An experimental evaluation of the relative effectiveness of insulin coma and electronarcosis therapies with schizophrenic patients

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AN EXPERIMENTAL EVALUATION OF THE RELATIVE EFFECTIVENESS OF INSULIN COMA AND ELECTRONARCOSIS THERAPIES WITH SCHIZOPHRENIC PATIENTS

A Dissertation Presented to the Faculty of the Graduate School The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

by Leon I. Heilman June 1950

UMI Number: DP30391

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T h is d is s e rta tio n , w r itte n by

.......... ^on__ I*__Hel_li?»n.......... u n d e r the g u id a n c e o f h is .... F a c u lty C o m m itte e on S tu d ie s ,a n d a p p ro v e d by a l l its m em b ers, has been p re se n te d to a n d a cce p te d by th e C o u n c il on G ra d u a te S tu d y a n d R e se a rch , in p a r t ia l f u l ­ f illm e n t o f re q u ire m e n ts f o r the degree o f DOCTOR

OF

P H IL O S O P H Y

D ean

Com m ittee on Studies

/" " n

C hairm an

ACKNOWLEDGMENT The author wishes to express his appreciation for suggestions and criticisms to the members of this doctoral committee:

Dr s. J. P. Guilford, Georgene Seward, Lee E.

Travis, Nell Warren, and particularly James Coleman, chairman, who was especially generous with his time and assistance.

Appreciation is also expressed to members of

the Neuropsychiatric Hospital, Veterans Administration, Los Angeles, and especially to Dr. Harry M. Grayson, Chief Psychologist,

for invaluable assistance rendered! to

Dr. Samuel Reznick who was in charge of the treatments administered and who also made the psychiatric evaluations of improvement! to Mr. Louis Jacobs,

senior aide of the

acute and intensive treatment service; and to the Veterans Administration psychology interns from the University of Southern California and the University of California at Los Angeles who participated in the administration of the

TABLE OF CONTENTS CHAPTER I.

PACE

THE PROBLEM AND DEFINITION OF TERMS USED . . . The problem

. . . . . .

...................

Importance of the study

.

.............

Scope of this i n v e s t i g a t i o n .............. *

1 2 2 4

Limitations and delimitations of this study ............... Definition of terms

. . . . . . .

. . . .................

Insulin Coma Therapy (ICT) Electronarcosis (EN)

............

............

Convulsive therapy . . .

...............

Shock T h e r a p y ..........

5 7 , 7 7 8 8

Psychological changes and psycho­ logical evaluations Psychiatric evaluations

...................

9

.................

9

Organization of the remainder of the dissertation . . . . . II.

.................

SURVEY OF THE L I T E R A T U R E .................

9 10

Development of effective somatic theories for schizophrenics . . . . . . . . . . . .

10

Insulin coma therapy . . . . . .

10

.........

Metrazol t h e r a p y ..........

11

Electro shock therapy

12

Electronarcosis therapy

................... ..........

12

V CHAPTER

PAGE Summary evaluation

*

............... .

13

Theories as to the effects of the somatic therapies .......................

13

The predominantly somatic theories

14

. . .

The predominantly psychological theories

. .................

19

The predominantly psychosomatic t h e o r i e s .................

22

Studies on the evaluation of no shock, ICT and EN therapies

. ............

24

Psychiatric studies made prior to the use of the Hshock11 therapies Psychiatric studies with ICT

. . . . .

25

. . . . . .

30

Psychiatric studies with E N .............

39

Summary of psychiatric researches . . . .

46

Psychological studies made prior to the 11shock11 therapies . . . . . . . . .

50

Psychological studies with patients who received I C T ................... *

52

Psychological studies with patients

III.

who received E N .......................

61

Summary of psychological researches . . .

62

THE EXPERIMENTAL D E S I G N .....................

64

The p r o b l e m .....................

64

vl CHAPTER

PAGE Selection of patients .....................

64

Selection of t e s t s

6?

. . .

P r o c e d u r e ................... . . . . . . . .

6?

Comparability of the experimental groups prior to t r e a t m e n t ............. Treatment of the d a t a .................

70 71

Psychological appraisal .............

. .

71

. .............. . * . . .

74

Psychiatric appraisal of results of treatment

Relationship between psychological and psychiatric c h a n g e s ............ IV.

THE TEST DATA AND THEIR INTERPRETATION

.

75

...

77

Psychological appraisal . . . . . . . . . .

77

Comparability of the two treatment groups prior to t r e a t m e n t ............

77

Test changes within ICT group . . . . . .

81

Changes within the EN group

85

..........

Comparative effectiveness of ICT and E N ...............

89

Comparative areas of effectiveness

...

93

Psychiatric appraisal of behavioral changes . . . . .

.

101

Relationship between psychological test changes and psychiatric appraisal of behavioral changes

. . . .

. . . . . . .

103

vii CHAPTER

PAGE D i s c u s s i o n ...........................

V.

.

.

108

SUMMARY AND C O N C L U S I O N S ............

124

Suggestions for further research

130

BIBLIOGRAPHY APPENDIX

.

. . . . .

........................ ..................................

131 141

LIST OF TABLES PAGE Psychiatric Studies of Improvement in Schizophrenia Without HShock11 Therapy

. .

29

.

32

Psychiatric Studies of Improvement in Schizophrenia with I C T ............... . Psychiatric Studies of Improvement in Schizophrenia With EN

...................

40

Comparison of Types of Psychiatric S t u d i e s ................. ................

49

Area of Mental Functioning, Test Vari­ ables Within Each Area and Source of Test Variable

. . . . . . . . . . .

Comparison before Treatment Comparison of Change of

. . ♦

...............

Scores in ICT

Comparison of Change in Scores in EN ♦

68 78

• ..

82

. ..

86

. .

91

Comparison of Mean Changes from the Two Treatments • Test Variables Classified Under Area of Functioning and According to Experi­ mental Groups

. . . . . . . .

...........

95

Psychiatric Evaluation of Improvement with ICT and EN

. . . . . . . . . . . . .

104

Relationship Between Psychological and Psychiatric Changes

. . . . . . . . . . .

105

CHAPTER I THE PROBLEM AND DEFINITION OF TERMS USED Schizophrenia is one of the major problems in the field of psychiatry in terms of the number of patients involved, the lack of an understanding of the disorder and the lack of satisfactory therapeutic procedures.

It has

been estimated that one half of the nation1s available hospital beds are occupied by mental patients and that schizophrenic patients constitute about fifty per cent of the resident population of mental hospitals, so about one quarter of all available hospital space is occupied by schizophrenic patients.

This disorder usually becomes

manifest in the second decade of life and generally runs a long chronic debilitating course with less than one third of untreated patients improving sufficiently to be discharged from the hospitals.

Since this single disorder Includes

such a high percentage of the nation* s hospitalized patients, any treatment that can decrease the period of hospitalization is of extreme Importance. There have been two Important developments in the physical treatment of this disease during the past fifteen years.

The first to appear was Insulin Goma Therapy; later

appeared the convulsive therapies, metrazol and electroshoek. A major modification of electroshock, known as electronarcosis

2 has been so recent that no adequate comparisons have been made between this new technique and the others* I.

THE P R O B L M

Statement of the problem*

The main problem of this•

investigation dealt with the comparative effects of insulin coma therapy (hereinafter referred to as ICT) and electronareosis (hereinafter referred to as EM) in the treatment of schizophrenic patients*

These comparative effects were

determined from two major sources of data:

(l) from changes

in performance on psychological tests of cognitive functions administered immediately prior to, and two weeks subsequent to, the termination of treatment; and (2) from psychiatric evaluations of behavioral changes made concurrently with the psychological testing. of the study*

Since EN, as a modification

of electroshock therapy, and IGT have been considered more effective than electroshock as treatments for schizophrenia, it was felt that a controlled comparison of IGT and EM was necessary.

If EN should prove as effective or more effective

than IGT, it may, in the absence of many of the limitations to the use of ICT, become the preferred method of treat­ ment*

Some of these limitations of IGT are as follows:

3 1.

Treatments must be given at least five times

2.

Treatment is expensive and cumbersome; the

weekly.

patient must be closely watched not only, during the period of the induced coma but also for the balance of the day. This consequently necessitates a very high ratio of attendants, nurses and doctors to patients. 3.

Serious complications such as cardiovascular

disturbances, prolonged coma, and respiratory failure are not infrequent. 4.

Sensitivity to the insulin varies'greatly among

the patients.

That is, some patients may be allergic to

insulin, hypersensitive to it or resistant to it. 5.

Treatment may be excessively severe on the older

age group, consequently most patients over the age of fortyfive are not given treatment. 6.

This treatment may aggravate co-existing physical

disorders such as febrile diseases, internal organ diseases, tuberculosis, and glandular disorders. Most of the above mentioned limitations and contra­ indications to the use of ICT do not hold for the electroconvulsive therapies,

consequently more schizophrenic

patients can be treated by EN than can be treated by IGT, and the relative effectiveness of EN as compared to ICT becomes a problem of major practical importance.

4 of this investigation*

fhis study was conducted

at a Veteran1s Administration Neuropsychiatric hospital containing approximately two thousand patients.

Fifty-eight

patients, all of whom were diagnosed as schizophrenic, who were able to cooperate were included in this investigation. Thirty-four of them received IGT and the remaining ti^entyfour received EN.

This investigation began in July, 1947,

and continued through April 1949, a period of approximately twenty-two months* This is the first report of a planned extensive investigation of the comparative values of IGT and EN in the treatment of schizophrenia.

An extensive battery of psycho­

logical tests designed to measure cognitive and other aspects of personality functioning was administered to the patients just prior to treatment and two weeks after the cessation of treatment.

Psychiatric evaluations of behavioral adjustment

also were made at the same time.

This, then,gave data for

an evaluation of the immediate comparative effects on patients who received either one of the two treatments based on psychological test data and psychiatric ratings; it also made possible a comparison of these two different methods of appraising patients*

changes.

Furthermore, it was desirable

to know the comparative long range-effects on patients who received these treatments as well as the immediate effects. It was planned, therefore, to reevaluate these same patients

both by the administration of the psychological tests and by the ratings of adjustment made by psychiatrists, about one and one half years after the cessation of treatment.

Because

of the magnitude of the data and the time necessary to adequately analyze all of the obtained data, it was not considered feasible to attempt a total analysis at this time. This report was limited, therefore, to a comparative analysis of the immediate changes that occurred in equated groups of schizophrenic patients who received ICT or EN, as manifested on psychological tests of cognitive functions, and on psychiatric rating scales; and also to an analysis of the relationship between these psychological and psychiatric changes. Limitations and Delimitations of this study.

For

various practical reasons the limitations of such a study, performed in a hospital situation, are many.

The short

period of time that existed between the cessation of treatment and the retesting of each patient is, theoretically, a severe limitation Inasmuch as certain temporary changes in the con­ dition of the patient may be influencing the test results. Thus, while it would have been preferable to retest the patients a month or more after the cessation of treatment, such a procedure was impossible.

This was due to the fact

that those patients who showed sufficient improvement in

their condition, in the pss'chiatrist1s opinion, had to be discharged at the expiration of two weeks because of the great need for the beds that these patients occupied for the use of other patients waiting to receive treatment (as well as the impatience of these improved patients to return home). Due to an administrative regulation, those patients who failed to show any Improvement within two weeks after cessation of treatment had to be given some other form of treatment at that time. It would have been desirable to include all patients who were seJLected for this study in the final compilation of the data.

This was not feasible since many patients who

were originally tested just prior to treatment, as subjects of this investigation, had their treatment stopped before the ^completion of a full treatment course. reasons for this were:

The two major

(l) individual physiological or

physical reaction to the specific treatment received was un­ favorable; and (2) some of the patients who had entered the hospital voluntarily demanded their discharge and consequently left the hospital before the completion of their treatment. This investigation was further delimited by the fact that no control group was available that could be equated to the two experimental (IGT and EM) groups.

This was so because

all schizophrenic patients who were considered suitable for 11shock11 therapy had to be given said therapy*

7 II*

DEFINITION OF TERMS

The definition of terms have been set forth so that a common semantic ground might exist between the investigator and the reader* Insulin Coma Therapy (ICT)*

The term Insulin coma

therapy (ICT) has been used to refer to a form of psychiatric therapy wherein the patient is given a sufficient amount of insulin, as a rule intramuscularly, as was the case in this study, to produce a hypoglycemic coma within a time range of an hour and a half to t\?o hours following the injection of insulin.

This coma usually is maintained for about two

hours and terminated by the administration of glucose.

The

specific technique of ICT used in this study was the technique described by Bond and Shurley In their article (7). Electronarcosis (EH)*

The term electronarcosis (EN)

has been used to refer to the application of an electric current to the patient by means of two electrodes placed bi-temporally.

The current varied between 180-300 milliam­

peres Initially and was rapidly dropped (within thirty seconds) to between 80 and 100 milliamperes.

After respira­

tion had been reestablished at this lowered amperage, usually in about forty-five seconds after the initiation of the treatment, the current was gradually increased at the rate

of one to five milliamperes per second until the patient showed increased tonus and flexion of the forearm at which point the current was maintained until a total time of seven minutes had elapsed from the beginning of treatment.

The

specific technique of EN used in this study was the one described by Tietz et al. Convulsive therapy.

(85) The term convulsive therapy has

been used to refer to those forms of psychiatric treatment wherein a convulsion was artificially induced in a patient. More specifically this refers to metrozol, electroshock, and electronarcosis treatments. Shock therapy.

The term shock therapy has been used

to refer to ICT and the convulsive therapies,

collectively.

It is known that the reaction of the patient to large doses of insulin or metrozol is not shock in the surgical sense of the term and obviously not in the electrical definition of the word.

Historically, however,

the term ”shock” was

attached to ICT and subsequently to the other drastic con­ vulsive therapies.

The term has been used on the basis of

its original psychiatric usage rather than to imply any specific physiological or physical definition. Psychological changes and psychological evaluations. The terms psychological and psychiatric both imply

9 evaluations as well as measures of behavior. been used in this report, however,

As they have

the terms psychological

changes and psychological evaluations have been used to indicate those behavioral manifestations or changes that were measured by means of ctirrently used psychological tests. Psychiatric evaluations.

The term psychiatric

evaluations has been used in this report to refer to those estimations of the patient1s behavior or behavioral changes made by the psychiatrists. Organization of the remainder of the dissertation. The balance of this dissertation was organized as follows: Chapter II contained a historical survey of the development of the “shock11 therapies, the theories as to the mode of action of these treatments, and a review of the literature applicable to this investigation.

Chapter III contained the

experimental design and the population of this study.

Chapter

IV contained the experimental findings, their interpretation, and discussion.

Chapter V presented the summary and con­

clusions drawn from this study.

CHAPTER II SURVEY OF THE LITERATURE By the beginning of the twentieth century psychiatry I had failed to devise any effective physical treatment for schizophrenia.

Early in this century the concept of focal

Infections in medicine led to the attempt to treat schizo­ phrenic patients by surgery on sites of infectious foci such as tonsils and teeth. results.

This failed to produce any significant

Developments in the field of bacteriology led to

various unsuccessful attempts to treat schizophrenia with various anti-toxic and anti-infectious vaccines and sera of recovered schizophrenics. I.

DEVELOPMENT OP EFPEOTIVE SOMATIC THERAPIES FOR SCHIZOPHRENICS

Insulin coma therapy.

In 1953, the first great advance

was made in the physical treatment of schizophrenia.

It was

in this year that Sakel made public his report concerning the use of insulin coma treatment for schizophrenia.

Prior to

this time Insulin was used by psychiatrists In order to increase weight, to influence excitement states, and to treat withdrawal symptoms in morphine addiction.

In this

symptomatic use of insulin attempts were made to avoid any

11 hypoglycemic coma s t a t e . H o w e v e r ,

individual reaction to

insulin is quite varied and occasionally a hypoglycemic coma state would occur.

It was Sakel who made the acute observa­

tion that this deeper hypoglycemic state, which occurred accidentally at times, had an apparent beneficial effect upon a schizophrenic* s psychosis. Metrazol therapy.

As early as 1929 observations had

been made on schizophrenics who were also subject to epileptic seizures.

These patients seemed to recover rapidly from the

schizophrenia when epileptic seizures were frequent.

(4)

A n investigation of six thousand cases of schizophrenia, made in 1931, indicated that only eight had had seizures at any time in their lives and, of these eight, four recovered shortly after seizures appeared.

More recently observations

have been published contradicting this concept.

For example,

Hoch (78) indicated a tendency toward a positive relationship between epilepsy and schizophrenia.

It was the concept of a

mutual antagonism of these two disorders, however, that led to the second major advance in the treatment of schizophrenia. On the assumption that epilepsy and schizophrenia were mutually exclusive, von Meduna (35) attempted to induce

Hypoglycemia is defined as a deficiency of sugar in the blood.

12 convulsions in schizophrenic patients.

In 1955, he reported

on the therapeutic use of a synthetic camphor compound, known as metrazol, which produced convulsions in schizophrenic patients. Electro shock therapy.

In 1957, the First Inter­

national Meeting; of Modern Treatment of Schizophrenia was held in Switzerland.

At this meeting two Italian psychia-

trists, Cerletti and Bini, suggested the possible use of an electric current in the place of metrazol as a convulsive stimulant in the treatment of schizophrenia.

A year later

they demonstrated their new 11electroshockH therapy.

This

treatment had many advantages over metrazol in the artificial induction of epileptiform seizures.

First of all, the

patients were less apprehensive and fearful of subsequent electroshock than they were of subsequent metrazol and, secondly, electroshock was much simpler to administer and control.

Since It has been demonstrated that these two

treatments are equally effective and electroshock has the above mentioned advantages over metrazol, the former rapidly replaced metrazol in the treatment of patients suffering from psychiatric disorders. Electronarcosis therapy.

The next developmental step

in the use of convulsant therapy was the application of Le Due* s animal experimentation in Helectric sleep.11

The latest

13 development is known as electronarcosis.

This was a

laboratory procedure until 1942 when it was first used on patients at Patton State Hospital, California*

The first

article on the use of EN as a therapeutic device was pub­ lished by Frostig and his co-workers (16) in 1942.

This

method was further developed by Tietz and a small group of colleagues.

Their first findings were published in 1945. *

(83) Summary evaluation*

Of these somatic therapies,

metrazol because of its severe effects, has been replaced by electroshock.

Some psychiatric therapists are now advocating

that electronarcosis replace electroshock and insulin coma therapy, as they believe that it is a more effective therapy than electroshock and equally effective and less dangerous than insulin coma for the treatment of schizophrenia. II.

THEORIES AS TO THE EFFECTS OF THE SOMATIC THERAPIES The nature of the mechanisms by which the MshockH

therapies bring about improvement in psychiatric disorders is as yet uncertain.

Many theories have been offered to explain

the mode of action of the various physical techniques used in the treatment of schizophrenia.

Such theories are dependent

upon the author*s theoretical concept of the origin of this disorder.

Inasmuch as there are a great many theories as to

14 the etiology of schizophrenia ranging from purely somatic causes to completely psychogenic ones, so likewise do the various theories propounded as to the effective action of shock treatment range from the completely organic through the psychophysiological to the completely psychogenic.

Each

of the three above mentioned categories may be subdivided into several classifications.

