THE RELATZONSHSP OF AUTONC‘MK‘. NERVOUS SYSTEM SUMULATEON TC} BEHAVIORAL ADJUSTx‘éEHT, CHANQE AND OUTCOME EN SCHIZQPHRENIA ‘E’hasis 5:: fhe Degree 9? Ph. D. MECHEGAH STATE COLLEGE Raigsh Hirschsfain i954 rHF‘S‘S This is to certify that the thesis entitled THE RELATIONSHIP OF AUTONOMIC NERVOUS SYSTEM STIMULATION TO BEHAVIORAL ADJUSTMENT, CHANGE AND OUTCOME IN SCHIZOPHRENIA presented by Ralph Hirschstein has been accepted towards fulfillment of the requirements for M degree in My MAW Major professor Date November 22, 1951; 0-169 THE RLLATlcienIP OE AJTOKOLIC LEdW ’ US SESJEM STIHULAIION TO U ZHAVIORAL ADJUL1 SKI, CHANGE THESIS ABSTRACT Submitted to the School of Graduate Studies of nicultuie and LJ" Kichigan State College of A Applied Science in partical fulfillment of the requirements for the degree of DO TOR OF PHILOSOPHY Department of Psychology 1954 Approved by: 4%;ZZZZ:%4EEQ%ZfiQE::¢éfi: ___ 1Htr~li~§ .5; . ’.” I? .133 “‘6 The purpose of this study was to investigate the re- lationship between autonomic nervous system reSponses to the injection of adrenergic and cholinergic drugs, and the beha— vioral adjustment, change, and outcome of a group of schizo— phrenic patients. The tires hypotheses around which this study was struc- tured were! 1. A significant relationship can be established between the quality of behavioral adjustment and the direction of blood pressure change after the injection of the adrenergic drug Epinephrine Hypochloride and the cholinergic drug Hecho— lyl Chloride. 2. A significant relationship can be established between Spontaneous behavioral changes and the direction of blood pressure change after injection of the cholinergic drug Mecholyl Chloride. 3. The outcome of institutionalization can be related to the direction of blood pressure change after the injection of the cholinergic drug Mecholyl Chloride. The tool used to investigate behavioral adjustment and change was the Gardner Behavior Chart, a five point scale,con- sisting of fifteen behavior categories. Behavior ratings were made by groups of nurses and attendants for a period of eight weeks. a), ‘7? L“ 't'fiIE ‘-3{ ")J V8Ximum blood pressure increases and decreases after the inJection of the adrenergic and cholinergic drugs were uSed in the analysis of the results. No significant relationship existed between the direction of blood pressure change after the injection of the adrener_ gic drug and behavioral adjustment. Significant relationships were established between blood presrure increase and poor be- havioral adjustment, and blood pressure decrease and good be- havioral adjustment, after the injection of the cholinergic drug. Statistically significant results were obtained in an analysis of behavioral changes over an eight week observa— tion period, after the injection of the cholinergic drug. Increase of blood pressure is associated with reduced ade— quacy of behavior. Decrease of blood pressure is associated with behavior improvement. A follow—up study five months after the initial eXperiment revealed a significant relation— ship between blood pressure change after injection of the cholinergic drug, and hOSpital status. Blood pressure de— creases larger than increases were related to hospital re— lease. Blood pressure increases larger than decreases were re- lated to continuing hOSpitalization. The blood pressure reaction to the injection of a choli- nergic drug is a valuable tool in the diagnosis of adjustment, the prognosis of behavior change, and outcome of the disorder in schizophrenic patients. THE REHALIOUZUIP OF AUTONOIIC NERVOUS SYSIEH SIIUULATION TO BEHAVIORAL ADJUSTIZKT, CHANGE AND OUTCOIE IT SCHIZOPHREKIA. v\ Lx‘y ‘4 Ralph Hirschstein Submitted to the School of Graduate Studies of Michigan State College of Agriculture and Applied Science in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Psychology 1954 The writer wishes to thank Dr. Albert I. Rabin for his criticism and advice in the writing of this dissertation. He also wishes to eXpress his appreciation to Dr. S. Howard Bartley, Dr. Donald M. Johnson, and Dr. Paul Bakan for their valuable suggestions. A special note of thanks is due to Dr. Katherine W. Wilcox for her valuable comments and editorial assistance. TABLE OF CONTENTS Page SURVEY AXD IITRODUCTION TO TfiE PROBLEM General Introduction to the Concept of SchizOphrenia. . . . . l Inteerative Ayprosches to the Problem of Schizophrenia. . . . . 4 Some Physiolosical Asp-eta of Schizo— phrenia. . . . . . . 6 The Autonomic Iervous System in its Relation to Schizophrenia . . . 9 The Autonomic Eervous System Test . . 14 STATEMEIT OF THE PRCBLEX ATD HEPOTEESE 22 IETTCDCLC”Y Selection of the Subjects. . . . 28 Procedure in the Administration of Drags . 30 Procedure in the Evaluation of Blood Pressure Changes. . . fl Erocedare in the Evaluation of Behavioral Adjustment . . . . 33 Procedure in the Evaluation of Hospital Status Five Honths after Investieetion . 36 RESUZTS Iethod of Analysis . . . . . F7 hesults vith Epinephrine Hypochlcride. . 39 Results with fiecholyl ChloriCe . . . 40 RESULTS (COKT'D) Results with Kecholyl Chloride in an Invest— igation Concerned with Behavior Changes. Results with Hecholyl Chloride in an Invest- igation Concerned with Patient Status Five Nonths After Drug Injection. DISCUSSION Practical Implications. . . . Theoretical Considerations . . . Implications for Further Research SUNKARY . . . BIBLIOGRAPHY . . . . APPENDIX Page 42 43 TABLES Table 1 Pearson r Correlations between Blood Pressure Changes as a Function of Epinephrine Hypochloride Injections and Necholyl Chloride Injections and Gardner Behavior Chart Mean Scores for Sixty SchiZOphrenic Patients. . . . . . 41 Table 2 Tests for the Significance of Difference of Gardner Behavior Chart Neans between the First and the Eighth Week of Obser— vation, for the Fifteen Subjects Having Largest Increases and the Fifteen Subjects having Largest Decreases of Blood Pressure Following Necholyl Chloride Injection. . 44 Table \JJ Chi Square Analysis of Release or Institu— tionalization Five Honths after the Initial Investigation, and Blood Pressure Reactions Following the Administration of Techolyl Chloride. . . . . . 46 (l) SURVEY AID INTRODUCTIOI T 13E PROBLEM General Introduction t the Concept of Schizophrenia e. __ Il— ‘ _A Attempts to define the disorder known as schizo— phrenia have met with many difficulties.v These difficulties are at least in part a function of the great variability of symptoms encountered in the schizophrenic patient. In study— ing the literature which deals with the problem of etioloay and diagnosis of the schizOphrenic, one is struck by the variability of judgments on the part of different authors re— sardine the origins, dynamics, and symptomatOIOgy of this disorder. Those points of agreement amongst authors dealing with the problem of schizophrenia are that the patient said to suffer rom a schizophrenic illness demonstrates such symp- toms as inapprOpriate emotionality and speech, bizarre behav- ior, and thinking disorganization. We freQuently find postue lated a clash between the world of reality and the fantasied world of the patient, which is evidenced by the presence of delusions and hallucinations. Attempts to define nosolocically the schiZOphrenic process have met with much criticism. When sub—groups are established having in common similar symptoms, much depends on what the individual examiner will choose to stress in order to arrive at a satisfactory classification. FreQuently, the patients have symptoms that out across several of the noso— losical catesories. Bleuler (4) called attention to the fact that clear sensorium of vision, audition, touch, and smell differentiates non—recovering patients from those who recover quickly and completely. Patients in the acute state of schiz— Ophrenia whose sensory functions are much disturbed are usual- ly those whose onset of illness was sudden and