Consumption of coca leaves at lower altitudes is exceptional. The amount of coca leaf taken daily per individual varies from 10 to 100 gm. The average adult man takes approximately 30 gm. daily, but there are exceptional chewers who will take as much as 200 to 300 gm. every day. Although one speaks usually of “coca chewing,” the act of consumption may not properly be called chewing, at least in its complete process. The habitual chewer usually takes a handful of coca leaves and carefully cleans it from dirt, debris, and the main nerves of the leaf. He puts the clean leaves into his mouth and chews on them for 3 or 4 minutes until a bolus is well formed. Then he takes the bolus in his fingers and pricks it deeply and repeatedly with a pointed stick which carries an alkaline powder, to be described below. The bolus is thereafter put back in the mouth and kept there, under the cheek, without chewing, for about 1 or 2 hours, during which the “chewer” sucks on it while he goes about his business. Finally, the bolus is either discarded or 2 swallowed. Usually, this process is repeated with 10 gm. of leaves every 3 to 4 hours, with interruption of current activities for about 45 minutes in order to prepare the bolus, in what might be called a “coca break.” It is exceptional to find “chain chewing,” which brings up daily consumption to about 300 gm. per person. The addition of an alkaline substance to the bolus is a rather intriguing subject. The composition of this powder varies from region to region, ranging from plain quicklime to ground seashells or ashes of different plants. In exceptional cases, chewers do not use the alkaline subshow that evidence is to there but archeological stance, in one way or another it has been used for as long as coca has been known to man. One might speculate that this procedure increases the yield of alkaloid in the mouth, but there is conflicting evidence that this is a real fact. Gutierrez Noriega, one of the authorities on this subject, claims that the yield is increased by only 4 percent. Other explanations have been offered—improvement of taste, breaking up of the cellular membrane, etc.—but there is an obvious need for further research in this direction. *Prepared by Fernando Cabieses, Professor of Neurosurgery, San Marcos University, Lima, Peru. Mailing address: Talara 655, Lima, Peru. �It is generally accepted that cocaine is liberated in the mouth, being extracted from the bolus. Actually, that should not be a very difficult point to settle, but nonetheless different observers have reported very conflicting data. The actual yield, which should result from subtracting the amount of cocaine in the discarded bolus from the content of a similar amount of leaves, is difficult to obtain because of the rather frequent spitting, the swallowing of part or all of the bolus, and the different methods of titration. Published results vary from a 10- to a 90-percent yield. Also, whether the saliva contains free or bound alkaloid is not well known. At any rate, some form of cocaine is swallowed and, again, not much is known about its fate on reaching the stomach and intestine. How much of it is destroyed or further activated by the digestive juices is also in question. F urthermore, we have no information about how much is absorbed into the bloodstream or about the behavior of the gastric and intestinal mucosa exposed to bound or free cocaine. Cocaine absorbed into the bloodstream reaches the liver through the portal system, but no one really knows much about its metabolism at this level. There is some evidence that liver tissue will detoxify cocaine in vitro, and this has led to the thought that only a minimal amount of the ingested alkaloid actually reaches the general circulation. Here, again, careful evaluation is needed, since it seems that blood itself will partly destroy cocaine added to it in vitro. And, to complicate matters further, the results of determinations of cocaine blood levels in coca-leaf chewers are riddled with very difficult problems of interpretation, mainly because of the lack of appropriate methods of titration. Even if this information were available, absolute figures on cocaine blood levels would have but little meaning, owing to the lack of information on the level of neural toxicity of this substance. How high a blood level of cocaine can be tolerated without nervous effects in a normal individual, in a cocaine addict, and in a coca-leaf chewer is thus unknown. In spite of all these important questions, it is quite evident that some cocaine, or a cocainelike substance, reaches the nervous system of the coca-leaf chewers. This is easily concluded from clinical observation. Cocaine is perhaps the best antifatigue substance known to man. And it is a well proved fact that coca-leaf chewing is an excellent means of combating fatigue, both in industrial work and under experimental conditions. The possible differences between the effects of parenterally or orally administered cocaine and those obtained by chewing coca leaves, in normal as well as in habituated persons, and the action of cocaine and coca leaves on different types of fatigue remain to be experimentally evaluated. Cocaine decreases hunger sensation, admittedly through its central action. And this is also a very well known effect of chewing coca leaves, brought about either through a similar mechanism or, as commonly assumed, through local anesthetic action on the digestive tract. Whatever the mechanism is, coca-leaf chewing kills hunger. And this effect has an obvious social implication. It is said, on the one hand, that because of this action coca chewing leads to malnutrition. Other groups of sociologists claim the opposite; that malnutrition leads to coca chewing. And a third factor is brought into play when one is reminded that the coca leaves contain a fair amount of certain vitamins which are ordinarily lacking in other constituents of the usual diet of the dwellers of the high Andes. A pharmacological problem thus becomes a problem of socioeconomics and of social anthropology. Malnutrition, poverty, low culture, and coca chewing all go together, and at times it becomes almost impossible to disentangle one from the other. And if to this mixture we add high altitude, the problem becomes more and more intriguing and complicated. One cannot but wonder why, if the coca tree is only cultivated at altitudes lower than 6,000 feet, the habit of chewing coca leaves is found mainly above that level. Very few communities in the coastal area show the habit, which is mainly concentrated in the high altitudes. Futhermore, the habit of chewing coca leaves, a habit carried on continuously for many years, is usually abandoned when the individual is permanently transferred to lower geographical levels. And one cannot dismiss the frequent claims of travelers and of cultured dwellers of the highlands regarding the beneficial effects of coca tea or coca chewing against the acute symptoms of mountain sickness. Unfortunately, no experimental evaluation has been made of these observations, which have been subject to much literary discussion in years past. It is true, of course, that high altitude is only one of the factors of a very complicated problem seen through the narrow light of an off—habit, on-habit proposition. But only a careful experimental approach will tell us what the real importance of this factor is, especially in the presence of a drug with as many unpredictable pharmacological actions as cocaine. It is commonly accepted that cocaine has a deleterious effect on the central nervous system when taken chronically. And it is only logical that this concept has been used in the interpretation of the mental functions of the coca-leaf chewers. This assumption, however, may not be entirely justified, since most of the alleged “facts” lack experimental verification. The so-called effects of chronic consumption of coca leaves are always related to the other factors of the socioeconomic complex sur‘ rounding the coca habit; poverty, malnutrition, low culture, poor educational facilities, high altitude, etc. And although coca may be an important determining cause, the alleged low mental output of the Andean dweller should not be blamed only on this factor, as it frequently is. The appraisal of chronic coca-leaf consumption com23 �pletely separated from its socioeconomic constellation is, however, very difficult to achieve. The acute action of coca-leaf chewing on mental processes also lacks sound and thorough experimental evaluation. A few experiments suggest that the effects are quite different in habituated and nonhabituated individuals, as would logically be expected. The extent and mechanism of these differences remain to be determined. There is also some indication that muscular activity during the process of coca chewing basically alters its mental effects. It is said that if the individual is resting, daydreaming and pseudohallucinations ensue, but that these mental effects can be prevented by physical activity. These observations need further experimental study, but this type of psychopharmacological study would meet with great obstacles in the markedly introvert personality of the