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The Effects Of A Self Shock Procedure On Hallucinatory Activity In Hospitalized Schizophrenics

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The Effects Of A Self Shock Procedure On Hallucinatory Activity In Hospitalized Schizophrenics

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Content 70—11,39.3 WEINGAERTNER, Arthur Hans, 1941- THE EFFECTS OF A SELF SHOCK PROCEDURE ON HALLUCINATORY ACTIVITY IN HOSPITALIZED SCHIZOPHRENICS. University of Southern California, Ph.D., 1969 Psychology, clini cal University Microfilms, A X E R O X Company, Ann Arbor, Michigan THE EFFECTS OF A SELF SHOCK PROCEDURE ON HALLUCINATORY ACTIVITY IN HOSPITALIZED SCHIZOPHRENICS by Arthur Hans Weingaertner A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Psychology) June 1969 UNIVERSITY O F SOUTHERN CALIFORNIA TH E G RAD U ATE SCH O O L U N IV ER SITY PARK LO S A N G E L E S, C A L IF O R N IA 9 0 0 0 7 This dissertation, written by ....AitiuiT.Jiflns.-WfiAnissfiE.t.nsE........... under the direction of h.iS... Dissertation C o m mittee, and a pproved by all its members, has been presented to and accepted by T he G radu ate School, in partial fulfillment of require ments of the degree of D O C T O R O F P H I L O S O P H Y Dean D a te.. / T f f DISSERTATION COMMITTEE Chairman ACKNOWLEDGMENTS I express my deepest appreciation to Dr. L. Douglas DeNike whose highly dedicated supervision throughout all as pects of this dissertation provided a stimulating portion of my education. I am also grateful to him for his personal support and encouragement. Thanks are due Dr. William Larson for his percep tive suggestions. Also appreciated was Dr. Norman Tiber's guidance in various aspects of this dissertation. I am indebted to Mr. Walt Braunstein for utilizing his ingenuity in electronics to design a shock box which met the unique needs of this research. Special gratitude is expressed to the staff at Sepulveda V A H for their indispensible cooperation through out all phases of this study. In particular I express my thanks to Dr. Armand Alkire whose help in innumerable ways was indispensible. Finally, I would like to thank my mother, Elsie M. Weingaertner, for her dedication in typing this manuscript. A.H.W. ii TABLE OF CONTENTS Page Acknowledgments ........................................ ii List of Tables......................................... v Chapter I. THE PROBLEM AND RELEVANT LITERATURE ........... 1 Hallucinations ................................ 1 The Concept The Nature of Hallucinations ... . . . . . . k Empirical Causation Content Contemporary Theory Schizophrenia ................................ 15 Clinical Experimental Findings Motivation and Performance The Nature of Symptoms and of Change...........23 The Use of Aversive Stimuli in Conditioning.-., 25 Characteristics of the Punishment Process Effectiveness of Punishment Aversive Conditioning with Humans ........... 29 iii Chapter Page Non Psychotic Patients Self Shock Procedures .................... 35 Psychotic Patients Experimental Hypotheses ............ .....40 II. METHOD................................. 42 Subject Selection and Assignment to Groups . . 42 Instruments................................... 44 Dependent Measures ............................ 46 Procedure ................................... 49 III. RESULTS................................ 53 Preconditions to Analysis ................... 54 Analysis of Treatment Effects by Groups: Change........................................61 Group Analyses of Differences in Change . . . 65 Individual Contributions to Group Means . . . 66 Other Variables Associated with Change .... 72 Data of Selected Patients ......... ..... 83 IV. DISCUSSION...............................86 Factors Related to Improvement............... 101 Report of Improvement........................105 Other Aspects Involving the Experimenter . . .107 Implications.................................. 109 V. SUMMARY...............................Ill References .............................................186 LIST OF TABLES Table Page I. Summary of Tests for Initial Comparability of Groups.................................. 58 II. BPRS Changes from Pre to Post on Hallucination and Total Psychiatric Pathology Scales . . . 62 III. BPRS Changes and Groups in which they Occurred 63 IV. Changes in Frequency of Hallucinations .... 64 V. Symptom Changes Reflected in the Symptom Checklist.............................. 65 VI. Differences in Change Between Groups ........ 66 VII. Unequivocal Positive Changes Occurring in the Three Groups................ 67 VIII. Frequency Count of Patients of Each Group Falling into Three Categories of Change . . 68 IX. Algebraic Sum of Symptom Changes for Individuals in Each G r o u p............. 70 X. Number of Patients in Each Group Showing a Rating of "Changed" in Hallucinating .... 71 XI. Comparison Between Examiners' and Other Professionals' Ratings of Improved ......... 72 XII. Ward Personnel Statements of Improved .... 73 XIII. Variables Related to Improvement .......... 74 v Table Page XIV. Change as Influenced by Onset of Illness Showing Group Contributions ................. 76 XV. Conditions Affecting Hallucinations Related to Change Showing Group Contributions ..... 77 XVI. Content of Hallucinations Related to Change in Hallucinations Showing Group Contributions . 78 XVII. Chronicity of Voices Related to Change Showing Group Contributions ....................... 80 XVIII. Chronicity of Illness Related to Change Showing Group Contributions ............ 81 XIX. Frequency of Patients in Each Category Who Felt Box Related to Improvement and Who Felt Box was Unrelated .............................. 82 vi CHAPTER I THE PROBLEM AND RELEVANT LITERATURE The object of this research was to try to eliminate or reduce, by means of aversive conditioning procedures, the occurrence of hallucinations in schizophrenics whose hallucinations persisted after placement on medication clinically considered optimal. The position taken in this study that such a change could be brought about grew out of several lines of research and theory. These included work on the nature of hallucinations, results of aversive con ditioning research and pilot work with schizophrenics. Hallucinations The Concept. Although in general usage, the concept of hallucination lacks a single precise, detailed specifica tion satisfactory to members of the various mental health and related professions. Many experimental psychologists in particular express dissatisfaction with the concept of hallucination, as they do with many clinical entities, on the grounds that adequate operational definitions of the concepts cannot be formulated. One main deficiency of many clinical concepts as seen by experimentalists is the fact that they cannot be produced at will for observation or ex perimental purposes. Unfortunately there are many in- 1 stances in which operational definitions of clinical con cepts which were adequate by most experimental criteria were so dissimilar from the original clinical concepts as to render results of the experimental manipulations of the concepts clinically useless. Laboratory studies of induced and manipulated anxiety exemplify the generally adequate operational definition of a clinically derived concept. It has been shown, however (Eysenck, 1961) that experimental anxiety is a very inadequate realization of the clinical concept of anxiety. It would appear that the difficulty conceptualiz ing hallucination in an experimentally adequate fashion ex plains, at least in part, the paucity of experimental lit erature on hallucinations. Despite some lack of precision of the concept of hallucination there is an abundance of clinical literature on hallucinations. Alexander (1966) notes that hallucina tions have been discussed almost since the beginning of re corded history. According to him, the interpretation placed on hallucinations varied with time and culture. For example, among primitive cultures the presence of hallucina tions was often considered to indicate one's fitness for the honorable position of witch doctor. In western societies, hallucinations in the adult have generally been considered a symptom of mental derange ment. Galen was one of the first western writers to clear ly specify delusions and hallucinations as indicative of mental disturbance. In early medicine, however, hallucina tions were not differentiated as a single symptom, but were more generally considered together with illusions and delu sions. Considerable investigation and clarification of the phenomenon of hallucinations, and hence refinement of the concept, has taken place since Galen's time. Lavater (1572) writing during the middle of the 16th century in Switzer land, discussed various modalities of hallucinations. In particular he commented on the greater frequency of audi tory over visual hallucinations. Lavater noted the content of hallucinations to be primitive and derogatory material often associated with guilt around misdeeds. He noted hal lucinatory phenomena to be associated with loss of reason in people who "are timorous and fearful." Lavater went on to discuss the roots of fearfulness. He felt that "it may be one's nature to be timorous or one may become fearful because of great dangers or by some other ways" (Lavater, p.6). Lavater then isolated hallucinations from delusions and categorized various types of hallucinations according to modality and content. He associated them with particu lar states (fearfulness) which would now be categorized as schizophrenia. In addition to these careful and percep tive contributions to the concept of hallucinations, he ap pears to have been aware of the process-reactive dimensions k of schizophrenia discussed currently. The 1572 translation of Lavater's work is the first known discussion of halluci nation in English. The next major refinement in the concept of hallu cinations came from Pinel's student Esquirol (I8*f5)» He, who like Pinel did not overly indulge in theoretical spec ulation, was the first to differentiate between hallucina tions and illusions. He gave the name hallucination to sensory impressions, for example, hearing or seeing ob jects that do not exist; illusions he defined as false im pressions of an actual, sensory stimulus. He stressed the role of affective preoccupation as the central source of symptoms. Baillarger, working around the same time, dif ferentiated hallucinations which occurred in the hypno- gogic state and those of alcoholic delirium. The Nature of Hallucinations Empirical Studies. Moreau (1859) appears to be the first to take the position that hallucinations and dreams are basically the same phenomenon. He indicated two processes analogous to Freud's conscious and unconscious and stated that hallucinations are normally found in the latter state in the form of dreams, but the same phenomenon in the "con scious" is pathological. He sought to understand the link between normal and abnormal in the study of dream phenom ena. Further understanding of the principal state in which hallucinations occur, namely schizophrenia, was con tributed by Kraeplin (1907) who distinguished schizophrenia from affective psychoses. Liebault (1889), Bernheim (1900) and Janet (1899) added to the understanding of unconscious phenomena through their work primarily with hysterics and hypnosis. The twentieth century finds an abundance of theoriz ing, with a concomitant reshaping of the concept of halluci nation, but with perhaps less clearcut refinements and more direct discussion of their nature and characteristics. The basic definition has remained pretty much as proposed by Es- quirol. Three major schools of thought in psychology and psychiatry have addressed themselves to the consideration of hallucinations: (1) First, Pavlov (1934) and his follow ers (Astrup, 1965; Popov, 1923; Ronchevski, 1941) who empha size conditioning and identified themselves with the physio logical community. (2) Second was dynamic psychiatry, largely shaped by Freud and the psychoanalysts. (3) Third was American behaviorism which although it purported to grow from Pavlov's work is in most respects sufficiently di vergent to be considered a separate entity. Although there is often disagreement between the three schools, there ap pears to be considerable agreement among them on the nature of hallucinations. There is almost complete agreement among theorists of the various schools (Arieti, 1959; Dollard and Miller, 6 1950; Fenichel, 1945; Freud, 1953; Jung, 1959; McClelland and Atkinson, 1948;,Miller, 1959; Murphy, 1947) that hallu cinatory phenomena are normal at an early stage of matura tion. Dollard and Miller, following Hull (1943)> describe hallucinatory phenomena as an innate response initially rel atively high on the response hierarchy. Freud (1953) makes essentially the same statement in more elaborate fashion. He describes hallucinations as part of the person's rudi mentary adaptive equipment usually found in early stages of development where primary process is the main means of ten sion reduction. Slight variations on the same theme are made by other writers. According to this generally held view, hallucina tions, like many other tendencies which occur at an early age, become almost completely suppressed before puberty by cultural influences in western societies. Behavior theory describes the process as relegation of these responses to a much lower position on the response hierarchy due to social reinforcements. Freud subsumes the same process under de velopment of the ego which functions on secondary process, planning for realistic satisfaction of needs. Language and concept formation, which are culturally mediated, assist vastly in the development of secondary process according to Freud. Suppression of hallucinatory phenomena by cultural influences is then apparently felt to be the rule in western societies. In support of the position that hallucinations are spontaneous or innate is Murdoch's (1934) report that there is a much higher incidence of hallucinations in societies not employing active suppressive measures than in other so cieties. However, Wynne (1965) in reference to our own so ciety states that " ... a surprising number of nonhospital ized individuals report having had distinct hallucinations" (p.20). Arieti (1955) also discusses spontaneous halluci nations in normal adults. It would appear that even in our society hallucinations have a higher incidence than is com monly believed, which leads to the question of what brings them about. Causation. Most writers are again in basic agreement as to the predisposing factors for hallucinations. Astrup (1965) Pavlov (1934) and Popov (1923) specify increased excitabil ity of the organism and/or decreased stimulation; Fenichel (1945) and Freud (1953) specify intense anxiety and with drawal from reality; Bleuler (1950), loneliness and/or a strong need, and Dollard and Miller (1950) and McClelland and Atkinson (1948) specify increased drive and low sensory stimulation as the necessary and usually sufficient pre conditions for the occurrence of hallucinations. Generally the terms excitability, anxiety and drive have been used interchangeably. Spence and Taylor provide empirical evi dence that anxiety is classified as drive and Hull (1943) used the word "drive" synonymously with Pavlov's excitabil- 8 ity. Hence there is no question that all schools are dis cussing basically the same entity as the first predisposing factor. There is ample support for the conviction that re duced sensory stimulation increases the probability of hal lucinations, both from clinical observations, reports of prisoners and castaways (Jackson, i960) and sensory depriva tion studies (Eysenck, I96I). That Freud's schizophrenic isolation has much in common with sensory deprivation is not immediately obvious. McReynolds (i960), who looks largely to empirical and experimental evidence for the basis of a very convincing theory of hallucinations, states that in the schizophrenic the "high level of unassimilated material has led to a drastic decrease in the influx of new percepts such that his condition is much like that of people in a sensory deprivation condition". He goes on to point out that where a person maintains intellectual activities (he cites the case of a prisoner allegedly in solitary con finement for 30 years) mental integration is not impaired. He draws the reasonable conclusion that it is not social or physical isolation per se which is crucial for the occur rence of hallucinations, but lack of novel data. He specu lates further that in a state of boredom one may create new stimuli (Dember and Earl, 1957). Content. Content of hallucinations is dealt with primarily by dynamic psychiatry. Content is seen to vary over a wide range. As Bleuler (1950) states: "Content may be anything a normal person perceives as well as whatever else the schizophrenic can invent" (p.31). Freud (1953)> who prob ably goes into as much detail as any writer on hallucina tions, makes a statement reminiscent of Lavater's (1572) that in schizophrenics content of the hallucinations is primarily fear-producing and derogatory, and is derived from objectionable and fear-producing impulses and acts. In addition to the more commonly described negative content many theorists (Bleuler, 1950; Fenichel, 1945; Freud, 1953; Jung, 1959; McClelland and Atkinson, 1948; and Pavlov, 1934) describe hallucinations the content of which is pleasurable, which Freud describes as wish fulfillment. There is then general agreement that hallucinations resemble sensory impressions but are entirely products of the mind and have the following attributes: (1) They are spontaneous at early stages of development. (2) They are modifiable by experience. (3) In western societies they are usually sup pressed by cultural influences before puberty. (4) In the adult in western societies they are symptoms needing treatment. (5) They are found predominantly in schizo phrenics in western societies. (6) Auditory hallucinations are considerably more common than visual and hallucinations in other modalities (Bleuler, 1950; Jung, 1959; etc.)* (7) Content seems to be mostly derogatory material based on guilt but often positive material re lated to needs is noted and almost anything can appear as content. (8) There seem to be two primary predisposing fac tors: (1) a state of decrease of novel data re gardless whether due to schizophrenic isolation, physical isolation or sensory deprivation; (2) a relatively strong drive. (9) The above are characteristics of "the main type" of hallucinations as opposed to hypno- gogic hallucinations, epileptic hallucinations, illusions, alcoholic and toxic hallucinosis. Contemporary Theory. A variety of theories, hypotheses and guesses exist as to other aspects of hallucinations, most of which are worthy of some consideration, if only for com pleteness. From the Russian and physiological approach such ex planations of hallucinations are offered as sensory imbal ance (Ronchevski, 1941), imbalance of excitatory and inhib itory processes in various areas of the cortex (Astrup, 1965; Pavlov, 1934; Popov, 1923); and general inhibitory state (Kuravitski, 1939). Penfield (1950) describes hallu cinations as possibly minor seizures but is probably talking 11 about a phenomenon referred to by Arieti (1959) as epilep tic. The question as to what is a hallucination appears to have the greatest divergence of opinion. At one end of the spectrum are those who feel hallucinations are nothing but lies (McCarthy, 1966). Adler (1956) appears to ex press this line of thinking at least in some cases. Rogers (1951) simply sees hallucinations as a symptom reflecting particular kinds of disturbance. Gould (1950) on the other hand, feels that at least auditory hallucinations are the patient talking to himself based on his work re vealing that "articulatory sounds" and movement of the vo cal apparatus are present during auditory hallucinations. He feels that the hallucinatory vocal movements can be re corded electrophysiologically and reports several demon strations of this (Gould, 1950). Many other theorists feel hallucinations are a reality producing measurable physiological patterns (Bateman, 1951; Collomb, 1959; Mulder, 1957; Mundy-Castle, 1951; Williams, 1951)* Heron (1961) describes a similar view based on EEG work during hallucinations reported during sensory deprivation work. Most theorists neither reject hallucinations as a legitimate psychological phenomenon nor attempt to define them in physiological terms. De Boismont's (1853) descrip tion of hallucinations as an idea in perceptual form ap pears to represent the basic position on hallucinations. 12 Arieti (1958), Fenichel (1945)» Freud (1953), Jung (1959) and most other major clinicians hold the position that hal lucinations are basically perceptions. Allport (1955) views perceptions as composed of images as do clinicians generally. Mowrer (I960) goes further, stating that actual sensations are experienced in hallucinations. Mowrer’s statement is an interpretation based on experimental work such as the sensory conditioning studies of Brogden (1939) with dogs, Ellson (1941; 19^2), Karn (1947), Brogden (1947)> and Chernikoff and Brogden (1949) with humans, and probably on studies conditioning "temporary after effect of an experience". Seitz and Mulholm (1947) on the other hand agree that many theorists view hallucinations as exaggera tions of mental images but attempt to show that hallucina tions are not directly related to imagery. They cite the work of Cohen (1938) and Roman and Landis (1945) indicating that hallucinations usually occur in the modality most de ficient in imagery in the absence of hallucinations. And Smythies (1953) reported that eidetic imagery can occur to gether with hallucinations, apparently implying that there fore hallucinations cannot be images. Mowrer elsewhere (1938) describes a theory explain ing hallucinations in terms of expectancy and set as does Allport (1954) in a more mathematical fashion. And Osgood (1951) indicates that suggestion may be the key feature of hallucinations. 