To date no theory has been

advanced that has received general acceptance*

some of the

more prominent of these, as cited by various authorities, have been reviewed in the following pages. THE PREDOMINATELY SOMATIC THEORIES: The various physiological theories may be considered in seven different categories.

Within each category one or

more theories have been presented.

Inasmuch as some

theories are more complex and involve more than one of the various categories, an arbitrary classification was made by utilizing what appeared to be the major emphasis of the theory. Theories that relate to action on phylogene11oally ancient neural pathways♦

Aocording to Sakel, in schizophrenia

there is a general lowering of neural thresholds through adrenal activity, which revives phylogenetically ancient and infantile patterns latent in normal waking thought.

Insulin,

being an adrenalin antagonist, is supposed to neutralize the

15 effect of adrenalin and reverse the process.

(61,66,75)

Theories that involve the concept of the matabolic processes of the central nervous system.

An impaired

cerebral j respiration prevents the complete oxegenation of the toxic products of metabolism which accumulate and give rise to schizophrenic symptoms*

Demole suggests that

insulin stimulates the oxybiotic processes necessary for detoxication.

(61,73)

In schizophrenia there is probably a primary dis­ turbance in cerebral respiration, which Preudenberg believes may be due to some lack of oxygenating substances.

This

disturbance leads to a collection of toxic products, probably originating from the protein metabolism.

Insulin

therapy induces the oxybiotic processes necessary for detoxication and also an irritation of the cell membranes, which results in an increased exchange between the cells and their surroundings.

(61,73)

G-eorgl assumes that schizophrenia is characterized by relative impermeability of cell membranes and suggests that Insulin stimulates the exchange between the cells and their surroundings by alteration of the cell membrane. (61,73)

Hypoglycemia affects the metabolism in the brain cells, as Ton Argyal has pointed out, due to the reduction of the sugar content which is followed as a compensation by an increased metabolism which stimulates the cells that are in a state of malfunction or degeneration.

(73)

While Meduna1s introduction of convulsive therapy was due to his belief that schizophrenia and epilepsy were antagonistic to each other, he suggests that the therapeutic effects may be due, in part, to increased cerebral oxygenation as a result of vasodilation.

(73)

Insulin produces cerebral anoxia (in the sense of interference with oxygen consumption of the brain) which Himwich indicates may be described as a dysoxia or dysoxidation.

The therapeutic effect is associated with the depth

of the anoxic or dysoxic effect and is probably dependent on it.

(B5,61) Theories that involve the concept of the elimination

of waste products*

Cossa and Bougeant believe that the

curative value is attributed to an oedema, Ha veritable lymphoid bath, which enhances enormously the physiological drainage of metabolic waste products from the nervous tissue.11

(13)

1? The shook therapies produce spasms in the brain capillaries which eliminate diseased nerve cells, thereby, Stief believe springing about the desired therapeutic results.

(35)

Theories that involve brain localization.

Nielson

says the basic pathology in schizophrenia is located in the diencephalon and he hypothesizes that the beneficial effects of EN is that the combination of narcosis with electrical stimuli causes a reorientation in the diencephalon that probably has a beneficial effect. *

(47,80)

All shock treatments have a marked influence on the diencephalon.

The regulatory mechanisms of the diencaphalon

are intensely stimulated under any kind of shock treatment and the changes in the vegetative regulation Ewaid feels to be the important therapeutic factors*

(35)

Theories that involve stimulation of the autonomic nervous system.

Cerebral anoxia is a common mechanism in all

forms of shock therapy.

The therapeutic effect on schizo­

phrenia, however, Gellhorn says, is not due to the depressant action on the metabolism of the brain but to a prolonged excitation of the sympathetic adrenal system.

(4,9,19)

The physiological changes following treatment, in general, are such as would occur if the adreno-sympathetic

18 system had been rendered more active.

There could he, as

Cameron has postulated, a compensatory reaction to the repeated administration of large amounts of insulin, i.e., insulin eliciting an outpouring of adrenalin.

(9)

The rationale of electronarcosis is, according to Medlicott, therapy1.M

«as obscure as any other form of socalled 1shock He does however state that

. . . know that there is a stimulation of the auto­ nomic nervous system more prolonged than electric shock therapy and an increase in circulating thyrotrophic hormone with hypertrophy of thyroid, adrenal, and gonad presumably due to pituitary activity. (45) Theories that involve brain enzymes.

Wortis, in his

review of physiological treatment for 1948, summarized as follows: A number of agents which can induce psychiatric dis­ orders, such as cocaine, quinine, atabrine, atropin, or hyperventilation, all inhibit acetlycholine production, and several agents which can relieve psyehoses, such as electroshock, insulin hypoglycemia, and carbon dioxide inhalation, all promote acetylcholine synthesis. (94) Theories that involve the concept of reduction of corticai activity.

Shock treatment has a depressant effect

and, according to Berrington, the convulsion or hypoglycemia reduces the activity of the cortex more permanently than the barbiturate s• Shook treatments decrease cerebral function.

Kennedy

has advanced the hypothesis that a temporary gross lowering

19 of activity results which when restarting again acts in the normal rhythm of activity*

(35)

The coma also has been credited as the common thera­ peutic factor in all forms of shock therapy. THE PREDOMINATELY PSYCHOLOGICAL THEORIES: The various psychological theories may be considered under four major subdivisions* theories have been presented*

Within each, one or more Some of these concepts fall

into more than one of these subdivisions, consequently,

these

have been classified according to the major emphasis of the theory. Theories that involve the concept of transference. According to Meier the more intimate contact with physician and nurses produced by 1shock1 treatments exerts a marked psychotherapeutic effect on the patient.

(35)

The apparent improvement, Katsenelbogen attributes to the accessory features of the treatment such as nursing, attention, and relation to the physician.

(25)

As a result of the treatment, Schatner feels that the patient becomes more helpless, sick, and dependent and the physician becomes a mother surrogate to the patient and, therefore, a better transference is formed and the patient

20 becomes psychotherapeutically more approachable.

(73)

Theories that involve the concept of emotional catharsis.

The various emotional and motor phenomena

occurring during hypoglycemia constitute an emotional cartharsis.

G-lueck states that the entire situation might

be viewed . • . as a highly condensed recapitulation of the process by means of which the fate of the ego dystonic impulses is determined, a process, which takes place normally, in the case of ontogenetic development and artificially in the course of psychoanalytic therapy. (73) Theories that involve the concepts of fear, punishment, and/or destruction and regrowth.

The view that fear is of

primary importance in shock therapy is held by Rubenovich, who states that the fear produced by the treatments is the therapeutic agent.

(35)

MThe treatment represents a punishment to the patient for his sins,B according to Mellet and Mosee;

this means that

. . . the treatment is desired because it is felt to be a fitting punishment acceptable from the hands of a trusted and kind doctor-father who really wishes to do no injury but to temper retribution with mercy. (35) 11In the psychoses the pathologic ego dominates the healthy one which experiences a rebirth and fortification through insulin.11

Bychowsky goes on to say that “the

cathartic abreaction then permits psychoanalytic approach and influence.11

(35)

21 The following hypothesis was advanced by Jelliffee, The main factor in the shock treatments is the psychic 1shock,1 i.e., the patients undergo the experience of impending death followed by the feeling of rebirth and the impetus of these sensations is so great that it breaks the autism of the patient and eliminates the regression and narcissism, (35) Others feel the threat of death mobilizes all the vital instincts in the patient, who now tries to overcome this threat, reappraising reality and accepting it.

(35)

The “dissolution-reconstruction11 hypothesis of Delmas Marsalet is that the coma represents a dissolution, and waking from the coma represents a reconstruction of psychic activity.

Cossa expresses it thus:

Figuratively, one may say that beginning with a given psychic configuration, dissolution reduces it to scattered fragments. Reconstruction must make use of these same fragments, but according to a new plan. This reconstruction phase does not simply reproduce in reverse the dissolutional phase; the various functions as re­ stored present spatial and temporal differences. He continues that in electronarcosis the treatment produces dissolution of greater duration than electroshock therapy and so is more effective with the relatively well developed and resistant psychotic organization such as paranoid schizo­ phrenia.

Functional dissolution does not require irreversi­

ble brain damage and there is little evidence to support the view that the various forms of “shock11 treatment produce clinical improvement in direct proportion to organic brain

22

damage.

(45) Theories that Involve the concept of amnesia.

Some

claim that the amnesia produced in convulsive treatment is the therapeutic factor, i.e., the release of inner tensions and transformations that occur in the resolution of the amnesic period. the predominately psychosomatic

theories;

Some of the theories concerning the mode of action of shock therapy tend to emphasize an interaction of the physical and the psychological reactions of the individual to the treat­ ment.

Three such theories are presented below. The theory offered by Schilder is that

The victory over the death threat, expressed in the epileptic fit and lingering on in the perceptual and aphasic difficulty, enables the individual to start life and relations to human beings all over again. But the effects of the treatment are deeper than the effects of just plain psychic influence. This is an organic treatment reflected in psychologic attitudes. The forces liberated by the treatment come from layers which are generally not accessible to the processes usually called psychic. (35) The effect of shock therapies is the release of patho­ logical inhibitions of emotions by stimulating the adrenal and sympathetic systems.

Yacorzynski also feels that

lobotomies also produce a release of emotions by removing inhibitory influence of the cortex on the hypothalamus*

(96)

Pathological symptoms are newly learned habits of response as contrasted with older ones and are more unstable and susceptible to breakup by metabolic shock.

Reiss and

Berman found that the effect of insulin varies with age or stability of habit system involved.

Insulin has a greater

disintegrative effect on learning of a habit which has been less well fixed than on one of greater fixation. Kennedy feels that shock treatments decrease cerebral function, i.e., a temporary gross lowering of activity acts in restarting the normal rhythm of activity. In concluding this presentation of a number of theories on the mode of action of shock therapy one should keep in mind the statement of Kalinowsky that Broadly speaking it can only be stated that shock treatment is an unspecific form of treatment, acting as a special form of sedation and stimulation on certain types of abnormal mental activity. . . . at present we can only say that we are treating empirically disorders whose etiology is unknown with shock treatments whose action is also shrouded in mystery. (35) The preceding review of the literature on the theore­ tical effects of ICT and EN provide a perspective of theproblem which adds meaning to the subsequent presentation of specific evaluations of these two therapies.

24 III,

STUDIES ON THE EVALUATION OF NO SHOCK, ICT AND EN THERAPIES

A survey of the literature pertaining to evaluations of therapy of schizophrenic patients showed two major types of researches:

(l) psychiatric evaluations; and (2) psycho­

logical evaluations of changes that occurred in the patients* Most of the studies reported utilized only one of the above mentioned methods of evaluating therapeutic results although some of them did use both types of data, as was done in this investigation.

In the presentation of an abstracted review of

pertinent researches this dichotomy has been maintained as far as possible.

The first part of this section contained

those studies which had as their primary source of data the psychiatric evaluations of behavioral changes that occurred in schizophrenic patients.

The second section presented

those studies which had as their primary s o w e e of data the psychological or both psychological and psychiatric evaluations of changes that occurred in schizophrenic patients*

These two

types of evaluations (psychiatric and psychological) of changes that occurred in schizophrenics have been made on patients who had received no specific treatment as well as on patients who had received various kinds of somatic treat­ ments*

Many of the researches concerned with the Investiga­ tion of the schizophrenic patients, that have appeared in the Journals since the advent of the «shock11 therapies, have lacked control groups*

This has been especially true for

those studies which attempted to determine the therapeutic value of EN.

It was felt, therefore, that it would be of

value to present some investigations that had been made prior to the use of the shock therapies, wherein no specific treatment had been administered to the patients, other than general hospital care.

In each of the two major divisions

(psychiatric and psychological) of this section, abstracts of studies concerned with changes that occurred in schizophren­ ic patients who had received no specific treatment, have been presented.

These will be followed by gome typical abstracts

of studies concerned with changes that occurred in schizo­ phrenic patients who had received IGT.

Then some abstracts

of studies concerned with changes that occurred in schizo­ phrenic patients who had received EN have been presented. A.

Psychiatric Studies Made Prior to the Use of the H Shock11 Therapies

Rennie (59) reported on five hundred schizophrenic patients who had been admitted to a hospital between the years of 1913 and 1923.

Since his study was completed in 1939, he

allowed between sixteen and twenty-six years for the study of

some of the patients.

He did not, however, include those

patients that he considered as chronically ill or as severely disturbed bed patients.

At the time of discharge

from the hospital 11.97 per cent of the patients were con­ sidered well, 30.11 per cent were considered improved, and 57.34 per cent were considered unimproved.^

After a period

of twenty years, 222 of these patients were reevaluated.

At

that time 27 per cent were well, 13 per cent were improved, and 60 per cent unimproved.

He found that of those patients

admitted to the hospital, 33 per cent never left the hospi­ tal, and of those patients discharged from the hospital, 32 per cent were never readmitted. Malamud et al (44) reported on a study of 309 cases of schizophrenia who had been admitted to a hospital between the years of 1929 and 1936.

Of this group, 147 were men and

162 of these patients were women,

fhe authors used a five

point rating scale and evaluated the change of condition of all patients at the time of discharge from the hospital. Of the total group of patients, 17 per cent were rated as recovered,

9 per cent as social recovery, 4 per cent as

pronounced improvement, 7 per cent as slight Improvement, and 56 per cent as no improvement.

One hundred and seventy-

® Discharge from a neuropsychiatric hospital does not necessarily mean that the patient has recovered.

seven of these patients were re-evaluated after a period of five years*

At this time, the authors rated 14 per cent as

showing recovery, 8 per cent as showing social recovery, 3 per cent as showing pronounced recovery, 7 per cent as show­ ing slight improvement, and 58 per cent as showing no im­ provement*

They commented on the lack of uniformity of

evaluating both the original condition of the patient and the condition of the patient at the later evaluation* Cheney and Drewry (10) reported on their study of five hundred schizophrenic patients, none of whom had been admitted to the hospital after 1935*

This group included two

hundred men and three hundred women*

At the time of the study,

486 had been discharged, six had died, and nine were still In the hospital*

They used a four point rating scale and then

regrouped their findings into a dichotomous one of improved and unimproved*

The Improved category included the first

three categories of the prior scale and the unimproved category was the same for both scales*

At the time of discharge, the

Investigators found 7 per cent of the patients recovered, 16 per cent much improved, 16 per cent improved, and 61 per cent unimproved*

On the two point scale, 39 per cent of the

patients were rated as improved and 61 per cent were rated as unimproved.

In a later followup of these patients that

the authors made, they found that when last heard of, 59

per cent ©f the patients were unimproved, 43 per cent were in hospitals, and 1© per oent were deceased.**

All of the

patients Included in this study had been observed for at least two years and some for a period of time as great as twelve years.

All of the patients were considered as

representative of a population of middle economic status, since the hospital was a semi-private Institution requiring some payment and not a free public hospital.

The authors

defined the various categories used in their rating scales. Osborne (49) reported on a study conducted with 491 schizophrenic patients.

Of this group 339 of them were

first admissions to a mental hospital and the remaining 152 patients had been in and discharged from a mental hospital at some time prior to the beginning of Osborne1s study.

He

organized his data on the basis of the various subtypes of schizophrenia and as to whether the patient had been paroled or not.

He found that 44 per cent of the patients

who were first admissions to a mental hospital were paroled while 37 per oent of the patients who were read­ missions to a mental hospital were paroled. Summary.

A summary of the above described investi­

gations has been presented in Table 1.

A wide range of

® Results taken from publications of other studies have been given as originally reported. At times these re­ sults, when expressed in per cent, failed to total to one hundred per cent.

TABLE I PSYCHIATRIC STUDIES OF IMPROVEMENT IN SCHIZOPHRENIA WITHOUT 11SHOCK H THERAPY

Number of Investigator Patients

Per cent Improved*

Comments Time discharged from hospital. Twenty years later.

*

500

42

222

40

309

30

227

25

Cheney

436

23

Time discharged from hospital.

0 sborne

339

44

152

37

491

41

Paroled first admissions -— at discharge. Paroled re-admisslons — at discharge. Combined group — at di scharge.

Rennie

Malamud

Time discharged from hospital. Five years later.

For the purposes of constructing this table and Tables II and III, the findings of each investigator were combined into the categories of improved and unimproved.

findings have been revealed in this table*

The percentage

of spontaneous Improvement ranged from a low of 23 per cent to a high of 44 per cent, with the median at 39 per cent and a mean of 34 per cent.

If only the data that was obtained

as a result of evaluations made at the time of discharge from the hospitals were considered, the percentage of spon­ taneous Improvement ranged from a low of 23 per cent

to a

high of 42 per cent, with the median at 39 per cent and

a

mean of 36 per cent. An evaluation of these varied results as well as those of the next two sections has been presented further on in this chapter* B.

Psychiatric Studies With IGT

Psychiatric evaluations of the results of IGT of schizophrenia have shown a wide range of results.

Table II,

arranged in chronological order and presented below, summa­ rized the findings of pertinent researches in this area*

A

number of these investigations compared the IGT improvement data with data obtained from control cases.

In all but two

of the Investigations this comparison was between IGT patients and patients who had not received any specific therapy other than hospitalization.

In one of these ex­

ceptions, Hotkin (48) administered salt solution to the control group and in the other exception, Garmany (17)

compared the IGT group with a group of patients who had re­ ceived “other shock therapies.”

This latter study, although

included in the column entitled 1controls1 was not included in the compilation of the mean and median of the IGT control data. In those studies where controls were reported, the percentage of patients who had “spontaneous” Improvement ranged from a low of 14 per cent to a high of 59 per cent, with a median of 22 per cent and a mean of 26 per cent.

In

considering only the data that was obtained as a result of the evaluations made at the time of discharge from the hospital the percentage of “spontaneous” Improvement was found to range from 15 per cent to 58 per cent, with a median of 33 per cent and a mean of 28 per cent.

It may be

seen from Table II that the percentage of Improvement found in the various studies for those patients who received IGT varied between 10 per cent and 80 per cent, with a median of 57 per cent and a mean of 48 per cent.

If the data that

was obtained as a result of the evaluations made within one month after the termination of treatment was considered, the percentage of patients who improved in the different investi­ gations varied from 10 to 80 per cent, with a median of 48 per cent and a mean of 49 per cent.

Every study that re­

ported a control group had results that tended to favor the IGT group.

