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Electric Shock Therapy and the Mecholyl Test

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Electric Shock Therapy and the Mecholyl Test Powered By Docstoc
					        Electric Shock Therapy and the
                 Mecholyl Test
                      ERWIN J. LOTSOF, Ph.D., and JAMES YOBST, M.D.

rXlNKENSTElN s ' ! ' in a series of papers               was felt that the mecholyl test would suffice
has reported on the response to mecholyl                 for group prediction, but when this test was
and its relationship to electric shock therapy           used for individual prediction its value was
(EST). On the basis of the mecholyl re-                  questioned.
sponse, the patient is placed into one of seven             Geokaris and Kookier10 administered the
categories reflecting the degree of sympathetic          Funkenstein test to chronic schizophrenics
reactivity. In general, patients falling into            and found that none of their patients fell into
Group I have the poorest prognosis for im-               the favorable prognostic groups. Although in-
provement after EST, sympathetic hyper-                  dependent observers classified the results of
reactivity, while those falling into Group VII           the Funkenstein test, it would have been
have the best prognosis, sympathetic hypo-               interesting to know whether or not the inde-
reactivity. Funkenstein reported that 96.9 per           pendent observers were aware of the particu-
cent of his patients falling into Group VII              lar problem investigated since this information
improved.8                                               might have led to a biased estimate. Pasqua-
   An earlier study by Lotsof and Yobst13 has            relli14 found that the Funkenstein test was
shown that the response to mecholyl and epi-             related to the adequacy of affect and improve-
nephrine, as measured by systolic blood pres-            ment when patients were in psychotherapy.
sure changes, is rather unreliable. The mecho-           Jones12 found the Funkenstein test extremely
lyl test was given on two occasions and the              helpful. Although the sample employed was
reliability (consistency) of response employ-            large, insufficient data is presented to evaluate
ing rise, fall, and other changes of blood               the effectiveness of the Funkenstein test be-
pressure were correlated. Since the correla-             yond that of subjective evaluation. The pres-
tions were significantly greater than zero it            ent authors certainly agree with Alexander1
                                                         when he states, "It is surprising how few
   From the Psychology Department, University of         statistically valid studies are encountered in
California, Los Angeles, Calif., and Columbus Re-        the literature in reviewing publications of
ceiving Hospital, Columbus, Ohio; data collected at
latter institution.                                      treatment results." Brothers and Bennett3 have
   Supported in part by funds from the Research          reported on the use of the Funkenstein test
Comm., UCLA; Lederle Laboratories, and O'Brine           in their office practice. In general, they feel
Student Research Fund, School of Medicine, Ohio          that the test has some value as an aid in pre-
State University, Columbus, Ohio.                        dicting outcome of treatment. Alexander2 has
   The authors thank Walter Downing, research            employed the Funkenstein test in his office
assistant, UCLA, for his aid in this project and
express their appreciation to Dr. J. B. Craig and        practice and felt that it has some value for
Dr. R. Patterson, Columbus Receiving Hospital and        him. As Alexander points out he obtained a
Dr. E. Ogden, School of Medicine, O.S.U., for their      higher incidence of recovery in Groups I-V
respective assistance during the initial stage of this   (56 per cent) as compared to Funkenstein's
                                                          11 per cent. Alexander feels that his sample
   Received for publication November 5, 1956.
                                                                            PSYCHOSOMATIC MEDICINE
LOTSOF &. YOBST                                                                           375

