University of Southern California Dissertations and Theses

The relationship of the pretreatment strength of social responses of schizophrenic patients to improvement with electric shock treatment

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The relationship of the pretreatment strength of social responses of schizophrenic patients to improvement with electric shock treatment

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Content THE RELATIONSHIP OP THE PRE-TREATMENT STRENGTH OF SOCIAL
RESPONSES OF SCHIZOPHRENIC PATIENTS TO IMPROVEMENT
WITH ELECTRIC SHOCK THERAPY
A Dissertation
Presented to
the Faculty or the Department o~ Psychology
University or Southern California
In Partial Fulfillment
or the Requirements for the Degre
Doctor or Philosophy
by
Trent Eggleston Bessent
January 1952
This dissertation, w1·itten by
.............. Trent .. Egg_le s ton .. Be s sent .............. .
under the guidance of lz.ia .. Fa u/ty Co1nmittee
on Studies, and approved by all its members, has
been presented to and a epted by the Council
on Graduate Study and Resear h in partial ful
fillment of 1·equiren1ents for the degree of
DOCTOR OF PHILOSOPHY
.
...... .... . ....... .
Dan
ommitt on tudi
\ \
TABLE OF CONTENTS
I. THE PROBLEM AND DEFINITIONS OF' TERMS USED
• •
l
A. The Problem
• • • • • • • • • • • • • •
l
B. Det1n1t1ona or Terms Used
• • •
• • • •
4
II. TEST MATERIALS AND PROCEDURE
• • • • • •
•
•
9
A. Related Projective Techniques
• • • •
•
9
B. The Social-Interaction (S-I) Test
• • •
10
III. POPULATION AND CRITERIA OF IMPROVEMENT
• • •
18
A. Controls
• • • • • • • • • • • • • •
18
B. Dependent Variable
• • • • •
0
• • • •
27
IV•
RESULTS AND EVALUATIONS
• • • • • • • • • • •
30
A. Result with the Total S-I Score
•
~
•
30
B. Results with Components or the S-I
Scor
• • • • • •
•
• • • • • • • • •
38
c. Research Problems
• • • • •
• • • • • •
44
v. THEORETICAL INTERPRETATIO SAND DISCUSSION
•
46
A. Schizophrenia
• • • • • • • • • •
• • •
46
B. Electric Shock Th rap
• • • • • • • •
56
VI. SUMMARY AND CONCLUSIONS
• • • • • • •
•
• • •
65
BIBLIOGRAPHY
• • •
• • • • •
• • • • • • • •
69
CHAPTER I
. THE PROBLEM AND DEFINITIONS OF TERMS USED
Recent trend• in psychology indicate an interest in
examining clinical methods, such as psychotherapy, trom the
trame ot reference or learning theory (6, 37, 62, 63, 65).
As yet, tew attempts have been made to explain in terms or
learning theory the changes in behavior which result trom
the physical and chemical psychiatric treatments (33).
However, an element ot learning worthy or xam1nat1on may
contribute to the improved social adjus ent which repre
sents a major criterion or the effectivene s or these
physical and chemical treatment.
A. THE ROBLEM
Statement ot the problem. Th problem cone rn th
-
use or a social interaction t t ~ ........... ini tered prior to
treatment to predict the 1mprov ~nt of chizoph enics
treated with Electric Sho k Th r py (EST). nc a
learning theory 1nterpreta ion o
to the hypothesis which t die ,
this line or reasoning 111 fol o:
An important motiv 1
T and chizoph nia 1 d
brie di cu ion or
havio
acquired need tor socia -intera ion, th ti oc1 1 an
emotional contact with oth r people (61, pp. 103- ). It
was assumed that in th schizophrenic th goal re ponses
related to this need tor social-interaction are inhibited
by avoidance responses which have raaulted trom painful
social experiences. It was turther hypoth~s1zed that EST
temporarily eliminates or reduces the inhibiting responsee
so that the patient exhibits former social responses and
that, as the effect of EST diminishes, the avoidance
responses reappear unless the social interaction responses
have met with reward while the inhibiting responses have
been extinguished in the post EST period.
2
The initial magnitude of the inhibited social inter
action responses depends on both the habit strength (26) ot
the responses, and the strength of the acquired need for
social-interaction.
the habit strength 1
Where the acquired need is weak and
low, there is less likelihood ot the
responses occurring during treatment than wher the con
verse is true. If the social inte action responses do not
occur, they cannot be re arded in h hospital environment.
Therefore, one deduction from this learning theory inter
pretation ould be that, other variables he d constant, h
patient who sho s a high socia interaction respons
trength 111 be ore likely to improv with tr atment than
a patient with lower social interaction response at ength.
A direct test o this deduction was not made in he
present research as evidence a n~ , available to indicate
the r lationship of the test scores to the more co only
accepted criteria or social respon strength and the
3
hypothetical constructs were not operationally defined.
Rather, the deduction served as a possible explanation ot
the results or the study. The specific problem investi
gated, then, was the relationship betwe?n the test scores,
which were interpreted as measuring the pre-treatment
strength or social responses in schizophrenic patients, and
improvement with EST as reported by the psychiatrists
treating t,1e patients. The test scores were obtained by
use ot a projective techniqu called the Social-Interaction
Test, which will be discussed later.
Importance or this study. The purpose and impor
tance ot this study are t~otold: (a) to relat isolated
phenomena to basic theoretical systems, and (b) to contrib
ute a imple and brief proJectiv t chnique or prognostic
value. Little need be said in support of the first purpose
of this tudy, for c1 nt1f1c progre sis easured partly
by the ab111 y ot c1ent1f1c la to account for and predict
the obs rvable happ n1ng 1n many and div r phenomena.
As to th econd purpo or the tudy, more Justifi-
cation is req 1 d n gh o the 1de election of
proj ctive tee niq es a read a1labl, and the success ot
the work hich has b n don h the Rorschac (5, 8, 20,
23, 31, 3, 50, 51, 52, 53, 58, 60) and oth r techn q es
(10, 22) in pred cting and evaluating recovery 1th the use
of shock therap1e. As 111 be di cus ed in Chapter II
the Justification lies in the following reasons tor the new
test: (a) development of a simpler task allowing use ot
social elements found in more complex psycho-social projec
tive tests (24, p. 104), and (b) simplicity or administer
ing and scoring. In order to ascertain the most effective
simple measure ot the strength or the social interaction
responses seven schizophrenic patients were tested with the
following four projective tests involving social elements:
Thematic Apperception Test (47, 68), Make a Picture Story
Test (64), Draw-a-Person (12), and the Social-Interaction
Test. The latter was selected for the present study
because it was administered easily to the schizophrenic
population, could be scored objectively and quickly 1th
high reliability, and showed the highest predictive valid
ity in the pilot cases. The seven cases used in the
exploratory study are not r presented in the final ample.
B. DEFINITIONS OF TE S USED
nd acquired need. As Cameron defined the
term, need refer~ to a "condition or nstable or di turb d
equilibrium in an rganism's behavior, pp aring typically
as increased or protracted activity and tension" (4,
p. 105). Hull stated:
••• hen a condition ar1 e for hich action on
the part of the organism is a prer qui ite to
optimum probability of surviv l ••• a stat er
ne dis said to ex1 t. Since need, either ectual
or potential, usually precedes and accompanies the
action or an organism, the need is otten said to
motivate or drive the- associated activity. (26,
P. 57.)
What Hull refers to in this detinition are primary needs
which deal with physical atisfactions. However, 1n any
extensive coverage or needs 1n the psychological liter
ature, much emphasis is placed upon secondary and ocio-
...
genie needs. Since secondary or acquired needs have not
been investigated as fully as primary needs the th .oriea
about secondary needs must be viewed as tentative and
subject to revision (44).
5
There appears to be agreement that these secondary
or acquired needs have b en learned in the social situation
(6). At birth the human organism presents ne d hich are
purely biological or primary in nature, such as n ds tor
fluids and nutrition. Thea needs are reduced or ati tied
largely by contact 1th other human organi sand, a
Cameron indicated, 'before the child is any months old,
nearly all or hi need-satisfaction se uenc s sho som
important modification hich can b relat d to his con
tinued interaction with other, father, and 1bl1ng ' (,
p. 104). These modi !cations represent the beginning
sta.ges ot the secondary or acquired nee
hunger needs are reduced hen the other
•
A the child's
present, her
presence eventually orrespond to a pleasurable stat ot
affairs, whereas the mother's absenc is as oc1ated to some
6
degree with anxiety or unrelieved primary need. In the
manner indicated by Dollard and Miller (6, p. 81), the
mother serves as a learned reinforcement and the need for
the mother's presence becomes a new drive. The organism's
further ~xperiences with its social world will detennine
the nature, type, and strength or the more specific
acquired needs. Many lists have been developed or these
socially acquired needs, and Murray has offered a theory of
personality 1n which such acq~ired needs as ambition,
recognition, dominance, aggression, and rejection are of
major importance (46).
Acquired need for social-interaction. In any exten
sive discussion or the developm nt or the acquired needs,
from psychoanalytic theory to learning t eory, the impor
tance ot the interaction of the organism with the physical
and social environment 1s stressed. F nichel, in dis