The greatest amount of difference between the

TABLE II PSYCHIATRIC STUDIES OF IMPROVEMENT IN SCHIZOPHRENIA WITH ICT x Investigator

No. of Patients Percent Improved 'controls ISS dontrols

Wortis Ross Notkin Bateman

30

« __ Comments

63

1089

1356

15

35

69

100

22

36 Controls received salt injections

325

416

39

44

Heilbrunn

78 90 147

Lieberson 165

165 165

72 Sick less than 6 months 54 Sick between 7 and 18 months 10 Sick more than 18 months 22

58

87

McKendree

34 Termination of treatment 30 Between 7 mos. and 3 yrs. 9 mos. later to 4| yrs. after treatment

Gottlieb

132

66

33

35

Bond

100

251

16

100

49 138

16

54 Time left hospital or end of ICT 41 5 years later 66 When last heard from 251 out of 564 yrs. health for ICT 78 out of 551 yrs. health for Controls

876

1128

59 44

Temporary Commis­ sion, New York

80 Discharged from hospital 59 End of study

TABLE II (continued) PSYCHIATRIC STUDIES OF IMPROVEMENT IN SCHIZOPHRENIA WITH ICT , Investigator Oarmany

No* of Patients controls ICT 100

Reznick

15

309

Bond

Finiefs

100

Percent Improved Controls fiJS

446

378

126

70 Controls received other shock 49 47 43 37

35 14

Comments

Termination of treatment 1 month later 1 year later 5 years later

54 Termination of treatment 38 5 years later IGT 3 months less in hospital 49 2 weeks after termination of treatment

0)

34 percentage of improvement found for a control group and the percentage of improvement found for the ICT group, in the same Investigation, was a difference of thirty-eight per cent*(6)

This excluded the study in which the control

group received other *types of shock therapy11 (17) where the difference between the percentage of improvement for the control group and the IGT group was 55 per cent.

The

least amount of difference found between the percentage of improvement of a control group and the ICT group, in the same investigation, was only 2 per cent.

(22)

For present purposes it will suffice to cite a few studies illustrating these researches*

Since results

varied greatly, a study that was highly favorable and one that was highly unfavorable and one that was between these have been cited.

Abstracts of the remaining studies

summarized in Table II, page 32, have been placed In the appendix* Of those studies quoting highly favorable results with IGT, that of the Temporary Commission on State Hospital Problems. (99) has been abstracted below. One of the most extensive and frequently referred to studies was the one conducted by the Temporary Commission on State Hospital Problems*

(99)

The Commission1 s report was

based on a study of 1,128 schizophrenic patients who re­ ceived ICT at the Brooklyn State Hospital between January 1,

1937 and June 30, 1942, and 876 schizophrenic patients who had received no specific somatic therapy, and had been admitted to the other Metropolitan New York mental hospitals but were otherwise comparable to the insulin treated group of patients*

The patients of the eontrol group had been

hospitalized during the same period of time (between January 1, 1937 and June 30, 1942) as those patients who received ICT*

Among the criteria used for indicating the results

of the shock therapy as well as the condition of the patients of the control group were the subsequent ability of the patients to live outside the hospital,

the length

of time the patients were able to remain out of the hospi­ tal, the length of hospitalization, and the extent to which social functioning was restored*

The data were obtained

primarily through personal visits to the patients* homes by experienced psychiatric social workers*

In general, all

findings were in favor of the Insulin treated group*

It was

noted that 79.3 per cent of the ICT group and only 58*8 per cent of the non treated group were able to leave the hospital.

In the paranoid subgroup, where the most marked

difference between the ICT and non IGT patients existed, 70.4 per cent of the former and 52 per cent of the latter group of patients were able to return home.

The average

length of hospitalization was three and two thirds months less for the Insulin treated patients as compared to the

non specifically treated patients*

A greater percentage of

the ICT patients were able to remain outside of a hospital for the entire period of the study than were patients of the non treated group, i.e., 58*3 per cent vs* 44 per cent, respectively.

At the conclusion of the study, 58.9 per cent

of all ICT patients were at home as compared to only 44 per cent of the untreated'patients.

Of

the insulin treated

patients 55 per cent were functioning in a useful capacity at home as compared to 40.5 per cent of the non insulin treated patients*

The Commission, in studying the economic

factors related to the administration of IGT, took into consideration the length of hospital stay prior to dis­ charge, length of time at home continuously from date of release from the hospital to the time of the study, and the length of time spent at home and in the hospital for those patients that had had subsequent hospitalization.

In com­

paring the two groups of patients, the Commission found a savings of approximately 286,695 days of hospital care in favor of the ICT group. hospitalization,

As a consequence of the reduced

the Committee estimated that a savings,

in the cost of food and clothing alone, of approximately $80,274.60 resulted.

This estimate did not include the

probable economic savings in maintenance costs, constructions for additional bed space, and so on.

This estimation also

did not take into account the additional number of patients

37 that could be accommodated and treated In the hospital. Of those studies quoting results near the averaged findings of the other studies shown in Table II, page 32, is that of Bond and Rivers.

(6)

They reported on their

study of 251 schizophrenic patients who had received IGT. They also investigated one hundred schizophrenic patients who were used as controls*

These patients had been hospita­

lized and discharged prior to the advent of the 11shook11 therapies.

At the end of their hospital stay, sixteen of

this group of one hundred non wshockw treated patients were considered as recovered or much improved.

Five years later

sixteen of this group were again considered as recovered or much improved. ported as well.

Six to seven years later fourteen were re­ At the end of treatment 138 or 54 per cent

of the 251 schizophrenic patients who had received ICT were considered as recovered or much improved. group of 138 recovered patients,

Of the original

forty-nine were re­

evaluated as to their condition five years after the termination of treatment.

At this time twenty-two or 41

per cent had maintained their initially Improved status. Based on Information obtained when these 138 Improved ICT patients were last seen (the time interval between this observation and discontinuance of treatment was quite varia­ ble) their condition, as noted, was as follows: eight,

eighty-

(64 per cent), were recovered or much improved;

twenty-five,

(18 per cent), had relapsed; four,

had relapsed and then improved; five, part of their gains; and sixteen, an irregularity of progress*

(3 per cent)

(4 per cent), had lost

(12 per cent), had shown

A novel method of comparing

IGT with no specific treatment was utilized by these authors They computed the approximate number of years of health available to each group on the basis of the time of the study and the time of discharge from the hospital.

They

found that 251 years of mental health out of a possible 564 years,

(44 per cent) was enjoyed by the group of patients

who had received IGT while only seventy-eight years of mental health out of a possible 551,(14 per cent), was ex­ perienced by the untreated group.

The authors also stated

that they thought that the quality of the improvement was better for the IGT patients as compared to the non ICT patients.

In the words of these investigators:

The years of health given are more important for the individual patients involved, the family groups in which they are functioning and therefore society in general, than are final statistics concerning the number re­ covered or relapsed at the end of an arbitrarily selec­ ted period of time. (6) Of those studies quoting the least favorable results with IGT, was that of Nothin et al.

(48)

They reported on

their study wherein one hundred schizophrenic patients received IGT and sixty-nine schizophrenic patients, used as a control group, received a salt solution.

They found that

36 per cent of the patients who received insulin showed

various degrees of improvement, while 22 per cent of the patients who received the salt solution showed any com­ parable improvement! C.

Psychiatric Studies With EN

Psychiatric evaluation of the results of EN therapy of schizophrenia have shown, as in the case of similar studies of IGT, a wide range of results.

Table III arranged

in chronological order and presented below summarized the findings of pertinent researches in this area*

None of

these investigations included a control group with which to compare their findings of Improvement that occurred In the patients who had received EN*

In five, or just more than

one half of the IN investigations listed, the number of patients included was relatively small ranging from a group of nine to a group of twenty* It may be seen from Table III that the percentage of improved patients found by the various investigators, for this type of treatment of schizophrenia, varied between zero per cent and 83 per cent, with a median of 53 per cent and a mean of 51 per cent*

It should be noted, that the

first three investigations shown in Table III had results a great deal more favorable to EN than were the findings In the remaining seven studies.

All three were conducted

either by Tietz, or by Tietz and co-workers*

TABLE III PSYCHIATRIC STUDIES OP IMPROVEMENT IN SCHIZOPHRENIA WITH EN

_ ^ Investigator

Number of Patients

Per:Cent Improved

4?

76

and C.Q. higher 1 month after treatment

42 18 20

83 78

1 month after treatment Grade A recovery Is promising - may replace ICT

9

0

Uniformity of results obvi­ ates need of large numbers ^treatment neither effec­ tive nor safe”

Bowman

37

19

About equal to EST

Medlicott

16

62

Compares with EST

Geohagan

16

56

Rezniok

74

31

Goldman

17 25 42

63 40 50

Tietz Tietz Tietz Patterson Garmany

Comments

Private patients State Hospital patients Above two groups combined

41 For present purposes it will suffice to cite a few studies illustrating these researches*

Since results varied

greatly, a study that was highly favorable and one that was highly unfavorable and one that was between these have been cited*

Abstracts of the remaining studies summarized in

Table III, page 40, have been placed in the appendix# Of those studies quoting highly favorable results with EH, that of Tietz et al (84) has been cited*

Their

study was the first one concerning Itself with the effec­ tiveness of this technique as a form of treatment for schizophrenia.

They reported on the results of the use of

this technique of treatment when administered to fortyseven schizophrenic patients, twenty men and twenty-seven women*

While the statement appeared that all had been ill

less than two years, the authors later commented that all cases were of recent onset except three of the failures which were over two years in duration.

The therapeutic

findings were grouped into four categories, labelled A, B, G, and D*

Nineteen or 4© per cent of the patients had

“A 11 recovery or 11complete remission with insight11; seventeen, or 36 per cent of this group had 11B M recovery or w social adjustment with some personality defects1*; five or 11 per cent had 11C“ recovery or 11some improvementM; and six or 13 per cent had l,D w recovery, or *no change*M

The authors

also reported their findings as 76 per cent recovered

42 (A and B combined), 11 per cent improved, and 13 per cent failures.

A further comment was made that the IQ and CQ

were higher after treatment and that memory defects were rare although they gave no substantiating evidence for these statements. Of those studies quoting results near the averaged findings of the other EN studies shown in Table III, page 40, was that of Goldman (El) who reported on his observa­ tions covering two years experience in the use of EN with 125 patients.

Forty-three of them were State Hospital

patients and the other eighty-two were private patients, some of whom were patients that the author treated for other physicians.

He noted that,

With few exceptions, the patients had all been sub­ jected to other forms of treatment which had produced little or no Improvement and were in the poor prognostic situation of having been ill for long periods. (21, p. 405) The diagnostic groups given EN and included in this investi­ gation . . . were chiefly schizophrenia, paranoid and catatonic; manic depressive psychoses; involution psy­ choses; psychoneuroses with chronic compulsive anxiety; and a few scattered other groups chiefly for experi­ mental reasons. (21, p. 405) Only those patients under the control of the author were Included in the tabulated findings which included twentyfive of the State Hospital patients and seventeen of the private patients, all of whom were diagnosed as

43 schizophrenic,

the findings were as follows:

of private schizophrenic patients,

three,

in the group

(17 per cent), were

considered as being in complete remission: eight, cent), as social recovery: five, and one,

(46 per

(3© per cent), as improved:

(6 per cent), unimproved.

Gf the twenty-five

schizophrenic patients who were state hospital inmates, two, (8 per cent), were considered as being in complete re­ mission; eight,

(32 per cent), in social recovery; ten,

per cent), in improved status; and five, unimproved status.

(40

(20 per cent), in

By combining the two groups the results

of the therapy were as follows;

12 per cent complete re­

mission, 38 per cent social recovery, 36 per cent improved, and 14 per cent unimproved. Of those studies quoting the least favorable results with EN, was that of Bowman, et al.

(8,26)

In a series of

three articles related to the use of EN they reported on the clinical evaluations ©f behavioral changes (8), the physiological effects of treatment, and the psychological test findings before and after treatment.

(26)

Since the

physiological effects of treatment are outside the scope of the present Investigation, the second of the above mentioned articles will not be abstracted herein.

A summary of the

psychological test findings will be presented in a subse­ quent part of this chapter.

The first publication (8) gave

the composition of the group, details of treatment, etc.

44 common to the three studies*

There were fifty-three

patients, Included in these studies, thirty-seven of whom were schizophrenic and the remaining sixteen patients were either manic-depressive or psychoneurotic.

The patients in­

cluded in the schizophrenic classification were individuals who apparently had had an insidious onset of the disease; those who had been 111 for more than one year; and many of them had received other 11shock** treatments which had failed to bring about any significant Improvement in their con­ dition*

All were under forty years of age and voluntary

admissions to the hospital*

It could be said, however,

that the recovery prognosis for this group of patients would be poor* All of the patients were evaluated as to their psy­ chiatric condition one month, six months, and one year after the cessation of treatment.

These evaluations were

made by psychiatrists who formed their opinions on the basis of direct interviews with the patients and on infor­ mation received from the patient1s relatives by means of written correspondnece *

A fourfold rating scale was used

with the various categories well defined*

The electrical .

machine and technique of administration of treatment was thoroughly described.

Four of the schizophrenic patients

had such increased excitement while undergoing treatment, that the psychiatrists felt that It was necessary to

45 discontinue this treatment for these four patients*

One

month after the termination of treatment seven of the f

thirty-seven schizophrenic patients (19 per cent) were con­ sidered recovered*

Thirty-one of the patients received seven

or more treatments and only five, showed recovery*

The findings were analyzed on the basis of

six groupings of the patients. very large,

(16 per cent), of them

None of these groups were

since the total number of patients was only 37,

consequently the largest of the sub groups was thirteen and the smallest only three. were as follows:

The findings, briefly summarized,

Of nine patients that had had one acute

attack and had been ill for less than three months, four showed recovery, one much improved, one improved, and three no change.

Of the six patients who had had one or more

psychotic attacks between three months and two years prior the starting of EN therapy, three showed recovery and three no change.

Of the thirteen patients who had had an in­

sidious onset of the disease and with a period of more than two years since this onset, one was much improved, four improved, and eight no change.

Of the three patients who

had had two or more psychotic attacks and with one of these beingnore than two years prior to the beginning of EN therapy none showed any change.

The same results (no change) were

true for the six patients who had been continuously psy­ chotic for more than two years.

In the opinion of these

Investigators, EH as a method of treatment for schizo­ phrenia was H• . . equivalent to ESTB (electroshock thera­ py)#

The comment was made that memory disturbances were

not particularly marked* D*

Summary of Psychiatric Researches

As can be observed, in the above three tables, pages 29, 32 and 40, there was a large variation within each type of study in the findings of the different in­ vestigators#

This large amount of variation in the findings

of the different investigators indicated some of the diffi­ culties in evaluating psychiatric research*

Some of the

factors involved in producing this lack of uniformity of results are the following: 1.

The various types of treatment have not been

fully standardized, consequently variations in techniques of treatment are multifold* 2*

The degree of chemical purity of the insulin

may vary considerably. 3*

The type of current and the particular con­

struction of the EN instrument may differ in the various installations. 4*

The selection of the patients may vary from

doctor to doctor* 5.

The criteria of diagnosis has not been completely

47 standardized so that diagnostic impressions may vary. 6.

There are no hard and fast criteria for assessing

the degree of improvement or lack of improvement. 7.

Many of the studies lacked control groups, or

when control groups were used, it was questionable as to how nearly they were comparable to the experimental groups. 8.

Frequently variables other than the experimental

ones had not been controlled or equated for the groups, such as attention from other hospital employees or the use of other therapeutic facilities. 9.

When attempting to evaluate a new technique the

hospital staff may devote much more time and attention to those patients who are In the experimental group, even though care has been taken to give all patients comparable treatment• 10.

Practically all research reported is a by­

product of the routine hospital work.

That is most of the

attempted research has not been planned in advance, and, therefore, lacked the essentials of good research design. 11.

Most medical researchers lack any statistical

knowledge and frequently reported results as significant which could readily have resulted from particular method of population selection. The range of the findings of psychiatric studies of the results of EH, ICT, IGT controls, and spontaneous

improvement has been so great that there has been a good deal of overlapping of the obtained results.

Table IV

was constructed so as to more easily compare the different types of studies by means of the central tendencies of each group of researches.

As indicated in this table, the

studies made prior to the advent of the shock therapies showed more favorable results than the control groups Included in the IGT studies.

This has been evidenced by

the fact that the range was smaller, the median and mean higher for the spontaneous improvement studies than for the controls of the ICT studies.

On the other hand, the

two types of treatment appeared to be fairly comparable Inasmuch as the medians differed by only four points and the means by only three points.

The differences between

either of the two types of treatment researches (IOT or EM) and either the IGT controls or the spontaneous improvement studies was rather large and favorable to the treatment groups. The data presented in Table IV was the result of combining all the findings within each of Tables I, II and III (pages 29, 52 and 40).

Since the evaluations of im­

provement were made within two weeks after the termination of treatment, in the present investigation, it was felt that the data in Table IV was inappropriate to this study. The data, therefore, was recomputed including only those

49

TABLE IV COMPARISON OF TYPES OF PSYCHIATRIC STU1IES

Range

Median

Mean

Spontaneous Improvement

23-44

39

34

IGT Controls

14-59

22

26

ICT

10-80

57

48

0-83

53

51

EN

studies that satisfied one or both of the following criteria (1) If no specific treatment, had been given the evaluations of improvement had been made at the time of discharge from the hospital; and (2) if treatment had been given (either IGT or EH) the evaluations of improvement had been made within one month after the cessation of treatment.

The

findings were almost identical to that of Table IV, page 49,

(within two points) with two exceptions.

In one In­

stance the IGT control group had a median eleven points greater (33) than In Table IV, page 49, which was much closer to the median of the "spontaneous11 Improvement group.

The second exception was that the median for the

IGT group was nine points less (48) than in Table IV, page 49.

This reduction of the IGT median made it about as much

below the EM median (difference of four points) In Table IV, page 49.

This data again tends to favor the "shock" treat­

ments as compared to non-specific treatment. E*

Psychological Studies Made Prior to the "Shook" Therapies

Those investigations that have been presented so far in this chapter have included only those that primarily utilized psychiatric evaluations of behavioral changes that occurred in schizophrenic patients.

The studies that have

been reported in the following three sections of this

51 chapter were those that included psychological evaluations of changes that occurred in schizophrenic patients*

'These

investigations may have utilized only psychological evalu­ ations or both psychological.and psychiatric evaluations of behavioral changes*

A similar order of presentation has

been maintained in the following sections as was used in the earlier part of this chapter, the use of 11shock" therapy;

i.e*

(l) studies without

(2) studies involving the use

of ICT; and (3 ) studies involving the use of EN therapy. Within each of these three categories,

the material has

been presented in a chronological order. Rabin (58) reported on his study of sixty hospitalized neuropsychiatric patients.

Thirty of them were schizo­

phrenic with an average age of 28.1 years.

They were tested

and retested with the same form of the Wechsler-Bellevue Intelligence Scale.

The period of time that elapsed between

the first and second testing varied for each patient with the minimum being one month, the maximum being thirty-five months and the average being thirteen months. special treatment was given these patients,

While no

they were re­

tested after some clinical improvement had been observed. He found,

for the schizophrenic group, that 20 per cent

showed a loss of more than five I.Q* points, 50 per cent showed a gain of more than five I.Q. points, and that 30

52 per cent showed no change or a change of less than five I.Q. points.

The findings given below show the test administered,

the weighted score of the first testing, weighted score of the retest.

followed by the

Information 10 - 9.9,

comprehension 9.2 «. 8.7, arithmetic 7.7 - 8.4, digit span 7.4 - 8.8,

similarities 8.5 - 8.8, picture completion 7.3 -

8.3, picture arrangement 7.2 - 7.2, object assembly 8.5 10.1, block design 8.5 ~ 9.6, and digit symbol 7.1 - 8.5. The major Increases were in object assembly (1.6 points), digit symbol (1.4 points) block design (l.l points), picture completion (1.0 points), and a moderate gain in arithmetic (.7 points).