is comparable to that employed by Funken-           TABLE 1. AGE AND SEX DISTRIBUTION
stein in the original studies. Although there           Age          Male        Female
might be similarity with regard to age and
sex, the writers feel that Alexander's group is       To 19            6            4
                                                      20-29            6           19
not comparable to that of Funkenstein's.              30-39            8           25
Patients who can be treated in an office are          40-49            5           16
usually less disturbed than patients who are          50-59           13            8
hospitalized; there certainly may be individual         60             4            8
                                                      Not stated       2            2
differences with regard to being in or out of           TOTAL         44           82
the hospital. However, it is our opinion that
in terms of groups, there would be differences               Test Administration
between the patients seen in the office and      Two hours after the last meal and after
those hospitalized.                           lying in the supine position for a half hour,
   The present study concerns itself with the systolic and diastolic pressure readings were
validity of the mecholyl test as a prognostic obtained by the cuff and auscultatory method.
indicator of EST; that is, to what extent doesFive readings at 1-minute intervals were taken
the mecholyl test measure what it is supposed prior to the administration of any solutions.
to measure. Funkenstein employed the mecho-   The mean of the readings during this 5-
lyl test which resulted in positive findings. minute period was used as the basal blood
Since selecting the "right" patient for shock pressure. The rationale for the 5-minute period
                                              was derived from a study by Shock and
treatment is such a difficult process, we incor-
                                              Ogden15 in which they showed that more
porated the mecholyl test as a predictor in our
study. In other words, if the psychiatrist em-than 5 observations contributed relatively little
                                              to the accuracy of the obtained blood pres-
ploys this test and only this test, can he state
                                              sure. Systolic and diastolic blood pressures
at a greater than chance basis that a particular
                                              were thus recorded for 5 minutes, after which
patient will profit from a series of shock treat-
ments and leave the hospital? The criterion   1 cc. of saline was injected intravenously and
                                              blood pressure readings were taken at ten
employed by Funkenstein for improvement       i-minute intervals. Following the saline in-
was whether the patient left the hospital     jection, 0.025 m g ' °f synthetic epinephrine in
within a month after the last EST and re-     0.5 cc. of isotonic saline were injected intra-
mained out of the hospital for a month, or forvenously and blood pressure readings were re-
nonimprovement whether the patient was in-    corded at half-minute intervals for 10 minutes.
capable of being discharged within a month
and necessitated further treatment. In our       The next day under similar basal condi-
study we employed this same criterion.        tions, the mean blood pressure was again
                                              obtained and used as a base level. Ten milli-
                                              grams of mecholyl were injected intramus-
                   Subjects                   cularly and blood pressure readings recorded.
                                              If the blood pressure returned to the base
   The total sample consisted of 126 psychi- level and remained there for 5 minutes the
atric patients exhibiting varying degrees of readings were terminated. If there was no
maladjustment confined to a psychiatric hos- return to the base level, readings were ob-
pital. Diagnostically the group ranged from tained for 25 minutes and then terminated.
personality disorders to schizophrenics. The Blood pressures were recorded from the same
ages of the patients ranged from 19 to 60 and arm as used for the injections. The above pro-
are presented in Table 1. The ratio of 2 cedure was repeated on all patients, i.e., Day
females to 1 male merely reflects the 2 to 1 1, epinephrine; Day 2, mecholyl; Day 3, epi-
bed capacity of the hospital at the time this nephrine; Day 4, mecholyl.
study was in progress.                           It was imperative that there be no con-
VOL. xix, NO. 5, 1957
tamination of the results. By contamination                     it was relatively easy to obtain the improved-
we mean the condition whereby the psychi-                       unimproved classification.
atrist knows the results of the mecholyl test
and this knowledge might affect his evalua-                                              Results
tion of the patient. The procedure was so
arranged that the individual administering                         Preliminary work did not warrant setting
the mecholyl test made no judgments regard-                     up a group referred to in the literature as
ing the effectiveness of treatment. In addition,                epinephrine or mecholyl precipitable anxiety.
after each mecholyl test, the results were kept                 When attempts were made to rate anxiety it
                                                                was found that there was a high degree of un-
apart from the patients' records and retained                   reliability; consequently, the aforementioned
by the investigator.                                            group was not evaluated in the study.
    The criterion for ratings of improvement or                    We have analyzed our data using the fol-
unimprovement selected was analogous to that                    lowing measures: base level, rise, fall, time,
employed by Funkenstein. In order to reduce                     and area. Grouping our patients by age
the bias of the therapist, which is present in                  (Table 2), it can be seen that there is a
many therapeutic endeavors, we resorted to                      moderate increase in basal level with age
the hospital record to ascertain whether or not                 which is in keeping with many findings.
the patient left the hospital i month after his                 Regarding rise, fall, and time there appear to
 last shock treatment. If the patient remained                  be no major differences. However, with re-
out of the hospital 30 days he was classified                   gard to area there is somewhat of a break
as improved. If the patient required further                    between patients below 49 and over 50. This
EST or was transferred to another hospital                      break we feel may be an artifact since area
for additional treatment, he was classified as                  is computed from resting level and time which
unimproved. By virtue of the record system,                     by themselves do not differ markedly.