cussing "early mental d velopment" in psychoanalytic
theory, stated that "the t ct that eternal obj cte brought
about the desired state of relaxed satisfaction introduced
the complication that objects became longed for (11,
p. 35). any or the Freudian concepts partly rest upon the
developmen or this need tor ex rnal objects. For
example, the dev lopment of the superego is brought about
when th 1nd1vid 1 "introject 'the attitudes o the
parents (11). The motivat on for "introjection"
corresponds, theretore, to what previously has been desig
nated as the acquired need tor social-interaction
originating in the individual's associations or need
reduction and non-need-reduction with the presence and
absence of parental figures. The maternal rejection which
has been described by Levy as resulting in affect hunger
(35) conceivably would result in a lack or an acquired
need for social-interaction.
Symonds' discussion indicates the importance or the
social interactions or the individual with his environment
in the development or acquired needs (67, pp. 12-49).
Maslow (39) offered a theory of a hierarchy ot needs
beginning at the first level 1th the basic physiological
needs and safety, and e·tending through the oc1ally
derived n eds or love, steem, and elf-realization at the
fifth level. To allo evelopment of aslo 's acq ired
needs of esteem and self-r al1zat1on the ore basic ne d
for love must be met. In th pr s nt disc ssion th1 need
for lov 1 co d red o on pct or the acq ired
n ed for oci 1-in ac o.
For th p rpose ot th theoret cal disc ssion it
will be a .............. ~d tat t e acqu1r n ed or soc1al-
1nterac ion (this n e clo 1 esembl s at Shafter has
7
called social approval
social drive o, to
6, pp. 03- ]) erves as a
ch them ltitude of socially
acquired needs and respon d velop. The behavioral
manifestations or this acquired need may change system
atically as the individual matures and the strength ot the
need will vary from individual to individual, depending
upon the developmental experiences. If the 1nd1v1dual•s
early social interaction experiences have frequently been
accompanied by primary ne d-reduction, it is assumed that
the acquired need tor social-interactions will be strong,
but it early experiences have been such that social inter
actions have not corresponded to need reduction, the
acquired social need 111 be slight.
8
Electric Shock Th rapy. El ctric convulsive therapy
was first introduced by Cerlett1 and Bini in 1938 (54).
The technique of electric shock or electric convulsive
therapy used with th experimental subj cts a essentiglly
the commonly used ethod in hich about 300 to 500
milliamperes or alt rnating curr nt are pa ed though
electrodes placed bilaterally on the fronto-te poral
cranium (29, 66). Concomitantly 1th th pa ag o
current, sub onvuls1ve reaction o g n ral1zed convulsions
appear. As ilcox (70) has de er b the tre tent, th r
first is an initial tonic phas, follo by a cloni
phase, an atonic phase, a stuporous pha , and a pot
convuls1ve mental state.
CHAPTER II
TEST MATERIAIS AND PROCEDURE
In this chapter attention will be confined to the
projective testing technique upon which the pre-treatment
scores were based. Thia is the predictive or independent
variable in the study.
A. RELATED PROJECTIVE TECHNIQUES
Before considering ind tail the Social-Interaction
(S-I) Test, it would appear advisable to consider briefly
the context of psycho- ocial projective techniques from
which the present test has developed. As has been di -
cussed by Shn idman (64, p. 155), there ar essentially
three types or psycho-social proJective tests: (a) the
subject responds v rball to standard pictorial stirm lus
material; (b) the subject complet s a picture by moving
pictur a, figures, or parts or figures; or (c) the subject
is given specific in truction for handling miniature
objects, h1ch include people. As the present te t belongs
to this third category, con id ration 111 be given to
tests or this natu •
Ees_ntially the S-I Test is a modification of
Hamburger's Dramatic Productions Test (46, pp. 552-582),
and Buhler' orld Test (3), i h the use or stories as
round 1n Shneidman's Make a Picture Story T st, also known
10
as M.lPS (64}. In the World Test the subject is instructed
to construct a lifelike cene using 232 items including
people, animals, buildings, vehicles and related pieces.
In the Dramatic Productions Test the subject is requested
to construct a dramatic scene with twenty-two pieces which
include seven human figures, furniture, vehicles and
related items. In the MAPS teat, which represents a modi
fication ot the Thematic Apperception Test, the subject is
requested to develop scenes and tell stories using twenty
two background pictures and any number of sixty-seven
figures, fifty-seven of which are human. In developing the
S-I Test the attempt was to use the social aspects or these
more complex psycho-social projective test, but to develop
a simpler task which could be scored more directly and
objectively.
B. THE Su IAL-INTE CTION (S-I) TEST
Teat material. The te t con ists or fourteen
items, s en of hich re human fi re, 1th the other
seven being 1te or r it re.
1
In th group ot human
tigures, ther ar o dent1cal ·adult men, two identical
adult women, one bo, one girl, and one baby. The figures
portr y hie American id 1 -class am1ly group.
1
These are tandard toy t ms manufactured by
Renwal.
11
The items or furniture represent some ot the usual
i tems found in the American middle-class home. These
include one armchair, a radio-phonograph combination, a
dining room table and on~ matching chair, a kitchen range,
a bed, and a washstand. These items were selected because
ot their use in situations where social interactions might
take place.
All of the fourteen items re presented in a divided
box which is ten inches by thirteen inches, and two and one
halt inches deep. Figur 1 indicates the divisions in the
box and the standard way in hich the stimulus material is
presented.
Directions for administering. Adequate rapport must
b established before beginning the te t. The subject is
seated at a clear desk or table aero from thee aminer.
The box containing the to rteen item i placed, still
closed, directly n ont of the subject, about six inches
trom the front edg o the ta le.
The exa i er begins the st by sa ing, I have
fourteen if ere em nth box. t th1 point the
lid or h bo emov
•
Th r continue, 'You
see, there ar some peop an 80 rn1t re. Select any
thre of th te , a e
P a
cen nd tell a brief story
involving the hre ite s yo ha e s lected.' The examiner
recor the s 1 ct on
•
Th tor and the
Man
.
(
1
Table
.-
.
Wash-
stand
Girl
Armchair
Radio
Baby
Boy Kitchen an
Range
OURE
SOCI LI E C 0
12
Woman Bed
Chair
oman
13
descriptions or the scene given by the subject are recorded
verbatim. When the subject has completed the story or
indicates that he has nothing further to ofter in regard to
the three items which he has selected, the examiner returns
the items to their appropriate places in the test box,
complimenting the subject on his performance.
The examiner continues the test by asking, "Select
three items again. They may be any of the ones you Just
used, or different ones. Any combination you wish. Then
tell another brief story about the three you have
selected." Again the selections made and the story given
are recorded, after which the examiner returns the items to
the box. For the third time the xaminer says, "Select
another three it ms. They may be the sam or different
ones than you used in the past. Tell another story about
these three." The selections and story or the third run
are recorded, hie completes the test situation. As can
be seen, the technique allo s the subject to select any
combination of animat or inanimate obj cts for his cene
and stories.
Scoring technique. In the scoring system two
psycho-social element are conaidere : the number of human
figures selected, hich is the base score, and the degre
of social interaction dep1cted in the seen or storj
narrated by the subject. To obt in the base score, the
14
number or human figures selected in each or the three
trials is totaled. For example, one subject used no human
figures in the first story, two human figures in the second
story, and one human figure in the third story. This
subject's base score was three. The range or possible base
scores extends from zero to nine.
To this base score are added scoree from a tour
point rating scale or th degree of social interaction
depicted. A score of zero is given when neither inter
action nor any relationship is indicated between the
figures hich may be sel cted. A score of one is given for
som awareness of a social relationship between the figures
used in th test, a score of two for some active social
interaction between two or thr e figur s, and a score of
thr e fore tensive social interaction bet een the figures.
A can be seen, the range of thi rating core also extend
from zero to nine for the tot 1 et. ore ample, the
subject noted before received a zero for h1 first and
third cene an core of one for th s cond story.
This core added to hi base sco e gave h ma total S-I
score of for. or detail d in£o at on in regard to the
ratings 1 as ollo
•
•
ating o o. This core s au oat c hen no human
figur are e ec d nd .no mention is ade of any ocial-
interaction n he ett1ng de c by the subject. It
people are selected but the s bJect does not attempt to
15
relate the individuals in any way, or does not indicate any
social interaction between two or three humans, the O score
-
is also given. Examples ot this scoring are the following
situations: "a girl going to bed," "a woman cleaning the
stove," "a woman and a little girl."
Rating or 1. This score is given when the subj ct