Peruvian Indian, his resistance to participation in experimental studies of this type, the frequent language difficulties, and the lack of basic psychological and social anthropological studies in the Andean milieu. It is thus evident that there are many questions to be answered concerning the pharmacology of coca leaves and the socioanthropological aspects of this widespread habit. Differences between the chronic or acute effects of parenterally administered cocaine (a subject on which much remains to be settled) and the chronic or acute effects of coca-leaf chewing should be investigated. The 24 former leads to a rather well known condition: cocainism, i.e., addiction to cocaine. The latter leads to a habit, cocaism, which apparently does not follow the same psychopharmacological pattern, since a simple change in socioeconomic status or a change in geographical milieu leads to its spontaneous discontinuance; there is not a clear tendency to increase the dosage, as there is in cocainism, nor are there any evident withdrawal symptoms. Are these differences due only to the route of administration of cocaine? One certainly can provoke a clear syndrome of cocaine addiction in experimental animals (dogs, monkeys) by chronically administering cocaine by the parenteral route. But so far it has not been possible to obtain similar results by oral administration of this drug. Research Opportunities There are many stimulating areas for research on cocaleaf chewing. Facilities for research in this field are potentially available at the Brain Research Center of the Armed Forces of Peru, of which I am director, and at the American Hospital in Lima, which has a good neurological and neurosurgical service. Investigators who wish to explore the possibility of conducting research related to coca-leaf chewing, or who wish to obtain further information, are invited to write to me at the following address: Dr. Fernando Cabieses, Talara 655, Lima, Peru. �Publications Tranquilizing and Anti-Depressant Drugs. Veterans Administration Department of Medicine and Surgery Medical Bulletin MB—6, September 12, 1960. Washington, D.C.: U.S. Government Printing Office. This 19page bulletin is by Eugene M. Caffey, Jr., Leo E. Hollister, Alex D. Pokomy, and Jesse L. Bennett, all of whom are members of the Executive Committee of the Veterans Administration Cooperative Chemotherapy Studies in Psychiatry. It presents a general summary of current practices in the use of tranquilizers and antidepressives in psychiatry and in nonpsychiatn'c practice, and includes tabulations of generic names, trade names, and range of total daily dosage of drugs for outpatients and for hospitalized patients. The price of the publication is $0.15. Copies should be ordered from the Superintendent of Documents, U.S. Government Printing Office, Washington 25, DC. Agressologie, an International Review of Physio-Biology and Pharmacology Applied to the Efi‘ects of Agression, is a recently established journal that should be of interest to psychopharmacologists. In the preface to the first issue, the title of the journal is explained: The commonly understood meaning of the word aggression is applied to the action of agents which harm the living organism by attacking it abruptly (from the outside or from the inside), including cold, heat, lack of air, surgery, disease, poisoning, and other causes of physiobiological disequilibrium which results in “more or less profound and lasting disturbances” in cellular metabolism. The purpose of the journal is to synthesize and integrate contributions which many basic disciplines are making to the study of the effects of “aggression” as previously defined, and to the prevention and treatment of such effects. The journal is being published and edited by Henri Laborit, of the H6pital Boucicaut, 78 rue de la Convention, Paris 15, France, and P. Huguenard, of the Hopital de Vaugirard, Paris 15, France. Metabolism of, and Analytical Methods for, Phenothiazine Derivatives Used in Psychopharmacology; A Selected Annotated Reference List, compiled by the Scientific Information Unit of the Psychopharmacology Service Center. This list of approximately 65 references is made up primarily of articles concerned with analytical methods for the detection of phenothiazine derivatives used in psychopharrnacology, together with a few more general articles on the metabolism of these agents. The annotations are factual summaries of the articles, and are not evaluative or critical. The list is arranged chronologically. Copies may be obtained by writing to: Dr. Lorraine Bouthilet, Head, Scientific Information Unit, Psychopharmacology Service Center, National Institute of Mental Health, Bethesda 14, Md. 25 U. S. GOVERNMENT PRINTING OFFICE: 1961 0- 580375 �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experimental Psychiatric Programs at Hillside Hospital, Psychopharmacology Service Center Bulletin, January 1961 (U.S. Department of Health, Education, and Welfare) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-009 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Article based on Hillside Hospital annual report. One of nine articles in the Psychopharmacology Service Center Bulletin: NIMH-sponsored collborative study of phenothiazine treatment of acute schizophrenic psychoses; NIMH grant support for early clinincal drug evaluation units; Research conference on drugs and community care; Confernce on informaiton needs of psychopharmacologists; The psychopharmacology research unit at the Downstate Medical Center, Brooklyn N.Y.; Experimental psychiatric programs at Hillside Hospital; Coca-leaf chewing in the Andes; Publications. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/9cd1485c72c87cfe41a9b822584a53cf.pdf 399d53acd860a7f8f327c824ea2685e0 PDF Text Text 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 phenomena that may be apparent during examination of patients with AMONG 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.1 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 mislocalization of one of two stimuli simultaneously applied to difi’erent 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. Jofie (Hinsie, L. E., and Shatzky, J.: Psychiatric Dictionary, New York, Oxford University Press, 1940) from the Greek 3w, out of ; mind, body, and al’dfiww, perception by the senses. �2 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 dis— closed bilaterally dilated ventricles and moderate “cortical atrophy,” particularly in the left temporal lobe. PsychiatricStatus—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 difficulty 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 Stanton—(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 touched. 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 disregarded 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. (17) 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. Comment—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. CASE 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 difliculties in perception of touch and pinprick stimuli, as described below. Psychiatric Statue—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. Anosognosia 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. 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 0mment.——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. CASE 3.—R. M., a 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 euro'logic Examination—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 StaWs.——-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 �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 difficulties 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 Statute—(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. ,Exosoimestheyiat—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 simultaneous 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 COM MENT 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 oneexamination. 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 Influencing Exosomesthesia.—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 everycase 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 Effect of Simultaneous Stimuli: 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. (6) 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 nexosomesthesia. 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 and displacement. Relation of Exosomest‘hesia to Extinction, Obscumtvian, and Displacement—In our experience, whenever exosomesthesia has been observed, the phenomena of extinction, obscuration, and displacement are also present. Exosomesthesia, however, 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. (13) �9 Relation of Exosomesthle'sia to- Body I wage—It might be said that exosomesthesia is a pathologic extension of the body image. The normal person is continually of cites the Head of examples For this boundaries example, the image. extending 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 disturbin identification difficulties show do who be not that noted should it patients ance, 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 of manifested who dis-placement A difficulties. 