13 The interpretations made by most experimentalists of their experimental data appear at best naive. It seems useless to spend time debating whether a hallucination is or is not a sensation, and eidetic image or v/hatever, under some highly specific set of conditions. In all probability hallucinations can appear as any one of the forms described by the experimentalists depending upon the momentary mental state of the hallucinator. Indeed, Bleuler (1950) noted that the intensity and clarity of hallucinations varied over a wide range, although they usually had the reality value of actual perceptions. Bleuler1s statement is the most useful from a clinical point of view and can probably be used as a summary of much of the experimental work even though it predated the work by many years. That suggestion and expectancy play a role in bringing about hallucinations was early noted by Jung (1959); however to propose sugges tion as the sole key to their explanation as does Osgood (1953)» seems ludicrous. Recent theoretical positions explaining hallucina tions and schizophrenia in general use the phrase "internal- external" for conceptualization (Lovaas, 1967; McReynolds, I960). Basically, this concept refers to the degree to which the patient is externally oriented as the normal al legedly is under normal conditions. Consistent with the material discussed under the empirical nature of hallucina tions, this position holds that an internal orientation, in Ik which hallucinations are more probable, comes about either when external stimulation is drastically reduced or inter nal preoccupation increases to the extent that external orientation weakens. Allport mathematizes their concept by stating internal material predominates when external stimu lation drops below internal. It would seem reasonable to say that intensity depends on the degree of imbalance in favor of internal orientation. One could speculate on the many ways in which an imbalance in terms of internal preoc cupation could come about, directionality, which first, etc., but for our purposes we will simply take the empiri cal fact that one’s statement that he hallucinates is in dication of internal preoccupation as Lovaas does. This state was recently described as interacting with one's self (Erickson, 1968). There appears to be general agreement both from an experimental point of view (Perkey, 1910) and a clinical one (Arieti, 1958) that breakdown of discrimination between actual perceptions and "imagery" leads directly to halluci nations. Perkey shows that this can occur in the normal when external cues are weak and an expectancy is present. Here however, breakdown of discrimination is externally produced. Arieti (1955) in describing the schizophrenic states that the breakdown of discrimination is internal. He feels the ability to discriminate is a function of higher conceptual processes. In schizophrenic states he 15 feels that which is usually conceptual becomes perceptual as a function of regression at which level conceptual dis criminations, which are required to distinguish between ex ternal "reality" and internal material, cannot be made. Schizophrenia Clinical. As indicated previously this study is concerned with auditory hallucinations in schizophrenics. A vast literature exists on schizophrenia with a myriad of con flicting theories, explanations, descriptions, treatments, alleged causes and symptoms (Beliak, 1958). The currently accepted definition of schizophrenia is: "Schizophrenia represents a group of psychotic reactions characterized by fundamental disturbances in reality relationships and con cept formations, with affective, behavioral and intellectual disturbances in varying degrees and mixtures. The disorders are marked by a strong tendency to retreat from reality, by emotional disharmony, unpredictable disturbances in stream of thought, regressive behavior, and in some by a tendency to 'deterioration1. The predominant symptomatology will be the determining factor in classifying such patients into groups" (Diagnostic and Statistical Manual of Mental Dis orders, 1952). Although roughly the same percentage of the popula tion appears to be classifiable as schizophrenic through the ages, regardless of culture (Coleman, 1964)* aspects of the disturbance examined have varied with the times as has the approach and attitude taken with regard to schizophrenia. Originally tortured, then placed in dungeon-like "hospitals" and later given a status similar to that of an animal, i.e., fed, cleaned and herded together with others of similar af fliction, the schizophrenic was finally looked upon as a sick person although virtually non-treatable. Descriptive approaches and attempts at treatment followed. With Freud's emphasis on psychodynamics and psychological causes more intensive efforts at treatment were made. A pessimism about producing substantial change continued un til the advent of the phenothiazine drugs. In some circles pessimism about change of any kind in the schizophrenic is still the prevailing attitude, and the term schizophrenic conjures up an image of a human being who is just about everything we are not as a result of faulty biological makeup. Pessimism is voiced among therapists as well as among researchers. A number of alleged characteristics of schizophren ics perpetuate the pessimism among therapists and research ers. Clinicians frequently view schizophrenics as unable to establish rapport or, at a deeper level, to establish a transference. The negativism and poor motivation of schizo phrenics are also seen as severe handicaps to therapy. The schizophrenic's characteristic difficulty form ing concepts leads to the assumption that he is unable to 17 learn what the "normal" learns or to understand as the "nor mal". Disturbances of attention, of set due to response to individual stimuli or minor nonadaptive sets, "splitting" of ideas, lack of cooperation, disruptive behavior and inabil ity to take responsibility are features seen to plague re search with schizophrenics as well as therapeutic efforts (Bleuler, 1950; Fenichel, 19^5; Freud, 1953; Lynn, 1963; Mishler, 1965; Schooler and Feldman, 1967; Silverman, 1963* 1964; Winder, i960). Indeed a grim picture is painted by many who have studied schizophrenics and on this basis Lind- sley (1956) justifies an operant situation for conditioning schizophrenics. His is a very distant mechanistic approach designed largely to simplify management of schizophrenics. A number of recent writers who have studied schizo phrenia extensively, both directly and from the literature, introduce some optimism and clarity on working with the schizophrenic, not in terms of hopeful speculations, but in terms of carefully documented observations, both clinical and research, on ways of optimizing the schizophrenic's functioning. Wolberg (195^) describes three basic points in es tablishing rapport with schizophrenics. First, a comfort able emotional atmosphere must be established. With schizo phrenics Wolberg says it is most important not to threaten him by over expression of warmth, but to communicate under standing by responding to his language and gestures, simple 18 language being best. Never must censure be shown in any form. Thinking of the patient as emotionally infantile is fruitful in understanding his vagaries. Cold logic is un fruitful in comprehending the patient - he desires a child ish relationship involving protection and help. He needs to be dependent and looks upon others for aid and often sees them as omniscient and is very demanding. If a relation ship can be formed which has pleasure value for the schizo phrenic, all the better. The second point is structuring the purpose of the interview. It is considered crucial to make very clear what the role of the patient will be as well as that of the ther apist (or the experimenter as the case may be). Lack of clarity leads to confusion and frustration and cooperation is decreased. It is important to be highly specific and concrete. The third aspect is dealing with resistance. A sug gested way of quelling this is by sympathetically verbaliz ing how the patient must feel, especially where there are clear cues in terms of facial expressions, etc. It is pointed out that much activity on the part of the therapist is required in relating when the patient is upset, has dif ficulty talking or talks or irrelevant material. Sometimes understanding can quell patient anxieties. Howtility, ques tions about the stranger in his presence and disappoint ment are frequent sources of resistance. Allowing the pa 19 tient to air his feelings in a non-punitive atmosphere ap pears crucial. Counter-hostility is never fruitful. The points described by Wolberg serve as a good cJinical guide for work with schizophrenics in general whether in therapy or research. Experimental Findings. In addition to and overlapping some of IVolberg's points are data derived from experimental work with schizophrenics. In discussing the problem posed in working with schizophrenics in research situations the term "psychological deficit" is used to describe their apparent inability to function as "normals" do (Buss and Lang, 1965; Lang and Buss, 1965; Shakow, 1963; Silverman, 1963; 196lf). Those authors base their discussion on extensive reviews of the literature and of their own research. Their work, and that of Uznadze (1966), which is exhaustive and perceptive may be considered to summarize the findings in the field. Shakow (1962) and Uznadze (1966) both examine the schizophrenic's functioning in experiments and conclude that a certain percentage will always provide unusable data. Shakow breaks this finding down and classifies schizophren ics into five categories labeled A through E on the basis of their functioning. Essentially those in the A group show no more disturbance in attention, set, cooperation or perform ance than normals whereas at the other extreme, the E's, are never usable where any form of cooperation is required. In the other four groups Shakow describes conditions modifying 20 deficits generally considered unmodifiable. He describes the conditions as "normalizing trends". Shakow reports that when schizophrenics are given more time than normals they are able to establish appropri ate set. When allowed to take their own time their per formance on some tasks approximated that of normals. Repe tition serves much the same purpose as allowing the schizo phrenic to take his own time. The explanation offered is that schizophrenics are simply slower to reach their physio logical limit, hence learning is not impossible but simply slower. Indeed, the work of Lang and Luoto (1962) and Spence and Lair (1965) indicates that contrary to most the orists the mediation processes in the schizophrenic are not impaired, but that performance alone is interfered with. Carson (1962) and Hall (1962) show that schizophrenics can form the same concepts as normals if conducive conditions exist. Brodsky (1963) showed that the crucial factor re sponsible for apparent impairment of concepts is threat. For example, concepts involving personal content persist ently show deficit. Allowing schizophrenics a period of ac quaintance with new conditions to remove strangeness is a crucial factor in raising their level of performance. Stress is fairly consistently found to bring about an improvement in performance (Buss and Lang, 1965; Lang and Buss. 1965). Shakow (1963) shows that schizophrenics’ per formance approximated that of normals on several tasks when 21 informed that their performance was not as good as the aver age. Better quality thinking in terms of clarity and con sistency was also revealed on a TAT test of thinking. This last result was interpreted by Shakow as demonstrating that schizophrenics are capable of forming a major adaptive set. Involvement was found to result through rapport and influ ence the experimenter established or by providing a social situation in which the schizophrenic was a member of a peer group. Involvement was found to be greatest under competi tive conditions. Motivation and Performance. Garmezy (1952) points out that schizophrenics vary greatly in their ability to learn or follow instructions. He suggests that their motivation to become involved in a task can be greatly enhanced by making the apparatus and methods maximally interesting to the schizophrenic patient. Such procedures, he has observed, strengthen the likelihood that the subjects will retain their instructional set and be less predisposed toward wothdrawal and avoidance. He stresses, in agreement with Shakow, the longer period of adaptation required by schizo phrenics to a new situation. He shows (Houston and Shakow, 1948) research to indicate that even in a dull routine task normal levels of performance can be achieved by this means. A study by Leventhal (1959) indicates the beneficial use of censure as a method of increasing performance. It was found by Heilman (1961) that this is true primarily with 22 good premorbids. With poor morbids he found censure to pro duce withdrawal. De Mauro (1965) shows evidence that cen sure decreases performance generally in schizophrenic sub jects. Encouragement and praise, whether response contin gent or not is most effective in increasing performance (D'Alessio and Spence, 1963; McDonald and Sheehan, 1962; Robertson, 1961). Failure experiences generally produce withdrawal (Shakow, 1963; Wilensky, 1952). Chapman notes that performance is impaired most when the schizophrenic has a large variety of stimuli present. He is distracted by irrelevant stimuli. When he must inhib it stimuli through one sensory channel his decrement is greatest. Integration of sensory data from more than one sensory channel impairs performance and motor sequences are disrupted by sensory data. Shakow warns against making a schizophrenic subject aware that he has the responsibility of control in an exper imental situation. Under that condition his performance is poorest. Control being in his hands without him knowing it, on the other hand appears to produce good results. Lindsley reports a technique for recruiting schizo phrenic subjects. Candy or cigarettes were offered to the patients in the ward if they followed the experimenter. Only ten per cent refusal resulted. Of that ten per cent some could be conditioned by giving them candy or cig arettes. Cigarettes appear to be a good reinforcer for 23 schizophrenics (Sommer et al, 1962). In his excellent book on the psychology of set, Uznadze (1966) reports that on the average, of many experiments with schizophrenics, one out of five or six provided unusable data due to disturbance of set. However, he did not indicate that any special motivat ing devices were used. Other factors shown to be related to performance in schizophrenics are chronicity, severity, process or reactive onset, good or poor premorbid adjustment and whether para noid or not. Perhaps the major single symptom impairing the schizophrenic's performance is his withdrawal from ex ternal stimuli. Lovaas (1967) makes this point. The Nature of Symptoms and of Change Great divergence of opinion exists between analyti cally based dynamic psychiatry and behavior theory on the nature of symptoms and their treatment. Dynamic psychiatry takes the position that all symptoms have their roots in deep-seated emotional complexes which involve the whole or ganism. Symptoms are seen as reflecting the underlying problem. Change in symptoms, say the dynamicists, should come about spontaneously when the underlying problem has been adequately dealt with. The way of treating the underlying disturbance pre scribed by analytic theory varies somewhat but generally in volves a long term relationship with the therapist. The re lationship is characterized by nonrejection by the therapist and develops primarily through verbalizations. The nature of the patients* attitudes, mostly as expressed toward the therapist (transference), is the material dealt with in ther apy. As pointed out by Freud himself, therapy can be but minimal when transference does not exist. On this basis, he saw psychoanalysis ineffective with withdrawn schizophrenics. Modern psychiatry is more optimistic than Freud regarding treatment of schizophrenia and prescribes a nonthreatening atmosphere, warmth and structuring rather than analysis. The major justification for optimism in the treatment of schizophrenia is probably based largely on the results of chemotherapy. Any treatment of symptoms per se is seen as a psychologically risk process which at best may result in the appearance of another symptom with the same dynamic roots. The behaviorists, on the other hand, tend to follow Eysenck (1961) and Wolpe (1958) in their interpretation of symptoms. Those two writers generally limit their discus sions to neuroses. They maintain that the symptom actually constitutes the disturbance. The symptom develops, they say, when fear becomes conditioned to a previously neutral stimu lus. Following that conditioning the stimulus evokes the fear which is experienced as anxiety. The treatment that logically fits is simple counter-conditioning of the fear by means of some behavior modification agent. This is the treatment prescribed by behavior therapists. Any neurotic symptom is considered by the behavior- 25 ists to be a response. As such it is subject to the prin ciples of conditioning. Some reluctance is generally shown by Eysenck, V/olpe and their followers in applying condition ing techniques in the treatment of psychotics. One reason may be that Eysenck and Wolpe focus most attention on anxi ety symptoms for which the negative antecedent stimuli are more or less in evidence. Exceptions such as Ayllon's token economy do exist (Ayllon, 1962). Bucher (1967) and Lovaas (1967) view symptoms some what differently. They stress the fact that although a symptom may have had functional significance at one period in a person's life, most symptoms lose their functional significance and, in essence, become functionally autono mous. The obscure roots of symptoms need not, assert those theorists, be of concern since any behavior, whether consid ered a "symptom" or not, may be considered a response. As so conceived, all behaviors are seen to follow the princi ples of conditioning and are thus modifiable by conditioning procedures. Lovaas (1967) has shown impressive empirical evi dence supporting the validity of his position. He has pro duced overtly appearing normal behavior in children who were highly autistic at the beginning of his treatment. The Use of Aversive Stimuli in Conditioning Aversive stimuli have been employed in experimental work and therapy under a variety of terms depending on the 26 way in which it is related to the behaviors to be modified. Escape learning is the paradigm in which a behavior on the part of the organism terminates the aversive stimulus. Re lated is avoidance learning in which the organism learns a behavior v/hich forestalls or prevents the presentation of the aversive stimulus. In both these paradigms the organ ism actively learns a response. Punishment on the other hand is the presentation of the aversive stimulus after a behavior; the organism learns passively what not to do (Solomon, 196^). Traditionally the punishment paradigm was seen to be least effective in modifying behavior and on the basis of Skinner's (1938) work was seen merely to suppress behavior where it was at all effective. The term punish ment appears to have been used loosely, for Mowrer (1950) emphasizes the crucial role of the temporal relationship of punishment to positive reinforcement, apparently implying that punishment does not necessarily follow the punished act immediately. Eysenck (1965) employs the term "aversive conditioning" wherein the aversive stimulus immediately follows the undesirable behavior. By old definitions then Eysenck's term would appear to be the most effective punish ment paradigm. Bucher and Lovaas use "aversive condition ing" to refer to association of the aversive stimulus with specific stimuli and "punishment" to mean aversive stimuli presented after performing responses intimately associated with the behavior to be modified. Others however (Azrin and 27 Holz, 1966) use the term "punishment" synonymously with Eysenck's "aversive conditioning". Punishment in the sense used by Azrin and Holz appears to follow the laws of condi tioning. Azrin and Holz supply ample evidence primarily from animal work that punishment can and does modify behav ior. On the basis of their work they state the following: Characteristics of the Punishment Process. There is often an increase in frequency of the punished response following termination of the stimulus. This is a temporary effect re ferred to as punishment contrast effect. It does not occur after complete suppression but does at all other levels. The effects of punishment are shown to manifest themselves immediately if at all. Generalization is found to occur initially such that when two stimuli are presented, one associated with punish ment and one associated with absence of punishment, a decre ment in responding to both stimuli occurs. This generalized suppression eventually disappears and the responses to the un punished stimulus recover to the original level in both cases. Generally, the effects of a punishing stimulus are considered by Azrin and Holz to be essentially the same as for a positive reinforcing stimulus, only in the opposite direction. That punishment only suppresses behavior is open to question. Azrin and Holz state that if proper precau tions are taken it appears that punishment actually does more than just suppress behavior. 28 The major undesirable effect of punishment appears to be the social disruption caused. By this is meant the fact that when one is punished by a member of a group the likelihood of the punished member leaving the group is in creased, hence reducing the possibility of changing the in dividual's behavior. Operant and elicited aggression re sult from punishment. The former is a tendency to attack the source of punishment, the latter is a tendency to at tack things present in the area when punishment occurs even when they are not the source of punishment. Neither chronic behavioral disruption nor emotional distress appears to re sult from punishment when an alternative response is avail able and the organism can be led to utilize it. Effectiveness of Punishment (From Azrin and Holz, 1966) Maximum effectiveness of punishment results when: 1. 2. 3. k. 5. 6 . 7. 8 . 9. No unauthorized escape is allowed Punishing stimulus is as intense as possible Punishing stimulus is presented for 100% of the undesirable responses Punishing stimulus is delivered immediately after the response Punishing stimulus introduced at maximum in tensity Extended punishing sessions avoided Punishing stimulus is a discriminative stimulus for extinction Punishing stimulus and positive reinforcement do not get associated Motivation to make the response is lowered 29 10.) Frequency of positive reinforcement for the undesirable response is reduced 11.) Alternate responses achieve the same reinforce ment the punished response originally achieved 12.) A conditioned punisher is used when no uncon ditioned punisher is available 13.) If no alternate response is available a dif ferent situation should be available 14*) Positive reinforcement reduction for the un desired response should be used when other methods cannot, as in some human conditioning where social or moral prescriptions preclude aversive stimulation. Aversive Conditioning with Humans In recent years aversive conditioning techniques have been applied by many workers to patients with a varie ty of problems and with a variety of results. The variety of results are probably attributable to a large number of factors. Contributing to the confusion have been single subject designs mostly without replication, the variety of ways of defining improvement, the various forms of aversive conditioning, the aspects of behavior punished, the various degrees of control of experimenter influence and the lack of data by which distinctions between subjects can be made, regardless of presenting symptom. A good deal of discussion has recently revolved around the question of whether punishment constitutes in strumental conditioning or classical conditioning. In view of the work of Azrin and Holz (1966), and Solomon's (I96J+) perceptive review of the field, it appears that many con- cepts such as "gradient of punishment" are inapplicable con cepts growing out of instrumental paradigms. Indeed, the work reviewed points consistently to the fact that instru mental acts are less affected by punishment than "consum- matory acts or highly reflexive responses", implying that innate acts with minimal skeletal components such as sali vating to food are most modifiable by punishment. This sug gests that a classical conditioning paradigm may be at the core of the effectiveness of punishment. In work with humans the term "aversion therapy" has generally been applied when an aversive stimulus is employed although a variety of paradigms have been used with humans - many in addition to those used with animals - some of which have their own descriptive subclassifications. Interesting ly, there seems to be a trend opposite from that in animal research, namely that instrumental conditioning is seen by some (Feldman, 1967) to be more effective than classical conditioning at least in treatment of sexual disorders. Non-Psychotic Patients. The earliest aversion therapy work employed simple straightforward classical conditioning paradigms. Max (1935) paired a shock with the fetishistic stimulus in treating a sexual disorder. Mowrer and Mowrer (1938) described early treatment of eneuresis in over 60 children, wherein a loud bell was paired with micturition. Lemere and Voegtlin (1950), Voegtlin (1940) and Voegtlin and Broz (1949) report work with over 4>000 alcoholics be gun in the 1930's. They exposed patients to the sight, smell and taste of alcoholic beverages after being given an emetic mixture producing nausea. At the onset of the nau sea and during it, the patient was given small amounts of liquor. Patients were given two 10-treatment sessions and extensive followup. A high degree of success was reported by these early workers. Wolpe (1954) in a similar vein discusses treatment of obesity by pairing shock with images of food. Five sessions of 10 reinforcements each were seen to bring about "excellent progress". Use of an avoidance technique in treatment of writer's cramp was reported by Liversedge and Sylvester (1955)* Shock was contingent upon muscle spasm or symptoms of it. Followup after four and one-half years showed 24 of 39 subjects "cured". Most of the recent work has been done with sexual disturbances, primarily homosexuality, fetishism, trans vestism and sadistic fantasies. The work of Barber (1963)> Clark (1963), Cooper (1963)> Freund (i960), Glynn and Harper (1961), James (1962), Oswald (1962), Raymond (1956) and Raymond and O'Keefe (1965) all use drug induced nausea as the aversive stimulus paired with various stimuli con sidered of relevance. In treatment of the disturbances other than homo sexuality nausea was paired with the actual stimulus. Re ported success rates were high. In work with homosexuality results are not as consistently positive. In treatment of 32 homosexuality aspects of homosexual activity, such as pic tures of males, etc., were followed by presentation of the aversive stimulus. Feldman, Schmidt and Castell and Thorpe have done most of the work with aversive therapy of sexual deviates and employ a variety of extensions of the above procedures. Thorpe, Schmidt and Castell (1963) and Thorpe and Schmidt (196if) employed an aversive stimulus which followed aspects of homosexuality, i.e., homosexual masturbation fantasies and nude male slides, and positive stimuli which followed heterosexual stimuli. Success was minimal. Later, an "aversion relief therapy" was used by Thorpe, Schmidt, Brown and Castell (1964) in which patients were shocked after reading various homosexual words. The last word, for which the patient is not shocked, was a het erosexual word, thus relief was paired with the last word. Success in three cases was reported for this approach. Schmidt, Castell and Brown (1965) reported improvement in eight out of 13 homosexuals treated by the aversion relief method and five refusals. Clark (1965) employed basically the aversion relief therapy using techistoscopically pre sented words. Homo- and hetero-sexual words were randomly interspersed and shock was given for the former, but not for the latter group of words. One patient was used and evaluation was in terms of increased heterosexual masturba tion fantasies. 