-
indicates some definite relationship between the subjects
selected or described in the story, and/or depicts some
social action which goes in one direction, such as an
individual doing something ror another per on, with no
return social response being made by the second individual.
Examples of this scoring include: "waiters at the table";
"a man and 1fe, he 1 out orking"· "a husband and ife
asleep in bed'; "she as g1ren the table by a friend of
hers"; 'a man taking car or a o a ho is sick· " oman
cooking a meal or her husband"; he is e ployed by
someone else to tak car or h hom , "she puts th baby
to bed"; "he i an ct ve person and ha a nice social
life.'
Rating of 2. This cor s iven hen the ubJ ct
-
depict a sc ne or tell story n hich to or thr
people are act e o n om h n tog th
•
It is a
so ial int change n h ch the o or o e peopl re
actively interacting and e pond ng to one another.
Example of this at ng are: 'a bo and g rl dancing
together"; "th family taking a trip"; 'pla 1ng record
16
together"; "she talks to the baby, he is happy and doesn't
cry anymore." The stories or scenes at level two will have
some elements or level one, but 1n the final rating the
score is always the higher rating.
Rating or 3. Thia score involves the same active
-
social interaction discussed under the rating or 2 with the
-
additional feature that t involves a series or two or more
different activities. The rating ot two is given for one
unit or event such as a party, dance, evening up~er, and
related activities. The rating of thre is given when the
subject comb1n s a series or these social interaction into
one story. or example, the story ay follo the sequence
or the family arising in the morning, having breakfast,
going to school and ork, returning for lunch ands pper
and the vario s family activities, playing a ga e 1n the
evening, the children going to b , th pr nts t lk1ng
over the problems of the d y and fin lly t1r1n. Ano hr
example is story of a o nc, v io 'd t e , th
edding, b ying a home a r sing amil ogether.
Quite often thee stories nvolv o her c aract
addition to the thre fig res selected.
Reliability or scoring ___ _ Th
in
cor ng pro-
cedur for the bas scor 1 la 1 ly o Ject1 e 1nce
scoring 1 s1m 1 matter of counting. To rrive tan
evalua on or the effect on total core reli bil1ty or the
17
more subjective rating scale, the total S-I scores on
torty-tour subjects as obtained by a clinical psychologist
were correlated with the total S-I score obtained by a non
psychologically trained scorer who studied the scoring
technique presented here. The Rho coefficient or .97
emphasizes the relative objectiveness and simplicity ot the
scoring technique.
Application in the experiment. The scoring tech-
-
n1que described above w s developed during the pilot study.
Since the selections and stories in the final xper1ment
were scored before evaluation of the patients' responses to
EST, the predictive variable wa determined entirely
independently or any kno ledge or th outcome of treatment.
CHAPTER III
POPULATION AND CRITERIA OF IMPROVEMENT
The present chapter will consist of a discussion or
two problems or experimental design: (a) the various
attempts at controlling extraneous variables, and (b) the
evaluation or improvement by the ward physicians, which was
the dependent variable.
A. CONTROLS
Environmental an~ testing controls. All patients
us din the study had been committed to the Norwalk State
Hospital, Norwalk, California, through the regular Court
procedure. Upon arr1v1n at the hospital they wer first
placed upon the receiving ard here they ere given a
physical and psychiatric ex in t1on. Follo 1ng a brief
observation period th dictation ot he psychiatric
report, each pa ient s bro b foe the hospital taff
for d1agno 1 nd reat nt recommendation.
The c e c a s b t r t std ithin
thre or for da s follo ing heir appearances at sta f;
th s all ca e er given th Soci 1-Int raction Test at
appro i a el th
In OB C progrr.m.
their be nn ng ES.
e p riod
th s
nth ir g neral treatm nt
ape 1od jut pro to
the receiving ard, th
Ho eve, 1nce tre tment
fourteen c tat ic case
as begun on
did not
19
take the S-I Test until they had completed one or two !ST.
Later evaluations did not indicate that this short number
ot treatments distorted the test results, so these cases
were included in the
1
otal research population (see
Table I). The S-I Test was given in the standard form
throughout the study.
Shortly after the patients' appearances in starr
they began their EST. They were given three treatments a
week until some modifications in behavior appeared. 1th
the experimental cases only EST was used. During th1
period the patients resided on the closed wards of the
hospital. As patients showed improvement the numbe.• of EST
was reduced to one a week. EST was ventually eliminated
as the patient's stability and reality contact improved.
During this latter phase or treatment, the patients ho had
shown improvement moved to open ards here they had free
access to the hospital grounds, and began to go on home
visits. They also had opportunity to o on various Jobs,
to attend occupational th rapy, and to en g in vario s
hospital activities during this 1 tt r p iod o reatment.
Because of the limited number of hospita staff members
the cases used tor the study ere not 1ven 1ndiv1d al or
group psychother py. t the end o th onth of hospi-
tal treatment, a re ere r ady to be place on leave
from the hospital hile others had hon no imp ove ent.
The hospital environment of each individual was not
20
identical and some situations may have allowed tor more
social experiences than others. However, for all practical
purposes, the hospital environment at the beginning or
treatment tor each individual might be considered as similar.
Therefore, it may be considered that the patients must be
dissimilar in some way if they give different responses to
the same situation, namely, the closed ward environment
and the EST.
Population controls. Since the research was
conducted as a differential study employing concomitant
variation and not as a real experiment in the true sen e or
the term, careful selection or the population had to
replace experimental controls. The population studied
consisted of fifty first admission patients who had not
previously had EST. They ere t ested from January through
June, 1950, at the Norwalk State Hospital, Norwalk,
California. Six of the original group could not be us din
the final st tistical evaluations because of the following
reasons: (a) three deport tions to state or residence,
(b) physical inability to take EST 1n two cases, and (c)
individual and group psychotherapeutic attention given to
one patient. T us, the present study as based upon forty
four subject. These cases ere cho en from a total
incoming population or approximately 700 patients, with
selection being based upon the following general
21
considerations:
As the cultural background or the individual might
play a role in responding to social stimuli, as presented
in the test, some control or this was achieved by selecting
only white American born subjects. Only urban residents
who had not been receiving State or County aid before
commitment were selected. Further, only subjects who were
considered or "average" or "normal" intelligence by the
examining psychiatrists, and had at least some high school
education, were selected. No one was selected who was
considered to be or superior or dull intelligence, and only
three were selected who had gone as far as one year of
Junior college, the majority being high school graduates.
Alo, no one was selected who had any physically crippling
disorder which might handicap social interactions.
nother 1 portant variable to control as the nature
of the behavior di order of th atients. To arrive at
some control ot this variable, onl easily diagnosed
schizophrenic p 1 n ere u ed. Th patients select d
were all ca e her th br ak with reality" a suffi
ciently marke to have them nt to State Ho pital, and
to be diagno e unanimou ly a th medical tarr clinics as
schizophren cs. The t f c 1n1cs t wh ch the diagnose
were made ere at ended by five to thirteen doctor The
sub-categorie of the chizophre 1c iagnoses were based
upon . e majority vote ot the doctors present. The
22
patients used were all autficiently in contact to cooperate
in the testing situation. Therefore, at a gross clinical
level the cases might be considered to fall within a
reetricted range of a general continuum or behavioral
severity. That is, their condit1ona were sufficiently
severe to be diagnosed psychotic, but they were sutt1-
c1ently in contact to cooperate in the testing situation.
Within that range it would be expected that there would be
variations in level or severity. For fur~her study ot this
problem a check 11st or rating seal should be used to
obtain additional refinement ot level of severity or
clinical behavior. Although all or the cases were easily
diagnosed schizophrenic because or the clinical behavior
picture, the variations 1n responding to social stimuli in
the S-I Test actually may reflect varying degrees or
severity.
This group ot schizophrenic patients as not as
homog nous clinically a might be desired, but actua ly the
heterogeneity of the s b-clas 1ficat1on of schizophrenia
did not contribute in a t t1st1call ignificant ay to
the variation in 1 prov ment sho n 1th EST or the S-I
Test score • A ind cated in able I, th s pl con 1sted
or twenty-one pa ano1d four een c tatonics, i mi ed,
and three hebephr nics. In stat1 tically ev luating the
possibility or signif cant differences bet een the
class1f1cat1ons as to improvement 1th EST, the Null
23
hypothesis could not be rejected in any or the relation