                                       AND CLINICAL OUTCOME OF PATIENTS

                       Schizophrenia          Depressive        Involutional           Neurotic            disorder
       N                       31                   19                 5                 43                   12
       Age                  31.1                 49.0               61.3                 39.5                 28.2
       Base                124.1                125.3              141.2                118.6                111.8
       Rise                 38.5                 46.4               39.6                 37.0                 37.7
       Fall                 25.9                 24.2               38.0                 25.1                 18.7
       Time                 14.4                 13.1               18.4                 13.6                 11.1
       Area                 31.9                 38.2               58.8                 34.5                 16.8
       Improved                18                   16                 4                 31                   10
       Unimproved              13                    3                 1                 12                    2

                           TABLE 3.           GROUPING BY SYMPATHETIC REACTIVITY

             Groups I-IV                    Group V                 Group VI                    Group VII            Group Z
             M          S.D.           M                 S.D.      M            S.D.           M           S.D.          M

N                 21                           14                          12                         8                  71
Age       41.0          10.5           32.1               9.2     39.7          11.1           31.6        11.6          38.3
Base     117.6          28.8          127.6              10.7    130.0          13.3          120.0        10.0         120.3
Rise      56.8           9.1           32.3              11.3     56.8           8.4           34.1         6.7          33.0
Fall      25.2           8.1           29.9               7.9     33.8           9.7           29.0         8.5          25.4
Time      11.3           2.1           25                         25                           15.5         5.8          11.7
Area      25.7          16.8           70.3              32.3     74.8          43.8           30.3        19.9          27.6

                                                                                          PSYCHOSOMATIC MEDICINE
LOTSOF 8c YOBST                                                                                          377

                              E.C.T.                                               Non-E.C.T.
             Improved                    Unimproved                    I mproved                Unimproved
         M           S.D.               M           S.D.           M            S.D.            M        S.D.
 N              30                             15                         61                        Ji
Age      47.6        12.3               33.7        12.8          34.5          12.1         41.7        10.3
Base    125.2        14.3              120.5        13.8         118.5          12.6        121.2        14.3
Rise     36.6        17.2               41.3        15.2          39.4          14.5         39.2        12.1
Fall     27.5        10.0               27.2         9.4          25.2          11.4         29.9         9.4
Time     13.9           7.1             17.3         6.9          13.1          10.7         17.1         6.6
Area     34:3        19.8               41.3        26.4          34.5          33.4         47.7        34.5