35 Solomon and Miller (1965) use a "double condition ing" procedure similar to the aversion relief therapy in treating six homosexuals. Mild changes appear to have oc curred but no heterosexual behavior emerged. Cautela (1966) and Gold and Neufield (1965) report treatment by means of relaxation therapy, and images of ho mosexual situations paired with negative images. Improve ment was reported. Rachman (I96I) reports use of electric shock with fetishes, as do Thorpe, Schmidt, Brown and Castell (1964) in an aversion relief therapy, with success. In general some success is reported by most in treating sexual disturbances using variants of the above procedures (Blakemore et al, 1963; David and Morganstern, I960; Davison, 1968; Evans, 1968; Feldman, 1965; Glynn and Harper, 1961; Kolvin, 1967; Kushner, 1965; Marks, 1968; Marks and Gelder, 1967; Marks, Rachman and Gelder, 1965; McGuire and Vallance, 1964; Mees, 1966; Morganstern, Pearce and Rees, 1965; Raymond and O'Keefe, 1965). Feldman (1966), Feldman and MacCulloch (1965) and MacCulloch, Feldman and Pinshoff (1965) use another tech nique called "anticipatory avoidance learning" involving presentation of a slide of a male nude for homosexuals. The slide remained on the screen for eight seconds during which time patients could perform the instrumental act of pushing a switch to remove the slide. Failure to press the sv/itch resulted in shock. 25 or 36 homosexuals were consid 3k ered improved by this technique. Feldman found the treat ment not very effective with alcoholics, however. Other work using some form of aversive conditioning done by Greene (1964) and Wilde (1964) was unsuccessful with smokers. On the other hand, Franks, Fried and Ashem (1966), Gandren and Dodwell (1968) report good results using a stim ulus relief paradigm with smokers. Overeaters were treated with minimal success by Ferster, Nurnberger and Levitt (1962) and Thorpe, Schmidt, Brown and Castell (1964). Cautela (1966) used a technique called "covert sen sitization" with overeaters. The technique employed pairing of an aversive image such as vomiting v/ith an image of the behavior to be modified. He reports successful treatment as does Stuart (I96I) using Cautela's covert sensitization. Gamblers were treated with success by Basher and Miller (1966b) by shocking the patient while in what was basically an aversion-relief paradigm. Gourney (1968) re ports success by shocking a gambler for paying attention to various events related to gambling. Campbell, Sanderson and Laverty (1964) and Campbell and Laverty (1963) injected a drug resulting in paralysis. They report success in treating alcoholics. However, using the same technique, Madill, Campbell, Laverty, Sanderson and Vandewater (1966) treated 45 patients in three groups and showed no difference between groups. Holzinger, Mortimer and Van Dusen (196?) used the same technique again but 35 with no significant results. And Clancy, Vanderhoof and Campbell (196?) showed some success with the technique but this success was not due to the conditioning. Farrar, Pow ell and Martin (1968), using the same technique, showed no improvement. MacCulloch, Feldman, Orford and MacCulloch (1966) used the anticipatory avoidance procedure with alco holics, all of whom relapsed. Blake (196?) and Anant (1967) also report little success in treating alcoholics. Kushner and Sandler (1966) also treated a man with suicidal ruminations, giving shock as the patient imaged su icidal thoughts. They report success. Brierly (1967) re ports success in treating spasmodic torticollis by shocking the wrist each time neck spasms occurred. Two patients were treated. Self Shocking Procedures Of particular interest is the work using a self shock procedure. McGuire and Vallance (196^) discuss the use of a small portable shock box such that patients could administer shock themselves. In treatment with homosexuals, they were told to conjure up their usual fantasies, then to shock themselves. Three out of six discontinued therapy, the other three improved. McGuire, Carlisle and Young (1965) commenting on the technique, see it as at least as effective as other forms of therapy. McGuire and Vallance (1964) used the same technique v/ith a fetishist and two transvestites with good results. Wolpe (1965) used a port- able self-shock device with a Demerol addict with the in structions to shock himself when he felt the urge for the drug. Treatment was successful for 12 weeks, after v/hich there were three relapses. McGuire and Vallance (1964) also discuss treatment of two transvestites with self shock, commenting that they improved. They also report six of 10 smokers discontinued smoking by shocking themselves. Powell and Azrin (1968) used a similar technique, differing only in that shock was delivered automatically when a cigarette was removed from the package. They found smoking to decrease only during treatment but to return to its previous level after discon tinuing shock. McGuire and Vallance also used automatically delivered shock for people with writers' cramp. "Excellent progress" was reported. Recently Bucher (1967) reports on the use of a portable self shock device in treatment of nailbiters. He reports quick suppression of biting in 18 out of 20 cases. Recently he also initiated research on the use of the device with overeating, inattention during lectures, and compulsive behaviors. However, no results have yet been reported. Bucher (1967) comments on the important aspects of aversive therapy. His main points are (1) the behavior pun ished should be as close as possible to the behavior to be modified, (2) the conditions of treatment should be as much like the patient's general environment as possible, (3) tern- 37 poral, quantitative and qualitative control should be possi ble. He, like Azrin and Holz and Feldman, points out the general superiority of electric shock. (i+) Therapist fac tors and understanding the patient should be emphasized. Psychotic Patients. The work discussed so far was primarily with non-psychotic patients. Recently behavioral techniques and, in particular, aversive therapy methods have been ap plied to psychotics (Lindsley, 1956; Lovaas, 1966, 1967, 1968; and Risley, 196^). The procedures generally used were punishment by electric shock of self destructive autistic behaviors in children and a shock-relief paradigm to build stimulus functions, i.e., make the child responsive to nor mal reinforcers. The position expressed by Lovaas and probably es poused by many who use aversive therapy is that the symptom itself may be treated without reference to its cause. Even though it may come about for a given reason it later becomes functionally autonomous. Hence, it is subject to the prin ciples of conditioning. Apparently some other aversion therapists have hesitated to punish psychotic symptoms. One reason may be that they generally focus attention on anxiety symptoms for which the antecedent stimuli are more or less in evidence, and for which punishment would be inappropriate and disruptive. Bucher (1966) takes the same basic approach to symp toms as Lovaas and has applied (Fabricatore and Bucher, 38 1966) a self shock procedure for eliminating hallucinations. He reports success in the one patient treated after two weeks of treatment. From the work reported in aversive therapy, one may conclude that at least some symptoms unal terable by other means show some modifiability with aversive methods. A variety of questions arise in connection with the use of aversive procedures especially those which are self administered. There is the theoretical question of whether actual conditioning or some other process is at work. Clan cy, Vanderhoof and Campbell (1967) feel that suggestion, ex pectation, social factors, anxiety and motivation may be agents producing symptom modification. Others suggest the relationship with the therapist is crucial. Rosenthal (1966) implies broadly that in most re search, the expectations of the experimenter and of the subjects are most important. While Bucher emphasizes ther apist's interpersonal skill, he entertains the interesting possibility that since self shock is more effective than self control, it may be that the shock serves to reorient the patient and extend his awareness to stimuli associated with the onset of the behavior to be modified. Lovaas (1967) makes a similar point especially in regard to schizo phrenics, saying that they are oriented to the external world by shock. Erickson (1968), working with schizophren ics, holds a view similar to that of Lovaas and describes 39 them as interacting with themselves, especially when hallu cinating. Erickson used responses theoretically incompati ble with hallucinating such as gargling, etc., and reports good success. Since gargling is not especially aversive their results can be looked upon as simply distracting the patient by external means from interacting with himself. This fits well into Lovaas* theoretical descriptions of schizophrenics. The aversive therapy with schizophrenics reported by Lovaas et al. has been very encouraging. Although use of a self shock procedure with schizophrenics might at first appear impracticable, the work of Bucher and Fabricatore, as well as pilot work by this writer with three hallucinat ing schizophrenics, indicates that cooperation can be good where the symptom, in this case hallucination, is highly disturbing to the patient. A previous unsuccessful attempt to gain cooperation in self shock with schizophrenics was brought to the writer's attention. That failure was probab ly due to insufficient rapport with the patients. This point is stressed by all who have worked with schizophren ics. It is, however, of interest that schizophrenics re spond well under stress of an objective type. In particular aversive stimuli appear to increase functioning with schizo phrenics on a variety of tasks (Brown, 1961; Foley, 1965; Lang, 1959; Rosenbaum, 1957; Venables, 1963). Viewed in the light of Lovaas1 ideas, these results could be seen to 40 indicate that the noxious stimuli seem to orient the schizo phrenic away from his inner world to the external. General ly, it would appear that schizophrenics would decrease schizophrenic features following most aversive stimuli. This study employed a self shock device, carried by the schizophrenic under instructions to shock himself when he experienced auditory hallucinations. The patients were run for a two-week period and evaluations were made of amount of change in their hallucinations from pre- to post treatment. Comparisons of amount of change in those with an actual shock box were made with two other groups: those with a placebo no-shock box and those who were merely evaluated twice, two weeks apart. Experimental Hypothesis The purpose of this study was to investigate the ef fect of a self shock procedure for hallucinations on the amount of hallucinating over a two-week treatment period. Based on the empirical findings that schizophrenics can car ry out such a procedure, it was predicted that cooperative subjects would show a significant decrease in hallucinations after the treatment period. Since placebo effects have been universally associated with treatments, especially new ones, two groups of hallucinating schizophrenics were run to con trol for the two main sources of placebo effects. As place bo effects were assumed to be present in the experimental group as well as in the control groups it was predicted that the experimental group would show a greater amount of im provement than the control groups. On the assumption put forth by behavior therapists that symptoms constitute the disturbance and are not merely by-products of it, the pa tients receiving self shock were expected to show no in crease in overall pathology. 42 CHAPTER II METHOD This study used a randomized three group design to assess the effect of self shock on the occurrence of audi tory hallucinations. Changes in hallucinatory activity in the group receiving shock, called the Self-Shock Group, were compared v/ith changes in two control groups, designated the Placebo Group and the No Treatment Group. The Placebo Group received treatment identical to that of the Self-Shock Group except that they received no shock from their shock device. The No Treatment Group received an initial and a final set of evaluations spaced as for the other two groups. The Placebo Group was necessary to isolate the main inde pendent variable of shock from adventitious variables as sociated with the means of producing it (i.e., the carrying of a shock box, expectations due to suggestion, etc.). The main dependent variables reflecting change in amount of hal lucinatory activity were assessed from (1) formal ratings made before and after treatment by a pair of trained neutral professionals, and (2) patient statements on an interview given before and after treatment. Sub.ject Selection and Assignment to Groups. Subjects were 45 male psychiatric in-patients from three psychiatric units at the Sepulveda Veterans Administration Hospital. All pa tients carried a primary diagnosis of schizophrenia; most were paranoid schizophrenics. Caucasians, Negroes and Mex ican- Americans were represented in the sample with an age range from 19 to 62. The mean age was 37.2. Religious backgrounds of the patients varied widely, as did socio economic level, educational level, occupation, and amount of time spent in gainful employment. The sample contained no patients known to use hallucinogenic drugs nor were any of the patients physically handicapped. Tv/o patients were known to have brain damage. All patients who came to the experimenter's attention who were described as "known to hallucinate" or "suspected of hallucinating" were interviewed by the experimenter. All patients who in the interview admitted to be currently exper iencing auditory hallucinations were told that the experi menter was doing work with patients who were having the ex perience of "hearing voices". The experimenter stated that many patients were helped to "get rid of the voices" by carrying a small portable shock box and shocking themselves each time they heard "the voices". The box was shown to the patient and its use demonstrated by the experimenter. The patient was then asked if he would be willing to try this procedure, which involved carrying the box during his waking hours for a period of two weeks. Patients who appeared un certain about volunteering were further encouraged; those kk who were definitely disinterested were not considered fur ther. The criteria for acceptance in the study were (1) the patient's admission to experiencing auditory hallucina tions and (2) his expressed willingness to carry out the self shock procedure for a two-week period. Of approximate ly 95 patients interviewed, about 50 either denied halluci nations to the experimenter or rejected the self shock pro cedure. Most were unacceptable for the former reason. All patients who participated as subjects, therefore, were bas ically volunteers. Once a subject was found acceptable for the study, his name was recorded and he was given a number correspond ing to the sequential position of his entry to the study. From this number he was assigned a second number from 00 to kk determined by a table of random numbers. By this means he was randomly assigned to one of the three experimental groups: the Self-Shock Group, the Placebo Group or the No Treatment Group. Instruments Independent Variables. Two basic forms of the independent variable were employed: (1) the self shock procedure in which shock was delivered when the shock box plunger was pressed, and (2) the placebo procedure in which no shock resulted when the plunger was pressed. A third form of the independent variable, namely the absence of treatment, was employed for the third group. Shock Boxes. The shock box was a 2" x 3" x 5" aluminum chassis held together by screws. Two belt loops were fas tened on the back, enabling the subject to v/ear the box on his belt. A four-inch by one-quarter-inch aluminum rod ex tended approximately one inch from the front of the box. This was connected at one end to a digital counter type ITT-GC #CM k CS mounted inside the box. Depression of the rod operated the counter and for the Self-Shock Group also produced shock to the hand. The boxes delivering shock contained a simple cir« cuit energized by four AA transistor batteries connected in series with the primary coil of a small transformer (type 79 D 33-29 ATC 1035-210) and a microswitch. Depression of the aluminum rod closed the microswitch such that six volts flowed across the primary of the transformer. The rod was returned to its original extended position by means of a spring in the counter (see Appendix B). Thus a pair of shocks was given in close succession, one as the field in the secondary was established and one when it was broken. The peak intensity of the shock was approximately 600 volts at less than 10 milliamperes. The aluminum plunger was in sulated from the rest of the box and connected to one lead of the secondary while the other lead was grounded to the box. The circuit was therefore completed through the pa tient's hand when the circuit was activated. Since the kS microswitch and counter were simultaneously activated, each pair of shocks registered one digit on the counter. New bat teries were used for each patient in the Self-Shock Group. The shock boxes which delivered no shock v/ere termed the placebo shock boxes. They were identical in external appearance to the boxes delivering shock. They, however, lacked the electrical circuit inside but contained the coun ter. To compensate for the weight of the electrical circuit a piece of clay was placed in the "placebo boxes" so that its weight was approximately equal to that of the shock de livering box. The only difference externally between the two boxes was the presence or absence of shock. Dependent Measures In order to assess the dependent variables of hallu cinatory activity and other psychiatric pathology, a variety of assessment techniques was used. These were chosen to pro vide estimates as independently as possible from the patient himself, the experimenter, and other ward personnel. The BPRS. The BPRS or Brief Psychiatric Rating Scale is a scale developed by Overall and Gorham from Lorr’s MSRPP especially for research purposes where a short (18 min ute) interview is desired which is suited to measure treat ment change. Evaluations are in terms of 18 common psychi atric symptoms including hallucinatory behavior and six syn dromes (See Overall and Gorham, 1962). Ratings were on a 0 (not present) to six (extremely severe) scale. The evalu k7 ative procedure consisted of a standard interview conducted by a team (pair) of raters. The interview was divided into three minutes of establishing rapport, 10 minutes of non directive questioning, and five minutes of direct question ing. The raters used in this study were drawn from a standard rating pool composed of psychologists and psychi atrists at Sepulveda VAH who were trained as a group in the use of this instrument. Inter-rater agreement has been high and the use of the procedure has been considered satisfac tory in many drug studies carried on at Sepulveda VAH. The raters were not aware of the project for which the patient was being evaluated. Ratings were therefore blind with re gard to the possible influence of rater biases and expectan cies. In many cases one pair of raters did the initial evaluations and a different pair the final ones. Generally, raters did not know whether a rating v/as the first, last or one of a series of routine ratings as required in some of the studies conducted simultaneously with this one. The tendency tov/ard an automatic improved score on the final rating was thus minimized. Patient Data Sheet. This was a semi-structured in terview (See Appendix A) developed by the experimenter based on pilot work with hallucinating patients aimed at eliciting background data and highly specific information from patients about their hallucinations. It dealt with frequency of occurrence of hallucinations, content, per ceived sources, conditions affecting them, attitude toward them, whether the patient discussed his hallucinations spon taneously, and other features. In addition, it contained questions concerned with suicidal ideation and self concept. Also elicited in the final interview was the patient's sub jective feeling about whether the box was helpful. Symptom Checklist. The symptom checklist was an abbreviated form of the IMPS. It was filled out by the ex perimenter based on patients' behavior during the interview for the Patient Data Sheet. The rationale for the apparent replication of data supposedly attained with the BPRS is the assumption that a patient will reveal at least some dif ferent reactions to someone with whom he is familiar or had prolonged interactions than he will in a brief formal inter view with unfamiliar people. The data will probably be more objective or "hard" in the formal interviev/, but the other source of data is at least as valuable. Progress Reports from Ward Personnel. Brief ac counts of patient's behavior during the "treatment" period were elicited from ward personnel, primarily nurses and aides, since their contact with patients is greatest and most informal. Where a close relationship between physi cian and patient developed, comments on patient change were also elicited from the physician or other staff member. These highly varied and subjective data ranged from simple 49 statements of "improved" or "no change" to extensive docu mentations of highly specific material. Data were in the form of nurses' notes, progress notes and/or oral accounts. Procedure Subjects were solicited by the experimenter. He spoke extensively with physicians, psychologists, social workers and ward personnel, asking for the names of patients who were either known to hallucinate or suspected of it. Each patient whose name was thus obtained was given an in itial interview which was minimally structured. In the interview the patient was told that the experimenter was interested in how the patient was getting along. The pa tient was asked to tell the experimenter about himself and how he was doing. If the patient avoided discussion of his problems and symptoms he was led to these areas by such questions as "Is there anything which upsets you", "Do you notice any changes in yourself since you've been here at the hospital?" If after approximately 20 minutes of discussion the patient failed to mention having any experiences which seemed to be hallucinations, the experimenter led to the direct question of "Have you ever had the experience of hearing voices or getting messages others do not" by start ing with oblique questions such as "Have you had any unusual experiences, or experiences you feel others might not have?" The experimenter closed the interview if the pa tient denied hallucinating under direct questioning by tell- 50 ing the patient that he is working with people who are both ered by hearing voices and this was the reason for his em phasis on hallucinations. The patient was then thanked for his cooperation and told that that was all unless he (the patient) had some questions. For patients who admitted to auditory hallucinations the interview was extended to an inquiry of whether the pa tient wanted to get rid of them.-*- If he said he did, then the self shock procedure was discussed, emphasizing that the patient himself would be doing his own treatment. He was shown the box and its use. The names of cooperative pa tients were submitted to the research office to be scheduled for further appointments. Scheduling was as follows: First, the patient was scheduled to be interviewed for evaluation by a team of raters on the BPRS. This accom plished, the patient was sent either the same day or the fol lowing day for evaluation by the experimenter on the Patient Data Sheet. The experimenter introduced this task by a statement such as "The other day we spoke about some voices you were troubled with. Today I want to ask you some more detailed questions about them as well as about you in gen eral". The interview followed. Depending upon the group to which the patient was ^Patients who liked their hallucinations were told "we feel you would profit from giving up the voices" and in most cases an incident of negative effects of the voices could be cited. 