can be traced back to recent emotional stress. Patients, on the other hand, whose senses appear to be relatively well preserved but whose thinking processes are severely disrupted, are usually those whose onset of illiess has been slow in developing and whose prognosis is poor. This observation has led a number of writers, such as Kantor, Wallner, and Winder (19), to invest— igate the schiZOphrenic disorder in terms of "process" and"re— active" types of the illness. The "process" type of schizo- phrenia might correspond to Bleuler's patients whose thinking appears much disturbed, but whose senses appear to be well preserved. The "reactive" type refers to patients whose sen— sory functions show much disturbance, and whose onset of ill— ness can be traced back to considerable emotional stress. Kantor, Uallner and Winder (19) could successfully make a crude differentiation between "reactive" and "process" schiz— Ophrenia on the basis of Rorschach findings as well as clini— cal histories. In their study, each patient was classified as a "reactive“ or "process" schizophrenic on the basis of (3) Rorschach protocols. Patients called "reactive" as determined by their history, tended tctm called non—psychotic on the Rorschach protocol. As the authors pointed out, patients whose pre-schiZOphrenic personality was relatively normal, who had an acute onset of the disease which could be related to a specific precipitating factor, and whose sensorium was much disturbed at onset, manifest the "reactive" type. Bellek (3) has pointed out that what is perhaps most impressive about the etiolOgy of schiZOp.renia is the wide variety of factors reported. He goes on to conclude that: (a) SchizOphrenia is not a disease entity, but a syndrome or reaction type associated with a large variety of etiolOgical factors. He refers to the reaction as a "deficit" reaction, implying the organism's inability to function properly. (b) The syndrome may be hypothetically completely psychosenic in nature, or, it may be hypothetically completely somatic in nature. Between these two polarities, a continuum is as- sumed to exist. (c) Predisposition to the reaction may be considered from a constitutional, somatic, or sociOpsycholOgical vieWpoint. Factors interact differentially for different individuals. Bellak also sugoests that each case be considered on the fol- lowing four—dimensional scheme: a, somatic predisposition, b, sociopsycholOgical predisposition, c, psycholohical (a) precipitating causes, d, somatic precipita tino onus as He feels that failure to understand the complexity of the schiz- cphrenic process is a function of our inability to concept— ualize mul t plicity of causes. ophr enia .__J. P] Interrative Approaches to the Problem of Schi *d —-—- m a A relatively recent and promisino approach to the problem of schizophrenia has been an attempt to link psycho— renic and somatomenic factors in the consideration of the schiz0phrenic process. Angya l, Freeman, and Hoskins (2) uti- lize the concept of "withdrawal" and incorporate in it a large number of physiological and psycholocical characteris— tics encountered in the schizOphrenic patient. "Withdrawal“ on the psycholoeical level implies a reduction in intensity and Quantity of relations between the person and his environ— ment. This partial break in relationships to the outside world results in an increas ins impoverishment of living, and is reflected by the indifference, emotional blunting, and lack of interests encountered in schizophrenics. On the psy- cholocical level, an impoverishment of a large number of ‘nins et el (18) have 0') body processes is likewise noted. Ho performed a vast number of experiments involving general me— tabolism as well as functions of the central and autonomic nervous systems. A similar integrative approach to the problem of schiz Oph renia, liizewise using factors of physiological and psycholosical concomitance, is one that uses the concept of (5) "stress" as an eXplanatory tool. By "stress" is implied a‘ disruption of the orcanism—environment relationship (25 , This disruption may be viewed as a function of three types of situations. One situation may occur when the organism is ex— posed to an external stimulus for which there is no adeQuate adjustive response available. Another kind of situation oc- curs when the organism attempts to satisfy two eQually strong needs aroused by the environment. A third type of situation is the one in which the environment lacks adequate structure in order to satisfy an aroused motive on the part of the organism. Selye's eXperiments (28) with animals have shown a number of alarm reactions as a function of situations in— volvins "stress". He points out that all organisms respond to "stress" producing situations, and that basic reaction patterns of a behavioral, physiolooical and psychological kind result, irrespective of the spent producing the stress (28). LeVay (20) comments upon failures to adapt to "stress" producing situations, and calls such failures "diseases of adaptation". Such failures are reflected at all levels of the organism's existence. As a "stress" producing situa— tion evolves, the organism is called upon to respond to it in an inteorative fashion. In this attempt, not only do pgy- cholomical changes occur, but internal physiolosical changes likewise are a part of the evolving attempt to deal with the "stress" producing situation. The anterior pituitary gland Cn‘x ( ) is stimulated, effecting release of the adrenal cortico— trOphic hormone ACTH. This in turn stimulates the adrenal cortex, the corticoid hormones of which produce widespread effects on target organs. Since conditioning patterns may considerably alter the reaction pattern to "stress" on a psycholOgical level, diverse symptomatology results. Indi— ‘viduals who are suffering from schiz0phrenia have evidenced a lack of ability to c0pe with situations. We are thus con— fronted by a vast number of symptoms in which the schizo— phrenic gives evidence of this lack of adjustive ability. It is Quite apparent that concepts such as "stress" and "withdraJal" have in common an increased emphasis upon an integrated approach to our understanding of the schizo— phrenic process. There is no evidence that the schizo- phrenic process is caused by either biological or psycholog— ical factors working alone. The value of these concepts rests upon their attempts toward a unified approach to the problem. The assumption of a psycho-biolOgical disturbance not only helps to clarify our conception of schizOphrenia as a disorder of the total person, but furthermore helps to cut across the nosology of either a psycholorically or organ— ically biased approach. It makes a distinct difference with regard to the type of problems investigated. Some Physiological Aspects pf Scnizophrenia A‘ The literature in the field of physiolOgical as— pects of schizOphrenia is voluminous. No attempt will be (7) made to include in this at Ivey more than a brief represent— ative sampling. Inasmuch as the present study will deal more specifically with autonomic nei vous system functions, these will be described under a sepa r te section. The present investigator he s oeen impressed by the many physiological investigations whi ch are ill sup— ported by factual data and lack statistical correctness. Many studies have a tendency to sound conclusive, but up- oncloser analysis are unsupportable because repeat in— vestigations show negative results. Few of them yield more than promising trends at best. A notable exception are the studies that, for a good number of years, have been car- ried out by the Worcester State 40.nit 1P . sea arch Service These studie encompass the areas of metabolic reactivity, central nervous system reactivity, and auto— nomic nervous sy stem functions in schizophrenic subjects. The overall impression one gains from these investigations is th t the schizophrenic