ships. As an example, the Chi Square resulting from a
comparison or the catatonic and paranoid groups was practi
cally zero when the Yates correction for continuity tor
small frequencies was applied (21, p. 169). This lack of
significant differences may be the result ot the small
samples in the subgroups as the subgroups usually are con
sidered to have d1fterent1al prognostic values. The mean
S-I Test scores have been noted on Table I as well. Here
no significant differences were found as tar as mean scores
were concerned tor the subclassifications. The highest
mean, that or the hebephrenic group, was based on too small
an N to be considered reliably different trom th other
-
means.
Other variables which may hav been related to
improvement with treatment ere the recency and type of
on ~t of the behavior 1sorder. Because of the marked
influx o. patients in the hospital at the ti or the tudy,
the social h1stor1 sin thirty-eight or the ca s
complete. Where h1stor1 s ere available, too th
paranoids and one mi d appeared to have had gradual
r no
ons ts, hile one catatonic and to hebephrenic had had
acute reaction. Thi rai es the poss1b111 y that th
hebephrenics wer not classical" ca es.
A re other variables which ere not controlled in
the sampling could be s t u ·ied statistically to ascertain if
TABLE I
SCHIZOPHRENIC SUBGROUPS, NUMBER SHOWING IMPROVEMENT WITH
ELECTRIC SHOCK THERAPY, AND MEANS-I TEST SCORES
Diagnosis
Paranoid
Catatonic
Mixed
Heb phrenic
Unimp oved
8
6
2
0
Improved
13
8
3
N Mean S-I Score
21 5.9
14 6.4
6
3
10.0
they contributed to improvement with EST:
The chronological age range or the subjects extended
trom seventeen to fifty-five inclusive, based upon age at
last birthday. When comparing the ages or those who showed
improvement with those who did not improve, no significant
differences were round between the means and sigmas. The
mean age and sigma of the improved group were 31.28 and
9.35 years respectively; in the unimproved group, 31.37 and
9.50 years respectively. The correlation between chrono
logical age and the S-I cores showed a Parson rot -.15.
In th sample there w e twenty-nine omen and
fifteen men. When they were compared in regard to improve
ment with EST, the Chi Square, corrected for continuity,
was 3.94 which a significant at the .05 level. Thirteen
or 87 per cent of the men improved, hile only fifteen or
52 pr cent of the omen improved. There as no statisti
cally significant d1ff rence bet een the mean S-I score ot
5.9 for the en and 6.6 for the o en. Thee means appear
contrary to the theo t1 . 1 discus ion in hich high ocial
response strength ould p edict 1 provement, but, a 111
be discus ed in Chapter IV, pat of th discrepancy
appeared to be related to the g eater variability of tha
women and th eke ed nature o th 1str1but1ons.
arital tat m ght be considered to be related to
social response strength. In the sample t enty-t o
patient ha been o
re married h1le t e ty-t o were
26
single. The Chi Square, with correction tor continuity,
resulting from a comparison or the marital status with
improvement was 2.46. The trend was in the direction of
married patients showing improvement. Since the Chi Square
was not statistically significant at the .05 level which
requires a Chi Square or 3.841, the Null hypothesis could
not be rejected. When the sexual variable as held con
stant and the marital status of women was compared with the
variable of improvement, a Chi Square, corrected for con
tinuity, of 2.75 resulted. This was in the expected
direction 1th nine of the single women nimproved and
five improved, with only four ot the married omen unim
proved and eleven improved. The Chi Square reflected thi
relationship of improvement to marital stats, but the
results in this small sample ere not tatistically sig
nificant at th .05 level. The smaller sample of men
limited statistical evaluation. All of the ev nm rried
men 1mpro , bile to or the single men ere unimproved
and six improved. Them r tal sta us o t e total ampl
was compar d 1th the -I co an it s round that the
mean and sigma or h a r d patient ere 7.5 an .1
respectively, h le those for the singl patients re
5.3 and 3.9 r sp ct v ly. Thi
t1on, 1th the arrie patien
in th e p cted direc
sho ng a higher man S-I
score, but th gnificance of the dift rence of the eans
showed only at o 1.83, hich as belo the 5 per cent
-
27
t1duc1al limit or 2.021 for this sample. This variable of
marital status should be evaluated turther with control or
age and sex 1n larger samples.
B. DEPENDENT VARIABLE
Selection of the measure of improvement. The
-------------------
criteria for improvement were ratings baaed on hospital
records or the patients' behavior three months after
starting EST. It had been noted that a few patients had
improved surticiently to return home "on leave" at the end
or approximately three months or hospitalization and treat
ment.
Criteria of improvement. It was assumed that pro-
---- - ------
fess1onal people in constant contact with the patients
during treat ent would make relatively accurate evaluations
ot the patient 'co 1t1ons. In addition, actual reports
of behavior problems, changes in ward placement or treat-
ment because of chan e on 1t1ons, and cons1derat on for
leave, er sed to det rmine the amo nt or improvement. A
dichotomou rt ng of improved versus not improved as de
be:ause of the 1ff1c lties involved in arranging data rom
any so rce in a scale. e rat1 gs ere based upon the
fir t escr pt1on or the patien 's condition which appeared
afte the nin tieth day after beginning EST in the contin
uous hosp1t l reco ds. The date of the recording of the
..
tirat description ranged from the ninetieth day to two
weeks arter the ninetieth day.
28
The rating or imp~oved was given when the records
showed one or more or the following reports and had none or
those listed under unimproved:
1. The doctor's tatement that the patient was much
improved, showed improvement,and similar comments.
2. Ward descript.ons or the pati nt as being more
cooperative, friendly, showing insight, and so on.
3. The patient being moved to an "open" ward and
given ground parole because or improvement.
4. Placed on lea e or discharged as improved,
based upon staff recommendations.
The rating or uni proved as given hen the patient
sho ed one or or of the follo ing conditions and none or
those listed under 1mprov d:
1. Th doctor' st t ent of no 1 prove ent.
2. War de criptions o the patient as b 1ng
viol nt, rgu enta iv, actively hallucinated, and
o on.
3. he pat nt be ng ov d o a disturbed ard
th m pr ls on.
•
n er nth n bro
because o di t rb nee.
All of the forty-or c
re tmen t given
din the final
statistical st die could be placed in one or the other
29
class1t1cat1on with no overlap ot descriptions. The number
of individuals making the recordings upon which the ratings
were baaed ranged from the one ward physician, through
statements by several ot the ward nurses and attendants, to
the opinion or the total staff in regard to further treat
ment or "leave." Unfortunately, there as no way to
evaluate the reliability or validity of these recordings.
However, there is an indication that the ratings of
improved ver us unimproved, as u ed in this study, did
relate to the hospital records. This is suggest d by the
finding that two individual raters showed exactly the ame
dichotomy classifications in evaluating the hospital
records or the forty-four case in th study.
CHAPTER IV
RESULTS AND EVALUATIONS
In this chapter attention will be directed to the
results or the study and evaluations of the predictive
ability of the test.
A. RESULTS WITH THE TOTALS-I SCORE
The problem studied was essentially the prediction
or improvement with EST from a knowledge of S-I scor a.
The data and statistics to be presented will attempt to
demonstrate and evaluate the predictive ability or S-I
scores.
In Table II, for example, which pr nts the distri-
butions of S-I scores for improved and unimproved pati nts,
it can be noted that the score of the i proved pati nts
tend to be higher than those of unimproved patientc. Table
III sho s the means and sigmas of the improved and unim
proved groups on the composite S-I core. The ean tor
improved patients was 5.75 point higher than that of the
unimproved patients, and at or 6. 6 as obtained ro a
-
test of the significance of this difference. 1th 42
degrees of freedom, at of 2.704 is sign1 cant at the .01
-
level. The composite S-I scores of the improv d patients
were significantly higher than scores of the unimproved
patients. However, the positively skewed nature of the
•
TABLE II
NUMBER OF CASES ANDS-I SCORES IN UNIMPROVED
AND IMPROVED CLASSIFICATIONS
S-I Scores Unimproved Improved
16 l
15
l
14 1
13 2
12 2
11 1
10 2
9 3
8 1 2
1
0 2
6 1
3
5
1
5
4
3 3
3
2
2 2
1
0
3
N 16 28
31
Total N
1
l
1
2
2
1
2
3
3
2
4
6
6
2
2
3
3
TABLE III
SIGNIFICANCE OF DIFFERENCES BETWEEN MEANS OF IMPROVED
AND UNIMPROVED GROUPS ON THE S-I TEST
32
Statistic Unimproved Improved
N 16
M
2.75
2.25
.58
~
t
.893
5.75
6.46
28
8.50
3.54
.68
33
distributions of S-I scores ·raisea a question as to the
appropriateness or the t statistic for evaluation.
-
Aa previously not d, the purpose ot the study was
the prediction or improvement or unimprovement with the
knowledge of the S-I Test score. This is essentially the
problem or "predicting an attribute from measurements" in
which the interest is in the accuracy of the predictions
and where the forecasting efficiency ot the test provides
an appropriate statistic tor the evaluation (21, pp. 181-
187). Pigure 2 present the di tr1but1on of the two groups
and indicates th location or the critical division point
which is needed to evaluate the predictive ability or the