51 assigned, one of the following statements was made: For the No Treatment Group, patients were told: "I want to see if any changes occur over the next couple of weeks in the voices. At the end of that time we'll talk more about the shock box." For the Placebo Shock Group, patients were told that all the shock boxes delivered the same amount of electricity but that some people feel it more than others, due to their skin, etc., so they might or might not feel the shock. They were reassured that if they didn't, it would be nothing to worry about, because the current that flows was designed to "activate the nervous system" and thereby help them get rid of the voices. Patients were then given a box and asked to try it. They usually commented that they didn't feel any thing. They were again reassured that it has been effective with many men if used as prescribed. On some occasions more explanation and reassurance of its effectiveness was offered. For the Self-Shock Group, the instructions were the same as for the Placebo Group up to the giving of the box. They were asked to try it and after they had the experiment er commented: "You seem to feel it" and elicited a comment from the patient to be sure it was working. Patients were then reassured that it had been effective with many men when used as prescribed. Other reassurance or description was offered when it was felt to be necessary. All patients in Placebo and Shock Groups were told 52 to retain the box for two weeks and to get in touch with the experimenter if they had any trouble. Any necessary adjust ments during the two weeks were made promptly. At the end of the two-week period, patients were again scheduled by the research office for a BPRS followed by an interview with the experimenter. In the interview the experimenter relieved the patient of the box, gave the Pa tient Data Sheet interview, and inquired if the box had been useful. After the patient left the box was opened, the num ber of presses recorded, and the counter reset to zero. As in the pre-interview, a Symptom Checklist was filled out after the patient left. 53 CHAPTER III RESULTS The three instruments used to assess patient improve ment were (1) the Brief Psychiatric Rating Scale (BPRS), (2) the Patient Data Sheet (PDS, designed by the experimenter) which included the Symptom Checklist, and (3) Ward Personnel Comments (WPC). Changes in patients over the two-week exper imental period were evaluated by comparing final ratings with ratings taken initially. Pre and post ratings were taken with the BPRS and the PDS (including the Symptom Checklist). Only a final statement of "improved" or "unimproved" was taken from WPC. The results appear in five sections. The first sec tion presents the reliability of the instruments, initial comparability of the groups, independence of the measures, and other evaluations carried out prior to analyses of ef fects of treatments. In the second section are presented analyses of treatment effects (change) by groups. The third section compares the Shock Group, the Placebo Group, and the No Treatment Group in terms of differences in change between groups. The fourth section reports other factors associated with improvement. The fifth section deals with character istics of selected individual subjects which appeared of 3k relevance to the study. 1. Preconditions to Analysis of Treatment Effects Reliability of the Instruments BPRS. The BPRS has been used extensively in research at Veterans Administration hospitals and also at Sepulveda VAH. Overall and Gorham (1962) reported reliabilities on the Hallucination Scale of .90 and .87 hut reliabilities on the Total Psychiatric Pathology Scale were not reported. In the present study inter-rater reliabilities for initial (Pre) ratings were R = .67 for the Hallucination Scale and R = .64 for the Total Psychiatric Pathology Scale.1 Inter-rater re liabilities on the final ratings were R = .72 for the Hallu cination Scale and R = .82 for the Total Psychiatric Pathol ogy Scale. The discrepancy between the reliabilities re ported by Overall and Gorham and those obtained in this study, especially for the initial ratings, appears to be due to the use in this study of newly trained raters and random assign ment of pairs of raters. The increase in reliability esti mates from initial to final ratings appears to be due to the increased number of ratings at the lower extreme (i.e., zero) in the final ratings. The obtained reliability coefficients indicate that agreement between raters is generally close although better 1r is the statistic described by Haggard (1958) and Guilford 7*1956) to assess the degree to which ratings on each individual by two judges using the same scale are identical. 55 agreement would be desirable. Inspection of the rating pro tocols revealed that only a few of the discrepancies between raters in all groups were more than one point. There are seven such large discrepancies in the ratings in the Hallu cination Scale and six in the Total Psychiatric Pathology Scale. The large discrepancies are, however, evenly dis tributed over the three groups. It is apparent from the fact that there are many one-point discrepancies that a change rating of less than one point is questionable. On the other hand any average change rating which resulted from pairs of highly discrepant measures would also seem suspect. It was found, however, that in most cases where large dis crepancies existed one rater was common to both initial and final ratings. Hence it was possible to determine a consist ency for ratings in all but two cases. On this basis it was determined that although large discrepancies existed in cer tain cases between the absolute magnitude of ratings there was in all but one case agreement that change had occurred. Thus only three change ratings (where large discrepancies existed between raters on absolute magnitude) were in ques tion or showed disagreement about whether change had oc curred. These three did not cluster in one group. It was concluded that agreement between raters was generally suf ficiently high to permit analysis of group changes. PDS. The assumption that the PDS elicited statements that were reliable was based on one major finding: From pre 56 to post assessment descriptive terms used by patients were generally comparable, and statements of frequency of hallu cinating were consistently expressed in the same order of magnitude, i.e., patients expressing frequency in two deci mal places generally did so on both occasions. The use of a single interviewer (the experimenter) who was well acquaint ed with the patients may have facilitated the report of rel atively "private" data. This practice, hov/ever, did not yield a measure of the interviewer's reliability, WPC. Comments of ward personnel figure importantly in patient treatment. They were not subjected to systematic analysis because it was not possible to get two ward person nel to give routine judgments on all patients in the study. There was indirect evidence of satisfactory inter-rater re liability based on the high level of agreement among ward personnel in staff meetings, in informal discussions and in chart notes. The use of WPC is based on the fact that ward person nel are maximally exposed to the patients. Hence WPC provide valuable reports of otherwise unmonitored behavior which may be more typical and less guarded than that obtained in formal interviews. Independence of Categories Subjected to Tests. The data of the BPRS and that of the PDS, although both based upon pa tient statements, were gathered completely independently. Statistical independence of the BPRS scales was assumed based 57 on Overall and Gorham's statement that each was a derivative of a separate factor on Lorr's MSRPP (Lorr, 1953). Initial Comparability of Groups. Despite the greater amount of private information assumed to be elicited by the PDS and WPC, assessment of initial levels of pathology of the groups was in terms of the BPRS. The BPRS was used for this pur pose because of its more objective nature and its known and acceptable reliability. The scale (Interpersonal Disturbance) on which max imum dispersion of means was shov/n was subjected to analysis of variance. Since significance was not shown (F = 1.50, df = 2/42, n.s.), it was assumed that the three groups did not differ initially on any of the BPRS scales. For completeness analyses of variance were carried out for the Hallucination Scale and the Total Psychiatric Pathology Scale. The tests showed that the groups were com parable on the Hallucination Scale (F = 1.31> df = 2/42, n.s.) and almost identical on the Total Psychiatric Pathol ogy Scale (F = .11, df = 2/42, n.s.). A Kruskel-Wallace analysis of variance by ranks was performed on initial frequency of hallucinations reported on the PDS. The groups were found not to differ significantly (H* = 2.98, df = 2, n.s.). The groups did not differ on other significant var iables of age, chronicity of illness, chronicity of hallu cinating, diagnostic category, medication, marital status, 58 TABLE I SUMMARY OF TESTS FOR INITIAL COMPARABILITY OF GROUPS2 Variable Test Value Significance Level 1. Age ANOVA F = .24, df=2/42 n.s. 2. Chronicity ANOVA F = .72, df=2A2 n.s. 3. Chronicity of Hallucination ANOVA F = .001,df=2A2 n.s. 4. Number of Symp toms Checked ANOVA F = 1.09, df=2A2 n.s. 5. Diagnostic Category X2 X2= 1.31, df = 2 n.s. 6. Medication X2 X2= 2.62, df= 4 n.s. 7- Marital Status X2 X2= 1.94, df = k n.s. 8. Self Concept X2 x2= 3.88, df= 4 n.s. 9. Work History X2 x2= 1.79, df = 6 n.s. 10. Accidents X2 X2= • 17, df = 2 n.s. 11. Degree of Adaptation X2 X2= 1.13, df = 6 n.s. 12. Attitude toward Hallucinations X2 X2= 3.30, df = k n.s. 13. Bring up Hallucina tions Spontaneously X2 x2= .60, -d- I I n.s. lif .Talk Back to Voices X2 x2= .24, df= 2 n.s. 15. Content X2 x2= 2.91, df = 8 n.s. 16. Conditions Affect ing Voices X2 x2= .60, df= 2 n.s. 2A number of variables are not self explanatory. 59 self concept, work history and occupational level, number of symptoms checked, degree of social adaptation, incidence of accidents, or expressed attitude toward the hallucina tions. (See Table I). It was concluded on the basis of the above anal yses that the three groups were initially satisfactorily equated. Those which are not are referred to by number and explained below. Further details appear in Appendix. #5* Diagnostic Category In this analysis the number in each group who were diagnosed Paranoid Schizophrenic were compared with the num ber who were not so diagnosed. Schizophrenic Reaction, Para noid Type was the diagnosis carried by the majority of pa tients in this study. #6. Medication This variable was dealt with by comparing the number of patients in each group on the three most commonly repre sented medications in the sample: Thorazine, Mellaril and Stelazine. A fourth category of "other" was also used. Marital Status Single, married or divorced were the categories used for analysis. Single was the most frequently encountered status. #8. Self Concept This was based on one section of the PDS. #9« Work History This variable also included occupational level. The four categories used for analysis were: Never Worked, Little or Spotty Employment, Worked and High Level Work. #11. Degree of Adaptation This variable reflected approximate time of onset of illness and degree of adjustment. Categories used were: (1) Difficulty Began in Childhood - No Adjustment, (2) Primary Difficulty Begins During or Shortly After Adolescence, (3) 60 Other Prerequisites to Analysis. While there was no objec tive evidence that patients pressed the plunger of their shock boxes upon hallucinating, as instructed, all patients carrying a box pressed even though the counters were con cealed within the boxes. A median of 123 (mean of 3^8) presses with a range from 19 to 2,362 was noted. It was concluded, therefore, that all patients who accepted a box used it and followed instructions at least to the degree in dicated. It is noteworthy that the Shock Group recorded significantly more presses than the Placebo Group (_t=2.43> df=28, £<.05). First Break After Adult Adjustment and (4) Chronic Marginal Adjustment. #12. Attitude Toward Hallucinations The categories were: (1) Completely Negative, (2) Generally Negative, and (3) Mostly Positive. The categories were based on patient verbalizations on the PDS. #li+. Talk Back to Hallucinations Most patients stated they interacted ;verbally with their auditory hallucinations, but some stated they did not. This variable reflects whether or not patients stated they talked to their hallucinations. #15. Content Five categories were formulated: (1) Voices insult or swear at patient, (2) Voices threaten or order the patient, (3) Voices comment to the patient or talk to him, including simply calling his name, (4) Voices both swear and order (or other), (5) Patient was either uncertain of content or con tent was unique. #16. Conditions Affecting Voices Patients were divided into two groups. In one group were tallied those patients who stated the voices were con ditional upon or affected by some event, such as a mood state, or beginning work on his work detail. In the other group were tallied those who expressed no such contingencies. 61 Changes in medication occurred during this study for only four patients, two in the No Treatment Group, one in the Placebo Group and one in the Shock Group. These numbers were considered too small to substantially affect the re sults. Some patients were simultaneously on other research studies, but none were on studies which would plausibly in terfere with this study except where medications were changed. It was, unfortunately, not possible to evaluate types of psychotherapy which the patients were concurrently receiv ing. None, however, were involved in intensive individual therapy, but all were to a greater or lesser degree involved in group therapies, milieu therapy and drug therapy. Many also had individual work assignments. 2. Analysis of Treatment Effects by Groups: Change BPRS. Analyses showed that the Hallucination Scale pre and post ratings differed significantly. Similar anal yses revealed the same to be true of the Total Psychiatric Pathology Scale (See Table II). It is evident from Table II that all three groups changed in the positive direction or showed improvement over the two-week experimental period on the Hallucination Scale. It is also of interest that the largest average im provement in a single symptom occurred for the Hallucination Scale (See Table of Mean Changes in Appendix C). 62 TABLE II BPRS CHANGES FROM PRE TO POST ON HALLUCINATION AND TOTAL PSYCHIATRIC PATHOLOGY SCALES Hallucination Scale t df £ Group NT 2.97 Ik .<.02 Group P 3.19 Ik <.01 Group S Total Psychiatric Pathology Scale 3.61 Ik <.01 Group NT .023 lk n.s. Group P 3.93 lk <.01 Group S 2.57 lk <.02 Only the Placebo Group and the Shock Group showed significant improvement on the Total Psychiatric Pathology Scale. Other BPRS Scales on which significant improvement was noted are presented in Table III. The No Treatment Group stands out with only one symptom change beside hallucinations, namely on the Excite ment Scale. It is noteworthy that neither of the other groups showed change on that variable. Clearly the box- carrying groups showed more improvements. The Placebo Group showed significant change on 11 scales and the Shock Group showed improvement on seven scales. Only four of the scales, however, showed change common to both the Shock Group and the 63 Placebo Group: Unusual Thought Content, Depression, Suspi ciousness and uncooperativeness. TABLE III BPRS CHANGES AND GROUPS IN WHICH THEY OCCURRED Scale (Symptom) Excitement Unusual Thought Content Conceptual Disorganization Depression Thinking Disturbance Tension Excitement Emotional Withdrawal Grandiosity Interpersonal Disturbance Suspiciousness Inappropriate Affect Uncooperativeness Guilt Tension Blunted Affect t df 2 Group in which _______________Change occurred 2.24 14 .05 No treatment 2.31 14 .02 Placebo 1.85 14 .05 Shock 2.05 14 .05 Placebo 2.35 14 .02 Placebo 1.36 14 .10 Shock 2.35 14 .02 Placebo 2.00 14 .05 Placebo 1.80 14 .05 Placebo 2.39 14 .02 Placebo 2.07 14 .05 Placebo 1.80 14 .05 Placebo 2.00 14 .05 Shock 2.41 14 .02 Placebo 2.09 14 .05 Placebo 2.15 14 .05 Shock 1.89 14 .05 Shock 1.59 14 .10 Shock 2.59 14 .02 Shock 6k PDS. Changes in frequency of hallucinating for each group are shown in Table IV. Analyses were in terms of rank ing in order to include qualitative reports of frequencies and thereby utilize all data from each group. All changes are in the direction of improvement or decrease in frequency of hallucinations over the two-week experimental period. TABLE IV CHANGES IN FREQUENCY OF HALLUCINATIONS Group U P NT 62.5 .05 P 83.0 .10 S 70.5 .05 The analyses show that significant changes in fre quency of hallucinations occurred in the No Treatment Group and in the Shock Group, and marginally in the Placebo Group. No reliable changes occurred on other PDS variables except on the Symptom Checklist. Table V shows the signifi cance levels of the analysis of this variable. WPC. Comments and evaluations by ward personnel were noted in reference to changes in hallucinatory activity and overall change. Evaluations of hallucinatory activity were recorded simply as (+) or (0), corresponding respectively to improvement noted or no improvement noted. Since comments were intended to reflect spontaneous statements, a zero rat ing did not necessarily mean that the patient was seen to make no progress. It also appeared when no notation was made for a given patient regarding improvement in terms of hallucinatory activity. Ratings were not in terms of a formalized scale of degree. Hence, no statistical analyses were possible to assess the significance of amount of im provement within each group. It v/as assumed, however, that the appearance of a comment by ward personnel constituted a clinically significant change for the patient. TABLE V SYMPTOM CHANGES REFLECTED IN THE SYMPTOM CHECKLIST Group t df P Shock 5.27 l*f .01 Placebo 2.70 lk .02 No Treatment k.52 lk .01 3. Group Analyses of Differences in Change Analyses of difference in changes between the three groups is presented in Table VI. It is evident from Table VI that the three groups did not show significantly different amounts of improvement in hallucinatory activity on the BPRS or decrease in fre quency on the PDS. Also, no significant differences in change in overall pathology ratings resulted. It was con- 66 eluded that measurement of differences in amount of mean group change failed to differentiate the three groups. TABLE VI DIFFERENCE IN CHANGE BETWEEN GROUPS Data Test Value df p BPRS - Hallucination Scale ANOVA i i • o < j \ 2A-2 n.s. BPRS - Total Pathology Scale ANOVA F=2.31 2A2 .05 PDS - Frequency of Hallucination Kruskal- Wallace H=2.47 2 n.s. Individual Contributions to Group Means BPRS. Despite the lack of significant mean group difference in change, the nature of contributions of individ ual patients to the group means suggested the need for exam ining data of individuals in each group. The relevant find ings were as follows: First, the group mean scores for all groups were significantly influenced by a few changes of large absolute value. In addition, one of those large changes appeared of dubious validity after discussion with the raters. Second, it was noted that in the No Treatment Group and in the Placebo Group half-point differences from pre to post characterized six of the changes. In the Shock Group, however, there were no half-point changes. Since half-point changes indicated disagreement between raters as to whether change had occurred, it was felt that unequivocal positive changes (i.e., on which there is a pre to post dif ference of one or greater) were somewhat obscured in group means. Third, the only negative BPRS change recorded on the Hallucination Scale was for a patient who was atypical for this study in that he was known unambiguously to have had brain damage^. That patient was in the Shock Group, fur ther obscuring positive change in that group. Since positive change was of primary concern, an an alysis was carried out on the number of unequivocal positive changes (one or more scale point) occurring in each group. (See Table VII). TABLE VII UNEQUIVOCAL POSITIVE CHANGES OCCURRING IN THE THREE GROUPS Group Negative, Dubious or Zero Change Unequivocal Positive Change Sho ck 2 13 Placebo 6 9 No Treatment 7 8 A chi-square analysis of the data in Table VII re vealed a significant difference between groups (X^= 6.88, df= 2, jd-c .05). Clearly the difference was between the Shock Group and the control groups, revealing that the Shock Group contained a larger proportion of patients who showed ^This was discovered after completion of the study. unequivocal positive change than the control groups. A similar analysis to assess individual contribu tions to group means on the Total Psychiatric Pathology Scale of the BPRS was not carried out since change scores of individuals were highly comparable for the three groups. PDS. The simplest natural breakdown of the PDS data on change of frequency of hallucinations was in terms of (1) Maximum Change (2) No Change and (3) Intermediate Change^. Table VIII shows (a) the number of patients from each group falling into each of the three categories and (b) the number of patients in the Shock Group falling into each of the three categories compared with the number of patients in the control groups in those categories. TABLE VIII (a) FREQUENCY COUNT OF PATIENTS OF EACH GROUP FALLING INTO THREE CATEGORIES OF CHANGE Group No Change Intermediate Change Maximum Change Shock 2 9 k Placebo 6 k 5 No Treatment 6 b 5 ^By maximum change is meant a change from some num ber of hallucinations per day to zero per day. No change is used when the patient reports the same frequency of hallu cinations per day in pre and post interviews. Intermediate is some change between the extremes represented by the other two categories. 69 TABLE VIII (b) FREQUENCY COUNT OF PATIENTS OF SHOCK GROUP AND CONTROL GROUPS FALLING INTO THOSE CATEGORIES OF CHANGE Group No Change Intermediate Change Maximum Change Shock Group 2 9 i f Control Groups 12 8 10 Table VIII (a) shows that the number of patients falling into each of the change categories is identical for the Placebo Group and the No Treatment Group. Since perform ing statistical analyses for differences between those two groups would add no useful information, the two groups were collapsed into one group labeled Control Groups in Table VIII (b). A chi-square analysis of the data in Table VIII (b) reveals that the two groups were disproportionate in number of patients falling into the three change categories (X2= 11.86, df= 2, 2 *01). Table VIII (a) shows clearly that the Maximum Change category fails to differentiate among groups, the dispropor tion occurring between groups in the No Change and Intermed iate Change categories. The larger proportion of patients showing intermediate change were in the Shock Group. Hence the Shock Group may be said to have been characterized by more intermediate changes and fewer No Changes in comparison to the control groups. Symptom Ratings. Adding the BPRS scores for all symptoms al gebraically for each patient provided an index of symptom trends. The number of unequivocal (one point or greater) positive changes in each group is shown in Table IX. TABLE IX ALGEBRAIC SUM OF SYMPTOM CHANGES FOR INDIVIDUALS IN EACH GROUP Group Unequivocal Positive Change Negative, Zero or Equivocal Change Shock 12 3 Placebo 13 2 No Treat- 7 8 ment A chi-square analysis of the data in Table IX shows group differences (X^= 6.66, df= 2, jd .05). It is clear that the No Treatment Group contained the smallest number of patients who showed overall improvement when individual change scores for each rated symptom were averaged. Analyses were also carried out for the Hallucination data from the Symptom Checklist. Table X presents a compar ison of number of patients in each group rated changed on the symptom checklist for that variable by the experimenter. A chi-square analysis of the data in Table X revealed 71 that the number of patients from each group was comparable in each of the two categories of change (X^= .21, df= 2, n.s.). Comparison between Table X of formal ratings done by the experimenter with Table VII of formal ratings done by neutral professionals revealed that the experimenter was more conservative in formal rating of improvement on hallu cinatory behavior. A comparison between the experimenter's rating of "improved" on the Symptom Checklist and the ratings of im proved by other professionals on the BPRS for each group is shown in Table XI. TABLE X NUMBER OF PATIENTS IN EACH GROUP SHOWING A RATING OF "CHANGED" IN HALLUCINATING5 Group "Changed" No Change Shock k 11 Placebo k 11 No Treatment 5 10 ^Patients were only considered changed (improved) if they were rated zero (not hallucinating) on the post rating. 