3) (Case patient position-sense sensation into extrapersonal space did not make errors in routine tests of position made by observations with is consistent previously This in extremities. the sense 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 the when As functioning reflected. rule, of a the are nervous system dysfunctions 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. of the cerebral diffuse disease, with phenomena in others and these In patients, 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. Ben7 described a case in which the clinical course was reflected in a Nathanson and der 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 occasion— ally demonstrable elsewhere, is most apparent in examination of the functions of the hand. Exosomesthesia in the Normal Child.—-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 frequently 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 � Dublin Core The Dublin Core metadata element set is common to 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. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-6b-009 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> 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 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/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/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/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/e014a6afb9c7514b91c71748685499ca.pdf 9f4aefec5e8c130c970f3538c3603299 PDF Text Text ELECTROENCEPHALOGRAPHIC AND BEHAVIORAL EFFECTS OF TOFRANIL Max Fink, M.D. Reprinted from “CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL” Volume 4 Special Supplement, 1959 McGill University Conference on Depression and Allied States, Montreal, March 19-21, 1959 �ELECTROENCEPHALOGRAPHIC AND BEHAVIORAL EFFECTS OF TOFRKNIL MAX FINK* With the rapid increase in the number of potential psychopharmaceuticals, the need for screening technics has become more acute. In studies of the electro— graphic patterns of convulsive therapy, the hypothesis evolved that behavioral changes induced by new compounds could be related to their neurophysiologic effects as reflected by the type and degree of electrographic change (1, 2). This suggestion followed a similar one by Wikler (3) who stated that “regardless of the nature of the drug administered, shifts in the pattern of the electroencephalogram in the direction ofdesynchronization occurred in association with anxiety, hallucina— tions, fantasies, illusions or tremors, and in the direction of synchronization with euphoria, relaxation or drowsiness.” Studies with various psychotropics (4) and anticholinergic hallucinogens (5, 6) supported such a relationship. It is the purpose of this preliminary report to describe initial behavioral and electrographic observa— tions with Tofranil'l, a new psychopharmaceutical, and to relate these observations to the neurophysiologic—adaptive hypothesis of the mode of action of physiodynamic therapies (1). Methods Two types of studies were undertaken in an open—ward, voluntary hospitalized population. In 28 acute experiments, consecutive patients referred for physiodynamic therapies were tested in the EEG laboratory at various stages of treat— ment. Tofranil solution (10 mg/ml) was administered intravenously at a set rate (1 ml/4O sec.) until electrographic or behavioral changes became prominent, for a total of 40—125 mg (0.5—mg/kg). Behavioral observation and electrographic record— ing continued for one to three hours. A second group of 16 patients manifesting depressive, withdrawn or retarded behavior were referred by their therapists for pharmacotherapy. The patients received daily oral Tofranil, 75—250 mg. Behavioral observations and EEG recordings were made prior to and during treatment. Patients ranged in age from 17 to 58, and were diagnosed as suffering from schizophrenia, manic-depressive and involutional depressive psychoses, and psychoneuroses. ' Observations I. dcute Studies: On acute administration, there was an initial restlessness, associated with dizziness, dry mouth, “faintness,” nausea, and on four occasions, vomiting. These symptoms persisted for 10—20 minutes, and were accompanied by lassitude, heaviness of the extremities and eventual drowsiness. Heart rate was un— changed or slowed. Subsequently, subjects were relaxed, quiet and disinclined to activity, even when returned to their ward. The electrographic patterns accompanying these behavioral changes were initiated by a gradual decrease in voltages during the injection. By ten minutes, the per cent time alpha and mean alpha voltage had been halved. In four patients with moderate amounts of beta activity, such activity increased in voltage and low behavioral with association lassitude, time. minutes, By in cent twenty per voltage (to 50 microvolts) random theta frequencies (5-7 cps) appeared (Figures 1 and 2). *Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, 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. Public Health Service; and by a grant from Geigy Pharmaceuticals. The technical assistance of Mrs. Hannah Mosquera in EEG recording is gratefully acknowledged. ’rTrade Mark. �Special Supplement pre-d rug WWW WWW LF-LO 8167 DEPRESSION AND ALLIED STATES W W after 75 mg after 30 minutes WNW RF-RO wWWv«w¢wanMV‘ I‘VWW LAT-LF RAT-RF k/\_Jl/L,Ah/L JL/\,JA/A,_JL/\, =72 #2638Hh WW W WWW HR after 45 minutes HR 50 Mv|—_l SEC. =74 HR =72 1 Fig. 1 Effect of intravenous Tofrinil on EEG delta (female, aged 46) pre—drug LF-LO «wwNWVHMWwNmN RF-RO WWW LAT-LF W W after 100 mg after 30 minutes hv after 30 minutes “NV“WJWWWWVVV¢ UWMerVkmeV4 WWW WWW RAT-RF LF-RF LPT-LO 0-0 EKG plvltul HR=84 #2138HH W MymMA/VW-WVN MWVWVWMN‘ HR=108 50/.1vl—__J 1 Fig. 2 HR=84 SEC. Effect of intravenous Tofrinil on EEG delta (male, aged 37) HR=9O �8168 Vol. 4, 1959 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL In six records with post—convulsive delta activity, there was a marked decrease in voltages and per cent time of slow wave activity. These electrographic patterns persisted for half—an-hour to two hours (Figure 3). There was considerable individual variability in the EEG response. In patients who received 100 mg or more of Tofranil, EEG and behavioral changes were Observed in all but three. In six patients, dosage Of Tofranil less than 50 mg were not associated with either EEG or behavioral changes. 2. Chronic fldministmtion Studies: Sixteen patients, manifesting depressive symptoms with varying degrees of insomnia, anorexia, withdrawal, and agitation, have received Tofranil medication for four weeks or longer. Medication was given in oral divided doses of 100—250 mg per day. Behavioral changes generally appeared during the second and were maximal during the third week of treatment. LF-lO after 100 mg pre-drug W W WW W W WWW RF-RO RAT-RF LF-RF . LPT-LO 0-0 #2348 after 30 minutes after 15 minutes iv HR=86 HR=84 ,_~,\_M, amw HR=75 50 uv HR=72 l_ 1 __ SEC. _J Fig. 3 Effect Of Tofranil on EEG delta (female, aged 41: 24 hours post convulsion no. 7) The most prominent behavioral adaptation was euphoric denial, which was noted in eight patients. The depressive attitude was nO longer apparent. They participated more fully in ward activities, complained less of somatic symptoms, and denied, minimized or displaced their illness on inquiry. Agitation decreased, and complaints of insomnia became less. It became increasingly difficult to discuss significant life relationships as the patients pressed for an early discharge from the hospital. In three patients somatization and restlessness increased, and depressive affect persisted. In two of these, restlessness, insomnia and vomiting led to cessation of therapy. Sweating increased in most patients, but became a focus of attention in these subjects. NO change in symptoms were noted in five patients after four weeks of therapy. While no serious complications of therapy were noted, nausea, increased sweating, vomiting, dryness Of the mouth, restlessness and excitement, and increasing �Special Supplement DEPRESSION AND ALLIED STATES $169 insomnia were reported. These were prominent early in therapy, and except for the vomiting and restlessness, did not limit the treatment. In three subjects medica— tion was initially administered parenterally without untoward effects. Abnormal motor patterns and seizures were not noted in these patients at these dosages. Electrographic studies on chronic administration showed minimal changes. Voltages became lower and record modulation became poorer. Well—defined fast activity became more prominent, and in four subjects low-voltage theta (5—7 cps) activity was noted. Discussion These observations indicate that Tofranil is an active central nervous system agent in man, both on oral and intravenous administration. The neurophysiologic effects are manifest electrographically as desynchronization of rhythms and a shift-in frequency spectrum to the slower range. In depressed retarded subjects, Tofrinil administration is associated with such behavioral changes as decreased depressive affect with increased participation in ward activities, increased use of denial patterns (7) and occasional excitement. In comparison to our previous experience with other physiodynamic therapies, the behavioral and electrographic patterns of Tofranil are most like those seen with central anticholinergic agents. We observed desynchronization of frequencies, with an increase in theta activity, to be prominent with experimental anticholinergic compounds such as diethazine and benactyzine* (5, 6). In those studies, electro— graphic desynchronization was associated with behavioral alerting, excitement and illusory and hallucinatory activity. On Tofranil administration, similar electrographic patterns of desynchronization were observed, accompanied by euphoria and increased ward participation. While we have not observed hallucinatory activity at our dosage ranges, Lehmann (it a]. (9) have reported hallucinations and hypomanic excitement in 7 of 84 patients receiving Tofra‘mil. In earlier reports, Wikler (3, 10) suggested that the electrographic patterns of synchronization and desynchronization reflected neuron systems distinct from those neuron systems subserving such functions as ‘sensation,’ ‘ideation’ and ‘level of awareness.’ While these systems were frequently interlocked, dissociation between EEG pattern and behavior was observable under a variety of drug—induced states. In our earlier studies we were impressed that the electrographic and behavioral patterns seen after induced convulsions, anticholinergic compounds and phreno— tropic agents were directly related. On acute administration of Tofranil, however, electrographic desynchronization was associated with clinical sedation. These studies are consistent with Wikler’s suggestion. These observations permit the classification of the neuropharmacologic activity of Tofrinil in the central nervous system as predominantly anticholinergic. However, we have noted aspects of the electrographic and behavioral patterns reminis— cent of increased cholinergic activity. These include the electrographic shift to slower frequencies and sedative, euphoriant behavioral effects. Such observations suggest that there may also be an effective degree of central cholinergic activity. Summary Intravenous administration of Tofranil in 28 voluntary, open—ward psychiatric patients elicited electrographic patterns of desynchronization and an increase of theta rhythms, associated with behavioral alerting, relaxation and lassitude. Chronic administration of oral Tofrinil in 16 depressed and retarded psychiatric subjects elicited behavioral adaptations of euphoric denial in eight, restlessness 'A recent report by Abood and Meduna (8) relates the behavioral. improvement in depressed patients with a new central anticholinergic agent which has Similar electrographic patterns. J B-329, H ” �8170 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol.4,1959 and somatization in three and no change in five. During the fifth week of adminis— tration, electrographic desynchronization was manifest. It is concluded that Tofranil is an active central nervous system agent, with a Spectrum of activity most like experimental anticholinergic hallucinogens. The theoretic significance for neurophysiologic-behavioral constructs is briefly discussed. Résumé Nous avons étudié la relation existant entre les efiets du Tofrinil sur le com— portement et sur le tracé électrographique, chez des patients atteints de psychoses aigués ou chroniques. Mét/zode Cas aigus: les patients retenus étaient examinés avant le traitement physioin— celui—ci. Tofranil Le de administré était stades divers ainsi en qu’a dynamique, jections intraveineuses d’une solution a 10 mg/ml, jusqu’a un total de 40—125 mg (0,5_2,5 mg/kg), concurremment avec des examens électro—encé—phalographiques. Cas chroniques: des patients présentant de la depression et un ralentissement du comportement étaient mis a la dose de 75—250 mg de Tofrz'mil par jour. Les examens encéphalographiques et du comportement étaient effectués avant le début du traitement, et a intervalles d’une semaine au cours de celui—ci. Observations 1° Cas aigus a) Comportement: au cours de l’administration du medicament, sur 28 cas, nous avons noté des nausées, des vertiges et de la faiblesse. Quatre fois des vomissements sont survenus. Le rythme cardiaque est demeuré inchangé, ou s’est ralenti. En 10 minutes ces symptOmes diminuaient d’intensité et les patients se détendaient. b) Electro-mcéphalogmmme: pendant le traitement, il y a eu une diminution du voltage dans toutes les fréquences. En 10 minutes le pourcentage de temps alpha baissait et les voltages tombaient a la moitié de leurs valeurs initiales. Chez les sujets a activité béta (4 cas), celle—ci devenait plus importante. Au bout de 20 5—7 de lentes ondes des minutes, cps, atteignant 50 microvolts, apparaissaient ici et la. Dans les enregistrements avec activité delta postconvulsive (6 cas) nous avons noté une baisse marquee des voltages et des pourcentages de temps danS l’activité des ondes lentes. Ces tracés électrographiques persistaient pendant M-Z heures. 2° Cas chroniques a) Comporz‘emem: seize sujets ont été observes a ce jour. Les effets~initiaux de la medication furent des nausées, deS vomissements, de l’agitation et de l’excita— tion, une exagération de l’insomnie et une transpiration tres augmentée dont se plaignaient les malades. Le traitement a été interrompu dans deux cas avec agita— tion. Des 13 autres sujets, 6 ont vu leurs symptOmeS de depression S’amender et ont pu reprendre une plus grande activité; ils ont pu étre renvoyés chez euX, ou ont été prévus pour un prochain licenciement. Les autres n’ont guere présenté de chan— a la soumis été n’ont leurs thérapeutique que pendant dans symptOmes, ou gements un temps trop court. &) Electra—encéphdlogmmme: Les enregistrements obtenus pendant 1e traite— ment n’ont montré que peu de modifications. Leur modulation était appauvrie et leurs voltages abaissés. Une activité rapide bien caractérisée a pris de l’impor— 5—7 de a bas activité noté voltage 4 malades chez une cps. nous avons tance; Conclusion: 1° Chez les psychopathes, les effets electrographiques du Tofrinil sont une Ces a tracés has lentes d’ondes activité voltage. suivie une désynchronisation, par a alors ressemblent les traités, et dans chroniques moins cas prédominants sont ceux que l’on Obtient avec la benactyzine. ' �Special Supplement DEPRESSION AND ALLIED STATES 2° En ce qui concerne le comportement, nous constatons une $171 augmentation de la motilité, un changement dans l’humeur et un malade plus éveillé. 3° Ces observations concordent avec les hypotheses neuro—physiologico—adaptatives expliquant 1e mode d’action des traitements physiodynamiques des psychoses. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Fink, M.: Hillside Hosp. J. 6:197, 1957. Fink, M.: Alteration of brain function in therapy, in Kline, N. S.: Psychopharmacology frontiers, Boston, Little, Brown, 1959, pp. 325-333. Wilder, A.: J. Nerv. & Ment. Dis. 120:157, 1954. Fink, M.: EEG and behavioral effects of psychopharmacologic agents. Read at 1st International Congress of Neuro—psycho—pharmacology, Rome, September 1958. In press. Fink, M.: A. M. A. Arch. Neurol. 8: Psychiat. 80:380, 1958. Fink, M.: Electroencephalog. 8t Clin. Neurophysiol. 10:776, 1958. Weinstein, E. A., and Kahn, R. L.: Denial of illness: symbolic and physiological aspects, Springfield, 111., C. C. Thomas, 1955. 'Abood, L. G., and Meduna, L. J.: J. Nerv. & Ment. Dis. 127:546, 1958. Lehmann, H., Cahn, C. H., and de Verteuil, R.: Canad. Psychiat. A. J. 3:155, 1958. Wikler, A.: Proc. Soc. Exper. Biol. & Med. 79:26], 1952. General discussion from the floor (summarized) The question was asked whether administration of a large dose of Tofranil once a day would not be as effective as multiple dosage. This would of course be a tremendous saving in the time of the nurses involved. In answer it was stated that Tofrénil is best given not in one large daily dose but in a series of small doses such as 2 tablets t.i.d. It was also brought out that Tofranil has a tremendous influence on transference phenomena and that these can be analyzed in dreams and symbolisms. While such observa— tions have been made, definitive results must await an extensive study. Another discussant asked what is the difference between the effect of barbiturates and anticholin— ergic drugs on the EEG. One discussant felt that the EEG was a poor tool, since it could be modified in only two ways, synchronization or desynchronization, and firm conclusions should not be drawn from such changes. He therefore felt that analogies between diethazine and Tofrénil were dubious and that nausea was not a specific effect of Tofranil. He wondered if EEG changes would always exist in the absence of nausea, and felt it important to correlate EEG changes with clinical changes. In replying to these comments, Dr. Fink stated that he considered Tofrfinil an anticholinergic drug because of its similarity to other anticholinergic drugs in regard to its EEG patterns. Dr. Fink recalled that Dr. Sigg’s paper had also indicated that Tofrfinil was an anticholinergic drug. Many anticholinergic compounds appear to have rather specific central effects, and some are also experimental hallucinogens. In his experience, barbiturates produce not