patient suffers from a hypo—reac-~ (\3 tivity of these body processes. Upon administration of met— abolic stimulants, such as desiccated thyroid substance, investigators found a strong resistance to t: “.e eXp acted in— crease of metabolic functioning (6, 17). Administration of the autonomic nervous system stimulant, Epinephrine, by Freeman (10) produced less response in OXygen consumption, (8) cutaneous temperatures, and perSpiration rate in twenty schizophrenic subjects than in control subjects. Studies of central nervous system reactions likewise tend to sup— port the assumption of hypo—reactivity in schizophrenic patients. Angval and Bla kman (l) discovered that vestib— ular activity to calorie and rotatory stimulation in a group of fifty-eight schiZOphrenic subjects was markedly re- duced, when compared to a control group. Rubin (26) found that, upon hyper—ventilation in a group of schizonhrenic subjects, only a 52% increase of slow waves as measured by the EEG will occur, when compared to a group of normal subjects. This latter study emphasizes the inability of the schizo— phrenic to cope with the metabolic problem inherent in the hyper—oxidation of brain tissue. The schizoyhrenic is appar— ently unable to absorb excess oxygen in his central nervous system. Hoskins (13, p. 15?), in summing up the total of physiological studies, states: "The schiZOphrenic is marked by numerous defects of adaptive efficien y, leading to in- adeuuate and uneconomical organic response to changing stin- uli. Obviously, in the human mechanism, failure of inte- gration might be due to functional imbalance arising in a variety of ways, including conditioning in the broadest of. terms. It would seem that the prodigality of effort re— quired for organic adaptation leaves the patient with but inadequate energy for successful adaptation in the social (9) field. Bellah (3) comments upon this by statine that all thes se ooserved cha.n.c es are but dizferen levels of eXpres— sion of an overall disturbance. The.Autonomic Kervous Systeg i_ its R a.tion :9 Schizophrenia This study attempts to relate he reaction sensi— tivity of the autonomic nervous system to the behavioral ad— justment of sch lizop re nic patients. The following discus- sion aims therefore to present briefly autonomic nervous cysten functions, aul a series of studies that investing te their relationship to the schizOphrenic process. he autonomic nervous system consists of nerves, ganglia, and plexuses which provide innervation to the heart, blood vessels, rlands, viscera, and smooth muscles. It is, therefore, a videly distributed system and controls autonomic or veaetative functions (15). This system can be divided in- to two divisions which serve rouehly different functions. The sympathetic nervous system is not essential to life, and animals deprived of it can continue a fairly normal exist- ence within the laboratory. This division freQuently dis- charges as a unit, which results in heart acceleration, red blood cell increase in the circulation, blood sugar rise, pupil dilation, and, in general, changes that prepare the or— ganisn for fight or flight. The parasympathetic system, on the other hand, is essential to life, and is organized for discrete and localized discharge. In its function as (lo) conserver and restorer, it tends to slow the heart action, lowers blood pressure, stimulates gastro_intestinal move- ments, aids absorption, protects retinas from excess light, and empties bladder and rectum. Greatly enhanced by the effects of sympathetic stimulation, the adrenal cortex secretes Adrenin, which in turn reinforces the sympathetic stimulation. Nerves in— strumental in the release of Adrenin are known as adrener- sic nerves. It furthermore appears that mainly upon pare- sympathetic stimulation, a substance known as Acetylcholine is secreted, e.hancinc the effects of this autonomic div- ision. While the actual method of production of this sub— stance in the body is not fully understood, it appears that it is secreted at the nerve endines of parasympathetic as well as some sympathetic nerves. These nerves are known as cholineraic nerves (15). The synthetic production of Adrenin and Acetylcholine has enabled investigators to study in more detail the reaction sensitivity of the autonomic nervous system. Investisations of autonomic nervous system pro— cesses in their relation to the schiZOphrenic process have primarily dealt with the efficiency of organs responsible for the secretion of the substances Adrenin and Acetyl- choline. (11) Hoaaland (16) has shown that, in a study of one hundred schiZOphrenics, two—thirds of this group was sub— normal in its adreno-cortical responses. This adrenal act— ivity is a function of autonomic nervous system stimulation. Adrenal stereoids have far—reaching metabolic repercussions on tiSSue metabolism, includinm that of the brain. Thus, there are mechanisms which mieht modify brain functioning .in the direction of producing the distortion of affect and association processes associated with the schiZOphrenic pro- cess (16). It is well to remember that th=re is no implica— tion here regardinm the cause of the schiZOphrenic process. The sienificance of these findinss rests upon the observa— tion of psycho—physioloaical Chane s in the orsanism, once the failure to adapt has commenced. Although the organism is regarded as functionine in a holistic framework, in which a breakdown of autonomic nervous system processes is an indication of failure to relate adeQuately to the environ— ment, the oriein of this adaptation failure remains multi- Investigations concerned with the functions of autonomic nervous system processes have devoted much atten- tion to the thalamic centers. A considerable body of evi— dence shows that the hypothalamus is of prime importance when one considers the effects of the autonomic nervous sys— tem in schiZOphrenics. Cannon's (5) pioneering work in re— lating the functions of the thalamic center to the emotional (12) life of the organism is much suppor ed by recent studies con— cerned with the functions of the autonomic nervous system. Pincus gt §l_(24, 25), in a series of studies have shown that hypo-activity.of the adrenal cortex is found when disturbed schiZOphrenics are subjected to situations involving a sud— den threat to the organism, such as loud noises. A confirm— ation of this finding comes from a similar study conducted by Hoaeland (16), who likewise finds consistent hypo—active adreno—cortical responsivity in situations of psychological stress. Freeman (8, 9, 10) suggests that the schiZOphrenic reaches a stable balance at the cost of losing contact with his environment. The behavioral picture of the chronic schiZOphrenic emerges as beind non—discriminating, non—adapt- ive, and inflexible. This state is likewise reflected in the schiZOphrenic's autonomic nervous system slugrishness, as in— dicated by defective adreno—cortical functioning. Primary control of autonomic functioning is lodged in the hypothalamus. The distinctive importance of the hypothalamus is its intesrative effects upon autonomic dis- charges (15). These integrative functions are derived from its relationship to the various neural and endocrine mechan- isms reaulating the internal environment of the organism. Nuclei contained in the hypothalamus can be divided into two main groups: a) the posterior and lateral nuclei, and b) the medial and anterior nuclei. When stimulating the former, (13) one obtains all the effects of sympathetic discharge, in- eluding pupil dilation, blood pressure elevation, and heart acceleration. When stimulating the latter, one obtains the effects of parasympathetic discharee, including blood pres— sure drOp, heart deceleration and pupil contraction. Emotional arousal changes the chemical and endo— crine balance of the blood. Release of Adrenalin from the medulla of the adrenal glands, activated by hypothalamic