72 TABLE XI COMPARISON BETWEEN EXAMINER'S AND OTHER PROFESSIONALS' RATINGS OF IMPROVED Group Experimenter Neutral Professionals Shock 13 8 Placebo 11 10 No Treatment 12 b A chi-square analysis of the data in Table XI shows that the cell frequencies are disproportionate. It is clear from the data that the experimenter considered more patients to have shown improvement, especially, however in the No Treatment Group. It will be noted that although the experi menter considered more patients to have shown improvement than the neutral professional raters, his bias did not appear to run in the direction of the hypothesis being tested. WPC. Table XII shows the number of patients in each group for whom statements of improved were made by ward per sonnel. A nonsignificant chi-square (X2=1.60, df= 2, 2^.10) revealed that data of UPC fail to differentiate the three groups. If. Other Variables Associated with Improvement Of the many variables examined (See Appendix D) only seven variables measured prior to treatment and one measured post-treatment were related to improvement. Table XIII pre- 73 sents the variables with associated significance levels. TABLE XII WARD PERSONNEL STATEMENTS OF IMPROVEMENT Group________No Statements of Improvement Improvement Noted Shock 6 9 Placebo 9 6 No Treatment 9 6 Hallucinations in other modalities appeared related to extremes of improvement, most having been in the Maximum Change Category or the Zero Change Category. This variable did not appear to influence the experimental group averages. It is notewor.thy that only two patients reported having ex perienced hallucinations in other modalities concurrent with this study, the rest reported them as past experiences. Analysis of differences due to diagnostic category showed most of the Chronic Undifferentiated Schizophrenics to show no change, most of the Schizo-Affective patients to show significant change and the Simple Schizophrenics to show only intermediate change. Great caution must be exer cised in interpreting these data since the number of pa tients in each category was very small. This variable also appeared not to influence experimental group averages. The other variables all appeared related to experi mental group. Again, adequate analyses were precluded by TABLE XIII VARIABLES RELATED TO IMPROVEMENT 7k Variable Chi-Square df Significance Level 1. Hallucinations in other Modalities X2= if. 80 2 <.05 2. Diagnostic Category X2= 5.91 k <.05 3. Onset of Illness x2=io.i8 6 <.05 4. Conditions Affecting Hallucinations x2= 3.82 2 <.05 3. Content of Hallucinations x2=15.10 8 <.05 6. Chronicity of Voices X2=13.18 k <.05 7. Chronicity of Illness x2=11.93 k <•05 - Post Treatment 1. Box of Help X2= 6.20 2 <•05 2. Number of Presses^ X2= .20 2 <.10 the very small cell frequencies, hence only descriptive data is presented. Frequency tables corresponding to variables presented in Table XIII are shown. Each cell shows the con tribution from each experimental group to the total cell frequency. Table XIV shows that amount of change does not ap pear to have been related either to onset of illness in %his varizble is included on the basis of its the oretical significance. 75 adulthood nor to never having functioned. However, patients whose illness began in adolescence showed no Maximum Changes and a predominance of Zero changes. Patients whose adjust ment was always marginal show the opposite: a preponderance of Maximum Change and Intermediate Change with minimal Zero Change. In terms of experimental groups, all the intermed iate change for the Adolescent Onset Category is contributed by patients in the Shock Group, but the Shock Group shows only one patient in the Adolescent Onset Category making no change. On the other hand in the Always Marginal Category, no patients in the Shock Group showed Maximal Change, the No Treatment Group showing the most patients making maximal change. The only patient in the Always Marginal Category showing Zero change was in the Shock Group. Within the Never Functioned Category, most patients from the Shock Group showed some change, with none showing Zero change from that group. The reverse was true of the other two groups. Table XV shows that the presence or absence of con tingencies for the hallucinations was not related to Zero Change. However, when change did occur, a smaller proportion of patients who had not verbalized a contingency for the hal lucinations were represented. Where no contingencies v/ere present a larger number of patients in the Shock Group showed intermediate change, with no No Treatment patients in the No Contingencies Category showing intermediate change. TABLE XIV CHANGE AS INFLUENCED BY ONSET OF ILLNESS SHOWING GROUP CONTRIBUTIONS Change____________ Adult Onset______Adolescent Onset Always Marginal Never Functioned Total Group Con- Total Group Con- Total Group Con- Total Contribu- tribution tribution tribution tion Maximum 5 NT 2 0 NT 0 5 NT 3 3 NT 0 P 2 P 0 P 2 P 1 S 1 S 0 S 0 S 2 NT 1 NT 0 NT 2 NT 0 Intermediate 5 P 2 3 P 0 6 P 2 2 P 0 S 2 S 3 S 2 S 2 NT 2 NT 2 NT 0 NT 1 Zero 5 P 1 5 P 2 1 P 1 2 P 1 S 2 S 1 S 0 S 0 -o CT\ TABLE XV CONDITIONS AFFECTING HALLUCINATIONS RELATED TO CHANGE SHOWING GROUP CONTRIBUTIONS Maximal Change______Intermediate Change Zero Change Total Group Contri- Total Group Contri- Total Group Contri- butions butions butions No Contingencies 4 NT 2 5 NT 0 7 NT 3 P 1 P 1 P 3 S 1 S I S 1 NT 3 NT 4 NT 3 Voices Contingent 10 P k 12 P 3 7 P 3 upon Something S 3 S .5 S 1 TABLE XVI CONTENT OF HALLUCINATIONS RELATED TO CHANGE IN HALLUCINATIONS SHOWING GROUP CONTRIBUTIONS Voices Insult Voices Threaten/Order Voices Comment Both Swear and Other Uncertain or Other Group Contri- Group Contri- Group Contri- Group Contri- Group Contri- Chanse Total bution Total bution Total bution Total bution Total bution NT 1 NT 0 NT 3 NT 1 NT 0 Maximum k P 1 0 P 0 7 P 1 2 P 1 1 P 1 S 2 S 0 S 2 S 0 S 0 NT 0 NT 1 NT 0 NT? 3 NT 0 Intermediate 2 P 0 2 P 0 2 P 1 8 P 2 3 P 1 S 2 S 1 S 0 S 3 S 2 NT 1 NT 0 NT 1 NT l NT 3 Zero 1 P 0 1 P 1 1 P 0 6 P 4 5 P 1 S 0 S 0 S 0 S l S 1 0 0 79 Table XVI shows that patients who made Maximal Change experienced hallucinatory voices the content of which was consistently insulting or consistently commenting in a neutral fashion. Patients making Zero and Intermediate Change predominantly experienced complex "voices" which were predominantly either derogatory, but had additional features, or were unclear. Patients in the Shock Group making Inter mediate Change experienced voices mostly containing deroga tory content. Derogatory content combined with other hallu cinatory elements was characteristic of Placebo patients showing no change. Patients showing Maximal Change showed the smallest proportion uncertain of the content, most pa tients who were uncertain of content showed zero change. This was characteristic of all patients in the No Treatment Group showing no change. Chronicity of illness in terms of years of hospital ization was quite different from expressed chronicity of voices for many patients. Essentially the same relationship to amount of change emerged for both chronicity of illness and chronicity of voices. The data for Chronicity of Voices is presented in Table XVII and that of Chronicity of Illness in Table XVIII. Tables XVII and XVIII show that most patients show ing Maximum Change or complete remission of hallucinations had been disturbed less than one year when examined. This was true of more patients in the No Treatment Group than in TABLE XVII CHRONICITY OF VOICES RELATED TO CHANGE SHOWING GROUP CONTRIBUTIONS Change Less than 1 year 1 Year to Less than 10 Years More than 10 Years Maximum To tal Group Contri butions Total Group Contri butions Total Group Contri butions 8 NT k k NT 1 1 NT 3 P 3 P 1 P l S 1 S 3 S 0 NT 0 NT 2 NT 0 Intermediate 1 P 0 11 P 3 5 P "I S 1 S 6 S 2 NT 1 NT 3 NT 2 Zero 2 P 1 8 P 3 h P 2 S 0 S 2 S 0 Oo o TABLE VIII CHRONICITY OF ILLNESS RELATED TO CHANGE SHOWING GROUP CONTRIBUTIONS Change Less than 1 Year 1 Year to Less than 10 Years More than 10 Years Maximum Total Group Contri butions Total Group Contri butions Total Group Contri butions 8 NT k k NT 2 2 NT 0 P 2 P 2 P 1 S 2 S 1 S 1 NT 1 NT 2 NT 1 Intermediate 2 P 0 11 P 3 k P 1 S 1 S 5 S 2 NT 1 NT NT 2 Zero 1 P 0 10 'P \ 3 P 1 S 0 S 2 S 0 0 0 82 the other groups. Most patients showing Intermediate or Zero change had been disturbed for more than one year. More of the patients disturbed between one and ten years showing Intermediate or Maximal change were in the Shock Group. More of the patients in the Placebo and No Treatment Groups disturbed from one to ten years showed Zero or Intermediate change. Table XIX shows the comparison of the number of pa tients showing Maximum, Intermediate and Zero change v/ho stated the box helped and those who stated it didn't. TABLE XIX FREQUENCY OF PATIENTS IN EACH CATEGORY OF CHANGE WHO FELT THE BOX HELPED AND WHO FELT IT DIDN'T WITH GROUP CONTRIBUTIONS Helped Maximum Change Intermediate Change Zero Change Total Group Total Group Total Group Yes 6 P 3 S 3 8 P 1 S 7 P 2 I S O No 3 P 2 S 1 5 P 3 S 2 P k _ 7. S 3 Table XIX shows that in the change categories most patients felt the box helped. In contrast, patients in the Zero Change Category felt the box did not help. In the In termediate Change Category all but one of the patients who felt the box helped were in the Shock Group. In the Inter mediate Change Category more of the patients v/ho felt the box did not help were in the Placebo Group. 83 No overall relationships between number of plunger presses and improvement were shown. Within the Intermediate Change Category, however, more patients in the Shock Group pressed above the median. The reverse was true for the Pla cebo Group. 5. Data of Selected Individuals Qualitative Effects of Shock Box. A number of patients volunteered qualitative state ments either to the experimenter or to other staff members. In the Placebo Group three patients made such statements. Two stated enthusiastically that the box was very helpful, but did not know in what way; the third stated the box made him realize he heard "the voices" more than he had original ly thought. In the Shock Group four patients volunteered statements of how the box helped them. It is noteworthy that their statements were all very similar to one another but quite different from the statements by members of the Placebo Group. A statement of one Shock Group patient which typified the four was: "It snaps me out of it; it breaks up the voices and enables me to think about other things."? Temporal Effect of Self Shocking. Four other patients in the Shock Group were able to ?In pilot work prior to this study two of three us ing shock boxes reported gaining increased control over "the voices" with their box. The more verbal stated: "It perks me up" and later, "It makes me less confused". specify another way they were helped. They, as well as all four discussed above, independently stated that they were helped most during the first few days of use of the shock box. One actually reported sharp diminution of the halluci nations during the first three days of use and complete ces sation of them after one week of use. Two others of the eight under discussion reported diminished effectiveness of the box with time. No such specific accounts were given by patients in the Placebo Group indicating that Shock Group pa tients gave a more differentiated account of the details of the change in hallucinations than did the patients in the Placebo Group. Pattern of Pressing. An estimate of the pattern of box presses was taken from examinations^ of the counters when patients returned with the box for repairs. This provided data on eight pa tients; five from the Shock Group and three from the Placebo Group. Of these eight, four (one of the four was from the Placebo Group and three from the Shock Group) revealed a descending function over time, i.e., most presses were at ^Repairs generally took five to ten minutes and usu ally consisted of adjusting batteries which had shifted out of place. On a number of occasions, however, damage ap peared malicious. This was more the case with boxes returned by members of the Placebo Group. Several patients returned three or four times. Although those who returned thereby received increased attention, there were many who did not return for repairs who spoke with the experimenter in groups, etc., and thereby received a certain amount of uncontrolled extra attention also. 85 the beginning, then tapered off with time. The other four patients from whom frequency data was noted during the exper imental period indicated a flat function, i.e., approximately an equal number of presses per unit of time with no appreci able decrease. Interestingly, three of the patients showing a flat frequency function recorded the three highest total press scores; two of these three were in the Shock Group. Follow Up. Follow up was done on a highly informal basis only on a few patients and at a maximum of four months after treat ment was discontinued. The only generalization for which there was any consistent support was that the patients whose frequency of hallucinations reached a zero level, regardless of treatment group, seemed to show greater durability of im provement. One patient who was allowed to retain his shock box for one month after the two-week experimental period showed no noticeable gains over those achieved during the experiment al period. 86 CHAPTER IV DISCUSSION In this study the central hypothesis was not sup ported; the Self Shock Group did not show significantly greater improvement than the control groups on any of the measures of hallucinating. Analyses of individual aspects of the data, however, revealed that significantly more pa tients in the Self Shock Group received reliable (unequivo cal) ratings of improvement in hallucinating (BPRS). This implied that improvement in some patients was attributable to the self shock procedure. The Shock Group and the Place bo Group showed significant improvement in overall pathology. Those two groups also evidenced significant improvement in a larger number of other symptoms than the No Treatment Group, although the No Treatment Group showed some improvement. No group showed overall increases in symptomatology or evidence of symptom substitution. Although the central hypotheses was not supported in terms of greater mean improvement for the Shock Group than for the control groups, this was not due to lack of group improvement. On the contrary, all groups showed significant reduction in hallucinatory activity in terms of BPRS ratings, frequency and statements by ward personnel. Thus there was 87 a large placebo effect found in this study which supports the hypothesis that improvements in a large number of pa tients on many past studies of psychotherapy are attribut able to placebo effects. It would appear in view of this that many case studies in aversive conditioning also appear susceptible to unchecked placebo effects. The target symptom, hallucinations, showed the larg est improvement of any symptom evaluated. In addition it was the only symptom on which all three groups improved, arguing for the presence in the study of a highly specific placebo effect. The placebo effect was clearly not attributable, however, to a rater bias or set to see improvement since raters were unaware of the phase of study that a patient was on and frequently pre and post ratings were made by different raters. It is highly unlikely that the effect could be at tributed to experimenter expectations (Rosenthal, 1966), since the BPRS ratings were double blind with regard to the experimenter's expectations as well as to the study for which the patients were being evaluated. In addition, analyses of ratings done by the experimenter revealed that for halluci nations his ratings were at least as conservative as the BPRS ratings. Hence, two usual sources of bias were ruled out as contributory to the changes obtained. The most probable cause of the highly specific place bo effect was sensitization of the patients to their auditory hallucinations through extensive specific discussion about 88 them during evaluation interviews. The highly specific na ture of the effect was demonstrated by the fact that the pa tient (of whom there were unfortunately very few) who also hallucinated in other modalities indicated that no changes had occurred in hallucinations in those modalities despite a decrease in auditory hallucinations. It may be that verbal sensitization of patients to their generally unpleasant hal lucinations somehow aided them in modifying that symptom. Another possibility is that patients stated they hal lucinated less out of fears about the shock without actually improving. A different line of thinking suggests that it may be the nature of hallucinations that excessive attention renders them temporarily unnecessary in the patient's psycho logical economy under conditions of increased attention. Changes in ratings of overall pathology and the fact that some changes in nontarget symptoms managed to reach sig nificance at the group level for all groups, implied a non specific effect due to elements involved in interviewing, instructing and evaluating patients. The effect is reminis cent of the Uncertainty Principle in physics, i.e., the act of measuring may produce changes of an unspecified degree in that which is measured. In this case the interventions nec essary to solicit patients for the study, to provide initial and final evaluations and the changed nature of the relation ships between patient and involved staff members appear to have all contributed to improvement in the patients. 89 Three other probable sources of change, both specif ic and nonspecific, are: (1) The patient's desire to please the experimenter with whom most of those who volunteered for the study were at least familiar. (2) The many similarities between the Shock Group and the Placebo Group compared with the No Treatment Group suggests common sources of improve ment. First, the undoubtedly similar expectations of im provement in the two box-carrying groups seem to have played a central role in the similar changes. Second, the invest ment in tne shock box per se may have given rise to a dis sonance. Resolution of dissonance could then come about by improving. Use of nonspecific shock should produce a sim ilar decrease if this explanation is accurate. Third, the social aspects of standing out socially and perhaps feeling martyred were shared by those two groups. The need for pun ishment was suggested in pilot work. In this study patients from the box-carrying groups volunteered statements about feeling conspicuous, boxes being uncomfortable, feeling awk ward and clumsy and that people sometimes commented negative ly, implying that box carrying had negative qualities. Those two groups improved on measures of depression, which is dy namically considered related to intropunition. The No Treatment Group, on the other hand, did not show improvement on depression. These findings imply that the negative as pects of box carrying provided some satisfaction of a need for punishment. This was especially true of the Shock Group 90 which also showed significant decrease in guilt. This sug gested a response similar to that of many patients. (3) A third source of change may have been the psychological in vestment in improvement made by agreeing to carry what was perceived as a shock box (whether or not it actually was) and carrying out the procedure as opposed to simply hearing the instructions. If the social aspects and psychological aspects do indeed lie at the core of nonspecific effects then nonspecific improvements would be expected for a pa tient who simply carried a box without pressing the plunger. Modification of instructions to preclude the idea of shock could be used to assess the role of thinking that shock was being given upon pressing the plunger. Other possible sources of improvement described as specific and nonspecific placebo effects were: patient set for improvement, patient expectations of rewards for improvement, fear of the conse quences of not improving, attention, overt and covert sug gestion that improvement is about to come or that a cure-all is planned for the patients, role playing in response to de mand, characteristics of the study or just the effect of be ing singled out. Most of these sources of change could be subsumed under the general description of Hawthorne effect. Despite the presence of placebo effects, examination of individual contributions to group change indicated that some apparently real improvement attributable to the self shock procedure per se were masked by other factors. As 91 mentioned in the previous chapter, half point changes on BPRS indicating disagreement among raters as to whether change had occurred constituted six of the positive changes in the control groups. On the other hand, in the Shock Group all positive changes were of one point or more, indi cating that all positive changes in that group were agreed upon by both raters. Comparison of the number of mutually agreed upon positive changes revealed that the Shock Group contained significantly more than either control group (See Table VIII). Another consideration related to masking of real changes attributable to the shock was that all three groups contained a proportionate number of patients who showed a large reduction in hallucinating to a zero level. Since those changes occurred mostly in patients whose hospitaliza tion prior to this study was short, it was conservatively assumed for purposes of analyses that those changes reflected spontaneous remission of the symptom or response to drugs. It is noteworthy, however, that a larger percentage of pa tients showing maximum change to zero in the No Treatment Group were hospitalized less than one year and experienced hallucinations under one year. This suggests the possibil ity that large changes to zero may have been due to sponta neous remission only in the No Treatment Group. Consistent with the hypothesis that actual improve ments in the Shock Group were masked by several large changes common to all groups and a moderate number of small dubious changes in other groups was the finding that the Shock Group contained a significantly larger proportion of patients whose change ratings reflected intermediate improve ment. It is noteworthy that all the patients in the Shock Group showing intermediate change reported that the shock box helped them. Several specified that effectiveness was greatest during the first few days, but decreased with time. In addition, several Shock patients showing intermediate change gave highly differentiated accounts of the mechanism by which the box helped in contrast to the vaguer reports from members of the Placebo Group. The contrast implies a more direct relationship between use of the shock box for those patients than for others. It also lends further sup port to the idea that improvement in those patients was at tributable largely to the use of shock. Also suggestive of a direct relationship between use of shock and improvement in patients in the Shock Group, es pecially those showing intermediate change, was the temporal pattern of plunger pressing. When temporal pattern of plung er pressing was noted, a descending function over time was generally characteristic. Thus, the initial period of use of shock, considered the most effective period, appeared to correspond to the period of maximum usage in the Shock Group. A related finding was that only in the Shock Group was press ing above the overall median of subjects who carried boxes related to improvement. The most obvious interpretation of the descending function of pressing over time which correlated with state ments of effectiveness in the Shock Group is in terms of ad aptation to the effects of shock. It would be assumed that initially the shock helped decreasing the discomfort of the symptom and concomitantly their motivation to remove the symptom. The additional fact of adaptation to the shock dim inishing its effectiveness further decreased motivation to use it. Box pressing would then partially extinguish. Evi dence for adaptation to the shock was found in pilot work. Although new batteries were used for each shock box when giv en to the patient voltage could have dropped during the two weeks. One way to control for adaptation and voltage drops would be to periodically measure and adjust the voltage. An alternate explanation could be given in terms of the novelty value of the shock box. Although the first ex planation seems more reasonable and consistent with the lit erature, the second cannot be completely ruled out since the patients in the Placebo Group showed many features in common with the Shock Group and the pressing trends of all patients were not examined. An additional explanation might be that the novelty of the shock per se or of the contingent shock bring about improvement. The effects of shock per se could easily be tested by examining the results of noncontingent shock. The other possibility will be discussed later. 9k The finding that few patients showed decrease in hal lucinations to a zero level could easily be explained in terms of adaptation to shock. It would be assumed that shock was adequate to initiate a diminution in frequency but adaptation to the shock occurred before the frequency reached a zero level. Although the explanation of adaptation to in itial impact of the box would also be consistent with some of the findings it does not seem adequate to account for the larger number of patients in the Shock Group showing reliable positive change. It could account, however, for the overall equivalency of improvements in the Shock Group and Placebo Group. The greater internal consistency of reports of changes and relation to shock in the Shock Group could be at tributed to the presence in that group of a stimulus around which a logical rationale could be formulated and expectan cies developed. One fact which emerges clearly is that the self shock procedure showed no harmful effects on patients. Nor was it so aversive as to be avoided by the patients. All patients who took a box recorded some number of presses on the counter concealed within the box to register number of presses. Clearly patients did not simply take the boxes out of fear of not doing so and then not use them. This fact together with several others discussed argues for coopera tion among patients. 