desynchronization, but rather synchronization. This becomes clear if the factors of dosage and time are considered. Thus the initial effect is hypersynchronization; if the drug is continued, sleep is of course produced and the initial effect disappears. The author replied to the criticism of his use of EEG. He agreed that it is a poor tool in many respects, but that it is possible to analyze EEG records for synchronization, desynchronization and fre uency shifts. One obtains different patterns with different agents even in the same patient. Dr. Fink explained that he was making a long—term study, and hoped that more conclusive data could be offered at a later time. ��’*” EEG uni nahtviernl striat: .2 nu nah, Torranil 3...». * 2h: rulltion hotvtcu thc filcetragrcphie and behaviortl «Itcctt at retranil in velunthry paychintrie pationtt wan datarnincd in taut. and thrsnic ntudioa. _ Kathodnr latto: Ganaaeutiva patiants rcturrod for phytiodynunic thtrupiol ttntod not: prior to and at yariatu itngal Of therapy. With 330 rocordinc, retruail nelution (10 ng/oc) was adminintorud intruvanouuly for I total of h0~125 I; (0.S~2.5 ng/ks). chronic: Pttiontp annitslting duprctuivo tad rotnrdod bchlvior aura plnoud an rogiucua o: 7S~2oe lg renunil daily. EEG oxnniuntionn and hchuyiornl obsothtiaus war. and. prior to and It weekly int-yttla during troutncnt. Oblarvntianus 1. Acute Stadielt a. Buhfiyiora Baring drug zduiniltrutiou in 25 albjoata, 3.13033, EIuIIncoo in! Ionknoan wort rcpcrtud. Viniting ocearrcd an tour oecaaicnc. fictrt rgto was Inshtngod, tr nluvcd. In 1&3 Iinutca, th... aynptoun were 103:, und puticnta war. roluxod. b. EEG: During ndninistrttion thtrc was a dccruuuc in yoltagc a: all trcquonans. By tan minuttu, thc par cant tint alpha ducronsed, lad valtngea were halt at thc initial values. In pationts with sodurnto anonntn of but. uctiyity (h), auch activity hocuno morc yroxincnt. fly taunty mintha, slow It?! nativity of k-7 apt, up to 50 uiarovclta upponrnd, rundouly. In roenrd: with poat~eenvulaiva daltg activity (6), thert in a nurkcd docrotio in voltngcn and in par tent tin. of claw wave nativity. tutu: electraartphic pattcrn: pcraictcd far 2. Chrunia I studioat _Bchnvi¢rn i. rittouu patient: hay. 2 hours.\ boon under ebccrvutiou to data. -Iai -n a van a at nodicntian inaludod nanaou (a) vaulting (a), roatlouuuocn lad axaitantnt (2), insomnin oxaggorntod (35, And aonplainta o: oxacstivo uwiating (11). In tha tun pationtn with roitlsasnoal, nedic;~. tit» at: diaoontinund. a: the thirtaon pntionts, nix Innitcttni In 3110'iatiun or symptoms a: doprnulion with incronnad pnrtiaipation in activitics, Ind hava Bean dilahargad or rccaunoudcd tar diuehnrga. Th: rcaaiuing buy. nhaun littlc engage in a tan. (3) at thcrapy ht! baan patitntl udniniltorud for too thort a ptriod (hgfp 3:. mm: In neat-d. «ht-sin“ during hottmnt, tiniaul change: taro obIcrvoa. fieduiation a: rucordu was poortr with lcwor yoltncct. H011 dutinod rant activity bee... not. proninont; tad in tour subject. 10v waltago 5~7 cps activity VI! noted. conclusion. Ll Sloetrozrtphic extactn o: Totrunil in payehiutriu patiuntc are thus: of duayuehroniantion, tullowod by law voltngo slaw wtva nativity. * Iron thc Duplrtuant at magazinpnttl Payehintry, nilluidc Rhapital, glig ggk" L010 301% �.2th¢to pattorna arc 1.0: proninnnt an chrcnie udntnintrntiau, tad rononblo that. or bnunctynin0¢ 2) Dihtviornl offset: arc that; of alurtiuc, Iced ch¢n¢a and inurilnnd motility. «autistant with fiha nauraphyszolagtau :Athivu hypathuntu at :h: act. at action or physiodyuania thcrupion 3) Thnss abaorvution¢ nae of paychoucu. � Dublin Core The Dublin Core metadata element set is common to 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 and behavioral effects of tofranil. Can Psychiatr Assoc J. 1959;4(Suppl):166-71. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-38a-004 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> 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 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Volume 4 Special Supplement, 1959 McGill University Conference on Depression and Allied States, Montreal, March 19-21, 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/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/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/f8b5cf3cf6b847561379d21a8181ceef.pdf 550c4683b921dafa008583e1e9dd5aff PDF Text Text ��COPY Clinical Release PRODUCT Combination of 'Thorazine' and Diparcol (SKF #1026-A) Diparcol alone 'Thorazine' mg/cag. ca . FORMULAS 50.0 mg. H01 2.0 Magnesium.Stearate Lactose 200.0 -__- ---- mg. mg. 300.0 mg. is. Restricted Medical Utility Studies - Dr. Herman Denber TOXICITY Acute Intravenous Toxicity The intravenous acute toxicity of a combination of SKF #1026—A ('Diparcol') and 'Thorazine' in the ratio of 5:1 was determined. Intravenous LD50'S in male mice (CFl) were determined for SKF #1026-A, 'Thorazine' and a combination of SKF #1026-A and ‘Thorazine' in the ratio of 5:1. The mice were observed for a 2h hour period, at which time all surviving mice appeared — normal. Combination significantly more toxic than SKF #1026-A (T.R. = 1.2) 'Thorazine' ngt_significantly'more toxic than combination. (T.R. 'Thorazine' significantly more toxic than - 1.36) SKF #1026-A (T.R. = 1.13) acute intravenous toxicity in mice of a combination of 'Thorazine' and ‘Diparcol', in the ratio of 1 part of 'Thorazine' to 5 parts of 'Diparcol', did not differ significantly from that of 'Thorazine' alone. Such a comparison is valid since the slopes of the toxicity curves are parallel. The combination is significantly more toxic than 'Diparcol' alone, but the comparison is subject to criticism.that the slopes of the toxicity curves are not parallel. The December 9, 1955 �DIPARCOL In answer to your request an attempt has been made to find data comparing the anticonvulsant activity of Diparcol (Diethazine, SKF #1026) with.that of other phenothiazine derivatives: Phenergan (SKF 1&98), 'Thorazine‘ (SKF 2601), Promazine (SKF 3h06), 'Compazine' (SKF h657), SKF 5277 and SKF 5116. No such studies have been done in our laboratory. The only SKF lab report on Diparcol gives its toxicity as LDSO * 31.2 mg/Kg I.V. as compared with 22.9 mg/Kg I.V. for 'Thorazine'. Balestrieri (1955) compared Diethazine, Phenergan, Parsidol and chlorpromazine with respect to their protective action against electroshock and Metrazol seizures in rabbits. Phenergan and chlorpromazine showed no anticonvulsant action against electroshock seizures; Diethazine, 5 mg/Kg I.V. protected 2/5 animals and at 10 mg/Kg I.V. 3/5 animals. Parsidol protected 2/5 animals at both doses. These results confirm SKF data obtained using maximal electroshock seizures in mice which showed no anticonvulsant activity for SKF lh98, 2601, h657 or 5116. SKF 3h06 did protect mice against seizures; the ED§Q was 155 mg/Kg p.o. SKF 5277 also demonstrated anticonvulsant activity with an oral ED50 of 71.0 mg/Kg. , Balestrieri snowed chlorpromazine to be Metrazol seizures. Phenergan was inactive inactive in protecting at 5 mg/Kg I.V. rabbits against but a 10 mg/kg I.V. protected h/5 animals. Diethazine protected h/5 animals at 5 mg/Kg and 5/5 at 10 mg/kg. ParSidol protected 5/5 animals at both doses. ’No similar SKF data are available. The experiments of Anticonvulsant action and molecular structure of phenothiazine derivatives. .krch. Int. Pharmacodynam. 103:1-11, 1955 Balestrieri, HLM:pz hc A. �COPY- PHARMACOLOGY REPORT November 8, 1956 10-(2'-Diethy1aminoethyl)-Phenothiazine Hydrochloride 0R (Diparcol) SKF No. 1026-A Compound: Code No. Lot No. 99 Structure: )W ii /” '\\ K\//h\§v/\ EV 1 9H2 l c H2.N-( 02H37~2 mignzim.R.T.Cmma' Tested for: Dose Range - .HCl Mmda Studies in mice after intravenous administration (11/10/55) Observations Dose rug/kg side effects 2.5 No 5.0 2/2 slight depression, loss of pinnal reflex 2/2 ataxia, sl. depression, loss of pinnal reflex, 'Thorazine' walk. 2/2 ataxia, marked depression, dyspnea, 'Thorazine' walk, loss of pinnal reflex. 10.0 15.0 6/6 clonic convulsions, apnea, prostration, ataxia after recovery, hypotonicity, 3/6 dead 2/2 clonic convulsions, apnea, prostration, ataxia after re- 20.0 25.0 . cover h otonicit Note-—all animals recovered from.prostration within 60 minutes.. Summary: exhibited 'Thorazine'-like side effects after intravenous administration in mice. Slightly higher doses were required to produce depression than with 'Thorazine' and the depression produced was of shorter duration. SKF #1026—A 'Thorazine'-like Activity: Charge: Biological screening GW/IB/m/mh �LILLY LABORATORY FOR CLINICAL RESEARCH INDIANAPOLIS GENERAL HOSPITAL INDIANAPOLIS 7, U. S.A. December 29, 1955 Max Fink, MOD. Hillside Hospital 75-59 263rd Street Glen Cake, New York Dear Dr. Fink: In answer to your recent request, Storey et a1. (Antibiotic Med. & Clin. Therapy, 2c258, September, I§§STI though they do not report electroencephalogram findings, do discuss the behavioral effects of cycloserine. There have been no publications, to my knowledge, reporting EEG findings in patients receiving 'Seromycin' (Cycloserine, Lilly). Veterans Administration hospitals have been doing EEG tracings but their reports have not yet been published. They will probably present their data at the Veterans Administration Conference on the Chemotherapy of Tuberculosis to be held in St. Louis in February. do be not we of further please may assistance, any If hesitate to w rite us. The Very truly yours, f th, M.D. ri Clinical esearch Division R. mlw 18760EIGHTIETH ANNIVERSARY-1956 �TELEPHONE: LEHIBH Form 90a-Adm. 4-1300 State of New York Department of Mental Hygiene MANHATTAN STATE HOSPITAL JOHN H. TRAVIS, M. D. DIRECTOR IN Ward’s Island, New York City 35, N. Y. ANSWERING REFER To ______.