act— ivity, results in the effects associated with sympathetic discharge. Nerve fibers associated with the parasyrpathetic system release acetylcholine which has effects similar to parasympathetic enervation. Release of this substance has similar effects to those produced by electrically stimulat— ing the medial and anterior nuclei of the hypothalamus. Research in this area points to the fact that ap— parently we do find unusual reactions of the autonomic ner- vcus system which are associated with the schizophrenic pro— cess. This is to be expected, if we reeard schiZOphrenia as m disease process in which communication between the indivi- dual and the environment has become severely disrupted. SchiZOphrenics react to sensations which are not in accord 5 with the real world. This leads on to suspect that the 0 would 0 I". U) mechanism whose function it is to c0pe vith sensati likewise reflect this impairment. If one were to investigate (it) the extent of such an impairment, one mihht obtain an in— dicator not only of the present state of the schiZOphrenic disease process, but also of its prorncstic implications. nochlor_ A Adrenin, or its synthetic eQuivalent Epinephrine Hy ids, and Acetylcholine, or its synthetic equivalent Mecho— lyl Chloride, appear to be the energizing substances se— oreted by the oreanism under stress. The Autonomic Fervous Eystem Test Funkenstein 33 al (11, 12, 13) have shown that a sienificant relationship exists,in a eroup of mentally ill patients, between reaction to the injection of autonomic nervous system stimulants, and the reaction to electric shock therapy (ECT) and insulin coma therapy (ICT*). The Funkenstein test of the autonomic nervous system was administered as follows: With the patient at rest, blood pressure measurements were obtained until con— stant for a period of five minutes. Che cc. of saline sol- ution was then administered intravenously, and systolic blood pressure measurements obtained for a period of thirty seconds. This had as its object the elimination of any pet- .ients in whom the suggestive element of the needle mirht ac— count for the blood pressure chanees. On the second day, a solution of .05 mo. of Epinephrine Hypochloride was inject- ed intravenously within one second, in order to raise blood * Henceforth, the above abbreviatibns will as used. (15) pressure. Systolic blood pressure measurements were ob~ tained every fifteen seconds, becinning at thirty seconds after injection time, until a return to basal pressure was recorded, and remained constant for five minutes. A solu— tion of 10 me. of Hecholyl Chloride was niven intramuscular- ly on the third day, in order to lower blood pressure. Sys— tolic pressure measurements were obtained every thirty sec- onds for a total of six minutes, and once every minute thereafter for nineteen minutes, until a total of twenty- five minutes had elapsed, at which time all patients' blood pressure had returned to basal pressure. Results of blood pressure reactions to these druss were recorded for each patient. Patients were subseQuently divided into seven sroupinas, differing from each other ac— cording to their blood pressure reactions, as described by Funkenstein (11). Since this original study, however, it has been found by Meadow and Funkenstein (22) that these sev— en groupings can be conveniently re—combined into three dis- tinct groups that yield distinctly different blood pressure reactions. These groups can be differentiated from each other by using the following criteria: (a) basal blood pressure (b) heiaht of blood pressure rise af er Epinephrine in— Jection (c) immediate fall of blood pressure after Kecholyl in. Jection (16) (d) possible delayed rise after Mecholyl injection (e) return to basal blood er ssure (r omeostasis) - The description of these sroups is as IOllOt : "Group A Epinephrine: Marked stronc rise in systolic pressure above 50 mm. of mercury, vith re— turn to pre—injection level within 3-7 min- utes. ' Mecholyl: Slisht fall in systolic pressure with early rise above cre- injection level, and no return to homeostasis Iithin 25 min— utes. Group B Epinephrine: Harked or moderate rise in eye- tolic pressure, not above 50 mm. of mercury, Iith return to basal pressure within 3—7 min— utes. Mecholyl: Moderate fall in systolic p-res sure with or without slisht rise above pre— injec— tion level, but return to homeostasis within 25 minutes. Group C Epinephrine: Moderate or marked rise in eye— tolic pressure, not above 50 mm. of mercury, with return to pre-injection level within 3—7 minutes. Mecholyl: Harked fall in pres sure with failure to reach pre-injection level within 25 minute oservation period" (22, p. 135). The followinc interpretations are offered, in an effort to explain these strikinsly different reactions to the injected druss. Meadow and Funkenstein (22) point out that Group A type reactions represent a sympathetic release phenomenon similar to that observed in sympathetic denerva- tion. Evidence for this is based upon the extremely marked .0 rise of systolic blood pressure, exceedinr 50 mm. 01 mercury rise, in response to Epireoh nine injections shown by patients A. A (17) in this group. Results of a long series of xperiments in— dicate that sympathetic denervation produces a heishtened reaction to Epinephrine (22). It thus appears warranted to state that the sympathetic nervous system of sroup A pat- ients does not react to physiolosically induced stress in a normal fashion. Funkenstein (11) .as demonstrated that this sroup shows the least inprovem nt after ECT, while Meadow and Funkenstein (22) have shown that this group suffers from the most sisnificant loss in abstraction ability. Group C patients includes those patients who evi— denced marked anxiety before, durinw, and after the injection of the drucs. All cases of severe chill after the Mecholyl injection were found in this grO‘p. Group B patients did not show marked anxiety reactions. It was furthermore reported that Group B patients, while evidencins severe emotional dio— turbances before and after the actual eXperiment, did not evidence any marked rise in blood pressure durins these dis— turbances. Group B patients, who show no particular autonomic system disturbance, yield only a fair prosnostic picture after ECT and ICT. Although these patients are apparently under considerable psycholosical stress, as indicated by their extreme disturbances in associations and affectivity, the autonomic system is apparently not intecrated with the - rest of the orcanism. This is shown by the virtual lack of (16) blood pressure channe when under violent mood spells severe enouch to warrant seclusion rooms. Group C patients show a heishtened reaction of their_autonomic nervous system to the autonomic nervous sys- F.) tem stimulant. This group has an excellent prornosi fo (D lowins ECT and ICT, while their abstraction ability is least impaired (21). The proanosis of group B patients following ECT and ICT, is better than that of Group A patients in whom the reaction actually reflects denervation. It is only sroup C, however, in which physiolosical stressors, in con- Junction with the psychological stress under vhich the schizophrenic usually Operates, produce heightened sympa— thetic activity, that appears to be the most favorable sign for improvement followino EST and ICT. Studies that have attempted to relate psycholosi— cal tests to the above discussed physiological stress re— actions have been relatively few. Meadow gt gl_(2l, 23) at- tempted to discover to what extent anxiety level related to specific autonomic groupings. The Hechsler—Bellevue disit span and arithmetic subtests, and the Rorschach sum shading and turnins scores, were used in an effort to investigate anxiety level in fifty-eicht schiZOphrenic patients. Hypoth— eses stated that a hish anxiety level would relate to auto— nomic group C, while a low anxiety level