The investigator noted that the verbal tests

showed comparative stability while changes were noted in the performance tests, especially in those tests that involve a speed factor.

He also commented that the obtained

rise in mental level appeared to be due to (l) an improve­ ment in the patient1s condition, and (2) to a practice effect in taking the same test twice. F.

Psychological Studies With Patients Who Received IGT

Jastak (34) subjected seventeen schizophrenic patients to psychological testing Just prior to and subse­ quent to their receiving IGT.

A period of eight to twelve

weeks elapsed between the first and second testing.

The

53 tests administered were the Stanford-Binet (1916), Terman vocabulary test, and the army individual performance scale, and a memory series (reversing digits).

He used a con­

stant fifteen year divisor to obtain the various quotients for each of the tests administered. follows:

His findings were as

in the vocabulary test the mean score changed

from 105 to 106; in the Stanford-Binet the mean I.Q. score increased from eighty-three to ninety-three; in the army individual test the increase was from seventy-five to eighty-six; and in the memory test the increase was from fifty-nine to seventy-two.

He also examined his data of

psychiatric ratings of recovered (none), social improvement (two patients), improved (ten patients), and unimproved (five patients).

He compared the highest and lowest mean

quotients (of the four tests combined) obtained by the patients before and after treatment.

He found that there

was a decrease in range from forty— six points to thirtyfour points.

In the socially recovered group (two patients)

the difference of the obtained quotients after treatment was only seven points, while in the improved and unimproved groups the differences were thirty-five and thirty-seven points respectively.

No change was noted in the vocabulary

test although the following changes were noted for the socially recovered, respectively*

the improved, and the unimproved groups

Stanford-Binet - twenty-six points, eleven

54 points, and two points; army individual test - twenty-three points,

twelve points, and four points; memory test - forty-

four points,

seven points, and one point loss,

fhe author

commented that the psychometric findings were apparently in close agreement with the psychiatric evaluations of changes. Wechsler et al (89) administered thirty psychological tests to twenty male schizophrenic patients who received IGT.

They were all between the ages of eighteen and thirty.

All of them were first admissions to a neuropsychiatric hospital.

The tests were administered prior to treatment

and Just before their discharge from the hospital or comitment to the hospital.

Inasmuch as the investigators were

trying to develop a prognostic battery only those findings that were obtained with fifteen of the tests were reported. The tests included in the final report were comprehension, information,

Stanford-Binet vocabulary, army alpha direc­

tions, digits forward, digits backward, reproducing a paragraph,

similarities, words in three minutes, counting

by three1 s, counting backward from twenty to one, draw a man, Rorschach, moral discrimination, and vocational interest.

The authors noted that vocabulary showed little

change but that 11tests of mental control or speed of asso­ ciation and sustained effort of attention showed the greatest changes."

(89, p. 475)

The patients were rated

by a psychiatrist on a fourfold scale immediately after

55 treatment and again between six and eighteen months after treatment*

The psychiatric ratings were regrouped into

the two classifications of improved and unimproved.

A per­

centage of change of the psychological data was obtained by subtracting the pre-treatment scores from the post-treatment scores and dividing this difference by the pre-treatment scores#

All percentages of change that were less than 10

per cent were given a zero rating, those from

10

to 20 per

cent were given a plus, and those with a percentage of change of 20 or greater were given a double plus rating; similarly, minus and double minus values were given to those percentages of change that were negative#

Fifteen

cases were tabulated for each test on the basis of a plus, a minus, or a zero score.

The findings for some of the

tests are given below in the plus, minus, and zero order: comprehension 8-4-3; information 5-2-8; vocabulary 6-2-7; digits forward 3-5-7; digits backwards 3-5-7; reproducing a paragraph 8-2-4; similarities 5-4-6; words in three minutes 6-2-75 and substitution 8-1-2#

All of these tests except

digits forward, digits backwards, and similarities had a greater number of plus than minus scores, that is more patients showed a gain than a loss.

It should be noted,

however, that in six of the nine tests almost half of the patients (six, seven, or eight) showed less "'than a 10 per cent change.

These investigators also obtained a

56 coefficient of colligation and percentage of agreement between test score changes and the psychiatrists evalua­ tions of much improved or unimproved.

The coefficients of

colligation and percentage of agreement as found for some of the tests are as follows:

comprehension .08-53 per

cent; information *20 - 60 per cent; vocabulary *22 - 40 per cent; digits backward .1? - 47 per eent; paragraph memory .17 - 57 per cent; similarities .50 - 73 per cent; words in three minutes .33 - 67 per cent; substitution .17 - 55 per cent.

The authors noted that the patients

mean score on the test battery (amount of change) at the termination of treatment gave a better forecast of his con­ dition six to eighteen months later than did the psychia­ trist1s ratings made at the same time. Me Neel et al (40) in their investigation of thirtythree schizophrenic patients who had received ICT ad­ ministered a series of psychological tests.

These tests

consisted of the Stanford-Binet, a test for perseveration, orientation (memory), logical thinking, and Healy perception. No statistical data was given but the authors, commented that as the psychiatric rating approached normal so did the psychological test results thus implying a fair correlation between the psychiatric and psychological ratings. Virginia Graham (23) administered the Stanford-Binet, the Kent-Rosanoff, and the Rorschach tests to sixty-five

patients,

thirty men and thirty-five women, all of whom were

treated with IGT.

Sixty-one of these patients were diagnosed

schizophrenic with the following sub classifications: simple, twenty-eight hebephrenic, catatonic.

six

twenty paranoid, and seven

Whenever possible they were tested Just prior to

treatment and about two weeks after the cessation of treat­ ment.

Some of the patients, however, were not retested for

as long as three months after the termination of treatment. Eleven of them were untestable prior to treatment but were testable after treatment.

They achieved a mean mental age

of twelve years six months ranging from a low of eight years, nine months to a high of eighteen years, two months* Five of the patients who were tested prior to treatment were untestable after treatment.

The total mean change in

mental age for the rest of the treated patients,

(thirty-

three in all) who were tested both before and after treat­ ment was one year nine months.

This average change in­

cluded patients who showed a loss in II.A. as well as patients who achieved a gain in M.A.

The U.A. changes,

therefore, ranged from the patient who had the greatest loss of two years eight months to a gain of four years five months.

Actually nine patients had a loss in the obtained

mental age while twenty—four patients had a gain in the obtained mental age.

The investigator commented that there

were some indications of psychological test changes

correlating with psychiatric ratings of changes that occurred in the patients. Wittman and Russell (9E) studied forty-two patients who received IGT and one hundred and twelve patients who received metrazol, all of whom were diagnosed as schizo­ phrenic.

They were tested before treatment, immediately

after the cessation of treatment, and again a year later. While a number of tests were administered to the patients (personal information, paired associates, general informa­ tion, paragraph memory, digits reversed, orientation, and retention of the memory paragraph) they were combined into what the authors called a mental efficiency battery so that data on most of the Individual tests were lacking.

The

only specific test data was on an information test and a paragraph memory test.

The former had a mean score of

57.9 prior to treatment which increased to 67.3 following treatment; the latter increased from a mean score of 36.2 before treatment to 44.2 after treatment.

The authors

noted that Immediately after treatment 85 per cent of the patients showed an Increase on their psychological test scores and 80 per cent of the patients were rated as im­ proved by the psychiatrists. Schnack et al (69) made a study of comparative change s in certain psychological test results that occurred

59 in male schizophrenic patients who received either ICT or metrazol treatment*

A group of fifty schizophrenic patients

was divided into twenty who received ICT, twelve who re­ ceived metrazol therapy, and eighteen who received IGT which was followed by one or more courses of metrazol, but at the time of retesting had received only IGT*

The age range was

from twelve to fifty years, with a mean score of 25*8 years. Eighty-one per cent of the total group had treatment started before the end of their tenth week of hospitalization.

All

patients who were untestable either before or after treat­ ment were excluded from the study*

A control sample was

used which consisted of forty-eight male schizophrenics who were taken from the same wards that the experimental groups were taken from*

This group of patients was comparable to

the patients of the treatment groups as to age, months of hospitalization preceding the first test, time between the first and second testing, mental age as determined at the time of the first testing, and degree of cooperation.

The

control group was not matched with the experimental groups as to clinical condition at any time after treatment, i.e., Improved or unimproved.

The tests administered were the

Stanford-Binet (1916), the Kent-Rosanoff 'word association test, tests of level of aspiration, the Rorschach test, and the thematic apperception test. not analyzed.

The projective tests were

Ratings of improved or unimproved were made

by the psychiatrists immediately after the termination of treatment and at the time of the analysis of the data.

The

period of time that elapsed between the termination of treatment and the second evaluation varied for each patient. The shortest period was one and eight tenths years while the longest period was five and one half years, with an average for the IGT group, of three and nine tenths years.

Seventy-

four per cent or twenty-eight of the thirty-eight testable patients who received IGT showed Improvement, following treatment.

immediately

The authors commented that in con­

sidering the ♦ . . test scores before and after treatment without regard to the outcome of treatment, that in almost every measure the effect of treatment, whether Insulin or metrazol, Is to change the mean In the direction which is considered to be advantageous. (69, p. 131) The specific findings for the patients who received IGT were as follows:

I.Q. increased from eighty-nine to ninety-eight

an Increase of nine I.Q. points, mental age increased from twelve and four tenths years to thirteen and seven tenths years, an increase of one and three tenths years; vocabulary changed from 51.4 to 52.9, an Increase of 1.5; digits for­ ward changed from 6.2 to 6.4, an increase of only two tenths; digits backward changed from 4.5 to 4.8, an increase of only three tenths.

The rest of the findings were on

tests not pertinent to this study and are, therefore, not reported.

The only scores reported for the control group

61 was the M.A. which showed a change from 11.9 years to 12.6 years, a gain of seven tenths years.

The authors noted that

droughly two thirds of the improvement in test scores may be accounted for by whatever it is that the control and the shock-therapy groups had in common.® however,

(69, p. 141)

This,

included the combining of the results of both IGT

and metrazol therapy.

In comparing the control group with

all patients who received IGT (including those who sub­ sequently had metrazol) the gain of the control group was equal to approximately one half of the gain of the insulin group (7 and 1.3 years In M.A. respectively). G*.

Psychological Studies with Patients Who Received EH

To date the only psychological study that has appeared in evaluating the effects of EN Is that of Harris, Bowman, and Simon.

(26)

The details of this study were

presented earlier in this chapter in the section concerned with the psychiatric findings whereih an abstract of the Investigation of Bowman (8) et al was presented.

The pa­

tients were given the Minnesota multiphasic Inventory and four subtests of the Wechsler-Bellevue Intelligence scale, namely comprehension, -symbol.

similarities, block design, and digit

These tests were administered to the patients prior

to treatment and within three weeks after the cessation of

62 treatment.

An estimate was made of the Intelligence quo­

tients of the patients on the basis of the scores obtained on the above mentioned four subtests.

Using this I.Q.

estimate as a measure of intellectual functioning,

(the

authors concluded that no marked changes in intellectual functioning) occurred in patients who had received EN.

It

was noted that psychomotor retardation prior to treatment appeared related to good prognosis,

that is, patients who

responded best to the treatment did better on untimed tests than they did on the timed ones while those patients who re­ sponded poorly to the treatment did equally well on both timed and untimed tests.

Sixteen schizophrenic patients were

tested before and after treatment, of these twelve showed losses averaging four and four tenths points while four showed gains averaging seven and three tenths points with a resultant overall loss of one and a half estimated I.Q. points.

A comment was made that this was the opposite of

what one would e3q>ect from practice effects.

It was also

noted that there was "no consistent relationship between the amount of change and the number of treatments or the out­ come" (26, p. 375) of treatment. H.

Summary of Psychological Researches

Eight psychological researches,

involving the testing

and retesting of schizophrenic patients, were abstracted earlier in this chapter.

One of these was conducted with

patients who had 11spontaneous" improvement, prior to the use of "shock" therapy*

Six of these researches were conducted

with patients who had received ICT and only one of these included a control group*

One research was conducted with

patients who had received EN* The study involving " spontaneous" improvement found a tendency toward improvement in psychological test scores, with 50 per cent of the patients having gained five or more I*Q. points and 20 per cent of the patients having lost five or more I.Q* points. The studies involving the use of IGT all found a general tendency toward an increase of psychological test scores after treatment*

Also, a tendency for psychological

test score improvements to correlate with psychiatric ratings of improvement was found in all six of these studies#

In

the one study that included a control group, it was found that the increase in M.A* in the control group was about equal to one half of the increase in M.A* in the experi­ mental group. The one psychological study involving the use of EN found only a little change in test scores which was in a negative direction.

CHAPTER III THE EXPERIMENTAL DESIGN I.

THE PROBLEM

The major purpose of this investigation was to determine the comparative effectiveness of ICT and EH treat­ ments of schizophrenia hy means of psychological test changes, and psychiatric evaluations of behavioral changes and the relationship between these two independent evalua­ tions. II.

SELECTION OF PATIENTS

The patients were selected for this study by the application of the following criteria: 1.

Diagnosis:

Schizophrenia

2.

Sex:

Male

3.

Age:

Under forty years

4*

Eligibility:

Veteran of U.S. armed forces during

World War II 5.

Consent:

Consent of both patient and responsible

parent or guardian 6.

Duration:

Illness less than two

7.

Physical condition:

years

Capable of receiving either

type of treatment, i.e., those patients whose physical condition barred their receiving one of

the two treatments were excluded from this study 8.

Contact:

Sufficient reality contact so as to he

capable of taking the psychological tests 9*

Suitability:

Unanimous agreement of a board of

three psychiatrists that “shock1* treatment was appropriate Those patients who satisfied the criteria indicated above were alternately placed in one of the two experimental treatment groups*

That this random method of selection

yielded equivalent groups, in respect to the psychological functions studied in this investigation, was later demonstra­ ted on the basis of the psychological tests administered prior to the initiation of the experimental procedures. One hundred subjects were selected but at the time of evaluation of the findings of this study, it was found that forty-two of the patients could not be Included. reasons for this were as follows:

The

(l) Twenty patients had

left the hospital, at their own request, prior to the com­ pletion of treatment.

(2) Eighteen of the patients had not

been tested both before and after treatment.

(3 ) Two of

the patients had to have their treatment changed from one type to the other.

(4) Two ©f the patients died.

There

were, therefore, fifty-eight patients included in the two experimental groups.

The composition of the two groups, in

terms of age and diagnosis, was as follows:

the IGT group

consisted of thirty-four patients, with a mean age of 27.3 years*

The age of the youngest patient in this experimental

group was 21 years while the age of the oldest member of the group was 38 years*

Twenty-four patients,

(71 per cent), of

the IGT group, were diagnosed schizophrenia, paranoid type* One patient,

(3 per cent), was diagnosed schizophrenia,

hebephrenic type* schizophrenia,

One patient,

simple type.

(3 per cent), was diagnosed

Eight patients,

were diagnosed schizophrenia, mixed*

Ml

(24 per cent),

the patients in

this study who received this last diagnosis showed schizo­ phrenic symptoms of both paranoid and catatonic types* thirty-two patients,

Thus

(95 per cent), of the IGT group were

diagnosed as schizophrenic, paranoid or mixed with paranoid elements* The EN experimental group consisted of twenty-four patients, with a mean age of 28.9 years.

The age of the

youngest patient in this treatment group was twenty years while the age of the oldest member of the group was thirtyeight years.

Twenty-two patients,

.diagnosed schizophrenia, paranoid.

(92 per cent), were Two patients,

cent), were diagnosed schizophrenia, mixed.

Thus the total

EN group was diagnosed as schizophrenic, paranoid or mixed with paranoid elements.

(8 per

EEL

SELECTION OF TESTS

It was the purpose, In this study, to sample a vari­ ety of mental functions*

This necessitated the use of a

fairly large battery of tests, which were limited to those sampling various areas of cognitive functioning* areas of mental functioning were explored*

Seven

These areas, the

test variables within each area, and the test source for these variables have been presented in Table V. IV.

PROCEDURE

As outlined in our definition of terms (Chapter I), the technique used for the administration of ICT was essentially that described by Bond and Shurley (7)* and the technique used for the administration of EN was essen­ tially that described by Tietz et al.

(84)

In order to exercise better controls, the patients in both experimental groups were placed in the same ward and given similar ward treatment.

The diet was the same

for both groups, and all the patients received occupational therapy at the same time with the same therapists, and other conditions were equated as far as possible. The psychological tests were administered prior to treatment and without the examiners1 knowledge of type of treatment to be given the patient.

For the published tests

standard administration and scoring procedures were used*

68

TABLE V AREA OF MENTAL FUNCTIONING-, TEST VARIABLES WITHIN EACH AREA AND SOURCE OF TEST VARIABLE Area New Learning

Test Variable^ Digit Span Forward Digit Span Backward Digit Span Object Memory Paragraph Memory Associated Learning

Source Wechsler-Bellevue Wechsler-Bellevue We ch si er-Bellevue Wells and Ruesch Wechsler Memory Scale Wechsler Memory Scale

Old Learning

Information Vocabulary (Recall) Vocabulary (Recognition)

Wechsler-Bellevue Wechsler-Bellevue Shipley-Kart ford

Psychomotor Speed

Digit Symbol Figure Eights Color Naming Verbal Fluency

Wechsler-Bellevue Brentwood Hospital Wells and Ruesch P r imary MentalAbilities

Perception, Visual

Beta (Same and Opposites) Revised Beta Grayson Pereeptualization Brentwood Hospital

Intelligence, Verbal I.Q. Verbal Vocabulary Age Abstraction Age Conceptual Quotient(C.Q.) Comprehension Arithmetic Similarities Abstraction

Wechsler-Bellevue Shipley-Hartford Shipley-Hartford Shipley-Hartford Wechsler-Bellevue Wechsler-Bellevue Wechsler-Bellevue Wechsler-Bellevue

Intelligence Picture Arrangement Performance Picture Completion Object Assembly Block Design Performance I.Q.

Wechsler-Bellevue Wechsler-Bellevue Wechsler-Bellevue Wechsler-Bellevue Wechsler-Bellevue

Intelligence, I.Q. General M.A.

Wechsler-Bellevue Shipley-Hartford

# Some of these test variables yielded several measures, i.e., two passages for the same test variable or speed and power measures for the same variable thereby yielding a total of thirty-six measures hereinafter simply referred to as test variables.

A description of the figure eights and Grayson perceptualization tests has been given below since publication is still pending for these two tests.

The figure eights test

was a simple motor test wherein the patient was asked to write as many figure eights as he could until he was told to stop (at the end of one minute).

He was also instructed to

Insert a dash when requested to do so (at the end of onehalf minute) but that he should not stop, but continue writing the numeral eight until told to stop. ■t

The Grayson pereeptualization testx consisted of two easy reading passages (Gray1s fourth grade level) that have been reproduced by placing a single space between each letter of a word but with no additional spacing between words and with no punctuation.

Befdre starting the test the

patient was shown an example of how the words were to be separated by means of drawing a slash (/) with a pencil between all words.

One minute and forty-five seconds was

allowed for each passage.

In a few Instances passage one

was finished ahead of this period of time and In such a case the exact time was noted..

This test was scored for both

speed and errors for each passage. The same battery of tests were used in pre and post treatment testing, except for the Wechsler-Bellevue.