______._____ Dr. Max Fink June 20, 1957 Hillside Hospital 75-59 263rd Street Glen Oaks, N. Y. Dear Max: your findings on I should like very much to include Chloram on I that writing the final in paper the 'Diparcol' me send Could of you Treatment Depression. promazine-Diethazine diethazine I.V. of the effects in general, note indicating, a brief on the EEG? Were there any concomitant psychological effects? of "personal reference under the of note I will course, this, communication." Many thanks. Sincerely yours, [/7 HD:SS Herman C. B. Denber, M. D. Director of Psychiatric Research �4;:- x} June a?) 1957. Dr. Hem 6. B. Ember, Dimmr of Payehiatma Bsmmh, Mahatma; State ammm, ”55W"! 1818M, ”at. f: , Dear Hm Itwaaaplmto Atlantic city. I am aomr that mm we We withyouandymwfiein mum could not. get. smother for "mucus“ much. Johanna and cmvisit. I social enjoyed bht very Mb: 5.3 who: moth with a wry Might. boy, But this yw' almdy may: Mahala, Ina 1mm. A9 fer our “parlance with your suggestion in 1 obtained some intmous manual from SKI. In the last 1w ‘mths we hm given it. to six ”news intmmly. Evin subject and tt. {um at" electroshock therapy and the trim of the I. of much. In sank instance high height. of m: mo 1n In: an the premix "mag abatmmphdogm u’mrity tam. the but situation, in which I and an we qmamm 3 and than remand after the parlour M the Watt-attests cf the d 50 2 of the The rate was mm. dosage drug gvmat smnmum. and than abuut for thirty ”cording a at. of the air. rate mast how the to for eight Manama unplug :pprmntnly mm hour. mm. mm mm, W 93.03th m m mm W» 6!me We: m. mum WW m W m ma Way m hiring the ministmtion, each patient Moped, batman the coma um fourth cc. m epdseda of waging. mare m macaw in breathing which an trunnion. This was the mat untoward attach a: m m alaotromcophnlosnphia ohms pared gradually but was mt. M: the: tho of minutes n injection. within tan 150 ace mm apparent. to thin tin mm veto mead rm a may a! than mansions 70 rum rmmyms toammcf in mm» Wt.- mmumm. tamper-u MWalimdzm;wnwegemmWoffimSma cent. tin 691th, however, mad about the sum. Mb 3:: «that peanut! far one to an hours and in :1]. WWW 1n the maples “loan about four to time: hours liter the Gilt: activity at at the pro-injection m1. In an. “outpatient:mdauutifltymmotthaomrofhto66330.3“ caplofion of the Winn in value” of he to 70 UN. mm the delta activity am: ”My ma in pomnt tiny and in voltage u: that. m an: amount! mam- him he Waits. nun appeand stupor-impound film �Dr» new at Bar mr, #2 a clearly defined 25 cpl. nativity... Tlmm records the the was an ”alerting? following. report Warmly animated by an incmaad methane” ai‘ we patient and a crust. “ibis greater difficulty in having the patient maintain his eyes gazed, ma tbs change in hm patients from: a "Home for this alerting phenm effect to a mgative am)... The changes in language after positive were the reverse of the changes in language which we have axperlmcod 131ml 1n the past after tho amatmtion a! mama-him. Since we use the identical w scone the changes in 11am in an Mammal fashion. In maimaim, three Mamas the questions prior to the of Dime}. wen 11-. and therefore to ovum.“ the changes in Imam. negative Waible & “manure" In one manna tha max-d changed in to an 1mm. mama clung» of the kind tkmt we see: with mbarbim. This dinmponcy I. cannot explain. m m m1 m 1mm W10 rm manna; am eontinning this study and I would 11m to pmmt the behavioral and electroeneephalog‘aphia effects My in the £111 to the Eastern EEG Association. Thaw observations are, of eourse, migratory and I am not 8m 8 UT the next batch or patients may not shot-7 us some other patterns. To tho flat extent. that. this inmatigation has confirmed the observations of Leann”, I an moat yieased. Ha I have no objection to war reporting some of this itfl'omtian in outline. If is of any help ta you, I will be pleased to see the paragraph: as yen intend to report, them and give you my reaction as to how they reflect. it our axpoziemaa, Sincerely yours,Kn: Fink, Dani-haunt at MFtJB mammal Pnyuhiatry. H.130 �“,f ‘i? ziirect i v . i of Diethazine on EEG ’5‘ 0+3 qt I for and Significance Theory of Convulsive Therapy Mauougflwk.fldb Previous studies of the role of EEG changes in convulsive therapy delta activity for have demonstrated the significance of the induced the behavioral re3ponse. Investigations concerning the biochemical substrate of delta in electroShock and convulsions EEG have indicated significance for the cholinesterase - acetylcholine system. reports on by Ulett concerning the effects of atropine and Recent 00’ scogfilflhine the delta response-effihe-EEE-showed a reversal of the-induced patterns. Boncurrent iswmvafi. reports by r and of diethazine on normal EEG and that following Lechner on the EEQ effects trauma provided the stimulus for the study of the effects of this drug in electroshock. Subjects: Twenty voluntary psychiatric patient in an openyward/psychiatric hospital have been tested to date. d " £5? During recording, at various maturing (Biparcol) is administred intravenously at per minuteI Maw “'5’57- £155; xi treatmen . rmi 94°" " the rate of 25 milligrams ‘1 250 milligrams, {My diethazime 70.,qu * �Observations : a) by the of All dryness cmgling, respond subjects Behavioral“ mouth and thickness of speech. Feelings of weakness of extremities illusory sensations are and There common. is an increase in rest- lessness and difficulty in maintaining eyes closed. In patients who have had sufficient electroshock to manifest syntactic and orientation language changes indicative of altered cerebral function, is there ‘ b) EEGSq a reversal of language patterns. . In all subjects there is desynchronization of frequencies \ and decrease in voltage. Alpha rhythms are less prominent. ! low Occasionally, \ -—-a c" In voltage “ILA 577’ frequencies appear. \ voltages-a25of delta with degrees varying activity, patients in decrease‘, frequencies decrease and burst activity disappears. Irregular alpha and beta frequencies of low voltage become c) The EEE and persist clinical effects consist for gradually disappear. one mmminent. to three hours, and �Discussion: The pharmacologic effects of diethazine are described as "anti- cholinergic" and "atropine-like," and in patients with altered brain function may be h described as "allert‘ electroshock induced m (Ulett). EEG delta is P The action of diethazine an 0 . scopfll ine similar to atropine and eeelpalemine (Zinc floss observations era‘similar to those in subjects with head injury (Jeéhker and Lechner). Conclusion: ‘1'“ Based on this data, as well as the cerebr¢{:§pinal fluid cholin- esterase studies of Bornstein) and Tower and McEachern, . fuedJLb£1 diethazine hes-e ready that: (l) ' ' it is .: enter the central axrhnL; and trauma induced electroshock by by delta system3(2) a . concluded nervous 4' may similar A have biochemical substrate;(3) electroshock may be looked upon as a controlled 6F Alana; method tc.indnge ce ebral dysfunction for The its induced behavioral significance of these observations for EEG studies of head trauma and the mode of action of gin-ilpconvulsiVe therapy discussed. effects. will be �//— £3th at Diethuine on 3%: and Significance for Theory at Germanium mm Previous studies of the rule of have demtrnted EEG changes in convulsive thenpy the eigmfieam or the induced delta activity for the behwioral response. Imeatigetions containing the substrate of EEG 1:10ch delte 1n electroshock and convulsions have inflated significance for the eholinestemae - mtwlchonne system. reports Ulatt concerning the «treats a! atropine and by anthedalta patterns, response otheEEGshemdamml of napalm theinducedm Goncurrent reports by Jemkner and Lochner an the offliethum «1110;14:11me Recent. effects mtrmmmmmmm atimelua for the study of the effects or this drug in electmahock. Subagetet Twenty voluntary psychiatric patimte in en upward/psychiatric hospital have been tested to date. Electroencephalogm have been obtained mutant. During the recording, at. various fines during (limit) is administer! intmemualy per me until at. the 250 Milligrams have been rate of Metered. diethume 25 milligrams a an �¢2~ mumations: a.) Behavioral - 51]. subjects respand by coming, dryness (J the math and thickness of speech. Feelings of weakness of extremities and mm. illusory sensations are Mamas is news in mt. an difficulty in maintaining eyes closed. In pgtients 3nd who have had There Mficient ehctmhwk to manifest syntactic and onentation language changes indicative of altamd cerebral function, them in a reversal of language pattern» b) EEG ~ In all subjects than in Voltage. and decrease Damionflly, 10w is «synchronization Alpha W of Inqueneies are less prominent. tnqmncies appear. voltnga In pstinnta with varying dogma of delta activity, voltaga is deemed, tmquemiea in “cram am} burst wtivity disappears; Irregular alpha and but: fmqmnoioa of law voltage become more a) Tho W and liy clinical eflwta diuppnr. . pox-stat mm gamut. for om to than hours, and �A! mammalian The phnmaeolog'ic effects of diethuine are described as ”anti- cholinergia“ and “atmpimlflm,” and in patients with altered brain function may be doacribod an ”martini." The action of electroshock induced (Butt). EEG delta is 3min:- to atropine Also, than. observations with hast! 11131211 («bunker and m diothum 8nd n W napalm 51:11” to than in subdue“ Mr). 