S-I scores.
By using th graphic method of locating the critical
point it can be een in Figure 2 that th core of four
divided the groups. A cor re obtained 1n whole num-
bers, it was nece ary to locat the point b teen to
whole numbers (21, • 18 ). Th c itical scor arbitrarily
selected was .5. 1 h h er t c
be predicted that all scor bov
ment with EST whil all tho e b o
cor of . 5 it ould
.5 o d sho improve
.5 ould not ho
improvement. Using th critical cor, 38 or 86. per cent
or the cases ere rd c dace a y. hi p rcentage o
accurately predicted c ses old be the s e i a critical
score or 3.5 inst ado .5 had been arbitrarily elected.
Without use of the test, and according to the principle of
-
Nor
cases
5
4
2
1 -
I
I
I
I
I
"
I \
I \
I \
I \
I \
\
\ A
\ I \
\ I \
Unimproved
---
Improved
O Division point
\ I \
~-◄ ~ r -~
\ I \
\ I \
'v' '----~
\
\
0 __ ..._ ....... ---.. ....... ____......__ ____ ......,_~--------..-.---------------
2 6 8 10 12 14 16 18
S-I core
FIGURE 2
D I STRI BUTIO SO S-I SCORES FOR
UNIMPROVED AND PROVED GROUPS
34
35
maximum likelihood, 28 or 63~6 per cent or the oases would
have been predicted accurately as improved. That is, by
simply guessing that allot the patients would have shown
improvement, the pr dictions would have been correct in
63.6 per cent or the cases. Thus, with knowledge of the
test scores and the critical point of 4.5, 10 additional
cases were predicted accurately, hich yields a forecasting
efficiency or 10/28 cases or 35.7 per cent in excess or
chance.
A stati tical indication ot the reliability of this
predicting 1th th total S-I Test scores and using the
crit cal point of 4.5 was gained from the Chi Square. When
a fourfold tabl, presented in Table IV, as developed
comparing the number of improved and unimprov d patients
whos cor s r bove and belo the critical core of
4.5, a Chi Squa , corrected tor continuity for small fre-
quencies (21, p. 69 of 19.05 resulted. A Chi Square or
6.635 1th on g e o fr om 1 ign ficant at the .01
le el. High -I cor or ponded significantly to
improv n t t e nd 0 core corres onded to
unimprove nt .
u 0 h g fican differenc bet een the
perc n g 0 om n C t ed a pro d, an
evaluation o t r t al pred1ct1 e ability of the
t t 1th r spect 0 h r er t see a mad • In
Table app ar the ra ata fro Table II divided into the
TABLE IV
COMPARISON OP UNIMPROVED AND IMPROVED PATIENTS WITH
RESPECT TO THE S-I TOTAL SCORES ABOVE AND
BELOW 4.5
Unimproved Improved
Total
3
ro
25 ro
28
(10.2 re> (11.a r
)
13 fo
3 fo
16
4.5-
( 5.8 r) (10.2 re>
16 28
'
44
I
TABLE V
RELATION OF S-I SCORES TO IMPROVEMENT IN THE
TWO SEX GROUPS
Female Male
37
S- I Scores Unimproved Improved Unimproved Improv d
16 1
15
1
14 1
13 2
12 1 1
11 1 0
10 1 1
9
2 1
8 1 1 1
1
0 2 0
6 1 1 2
5
0 1 1
4
3
0
3
3
2 0
2 2 0
1 2 1
0
3
N 1 15 2 3
38
clasaitications or male and female cases. The mean S-I
score tor women was 6.6 with a sigma of 4.72. The mean
S-I score tor men was 5.6 with a sigma or 2.67. There was
a marked difference in the torecasting efficiencies tor the
two sexes. Fifteen women were predicted correctly as
improved without knowledge of the test, while twenty-seven
were predicted accurately with knowledge of the test scores
and the cutoff point ot 4.5. This yields a forecasting
efficiency or 80.0 per cent. In contrast, thirte n men
would have been predicted correctly as improved with ut
knowledge ot the test. It the cutoff point or .5 w re
used with the men, only eleven men would be predicted
accurately, which 1e two le a than would have b en pre
dicted without use or the test scores! Using a cutotr
point of 3.5, th ituat1on ould be slightly revered 1th
fourteen men being predicted accurately with the teat,
resulting in a limit d for ca ting eff1c1 ncy or 7.7 per
cent. The significance of these differences bet een en
and omen cold not be legitimatel eval ated because o
the small size an pee liar d1 r1but1on or the mal a ple.
B. RESULTS ITH CO PO TSO THE S-I SCORE
A the total S-I score ctually a co posit
score, some evaluation of the ar1ous aspects or the score
was necessary. In Tables VI and VII appear the ra data
from the two measures compo ing the total S-I score. The
TABLE VI
NUMBER OP CASES AND HUMAN FIGURES SELECTED IN
UNIMPROVED AND IMPROVED CLASSIFICATIONS
39
N Human Figures Unimproved Improved Total N Expected r
9
1 1 l
8 0 0 2
1
4 4
6
3 3 7
5
1
7
8 8
4 2
5 7
8
3 3
6
9 7
2 2 6
l
3 3
2
3 3
1
6 28
Rating
9
8
7
6
5
4
3
2
1
0
TABLE VII
NUMBER OF CASES AND RATING SCALE SCORE IN
UNIMPROVED AND IMPROVED CLASSIFICATIONS
Unimproved
2
1
16
Improved
1
l
l
5
1
7
5
3
28
Total N
l
l
1
5
l
4
9
6
1
9
41
The mean number ot human figures selected by the total
sample was 3.75 with a sigma ot 2.06. The mean rating
scale score was 2.75 with a sigma or 2.34. The correlation
between the number ot figures selected and the rating scale
scores could not be computed because both distributions
were markedly skewed.
To evaluate the contribution or the two components
or the total S-I score to the test's predictive validity,
~he forecasting efficiencies or these subscores were
obtained. A score of 2.5 human figures was arrived at
graphically as the critical division point between improved
and unimpro ed patients. An increase of eight cases over
chance in the accuracy or predictions ot response to EST
resulted from the use of the critical point, and a fore-
ca ting efficiency of 28.5 per cent as obtained. Thus
this single measure as less effective than the composit
S-I score.
A problem r late to the number of human f1gur
selected involves the assumption th t humans have an ed
for social int raction hich i d monstr t din the S-I
Test. It might be deduc d that human, on th ba is o
this deciding ot1vat1on, ould choos or human figure
than would occur from a p rely randoms 1 ction ong the
teat items. In Table VI it can bes n that the sel ct1on
or human figures by the sch1zophr nic patient tended to
be les than chance hen corupar d to the expect d
42
frequencies arrived at on the basis of the binomial expan
sion . However, a Chi Square, corrected tor continuity, or
5.31 significant just above the .20 level, which requires
a Chi Square or 4.64, suggests that this poorer than chance
......
selection was not · statistically significant. Although it
111.ght be suspected that normal individuals who are moti
vated to have social interactions in contrast to the
schizophrenics who wer assumed to have a deficit in the
need tor social interaction wouid select human figure in
xcesa or chance, there is no evid nc at present to test
this prediction.
In predicting improvement from the rating scale
scores by use of a graphically det rmined critical point of
1.5, the forecasting efficiency as the same as that of the
composite S-I core, that 1, 35. per cent. This finding
raises a que tion a to the value ot including in the S-I
score the numb r of gu es selected since the rating scale
alone offered as much predict ve validity as the total S-I
score.
One compon
nt of _ ra 1ng C 1 cor a valu-
ated to determine its for ca t ng e t1c1 ncy. Th s as th
total numb r o o d cr1b1ng the C n or
t lling the or nth h e ls n the t t. Table
VIII sho the t but on o 0 1 or 8 U ed in rel t1on
to impr v an n1mp oved go pa. B a ng the critic l
score of .5 and kno ledge o the n mber or ords used, a
N Words
875-899
500-524
350-374
325-349
300-324
275-299
250-274
225-249
200-224
175-199
150-174
125-1 9
100-12
75- 99
50- 7
25- 9
0- 2
TABLE VIII
NUMBER OF WORDS USED IN TELLING STORIES IN
UNIMPROVED AND IMPROVED CLASSIFICATIONS
Unimproved
l
2
0
0
l
1
3
5
3
Improv d
l
l
l
2
0
0
0
l
l
1
2
3
2
3
7
3
torecast1ng efficiency ot 17.9 per cent was obtained. Thus
there was some predictive ability in simply knowing the
number or words used, although not to ·the extent ot the
other test measures. It may be that more words used 1n
telling a story to the examiner is related to interest in
social interactions, which in turn is related to improve
ment with EST.
C • RESEARCH PROBLEMS
The positively skewed nature or the d1str1but1on or
test scores suggests that the range or social response
strength or schizophrenic patients may extend below th
level or the test. In regard to the matter or the range or
the test, it might also be ~redi d that altho gh "nor
mals" may achieve higher S-I co es than schizophrenic,
the differences would be necessar1 y mall caus of the
test's limited range. Ho ver, sch1zophr nic pa 1ents a
be able to show some soc1 1 resp ns s o h , b t not
to stimuli more closely rel d to ac 1 ocial n r-
actions, whereas "normals" may ble tor spond to both.
Another related problem ould b he fer nee n pro
ance on the S- Teto improved and ni pro d chizo
phrenics after treatment. It ight b p d cted hat
improved patient ould sho ore soci 1 n eraction
responses on the test. An associated problem 1s the
-
situation in which a patient shows a high S-I score,
improves with EST, but shows a return ot psychotic
symptoms a few weeks after termination of EST. Further
studies and modifications ot the test will be necessary to
determine the possibilities.
CHAPTER V
THEORETICAL INTERPRETATIONS AND DISCUSSION
A relationship between S-I Test scores and responses
to EST has been indicated. In this chapter a tentative
explanation tor this relationship will be presented. As
was noted, 1n the study being reported, the sample of
subjects was selected from a population of chizophrenic
patients receiving EST. Therefore, this chapter first will
be concerned with the nature of schizophrenia, with par
ticular reference to th- conditions which may relate to
recovery from schizo-phrenia. S condly, an analysis of the
theori s which attempt to xpl 1n the rrect1venes of
shock will be presented. A gen ral indication of the
ppl1cat1on or learning theory