95 Not only did shock fail to show harmful consequences, but patients in the Shock Group revealed a significantly higher average number of presses than the Placebo Group. De crease in suspiciousness and increased cooperativeness in that and the Placebo Group further dispel notions of negative side-effects of shock or box. Yet, by initial reactions of Shock Group patients it was judged that the shock itself was not pleasurable. From these findings it was concluded that the higher number of presses reflected effects of the shock which were rewarding. One effect apparently considered by patients to outweigh negative aspects was that, in the words of one patient, "it snaps me out of it, breaks up the cycle of voices and confusion ... and enables me to think straight". The lack of such statements from patients in the Placebo Group indicates that where change came about it was by a dif ferent means. The effect described by the patient quoted reflects the descriptions of other Shock Group patients who verbalized the effect of shock. The described effect is highly consist ent with much research with schizophrenics. It has been shown that schizophrenics improve performance under stress, e.g., showing greater clarity of thinking and concept forma tion in response to the TAT, and increasing speed of motor functioning in laboratory tasks. Censure impedes performance, but objective forms of stress, in particular electrical stim ulation, seems to bring about improved functioning. Moreover, the theoretical formulations of Lovaas and Bucher (196?) and Erickson (1968) that schizophrenics orient or respond to in ternal rather than external conditions are highly consistent with the results. In particular the interpretation of hallu cinations as interaction with oneself expressed by Erickson and implied by Lovaas appear to be the conditions which the self shock patients in this study describe the shock as "breaking up", "interrupting" or "snapping" them out of. It is proposed that it is this "snapping out of" or reorienting away from unpleasant hallucinations that is re warding. The statements quoted from patients serve as indi rect evidence that patients at least in the Shock Group shocked themselves as instructed, namely when the voices be gan. If reorienting toward external events is accomplished by contingent shock, as implied, it is possible that such re orienting could also be brought about by noncontingent shock. The theories discussed are certainly not inconsistent with that expectation. Such patient descriptions as "snapping out of" and "interrupting" to describe the effect of shock where such ac counts were given do not seem to be what one would typically expect if the shock simply served to suppress or decondition the hallucinations. The statements given appear far more compatable with disorienting the patient away from the voices and/or reorienting their attention toward external reality. This explanation is essentially that proposed by Bucher and Lovaas (1967) and which Erickson's research sug gests. The idea of external mechanisms serving to orient or distract the patient from hallucinations is implied from statements of a number of patients that they can "turn off" their hallucinations by engaging in some activity incompat ible v/ith the hallucinating. Basically, then some patients appear to have learned a process resembling reciprocal in hibition by which hallucinations are temporarily suppressed. This is the very mechanism explored by Erickson. It appears that improvements due to shock may be due to the same mechanism. It may be that improvements attribut able to shock were not due to the punishing effect of shock. Since the shock appears to function by means of distraction, thereby disrupting ongoing experienced negatively self inter actions, reinforcing effects of the relief from confusion and unpleasant hallucinations following the reorienting ef fect of shock may serve as the agent of conditioning. It is also possible that the positive effects act in conjunction with the aversive effects as in the aversion-relief paradigm. If this explanation were accurate then why, one might ask, would patients now show an increase in behaviors which by their own admission aided in reducing hallucinations? Prob ably a combination of things is responsible. First, their own techniques were not imbued with the "magic" of authori tative endorsement. Second, their own techniques such as talking to others, reading, etc., did not begin to disorient 98 them at the inception of the hallucinatory experience, nor was the effect as dramatic as for shock, or always available. Adaptation to some of the self devised techniques would ap pear to have been very rapid. It is noteworthy that most patients reported little or no hallucinating during gargling or brushing their teeth. Those behaviors are incompatible with subvocal speech, the mechanism seen by Gould (1950) to produce auditory halluci nations. Erickson (1968), following Gould's theory of hal lucinations, provided research evidence (unfortunately with small samples) that indeed having a patient gargle when he hallucinated terminated his hallucinations. He interpreted his findings in terms of reciprocal inhibition of the mechan ism responsible for producing the hallucinations. However, if Gould's hypothesis were valid to account for all auditory hallucinations, then it would follow that when a patient talked he would also reciprocally inhibit the mechanism for hallucinating. In this study only about fifty percent of the patients reported that their hallucinations stopped while talking. The other fifty percent stated the voices continued while they spoke. Hence it appears that Gould's theory does not fully account for all types of auditory hallucinations. Since Gould's theory appears a questionable account of the mechanism of hallucinations, the proposition based on that theory by Erickson also appears questionable. If indeed the vocal apparatus is not the source of auditory hallucina 99 tions or if other techniques which are more distinctly in compatible with use of the vocal apparatus for hallucinating do not reciprocally inhibit hallucinating, then the basis for specifying reciprocal inhibition as the mechanism respon sible for diminishing hallucinations in Erickson's study also appears suspect. The explanation that all the mechanisms found to terminate hallucinations serve simply to distract or reori ent appears far more consistent with the findings of this and other studies. For example, forced gargling certainly qualifies as a distraction. An interesting test of this hy pothesis would employ a benign distractor such as music or a pleasant sound, etc., at the onset of hallucinating. If the stimulus did bring about a similar termination of hallucina tions, even though perhaps reinforcing in and of itself, the hypothesis would be confirmed. Bucher raises the interesting question of why a sim ple act of will is not adequate to terminate unpleasant hab its when shock is. He proposes that will power may not act upon the antecedent conditions of the habit, but shock ap pears to sensitize the individual to the antecedent condi tions. It is suggested then, that sensitization by high lighting or making conditions more discriminable increases the subject's self control. There seems to be an adequate basis for assuming that the role of sensitization or discrimination does play 100 an important part in bringing about highly specific changes. The question, however, of whether (1) shock itself serves to sensitize or whether (2) sensitization independent of and prior to shock, v/hich could have occurred in Bucher's work, works together v/ith the shock is open. There may be some differences along these lines depending upon whether psychot- ics or other groups are used. Dissonance theory would also predict that a patient shocking himself for a specific symptom would attempt to re solve the dissonance associated with shock. One logical way of doing so would be to give up the symptom. This theory, however, would predict the same for noncontingent shock or any other condition giving rise to some dissonance such as simply carrying a box, pressing a shockless box, etc. Inter estingly that theory seems more compatible v/ith the cogni tively tinged patient statements than interpretations involv ing reciprocal inhibition. Also handled by dissonance theory is the decrease in depression in patients harboring a need for punishment. Also the nonspecific symptoms seen to im prove in various groups could be seen to be those troubling most patients. Due to its breadth dissonance theory does cope well v/ith the data, including many of the apparent pla cebo effects discussed earlier. Dissonance theory would pre dict that the more unpleasant the stimulus the greater the dissonance, hence the greater the improvement regardless of v/hat made the stimulus unpleasant. Since large improvement 101 occurred in the Placebo Group as well as in the Shock Group it may be that the overall aspects associated with the Pla cebo Box are just as unpleasant as those associated with the Shock Box, although different in nature. Factors Related to Improvement A variety of factors were found to be related to im provement per se. Hallucinating in other modalities seemed related to extremes of improvement for auditory hallucina tions. Statements that the box was helpful were positively related to improvement, but most noticeably so in the Shock Group for patients showing intermediate improvement. Consistent v/ith much clinical data was the negative relationship between chronicity and improvement. Patients who were hospitalized less than one year showed largest im provements, especially in the No Treatment Group. Most im provement for patients hospitalized over ten years was found in the Shock Group. Similar findings occurred for chronicity of hallucinating. Generally, the negative relationship be tween chronicity and improvement was most pronounced in the No Treatment Group and least in the Shock Group. Usually an intermediate relationship was found for the Placebo Group. These findings implied that the Shock Group was maximally responsive to effects of intervention and treatment and the No Treatment Group least responsive, with the Placebo Group intermediate. Related to chronicity is onset of illness. Adult on 102 set of illness was not related to improvement or to groups. Lifelong inability to function related positively to improve ment, but only for Shock Group patients. Patients in the Shock Group with an adolescent onset of illness showed the only (intermediate) improvement. This implied that the shock procedure constituted a means by which these patients could begin to cope v/ith their illness. L.ifelong marginal adjust ment appeared positively related to improvement but unrelated to experimental group. It may be that people making marginal adjustment all their lives made some adjustment to their symptoms which was satisfactory to them. Hence they were not receptive to externally imposed coping mechanisms. The con clusion drawn from examination of the factors related to im provement and their contributions to experimental group dif ferences was that changes in the Shock Group were least at tributable to other factors. Hence, shock appears to con tribute independently to improvement. Patients v/ho verbalized awareness that their halluci nations were contingent upon some event shov/ed a larger per centage of patients improving than those who did not verbal ize such a contingency. This suggested that awareness may play an important role in coping with the hallucinations. This hypothesis is consistent with the position taken by DeNike in regard to verbal conditioning (DeNike, 196^5 Spiel- berger and DeNike, 1966). DeNike sees awareness of the ex perimenter's hypothesis to be prerequisite to performance 103 gains on verbal conditioning task. Performance, however, is also seen to depend upon motivation. Applying DeNikefs con ceptualization to hallucinations would require the assumption that there are certain attributes of hallucinations, the awareness of which would lead to control over the hallucina tions, assuming adequate motivation. Bucher (1967) apparent ly thinking along similar lines suggested that those crucial conditions may be the antecedent conditions to the hallucina tions. He, however, feels that shock is one of the few means by which awareness of those antecedent conditions can be brought about. The data of this study support the idea that aware ness of preconditions helps a patient gain control over hal lucinations. These data imply in addition, however, that awareness of other conditions related to hallucinations is at least as important as awareness of antecedent conditions and may be brought about by means other than shock.1 The find ings in this study that most patients in the no precondition category who showed improvement were in the Shock Group, and tended to show intermediate change, suggested that shock can indeed bring about the awareness necessary to gain some con- lA variety of features is included under contingen cies. Onset of voices were contingent upon such things as anger, tension, new circumstances. Decrease or termination of voices was contingent upon such things as reading, being alone, etc. trol over the hallucinations. An alternate explanation of the data is that pa tients who verbalized no conditions affecting the voices were not simply unaware of what influenced the hallucina tions, but that in point of fact there were no such influ ences. The information acquired on the PDS, however, sug gested that the hallucinations of almost all patients had contingencies. This hypothesis, then appears not to account well for the data. It was found that most patients making no change re vealed the content of their hallucinations to be complex and/or highly unusual, whereas simple content (regardless whether benign conversation or derogatory or threatening, etc.) was associated with improvement in hallucinating. These findings may imply that confusion is the underlying variable reflected by the dichotomy of single vs. complex hallucination content. This is plausible in that interac tions with patients were constituted by asking many questions and forcing patients to conceptualize more clearly in regard to their hallucinations. On the other hand it was only in the Shock and Placebo groups that significant improvements in symptoms related to confusion resulted. This may imply, however, that the more confused patients were motivated by the effects of carrying a box to utilize the awareness of factors relating to confusion to gain control over it. Al ternatively confused patients may simply be more responsive to the nonspecific stimuli of carrying a box. The findings of the study, then indicate that aware ness of factors associated with hallucinations helps bring about improvement. Awareness can be brought about by shock, by highly specific questioning or by other less specific stimuli referred to as placebo. Shock also appears to be independently capable of bringing about improvement in hallu cinations and possibly general improvement by reorienting patients away from the internal environment toward the ex ternal. It is plausible in terms of most theories that non specific shock could duplicate this function of contingent shock. The process by which the shock becomes useful was seen to be the positive effects of relief from unpleasant hallucinations following orientation away from them. Shock may work only in that way or in conjunction with its aversive properties such as the aversion-relief paradigm described in the aversive conditioning literature (Feldman, 1966) appears to. In this study shock appeared to manifest its effect despite the presence of other factors associated with im provement in hallucinating. Report of Improvement An interesting feature of improvement noted in WPC was that patients' improvement was reported in terms of in creased socialization, i.e., in terms of initiating conversa tions, speaking to others more, getting along better with 106 others, seeming more comfortable with others and being more productive and regular on their assignments. While this is to be expected for spontaneous remissions it was frequently associated with patients in the Shock Group who showed inter mediate changes. Although this may be an artifact of the larger absolute number of such patients in the Shock Group, it is consistent with the hypothesis that shock snaps one out of internal preoccupation or orients patients to external events and objects. This was also suggested by pilot data and by Erickson's study. It might well be speculated that nonspecific shock would produce a similar overall change in schizophrenics. For research examining such a proposition, however, a more structured form of eliciting specific, detailed information from ward personnel than the spontaneous reactions sought from that source in this study, which were somewhat sporadic, would be desirable. It was found that considerable informa tion was lost by structuring patient interviews over pilot work in which the patient was allowed to provide the data himself. It is interesting in connection v/ith the overall im provement of all groups being approximately equal, that the experimenter, consistent with many therapists, viewed more patients as improved (Although not significantly more) than other professional raters, consistent with many previous findings that therapists tend to see more improvement in 107 their patients than other people. Whether this is because the therapist has access to more subtle changes, as suggested earlier in the study, rates on different things, projects his needs, or justifies his efforts by dissonance reduction, is unclear. Other Aspects Involving the Experimenter The role of the experimenter in self shock work has not been studied per se although numerous speculations and assumptions have been put forth (Bucher, 1967; Wolpe, 1958) implying that rapport must be very good and the patient well motivated. It has also been brought to the experimenter’s attention that in one previous attempt to employ patients on a self shock study with psychotics done by an experimenter unknown to patients was totally unsuccessful. Indeed the speculations of previous writers seem well founded. Out of approximately 95 patients reported to hallucinate, or showfed behaviors indicative of hallucinating who were interviewed by the experimenter, approximately 50 either denied halluci nating or flatly refused to carry out the self shock proce dure (most fell into the first category). Refusals were more the rule than the exception for patients completely un familiar with the experimenter. It appears then that Shakow's (1962) finding that schizophrenics require a long period to familiarize themselves with a situation before they can deal with it, applies regarding the use of adminis tration of a self shock procedure. One might reasonably as- 108 sume that susceptibility to placebo developing latently over this time of familiarizing might well be released by almost any direct intervention by the therapist when the patient's attitude ripened. It is concluded in view of the above find ings that self shock procedures with psychotic patients while perhaps superior to many other conditioning procedures, and perhaps efficient with selected patients for treatment of single resistant symptoms, are far from a panacea of effi ciency for producing overall changes as some naive users of this and related methods might have us believe. If indeed shock works not in terms of punishment (aversive condition) but in terms of the positive reinforcement attendant upon temporary relief from the disturbing symptoms, then the same statement may well apply to aversive conditioning "cures" in general. A second point related to acquiring cooperation in hallucinators was that patients often did not refer to their hallucinations as "voices" but by some esoteric sounding word or phrase necessitating, on the part of the experimenter, the evocation of the patient's idiosyncratic term in order to communicate. Amazingly even though the patient population employed was comprised predominantly of paranoid schizophrenics little difficulty was encountered on the basis of suspiciousness at least not among those accepting the procedure. In view of the tremendous amount of work involved in 109 getting a conditioning program operating as in this and most studies reported as well as the great amount of personal con tact v/ith the patient in this and other studies to establish rapport, make evaluations and make reasonably sure the proced- iire is being carried out, in addition to the enthusiasm, sug gestion, etc., of experimenters, the optimism of some authors about conditioning procedures appears ill placed. Most im portant is the need, in evaluating outcomes, of adequate con trols for these nonspecific effects. Implications It is clear from the marked placebo effects, despite generally good control over two usual sources of placebo ef fects (the experimenter and the raters), that much of the confusion and conflicting reports in the aversive therapy literature stems from unchecked placebo effects which are confounded with or actually constitute the "treatment" agent in the many single subject experiments, in v/hich a baseline is established against v/hich changes are evaluated following introduction and removal of the independent variable, it is clearly impossible to separate the variable from means of in troducing it. This makes it impossible to determine the de gree to which each contributes to change or controls the re sults. Clearly, this type of research requires samples suf ficiently large to permit statistical evaluation of nomothet ic representativeness. The ideal paradigm for research of this nature ap 110 pears to be one in v/hich each group may be looked upon as composed of n single subject experiments receiving similar treatment; groups being used to present major differences in the treatment, but extensive information taken at an individ ual level. Assessment should permit not only assessment of differences, but differences in change between the groups as v/ell as assessment of amount of change within each group. And the questionable durability of change makes long term follow-up an important feature of all research of this type. The question of evaluation is a puzzling one. On one hand extensive data appear necessary beside simple state ments of whether they improved, but on the other hand the ex cessive questioning which seems necessary for evaluation of subjective phenomena such as hallucinating appears to mask true changes to an uncertain extent by sensitizing the pa tient and by other means. Clearly objective criteria closely related to hallucinations which could be evaluated without patients' awareness would be the most desirable means of as sessment. Behavioral data is the most desirable but physio logical indices of schizophrenic improvement (Bemel, 1965) also could be useful. A final point to be made is that it seems whatever serves to motivate people to become involved enthusiastically with patients appears to induce improvement albeit of ques tionable durability. Various symptoms, however, do appear differentially affected. Ill CHAPTER V SUMMARY Reviews of the literature on hallucinations and aver sive conditioning suggested the possible value of aversive techniques for decreasing hallucinating. This study ex plored the effects of a self shock treatment procedure for auditory hallucinations in chronic schizophrenics. Subjects were forty-five male schizophrenic.