091191113th Band on this data, us all 0 as the carom spinal fluid wanna «tea-am swarms of Bernstein and Tower and IicEnchem, it is minded that: (1) diothuine has a randy ability to enter the central nervous system (2) delta induud by electroshock and by trauma my have similar Mommioal substrate (3) electroshock my be loolwd upon as a controlled m’chod to induce cerebral dysfunction for Ema tm its induced behavim'al effects. hand for'EEG of atxfiias of these obsamtiona significant: and the mode of discussed. act-.1031 of electmcomluvo therapy will. be �MM or blow swam m and Gmmlaim Therapy on m m, for 1119on of 24.13. me changes in wmulsive therapy have the signifiam of the induced delta actdxiw for the biochemm umoarning the Invasfigatlans tome. have EEG and indicated electroshock emulsions of delta in mutate nignfimm tor the ahonmuem - mmdcholine system mm. Pruvioua studies Wand 1:6de at the rails of. otatropdmandaoopolmo Wbymttcommmgmeflw EEG induced showed EEG or cloctrashook a moral in an pattom. am: Comm-rent reparts by Janka»: and Lechner an the: extent: of on mm]. EEG and that. following tram provided this stimulus far the study of the effects at this drug in electroshock. mm Salaam” treatment various during ht stages patina“ puma-lo in an open—ward voluntary psychiatric hospital have been tested to (Dimmol) is manicured date. "During EEG recording, int-.mwaly at the rate of 25 milligrams- por minute, for a total at 2% Twenty diam W0 Mmtionu ' : a) %: b) m m All subjects respond by coughing, dryness of the thickness of mach. Feelings of weakness of emu-mitten mm and illusory marathons are cam. more is an immune 1h restless. mas and mamty 1n maintaimng eyes clued. In patients who have had sufficient. electroshock to manila“ syntactic and orientation language changes indicative of album earabral function, there is a reversal of language patterns. more 13a doaynchrmiuuon of rmmdes down» in voltage. Alpha rhythms are less lament. Occasionally, 1m? voltage theta frequencies appear. In all subjects In patients with varying demos of delta activity, voltageand burnt increase frequencies activity disappears. Irregular decmo, alpha and beta Imumcies of low voltage become prominent. c) The EEG and clinical effects persist for one to three hours, and gradually disappear. Fm Department of men Oaks, ELY. than 1.1-6.5? - EAEEG mmm Psychiatry, Hillside Hospital, �‘5 of downbeat afloat: dawn» m Wohgie u ”antiwhonmtgie" and 'ttropine‘uka," and in patina“ With slated brain imam any be 6030de as ”wrung.” the mum at on ahctroshack induced EEG delta is amm to atropine 610mm um! £39me (010%). mm ebmmfiom an aim similar to firm in aubjccta with bud injury (Janina: and helmet). The cmcluaiam Mac! on this duh, as «11 as this cerebmspinal fluid cholimatamso studios of Ben-MW, and Tower and Wuhan, is wmludod that: (1) damn» mam entm the «antral nervous system; (2) delta nativity inducod kw alwtrodmck and and by tram may ham: 3 similar (3) mutate: mm be lookad upon an o. watt-0119c! ”that! of naming «mural to: its behaviaral affaa‘w. it mmwu m Wanna The «:1ng the or action of convulsive: therapy will trauma and node of thew than mamtiom for m ”adieu or had be animated. �v -r:‘V?\'(‘r.uv' w--w—ILW|>L‘»V‘V'~B—w"y:mm w—r-mw-vwn»vww.,u—A » v —.-.r. -- .vr. w—y ~ w — "av/\— <7 r ,rw-I'IWK . aw u 'mwl' - - - "a.“ AM'HV'Wwv _,,, A was �wan-my r'm ��Form 90-Adm. éhhft$nk jfluh fisgrlfiatrit gustitute 722 WEST 188'"! STREET. LAWRENCE B. KDLI, M. D. nlnlm'run NEW YORK December 4, 1957 Dr. Max Fink Dept. of Experimental PSychiatry Hillside Hospital 75—59 263rd Street Glen Oaks, New York Dear Max: feelings about Saturday night are reciprocal. Weihoroughly enjoyed the gracious company of you and Martha. With the intuitive perceptiveness of the female, Yetta informed me of a forthcoming event in your family, and we Wish you the best of everything. I indeed look forward to the reprints on your Work which you described in your letter and our discussing them together. The next edition of the Kalinowsky and Hoch will be expanded to include tranquilizers, and I would also appreciate any reprints of yours in this area. I have enclosed my own reprint on the clinical effects of Win-2299 and the basic paper by Luduena and Lands. As you will note, the compound is a peripheral anticholinergic and produces a "disorientative" reaction in cats by central action. Its psychotomimetic action in man appears basically to be an acute toxic reaction type. I would imagine that its central mech~ anism of action is similar to that of atropine (which also produces acute confusional states in high doses). Win—2299 is effective at much lower dosages than atro— pine. Possibly both atropine and Win—2299 both produce central effects by an anticholinergic action but, as far as I know, this modus operandi has not been pinned down crucially as far as the C.N.S. is concerned. I would not expect all anticholinergic agents to be psychotomimetic, of course. Win-2299 is a tertiary amine. Monodral is a closely related drug, differing only by quaternization of the terminal nitrogen in Win—2299. It is Win~4369 in the paper of Luduena and Lands (p.283), i.e. the methobromide form. According to Winthrop-Sterling, it is a peripheral anticholinergic in man in doses of 5-40 mg. per day. Central or psychic actions are not mentioned in their account. Presumably, quaternization reduces central activity by reducing permeability. Our �Dr. Max Fink (cont'd) ’ -2— I imagine that other agents in the Win series with central effects in cats might also be active as psychotomimetics in man. I am not familiar with the formula of diparcol and if you have it available would appreciate learning where to look it up. The drug is not covered by Goodman and Gilman. I would appreciate return of the Luduena and Lands paper when it has served your needs. We gave the Win—2299 the orally, The compound being drug was supplied as the supplied in tablet form. racemic mixture, the asymmetric carbon atom being terminal in the aliphatic chain. Sterling—Winthrop may have it for intravenous use and I suggest that you write M. L. Tainter, M.D., Director, Sterling-Winthrop Research Institute, Rensselaer, N.Y. about it. Our oral supply was used up in the study. As you know, all psychotomimetics not only create new symptoms in mental patients but also intensify or revive pre-existent symptoms. Best of luck. Cordially, ”2a Harry Pennes, H. HHP/ys Encl. M.D. �PA if .. _ * (on 1M5? I Effect of Diethazine on EEG and we Significance for Theory of Convulsh M Therapy MD Mow In a previous report to-this society we noted the relationship between the degree of induced delta activity during the course of therapy and the behavioral reSponse to electroshock. Those patients, in delta activity were induced early, and were degrees of behavioral change, as well as a significantly greater percentage W gm vial £64414a Law In. Box} EH: acetylcholine and in whom only low degrees were induced (Fink and Kahn, 1957). activity 1, (ii; '1.) high degrees of sustained, manifested the greatest of improvement and recovery than those patients of delta whom ,hML-wQA‘O‘ . a, W" , ‘Jawc‘z MM L Mkfil‘g‘f‘” ’M‘Af‘z‘ mv’efrff " in!“ (.4 Mfianges infree” ' a variety é‘fu‘reports, cholinesterase in the Spinal fluids of patients (Sachs, 9. Ward) and animals (Bdrnstein, Tower and McEachern) following head Wig; . . I the observations that by trauma M o (Bfrnstein, flue/4% In 1956 .c‘ E agents liq—alter the EEG patterns induced Ward, Jenkner-Lechner) and by electroshock ( “knew“at?mp (Ulett)pu_l Ulett reported that atropine g’scbpolaminerwhea-aéiénéstered— / W, blocked the appearance of the delta wea»...have come to associate with - _,-.,..«-'V'F-r -v~ WWW ahaaul,” "‘4“qu w. traumalawfl electroshock therapy. A!” 791’] am’LlLJ/g/J M ’L “‘2‘“ 4“““4/ié’MWrrW ”“an“ j?” activity {lama/Wye? v» �-ebeervetions~ Previously, ward (193) following the suggestion of Bornsteiny (19h6) had noted that atropine altered both the EEG patterns and the neurologic signs induced in.man by head trauma. afiereT-tee, the side ZZ,AQA7V ~effects were marked. In 1955: Jenkner and Lechner reported that EEG behavioral effects similar to atropine were achieved by diethazine istered in patients with head trauma.