would relate to groups A and B. These hypotheses were not confirmed. The authors felt that the questionable reliability and validity of the anxiety measures were to be held accountable for the negative findings. Meadow and Funkenstein (22), in an in— vestisation desicned to relate the extent of abstraction ability in a group of fifty—eight schiZOphrenic patients to autonomic groupings, utilized the Hechsler-Bellevue similar— ities and block desisn subtests, the object sorting tests, and the Benjamin Proverbs tests. Hinhest loss of abstrac- tion ability was encountered in patients belonsing to the prosnostically poorest autonomic group A. Highest abstrac— tion ability was sisnificantly related to group C reactions. Ficca (7) attempted to relate Hechsler—Bellevue clinical patterns as well as Rorschach scores and signs to the Funkenstein autonomic groups. His subjects were com— prised of twenty—einht schiZOphrenic, thirty—one neurotic, and seven psychOpathic patients. No statistically signifi— cant relationship could be established between autonomic proupinq and Yechsler-Bellevue pattern. It appears, accord- ing to the author, that attainment and scatter measures seem characteristic of the hospital pOpulation as a whole, rather than of autonomic groupings. Rorschach scoring cateoories, locations, pOpular responses, and sum of color were used as a further basis of comparison. Sienificant relationships could be established between the number of human and in- animate movement responses and sfecific autonomic groupinss. r4 ”.3 “3 Movement responses were sir i icantly hisher in the (20) autonomic groupinn that is related to a favorable proxnosis. The number of schiZOphrenic "signs" appeared to be sisr ifi- can tly related to the autonomic sroupinps. The prOpnostical- ly more favorable autonomic group contained patients who had les es schiZOphrenic "sisns" in their FJor schach urotocols. The v i J author admits, however, that the number of subjects for each (D ”A group were so small that th iidinr do not warrant any def— 5... U) inite conclusions. The author furthermore utilized Funken— stein’s orisinal seven group breakdown, a method that, since Ficca's study, has been found to be not reliable, and which furthermore requires very larse groups of patients. '3‘ The investigations discussed so far ave attempted 1 to discover relationships between pnysiolos *4. cally induced autonoric nervous system reactions, psycholosical test find— inns, and provres s of the schiZOphrenic disorder after, or before, electric and insulin shock treatments.' Bo attempt has been made to investigate th e possible relationship oe— tween autonomic nervous system reaction to physiolomically tmsnt, and trends of induced stress, level of current adjus behavioral change in untreated schizophrenic patients. The importance of a study desisned to investigate the relationship between autonomic reaction patterns and 5 spontaneous improvement rests uzo. its conseQuent predictive J. .L g) g. value regarding the outcome of illness. It has become a (21) standard procedure to utilize shock treatment technigues almost immediately upon hospitalization of a schiz0phrenic patient. The effects of such technigues, while beneficial in some cases, are relatively uncontrolled, and furthermore not understood. Patients rho give a favorable autonomic response to the Funkenstein test (11) would conceivably be apared from the possible undesirable side effects of indis- criminate shock treatments. The theoretical implications from such an investigation are likevise of great interest. Our conception of the etiolowy and pronress of the schizo— phrenic illness has become so overwhelmed by personality dynamics and direct observations of the patient's behavior, that body processes are by-passed. It is felt that the type of investication prOposed is an important step in the dir— ection of viewing illness as a total process. . --g—..J..4 VI.%"D Iv“C""W‘m‘ This study is an attempt to relate observed be— havioral adjusts tent of institutionalized scci"ac renic pat— ients to blood pressure chances following the injection of the adrenerric drug Epinephrine .ypo hlo de and the chol inergic drug, Mecholyl Chloride. This study furthermore is an att m:.t to relate behavioral changes observed over a two months time span to characteristic blood pressure changes following the injection of the drugs, Epinephrine hypo- chloride, and Hecholyl Chloride. The objective in this particular study rests upon the need to possess a clinical tool that can be used as a possible prornostic instrument to predict whether or not a patient su fe ring from a schiZOphrenic break will recover without the interference of shock treatments. Shock treat— ment may be regarded as possessins chiefly an ameliorative value, especially when viewed as a tool to calm the disturbed patient or to elevate the mood of the depressed patient. The choice between the use of barbiturates and shock treatment in calming the patient has become in many instances a hishly arbitrary one. It is no exasseration to state that in many state hOSpital settings, usesof'ECT and ICT have become a standard procedure. The indiscriminate use of such treat- ment appears to be highly undesirable as a aenera l policy, since neither improvement nor failure to improve after (23) shock treatment can be eXplained nor accurately predicted. While it is Quite true that shock treatments frequently do have beneficial effects, it appears hishly desirable to this investigatorlto predict a patient's behavioral adjust— ment more accurately before subjecting him to a series of shocks. It is with this consideration in mind that the present study was develoPed. As Funkenstein, Greenblatt, and Solomon (lb) have indicated, success or failure of ECT and ICT can be significantly predicted on the basis of characteristic blood pressure reactions to the adrenergic drug, Mecholyl Chloride. It appeared to this investigator that it would be hishly desirable to investigate the behavioral changes of schiZOphrenic patients, after first having obtained their characteristic blood pressure reactions following the injec- tion of Epinephrine and Mecholyl Chloride) without any shock treatments at all to be administered during the observ- ation period. In other words, can one significantly predict behavioral changes without shock interference, using blood pressure reactions to these two drugs as a criterion? If using these drugs results in sinnificantly accurate predic- tion, we would have a prOpnostic measurement of considerable value in deciding who is and who is not to receive shock treatment. It would, furthermore, be of great value to know whether characteristic blood pressure reactions following the injection of Mecholyl Chloride could be used as a prosnostic device in predicting what patients would be discharged after a certain period of hospitalization. The problem may be stated in the following 1) The Quality of behavioral adjustment in a group of schiZOphrenic patients is sisnificantly related to a characteristic autonomic nervous system reaction, as defined by the direction of blood pressure change, induced by the adrenersic drug, Epinephrine Hypochloride, and the cholinergic drug, Mecholyl Chloride. a) Decrease of blood pressure following the injec- tion of Epinephrine Hypochloride is related to unfavorable behavioral adjustment. b) Increase of blood pressure following the injec— tion of Epinephrine Hypochloride is related to favorable behavioral adjustment. c) Decrease of blood pressure following the injec- tion of Mecholyl Chloride is related to favor— able behavioral adjustment. d) Increase of blood pressure following the injec— tion of Kecholyl Chloride is related to unfav— orable behavioral adjustment. A i a U1 V The trend of spontaneous behavioral adjustment changes over an eight week observation period in a group of O schiZOphrenic patients is sisrif cantly