In

^ See appendix for sample of the Grayson perceptualization test.

the ease of the Wechsler-Bellevue Form I and Form IX were administered to each patient, some receiving From I before treatment and Form II on the retest, while others received these forms of the test In the reverse sequence*

This was

done in both experimental groups* Tests were given in the same order prior to treatment and two weeks after treatment to all patients included in this study*

There were some exceptions to this when some

of the patients failed to receive one or more of the tests. This was generally due to the discharge of the patient or that the patient had been placed on some other form of treat­ ment (usually the other of the two experimental treatments) before the full retest had been completed. 0omparabllity of the experimental groups prior to treatment*

As stated previously the patients were selected

by chance for each form of treatment by assigning them alternately to the two experimental treatment groups.

It

was assumed that two groups selected In such a manner would be fairly well equated In terms of those factors which might influence susceptibility to profit from treatment,

for

example, age and duration and severity and type of disorder. It was important that the groups be comparable not only in their ability to profit from treatment, but in their Initial status on the test variables used in evaluating and

comparing the changes that occurred in each of the experi­ mental groups*

This equivalence,

in terms of Initial test

status, was desirable in that the units of measurement might not be equal at different levels of the scales*

As a check

on the equivalence of these two groups, they were compared prior to treatment on each test variable reported in this investigation.

For each test variable,

the difference be­

tween the means of the two experimental groups was divided by the standard error of the difference and checked for statistical significance, by the application of Fisher's Mtw test.

No significant differences were found* V.

TREATMENT OF THE DATA

The two major sources of the data obtained from this investigation were the psychological test scores and the psychiatric appraisals of behavioral changes.

The findings

obtained from each of these sources were evaluated separately. These were then tested for any relationship between them* A.

Psychological Appraisal

The psychological test scores were first inspected for changes that occurred within each treatment group.

The

obtained data was then evaluated as to the differences be­ tween the two treatment groups.

These two evaluations were

made on the basis of the tests used*

The differences of the

72 changes that occurred between the groups were then evaluated In terms of the areas of mental functioning tested*

The

following three sections have presented the method of analyzing the psychological test data: Changes within experimental groups*

Although the

main problem of this investigation was to compare the rela­ tive effectiveness of two types of psychiatric “shock* therapy,

the question of the reliability of the differen­

ces, before and after treatment, might be raised.

occurring within each group

In order to answer this, the mean differ­

ences between the initial and final scores of each test variable,

for both experimental groups, were tested for

significance by the application of Fisher’s 11tM test. However, even if the differences within the groups were found to be statistically reliable, they still could not be attributed to the operation of the experimental factors.

In order to do this, a control group, which could

be tested for initial and final test status without benefit of intervening therapy would be necessary*

It would be

necessary to subtract any changes that might occur in a control group from those changes that occurred in each of the experimental groups in order to ascertain the net change attributable to each experimental factor.

It was impossible

in the hospital situation to establish such a control group.

From the data and statistical treatment of the data yielded by the experimental design, it. would not he possible t© say whether the obtained differences, even though re­ liable, were due to practice effect, spontaneous improve­ ment, the experimental treatment, or some combination of these factors*

Nevertheless, in view of the length of time

(approximately three months) between initial and final tests, it would seem unlikely that practice effect of sufficient degree to produce reliable differences would occur*

(There

should be even less practice effects in those test variables included^ in the Wechsler-Bellevue intelligence scale where two forms of the test were used.)

It was also unlikely that

spontaneous recovery would produce reliable differences, in three months,

especially in the light of Rabin1s (58) study,

wherein he noted that the average time lapse between ad­ mission to a hospital and spontaneous improvement of schizo­ phrenic patients was 13 months.

Therefore,

if reliable

differences should be obtained they would most likely be due to the experimental treatments.

While such a conclusion

could not be validly demonstrated in this study, it might be implied.

This issue is of secondary importance, however,

since the main problem of this study dealt with the com­ parative effectiveness of the two forms of treatment. Comparative effectiveness of ICT and 35N*

The pre­

ceding section dealt with the changes within each

74 experimental group tested separately.

In the discussion

it was pointed out that the absence of a control group made It Impossible to evaluate the net effect attributable to the escperlmental factors.

In comparing the relative effec­

tiveness of the two experimental treatments, however, no such problem presented Itself, since the changes which would occur in a control group would be subtracted equally from both experimental groups.

It was, therefore, only the

mean difference in the changes that took place in the two experimental groups that were compared and checked for sig­ nificance by means of Fisher1 s “t* test. Comparative areas of effectiveness.

The prior sec­

tion discussed the comparison of the ICT and EN in respect to the Immediate effects of these treatments as measured by the tests employed in this investigation.

The question

arose as to the comparative effects of these treatments on the different areas of mental functioning and,

incidentally,

as to which areas of mental functioning showed the greatest differential changes in each of the experimental groups. Since some of the tests apparently measure more than one area of mental functioning,

the results have been also

grouped within each area as well as by individual test. B.

Psychiatric Appraisal of Results of Treatment

At the same time that the psychological tests were

given to the patients a psychiatric appraisal was made as to clinical changes on the basig of a four point rating scale, i.e.,

(1) remission,

(e) social improvement,

(3)

administrative improvement, and (4) no improvement.

As a

basis for the statistical treatment, those patients,

in

each experimental group, whose Improvement was rated as either remission or social improvement were classified as improved, while those who were rated as either administra­ tive improvement or no improvement were classified as tinimproved.

A comparison could then he made between the two

experimental groups on the basis of the proportion of improved patients in each treatment group* C.

Relationship Between Psychological and Psychiatric Changes

Another question that arose within this study is what relationship, if any, existed between any changes that occurred In the psychological test results of cognitive functioning and the psychiatric appraisal of changes of a clinical nature.

In order to determine the degree of

relationship between these, biserial coefficients of correlation were computed between the dichotomous psychi­ atric variable and the distributed psychological test variables.

This was done separately for each test variable

and each experimental group.

0 HAP TEH IV THE TEST DATA AND THEIR INTERPRETATION In presenting the results of this investigation and testing for the signifieanoe of the experimental findings, Fisher1 s nttt test was applied-

Inasmuch as the signifi­

cance of a Mt** ratio Is dependant on the number of measure­ ments Involved and since not all of the patients included in this investigation received all of the sub tests, the value of Mtw required for fiducial limits varied somewhat for a number of the test

variables#

Consequently, it be­

came necessary to indicate for each test the 11tM value required to achieve satisfactory reliability#

In order to

simplify the tables, therefore, the symbols VS (very sig­ nificant), S (significant), and # (not significant) have *s

been utilized with the following implications: VS - has been used to indicate the probability that the results attributable to chance are .01 or less; S

- has been used to indicate the probability that the results attributable to chance are #05 or less but greater than -01J

■ /

*

- has been used to indicate the probability that the results attributable to chance

/

'

are greater than .05#

This Is In accordance with Fisher1s terminology#

1+

PSYCHOLOGICAL APPRAISAL

Comparabllity of the two treatment groups prior *to treatment*

As has been said, the patients were selected to

receive one of the two types of treatment by alternate placement in the treatment roster*

While this process of

selection assumed fairly comparable groups it was possible to check further the comparability of the patients in the two treatment groups by comparing the results achieved in the psychological tests administered to them prior to treatment. Table VI showed the mean scores obtained by the patients of each treatment group as well as the standard deviation of these means and the difference between the two means*

The minus (-) sign before the mean differences, in

column 5, was used to indicate that the patients who were to receive EH had a higher mean score In that sub test than had the patients who were to receive ICT, and, consequently, the lack of a minus (-) prefixing the mean differences Indicated the opposite relationship, that is, the formula used was ICT minus EN.

The last column of this table

indicated the level of confidence one may have that these mean differences were true differences. It was noted that half of the test variables were slightly favorable to the one group and half to the other,

TABLE VI COMPARISON BEFORE TREATMENT

feet Wechsler-Bellevue Information Comprehension Digit Span Forward Digit Span Backward Digit Span Arithmetic Similarities Vocabulary Picture Arrangement Picture Completion Block Design Object Assembly Digit Symbol Verbal I.Q. Performance I.Q. Total I.Q. Color Naming

Mean ICT

Mean EN

SD ICT

10.533 10.133

11.571 10.905

6.200

6.238

4.400

4.619 8.333 8.952 10.333 10.524 9.286 10.048

2.093 3.019 1.108 1.451 2.970 4.282

8.100 $.167 9.667 10.400

10.100 9-500 9.800 11.633 9.400 101.633 102.433 102.400

8.524 104.524 101.857 103.714

37.500

40.300

10.256 10.66?

3.080 2.776

3.166 2.907 2.372 1.853

SD EN

2.422 2.46? .971 •899

2.168 3.618 2.981 2.575 2.491 3.645 3-071 3.482 3.111 11.583

- 1.038 - .772 - .038 - .219 - .233

.215 - .666 - .124 .814 - .548 •“ .456

.966 .87 6

SE Diff

Signlfi-'* cance

1.557 .981 .127

.816

•559 1.134 I .099 .777 .164 •331 .730

16.310 13.621

-2.891 .576 -1.314

15.472: 10.526

-2.800

3.834

14.391 12.774 13.693

^

- .667 - -787 •299 •336 •735 1.134 .879 •773 .810 •978 .852 •797 3.721 3.512 3.968

2.091

^ - is used to indicate that the probability that chance are greater than .05* S - is used to indicate that chance are less than .05

Diff Means

.652 •317'

* # # *

.190 •758

.160

*

1.005

.560

the results attributable to

the probability that the results attributable to and greater than .01.

VS - is used to indicate that the probability that the results attributable to chance are less than .01.

*

*

TABLE VI (continued) COMPARISON BEFORE TREATMENT Diff. Means

SE Diff.

t

Signifi-< cance

2.677 3.498

*1.284 -1.438

.86? 1.133

1.481 1.269

«• *

2.655

2.979 3.257

-1.218 .199

1.035 #941

1.176 .211

*

31.500

14.424

13.873

1.633

4.160

.392

49.000 48.950

16.160

15.093 18.605

- .581 5.017

4.550 6.195

.128 .810

Mean ICT

Mean EN

SD ICT

10.400 13.720

11.684 15.158

2.912 3.800

7.893 7.143

9.111 6.944

3.858

33.133

Gray son Perceptual!zation Passage 1 48.419 Passage 2 53.967

Test Object Memory Trial 1 Trial 2 Paragraph Memory Concept 1 Concept 2 Fluency

24.597

SD EN

#

* - is used to indicate that the probability that chance are greater than *05.

the results attributable to

S - is used to indicate that the probability that chance are less than IGJ^and greater than .01#

the results attributable to

VS - is used to indicate that the probability that chance are less than #01.

the results attributable to

-3

CO

TABLE VI (continued) COMPARISON BEFORE TREATMENT Mean ICT

Test Beta Perception 3 Minutes » « Errors Total Time Total Errors

48.16? 2.222 297.440 58.444

Mean EN

SD ICT

SD EN

SE Diff

•“ ~ W t nifi-** cance '

2.560 .842 25.924 . 1.114'

.846 .086 •991 .311

* »

3-113

2.167 .072 25.698 .347

8.044 2.150 2-393 271.742 108.810 58.097 4.485

2.636 68 .665

46.000

Diff. Means

7.313

*

Figure Eights

80.200

79.000

18.586

14.690

1.200

4.978

.241

*

Shipley-Hartford Vocabulary Abstraction Verbal Age Abstraction Age M.A. Conceptual Quotient

27.938 17.315 16.153 12.684 14.025 77.531

26.200

5.645

15.800 15.535 12.080 13.540 78.157

5.761 11.427 2.374 3.453

5.242 2.757 .664 .644 .714 6.258

•331 .549 .931 •938 .679 .100

* * * « * «

Associated Learning

14.911

16.263

1.071

1.262

#

2.745

2.218 .765 2.254

18.909

22.302

1.738 1.515 .618 .604 .485 - .626

3.976

3.176

-I ..352

8.023

* - is used to indicate that the probability that chance are greater than .05.

the results attributable to

S - is used to indicate that the probability that chance are less than .05 and greater than .01.

the results attributable to

VS - is used to indicate that the probability that chance are less than .01.

the results attributable to 03

o

and, in no case did the "t* ratio approach significance. The Hull hypothesis, therefore, was accepted and it was assumed that these two experimental groups were comparable as to the initial test battery prior to undergoing treatment. Test changes within ICT group.

Two weeks after

cessation of treatment the patients were retested*

In each

case the pre-treatment score was subtracted from the post treatment score and the mean change was obtained from each sub test for all patients within each treatment group. Again a "t" ratio was obtained to help ascertain how much confidence one might place on the noted test score changes. In Table VII the various test variables,

the number

of patients who received each test, the mean of the score differences,

the standard error of the mean, the MtM value

and the reliability of the mean changes for the ICT group, has been presented. It was noted that of the thirty-six test variables that were studied in this experiment, twenty-one showed gains that were significant at the 5 per cent level of confidence, and seven of these were significant at the 1 per cent level.

Since, by a chance distribution, only two

variables might have been expected to show a significant change,

(in either direction), it was obvious that the

degree of Improvement (in the sense of a more efficient test performance) Indicated among the various test measures

TABLE VII COMPARISON OF CHANGE OF SCORES IN ICT

Test

N

Wechsler-Belleview Information Comprehension Digit Span ForwardDigit Span Backward. Digit Span Arithmetic Similarities Vocabulary Picture Arrangement Picture Completion Block Design Object Assembly Digit Symbol Verbal I.Q. Performance I.Q. Total I.Q,

30 30 30 30 30 30 30 30 30 30 30 30 30 30 30 30

Mean

.633 1.46? .200 .86? 1.36? •533

1.600

.800 .433 .800 1.033 - .200 - .26? 6.700 2.500 5.067

SD

SEffi

t

1.888 3.253 1.249

.351 .6o4

1.803 2.429

.2 3 2

.8 6 2

1.3 6 0

.253 .481

3.427 2.842 .858 3.002

2.588 3.344 2.870 1.66l 2.348 3.200 1.835 2.762

.6 2 1

8.684

.533 .308 .436 .594 .341 .513 •37? 1.613

1 0 .01 6

1.8 6 0

8.497

1.578

2 .0 3 2

2.6 0 0

■993 1.347 3.029 •390 .708 4.154 1.344 3.211

Signifi-## cance

S * vs vs # vs s * * vs * vs * vs

* - Is used to Indicate that the probability that the results attributable to chance are greater than ,05. S - is used to indicate that the probability that the results attributable to chance are less than *05 and greater than *01* VS - is used to indicate that the probability that chance are less than *01.

the results attributable to

TABLE VII (continued) COMPARISON OP CHANGE OF SCORES IN ICT Sie;nifi-## cance

SD

SEm

t

4,786

17.083

3.288

1.456

#

25 25

2.200 1.440

3.046 3-383

.622 .691

3.537 2.084

VS S

Paragraph Memory Passage 1 Passage 2

28 28

1.571 1.429

3.765 3.580

•725 .689

2.I67 2.074

S S

Fluency

30

1.900

9-527

1.769

1.074

*

Grayson Pereeptualization Passage 1 Passage 2

31 31

6.414 7.621

7.525 4.188

1.374 •765

4.668 9.962

VS vs

Test

N

Mean

Color Naming

28

Object Memory Trial 1 Trial 2

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S - is used to indicate that chance are less than ,05

the probability that the results attributable to and greater than ,01,

VS - is used to indicate that the probability that chance are less than ,01.

the results attributable to a>

ca

TABLE VII (continued) COMPARISON OF CHANGE OF SCORES IN ICT

t

Signifi-** cance

17.873 .481

4. 264 .083 2.189 2.549

VS * S S

1 2 .219

2.269

.632

*

^.010 6 .7 9 6

•720 1.221 .285 •374 .324 2.52 0

.999 4-.09 5 I.239 4-.035 3-753 3.522

. -598

.776

Mean

20 20

8 .0 5 0 .0 5 0

8 .2 3 1 Z.6kk

1 .8 8 8 .6 0 6

31 31

39.129 1.226

97.896 2 .6 3 6

Figure Eights

30

1.^33

Shipley-Hartford Vocabulary Abstraction Verbal Age Abstraction Age M.A. Conceptual Quotient

32 32 32 32 32 32

.719 5.000 .353 1.509 1.216 8.875

Associated Learning

28

Beta Perception 3« 3 «-Errors Total Time Total Errors

-3*

N

VO -3.

Test

SD

1.587 2.082 1.806 14, 03 I 3.105

VS #

vs vs vs #

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S - is used to indicate that the probability that the results attributable to chance are less than ,05 and greater than .01* VS - is used to indicate that the probability chance are less than .01.

that the results attributable to

could not fee attributed to chance and were therefore, statistically significant.

It was also noted that of the

remaining fifteen test variables, a positive direction.

thirteen of them were in

That is, of the total thirty-six vari­

ables thirty-four of them or 94 per cent were in the direc­ tion of gain in efficiency of mental functioning. According to the discussion in the preceding chapter one could not definitely state that these improvements were the result of IGT inasmuch as no control group, I.e., a group of comparable patients receiving no specific treatment was available.

It was felt, however, that the most likely

probability was that the attained gains were attributable to the experimental factor. Changes within the EM group.

In similar fashion the

differences between initial and final scores on each of the tests given to the EN group were also treated for statisti­ cal significance.

The essential data appear in Table VIII.

As can be seen in this table ten of the thirty-six test variables showed changes that were significant at the 5iper cent level of confidence, and two of these were sig­ nificant at the 1 per cent level.

All ten test variables

that showed significant changes were changed in a negative direction, indicating a less efficient functioning in these tests.

Since by a chance distribution of changes only two

variables might have been expected to show a significant

TABLE VIII COMPARISON OF CHANGE IN SCORES IN EN

Test

N

Wechsler-Bellevue Information Comprehension Digit Span Forward Digit Span Backward Digit Span Arithmetic Similarities Vocabulary Picture Arrangement Picture Completion Block Design Object Assembly Digit Symbol Verbal I.Q. Performance I Total I.Q.

Mean

t

SD

Signifi-** eance

21 21 21 21 21 21 21 21 21 21 21 21 21 21 21 21

-2.333 - .762 - .571 - .14-3 -1.095 - .810 -1.333 - .619 - .619 -1.095 - .667 -1.619 -1.524 - 6.667 -7.285 -7.333

2.949 2.307 1.137 1.037 2.706 3. 554 2.731 2,419 3.457 3.676 1.886 2.952 2.872 11.290 13.254 12.190

.659

.516 .254 .232 .605 •795 .611 .541 •773 .822 •733

.660

.642 2.524 2.964 2.726

3*540 1.477 2*248 •6l6 1.810 1.019 2*182 1* 144 .801 1.332 •910 2.453 2*374 2.641 2.458

2.690

VS * S * *

s

#

# #

s s s s s

* - is used to indicate that the probability that the results attributable to chance are greater than *05» S - is used to indicate that chance are less than *05

the probability that the results attributable to and greater than ,01*

VS - is used to indicate that the probability that chance .are less than .01.

the results attributable to

TABLE VIII (continued) COMPARISON OP CHANGE IN SCORES IN EN

t

Signifi-.* cance

Test

N

Color Naming

20

-6.050

27.283

6.259

.967

Object Memory Trial 1 Trial 2

19 19

.158

.790 .971

.200 .650

#

- .632

3.352 ^.119

Paragraph Memory Passage 1 Passage 2

18 18

*333 *833

2.357 3.078

.572 .747

•582 1.115

*

Fluency

20

-5.200

9.277

2.128

2.443

3

Grayson Pereeptualization Passage 1 Passage 2

20 20

-1.650 ^.050

10.625 20.12A

2.437 A. 617

.677 .877

*

Mean

SD

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S - is used to indicate that chance are less than .05

the probability that the results attributable to &nd greater than .01.