- patients at the Sepulveda Veterans Administration Hospital. All patients on the study volunteered for the self shock procedure. No patient was used who evidenced heart trouble. Patients were randomly assigned to one of three groups. Each Self Shock patient carried on his belt a box giving shock upon pressing a plunger. Patients in the Pla cebo Group carried a box identical in external appearance which gave no shock. The No Treatment Group received only the pre and post evaluations which were given all subjects. Instructions to the box-carrying groups included statements that they would receive electrical stimulation upon pressing the plunger (whether perceptible or not) and that they should shock themselves each time they heard voices. The No Treatment patients were told initially that the shock box would be discussed again in approximately two 112 weeks if they still had their problem at that time. Evaluations were made by means of the Brief Psychiat ric Rating Scale (rated double blind), Ward Personnel com ments, and a Patient Data Sheet (designed by the experimenter, eliciting extensive data on the patients' hallucinations and background). Each of the group showed significant decreases in hallucinating over the two weeks on all measures. These were interpreted as placebo effects due to sensitization of patients to their hallucinations and factors associated with them. Improvement in overall pathology was shown for the box-carrying groups, indicating specific placebo effects due to social conspicuousness of box carrying, expectations, etc. No overall differences in amount of change were shown between groups, however examination of individual changes re vealed the Self Shock Group to have significantly more sub stantial improvements than control groups. This finding in dicated that some changes were attributable to effects of shock per se. A number of factors v / e r e cited which appeared to mask the effects of shock. In no case was there evidence that a patient was harmed by the procedure. Intermediate change without complete cessation of hallucinations appeared to characterize the improvement of self shock patients; larger changes were apparently due to other factors. Most change in the Self Shock Group took place in the first few days of use of shock. The process of change v / a s interpreted primarily as positive conditioning., 113 resulting from shock-induced temporary relief from unpleas ant hallucinations. Findings were seen to be consistent with Lovaas1 interpretation of schizophrenia as inwardly fo cused attention. Patients in the Self Shock Group who des cribed shock as "snapping" them "out of the voices" together v/ith decreased depression and reports of greater socializing suggested shock served to reorient inwardly focused atten tion tov/ard external events. A positive relationship was found between improvement and verbalization of factors related to hallucinating. More differentiated descriptions of how change came about were given by Self Shock Patients. These findings suggested that conscious cognitive factors may be important in bringing about change. Results v/ere discussed in terms of several other theoretical viewpoints. Dissonance theory appeared congruent with most of the results. On the basis of the large effects apparently due to the measurement process, attention, expectancy, etc., it was suggested that the results of single subject design research on human aversive conditioning may be influenced by un checked sources of placebo. APPENDICES Ilk APPENDIX A RATING INSTRUMENTS and INTERVIEW FORMS 115 INTERVIEW (Pre-- (Post— Name _______________ Date _______________ Time in hospital __ Medication Marital Status Children? _________ Age ________________ Race or Nationality Diagnosis _________ Other projects ____ Does patient bring up topic of voices spontaneously? VOICES: 1. Describe the voices 2. What kind of voices do you hear? 3. Are they clear, that is, can you understand what they say? 4. Can you identify the sex of the voices? 3. How long have you heard the voices? 6. When did you first hear the voices? 7. Was there any special event after which you began hearing the voices? 8. Was there any time when you weren't disturbed by voices? 9. Have you ever seen, felt, smelled things which others did not? 10. Other ATTITUDE TOWARD THE HALLUCINATIONS: 1. How do you feel about the voices? If no answer - Do you like or dislike them? 2. How do the voices affect you in your daily life, work, other? 3. Would you like to get rid of the voices? 4. How badly do you want to get rid of them? 5. What would you be willing to do to get rid of them? 117 if. FREQUENCY: 1. How often do you hear the voices? 2. Hov; often per day? 3. Can you give me a number? if. How often did you hear them today? 5. When did you hear them last? 6. Do you hear them now? 7. Have you heard them during our session? Hov/ many times? 5. CONTENT: 1. What do the voices say, do, or ask? 2. Do they tell you to do things? 3. Do they call you names? if. Tell me some of the things they have said. 5. Are they ever helpful? 6. SOURCES: 1. Where do you think the voices come from? 2. Where do they sound like they are? 3. Do they ever seem to be inside your head? (Describe) if. Do you hear them with your ears? one? both? 7. CONDITIONS AFFECTING THE VOICES: 1. Is there any time when you hear the voices more? less? (Describe) 2. Is there anything that happens that makes you hear them more? less? 3* Is there anything which you can do which makes them increase? decrease? 4. Do you hear them when you: a. talk b. are busy c. watch TV d. are involved in a conversation with others e. showering f. gargling or brushing your teeth g. are involved with anything. 5. Do they seem to increase when you are: a. alone b. in bed c. in the morning d. eating e. in the evening f. when it is quiet, noisy g. other 6. Do you ever talk back to the voices? A. How do they respond? B. What else happens? 7. Do you do what the voices tell you? A. What happens then? 8. Other 8. ATTITUDE TOWARD SELF: 1. How do you feel about yourself? (Describe) 119 2. What do you like about yourself? 3. What do you dislike about yourself? /f. Have you ever thought of suicide? (V/hen) 5. Have you ever tried suicide? 6. Do you ever think of suicide now? Why? What makes you think of it? 7. How long do you think it will be before you feel well enough to leave the hospital? 8. Is there anything you feel guilty about or unworthy of? 9. How do you feel about the future? Plans? 10. Observations relevant to self concept. 9. CHILDHOOD: 1. How would you describe your childhood? Happy or unhappy? 2. Any brothers or sisters? 3. Raised by both parents? (Which) 4. How did you get along with your parents, brothers, sisters? 5. Did you have many friends as a child? In high school? 6. Were you alone much of the time as a child? In high school? 7. Did you ever hear voices as a child? 8. Did you date much in high school? 9. Were you active in sports in high school? 10. What did you enjoy doing by yourself as a child? In high school? 11. Other 120 10. ILLNESSES: 1. Any unusual illnesses as a child? 2. As an adult have you had any trouble v/ith your heart, lungs, head? 3. Have you had fevers with your illnesses? if. Did you notice any changes in yourself after any illnesses? 11. ACCIDENTS: 1. Have you had any accidents in your life? (Describe) 2. If so: how recently? were you hurt? how did it affect you? do you think it had any effect on your present illnesses? on the voices? 3. Have you ever had any injury to your head? 12. WORK: 1. Are you working here at the hospital? 2. What kind of work do (did) you do? 3. How long employed? if. Did you like the work? Were you good at it? 5. Can you go back to that work? SYMPTOM CHECKLIST NAME Porj.# Subj.# DATE INSTRUCTIONS: Circle or Excitement (EXC)____ 7 Unrestrained 9 Hurried Speech 12__Elevated Mood 15 Superiority 17 Dramatization 2 0__Loud 26 • Overactive 35 Excess Speech 37 Dominates Anxious Intropuni- tiveness (INP)________ 14 Blames Self 2 1__Anxiety (specific) 24 Apprehensive 2 7__Self Deprecating 29 Depressed 31 Guilt 39 X-l Insight 4 0__Suicidal 4 1__Obsessive 4 2__Fears 66 X8 Sinfulness 8 scoring constant check appropriate item Perceptual Distortion (PCP) 45 Hears Voices 53___X2 Voices Accuse 55 X2 Voices Threaten 5 6___X2 Voices Order 57 X2 Visions 5 8___X2 Other Hallucination 67 X8 Ideas of Change Hostile Belligerance (HOS) 5 Verbal 11 Contempt 18 Attitude 25 Irritability 28 Blames Others 32 Bitter 34 Complaints 36 Suspicious Paranoid Projection (PAR) 44 Delusional 5 9__X8 Reference 54_ 6 0__X8 Persecution 641 6 1__X8 Conspiracy 65~ 6 2__X8 People Controlling & 9 ~ 6 3__X8 External Controlling 68 X8 Body Destruction Grandiose Expansive- ness (GRN) 15 Superiority _X2 Voices Extoll ~X8 Unusual Powers ~X8 Great Personality "X8 Divine Mission SYMPTOM CHECKLIST (Continued) Retardation and Apathy ________ (RTD)_________ 1__Slowed Speech 8__Lack of Goals 13__Fixed Facies 16__Slowed Movements 19__Memory Deficit 2 2__Speech Blocking 2 3__Apathy 33__Whispered Speech 38__Failure to Answer Motor Disturbances (MTR) f e Posturing 10 Tension Disorientation (PIS) 7 0__X-l Hospital 7 1__X-l State 7 2__X-l Knows no one 7 3__X-l Season 7 4__X-l Year 75 X-l Age 6 scoring constant 30 Slovenly 46 X2 Giggling k7 X2 Grimacing 48__X2 Repet. Movements 5 1__X2 Talks to Self 5 2__X2 Startled Glances Conceptual Disorganization (CNP) 2 Irrelevant 3 Incoherent k Rambling 49 X2 Neologisms 5 0__X2 Stereotypy Completed by: APPENDIX B ADDITIONAL EXPLANATIONS and TABLES 123 Q CO CO 4 £P 0 O O H pi O Hj *4 P ? Q 4 H O 5 U pi O >4 C D o' Q B i - 9 t 2 j 4 C D 4 O O 3 C D Pi c + JD >4 <+ I H oo [Somatic Concern Cm I VM VM VM o ro [Anxiety Cm I VM vO VM -0 4 ^ - [Emotional Co (Withdrawal -p- H VJl -s3 vji [Conceptual ^ (Disorganization VM O H VO H VM Guilt Feelings VM V J l ro -o VM Cm Tension ro cn o > i ro vO Mannerisms and Posturing H VJ l ^ IGrandiosity • I oo I H ro ov H C T v Depression ro fo H VJl VM - P “ Hostility VM H ro vO y [Suspiciousness Co I VJl ■p- V J1 -a - p- [Hallucinatory (Behavior *721 ro Cm h C " \ ro o Motor Retardation TABLE OF INITIAL DISTRIBUTION OF GROUP MEANS FOR BPRS FACTORS Qtntn Q t) O S t l 'O * " J H 4 < D 4 O o o h o p i o p r o £ o Hj c o £ c+ p i t ) ? f C D V c+ 0* I o H ro ro • • • - P " o V M - p - VJl VJl • f t • VM O'! VJl VJl - F - - P - • • • • P - 00 ro V M ro • • • VJl VJl vO H H V M • » • vO H ro VJl VJl - o • • • ON Ov ro -p- CT\ ON • • • V jv l VJl vO ro V M • • • •p- VJl ON ro ro ro • • • o H VJl ro H H • • • - p - 00 ro ro V M V M • f t • -s3 oo ON O'! f t - o f t -o • Blunted Affect Inappropriate Thinking Disturbance Disturbance Retardation VM VJl Total Psychiatric Pathology o o 3 c+ H- E CD & TABLE OF INITIAL DISTRIBUTION OF GROUP MEANS FOR BPRS FACTORS 126 ASSIGNMENT OF PATIENTS TO GROUPS Group No Treatment Placebo Self Shock Coded Entry Coded Entry Coded Entry Iden- to Random Iden- to Random Iden- to Random tity Study H tity Study # tity Study # N1 3 36 PI 1 13 SI 2 24 N2 7 kk P2 5 02 S2 4 25 N3 16 31 P3 6 00 S3 12 27 m 17 kO P4 8 08 S4 13 21 N5 19 kl P5 9 07 S5 18 25 N6 20 30 P6 10 04 S6 21 16 N7 25 33 P7 11 14 S7 23 17 N8 28 39 P8 14 03 s8 24 22 N9 34 35 P9 15 10 S9 27 26 N10 35 42 P10 22 06 S10 29 15 Nil 36 3k Pll 26 09 Sll 31 29 N12 39 43 P12 30 12 S12 37 20 N13 kO 32 P13 32 01 S13 38 18 N14 kl 38 P14 33 05 S14 42 23 N15 kk 37 P15 43 11 S15 45 19 Assignment to groups was on the basis of the number which a patient received from the random number table. Ran dom numbers from 30 to 44 were assigned to the No Treatment Group; those from 00 to 14 to the Placebo Group and the rest to the Shock Group. PHYSICAL LAYOUT OF SHOCK BOX BACK (Inside) Batteries Trans former FRONT (Inside) ^-Plunger .Grommet P Grommet Micro switch Plastic Screw lastic Washer Counter SIDE 128 ■elt iOOp Batter^e Trans former Plunger Microswitch Counter ELECTRICAL CIRCUIT OF SHOCK BOX 9 volts (Z* AA Penlite Batteries) Transformer #79 D 33-29 ATC 1035-210 Microswitch Grounded to Chassis Insulated Plunger A Note: Box is grasped with hand. Thumb depresses insulated plunger which automatically closes microswitch and registers one count on the counter. Depression of plunger closes circuit between microswitch and chassis through hand (A-B). APPENDIX C SUMMARY OF STATISTICAL TESTS 3 29 130 INITIAL COMPARABILITY OF GROUPS Analyses of Variance of Initial BPRS Ratings of All Symptoms, of Hallucinations and of Total Psychiatric Pathology (Summary Tables) Symptom (Interpersonal Disturbance) Showing Greatest __________________Dispersion of Means_________________ Source Sum of Squares df Mean Square F Between Groups 6.98 2 3.49 1.50 Within Groups 97-43 42 2.32 Total 104-41 44 Hallu cinations (BPRS) Source Sum of Squares df Mean Square F Between Groups 5.91 2 2.96 1.31 Within Groups 104.07 42 2.26 Total 109.98 44 Total Psychiatric Pathology (BPRS) Source Sum of Squares df Mean Square F Between Groups .48 2 .24 n.s. Within Groups 87.77 42 2.09 Total 88.25 44 131 INITIAL COMPARABILITY OF GROUPS Analyses of Variance of Initial PDS Data for Chronicity of Illness, Chronicity of Voices and Number of Symptoms Rated on the Symptom Checklist and Age Source Sum of Squares df Mean Square F Between Groups 4,160.12 2 2,080.06 n.s. Within Groups 120,644.88 42 2,872.49 Total 124,805.00 44 Chronicity of Voices (Patient's Estimate of Total Time Disturbed by Auditory Hallucinations) Source Sum of Squares df Mean Square F Between Groups 11.50 2 5.80 n.s. Within Groups 162,774.80 42 3,875.50 Total 162,786.30 44 Number of Symptoms Rated on Symptom Checklist Source Sum of Squares df Mean Square F Between Groups 98.31 2 49.16 1.09 Within Groups 1,954.60 42 48.68 Total 2,042.91 44 Age Source Sum of Squares df Mean Square F Between Groups 52.00 2 26.00 Within Groups 4,530.00 42 Total ^,582.00 44 n.s. 132 INITIAL COMPARABILITY OF GROUPS Chi-Square Analyses of Frequency Distribution of Factors among Groups _____________ Diagnostic Categories_______________ Group_____________ Paranoid Schizophrenic______________ Other No Treatment 9 6 Placebo 11 k Self Shock 10 5 X2= 1.31, df= 2, £ >.10 Medication Group Thorazine Mellaril Stelazine Other No Treatment 6 3 2 Placebo k 7 2 2 Self Shock 6 6 2 1 X2= 2.62, df= 6, £ >.10 Marital Status Group Married Single Divorced No Treatment 3 10 2 Placebo 5 7 3 Self Shock 5 8 2 Chi-Square Analyses of Initial Conditions (Continued) Self Concept Group Likes Himself Has Some Dislikes about Himself Other No Treatment 9 k 2 Placebo 8 6 1 Self Shock 8 7 0 X2= 3.88, df= 4, £>•10 Work History and Economic Level Group Never Little or Spotty Worked Worked Employment High Level Work No Treatment 2 6 7 0 Placebo 3 5 6 1 Self Shock 2 k 8 1 X2= 1.79, df= 6, £>•10 Incidence of Accidents Group Serious Accidents or Head In.iur.y No Injury No Treatment 9 6 Placebo 9 6 Self Shock 8 7 13k Chi-Square Analyses of Initial Conditions (Continued) Degree of Adaptation - Social and Developmental Group Difficulty Primary Dif- Began in ficulty Began Childhood - in or immedi- No Adjust- ately after ment teen years Break Oc- Chronic curred af- Marginal ter adult Adjust- adjustment ment was made No Treatment 2 k 5 k Placebo 2 3 k 6 Self Shock X2= 1 2 3 ..13, df= 6, jd^.,10 6 k Patient Approach to Discussion of Hallucinations Group Patient Brought up Topic of Hallucinations Spon taneously Probing Required to Elicit Discussion of Hallucinations No Treatment 10 5 Placebo 9 6 Self Shock X2= . 11 60, df = 2, jd ■>.. 10 k Patients Converse with the Hallucinations Group Patients Admit Convers ing with Hallucinations Patients do not Admit Overtly Responding to Hallu cinations No Treatment 12 3 Placebo 11 k Self Shock 11 k X2= .2k, df= 2, £>..10 135 Chi-Square Analyses of Initial Conditions (Continued) Conditions Affecting Hallucinations Group Patients Verbalize Conditions under which Hallucinations Increase or Decrease Patient does not verbal ize Conditions which In crease or Decrease Hallucinations No Treatment 11 b Placebo 9 6 Self Shock X2= . 10 60, df* 2, p >.10 5 Content of Hallucinations Group Voices Insult Voices Threaten Voices Comment Voices Swear and Order Patient Uncertain of Content No Treatment 2 2 b 5 2 Placebo 3 2 2 5 3 Self Shock 5 1 b b 1 X2= 2.91, df= 8, p^.10 136 ANALYSES OF VARIANCE OF DIFFERENCES IN CHANGE BETWEEN GROUPS (SUMMARY TABLES) Hallucination Scale (BPRS) Source Sum of Squares df Mean Square F Between Groups .20 2 .10 n.s. Within Groups 77.73 42 1.85 TO tal 77.91 44 Total Psychiatric Pathology Scale (BPRS) Source Sum of Squares df Mean Square F Between Groups 2.54 2 1.27 2.30 Within Groups 23.27 42 .55 Total 25.81 44 APPENDIX D RAW DATA 137 138 NUMBER OF TIMES PATIENTS PRESSED FOR "SHOCK" IN THE TWO BOX GROUPS AND WHETHER THEY FELT BOX HELPED Placebo Group If Presses Box of Help p 1 96 No P 2 37 No P 3 k9 Yes P 4 285 Yes P 5 1987 0 P 6 55 No P 7 58 ? P 8 120 No P 9 62 Maybe PIO 93 Yes Pll 277 Yes P12 20 No P13 42 No P14 141 DK P15 422 No Shock Group $ Presses Box of Help S 1 322 Yes S 2 287 No S 3 124 DK No S 4 407 Yes s 5 79 Yes S 6 449 Yes S 7 24 2 Yes S 8 166 No S 9 561 Yes S10 21 Yes Sll 2362 Yes S12 19 No S13 122 Yes S14 29 No S15 1126 Yes 139 TOTAL PSYCHIATRIC PATHOLOGY RATINGS ON BPRS (INITIAL AND CHANGE) Change Initial Change Initial Change Initial from pre Rating from pre Rating from pre Rating to post to post to post N 1 1.5 3.5 P l .5 4.5 S 1 0 4.5 N 2 .5 3.5 P 2 1 3 S 2 • 5 5 N 3 0 4 P 3 • 5 2 S 3 1 3 N 4 1 4.5 P 4 1 3.5 S 4 1 2 N 5 -1.5 3 P 5 .5 3.5 S 5 0 3 N 6 -1 1 P 6 0 5.5 S 6 1 5-5 N 7 .5 5 P 7 • 5 4 S 7 0 3.5. N 8 0 3.5 P 8 0 4 s 8 0 3.5 N 9 0 5 P 9 .5 4-5 S 9 1.5 4 NIO 0 3 PIO 1.5 3 S10 -l 3 Nil -1 4.5 Pll 0 3 Sll -l 4 N12 0 4 P12 l 4 S12 0 5 N13 0 1.5 P13 0 4 S13 0 4 N14 -1.5 3 P14 1 4 si4 .5 2 N15 3 5.5 P15 0 6 S15 0 3 WARD COMMENTS ON CHANGES (THREE GROUPS) N 1 Ward Com ments re garding Change in Halluci- nating (Positive Change Present (+) or not (0)) 0 Ward Com ments re garding Other Change (Type Change) Looking more alert P 1 Ward Com ments re garding Change in Halluci- nating (Positive Change Present (+) or not (0)) Ward Com ments re garding Other Change (Type Change) Still nervous but rum inates less S 1 Ward Com ments re garding Change in Halluci- nating (Positive Change Present ( + ) or not (0)) N 2 0 Little change. Still talks to self P 2 0 A little less pre occupied. More talkative S 2 0 N 3 0 Requests to talk with staff members P 3 Much better Looks normal S 3 0 V/ard Com ments re garding Other Change (Type Change) More mo tivated. Talks more No change. Still very disturbed Looks better. Has plans OhI WARD COMMENTS ON CHANGES (THREE GROUPS) (Continued) N 4 Ward Com ments re garding Change in Halluci- nating + Doesn1t halluci nate Ward Com ments re garding Other Very- friendly, Coopera tive P 4 Ward Com ments re garding Change in Halluci- nating Ward Com ments re garding Other Less with drawn S 4 Ward Com ments re garding Change in Halluci- nating Ward Com ments re garding Other More social. Speaks up much more N 5 N 6 + Doesn1t halluci nate Looks very normal Seems to have remitted P 5 P 6 0 More talk ative No change S 5 S 6 Seems less confused. Speech coherent Very disturbed N 7 0 No change, Still pani cky P 7 0 No big changes S 7 0 More coop erative . More verbal N 8 Looking better P 8 0 About the same S 8 Still with drawn and depressed H - f - h- 1 WARD COMMENTS ON CHANGES (THREE GROUPS) (Continued) N 9 NIO Ward Com ments re garding Change in Halluci- nating 0 Nil 0 Ward Com ments re garding Other No change P 9 Talks to everyone. Still rambles a lot No change P10 Pll Ward Com ments re garding Change in Halluci- nating 0 Ward Com ments re garding Other Dresses better. More co operative Less de pressed. Could make it Seems preoccu pied. Very withdrawn S 9 S10 Sll Ward Com ments re garding Change in Halluci- nating 0 N12 0 No change. Still shy P12 0 Very confused yet S12 0 Ward Com ments re garding Other Eager to go out on weekends now Still dis cusses his "vision" Still ag gressive to ward female personnel in crude way Shows his feelings more openly h-’ fu WARD COMMENTS ON CHANGES (THREE GROUPS) (Continued) N13 Nlif N15 Ward Com ments re garding Change in Halluci- nating 0 0 Ward Com ments re garding Other Change No change, Still angry Seems angry No Change. With drawn P13 PlZf P15 Ward Com ments re garding Change in Halluci- nating 0 0 Ward Com ments re garding Other Change Calmed down. Much better Somewhat more co operative No Change S13 Slif S15 Ward Com ments re garding Change in Halluci- nating 0 V/ard Com ments re garding Other Change A nice guy. Seems much im proved Talks more freely Coopera tive t —1 - p - ui SUICIDAL TENDENCIES AND SELF CONCEPT Suicidal or not Self Concept Has Pre- Any Tried occu- Basic Change P, ie. d ____________ N 1 No No Guilt More + Pep N 2 No Yes Self Self 0 Anger Anger N 3 No Yes Like Dis- more like than more dis like Suicidal or not Self Concept Has Pre- Any Tried occu- Basic Change pied ____________ P 1 Yes Yes Quit Bet- + Cry- ter ing P 2 Yes Yes Feel Des- - Good cribes Fail ures P 3 Tried Yes Pret- Very ty Good + Good Suicidal or not Self Concept Has Pre- Any Tried occu- Basic Change pied ____________ S 1 Tried Pre- I'm Good + occu- O.K. pied S 2 No No I'm al right Like 0 S 3 Ges- V/as Feel Fail-0 ture pre- a ure occu- Fail- pied ure N k "No Comment" No Every+ dis- thing likes is fine P k No V/as one Pret- Good 0 ty year Good ago S Z+ Tried Was De- Bet- + pre- press-ter occu- ed. pied O.K. 'What to live for t —1 • p - - p - I SUICIDAL TENDENCIES AND SELF CONCEPT (Continued) Suicidal or not Has Pre- Tried occu- pied Self Concept Any Basic Change N 5 No No N 6 No Yes N 7 No No N 8 Ho No N 9 Doesn't answer Gets Gets 0 angry angry Likes Ready+ Self to work I'm I'm 0 fine good Likes LikesO Self Self very very much much Does- Al- ? n't right com ment Suicidal or not lias Self Concept Pre- Any Tried occu- Basic Change pied ____________ P 5 Tried No Suicidal or not Has Pre- Tried occu- pied Self Concept Eny Basic Change No No Don't Likes + S 3 think Self have good fu ture P 6 No At Likes Likes 0 S 6 No Yes times Self Self P 7 Tried No Self Un- 0 S 7 Yes V/as Anger happy P 8 No No Com- Com- 0 S 8 No Yes pe- pe- tent tent Likes Feel ? Self Good P 9 No Yes+ 0 S 9 Start- Yes ed to Guilty Guilty 0 Feel I'm 0 111 Sick Lousy Bet- + ter Like Like 0 -p - V J l SUICIDAL TENDENCIES AND SELF CONCEPT (Continued) Suicidal or not Has Pre- Tried occu- pied Self Concept Any Basic Change Suicidal or not Self Concept Has Pre- Any Tried occu- Basic Change Ei. e d ____________ Self Self O.K. Suicidal or not Self Concept Has Pre- Any Tried occu- Basic Change _____ pied ____________ N10 Yes Yes Likes Likes 0 P10 Tried V/as Guess Great + S10 No No Feel No D 0 good about self Nil No Yes Likes O.K. 0 Pll Yes Yes Likes Likes 0 Sll No Self No Dis- Al- + likes right much N12 No Yes O.K. O.K. 0 P12 No No Would No D 0 S12 De- Was Likes LikesO like to work nies N13 Yes Yes Feel Feel 0 P13 No fine fine No A lot + S13 No bet ter No Like Dis- 0 I'm gust- trash ed - p - SUICIDAL TENDENCIES AND SELF CONCEPT (Continued) Suicidal or not Has !Pre- Tried occu- P, ied N14 No Yes N15 No No Self Concept Any Basic Change Suicidal or not Has Dis- Dis- 0 P14 Yes likes likes being being de- de pend- pend ent ent - - P15 Pre- occu- pied Yes Self Concept Basic Any Change I sin I 0 have sin ful thou ghts Un Un- ? able able to to eli c- elic it it Suicidal or not Has Pre- Self Concept Any Tried occu- Basic Change _____________ S14 No Was Al- Good + right S15 Yes Was Get ting heal thy Good 0 SYMPTOM CHECKLIST (FILLED OUT BY EXPERIMENTER Initial Final Difference Hallu Other Hallu Other Hallu Other cina Symp cina Symp cina Symp tions toms tions toms tions toms N 1 Yes 17 Yes 12 0 + 5 N 2 Yes 18 Yes 6 0 +12 N 3 Yes 21 Yes 13 0 + 8 N k Yes 19 No 9 + +10 N 5 Yes 20 No 9 + +11 N 6 Yes 23 No 5 + +18 N 7 Yes 31 Yes 29 0 + 2 N 8 Yes 10 No 0 + + 10 N 9 Yes 12 Yes 10 0 + 2 NIO Yes 17 No 10 + + 7 Nil Yes 11* Yes Ik 0 0 N12 Yes 13 Yes 16 0 - 2 N13 Yes 32 Yes 20 0 + 12 N14 Yes Yes 6 0 - 2 N15 Yes 12 Yes 4 0 + 8 149 SYMPTOM CHECKLIST (FILLED OUT BY EXPERIMENTER) (Continued) Initial Final Difference Hallu cina tions Other Symp toms Hallu cina tions Other Symp toms Hallu cina tions Other Symp toms p 1 Yes 23 Yes 10 0 +13 P 2 Yes 19 Yes 12 0 + 7 P 3 Yes 10 No 3 + + 7 P 4 Yes 14 Yes 6 0 + 8 P 5 Yes 12' Yes 6 0 + 6 P 6 Yes 17 Yes 23 0 « 6 P 7 Yes 15 Yes 11 0 + 4 P 8 Yes 17 Yes 17 0 0 P 9 Yes 20 Yes 17 0 + 3 PIO Yes 7 No 0 + + 7 Pll Yes 11 Yes 12 0 - 1 P12 Yes 10 No 4 + + 8 P13 Yes 23 No 6 + +17 P14 Yes 11 Yes 7 0 + 4 P15 Yes 18 Yes 18 0 0 150 SYMPTOM CHECKLIST (FILLED OUT BY EXPERIMENTER) (Continued) Initial Final Difference Hallu cina tions Other Symp toms Hallu cina tions Other Symp toms Hallu cina tions Other Symp toms S 1 Yes 22 Yes 13 0 + 9 S 2 Yes 28 Yes 24 0 + Z f S 3 Yes 14 No 5 + + 9 s 4 Yes 11 Yes 2 0 + 9 S 5 Yes 17 Yes 4 0 +13 S 6 Yes 29 No 15 + +14 S 7 Yes 22 Yes 11 0 +11 S 8 Yes 20 Yes 13 0 + 7 S 9 Yes 8 Yes 4 0 + 4 S10 Yes 21 No 20 + + 1 Sll Yes 12 No 6 + + 6 S12 Yes 8 Yes 8 0 0 S13 Yes 7 Yes 5 0 + 2 S14 Yes 3 Yes 3 0 0 S15 Yes 21 Yes 18 0 3 PREMORBID STATE - NO TREATMENT GROUP N 1 N 2 N 3 N 4 N 5 N 6 N 7 N 8 Work Mostly unem ployed Little work Little work Worked Worked Worked Worked Spotty employ ment but worked Childhood poor - generally no ad aptation Few friends - worked or got along poorly Alone most of life Alone much - describes bad Childhood O.K. relationships O.K. Poor adult adjustments Poor adulthood Always trouble Childhood O.K. Relationships O.K. Good adult adjustments Broke after college Chronic mar ginal Made adjustment marginal Adjusted Adjusted Marginal adjustment Accident or Serious Illnesses Hit in head Hit head as child No Deaf (partly) from mortar Denies Run down by car (child) None mentioned Auto accident vn N 9 N10 Nil N12 N13 N14 N15 PREMORBID STATE - NO TREATMENT GROUP (Continued) Work Never worked Worked off and on Almost no work Childhood poor - generally no ad aptation Childhood O.K. relationships O.K. Poor adult adjustments O.K. while de pendent Always trouble Childhood O.K. Relationships O.K. Good adult adjustments Marginal ad justment Always trouble Accident or Serious Illnesses Seizures noted in history Heart trouble as child Motorcycle accident Little work Never worked Worked Worked N o t elicited Withdrawn in high school - rejected as child Adjusted Adjusted Convulsion as child. Birth damage None None noted V Jl r \ j Work P 1 Worked P 2 Worked P 3 Worked P k V/orked P 5 Very little P 6 Denies work. Indica tions of being jazz player PREMORBID STATE - PLACEBO Childhood poor - Childhood O.K. generally no ad- relationships aptation O.K. Poor adult _________________ ad.jus tments Seems a Rheumatic heart at 5 Raised by mother since 5 Always Parents died at 13. Mediocre childhood 1 w a y s v/ i t Since high school felt like outsider GROUP Childhood O.K. relationships O.K. Good adult adjustments h d r a w n Adjusted Accident or Serious Illnesses Accident in 1959. "Made nervous" Kicked in head by mule. Run over at 4. Hit head at 12 very sheltered Better adjust- Some adult ad' ment in high justment school O.K. till adult hood a w n