ettect ot EST 111 b oft r
th int rpr tatio f h e
th pl n t1on or he
1 h attentio dir ct d to
ts of the p ent stu y.
A. HIZOP
e o chizo I n co pl t t ory ot
schizophr n1a, both ph solo 1cal n p ychological factor
m t be on d r (2). Ho ever for the pr ent st dy,
tt ntion
th 1 r 1 V
The
1 be con ne to tho tic l co id rat on at
and !th sociogen c behavior.
n te t pto s of chizophr n1 a e ult1ple
and have been described xtens1vely in the literature
since the early writings of Kraepelin and Bleuler. These
symptoms have been characterized variously as representing
breaks with reality, regressions, formations of vicious
mental habits, habit deterioration, and disorganization ot
biosocial reaction patterns. As an example, Fenichel, in
ottering the psychoanalytic interpretation, stressed that
"the nucleus or schizophrenia is the patient's break with
reality" (11, p. 439). He indicated the importance ot
regression in the process (11, p. 439) by stating:
Psychoses as w 11 as neuro es are based on th
organism's reactions to conflicts by regres ion;
however, the depth of th regression is different.
Early infancy has no "reality"; a subsequent
"loss of reality" represent a regression to this
early time.
Adolf Mey r (7) indicated that schizophr nia 1s the end
ulty habit r actions result or gradually d v lopin
resulting from an 1nadequat dj tm n to th nv ronme t.
When diff1cult1 ri nth v onm t th 0
frustrations, the ind.iv_ al is nable o ak a direc
attack upon the probl nd 0 C 0 at ac on
and feeling o
satisfactions.
n er1or
aslo and
ate t o b tit t ima n r
lmann ( 0 p. 81) t
the importance of repr
said:
on nth ch zophrenic hen h
••• hi e otiona
painful, o fr ught
the • This rep io
on e o int n
danger that he rep
o in n that 1
1 reference bo
et. Th orld
all his emotional proc e
himself nd to his nviro
I 0
esses
ar ec s
h to
8 0
ed
full or danger and pain tor him that he withdraws
trom it emotionally.
48
Cameron (4, p. 486) indicated the importance of "b1osoc1al
disorganization" in the schizophrenic by stating:
The schizophrenic patient 1s usually a person
who has never acquired the degree of social skill
he needs for shitting his perspectives through
taking successive culturally determined roles
when he is under stress •••• The initial dis
organization which develops ••• renders the
socially unskilled and immature person still
more inadequate and isolated.
It may be noted in the above descriptions or
schizophrenia that there is a wide range of descriptive
vocabulary, but certain basic similarities or areas of
agreement can be found. In the first place, these state
ments suggest that schizophrenia is a reaction to a con
flict or frustration. The conflict 1 viewed differently
by the various riters, but for all it presents som prob
lem in the individual's adJu tm nt to hi social or cul
tural environment. It is also 1 portant to note that there
is agreement that the reaction of the nd1vidual results in
an avoidance of his social or cultural environment.
The theoretic descriptions cited imply a distu b-
ance in interpersonal re ation and changes in soc1a
responses, but more det iled valuations of these change
can be reported. In di cussing the language of schizo
phrenia, which could be considered as one aspect of oclal
response, Sullivan (30, p. 15) stated:
The schizophrenic does not have our pleasant
illusions that speech will help him to satis
factions, because he is quite sure there are
none. He uses speech exclusively for counter
acting his reeling ot insecurity among other
people. The schizophrenic's speech shows
characteristic peculiarities because or r cur
rent severe disturbances in his relationship
with other people and the result is a confusion
ot the critical faculties concerning the structure
or spoken and written language.
49
Cameron clearly pointed to a disturbance in inter
personal relations when he described schizophrenia as a
"disarticulation from the social group" (30, p. 51). He
indicated that the schizophrenic becomes isolated from the
common social environment and that he is unable to share in
"the attitudes and perspectives or those around him, to
take their roles when mutual misunderstanding arises, and
so to be able to assume their poin of vi ••• and
modify his own behavior to neet them" (30, pp. 50-51).
In summary, it y be id that schizophrenia partly
involves a respon e to a conf 1ctful or str rul situation
in which distortions n social responses and int rpersonal
r lationshipa occu.
Approach-avoidanc cont ict. Being fully aware ot
the dange of apply1n pr1ncipl v loped in laboratory
re earch 1th nim 1 to he far mor complex social
behavior or human orga 1 m, n verthele sit would ee of
value to co s1d th confl1c it ation in schizophrenia
in the light or ome or t
r nd1ngs from e peri ntal
studies or contlict--more specifically, in the general
terms or the approach-avo~dance competition described by
Miller (43). In this conflict he lists tour fundamental
principles (43, pp. 433-434):
1. The tendency to approach a goal is stronger the
nearer th subject is to it. This [is] ••. the
approach gradient.
2. The tendency to go away from a place or object
avoided is stronger the nearer the subject is to it.
This [is] ... the avoidance fradient.
3. The strength or avoldancencreases more rapidly
with nearness than doe that or approach •••
4. The strength of the tendencies to approach or
avoid varies with the strength or the drive upon
which they are based •••
50
A difficult task is presented in attempting to translate
the complex nonspat1al problem of schizophrenia into these
spatial terms used in animal tud1es. Ho ever, this
attempt at translation ould have value if, on the basis of
such an application, deductions and predictions could be
made hich could b teste experi nta ly. In oder to
relat he chizo hre c isord r tot approach-avoidance
conflict of er
ot aid o pc
b e p ri en a ps c ology, it ould em
diode
cally in 1 r 3.
h ar
a
1 0
on h
o h o h C
0
nc
h
di du
r
o d
eed o
lopmen o th beha 1o
C t d ache ati-
A nd d ton gl c ad
C ldhood. A disc ed in
pc d hath old
oc
- nt
ct on an ould
reJec
the fir
deve o
ther for nr pons1ve o oc1al ti ulat1on. If no
51
100----------------~-------~
'
· ' · · Approach gradient
', --- Avoidance gradient
, X Point or conflict
'
'
' ' B'
Response
'
'
'
'
'
'
B
I '
Strength
A
I '
I '
I '
I '
I '-
t '
I
O'------------------------------.
S-I response
to humans
Stimulus Dissim lar
FIGURE 3
APPROACH-AVOIDA CE CO LICTS
y
S-I re ponse
to doll
Por simplicity the gradien ar p
lines in this figure . Curved 1 ne
in this situation , but sim ar de uc
n ed a
be
ra gh
with curved l ines having cont nuous ativ
were steeper fo r avoi dance than approach
above the abscissa.
lop
each p
52
additional avoidance responses were involved, he would
show occasional weak social responses. Each point on the
approach gradient, presented in Figure 3 as A, might be
considered as a graphic presentation of the average
response trength or various social responses of individual
A to some specific uocial stimulus. Along the stimulus
dissimilarity continuum could be represented such stimuli
as family, friends, social gatheri gs, st angers, psycho
logical examinations, presentations of replicas of human
figures as in the S-I Test, novels, animals, as well as
inanimate objects such as furniture, tre s, rocks and
others. Stimuli consisting of humans involved in social
situations would elicit the strongest social responses, and
stimuli differing from humans ould produce weak r social
responses in accordanc
1ty.
th the extent of the dissimilar-
Inc rr n th1 hypothetical case A further, if in
-
his later c ldhood and adolescence h eak social
response
ind sf VO
soc
and h
r 1
0
e gth and 11m1~ed in erest in people placed hi
th hi contemporarie, then emotional and
ons th people ould take on a painful aspect
ho avoidance responses hich might general-
ze to many oci 1 ti ul. He ould hav strong avoid nee
r pon to t ul1 r presenting the close human relation-
sh ps h1ch had be n paint 1 to him, and eak r avoidance
respon to stim 1 differing from these social situations.
53
The avoidance gradient A' in Figure 3 indicates graphically
the average strength of the avoidance responses to social
stimuli.
In the case where the avoidance responses to human
stimuli were stronger than social or approach responses,
the occurrence of the social response to any human stimuli
would be prevented. However, social responses might occur
to some generalized form or the human stimuli such as
dolls, becau e the strength of avoidance respons s would
decrease more rapidly than that or the approach responses
as the stimuli become less repres ntative or clos human
contacts ( 1ller's principle number three). Individual A
could respond socially only to those stimuli at orb yond
point X in Figure 3, that is, th point or conflict or
wher the strengths of approach and avoidanc t ndenc1e
are equal. This tatement assume di n ion ot qual1ta-
tive psycholog1c 1 di si lar1t or sti ul int ad of a
spatial situation.
In individual A 11 social re pon o d b
inhibited by th vo danc pons e c pt or th
eocial respon to social ti uli h ch r r removed
from situations of close h an cont c • Dollard and
Miller have indicated, th height o the point of conflict
may indicate the strength of anxi t (6, p. 359). A
individual A 1s r lat1vel eak in social respon e str ngth,
it would be predicted that his lev 1 of overt anxiety (42)
in such situations to which he can respond would be low or
nonexistent and he would fit a schizophrenic description or
"withdrawal" and "blandness."
As a contrast, hypothetical individual B will be
-
considered. In his early childhood his contacts with other
humans corresponded to need reduction, so it would be