‘ They and admin— also reported the effect‘of diethazine in normal subjects. It is the purpose of this report to describe the effects of intravenous diethazine on the EEG of patients during electroshock therapy; and to relate their these findings to the present neurophysiologic-adaptive hypothesis of the ndde of~action of convulsive therapy. w ‘flwmwmflmwwwfl_fl____.imm 3" Diethazine is a soluble phenothiazine compound with phamacologic properties similar to atropine. In experimental animals, (19h?) have noted that diethazine blocks vagal slowing of the heart‘) M suppresses the bradycardia, bronchospasm, salivation, and fasciculation and seizures induced by acetylcholine, DFP ‘‘‘‘‘ ‘wywwflfimgimww‘fizoxsum-“:- w' ”mm—«MA..- and pilocaxxfixg and induces dry mouth, mydriasis and hypotension. L/——' / Heymans EE.E£ a“: nevus-aw» 4.: '2‘ YW',‘47"’~"5‘W1‘-05 Emma-gwhz - .— ' .~_4~:_MD~J �93" ”w W Subjects: Twenty-two psychiatric 42‘ patients,” various stages of electro- shock treatment in an open-ward, voluntary psychiatric hOSpital have been studied. the laboratory. Following a routine EEG administered intravenously at the rate of of 2630 to 250 mgm, the i Tl’br.‘ EEG 25 mgm per minute, for a total effects. Prior to the historical interview and a structured questionnaire period were tape-recorded. EEG recording, diethazine was depending upon the behavioral drug administration, an unstructured both EEG gubjects were tested in Following drug administration, recording‘ and recorded interview periods were continued until record again manifested.the pre-injection patterns on visual inspection. Mm New. ‘>IIVW~.. Qbservations: in Le ,, (a) Clinical: AH su jects manifesm Spontaneous coughing mutual-i33- @ followed by a dryness of the mouth and a thickness of speech. flgrtrf They note‘, ' 3'37 a feeling of lassitude and weakness of the extremities? soon followed by increased restlessness and difficulty in maintaining eyelid closure. phenomena were PSymW/clearly between 15 and 30 minutes . manifested in after some subjects. In the rest period drug administration, six subjects spontan- ..,. _‘ ... _ A �4,. eously voiced feelings of unreality, visual and haptic illusions, and delusional thoughts about their illness, the setting of the test procedures or our identity. Such patterns were transient and had disappeared In by the termination of the experiment,-asaallyhiééfifiurdfinnxrdnmzns. three subjects, increasing agitation . and panic led to a cessafion of the recording. éHere7-tccy—restétation_a£—pme—énjenfifinnrdnfiuufiuuaauua I 'li' g“, , I! i . fiilliwuwfi (b) In previous studies, the intimate relationship we had noted between changes in syntactic language patterns with alteration in cerebral function induced by electroshock. In subjects tested prior to electroshock, diethazine induced changes in syntactic pattern of an "alerting" variety. I - gal [5% In subjects with elta activity‘ with clinical syntactic patterns indicative of an alteration in cerebral function, diethazine induced a transient dis- appearance or minimzation of Such language in language (c) was concurrent with changes EEG Patterns: In all patterns. The period of changes in electroencephalogram. records, there is a decrease in voltage and desynchronization of frequencies. There is a decrease in prominence of prevailing rhythms. In patients without delta activity (pre-electrodhock)’ �-s5‘ 4/ this deéhronization and voltage decrease is occasionally accompanied by the appearance of small amounts of low voltage These are demonstrated in Slides 1, not appear to be altered. The and 2. The 5’7 '5' cps activity. basic alpha rate does build-up in voltages and appearance of thm slower frequencies with hyperventilation is blocked. In patients with varying degrees of induced high voltage activity voltage”, both random and 4 This change It and 3 dub is a decrease in burst delta activity disappears; and irregular, / low voltage alpha and beta frequencies become prominent. are noted in Slides delta These changes LL. 5W in is manifest in appears during drug administration, and all electroshock subjects. persists for awe. [WM filwwx 13% 2/1. floncurren WithAelectroencephalographic hours vtwv ‘ ”fly to three age MM» Wrens-em fiith the 8&3 17TH 770 n moustita—tion— of the pre-injectionEl'I} patterns, the pre-injection behavioral and language patterns again appeared. �DISCUSSION: report of Jenkner and Lechner of the t”t.¥£~£ dikd/“4lz‘ijzz7' effects of diethazine in"normal" subjects. 'Wa.alsa—nnta_tha§21iethazine These observations confirm the alters records-snd-fiith electroshock induced delta activity in‘a fashion similar to atropine and scopolamine, as described by Ulett, A Mada» W was. . 1%,. is apparent, therefore, thatngfi readily affects the central nervous and.é53 duration system, ofiactivity is most useful for experimental purposes. The-previeusiy—eitnd studies by numerous Observers of nervous system effects of head trauma point to an intimate relationship between the degree of neurologic dysfunction, the degree of EEG alterationjgand the level of free acetylcholine in the spinal fluid. The effect of atropine both the Echand ill on concomitantly on behavior in subjects with head trauma lends further support to the significance of figs: acetylcholine as the biochemical basis for the observed EEG patterns. In these studies of diethazine electroshock, the intimate relationship between EEG patterns and and behavior �-7have been reported. We note the parallel to the observations in head \ trauma. On the basfis of these observations, as well as studies of Spinal fluid Woholinesterase levels; (Tower we would and HoEachern, Fink and Goldenberg)‘ suggest that the biochemical substrate of the electroshock process. is isimilar to that of head controlled trauma.9 method of inducing ectroshock hLauri. may be looked upon cerebral dysfunction for its as a behavioral effects. Previous studies have demonstrated that alteration in cerebral function provides the physiologic basis for the behavioral changes in electroshock (Fink and Kahn, 1957). Such alteration in cerebral function provides the milieu for a change in the organism's adaptation to his environment. aSpects of behavior, as perception, language, mood, recall, memory, All affect, undergo change, and provide the basis for the therapist's evaluation of improvement. The studies of diethazine amplify this neurophysiologic 9.39.9. adaptive hypothesis of electroshock by suggesting the type of biochemical substrate that underlies both the physiologic and the behavioral changes. �Mm= 0 Diethazine, a pftent anti-cholinergic compound, u was experimentally introduced intravenously in psychiatric subjects,;fi various stages of convulsive therapy. Electroencephalograms manifested a desynchmnization of frequenciesfue («C decrease in voltage records without prior delta activity. Records with delta activity showed similar changes with disappearance of delta burst activity. Concomitant with the electrographic patterns indicative of It is concluded a effects, behavioral reversal of the electroshock effect enters the central nervous System upon intravenous (b) The biodemical basis for that of head trauma; (c) therapy The may EEG compound that readily adninistration. changes in electroshock is similar and biochemical basis of the lie in were observed. that: (a) Diethazine is a Bitent anti-cholinergic to and language mode of action of convulsive the acetylcholine-cholinesterase system. a, �@ Research and Development Division SMITH, KLINE & FRENCH LABORATORIES PHILADELPHIA - I ESTABLISHED I84| December 11, 1956 Max Fink, M.D. Director of Research Hillside Hospital 75—59 263rd Glen Oaks, Street New York Dear Doctor Fink: associate, Mr. C. W, French, has referred your letter of November 12 requesting a supply of diethazine to me for reply. It has taken me a little While to uncover-sufficient supplies for the short clinical trial you want to conduct since our interest in diethazine alone and in come bination with 'Thorazine' isn't too great at this time. My not have this compound available in 500 mg. capsules as you requested. It is only available in 250 mg. tablets. A supply of this strength has been sent to you together with a supply of the intravenous we do material so that you is all the literature we this will be of some help. Enclosed hope the may Observe EEG effects on 10 have available on Sincerely yours, .\ to 15 patients. diethazine. I , J”, Meagan? Ms (,7 . John F. Buckley a Research Associate / ’ ' Medical Department JFB:hc Enclosures P.S. Will you kindly sign the enclosed FDA card and return so that we may keep our files up-to-date. it to us � Dublin Core The Dublin Core metadata element set is common to 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 Diethazine on EEG and significance for theory of convulsive therapy. Electroencephalogr Clin Neurophysiol. 10 207-208. (abstract). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-29a-004 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 Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 13 items. 1: Handwritten notes. 2: Clinical Release. 3: Diparcol. 4: Pharmacology Report. 5: Letter to Fink from R. S. Griffith. 6: Letter to Fink from Herman C. B. Denber. 7: Letter to Denber from Fink. 8: Draft with edits. 9: Two drafts. 10: Handwritten notes. 11: Letter to Fink from Harry H. Pennes. 12: Draft with edits. 13: Letter to Fink from John F. Buckley 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