most of life VJ1 Fell on head Concussion at age 10 Much drug use W i t h d r P 7 P 8 P 9 P10 Pll P12 PREMORBID STATE - PLACEBO GROUP (Continued) Work Worked Childhood poor - generally no ad aptation Childhood O.K. relationships O.K. Poor adult adjustments Childhood O.K. relationships O.K. Good adult adjustments____ Got along poorly with others all his life Accident or Serious Illnesses 3 auto accidents Worked at high level Broke as adult Not mentioned Never worked Always disturbed Not mentioned 'Worked Worked some Alone much Alone much Major trouble after sent here Always problems. May adjust Yes Heart. Auto accident Little work Broke as adult Not mentioned h - > Ml - p - PREMORBID STATE - PLACEBO GROUP (Continued) Work P13 Little work Childhood poor - generally no ad aptation Childhood O.K. relationships O.K. Poor adult adjustments Childhood O.K. relationships O.K. Good adult adjustments Marginal adjustment P14 Little Always work marginal adjustment P15 Doubt- Cannot elicit this ful if worked information Accident or Serious Illnesses Denies Denies VJ1 vn PREMORBID STATE - SHOCK GROUP S 1 S 2 S k S 5 S 6 S 7 S 8 Work Very little work H years work S 3 Worked Worked Worked Worked Never worked V/orked Childhood poor - generally no ad aptation Childhood O.K. relationships O.K. Poor adult adjustments Withdrawn in high school Childhood O.K. relationships O.K. Good adult adjustments Poor childhood - but seems some adjusted till first hospitalized as adult. Adjusted till married Always marginal adjustment Adjusts when not isolated Good adjustment until relative ly recently No adjustment since service Generally good adjustment. Break after crisis Accident or Serious Illnesses Drank poison Temple caved in Yes No No Ik stitches to head Shock treatment No H VJ1 ON S 9 510 511 512 513 SIZf S15 Work Little work No work Very little High level A few odd jobs Y/orked 12 years v/ork PREMORBID STATE - SHOCK GROUP Childhood poor - generally no ad aptation N o t e 1 i Always N o a d j u Childhood O.K. relationships O.K. Poor adult adjustments cited i l l t m e n t Difficulty since teens teens (Continued) Childhood O.K. relationships O.K. Good adult adjustments 111 since service Broke as adult Broke as adult Alv/ays marginal adjustment Accident or Serious Illnesses Yes Yes Denies Denies 2 auto accidents - head-on Denies None H Vjl DIAGNOSES AND HALLUCINATIONS IN OTHER MODALITIES N 7 N 8 N 9 Hallucinates in other Modalities Diagnosis Hallucinates in other Modalities Hallucinates in other Modalities Schizo P 7 Affective Yes Para.S. Chronic Undiffer entiated P 8 P 9 Chronic S 7 Para.S. S 8 Para.S. S 9 N 1 - Para.S. P 1 - Para.S. S 1 - Para.S. N 2 — Schizo Res'd Type P 2 — Para.S. S 2 — Para.S. N 3 - Para.S. P 3 - Para.S. S 3 - Para.S. N k - Para.S. P k Yes Para.S. S b - Simple S. N 5 Smell Para.S. P 5 Yes Para.S. S 5 Yes Para.S. N 6 Smell Para.S. P 6 — Para.S. S 6 A vision Psychotic Depressive with Para, features Para.S. Para.S. Para.S. H Vjl CO DIAGNOSES AND HALLUCINATIONS IN OTHER MODALITIES (Continued) Hallucinates in other Modalities NIO Nil N12 N13 Yes ‘'All" N14 N15 Diagnosis Schizo P10 Affective Chronic Pll Undiffer entiated Para.S. P12 Para.S. P13 Para.S. Pl/f Cata- P15 tonic S. Hallucinates in other Modalities Yes Diagnosis Hallucinates in other Modalities Para.S. S10 A vision Para.S. Sll Yes Chronic S12 Undiffer entiated Schizo S13 Affective Para.S. S Ik Chronic S15 Undiffer entiated - Para.S. = Paranoid Schizophrenic - S. = Schizophrenic Diagnosis Para.S. Chronic Undiffer entiated Para.S. Schizo Affective Para.S. Para.S. VJ1 MD 160 FACTORS NOT RELATED TO HALLUCINATING (MEDICATION, OTHER STUDIES, AGE, MARITAL STATUS) Medica- Other Marital Medica- Other Marital tion Studies Age Status tion Studies Age Status N 1 Mella- Driving 37 ril P 1 Thora zine zme N 2 Stela- Driving kO D P 2 Thora- None zine Stela- zine S P 3 Mella- None ril S P k Stela- None zine N 3 None Driving 35 N Thora- Driving kk zine N 5 Mella- Driving 3k ril N 6 Thora- None 30 zine D P 5 Pro- None lixin S P 6 Mella- None ril N 7 Thora- Lithium 32 M P 7 Mella- None zine ril N 8 Stela- Tokar 31 M P 8 Mella- Tokar k7 kk 21 20 30 33 36 35 zine N 9 Thora- None zine ril 51 P 9 Thora- Driving 19 zine N10 Lithium Lithium 25 M P10 Mella- None ril Nil Thora- None k7 S zine N12 Stela- None 31 S zine N13 Thora- None 3*1 S zine Nl/f Mella- None kk S ril N15 Mella- Tokar 37 S ril Pll Thora- None zine P12 Stela- None zine kk 30 58 P13 Lithi- Lithi- 50 urn um Pl/f Mella- None 3k ril P15 Mella- None 38 ril M M S M S D S M S D S D M S S 161 FACTORS NOT RELATED TO HALLUCINATING (MEDICATION, OTHER STUDIES, AGE, MARITAL STATUS) (Continued) Medication Other Studies Age Marital Status S 1 Stelazine None 21 S S 2 Thorazine and Stelazine None 48 S S 3 Mellaril and Librium Driving 27 M S 4 Mellaril Driving 40 S S 5 Stelazine Driving 57 D S 6 Mellaril None 62 M s 7 Thorazine None 32 S s 8 Mellaril Driving 48 M s 9 Prolixin None 28 S SIO Thorazine None and Stelazine yes 31 S Sll Thorazine None 29 s S12 Mellaril None 44 D S13 Thorazine None • - ■ » 34 M S14 Thorazine None 51 S S15 Mellaril None 32 M FACTORS ASSOCIATED WITH HALLUCINATIONS - NO TREATMENT GROUP Attitude toward Halluci- nation N 1 Irritat ing N 2 Make feel bad N 3 Don't like N 4 Denies Dislike of N 5 Weird - scary N 6 Often fearful N 7 Keep angry Content Comment on daily life. Swear at Conditions Affecting Stop when quiet Some Aspects to Voices No Qualita tive Changes in Voices No Chronicity based on years hos pitalize^ 6 Years Chron icity of Voices 12 Years Bring up spon taneous ly______ Yes Call names - order Stop v/hen someone talks to No No 10 Years 10 Years Yes Threaten Decrease No or swear v/hen at talk Swear at Nothing Yes affects Yes 4 Years 6 Weeks 3 Years 4 Years Yes No Conver- Only when sation nervous Swear at Most in define presence delu- of those sions v/ho dislike Call names Most when angry No Yes No 1 Month 9 Months No 4 Y ears 6 Months 6 Months 4 Y e r.r s Yes Yes Yes Talk Back to Voices Yes Yes No Yes Yes Yes Yes £ i \ > FACTORS ASSOCIATED WITH HALLUCINATIONS - NO TREATMENT GROUP (Continued) Attitude toward Halluci nation Conditions Content Affecting N 8 Frighten- Order ing N 9 Don't un- Call his No change derstand name NIO Nil N12 I v/as lonely when heard Called his name Confusing Not clear Pester me Mostly when alone Mostly when alone No D1 N13 Annoying Great All time variety No D Some Aspects to Voices More talks Yes More hears No No Yes Yes Yes Qualita tive Changes in Voices Yes No No Yes Yes Chronicity based on years hos pitalized 5 Months 2 Years "40 Years" (actually 15 years) "Years" (11 years) 3 Years Chron- Bring Talk icity up spon- Back of taneous- to Voices ly______ Voices 3 Years Yes "3 Months" 3 Years No 3 Weeks Yes "Long Time" (7 years) No "Years" Yes (35 years) 12 Years Yes Yes Yes No Yes Yes Yes H cr\ FACTORS ASSOCIATED WITH HALLUCINATIONS - NO TREATMENT GROUP (Continued) N14 Attitude toward Halluci- nation Wished didn1t have Content Swear - Order Conditions Affecting Some Aspects to Voices When sees No people not like Qualita tive Changes in Voices No Chronicity based on years hos pitalized 5 Years Chron4 icity of Voices 6 Months Bring up spon taneous ly_____ No N15 Confus ing Talk to None No 3 Months 3 Months No 1 nDn means change Talk Back to Voices No Yes < T s FACTORS ASSOCIATED WITH HALLUCINATIONS - PLACEBO GROUP P 1 Attitude tov/ard Halluci- nation Rather do without P 2 Orders - Calls name P 3 Accepts as part of P k Would like to get rid P 5 Dislikes P 6 Don't like Conditions Content Affecting Cussed Go away out by - when reads Threat ened Nuisance Most when has to make a decision Some Aspects to Voices No Order - insult More when excited Just More at meaning- night less phrases Order - insult No con trol over Reject "More when Nonsense sick Yes Yes Yes Yes No Qualita- Chronicity tive based on Changes years hos- in Voices pitalized Yes Yes No No 6 Years 3 Years 3 Months Chron- Bring Talk icity up spon- Back of taneous- to Voices ly______ Voices k Years Yes 6 Years Yes 3 Months No Yes Yes No 3 Weeks 2 Weeks No Yes 4 Years 8 Years Yes Yes 6 Years 23 Years Yes Yes H C T l VJI FACTORS ASSOCIATED V/ITH HALLUCINATIONS - PLACEBO GROUP (Continued) Attitude toward Halluci nation Content Conditions Affecting Some Aspects to Voices Qualita tive Changes in Voices Chronicity based on years hos pitalized Chron icity of Voices Bring up spon taneous ly Talk Back to Voic< P 7 Would like to get rid Call names - Reject Mostly at work No Yes 10 Years 1* Years No Yes P 8 Dis likes Order - Insult No D Yes No 1 Year A long time No Yes P 9 Dis likes Order - Insult No control No No 1 Year ’'Years1 1 No Yes P10 Dis likes Insult More when alone No - 3 Years "Years" Yes Yes Pll Dis likes Voices of Enemies More when work No No 8 Years 10 Years Yes No P12 Dis likes Not re member In morning Yes - 12 Years 9 Yes No M ON ON P13 PlZf P15 FACTORS ASSOCIATED WITH HALLUCINATIONS - PLACEBO GROUP (Continued) Attitude toward Halluci- nation They're my friends Content Promise things. God talks Conditions Affecting Some Aspects to Voices No change Yes Qualita tive Changes in Voices Chronicity based on years hos- pitalized 2 Years Chron icity of Voices 3 Months Bring Talk up spon- Back taneous- to iL Yes Voices v i es O.K. Talk about sex Less when working Yes No 12 Years k Years Yes Yes Would like to get rid Non sense. Call names No change Y es 3 Years "26 Years" (Actually 2 years) No Yes ON -o FACTORS ASSOCIATED WITH HALLUCINATIONS - SHOCK GROUP Attitude toward Halluci- nation S 1 Don't like many of them Content Order - Non sense - Insult Conditions Affecting More at night Some Aspects to Voices Yes Qualita tive Changes in Voices Yes Chronicity Chron- Bring based on icity up spon- years hos- of taneous- pitalized Voices ly______ 8 Years 20 Years Yes Talk Back to Voices Yes S 2 Like to get rid of S 3 Know not supposed to hear so bother Any thing to get angry Deroga tory Most in morning More when nervous. Less when occupied No No Yes 3 Years 3 Months 2 Years Yes 6 Months Yes Yes No S 4 Very annoying S 5 Dislike - Confusing Says not se vere be cause not clear Little change crazy mu- More in sic. Re- morning peat thoughts No No Yes 6 Years Several years. (3 Years) 3 Months 1 Year Yes Yes Yes Yes H < T > CO S 6 S 7 S 8 S 9 510 511 FACTORS ASSOCIATED WITH HALLUCINATIONS - SHOCK GROUP (Continued) Attitude toward Halluci- nation Scares me Frighten me Bother Depress me Dislikes Dislikes Conditions Content Affecting Comment on his fate Order. Call names Call names Calls others Call names More in evening When T.V. on most Insult No D More when around Mexicans "When it gets ac tive" 'When angry Some Aspects to Voices No Yes No Yes Qualita tive Changes in Voices Chronicity Chron- Bring "Very seldom" Yes No No Yes based on years hos pitalized 15 Years 2 Years 2 Months 12 Years 6 Years icity of Voices 5 Months 1 Year up spon taneous ly______ No 5 Years 6 Months A few Years (2 Years) 9 Years k Years No No Yes Yes No Talk Back to Voices No Yes No Yes Yes Yes VO 512 513 514 515 FACTORS ASSOCIATED WITH HALLUCINATIONS - SHOCK GROUP (Continued) Attitude toward Halluci- nation Dislikes wants to kill them Gets mad at them Wants to get rid Make me worry Conditions Content Affecting Call him No control names, get him angry, plot against him Some Aspects to Voices No Order - insult Build up then drop Order Periodical- Yes ly more No Y es More under Yes tension Qualita tive Changes in Voices No Yes No Yes Chronicity based on years hos- pitalized 1 Year Chron- icity of Voices Bring Talk up spon- Back taneous- to 11 Years 1 Year 3 Years iL 1 Year Yes 10 Years Yes 1 Year Yes 6 Years Yes Voices No Yes Yes Yes H1 -o o RAW DATA FOR FREQUENCY OF HALLUCINATIONS FROM PDS BY GROUP Sub- Ini- Differ- Sub- Ini- Differ- Sub- Ini- ject tial Final ence .iect tial Final ence .iect tial Final N 1 Most all the time Not quite as much 20 U P 1 15 10 Mod erate S 1 Con stant ly - sev eral hun dred A lot less Maybe 20 N 2 Al most all the time Not much Large P 2 12 Fad ing Mod erate S 2 Con tinu ally Con tinu ally N 3 20 12 8 P 3 20 0 20 S 3 2 0 N k All the time Not hear 0 Great P k 3 0 3 S k Al most all the time Less. Not less N 5 b 0 k P 5 10 Same 10 0 S 5 20 10 N 6 20 Not hear 0 20 P 6 All day Con tinu ally 0 S 6 Most of time 0 Differ- ence Very- large 0 2 Moder ate 10 Great 171 RAW DATA FOR FREQUENCY OF HALLUCINATIONS FROM PDS BY GROUP (Continued) Sub- Ini Differ Sub Ini Differ Sub Ini Differ' .iect tial Final ence ject tial Final ence ject tial Final ence N 7 Al- All 0 P 7 2 2-3 0 S 7 1000 500 500 most day- all the time N 8 All the time Not much Large P 8 20 20 0 S 8 100 50 50 N 9 2 2 0 P 9 100 70 30 s 9 2 1 1 N10 k 0 k P10 10 0 10 S10 1 0 1 Nil 6 6 0 Pll 50 50 0 Sll 10 0 10 N12 15 15 0 P12 1 0 1 S12 Con tinu ally almost Con tinu ally almost 0 N13 Con tinu ously Con tinu ously 0 P13 k 0 k S13 5 .5 k H -o i\ j RAW DATA FOR FREQUENCY OF HALLUCINATIONS FROM PDS BY GROUP (Continued) Sub- Ini- Differ- Sub- Ini- Differ- Sub- Ini- Differ- .lect tial Final ence .iect tial Final ence .iect tial Final ence N14 1 0 10 P14 5 Less 2 Sib 4 2 2 N15 10 0 10 P15 To an As 0 S15 10 5 Less Maybe 31 To an As amaz much ing as ex ever tent l-1 -o ui No Treatment Group RAW DATA FOR BPRS RATINGS ON HALLUCINATION BY GROUP Shock Group Placebo Group Sub- Ini- Differ- Sub- Ini- Differ- Sub- Ini- Differ- .iect tial Final ence .iect tial Final ence .iect tial Final ence N 1 4 2 2 P 1 4.5 4.5 0 S 1 5 3 2 I ' l 2 2 0 2 P 2 .5 0 .5 S 2 0 3 -3 N 3 5 4.5 .5 P 3 1.5 0 1.5 S 3 1.5 0 1.5 N 4 1.5 0 1.5 P 4 1.5 0 1.5 S 4 3 1 2 N 5 0 0 0 P 5 4.5 1.5 3 S 5 2.5 1.5 1 N 6 5-5 0 5.5 P 6 4.5 4.5 0 S 6 3.5 2.5 1 N 7 4 4 0 P 7 3 2.5 .5 S 7 3 1.5 1.5 N 8 2 1.5 .5 P 8 4 3.5 .5 S 8 4.5 3 1.5 N 9 0 0 0 P 9 3.5 2 1.5 S 9 2.5 .5 2 NIO 1 0 1 PIO 2 0 2 S10 4 3 1 174 RAW DATA FOR BPRS RATINGS ON HALLUCINATION BY GROUP No Treatment Group Placebo Group Shock Group Sub ject Ini tial Final Differ ence Sub ject Ini tial Final Differ ence Sub ject Ini tial Final Differ' ence Nil .5 .5 0 Pll 3 3 0 Sll 3 0 3 N12 3.5 2.5 1 P12 1 0 1 S12 5 5 0 N13 2 2 0 P13 3 0 3 S13 5 2 3 N14 1 0 1 P14 4 3 1 S14 2 1 1 N15 3.5 0 3.5 P15 4 4 0 S15 4 2.5 1.5 176 SYMPTOMATIC CHANGE FOR NO TREATMENT GROUP (BPRS) with t values f - l m w 0) •rH to u « r i f l a o •H o rH H -rH rH o i —1 05 C t f -P 0 rt 5 0 o >5 £ c t f •P N •H •p O £ h Pr-H -P o •H Xl 0 (H -P C t f •H +> A o n5 rH S O -P f l to •H o S *H o ^ CO <U W ~5 O O C5 N 1 .5 .5 -1 -2 1 .5 N 2 0 l 2 1 3 2 N 3 .5 3 0 1 1 1 N 4 .5 1.5 .5 • 5 0 1.5 N 5 0 -.5 .5 0 -.5 0 N 6 -2.5 l -3 .5 -.5 1 N 7 0 .5 .5 -1 -.5 0 N 8 -.5 • 5 -.5 0 -.5 0 N 9 1.5 1 • 5 2 1.5 2.5 N10 .5 -2.5 1 2 .5 -2 Nil -3 -2.5 3 -5 0 -2.5 N12 0 0 1 -1 1 1 N13 2 5 2 5 2 3 N14 l 1 0 0 1 1 N15 0 -3 1 -3 -1 .5 Total 1 for pa tients 6.5 5.5 0 8 9.5 t value n.s. for pre to post change n.s. n.s. n.s. 1.89 1.89 177 SYMPTOMATIC CHANGE FOR NO TREATMENT GROUP (BPRS) with t values (Continued) Patient Mannerisms and Posturing Grandiosity Depressive Mood Hostility Suspi ciousness i Hallu cinatory Behavior N 1 -1.5 -1 2 .5 -.5 2 N 2 1.5 2 0 .5 0 -3 N 3 1.5 1 -1 0 1.5 1.5 N 4 0 0 1.5 1 2 2 N 5 .5 0 0 0 -.5 1 N 6 -1 -1.5 1 -.5 2 1 N 7 1 -2 .5 -.5 3.5 1.5 N 8 .5 0 0 -.5 0 1.5 N 9 .5 0 -.5 1.5 3 2 N10 3.5 -1 0 0 -1 0 Nil 0 0 0 -.5 .5 3 N12 l 0 1 1 0 0 N13 2 0 0 0 3 3 Nlif -1 -.5 1 0 .5 1 N15 -1 -.5 -1 0 -1 1.5 Total 5.5 -3.3 if.5 a.5 12 18 for pa- tients________________________________________ t value 1.09 1.10 1.36 n.s. 2.0 2.97 for pre to post c h a n g e ______________________ c+ H>|ct- c J 4 3 i-b t-3 O O H 'J S O O 4 < CD 1 4S c+ 43 SD PS flJ O 43 H c+ H CD 4 C CO c+ CD CD PS ^ 3 • • CO VJI • ro CO • • H VJI VJI H -o • • OO VJI VJI H ro ro • VJI VO i P< H • • CO VJI • PS • • CO VJI • PS o CSV CO • VjJ i s ! i s ! i s ! 5! PS id i s ; 2! id id id id H H H H H H VJI -p- VN ro H O MD OO -o cr\ VJI -P- I ooruooHO (-> t-> ro o o m • • • VJI VJI VJI M O O O M O O O M O M O O r o M • • • VJI VJI VJI ro fO O H M VJI o • • VJI VJI I ro H • • • • VJI VJI VJI VJI I M H V/J O V» H ro M H O 1 M I • • • • • • VJI VJI VJI VJI VJI VJI I I I I i orooroHOonroo o ro • • • • • VJI VJI VJI VJI VJI I I i ooo-p-roHOi rooH ro h VJI VJI VJI VJI VJJ I I VJI H O fY) O -P" H H vn VJI i H 1 • • • VJI VJI VJI i H I • • • VJI VJI VJI VJ1 VJI v j i v ji I H Patient Motor Retardation Uncooperative ness Unusual Thought Content Blunted Affect Inappropriate Affect Excitement Thinking Dis turbance Interpersonal Disturbance 03 k! K ►d i-3 O s > h3 H O P- O c i - id P S* > . id lc+ O f c d < J D ^ H O P i d C D C O 3 o O H 3 o i d PS t d c+ > H- £3 3 S s= t d C D i d O i d o cd >d t r i *d id 03 H -o CO O <+ H j|c+ f f o o P 4 < P > P p j) oy h r o r a 4 P c+ r o r o H • O' ci->p h, t - 9 F- p O O ro I 4 c+ P c+ C O P I-1 VJI i —1 ) —* i —■ i —* i —■ i —> VJl-F-UWHOvO®>JroUl^-VMPH o o h o ro i o o i o o m • • • • • • VJI VJI VJI VJI VJI VJI p 1 o o 1 F* o i M o ro H M M • • • • • • • • • C Q • VJI VJI VJI vji vn vn vn vn P 1 • ro ro H o ro o O O i o O o C O • • • • • • • VJI VJI vn vn VJI vn p i 1 i I • M i O ro o o o M o H ro H C O • • • • • • • VJI VJI vn vn vn vn + 1 + + + + 1 + V M + H + ro + + + + ro H ro + Ov OO -p- -p- OV V ji ro ro Vn -p- o M vn H -o • • • • • • • • • • • • • • • VJI o o o V JI vn vn vn vn o VJI vn o O o H M M M o v 00 VJI Ov -p " 00 ru ro vn ro ru O ■ P - O O -p- H M ov M V M r o o o o o o o -p -v ji i- 'O M r o Patient Withdrawal Retardation Tension Excitement Depressive Disturbance Inappropriate Affect Algebraic Sum Number of Positive (Significant) Changes Number of Negative Changes H -o vO SYMPTOMATIC CHANGE FOR NO TREATMENT GROUP (BPRS) with t values (Continued) O <+ Mj1 c+ i f o o S3 4 < S W S3 K OW H C D C D 4 C c+ C D C D v£> -O V/ 3 VJI c+ ' r J h> i - 3 H* S 3 o O CD I 4 rt P r t - c d S 3 M VJI VJI ► d *TJ ► d *d •d *d •d *d •d *d >d *d *d >d •d M VJI (-> -p- H VM H ro H H I - 1 O vO CO ~ o ov VJI -p- VM ro H I I I V J I O H O O O O I —'I—> I —i I • • • • • VJI VJI VJI VJI VJI h-1 o v O r o o r o o H i o 1 r— 1 I - 1 i H H o • • • • • OV VJI VJI VJI VJI o v r 1 1 1 1 H vO VM VM i H H o i h-> o M 1 o • • • • • • • • • • • OO VJI VJI VJI VJI VJI VJI VJI VJI VJI VJI o H* 1 r o H M -p- H O H H o o Id r o H o • • • • • • • o VJI VJI VJI VJI VJI VJI VJI 1 1 VM o r o o I - 1 O H 1 M 1 o (-> H t o 1 i • • • • • • VJI VJI VJI VJI VJI VJI i 1 1 3 VJI o r o VM M M o 1 H r—1 o H • • • • • • • • • C D VJI VJI VJI VJI VJI VJI VJI VJI 1 1 VJI H -p - o o o o H r o o M t— 1 1 • • • • • • • C D • VJI VJI VJI VJI VJI VJI r o VO M o r— t - o M o o H • o o O o r o O • • VJI vO VJI OO 1 M O VM o O r o 1 — 1 O r o o 1 r o O • • • • • VJI VJI VJI VJI Patient Somatic Concern Anxiety Emotional withdrawal Conceptual Disorgan ization Guilt Feelings Tension Mannerisms and Posturing Grandiosity Depressive Mood I H OO O SYMPTOMATIC CHANGE FOR PLACEBO GROUP (BPRS) with t values <+ t+ 4 i M, h9 41 4J ► 0 4J 4* 4 ) 43 41 43 4 ) 4J 41 41 4 ) 4 ) O O H- 4 o o M h-1 H M H M 4 < C D 1 4 ct- v n -P- V M ro M O vO OO -V] ov VJI -P- V m ro r—1 4J S O 4 4 O 4 ! H <+ M C O 4 4 C O I 1 1 c+ C D C D ro o o H o O O H I-1 i h -> M H ' i- 1 o • • • • • • VJI vn VJI v n VJI v n 1 1 H Oo H V M O o O H H H ro l H H H o • • • • • • • OO o VJI v n Vji Vn vn vn M V M cr\ o I - 1 V m H o ro I-1 O Vm M I-1 c • • • • • • • H vO vn vn VJI vn v n vn 1 l l l i 4 vji o h-> VM ro o l o O ro ro ro O H O o • • • • • tn • VJI VJI v n VJI ro 'O Vm o o O o o M o r— 1 O o o • • o • • • • o VJI Vn VJI vn Vn v n vO M ro ro M I-1 O o 1 ro o i r— 1 ro o • • • • • • • • • • • vm VJI v n v n Vn VJI v n v n v n vn vn H 1 1 I l I 4 H H H ro H o H 1 ro i l -1 O m 1 • • • • • • • • • C O v n v n Vn V J1 v n v n v n VJI 1 I I M ov ro 1 — 1 o 1 o ro H o VM ro M o M o • • • • • m v n vn vn vn V - A J 1 i 4 VM ro O ro o M O 1 i H O o M o • • • • • • • C O • v n v n v n v n VJI VJI M ro o H -p- o H M O 1 o H H o • • • • • • • VM v n VJI v n v n VJI vn VJ1 Patient Hostility Suspiciousness Hallucinatory Behavior Motor Re tardation Uncooperative ness Unusual Thought Content Blunted Affect. Inappropriate Affects Excitement Thinking Disturbance CD k3 K 4 H3 O 5 > H3 S: H H- O c+ 4* O \ct > <3 4 H r —1 4 4J C O O co a 4 ) O f* o > 4 O c+ W H- td 4 o 4 CD Q P* W — O <4 4J W w CD H OO M a ct - H)|{+ ts'O o S a d < O d sa k oy h (D 0 1 4 C ci - r o ro ro o -c t s C O ro o M O ro -p- M c+ Hj 1 - 3 M O O C D 4 cl- tf sa ct-d M cn sa I co V j i l ro vO VJI V ji c o • O d d d d d d ' O ' d ' O ' O d ' d d d H H H m i— 1 M y i - f ' j i M H O v o a i - v i o M j i - t - V M W H V M M O M • • VJI VJI VJI I M O O ro O H M VJI VJI I I I V M H V M M O m o m o m o o o o VJI VJI + vm o ro VJI VJI VJI i M O O VJI + + + + M ro M H O OO o VM VM 1 O M 1 M O ro O • • • • VJI VJI VJI VJI ro O O M 1 O M o 0 • • • VJI VJI VJI VJI M O VM M « • • • • • • VJI VJI VJI VJI VJI VJI VJI + + 1 + + + M + + ro 1 M M M M -<] VJI VJI M VM O VM -o VM + • • • • • • • • • • VJI o VJI VJI o VJI o o VJI VO M M M M VM VO C SV O -<1 V m O VJI - o o _ M -P'VM'vJMOMrorviM-P'MO-P'OM Patient Interpersonal Disturbance Withdrawal Retardation Tension Excitement Depressive Disturbance Inappropriate Affect Algebraic Sum Number of (significant) possible changes Number of Negative Changes CO K 3 ► o i-3 O 3 > i-3 5: M M O ci ts' O lcl-> < a sa td M C d ro O C O to ' *o o to o > ts o <+H M C O ts o c ro o m to ^ o cd ►o C O ►o to Co M O o ro C+ Hj|c+ O O 4 < r o O « M C O hi C c+ r o r o -o CTN -o ro ro Vn H 00 VM VJI H o VM vn ^3 vO H -P- c+ H > 1 - 3 H- O O ro *-j c+ ro ro c+y l-J co r o I I C i C f l t f l t n t n t n t o C o t n t f l t a C n t n t o t o I —1 I —1 I —1 l —’ I —1 I —1 V H P U l W H O c 0 C 0 \ 1 0 \ \ J l - r U I \ ) H -p- O I-1 O O O H O O r\> o H ro -P - O o • • vn vn 1 1 1 i i M O H o O O i o H i H H H ro ro • • • • • • vn vn vn vn vn vn I i 1 1 OV VM o O 1 i H O M M I O o i • • • • • • • • vn vn vn vn vn vn VJI vn I i l 1 I O v (— 1 -P- o o ro H H ro ro vn H i • • • • • • • • • • vn vn vn VJI VJI vn VJI vn vn vn 1 I VM O O o o O H o M o o O H * ro • • • • • vn vn Vji vn vn i 1 vn H VM o o O i-1 H I-1 -P- o I • • • • • • VJI vn vn vn vn vn 1 I H H o H I-1 I i O H I o ro o o i • • • • vn vn vn vn I i •p- O o O o o H O O o vm ro o • • • • • • VJI vn vn vn vn vn 1 1 i i O H O H o VM M ro O O I Vm ro • • • • » • vn vn vn vn vn vn Patient Somatic Concern Anxiety Emotional Withdrawal Conceptual Disorgan ization Guilt Peelings Tension Mannerisms and Posturing Grandiosity Depressive Mood oo VM SYMPTOMATIC CHANGE FOR SHOCK GROUP (BPRS) with t values O c+ Wjlct- 3 “ o o JD t-i 3 >3 J q O >3 O t i l 4 c t * ( D < S 3 t — ' c CD V M -p" V m V m • C T \ 1 —1 M C T \ V M o OO Vm M V M ro ru -p- ct- H i t-3 M O O f f l M rf 3 S 3 rt-W M Cn S 3 I M O V M # ■ VJI M ~o vn Vm vn oo C o C O C O C O C O co C O C O C O C O C o C o co C O C o M Vn M -p- H V M M ru M M M O v £ > 00 ^3 C T \ vn -p- V M ru M I o o o o ru m o vn O I • • • vn vn vn i ru h o vn vn vn vn V M (-■ o o o vn M O vn vn ru i — o • • • vn vn 1 O .e- I M • • vn vn O M ru • • vn vn vn ■ I I -P " V M ru O I O O M O O I M O vn I vn vn vn i o o o o r u r u o i o m i u m m o • • • • vn vn vn vn i I i 1 1 C T 3 ru ru o o ru o VM ru l o O • • » • • • • • vn vn vn vn vn vn vn V JI i i vn vn i o M o o M M O o ru i ru i • • • • • • vn vn vn vn vn V ji i l 1 i -P^ o o o o ru O ru M M V m o VM M f\> vn vn o o o o o o o vm m o ru • • • • • • vn vn vn vn vn vn Patient Hostility Suspi ciousness Hallucinatory Behavior Kotor Retardation Uncooperative ness Unusual Thought Content Blunted Affect Inappropriate Affect Excitement Co Kt 2 TJ i - 3 O 2 > ~ ~ h - 3 M M c+ O 3* , O l e t W > < 2 S 3 O H H < o 2 C D O « O C O o 3 O c+ O M W 3 3 O < 1 3 td 3. O — ' <3 >d td *3 SO C O oo -p- O C+ Mj|c+ f f o o S B 4 p s ' n » ow ro co 4 c+ r o < sa H s = r o O V M oo vn VM o v ro ~v vn ON <+ wj i - 3 H- O O r o 4 <+ 4 sa c+W t —1 co sa I vn v n -p- v n I ro -p- i V M o t o CO CO C M c n CO Co CO CO Co Co Co CO CO CO H M M H H h-> V n -p - VM r o t—1 O v o OO •VI o v v n 4 ^ VM r o M 1 l i r o M o o o Vm o o H r o H o M • • • • • v n v n v n v n v n 1 1 I I r o M 1 i h -1 H o o M ro r o o r o • • • • • • • v n v n v n v n v n V n v n 1 i 1 i V m VM o O 1 r o o o o O H O H • • • • v n v n v n v n O o I l O i o o o O VM O H • • • e • • v n v n v n v n v n v n I o r o o o H O o o o • • v n v n I I o vm o i ro ro i i o o ro vm ro v n v n i i— 1 i i r o r u h h • • • •• • •• v n v n v n v n v n v n v n v n l i r o « 1 i + r o + + l I M + VM + I + r o VM OO o r o VM o VM -p - o v n H v n -p- v n VM • • • • • • • • • • • • • • • v n o v n v n o o o v n o v n O v n o o v n 1 0 r o 3 3 H 1 3 o o v r o H OV M -P - o v v n H V m r o 1 2 H o OV VM t—1 -p - Vm • v i vO o v n o v O Patient Thinking Disturbance ^ K ss Interpersonal ^ Disturbance 2 > 3 H3 H * H Withdrawal g: ° Retardation o lc+ w > Tension s a g Excitement c r o c o o w Depressive Disturbance o a 3 o c+ o H* Inappropriate p s Affect g g PL o 4) w ►o w c o Algebraic Sum Number of Positive (Significant) Changes Number of Negative Changes oo v n R E F E R E N C E S 186 REFERENCES Adler, A. 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Creator Weingaertner, Arthur Hans (author)

Core Title The Effects Of A Self Shock Procedure On Hallucinatory Activity In Hospitalized Schizophrenics

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Advisor De Nike, L. Douglas (committee chair), Larson, William R. (committee member), Tiber, Norman (committee member)

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