assumed that he would show some development or the need tor
social-interaction. Some of his social respon es have
acquired considerable habit strength because of their
association with ne d reduction. Because ot various emo
tional problems, ocial stimuli may become cues for tear or
anxiety and avoidance responses may inhibit the former
social responses in individual B. If thee avo dance
-
responses are sufficiently strong, then the ituation 111
exist as depicted in Figure 3. Th point or conflict or
individual B 111 be the same as for 1nd1v1du 1 A on th
- -
continuum of stimulu dis m1lar1ty and the stimuli to
which B can respond 111 be com arable to those to hich A
- -
can respond. Ho ever, th s r ngth of the ocial r pon
which my occ r 111 in o C b tong r or B tha
-
for A nd lso it old b pr diet d th t B' 1 vel o
- -
overt anxiety ould be high~.
Tor la e th o hypo het cal ca
phrenia, som valuat on o th continu
similarity, as pres nted n igure 3
to ch zo-
ot timulu d1 -
t b mad • Th
point of conflict or of balan e between tendenc1e to
55
respond to and avoid sooial stimuli tor both A and B occurs
- -
at approximately the same point on the continuum of
stimulus dissimilarity. That is, they could give approach
.responses only to stimuli sufficiently dissimilar trom
humans. For the point of view of theory formulation, it
may be considered that schizophrenic patients can be
described in terms or their inability to respond to any
social stimuli except those differing markedly from situ
ations of close human interrelationships.
As was previously noted, the height or the point of
conflict will indicate the level of overt anxiety experi
enced by the individual. Individual A might have be n
-
considered a schizoid character before his psychotic break
because of his low social response strength and lack of
ov rt anxiety • . Individual B would sho more overt anxiety
as an aspect ot his p ychotic reaction, and hi pre
psychotic personality would have b en more social than A's.
-
Both would sho a schizophrenic disorder in term of their
ability to re pond only to certain o the social timuli on
the continuum or st mul dissimilarity.
On the basis or the descriptive theory of ch zo
phrenia which has been rormulated, hat changes must occur
for elimination of the behavior disorder? The most advan
tageou technique ould be one in h1ch the strength of the
acquired need for social-interaction as increased thus
increasing the response trength of the social or approach
responses, while the rear and avoidance responses were
extinguished. Both or these conditions appear to be sat1s
t1ed by the marked emotional closeness presented in Rosen's
(57) therapeutic technique since his approach attempts to
increase the need for relations with people and reduces the
tear of such relations. Fromm-Reichmann•s psychotherapy
also stresses the importance of the transference relation
ship and indicates that the schizophrenic first must be
"cured of the wounds and frustrations of his life" (15,
p. 380). She attempts to increase the need for social
interactions through the transference relationship while
also lowering the avoidanc reactions through extinction of
fear responses to social stimuli. The tollo ing section
will di cus the po s1ble effects of EST on the schizo
phrenic conflict.
B. LECTRIC SHOCK THERAPY
Theories for shock therapies. Oner vie of the
literat re on pha ceut1cal nd e ctric shock included
fifty epara e theo ie fo the gen ral oc therapy
mech n1 , t e - ven o hich ere essent ally somato
gen1c, 1th tent -th eing psychog nic (19). Cameron
looked pon thi o hel in group of hypotheses as till
vague and contradictory and cons1dere the major contribu
tion of shock he ap1e to b the i espread substitution
ot an aggre iv, hopef 1 attitude on the pat of
therapists in place or the old stagnant pessimism" (4,
p. 446). However, a close examination or the psychogenic
theories indicates that there are essentially two general
groups: those related to psychoanalytic theory, and those
related to behavior theory.
57
In the psychoanalytic point of view the emphasis is
often upon the punishment aspects of shock treatments. It
is hypothesized that inwardly-directed destructive tenden
cies of the superego are disrupted by the attack of reality
and the patient can again turn in the direction of reality,
after the reduction in guilt fee ings (13, 17, 27, 69). A
somewhat similar hypothesis ascribes the efficacy or EST to
the production of objectiv anxiety and a threat of ex r
nal danger hich orient the individual to the current
reality situation and rs lt 1n an anxiety motivated
repre sion of the psychot c content (32, 40, 66, p. 51).
Thee p ychoanalyt c discus ion generally emphasize the
point or vi that the shock t atment may 1nterru t the
nten e pr occ pa on o th p ychotic episode but cannot
p oduce th n t e or a ast1ng cur. A third
int rpr ta 0 rom th
p choana y c orien a on 1 the
id 0 b ch e t bl she rim V t an
re -
enc a on evea a o th pa 1 nt that th goo
and b love par n r a an tha the negative
"s pe:rego g no r ph t ov r the loving
surro ates (18). This h rd interpretation indica e the
58
importance ot an emotionally accepting hospital environment
and follow-up psychotherapy. Through such treatment the
patient can re-experience childlike relationships in which
the "parents" are loving figures. With this experience,
the tears or negative "superego images" are extinguished.
The second general group or theories, those related
to behavior theory, to a large extent emphasize the dis
rupting ettect or EST on recently acquired memory and
associative material, particularly the recently elaborated
set or ideas which produced the psychotic break (7, 36,
48). A second hypothesi 1 that EST produces a tunctional
ablation or the frontal cortical areas and eliminates
"psychologic projectiort'' into the future or anticipation
with its elements or anxiety (16). Kesler and G llhorn
(33) ofter a theory hich is expres ed or directly in
behavior terms. According to his th ory, learned
responses which have been inhibited during the psychotic
episodes can be d1s1nh1b1ted by mean ot cortical de truc
t1on resulting from shock technique •
It 1s important to note that 11 o th theor1
similarly emphasize the lo ering o the avoid nee or
inhibiting respon e, and th eturn of fo r appro ch
responses and the chance tor le rn po
attitudes.
1v e ot on
nd
59
the effect of shock from the frame of reference or learning
theory (25, 63), attention again must be turned to the
approach-avoidance conflict as presented in Figure 3. The
approach gradient consisted or generalized social responses
based on the acquired need for soc1al-1nteract1on, while
the avoidance gradient consisted of generalized avoidance
responses based on fear or anxiety in the presence of
social stimulation. In the schizophreni disorder it was
assumed that the generalized avoidance responses inhibited
the majority of the generalized ocial response •
Kessler and Gellnorn theorize that the inhibited
responses can be brought back into functioning by means of
cortical de truction sufficient to reduce the inhibiting
effect. They present as videnc an experiment in which
a conditioned r sponse in experimental animal as estab
lished and then inhibited by a ne respon e. hen the
experim nt 1 animals re treated by shock methods,
incl ding electro hock, the inhibited conditioned response
returned 1tho tr th r inforcement herea a ro pot
control ani al ho d ~ont1nuou inhibition (33).
Ar cent tudy by asserman and co- orker ( 1)
also suppor the ler and Ge lhor h othesis In the
a se an t dy, nin ca ere t ained to obta rood in
cope
situation a
tion. In five of the cat a conflict
d v loped by establishing an avoidance
response to the cues that r rmerly indicated the pr sence
60
of :food. Two other cats developed "neurotic disorders"
because of accidental injuries during the training period
for the approach responses. No avoidance response was
established in two cats used as controls. After electric
convulsions administered at the end or training, the
behavior of the two control cats showed confusion for a
period or twenty-four hours, after which normal per:fonnance
was observed. With the seven "neurotic" cats the results
were of a different natare. After four treatments the
"neurotic" animals were less resistant to entering the
apparatus, ere les ea ily startled, and ere less avoid
ant to signals, to the food box, and to other cues in the
environment. They re-explored the cage, and resumed some
of their p eviously earned patterns for securing food.
The avoidance responses apparently had been reduc d suffi
ciently by EST to allo the return of the prev1o sl
inhibited ppro ch spons
•
0 tu s h1ch s ge tha the hock mechanism
1the nh1b1 0 1 gu he 0 C 1 lea d
ma er1 C C t d. nca ( ) died f ect of
lectro hoc 0 r p 0 rat dif e 1 g
1nte v 0 t ch 1 1n trial in n VO
d-
C on o nd a d d ct o nth
ar -
ng o h oup ct o oc ho tl rter each
t 1, h 1 the 1 or no int rf r ce h learn-
ing in th o her roup 1 en hock at later intervals.
61
I
Rodnick (56), in a study with twenty-one schizophrenics,
had the patients learn two similar but antagonistic habits
of moving the fingers either to the right or to the left
depending upon the frequency or a tone. A full day inter
vened between learning the two tasks. The patients were
tested shortly after metrazol shock to determine habit
dominance, and he found a statistically higher number of
"reversals" to the older habit in the shock group than in
the control group.
However, it may be that omething more than recency
is needed to account for the modification of the inhibiting
responses, especially in th behavior disorders where