related to the direction of bloc pressure ch nnes fol lowins th in— jection of: Mech lyl Ch loride. a) Decre a.se of olood pressure followin~ the injection of hechoiyl Chloride is re elate to favorable be- _havioral adjustment chanses over an eisht wee; ob- servation period. b) Increase of blood pressure following the injec- tion of Hecholyl Chloride is related to unfavor— able behavioral adjustment chances over an eirht week observation period. Discharge from the Traverse Ci.y State Hospital is significantly related to blood pressure changes fol- lowinc the injection of Hecholyl Chloride in a group of schiZOphrenic patients. a) Decrease of blood pressure ollowin~ the injec- tion of ”echo lyl Chloride is related to hospital discharge within a five months period after ad— mission of a group of schiZOphrenic subjects. b) Increase of blood pressure following the injec- tion of ”echolyl Chloride is related to co;.tin- ued hospital confinement beymui a five months period in a group of schiZOphrer 110 patients. (26) Funkenstein (ll) reports that the characteristic reaction in patients who are more apt to improve followinr hock treatment is a gradual decrease in blood pressure fol- lowinr the injection of Mecholyl Chloride, with the blood pre sure remainins below the individual's normal pressure for an approximate twenty-five minute observation period._ Most characteristic of poor prornosis following shock treatment is a blood pressure reaction that, while often in— dicating a short fall in blood pressure,is Quickly followed fl 1 his 1 F— by a large increase of blood pressure. considered U) an abnormal reaction. Administration of a cholineroic drug should normally energize the garasymoatnetic system with .5 *3 resultant blood pressure decrease. These two most charac— teristic reactions to Hecholyl Chloride injections will be used in an analysis of their sionificance in relation to be- hevioral adiustment, behavioral change, and discharge from U the institution. ‘ Funkenstein's results with Epinephrine have oeen less conclusive. He reports frequent abnormal blood pressure changes in patients who react most poorly to shock treatment (ll). He found that the sub cetive evaluation of manifest 9. I u 9.) aixiety was the most signific nt indicator of a good prog— nosis following shock treatment. In this investigation, the attempt will be made to evaluate blood pressure section to Epinephr’ne in terms of abnormal increase as well as (27) of h latter phenomenon }. I. U) ecrease of blood pressure, althcurh ,_-J has not been preViously dealt pith. Can such an abnormal blood pressure reaction to Epinephrine be related to behav— ior adjustment in a manner similar to one which utilizes the parasympathetic stimulant Hecholyl Chloride? It was not felt that the evaluation of "manifest anxiety", how— ever, could be used as a valid and reliable criterion, due to the inherent diffic lties in such a subjective evalua— tion. (99 ~v HE‘HODOLOGY .5 .. .— The subjects selected for this study consisted of sixty patients, diagnosed uneCuivocally as suffering from a schizophrenic disorder. These subjects were obtained at the Traverse City State H epital. Care was taken to uti— lize only patients free from the following disorders: heart disease, thyroid disorder, tuberculosis, diabetes, .yper— tension, or any organic disorder involving central or peri- pheral nerve mechanisms. Inasmuch as the druss Epinephrine and Mechclyl Chloride constitute some threat to the organism when administered, it was felt that any complication arising from usinr the drugs would be minimized in this manner. The age ranre of the subjects extended from are nineteen to forty—one years, with a mean of 28.7. An at- tempt was made in this study to avoid older subjects, since the use of the druss can constitute a possible health haz— ard, especially for the older patient. With the exception of the senile groups at the institution, the are group uti- lized well represents the average are of the patients at the hOSpital. While it was not felt that the range of intelli— nence had to be considered as a possible factor to be controlled, care was taken not to utilize any patients who were found to be mentally deficient. This was felt to be a further safecuard in avoidino any subjects who might conceiv— ably be sufferinc from a central nervous system disturbance. One of the objectives in this study was to invest— irate spontaneous behavior chanoes over a two month time span in patients sufferins from schiz0phrenia, without the administration of any of the physical therapies. This proved to be one of the most difficult aspects to control. While ICT was not difficult to control since during the time of study, it was not administered; ECT was administered as standard procedure. The crisinal sample of eiehty—seven patients was reduced to a total of sixty, primarily due to the administration of ECT at some time during the observation period. None of the patients received any psychotherapy dur— ing the time of this study. Some of the patients did receive hydrotherapy. It was not felt that the effects of this ther— apy have any more far—reachins effects than the general en— vironmental chance that occurs when a patient is admitted to the hospital surroundings. The orieinal aim had been to utilize a sample of patients totally comprised of recent first admissions to the receiving hospital. However, sample controls as described above necessitated the use of a sample of schiz0phrenic patients who had been institutionalized for a period not exceeding three years. While the majority of subjects had been institutionalized less than one year (70%), none of the subjects used had received any ECT. The sample thus includes sub-acute as well as acute schizophrenics. Care was taken to include only subjects who had not previously been institutionalized. This was deemed to be important, since freQuently the record accompanying the patient ne— glects to include possible therapy the patient mirht have obtained. Althoueh the sex of the patient did not appear to have any bearing on the results of the study, it develOped by chance that the population of sixty was divided evenly into thirty males and thirty females. Procedure in the Administration of Druss The drugs, Epinephrine Hypochloride, a synthetic eQuivalent of the adrenerqic hormone adrenaline, and Hecho— lyl Chloride, the synthetic eQuivalent of acetylcholine, were administered to all sixty subjects. O The injection of Epinephrine hypochloride was performed by medical personnel, since due to its rapid dis- integration, it has to be administered intravenously. A dosage of .05 ms. of Epinephrine Hypochloride was adminis- tered, accordins to Funkenstein (ll). Prior to the (31) intravenous injection of the drug, the subject was subject— ed to an intravenous injection of saline solution, the pur~ pose of which was to control the possible psycholowical ef— fects which may cause great fluctuations in blood pressure; Any subject fluctuating more than ten points from his rest— ing blood pressure was eliminated from the sample. After each patient had recovered from the Epin— ephrine Hypochloride injection, as indicated by blood pres— sure return to normal, Kecholyl Chloride was administered intramuscularly. A dosage of 10 ms. of Hecholyl Chloride was administered, following Funhenstein (ll). It is to be noted that this procedure differs from Funhenstein's, inso— far as the Mecholyl Chloride injections were administered on the same day as the Epinephrine Hypochloride injections. This was done in an effort to avoid the considerable upset of patients when they are transferred to different surround— ings, reQuired in order to administer the druss. The fact that Mecholyl Chloride was administered after basal blood pressure measures had been obtained for a minimum of five minutes, indicates that the injections of Epinephrine Hypo- chloride had been