VS - is used to indicate that the probability that chance are less than .01.

the results attributable to a> -3

TABLE VIE (continued) COMPARISON OF CHANGE IN SCORES IN EN

Beta Perception 3 Minutes 3 H Errors Total Time Errors

18 18 18 18

- .278 •621 48.389 - .222

Figure Eights

19

VO rv .

SD.

Shipley-Hartford Vocabulary Abstraction Verbal Age Abstraction Age M.A. Conceptual Quotient

20 20 20 20 20 19

- ,24o .385 .110 2.053

Associated Learning

19

-3.184

4.411

DJLjq

t

nff?-** cance

8.326 2.812 111.^39 3.938

2.019 .682 27.028 •955

.138 .911 1.790 .233

CO

N

1

Mean

Test

18.074

4 .260

.086

#

- .650

3.135 6.567 1.227 1.903 1.483 11.972

.719

*

.340 2.822

.904 .764 .854 .883 .324 .728

1.040

3.062

1 .1 5 0

1.506 .281

.436

*

*

vs

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S -

is used to indicate that chance are less than .05

the probability that the results attributable to a M greater than .01.

VS - is used to indicate that the probability that chance are less than .01.

the results attributable to

change,

(in either direction),

the degree of lose indicated

among the various test measures could not be attributed to chance and are, therefore,

statistically significant.

It

was also noted that of the remaining twenty-six test vari­ ables that failed to show changes significant at the 5 per cent level,

sixteen of them were in a negative direction.

That is, of the total thirty-six tests, twenty-six of them or 72 per cent showed changes in the direction of loss of efficiency in functioning. In light of the discussion in the preceding section on changes that occurred in the ICT group and in the preceding chapter some of this loss could be considered k:

a

-

■

to be the result of the EN treatment. Comparative effectiveness of ICT and EN.

In the

preceding two sections the lack of a control group made it difficult to evaluate adequately the effects of the experi­ mental factors.

In comparing the relative effectiveness of

the two treatments the lack of a control group became unimportant.

This was so because any changes that would

have occurred in a control group would have been subtracted equally from each of the two experimental groups, thus the i. . ■

differences between these two groups would remain the same whether or not a constant value was subtracted from each. It was,

therefore, only the difference in the changes that

took place in the two experimental groups that need be

In the analysis of the changes within each group it was found that the ICT group showed significant test changes In a positive direction whereas the EN group showed sig­ nificant test changes In a negative direction on a number of variables.

A comparison of the two groups, therefore, might

be expected to show statistically significant differences favoring the ICT group.

This expectation was borne out in

the data which appear In Table IX which presented the various test variables, difference of the mean changes before and after treatment, of the two treatment groups (M^ referring to the mean of the changes that occurred In the IGT group and Mg referring to the mean of the changes that occurred in the EN group), the standard error of the obtained differences,

the “t* value and the level of confi­

dence one could place in these differences. Of the thirty-six test variables studied, nineteen showed differences in the changes following treatment that were significant at the 5 per cent level of confidence, eleven of these being significant at the 1 per cent level. All of these differences In the changes following treatment were favorable to the IGT group.

Again, since only two of

the test variables would be expected, by chance, to be significant (in either direction), the obtained differences in the changes occurring in the two groups were not the

TABLE IX COMPARISON OF MEAN CHANCES FROM THE TWO TREATMENTS

Test

%

-m 2

s% i f f

t

.747 .795 . 344 .343 .773

3.971 2.804 2.241 2.945 3.185 1.331 3.617 2.278 1.186 I .869 2.104 1.698 1.687 4.463 2.797 3-937

Sienifl-** cance

♦•

Wechsler-Bellevue Information Comprehension Digit Span Forward. Digit Span Backward Digit Span Arithmetic Similarities Vocabulary Picture Arrangement Picture Completion Block Design Object Assembly Digit Symbol Verbal I.Q. Performance I.Q. Total I.Q.

2.96 6 2.22 9 .771

1.010 2.462 1.343 2.411 1.419 1 .0 5 2

1.895 1.700 1.419 1.257 13.367 9.786 12.400

1 .0 0 9

.811 .6 2 3

.887 1.014 .808 .8 3 6

.745 2.995 3.499 3.150

vs VS

s vs vs *

vs s *

s *

vs vs vs

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S - is used to indicate that the probability that the results attributable to chance are less than *05 and greater than *01, VS - is used to indicate that the probability chance are less than *01#

that the results attributable to

TABLE IX (continued) COMPARISON OF MEAN CHANCES FROM THE TWO TREATMENTS Test

Mi -M 2

SEdiff

Golor Naming

10.836

7.070

1.533

2.042 2;0£2

1.005 1.192

2.032

Object Memory Trial 1 Trial 2

.

t

nil1!-## cance #

1.738

S # * *

Paragraph Memory Passage 1 Passage 2

1.238

•923

.596

1.016

1.341 •587

Fluency

7.100

2.767

2.566

S

Grayson Perceptual!zation Passage 1 Passage 2

7.650 3.079

2.798 4.680

2.734

VS «

8.328

2.764 .917 3.240

3.013

.612 27.012

1.069

1.355

vs# vs*

Beta Perception 3« 3 H Errors Total Time Total Errors

- .561 87*518 1.448

.658

Figure Eights

1.802

4.827

•373

*

Shipley- Hartford Vocabulary Abstraction Verbal Age Abstraction Age M«A, Conceptual Quotient

1.369 3.850 •593 1.124 1.106 6.822

1.018 1.939 .400 .574 .470 3.783

1.345 1.986 1.483 1.958 2.353 1.803

*

Associated Learning

3.648

1.500

2.432

*

s s

re stilt of chance but were the result of the application of the esqoerimental treatments employed.

There was no question,

therefore, but that as measured by the battery of cognitive tests utilized in this study, the effects of ICT within the time interval of this investigation, were decidedly superior to the effects of EH in the treatment of male schizophrenic patients. It was noted that the test variables appeared as very significant when the two groups were compared with each other, whereas, they might not have been significant in com­ paring the changes within either of the two groups.

Con­

versely, the test variables may have appeared significant within each group, but not significant when the groups were compared. stance,

The reason for this was due, in the first in­

to the fact that a gain for one group and a loss for

the other group on the same test variable may have produced a large enough difference to be significant.

In the second

instance, it was due to the fact that significant changes made by both groups were in the same direction and of approximately the same size so that the differences between them became Insignificant. Comparative areas of effectiveness.

The previous

section conclusively demonstrated the over-all superiority of ICT over EH In respect to the immediate effects of these

94 treatments as measured by the tests employed in this study. It should be noted that the superiority, although con­ sistently favoring the IGT group, was not distributed over all test variables.

The question arose, therefore, as to

which areas of mental functioning were most subject to change as a result of each treatment and also which areas of mental functioning showed the greatest differential changes. In Table X the tests have been classified according to the area of functioning measured.

The changes both

within and between groups were identified as very signifi­ cant,

significant, or not significant for each test

variable. In Table X the tests were classified in the following seven major areas:

(l) new learning,

(5) psychomotor speed, gence,

(4) perception,

(2) old learning, (5) verbal intelli­

(6) performance Intelligence, and (?) general

intelligence.

In the discussion which follows,

It should

be kept in mind that only two out of the entire group of 36 variables studied would be expected to show significance at the 5 per cent level of confidence purely on a chance basis.

Since the number of test variables within any of

the classified areas of mental functioning ranged from two to eight,

e.g., general intelligence and new learning, the

operation of chance to produce statistical significance

TABLE X TEST VARIABLES CLASSIFIED UNDER AREA OF FUNCTIONING AND ACCORDING TO EXPERIMENTAL GROUPS Area

ICT

New Learning Digit Span Forward (Wechsler-Bellevue) Digit Span Backward (Wechsler-Bellevue) Digit Span (Wechsler-Bellevue) Object Memory Trial 1 Trial 2 Paragraph Memory (Wechsler-Memory Scale) Passage 1 Passage 2 Associated Learning (Wechsler-Memory Scale)

EN

ICT vs EN

-s

S VS vs

*

s if

VS VS vs s s s

•if if -VS

# if s

Gild Learning Information (Wechsler-Bellevue) Vocabulary (Wechsler-Bellevue) Vocabulary (Shipley-Hartford)

* s #

-vs «f #

vs s if

Psychomotor Speed Digit Symbol (Wechsler-Bellevue) Figure Eights Color Naming (Wells & Ruesch) Fluency

*

-s if if -s

if # s

* - is used to indicate that the probability that the results attributable to chance are greater than .05* S - is used to indicate that the probability that the results attributable to chance are less than *05 and greater than •01. VS - is used to indicate that the probability that the results attributable to chance are less than .01.

TABLE X (continued) TEST VARIABLES CLASSIFIED UNDER AREA OF FUNCTIONING AND ACCORDING TO EXPERIMENTAL GROUPS Area Perception "Beta** (Same and opposites from Revised Beta) 3 minutes 3 minutes - errors Total Time Total Errors Grayson Perceptualization Passage 1 Passage 2 Intelligence, Verbal Verbal I,ft. (Wechsler-Bellevue) Verbal Age (Shipley-Hartford) Abstraction Age (Shipley-Hartford) Conceptual Quotient (Shipley-Hartford) Comprehension (Wechsler-Bellevue) Arithmetic (Wechsler-Bellevue) Similarities (Wechsler-Bellevue) Abstraction (Shipley-Hartford) Intelligence Performance Picture Arrangement (Wechsler-Bellevue) Picture Completion (Wechsler-Bellevue) Object Assembly (Wechsler-Bellevue) Block Design (Wechsler-Bellevue) Performance I*Q« (Wechsler-Bellevue) Intelligence, General I.Q* (Wechsler-Bellevue) M.A. (Shipley-Hartford)

ICT

EN

ICT vs EN

VS

*

VS

to

to

S s

to to to

VS

VS vs

to to

VS

vs

-s

VS

to

to

to

vs vs s

to to

to to

to

VS

to

vs vs

to to to

to

-s

to

to

to

to

to

VS

to

s

to to to

to

-s

s vs

vs vs

-s

vs

to

to

to

vs s

9? could be virtually ruled out so that it could be safely assumed that differential findings which were statistically significant were a result of the experimental treatments. This was especially true where more than one test variable in a given area was found to be statistically significant. We may now turn to the findings within areas.

Prom

Table X, page 95, it can be seen that improvement in new learning was unquestionably produced in patients receiving ICT,

since six out of eight variables were significant at

the 5 per cent level of confidence,

three of these being

significant at the 1 per cent level. ceiving

For the patients re­

EN treatment the results were not as marked sta­

tistically.

However,

the fact that two of the eight vari­

ables showed significant adverse changes, one of these being at the 1 per cent level,

strongly suggested that this form

of treatment hindered new learning within the two-week period following cessation of treatment. In comparing the two treatments we find that five of the eight variables showed significant differences, at the 1 per cent level of confidence.

two

All but two of

these were essentially resultant of gains in the ICT group while the other two were essentially resultant of loss in the EN treatment group. In the area of old learning, three test variables,

since there were only

the fact that one showed significant

gain for the ICT group and another a very significant loss for the EH group suggested that retention of old learning was favorably affected in the group receiving ICT treatment and hindered in the group receiving EH treatment, although these findings cannot he considered as entirely unequivocal* Consequently, in comparing the two treatments In this area,

two of the three test variables showed a sig­

nificant difference in the changes that occurred in the two treatment groups, one being very significant and apparently due to losses that occurred in the EH treatment group, while the other was significant and apparently due to the gains that occurred in the ICT group. In the area of psychomotor speed no significant changes were produced In the ICT group*

However, the EH

treatment group again appeared to have immediate impairment as shown by the fact that two of the four test variables were statistically significant in a negative direction. In comparing the two treatment groups only one of the four test variables (fluency) had sufficient differential change to be significant at the § per cent level of confi­ dence.

In this area the comparative value of the two

treatments seemed to be about the same. In the area of perception the ICT treatment group had significant changes in six of the six variables,

three

of these changes being significant at the 1 per cent level.

99 The EN group showed no significant changes in either direction in the area of perception. In comparing the two treatment groups, three of the six test variables showed differential changes significant at the 1 per cent level.

In each of these cases this seemed

to be due to gains in efficiency in the ICT group. The area of intelligence was favorably affected in the group receiving ICT and adversely affected in the group receiving EN treatment.

The area of verbal intelligence

was the one most favorably influenced in the group receiving ICT with six out of eight variables showing statistical significance,

five of these being significant at the 1 per

cent level. The differential comparison of the two treatment groups showed three of the eig#it test variables significant at the 1 per cent level.

Two of these apparently were due

to both a gain for the ICT group and a loss for the EN group, while the third seemed to be primarily due to a gain in the former group. The area of performance intelligence gave equivocal results for the ICT group since only one of the five test variables,

the block design test,

showed statistical sig­

nificance, albeit this was at the 1 per cent level of confidence.

As usual,

the trend for the EN treatment group

was in a negative direction,

two of the test variables,

'object assembly and overall performance I.Q. showing a significant loss. Two of the five test variables in this area showed a significant change in the differential performance of the two treatment groups.

One of these (block design) apparently

was due to a gain for the ICT group and the other (perfor­ mance I.Q.) resulted primarily from a loss in the EN group. In the area of general intelligence, as measured by the Weehsler I.Q. and Shipley M.A.,

the ICT patients showed

very significant positive results whereas EN treatment patients showed a significant negative result for the Weehsler I.Q. Consequently,

in comparing the changes that occurred

in the two groups, we find that both measures of general intelligence showed a significant difference in the amount of change that occurred for the two groups, and in eaeh case the gains for the ICT group played a significant role, while in the Wechsler-Bellevue test the loss experienced by the EN group,

significant at the 5 per cent level, helped to produce

a differential that was significant at the 1 per cent level of confidence. In summary, then, the analysis of changes produced by the experimental treatments in the areas of mental functioning explored in this study revealed the following major findings:

For the group receiving ICT, improvement was found in the functioning of schizophrenic patients in the ability to learn new things, in the field of perception, in verbal intelligence and in over-all I.Q.

Equivocal results were

found in the retention of old learning, and intelligence tests of the performance type.

Mo change in either direc­

tion as to psychomotor speed was found. For the group receiving EN treatment deleterious effects were found in the functioning of schizophrenic patients in the ability to learn new things, in psychomotor speed, in verbal intelligence, and in over-all I.Q.

in performance intelligence

Equivocal results were found in the

ability to retain old learnings.

Mo results of signifi­

cance, in either direction, were found in the field of perception. In comparing the differential effects of the two forms of therapy, two weeks after termination of treatment, ICT was found superior to EM in the areas of new learning (five of eight variables), old learning (two of three variables), perception (three of six variables), verbal Intelligence (two of five variables), and general intelli­ gence (two out of two variables). II. ' PSYCHIATRIC APPRAISAL OF BEHAVIORAL CHANGES It has been demonstrated that, as based on the psycho­ logical test results two weeks following cessation of

102 treatment, ICT was conclusively superior to EN in the treatment of schizophrenic patients*

The question next

raised for consideration was whether changes of a clinical type noted hy psychiatric rating made at the time of the psychological testing showed comparable findings* The psychiatric ratings were made on the basis of the following four categories!

remission, social improve­

ment, administrative improvement and unimproved*

The

definitions of these categories that were adhered to in this study were the following! Remission - return to pre-morbid status,

good social

adjustment, and good insight* Social Improvement - return to good social adjust­ ment, but with residuals of illness as manifested in such symptoms as emotional dullness and anxiety* Administrative Improvement - lessening of Intensity of symptoms, but with fundamental process unchanged. Unimproved - no Improvement noted. Patients classified in the first two categories were considered by the psychiatrists as sufficiently Improved to function adequately outside the hospital.

This, of

course, was not true for the patients in the other two categories. Preliminary inspection of the classification

of the

patients into the four categories noted above failed to

reveal any differences in the effects of the two forme of treatment compared, apparently because of the small number of cases-

Therefore,

the patients were classified into

two major groupings of improved and unimproved, with results as indicated in Table XI.

Presented were the findings of

the psychiatric appraisals of the two types of treatment. It was obvious that there was no significant difference between these treatments (ICT and EN) on the basis of this method of evaluating them. III.

RELATIONSHIP BETWEEN PSYCHOLOGICAL TEST CHANGES AND PSYCHIATRIC APPRAISAL OF BEHAVIORAL CHANGES

In order to determine the degree of relationship between psychological and psychiatric changes, biserial coefficients of correlation were computed between the dichotomous psychiatric variable and the distributed psy­ chological test variables.

The results of these treatments

appear in Table XII, page 105.

(The blserial coefficients

of correlation which appeared in this table have been classified in terms of area of mental functioning so that possible differences in relationships in the different areas could be noted.) Inspection of the correlation coefficients within the areas of mental functioning revealed some differences

104

TABLE XI PSYCHIATRIC EVALUATION OF IMPROVEMENT WITH IOT AND EN

Number of Patients

Per cent of Patients Improved

Improved

Unimproved

ici

20

14

59

EN

13

11

54

105 TABLE XII RELATIONSHIP BETWEEN PSYCHOLOGICAL AND PSYCHIATRIC CHANGES Area

ICT

EN

rbis

rbis

New Learning Digit Span Forward Digit Span Backward Digit Span Object Memory Trial 1 Object Memory Trial 2 Paragraph Memory Passage 1 Paragraph Memory Passage 2 Associated Learning

-.2? -.11 -.02 .30 .05

.48** .05 .47 .05 -.01 -.19 .10 .59

Old Learning Information Vocabulary (Wechsler-Bellevue) Vocabulary (Shipley-Hartford)

.09 -. 60* .02

-.62* .37 .17

.01 •23 .24 .18

.43 .38 • 45“ -.03

-.18 .56* .36 .25 .51* .21

.35 .01 -. 87* 185* .45 -.02

.65*

.16

Psychomotor Speed Digit Symbol Figure Eights Color-Naming Fluency Perception Beta-three minutes Beta-three minutes errors Beta-Total time Beta-Total errors Grayson Passage 1 Grayson Passage 2 #

* Significant at the 1 per cent level of confidence. ** Significant at the 5 P©3? cent level of confidence.