emotional needs motivate the behavior. The theory explain-
ing the effect of EST a functional ablation of ti1e
rea ma describe more adequately the
rength of h nh1b1t1ng responses 1s
frontal cortical
manner in h1ch t
r due d (16). Do 1 and 1 ler (6 • 378) offer
tentative hypoth
loboto y h ch
1 or he ct1ven of prefrontal
0 r 1 t d. h gg st that
"prefronta oboto po c d r ntial ecre ent 1n
the pa1n-fe r echan m
inhibit and r pre •
h h cs the motivation to
ha bend c ed the moti ation
behind the g n a zed ro1
associated 1th ocial st
nee pon s 1 the far
Te Dol ard and Miller
hypothe 1 ug st th
so that the t ength o
h r ar ot vat1on is reduc d,
the gener lized avoidance responses
will be reduced, and the generalized approach responses
will be d1s1nhibited. Because of the importance ot tear
reduction, it might be anticipated that more change in
behavior will occur when the anxiety has been high than
where it has been low. Because the organic ettect or EST
may be temporary, the reduction of the strength or the
avoidance respo # ses also may be temporary.
62
If it is true that the effect of EST on the inhibit
ing responses is only temporary, ho can changes in
behavior appear after a series or shock treatments9 As has
been discussed, here the acquired need for social
interaction is limited, few social responses 111 hav been
established to social stimuli. 1th the hypoth tical
nd1v1dual A, for xample, EST old r duce t porarl y the
strength or the inhibiting r ponses, but his limited need
for social-interaction also oul trict th po ib111 y
of social respons s. 1 o, hi n 1 t s 11 1ted, the
reduction or fear ould have on y 11 ht rrect on hi
behavior. he voidance po e ould b a tron a
before, after th tempo ry ct o E h d b n d
-
pated. Thu, it ould not be p cted
-h
t ST ld
influence to ny s gn1f1c n d r pay hotlc behavior
or the pat en hose n d or oc1
- n
ct on a lo ,
except for some temporary cont sion.
A a contrast, con der the rr ct o ES upon
individual B ho as assumed to have a moderately strong
-
63
acquired need for social-interaction. In this case EST
would allow the return or inhibited social responses which
had been moderately strong. During the periods following
shock it would be predicted that he would make social
responses to the social environment. It these social
responses were to a large extent rewarded, they would be
repeated. B would be more active in responding to social
-
stimuli than A. Also, because ot his greater anxiety, a
temporary reduction of anxiety would have more errect upon
his behavior than in the case or A. Individual B would
- -
experience re ard rather than pain to his social responses
and the avoidance and anxiety responses would be extin
guished gradually. The probability of the return of
inhibited social responses follo ing EST is supported by
the common clinical observation of euphoria and sociability
in patients shortly after EST.
In this formulation, EST is considered to have no
direct effect upon the approach gradient, and only has a
t mporary effect on the avoidance gradient A deduction
from the theoretical discu sion ould be that chizo
phrenice hose soc al r sponse strength and anxiety are
high w11 improve fter ET; chizophrenics whose social
response trength ad n ety are 11 ited 111 improve
little or none. Thi p ognos sis in accordance 1th
observations nth 1 tr tu e d scribing schizophr nic
patients ho benefited from shock treatments as having ell
64
.
,
integrated pre-psychotic personalities, as showing records
or social achievement, and as having affective elements
- (28, 38, 49, 55). The same prognosis can be made on the
basis of social response strength as measured by the S-I
Test.
CHAPTER VI
SUMMARY AND CONCLUSIONS
The purpose of the study was to evaluate the rela
tionship between responses or schizophrenic patients to
social stimuli prior to treatment and improvement with
Electric Shock Therapy. In the study the Social-Interaction
Test was used as the independent variable and the measure
of social response strength. This test involved the tell
ing of brief stories about thre items selected from a
total of fourteen miniature items, half of which were
replicas of human figures. The test was s. imple to admin
ister and the scoring was relatively objective and
reliable.
An attempt was made to control by the selection of
cases, the cultural backgro nd, int 111gence, education,
and physical condition of the s bj eta studied. The
ratings of improved versus unimproved ere based pon
evaluations of the condi ion of the in iv1dual p ie ts by
the ward physician and ard personn 1. Th rating er
made three months after the first EST tr atment for each
patient. This period as elect d arb1trar1 y b cause to
or the patient had improve to the po nt here the medical
staff approved their eav •
The results er interpreted in light of a descrip
tive theory in hich it as hypothesized that the
66
achizophrenic · behavior disorder represented an approach
avoidance conflict. The approach gradient was considered
to consist or the generalized social responses whose
strength was related to the strength of the acquired need
tor social-interaction. The avoidance gradient was con
sidered to consist of generalized avoidance responses moti
vated by anxiety related to social situations. In the
presence of strong generalized avoidance responses, many of
the individual's social responses would be inhibited, and
when approach responses could be made only to stimuli
markedly remote from human stimuli, it was assumed that a
schizophrenic disorder was present.
To bring about a change in the behavior disorder
would require some combination of increases 1n the strength
of the approach tendenci sand decreases in th strength or
avoidance tendenc1e. The role of EST as considered to be
one or temporarily reducing fear, thereby lowering the
avoidance gradient and perm ttlng the occurr nee of
previously inhibited social responses. Thus it ould be
necessary that the patient have a c rta1n minimum n ed for
soc1al-1nteract1on and social response strength in order
that social behavior could reappear after EST. If the
social responses reapp red and were rewarded, the anxiety
responses to ocial cue old gradually extinguish and
furth r reduce the strength of avoidance responses.
A deduction from th theory outlined above would be
67
that schizophrenic patients who show strong social response
strength before treatment would improve after EST, while
those with limited social response strength would not
improve.
~
This deduction was presented as a possible expla-
nation of the results or the study.
With the general purpose of the study in mind, the
specific procedure and results were as follows:
1. From January through June, 1950, fifty selected
schizophrenic patients were tested with the Social
Interaction Test shortly after entering the hospital, and
Just prior to their beginning EST. Forty-four or these
patients remained in the hospital under treatment in the
regular hospital routine, and were the ones selected for
the final tatistical evaluations.
2 . Three onth after beginning EST and with con
tinuous ospi al treatment, t enty-eight of these patients
were class1f1 d a 1 prov h1le xteen ere considered
to be unimprov
•
3. Th go of sh zoph enc patients consi ted of
t enty-one pr nod, o
thre heb phren c. Th r
can di e nc
the nub r ho 1ng imp ov
n catatonic, 1 mixed, and
r no stat1 tically s1gn1f1-
h cl a 1f1c tions in regard to
n or remaining uni proved.
•
Th
hi the n o
n co
h
of u
p ov
pro ed patient
gro p a 8.50.
as 2.75,
The t for
the 1gn icance o hi 1 f r n as 6.46, which is far
68
beyond the requirement tor a very a1gn1t1cant difference.
5. In evaluattng the predictive efficiency ot the
teat with the present sample, a critical score or 4.5 was
selected. With knowledge ot the test scores and the criti
cal score the forecasting efficiency was 35.7 per cent.
A Chi Square, corrected for continuity in a small sample,
and based upon th critical score or 4.5, was 19.05. Thi
further supports the significance ot the difterenc.
6. At an operational level it can be said that
scores on a projective te t involving the use of m1n1at e
human figures did predic, to a tat1 t1cally a1gn1t1cant
degree, the general nature or the ratings given by
p ych1atr1st on the adJu tm nt or elected schizophrenic
patients thre months fter tarting EST. The d due ion
from the theor tic 1 sy t m old pr diet thi re lt
providing the S-I T scor or h in rv ning variable o
--------
str h act ally a rela d to th h o-
thetical const c o cov r p rsonal t variabl of
ocial respon t g h
B I B L I O G R A P H Y
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DOLLlRD, J., & MILI,EQ, N. E. Personality and Psycho
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Asset Metadata

Creator Bessent, Trent Eggleston (author)

Core Title The relationship of the pretreatment strength of social responses of schizophrenic patients to improvement with electric shock treatment

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Psychology

Degree Conferral Date 1952-01

Publication Date 01/01/1952

Defense Date 01/01/1952

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, Pathological,Schizophrenics -- Rehabilitation,Shock therapy

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC112724835

Unique identifier UC112724835

Identifier A no.36 (Film) (call number),Ph.D. Ps '52 B558 (call number),etd-BessentTrent-1952.pdf (filename)

Legacy Identifier etd-BessentTrent-1952

Document Type Dissertation

Format theses (aat)

Rights Bessent, Trent Eggleston

Internet Media Type application/pdf

Type texts

Source 20230207-usctheses-microfilm-box7 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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