neutralized by the organism. Procedure in the Evaluation of Blood Pressure Changes The critical aspect of this study involved the ac— curacy of blood pressure m asurements prior to, during, and iollovino the admi istration of the drurs. The instriment used was the reliable arm cuff manometer. Crea t ca -re yas taken to instruct student nurse personnel in the accurate measurement of blood presSure, since careless use of the measurin" inst: unent could seriously impair the accuracy of reaiinss. According to iu.kenstein, only systolic readinrs were recorded (ll). Speed and accuracy of measurement were of prime importance in the evaluation of extremely rapid blood pressure chnnres At the berinnino of the e"rerinenu, patient were kart in a su-iie position for a minimum of fifteen minutes. Durina th is time, a minimum of three blood pressare readines were obtained. Followinn this restinr period, the saline solution was administered and an additional three blood pressure rea ndinns were obtained. vCut of this minim m total of six reafinrs avereve systolic pressure was obtained. After the administration of E Anephr ins Hygochloride, blood pressure readinas were obtained every fifteen seconds, for a period of seven minutes. I d returned to normal, (0 ( After blood pressure :eriol the drir, Hecholyl c!" (D .-4 usually within a fifteen minu~ Chloride, was administered. slooa pressure readinds were ob- tained every thirty seconds for a period of six minutes, fol- 1‘ loved by ree: inds every sirty seconds, until a total 3- twenty—five minutes had elapsed since injection t he. Darius (33) both Epinephrine Hypochloride and Lecholyl Chloride reac— tions, blood pressure readines were stopped when a subject' yielded a minimum of three readines in succession of eQual pressure. Usins normal blood pressure as a base line, in— creases and decreases of blood pressure were carefully re— corded. The maximum amounts of blood pressure increase and of blood pressure decrease were used as the critical ficures in this study. Tie reliability of blood bressure reactions to J. ) the drwes administered was considered to be of great impor— tance. Will the obtained maximum blood pressure reactions to these druss be fairly stable? While it is generally ac- cebted that normal blood oressure remains very stable over long time periods, it was of creat concern in this invest- ivation to have some knowledce regarding the reliability of the lrun reactions. Funkenstein, Creenblatt, and Solo— mon (1h) report on such a reliability investisation, in which they found no sienifi ant differences between arougs of twenty-one, sirty—four and fifty-five subjects run in two trials. dehavioral Adjustment OJ Eroce .LPG in the Evaluation 0; “-— .—>-o-—.— fl The instrument used in the evaluation of behavioral adjustment and of chanwes in behavioral adjust— ment was the Gardner Behavior Chart (30). This chart was developed as an aid in obtainins such a record in the get- ients' behavior, so as to allow a runnins commentary on be- Cf havioral adjustnen as well as chances in adjustment. The {)1 followins cateeories are use in determining behavioral ad. justnent: attention to personal appearance, sleep, appe— tite, sociability, activity control, care of property, self-entertainment, COOperation on routine, work capacity, work initiative when alone, work initiative when supervised, willincness to follow directions. Under each catevory five brief phrases characterize the degree of adjustment for the Specific behavior sesment. The numerical evaluation for these five phrases runs from 0— none, 1— poor, 2— fair, 3-sood, and s_extra sood, (See Appendix). In this man— ner, a possible maximum mean score of four, and a possible minimum mean score of zero can be obtained. The Gardner Behavior Chart appears to be well suited for behavioral evaluations. It utilizes a number of Questions desirned to elicit direct information that ap— pears to be inherently valid, since these Questions deal demand a (’1' concretely with those as;ects of behavior the direct ansver. The wording of the Questions appears to be of such a nature as to allow little if any misconcep- tion on the p-rt of nurses and attendants who sueply th I information. In a study of post-Operative changes in a 1 4 (D r). (U 4 H O ’3 O ,3. I} *3 6+ lohotomized patients, the Gardner was used extensively. Schrader and Robinson (27) point out that these scores make possible the Quantitative con- sideration of sroup averanes, as well as affordins conven— ient indices for judcing the status of individual patients. In their particular study, it was of sreat value inasmuch as it sisnificantly indicated critical differences between pre- and post—Operative scores. Patients in the sample were rated tvice weekly for a period of eieht weeks. Each weekly rating was obtained twice on the same day from two different shifts of nurses and attendants. This was done for the following reasons: one was that practical circumstances reguired different at— tendants and nurses due to freQuent shift in personnel; another was that possible halo and anchoring effects were avdided; and a third was that double ratings could be used in a reliability estimation of the instrument. Observation over a period of eieht weeks was felt to be a minimum in ) order to discover any trends of behavioral change in the 3) "S 0 up of patients. No previous study had investiaated the reliabil— 1.. ity of the dardner Behavior Chart. It was felt that snow— ledce concernind its reliability as a clinical instrument was essential if one were to use it as a criterion measure for behavioral adjustment. In order to arrive at an est— imate of reliability, the judrments of two independent sets of judges, consistins of nurses and attendan s, were analyzed. These two sets of judges had rated each of sixty patients. Judsments durins the eimhth week of behavioral observation were utilized, and a Pearson r was computed. A correlation :- CF? Oi . 0*-) # . O 30 was obtained. This relationship is considered sionificant at well below the one percent level of confi- H) dence. This indinw suaports the assumption that the Gard— ner Behavior Chart is a reliaole instrument for the evalua- tion of behavioral cateeories. Procedure in the Evaluation of Toss ta Status Konths after Investieation The sixty patients were classified as to status five months after the drus injections. This classification was as follows: paroled from hospital, in hospital, and on indeterminate status (such as home visit or family care). Only the first two aroujs were used in the evaluation of status and its relationship to drue reactions. These first cateeories represent clearly definable status. The last Icatesory represents a poorly definable status, EEC was not used in the evaluation. In this manner, fifty—one sub— jects could be used in this investiaation. (37) RESULTS The following data were obtained for each of sixty subjects used in this investigation; blood pressure measurement when at rest, blood pressure measurement after intravenous saline injection, blood pressure measurement after intravenous Epinephrine injection, blood pressure measurement after intramuscular Mecholyl Chloride injec— tion, weekly behavior chart ratings for eight weeks, and hOSpital status five months after the initial experiment. After the resting blood pressure recordings had been obtained, maximum increase and maximum decrease of blood pressure after the injection of Epinephrine and Hecho— lyl Chluride were recorded. This procedure differed from Funkenstein's original procedure(ll). Funkenstein had re— corded the total number of pressure readings, on the basis of which he assigned patients to seven groups differing from each other in their blood pressure recovery rates . He was forced to eliminate two groups due to their unrelia— bility, reducing the total to five groups. Headow(2l), in a similar kind of investigation, had been forced