TABLE XII (continued) RELATIONSHIP BETWEEN PSYCHOLOGICAL AND PSYCHIATRIC CHANGES

ICT

Area Intelligence, Verbal Verbal I.Q. (Wechsler-Bellevue) Vocabulary Age (Shipley-Hartford) Abstraction Age (Shipley-Hartford) Conceptual Quotient (Shipley-Hartford) Comprehension Arithmetic Similarities Abstraction (Shipley-Hartford) Intelligence, Performance Picture Arrangement Picture Completion Object Assembly Bloch Design Performance I.Q. Intelligence, General I.Q. A#

rbis .23 .20 .08 .01 .41 -.37 .30 .01 -.20 .04 -.01

rbis .13 •31 .19

.06

.37 .09 -.08 .20 .11 -.26

.16 .26

4 3 -.49* -.02

• 34 .22

.05 .26

* Significant at the 1 per cent level of confidence. ** Significant at the 5

EN

cent level of confidence.

although in most cases these were not significant*

In the

area of new learning the coefficients indicated some positive relationship for the ICT group and the EN group with both groups showing a significantly high positive relationship for digit span forward . In the areas of old learning vocabulary (WB) showed a significant negative correlation for the ICT group and a positive correlation for the EN group while Information had a significant negative correlation for the EN group. In the area of psychomotor speed there seemed to be a slight positive correlation for the ICT group which was more strongly positive for the EN group. In the area of perception the coefficients showed a generally positive relationship for the ICT group with two of the six test variables significant and similarly for the EN group.

In the latter group psychiatric ratings of im­

provement were highly associated in a negative direction with speed and in a positive direction with accuracy of performance. In the area of verbal intelligence there was a slight positive relationship between psychiatric Judgments and psychological test changes for both the ICT and the EN groups, the size of the correlation coefficient being generally smaller for the EN group.

For the ICT group

there was a negative relationship between psychiatric

ratings and changes in arithmetic ability. In the area of performance intelligence there was no clear relationship between psychiatric Judgments and psychological test changes, for the ICT group, and there was some tendency toward negative relationship for the EN group. In the area of general intelligence there was some degree of relationship between psychiatric Judgments and psychological test changes for the ICT group, and little relationship for the

EN group except for a significantly

negative block design. IV.

DISCUSSION

None of the previous studies on psychological test changed that occurred in insulin treated patients indicated the degree of statistical confidence to be placed on the ob­ tained gains.

It should be noted, however,

consistent in reporting gains.

that all were

Schnack*s (68,69) study was

the only one to utilize a control group and he found that the gains of the control group was about one half the mag­ nitude of the gains of the ICT group.

The control group

had a lower M.A. than the ICT group on the first testing and it was noted that the retest M.A. of the control group was within a two month M.A. treatment M.A.

of the ICT group*s pre­

If the groups had been more nearly equal

on the first testing It is possible that the increase attributable to the IGT might have been greater*

fhls

would help strengthen our assumption that some of the gains found in psychological test performances in patients receiving ICT were directly attributable to the experimental factor* In the following discussion wherein a comparison of the findings in the ICT group of this study is made with other similar studies, reference is constantly made to Table VII, page 82, dealing with significance of changes that occurred in this treatment group.

Each of the test

variables that could be compared to other studies has been discussed In the order that they appeared in this table. In discussing Weehsler* s study (89) the terms gain, loss, and no change have been used on the basis that a gain represented changes that occurred with a 10 per cent or greater increase of test scores, a loss represented a de­ crease of test scores of 10 per cent or more, and no change represented any change In test scores that ranged between a 10 per cent increase or decrease of test scores. On the Information test Weehsler found that five patients gained, two lost, and eight had no change*

Wittman

(92) found a mean gain of 9*4 points or about 16 per cent; however, it is doubtful if the same test was used by Wittman and Weehsler and this study.

In the present

investigation a gain was noted which was not statistically significant.

The three studies did, however,

find a gain

for this test in insulin treated patients which can, there­ fore, he considered consistent. For the comprehension test Weehsler (89) found a gain for eight subjects, a loss for four subjects and no change for three subjects.

In the present study a gain

was found that was significant at the 5 per cent level of confidence.

These studies can be considered in agreement

as to this test variable. In the test of digit span forward

Weehsler found

that three patients gained, five patients lost, and seven patients had no change, whereas both Sehnackfs (69) study and this one found a gain of .2 which was found in Table VII, page 82, to be statistically insignificant.

It was

felt that the discrepancy between these two studies and Weehsler1 s was not necessarily a true discrepancy inasmuch as almost half of the latter*s subjects showed no change and the number of patients showing a loss was only two greater than those showing a gain which seemed to be a relatively insignificant loss. The test of digit span reversed showed less agree­ ment in the various experimental findings.

Weehsler*s

results were exactly the same as his findings for the digit span forwards given above.

Schnack (69) found a gain of .3

Ill or about 7 per cent while Jastak (34), using a different scoring system, found a gain of thirteen points or about 22 per cent*

The findings of the present investigation was

a gain of .867 (about 17 per cent) which was significant at the 1 per cent level of confidence.

A gain was noted in

three of the four studies utilizing a digits reversed test, with the findings of this present study being between the extremes of the other studies.

However, it would seem that

changes occurring in the ability to recall digits in a reversed order in patients receiving IGT are inconsistent. Similarities was found to have a gain significant at the 1 per cent level of confidence in this study. (©9), on the other hand,

Weehsler

found that five patients had

gained, four had lost, and six had no change which does not seem in agreement with the findings of this study.

As will

be seen later, however, this test variable showed a fair correlation with psychiatric findings for both studies and, therefore, the amount of agreement between these two studies for this variable may be greater than appeared. Two vocabulary tests were used in this study.

The

one, from the Wechsler-Bellevue, was essentially one of recall, while the other,

from the Shipley-Hartford, was

essentially one of recognition.

The former showed a gain

significant at the 5 per cent level of confidence while the latter showed a slight gain which was not statistically

118 significant.

In the other studies Jastak (34) found only

about a 1 per cent gain (using the Terman vocabulary), Schnack (69) found about a 3 per cent gain (using the Stanford— Binet vocabulary) and Weehsler (89) found an in­ crease for six subjects, a loss for two subjects, and no change for seven subjects.

The latter*s results seem to

closely approximate the findings of this study for the Weehsler-’Bellevue vocabulary test.

The other two studies

seemed to have fairly comparable findings of no gain.

This

may be a factor of the particular vocabulary test used.

It

should be noted that these findings closely approximated the findings of the Shipley-Hartford vocabulary in this study. The difference of the findings of the two vocabulary tests of this study, although both had a change in the direction of gain, might be due to the differential effects of the disease on the factors of recall and recognition.

The

factor of tangentiality of response which is characteristic of schizophrenia is more likely to produce a lowering of a vocabulary test score in a test where the patient must give a definition than in a test where a patient only had to recognize a synonym.

Consequently,

following treatment one

would expect to find less change, if any, in the latter case than in the former.

It was noted from Table ¥1, page 78,

of the mean test scores prior to treatment, that the Weehsler—" Bellevue vocabulary score was approximately at the test* s

115 standardized mean while the vocabulary M.A. of the ShipleyHartford was above its standardized mean* In the area of intelligence, Graham (23) found an increase of one year nine months in M.A., Schnack (69) found an increase of one year three months in M.A. or nine I.Q. points and Jastak (54) found an increase of ten I.Q. points. In all of these studies the Stanford-Binet test was used* In this study an increase of five I.Q. points was found in the Wechsler-Bellevue test which was significant at the 1 per cent level of confidence and an increase of one and two tenths years In M.A. was found in the Shipley-Hartford test which also was significant at the 1 per cent level. The somewhat lower, even though very significant, I.Q. gain found in this study as compared to the other studies might be due to the fact that different intelligence tests were used and/or to the fact that the average I.Q. was higher for the 10T group of this study, prior to treatment, than for the other groups.

The fact that all studies indicated

a gain in either I.Q. or M.A. and that these were signifi­ cant at the 1 per cent level of confidence in this study indicated that for patients receiving IGT there was an improvement in intellectual functioning* Both tests of paragraph memory used in this study showed a gain of about 20 per cent which was significant at the 5 per cent level of confidence.

Wittman (92) found

114 about a 24 per cent Increase in efficiency in this test* Weehsler (89) found a gain in eight subjects, a loss in two subjects and no change in the other five subjects.

All

studies seem in fairly close agreement in the findings of changes occurring in this test in patients who received ICT. The psychological test score changes that were found in this study for patients who received ICT was in fairly close agreement with the findings of similar studies*

In

only two of the eleven variables of this investigation, that could be compared to other studies, was a discrepancy noted.

These were digit span backwards and similarities.

It seemed reasonable to assume, therefore, that a similar degree of reliability could be expected for the other test variables used in this investigation that have not been in­ vestigated previously. The study by Harris et al (26), Is the only psycho­ logical study available on patients receiving (84), in one of her Investigations, and O.Q. were higher, gave no data*

EN.

Tietz

commented that the I.Q.

one month after treatment, but she

It should be noted that Tietz1s (83) results

have been consistently higher than those of other investi­ gators.

Perhaps this was due to the selection of patients

used in her studies, none of whom were hospitalized. Only four of the tests, used in this present study, all from the Wechsler-Bellevue intelligence scale, were

115 common to Harris1 (26) study.

He estimated an I.Q. from

these four sub tests and found a loss of 1.5 points whereas in Table VIII, page 86, it was seen that a loss of 7.3 I.Q. points was found in the present investigation, at the 5 per cent level of confidence. mean loss of 1.1 points,

significant

However,

there was a

in this study, for the same four

test variables that Harris used.

He noted that sixteen of

twenty subjects in his study had a loss in test scores following treatment which appeared to be in agreement with the findings of this study that practically all test variables had a lowered psychological test score following EN treatment although only, ten of these were statistically significant. Since testing and scoring in this study were done without knowledge of the treatment that the patient had had, the same degree of reliability of test score changes might be expected for the EN group as was found for the ICT group. This was partially borne out in the comparison with Harris* study. Rabin (58) and Schnack (69) both found that schizo­ phrenic patients not subjected to any specific treatment but retested after a period of time showed an increase in test scores.

In light of this some increase in scores could’

have been expected in this study if the experimental factors had not been introduced.

Contrary to this expectation the

116 EN group showed a consistent loss in scores and therefore it seemed reasonable to assume that this loss could be attributed to the experimental factor.

For the same

reason Table VIII, page 86, probably underestimated the amount of loss that occurred in the EN group. It can be said that IGT was superior to EN from the view point of psychological test changes within two weeks after cessation of treatment. As to the psychiatric evaluations, 59 per cent of the IGT patients included in this study were rated by the psychiatrists as improved.

This was practically at the

median of the various psychiatric studies with IGT although somewhat above the mean.

For the EN group the results of

this study approximated the mean of the other EN studies but was below the median.

For both groups the results were

well above both the means and medians of the untreated groups. Since the psychiatric evaluations made in this in­ vestigation were close to the central point of the other psychiatric studies, the assumption might be made that our assessments of behavioral changes were consistent for the two treatment groups.

A comparison, therefore, between the

two types of treatment could be assumed to be valid.

It

can then be said that there was no real difference between the two forms of treatment based on psychiatric appraisal of behavioral changes within the time and other limitations

117 of this investigation. All of the psychologieal studies quoted on patients who received IGT commented that they found indications of a correlation between psychological test changes and psychi­ atric ratings of improvement.

In comparing Wechsler* s (89)

coefficients and percentages of agreement with the findings of this study there seemed to be a general agreement for the test variables of information, digit span backwards, similarities, and paragraph memory (passage 2 in this study) with a lack of agreement for comprehension and vocabulary. In the present study the former had a positive and the latter a high negative correlation and Wechsler found coeffi­ cients of colligation of .08 and .22 and percentages of agreement of 53 and 40 respectively. Wechsler also cheeked the agreement of psychological test changes Immediately after treatment with the psychiatric ratings of the patients six to eighteen months after treat­ ment.

He found the agreement between these two variables

greater than the agreement between the two psychiatric ratings made at the time of the retesting and the later date.

In. view of this, high correlations between psychologi­

cal changes and psychiatric ratings of improvement shortly after cessation of treatment would not be expected.

Also

close agreement of different studies making similar types of correlations would not be expected but rather it would

118 be anticipated that the different studies would all show some although varying degrees of correlation between psycho­ logical and psychiatric findings. In the present study the biserial coefficients of correlation, between the psychological test variables and the psychiatric assessments of behavioral changes, for the ICT patients,

ranged from -.60 to *.65.

Fifteen or 42 per

cent of these correlations were between plus and minus .20. Of the remaining twenty-one correlations, seventeen or 47 per cent of them were above ♦.BO, below ,20.

and the other four were

Of these only five reached statistical signifi­

cance and these were somewhat inconsistent.

There seemed to

be little relationship between the psychological test vari­ ables and the psychiatric ratings of improvement with patients who received IGT. The biserial coefficients of correlation obtained from the EN treatment groups ranged from -.87 to*-.85. Eighteen of 50 per cent of them were between plus and minus .20.

Of the remaining eighteen coefficients obtained,

fourteen of thenn or 59 per cent had a coefficient greater than .20, and the other four had a coefficient less than .20.

Of these six reached statistical significance and

they were inconsistent.

Again there appeared to be little

relationship between the psychological test variables and the psychiatric ratings of Improvement with patients who

119 received EN. The present findings of generally low and Inconsistent relationship between psychological and psychiatric indices of improvement should be considered in the light of Wechs­ l er1s (89) investigation in which he found that immediate test changes correlated more highly with later psychiatric evaluations than they did with immediate psychiatric evalu­ ations of improvement*

In addition, it should be noted that

the psychological and psychiatric evaluations may have emphasized different aspects of personality functioning. Within the framework of this investigation, the psychiatric data failed to reveal differences between the two treatments, whereas the psychological test data clearly favored IGT over EN.

If conclusions were to be based solely

on the demonstrated fact of statistically significant differences In the results of the psychological tests em­ ployed in this study, they would unequivocally support the superiority of IGT as against EM. However, an over-all effectiveness of IGT and EM

evaluation of the relative would require the application

of at least the following criteria: Griterion 1.

The relative effects

on the total personality of

of each treatment

the patients, as ascertained by

psychological tests and psychiatric ratings. Griterion 2.

The permanence or transitoriness of

120 any differential findings, as ascertained by a long range study. Griterion 5.

The statistical significance of the

obtained findings, according to accepted procedures. Criterion 4.

The practical significance of the ob­

tained findings, based upon the opinions of qualified judges. Griterion 5.

Such administrative considerations as

to the comparative hazards of each treatment, number of personnel required to administer each treatment, administration, etc.—

expensiveness,

ease of

time required for each,

based upon actual experience in the hospital setting. Such an overall kind of evaluation was outside of

the scope of the present investigation and,

therefore, could

not be made at this time. The first criterion was not completely met since the psychological tests reported measured only the cognitive as­ pects of personality functioning rather than 11total person­ ality.w Although distorted cognition is typical of schizo­ phrenic patients,

so that Improvement in cognition would take

on considerable significance, affective and conative aspects of personality are at least as significant, as noted in the common expression of Mlack of affectH in schizophrenic pa­ tients.

These aspects of the 11total personality were ex­

cluded from the report. It was interesting to note that psy­ chiatric appraisals, which were presumably judjments of the 11totaln personality, failed to reveal significant differences

121 between the treatments, and showed low correlations with psychological test results, thus supporting the idea that different things were being appraised by the psychological and psychiatric data* The second criterion (stability of findings) was not applicable in this study which dealt only with a comparison of the immediate effects noted within two weeks of cessation of the treatments.

Since most studies reported in the

literature are in agreement that the impairment of intellec­ tive processes resulting from electric shock treatment (of which EN is a modification) is of temporary duration only, it might be inferred that the same thing would hold true for EN.

In that case, the significance of the differences

obtained in this experiment might be expected to be markedly reduced m d perhaps even obliterated,

since we have no

conclusive evidence of the permanence of psychological changes obtained in the present experiment. The third criterion,

the statistical significance of

the obtained findings, was applied and at least as far as the psychological tests i^ere concerned,

clearly favored IGT.

However, in this connection, the limitation of the investi­ gation with regard to the second criterion — findings —

stability of

and the available literature suggesting the

lack of permanence of impairment resulting from EST (and possibly,

therefore,

of EN) suggested that if this criterion

122 had been applied, the superiority of IGT might have been attenuated or entirely eliminated. The fourth criterion,

the practical significance of

the findings, was not subjected to rigorous application by relying on the opinions of several qualified judges.

How­

ever, Inspection of the size of differences, although sufficiently large not to be explained by chance, do not appear of the magnitude to be of sufficient practical sig­ nificance as to over-ride other important considerations. For example, the gain in I.Q. by the ICT group, and the loss in I.Q. by the EN group still was not sufficient to take either group out of the “average range11 of Intelligence in which the pre-*treatraent test scores fell. The fifth criterion, administrative considerations, unquestionably favors EN over IGT.

IGT was more hazardous

(in this experiment there were two fatalities in the IGT group, and none in the EN group, and the literature also holds ICT to be hazardous, required more personnel and mueh more care In administration, was more time-consuming, more expensive,

etc.

The fifth criterion, although casually,

rather than rigorously applied, unquestionably favors EN over ICT. Although the bald statistics derived from the experi­ ment proper (which was necessarily restricted In scope) appeared to favor ICT over EN, a broader perspective which

123 would take into account the considerations discussed above could reflect the data in a different light*

However, a

complete answer to this question would necessitate further rigorous experimentation,

especially with respect to the

application of the first and second criteria,

that is,

evaluation of the permanence of the effects of the two treatments in terms of the functioning of the total personality.

CHAPTER V SUMMARY AND CONCLUSIONS The purpose of this study was to compare the relative effectiveness of insulin coma therapy and electronarcosis in the treatment of schizophrenic patients in a mental hospital. The treatment groups were comprised of patients satisfying the following criteria for shock therapy.

All patients were

male veterans of World War II between the ages of twenty and forty, and diagnosed as schizophrenic.

None of them had

received prior shock treatment and none had a history of psychosis prior to two years preceding treatment.

All

patients had sufficient reality contact to take the psycho­ logical tests.

No patient was included in this investigation

unless a board of three psychiatrists unanimously agreed that shock treatment was appropriate and also that there was no Impeding physical condition to the use of either type of shock treatment.

It was also required that the patient and

his parent or guardian consent to his receiving shock treat­ ment. In order to obtain a random selection, the patients satisfying these criteria were placed alternately into one of the two experimental groups.

The ICT group of schizophrenic

patients consisted of twenty-four paranoids, eight mixed with paranoid features, one hebephrenic and one simple, totalling

125 thirty-four patients. years.

The mean age of this group was 27*3

The EN group of schizophrenic patients consisted of

twenty-two paranoids and two mixed with paranoid features totalling twenty-four. years.

The mean age of this group was 28.9

The equivalence of the two groups was further

established on the basis of their initial test scores on the thirty-six test variables which formed a basis of this study.

In no instance was there a difference of statistical

significance. All patients were subjected to psychological tests and psychiatric appraisal prior to treatment, and two weeks after the cessation of treatment.

The psychiatric changes

were assessed on the basis of the following rating cate­ gories:

remission,

social improvement, administrative

improvement, and no improvement.

These psychiatric ratings

were reclassified into the two categories of improved and unimproved.

The improved classification included the

categories remission and social Improvement.

The unimproved

classification included the categories administrative im­ provement and no improvement.

The psychological changes

were determined on the basis of differences between preand post- treatment scores on a battery of psychological tests providing thirty-six measures of mental functioning in the following seven areas:

new learning, old learning,

psychomotor speed, perception, verbal intelligence,

126 performance intelligence, and overall intelligence. With the psychiatric and psychological measures employed, hoth the changes within groups and the differences in changes between groups were tested for statistical sig­ nificance by means of Fisher*s ttt M test.