   The diagnostic grouping of our patients is              nonshock, and improved-unimproved. Upon
presented in Table 2. The findings appear to               analyses we found that we had insufficient
agree with results generally reported, namely              cases in each of the groups to warrant mean-
age and the affective disorders. There appear              ingful statistical analyses.
to be no marked relationships between diag-
nostic category and the measures employed.
   In Table 3 we have grouped our patients in
terms of Funkenstein's categories. Because        The present study was an attempt to predict
of insufficient cases in Groups I, II, III and the outcome of EST via the mecholyl test as
IV we have consolidated the four groups in
                                    O    JT
                                               an indicator of sympathetic reactivity. A pre-
one group which will be referred to as the
 ne                                            vious study by the authors indicated that
                                               response to mecholyl and epinephrine was
a-I-IV) group. In addition, we have set up
                                               rather unreliable for individual prediction but
          roup which we are designating as would have some merit when used with
Group Z. This latter group consisted of 71 grouped data. The present investigation at-
patients who would have fallen into the un- tempted to assess the validity of the mecholy]
favorable groups but did not meet the initial test; on the basis of sympathetic grouping
requirement of an epinephrine rise of 50 which patients will improve or not improve as
mm. Further inspection of Table 3 does not a function of EST. In our study we used the
reveal major differences among the groups.     following measures: area, time, rise, fall, and
   What some might consider the crucial as- basal level. While some of our basic data agree
pect of our work is presented in Table 4. Here with that of Funkenstein's as well as other
the improved group is compared to the unim- investigations, there is also some disagreement,
proved group; both groups having received thus giving rise to rather marked differences
EST. One of the outstanding characteristics between our study and that of other investi-
of the table is the relatively large amount of gators. One can only look forward to more
variability in our patients. When the means controlled research to ascertain the efficiency
of the groups are compared there are no sig- of the mecholyl test. At present we can only
nificant differences between them. In addition speculate as to the lack of prediction in our
to the EST group we employed another group study. Perhaps there were differences in age,
which did not receive EST and this latter severity of maladjustment, and the different
group was also separated into improved and criteria employed by the psychiatrists for send-
unimproved. Here again our results are simi- ing or not sending a patient home. In addition
lar to the EST group; that is, there are no our study has attempted to reduce the sub-
major differences between them.                jective element and employ a sound method-
   We had planned to do a further breakdown ology. One can only urge for more controlled
of our data regarding the specific prognostic experiments than those already carried out.
grouping separating our patients for shock,
VOL. xix, NO. 5, 1957
In general, we can say that at the present             autonomic nervous system as determined by the
time we have not been able to achieve the              reaction to epinephrine and mecholyl. Am. ].
                                                       Psychiat. 106:16, 1949.
same degree of success as other investigators       6. FUNKENSTEIN, D. H., GREENBLATT, M., and
in predicting the outcome of EST using the             SOLOMON, H. C. Changes in the reactions to
mecholyl test.                                         epinephrine and mecholyl after electric shock
                                                       treatment. Am. ) . Psychiat. 106:116, 1949.
                                                    7. FUNKENSTEIN, D. H., GREENBLATT, M., and
        Summary and Conclusions                        SOLOMON, H. C. A test which predicts the
                                                       clinical effects of electric shock treatment on
   An attempt was made to determine the                schizophrenic patients. Am. ]. Psychiat. 106:
efficiency of the mecholyl test as a predictor         889, 1950.
of EST. The criterion employed was whether          8. FUNKENSTEIN, D. H., GREENBLATT, M., and
the patient improved or did not improve after          SOLOMON, H. C. An autonomic nervous sys-
                                                       tem test of prognostic significance in relation
a course of EST. In general, we found no               to electro shock treatment. Psychosom. Med.
consistent relationship between grouping as             14:5, 1952.
based on the mecholyl test and the criterion        9. FUNKENSTEIN, D. H., GREENBLATT, M., and
of recovery following EST. In our study we             SOLOMON, H. C. Nor-epinephrine and epi-
were not able to verify the results of Funken-         nephrine-like substances in psychotic and psy-
                                                       choneurotic patients. Am. ]. Psychiat. 108:652,
stein. The differences in the two studies              1952.
might be attributed to many variables that are      10. GEOKARIS, K. H., and KOOKIER, J. E.      Blood
difficult to control.                                   pressure responses of chronic schizophrenic pa-
                                                        tients to epinephrine and mecholyl. Am. ) .
                                                        Psychiat. 112:808, 1956.
                  References                        11. GELLHORN, E. Physiological Foundations of
                                                        Neurology and Psychiatry. Minneapolis, Univ.
 1. ALEXANDER, L. Treatment of Mental Disorder.         Minnesota Press, 1953.
    Philadelphia, Saunders, 1953.                   12. JONES, C. H. The Funkenstein method in
 2. ALEXANDER, L. Epinephrine-mecholyl test.            selecting methods of psychiatric treatment. Dis.
    Arch. Neurol. & Psychiat. 73:496, 1955.             Nerv. System 17:37, 1956.
 3. BROTHERS, A. V., and BENNETT, J.   The Funk-
                                                    13. LOTSOF, E. J., and YOBST, J.    The reliability
      enstein test as a guide to treatment in the
      neuroses and psychoses. Dis. Nerv. System         of the Mecholyl test. Psychosom. Med. 19:370,
      '5:335. J954-                                     1957-
 4. FUNKENSTEIN, D. H., GREENBLATT, M., and         14. PASQUARELLI, B., et al. Further appraisal of
      SOLOMON, H. C. Autonomic nervous system           the adrenalin-mecholyl test. Psychosom. Med.
      changes following electric shock treatment.       18:143, 1956.
      /. Nerv. & Ment. Dis. 108:409, 1948.          15. SHOCK, N. W., and OGDEN, E.      The probable
 5. FUNKENSTETN, D. H., GREENBLATT, M., and             error of blood pressure measurement.   Quart. J.
      SOLOMON, H. C- The status of the peripheral       Exper. Physiol. 29:49, 1939.

                                                                         PSYCHOSOMATIC MEDICINE