In addition, the

relationship between the psychiatric ratings of changes following treatments and the psychological test changes was determined with each treatment group for each test variable by means of blserial coefficients of correlation. On the basis of the psychological tests, the ICT group showed significant improvement on twenty-one of thirty-six variables studied.

The following fourteen

variables were significant at the 1 per cent level of con­ fidence:

digit span backward , digit span, similarities,

block design, verbal I.Q., total I.Q., object memory (trial one), Grayson perceptuallzatlon (two passages), beta per­ ception in three minutes, abstraction, abstraction age, mental age, and conceptual quotient.

The other seven tests

significant at the 5 per cent level of confidence were comprehension, vocabulary (WB), object memory (trial two), paragraph memory (two passages), and beta perception (time and errors)•

No test variable, showed a loss, significant

or otherwise. Of the seven areas of mental functioning, tested by these thirty-six variables, four showed (Significant

127 improvement with. ICT.

These were new learning, perception,

verbal intelligence and overall I.Q*

Equivocal results

were obtained in two areas, namely old learning and per­ formance intelligence.

Psychomotor speed was unaffected*

The EN group showed significant loss on ten of the thirty-six variables studied, and of these, two showed a loss significant at the 1 per cent level of confidence. These were Information and associated learning.

The other

eight tests significant at the 5 per cent level of confi­ dence were digit span forward , similarities, object assembly, digit symbal, verbal I.Q., performance I .Q., total X.Q*, and fluency. gain.

No test variable showed a significant

Of the seven areas of mental functioning, tested by

these thirty-six variables, five showed significant impair­ ment with EN treatment.

These were new learning, psycho­

motor speed, verbal intelligence, performance Intelligence, and overall I.Q*

Equivocal results were produced In the

area of old learning.

Perception was unaffected.

There appeared to be little relationship between psychological and psychiatric indices of changes associated with the IGT and the EN treatments.

For the IGT group five

of the thirty-six correlations were significant.

These were

digit span forward, digit span, Grayson perceptualization (passage one), W.B. vocabulary (negatively), and beta perception (errors in three minutes).

The first four were

significant at the 1 per cent level of confidence and the last one at the 5 P©** cent level*

There was little consist­

ency of significant correlation within the areas of mental functioning tested in this study* For the EN group six of the thirty-six correlations were significant*

Information and beta perception (total

time and total errors) were significant, in a negative direction, at the 1 per cent level of confidence*

Digit

span forward, associated learning, and block design (nega­ tively) were significant at the 5 per cent level of confidence*

There was little consistency of significant

correlations, however, within the areas of mental function­ ing tested in this study* The major findings of this study were the following: 1*

Statistically significant improvement resulted

with ICT treatments in more than half of the tests employed* 2*

Statistically significant Improvement resulted

with ICT treatments in most areas of mental functioning measured. 3*

No statistically significant impairment resulted

with ICT treatments in any of the tests employed in this study* km

Statistically significant Impairment resulted with

EN treatments in a third of the tests used in this study.

129 5*

Statistically significant impairment resulted

with EN treatments in most areas of mental functioning measured. 6.

No statistically significant improvement resulted

with EN treatments in any of the tests employed in this study. 7.

The superiority of IGT over EN, within the scope

of this study, as measured by the psychological tests employed was unequivocally established. 8.

The relative superiority of IGT over EN was more

marked in the areas of new learning, old learning, percep­ tion, verbal intelligence and general intelligence, than in the areas of psychomotor speed and performance Intelligence. 9*

No statistically significant difference was

found between the two treatments, on the basis of psychiat­ ric evaluations. 10.

There appeared to be little relationship between

psychological and psychiatric Indices of changes resulting from either the ICT or EN treatments. The two basic limitations of the scope of the present study,

(A) restriction of psychological tests to cognitive

aspects of personality functioning and (B) restricted duration of the experiment to ascertain only the immediate rather than the inclusion of the prolonged effects of the two treatments made it impossible to reach a conclusive

130 Judgment as to the relative desirability of the two methods. The major question as to whether the practical limitations of ICT are outweighed by its superior results must await further research which will tahe into consideration other (non-cognitive) aspects of personality functioning and also whether the differential findings of the present study are maintained over a period of time. Suggestions for further research.

This report was

the first of a planned long range investigation.

Extension

of this research is planned to note (1) the differential effects of the two treatments on tests of personality; (2) the delayed effects of the two treatments as measured by psychological tests and psychiatric appraisal;

(3) a

factor analysis of the psychological test battery is planned in order to insure a more accurate classification of tests in terms of areas of mental functioning; and (^) development of a new test battery to predict possible therapeutic results prior to the administration of treatment,

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APPENDIX

APPENDIX I.

PSYCHIATRIC STUDIES WITH ICT

Wortis et al (95) reported on a study of sixty neuropsychiatric patients.

Fifty of these were diagnosed

as schizophrenic and thirty of this group completed a course of ICT,

The technique used followed “Sakel1^ method.11 The

authors evaluated the changes that occurred in the patients on a four point rating scale, with each category well de­ fined,

The patients were also classified on the basis of

the probable duration of their illness.

The results

indicated full remission for eleven of the thirty patients (37 per cent), social remission for eight of the patients

(27 per cent), improvement for two of them (7 per cent), and no change for nine of them (30 per cent).

Of the

twenty-one patients who had been sick for less than one and a half years the findings were as follows: per cent) full remissions,

nine (k3

six (29 per cent) social

remissions, one (5 per cent) Improved, and five (2k per cent) unimproved.

The authors claimed that diagnoses were

made by staff members in the Husual w a y 11 and that only 11clear and typical cases11 were included.

As to the deter­

mination of the duration of the illness they stated Mwe have had our difficulties, of course, in deciding date of onset in any particular case.

Date of onset often

143 represents the date when the patient first became trouble­ some* M (p* 15^)

^he authors did not report the use of any

control subjects to compare with the experimental group. One of the earliest investigations of the thera­ peutic effects of IGT that contained a large number of subjects was that of Ross (65)*

He reported on his study

of 1356 patients who had received IOT, 523 patients who had received Metrazol, and 1089 patients who had not received any special treatment and were, consequently, used as a control group for the two experimental groups of patients* He used a four point rating scale and carefully described each category of the scale.

In addition to his making the

above mentioned definitions, he also defined the term Hinslghttt which was used in one of them, which most other investigator^ have failed to do* His findings were as follows: had

the control group

per cent recovered, 11 per cent much improved,

cent improved, and 78 per cent unimproved.

P©**

The IGT group

had lty per cent recovered, 21 per cent much Improved, 26 per cent improved, and 39 pe** cent unimproved*

The Metrazol

treatment group closely approximated the control group except that the improved category was increased from the 7 per cent found in the latter group to 32 per cent in the former group, thus decreasing the percentage of patients In the unimproved classification to 53 P©** cent.

144 Bateman and Michael (3) reported on their investi­ gation wherein 416 schizophrenic patients received IGT and 326 schizophrenic patients received no special treatment. The findings were as follows:

the group of patients who

received ICT had 31 per cent recovered, 13 per eent much improved, 28 per cent Improved, and 28 per cent unimproved. The untreated group of patients had 16 per cent recovered, 24 per cent improved and 61 per eent unimproved. Heilhrunn and Sternleib (27) reported on their study of 316 schizophrenic patients who had received IGT.

These in­

vestigators analyzed their results on the basis of the proba­ ble duration of schizophrenia in the patients. Seventy-eight of the patients had been ill for six months or less. For this group the findings were 72 per cent recovered which included 10 per cent who had had a social recovery. Ninety of the total group of patients being studied had been ill between six and eighteen months.

Of this group 64 per cent were paroled,

per cent as recovered and 20 per cent as greatly improved. One hundred and forty-seven patients had been ill for more’ than eighteen months.

Only 2 per cent of this group

were considered as having recovered and 8 per cent as having had a social remission.

A year later it was found

that 60 per cent of those patients who had been 111 for less than eighteen months prior to recovery still main­ tained their improvement.

Every patient included in this

34

145 study was given either ICT or convulsive therapy and if the latter therapy failed the patient was then given ICT.

The

authors noted that patients whose diagnosis was considered doubtful were not included in the study., The degree of change or improvement was rated by hospital staff members but in some cases the doctors had not seen the patients previous to their evaluation. Libertson (38) reported on his study of 330 schizo­ phrenic patients*

One half of this group received ICT while

the other half received no special therapy.

While he did

not describe the specific technique of the administration of the ICT, Libertson did define the four categories used to rate the change that occurred in the patients.

The

patients who received ICT were evaluated as to psychiatric change at the cessation of treatment and again in 1941. The latter evaluation was made so that the period of time that had elapsed since the cessation of treatment varied for the different patients from seven months to three years and nine months.

At the time of the first evaluation the

findings for the ICT group was as follows:

3 per cent

recovered, 31 per cent much improved, and 37 per cent un­ improved*

In 1941 9 per cent of this group were recovered,

21 per cent were much improved, 10 per cent were improved, and 58 per cent were unimproved.

The changes that occurred

in the untreated group were evaluated at the later time and

146 it was found that 5 P©** cent were recovered, 17 per cent were much improved, 18 per cent were improved, and 5 6 per cent were unimproved.

The author noted that the initial

rate of improvement of 63 per cent of the treated group dropped after a period of time to 40 per cent of the group which was about equal to the improvement rate for the untreated group.

This latter group could not he considered

as a true control group inasmuch as it was not equitable to the treatment group.

The patients included in the untreated

group were those who were considered the least likely to benefit from therapy.

The average age of this group was

thirty-seven years and the average estimated duration of illness was nine years while the average age of the ICT patients was twenty-eight years with an average estimated duration of illness of two and four-tenths years. McKendree (39) studied eighty-seven schizophrenic patients, fifty of them were men and thirty-seven were women.

All of the patients received ICT and were evaluated

as to clinical changes on a four point rating scale imme­ diately after treatment and also after a lapse of time varying from one and a half to four years after discon­ tinuance of treatment.

In this study the patients were

observed by a psychiatrist and a social worker and also evaluated as to changes in their condition by means of a questionnaire sent to the relatives or close friends of

147 the patients as well as the patients themselves. findings of this study were as follows;

The

immediately after

treatment 30 per cent of the patients were recovered, 28 per cent were much improved, 23 per cent were improved, and 23 per cent were unimproved.

At the time of the second evalu­

ation 21 per cent were recovered, 1? per cent were much improved, 9 per cent were improved,

per cent were unim­

proved, and 5 per cent were worse. Gottlieb and Huston (22) studied thirty-six men and thirty women schizophrenics who received IGT as well as sixty male and seventy-two female schizophrenic patients who received no specific treatment.

They carefully described

the technique of treatment applied and adequately defined the four categories of the scale used for rating changes which occurred in the patients.

The authors also rated the

patients as either improved or unimproved.

Of those patients

who received IGT, the authors found, 12 per cent recovered, 23 per cent social recovery, 12 per cent improved, and 52 per cent unimproved.

For the group of patients who had not

received treatment other than hospitalization, the authors found 21 per cent had recovered, 11 per cent had had a social recovery, 11 per cent had Improved, and 5^ per cent were unimproved.

In the twofbld classification of improved

and unimproved the investigators found 35 per cent of the ICT group and 33 per cent of the control group in the former

148 category thus leaving unimproved 65 per cent and 67 per cent re spectively, Garmany (1?) reported on his study of two hundred schizophrenic men seen in the army*

One hundred of them had

received IGT and the other one hundred received Hsome other form of somatic therapy, ? (17 p. 802)

He used a four point

scale for rating improvement in the patients, which was apparently a good deal different from the rating scales used by most other investigators.

For the various cate­

gories he used the terms certified (apparently meaning unimproved), marked invalidism, slight invalidism, and cured.

According to his findings only 2 per cent of the

non IGT group of patients as compared to 56 per cent of the ICT group were cured; 13 per cent of the non insulin treated patients as compared to 14 per cent of the IGT group showed slight invalidism; 61 per cent of the non IGT group as com­ pared to 12 per cent of the insulin treated patients showed marked invalidism; and 24 per cent of the insulin treated patients as compared to 18 per cent of the insulin treated patients were certified. Bond and Shurley (7) reported on their study of 309 shhizophrenic patients who had received ICT, changes, observed by the authors, were as follows:

The At

the time of termination of treatment 48,8 per cent of these patients were recovered or improved; one month later

149 4? per cent were recovered or improved; one year later (after cessation of treatment) 43 per cent were recovered or improved; five years after conclusion of ICT, 37 per cent of the patients were recovered or improved.

As a

hasis of comparison of the results of this study, the authors referred to an earlier investigation made hy Bond and Rivers (6) wherein it was found that of one hundred schizophrenic patients who had not received any specific treatment, 16 per cent were recovered or Improved at the time of leaving the hospital and also that the same per­ centage of patients were in the improved or recovered condition five years later* Finiefs (15) reported on the results of his inves­ tigation of one thousand schizophrenic patients*

According

to him, all of these patients had the same hospital manage­ ment and nursing care; the criteria for diagnosis was ^essentially the same for all n; and all cases of doubtful diagnosis were excluded*

He commented that Hduration of

illness, was very difficult to assess accurately and im­ possible to determine when onset was Insidious.11 (p. 576) He rated changes that occurred in the patients within one of three categories, i*e, much improved, Improved, and un­ improved, each of which was carefully defined*

Ofetheeone

thousand patients 446 received no special treatment, while 378 received IOT and the remaining 176 received various

150 other somatic therapies*

It should he noted that all of

the patients who did not receive any specific treatment had been admitted to the hospital between the years of 1930 and 1942, inclusive, while those patients who received ICT had been admitted to the hospital between the years of 1937 and 1947, inclusive.

He found that 34.5 per cent of the

non specifically treated group of patients were considered improved or much improved and that eight and three-tenths months had been the average period of hospitalization for the patients included in this group.

It was also found

that 54.2 per cent of the group of patients who received ICT were either much improved or improved in their condition and that their average period of hospitalization was only five months.

A follow-up study was made five years after dis­

charge of the patients as to their adjustment.

This was

accomplished by means of a questionnaire sent to the patients and their families and also by means of a social worker1s evaluation following a visit to the homes of the patients.

Included in the later survey were 156 of the non

specifically treated patients and 188 of the insulin treated patients.

It was found that after a period of five years,

40 per cent of non treated patients who had been discharged, or 14 per cent of the total group were well, while 62 per cent of the ICT patients who had been discharged from the hospital or 37.5 per cent of the total group were well.

151 II.

PSYCHIATRIC STUDIES WITH EN

As has been stated previously, the first article concerning the use of electronarcosis in man as a possible therapeutic technique was the publication of the research conducted by Frostig et al (16).

This study, however, was

primarily concerned with the physical and physiological reactions of dogs and man to a prolonged coma produced by electrical means and indicated the relative safety of this technique* In a later paper, Tietz et al (8*0 reported on the results of EN with forty-seven cases of early schizophrenia, all of whom were predominantly paranoid. commented that,

The investigators

HIt was not always possible to make certain

that the patients were in fact, early schizophrenic, partly because in some cases, the history was not readily obtain­ able or not reliable as to time of onset or the prepsychotic adjustment. M (p. 145)

The patients were evaluated one

month after the cessation of treatment.

At this time the

findings, given below, were as follows:

nineteen (40 per

cent)

,,A M recoveries, sixteen (34 per cent)

five (12 per cent) HD H recoveries.

ttB n recoveries,

f,0 n recoveries, and seven (15 per cent)

These results were fairly comparable to

those of their first study.

It was noted that four of the

D recovery patients had been ill for more than two years

152 and that two others of this group (BD rt) had had a very gradual onset of the symptoms of their psychoses.

Thirty-

five of the patients with whom satisfactory results (,,A U and MB H recoveries) had been obtained were studied for a period of six months, during which time six had relapsed* Tietz (81) in a still later paper reported on the use of EN with forty-six patients, eighteen of whom were schizophrenic.

At this time she claimed that fourteen of

the eighteen or 78 per cent had made a grade r,A M recovery. Patterson et al (5^*) reported their observations as to the effects of EN on twenty scizophrenic patients. They stated that their study was not complete but that the predominant trend seemed promising and that EN might re­ place ICT as the preferable (somatic) treatment of early schizophrenia.

No data was presented in this publication.

Garmany and Early (18) reported on their observa­ tions made with twenty-eight patients who received EN. Eleven of them were diagnosed as having schizophrenia and six others as having paraphrenia.

Pour of the schizo­

phrenic patients had been ill less than one year.

Two of

them received a full.course.of treatment and the other two had treatment stopped because of circulatory collapse. None of this group of four showed any improvement.

The

seven other schizophrenic patients also failed to show any improvement.

They had been ill between two and three years.

153 One of this group refused treatment, two had circulatory collapse, one had haemoptysis, and three had a full course of treatment.

In the group of six recent paraphrenias (an

older age group of patients with ”good personality preser­ vation, "better facade and better affective preservation,11 (p. 445) than the usually diagnosed schizophrenic) one refused treatment, one had such an increased severity of confusion that treatment was stopped and the other four had a full course of treatment.

Two of them showed no improve­

ment and the other two did show some improvement which was not maintained.

The investigators commented that nalthough

the series is small the uniformity of results obviated the need of larger numbers and have failed to confirm the findings of the American workers.” (p. 446) Medlicott (4*5) reported on his observations of sixteen schizophrenic patients who received EN.

He com­

pared his results with those of Tietz et al (83) and with subshock insulin and straight electroshock therapy.

He

claimed to have attempted to use the same rating scales that Tietz used so that their results could be more adequately compared.

He found that 37 per cent of the

group studied achieved recovery with insight, 25 per cent achieved some improvement, and 25 per cent had had no change.

This investigator felt that EN was the most

promising type of treatment for schizophrenia as compared

154 to subshock Insulin and electroshock especially if the patients were treated in the early stages of the disorder. Geohagan (20) recently published a report on his experiences with the use of EN as a treatment for schizo­ phrenia.

He observed the results on sixteen schizophrenic

patients who had been sick less than eighteen months, ten of whom were diagnosed as paranoid schizophrenics.

Seven

of the total group had not received any prior treatment while the other nine had had some form of BshockH therapy without showing any improvement prior to being given EN. Filre of the seven (71 per cent) for whom EN was their first physical psychiatric therapy improved and four of the nine

{kb per cent) who had failed to improve with prior wshock11 therapy improved following EN. Beznick and Arnett (60) reported on their investi­ gation in comparing the results of ICT and EN.

The former

treatment was given to 126 schizophrenic patients and the latter treatment was given to 7^ schizophrenic patients. Fifty-six of the patients who received ICT and thirty-eight of those who received EN had had previous Mshock11 treatments. Two weeks after the cessation of treatment the investigators rated the clinical changes that had occurred in the patients as remission, social improvement, administrative improvement, or not improved.

In analyzing their data the first two

categories of change were combined as being essentially

155 improved and the latter two categories were combined into a single group of patients who were considered essentially unimproved*

These investigators found that improvement

occurred in 49 per cent of the patients who had received IGT and in 31 per cent of the patients who had received EN*

156

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