to reduce these groups further into three separate groups . He foll— owed this procedure due to the extremely small number of subjects he had been able to obtain for the eliminated two groups. This investigator was struck by the very large (3:) decreases or increases after the injection of the drurs. It was therefore felt that tao troupe which could simnlv A V se and blood pressure go be regarded as blood pressure incre decrease sroups, would most adegue tely inCic ate the gross— ly different reactions. A further consideration had been the number of subjects that were available for this study. In order to attempt to obtain sufficiently large groups, a much larcer number of patients would have been necessary. Analysis of the data revealed furthermore that the tenden— cy amonest the patients was to either decrease, or increase their bloodp essure; fluctuations in both directions vere us ally sma ll or did not occur at all. L In order to discover the strenrth of relation— ship betveen maximum blood pressure increase and maximum blood pres mare decrease, e.nd the injection of Epinephrine and hecholyl Chloride, Pearson r co— efficients were com— puted between these blood pressure peaks and the behavior ratine mean scores. In order to arrive at an estimate of the differ- ence between first week and eirhth week behavioral observ- ations, and its relationship to maximum increase and maxi— mum decrease of blood pressure follovine the Mecholyl in— jections, the sicnific -nce of the difference oetvwe n oehav- ior retina mes ns was computed. Inspection of the data indicated that selection of the fifteen largest blood pres- sure increases and fifteen larnest blood pressure decreases would most succinctly show the predicted trend. In order to discover the extent of relationship between hos pitel status five months after administration of the drugs, and the increase or decrease of blood pres— sure as a function of the administered drues, Chi Eduare analysis was utilized Results with Eoinephrine Ev;ochloride It had been predicted that si. ‘ fic ant relation- ships could be ootained between cood oehavioral adjust— ment and an increase of blood pressure after the adminis— tration of Epinephrine Hypochloride Conversely, it was predicted that a siwnificant relation ship could be obtained between poor behavioral ad justment and a fall in blood pressure following the administration of Epinephrine Hypo— chloride. The concepts of "good" and "poor" behavioral adjustment are a function of the relative standine of the Tardner Behavior Chart mean score for sec on patient A maxi— mum "hood" adjustment would be reflected by a .ea n score of four and a maximum "poor" adjustment by a mean score of O. In other words, "good" and ”poor" indicate hieh and low scores on the Cordnor Beh.avior Chezrt, and are a function of the total sa.znp?_e used in this investigation. ~(40) Using Pearson r co—efficients in order to invest- igate these predictions, no significant relationship could be established4 l ** Sisnificant at between the one percent and two per— cent levels of confidence. DISC'SSION’ Practical Implications The need for a broader base and greater usefulness of our clinical understanding cannot be sufficiently stressed. Useful as the psychodiagnosis of the schizophrenic disorder is, it is not enough if we hope to be able to appraise the to- tal functioning organism. One of the primary problems that confronts us in the appraisal of the schizophrenic disorder is the extent of physiological imbalance which accompanies an existing or incipient schizophrenic withdrawal. It is felt that this study emphasizes the importance that one must assign to the influence of the autonomic nervous system in the etio— logy and prognosis of schizophrenia. While this investigation did not deal with etiological considerations, it was concer- ned with the prognostic implications that a knowledge of au- tonomic nervous system sensitivity would entail. Further re— search will have to determine whether autonomic nervous system imbalance can be viewed as a causative, a concomitant, or a prediSposing agent in the deveIOpment of schiZOphrenia. It may not be unlikely that all three possible influences of the au— tonomic nervous system must be considered in the evaluation or the individual case. 0 - The motivation that led to the present investigation had been to inquire into the prognostic significance of the Funkenstein autonomic nervous system test(ll) as related to (IL/S) behavioral adjustment, change, and outcome of untreated schizophrenic patients. Funkenstein(ll) had been able to pre— dict whether a patient would, or, would not, recover from schizophrenia when treated with ECT or ICT. He had been able to distinguish between patients who recover from ECT and pa. tients who recover from ICT, on the basis of characteristi— cally different blood pressure reactions as a function of the injection of adrenergic and cholinergic drugs. What is so par— ticularly remarkable about this finding is that no adequate theory has been offered to explain the curative aspects of ei- ther ECT or ICT. It must furthermore be noted that no actual theoretical formulation has been offered to explain these cha— racteristically different blood pressure reactions. It is a case in point in which empirical application is ahead of any satisfactory theoretical body of knowledge. Autonomic nervous system activity is still very much of a puzzle, a fact which the literature reflects(l§). This author has been much concerned with the empi— rical application of shock treatments to schizophrenic pa. tients. We find here another example of empirical application without theoretical support. One of the most frequent questions arising in a state hOSpital setting is " should one attempt shock treatment?“ The answer to such a question, while periphe— rally involving such considerations as suicidal risk,uncon- trollable violence, or age factor, requires largely an intui— tive affirmation or rejection. Extent of custodial care (#9) available, and the dynamics of the personality of the phy- sician will often be the crucial factors in such a decision. It is quite readily apparent that such shock methods as ECT, ICT,camphor injections,ammonia injections,metrazol and tria- zol injections, acetylcholine shock,pure nitrogen inhalation, and extended sedation therapy, all constitute severe trauma to the organism. It is unknown to what extent different organisms will differ in their reaction sensitivity to such treatments. It is not even known to what extent organisms will react in a like manner to such shock treatments as a function of the shock proper(3). If one were able to predict more accurately which patients will improve spontaneously without intervening shock treatment, such a hit—and_miss application would be reduced to patients who react unfavorably to the procedure used in this investigation. While Funkenstein's autonomic nervous system test(ll) had been successful in predicting success or failure of shock treatment, it appeared to be highly desirable to uti- lize this test in an effort to investigate the course of ill— ness without shock treatment. Results of the study support the considerable prog- nostic significance of patients: reaction sensitivity to the cholinergic drug Mecholyl Chloride. Favorable blood pressure reaction, indicated by a blood pressure fall, was related sig— nificantly to Spontaneous improvement, It was furthermore shown that, five months after the initial eXperiwent, a significantly larger number of patients who had reSponded favorably to the A \ J1 C) V cholinergic drug injection, had been discharged from the hOSpital. Practical application of this finding appears self— evident. The actual time consumed in administering the test takes approximately one half-hour. The test can be administered by a nurse without direct medical supervision. Results of the test can easily be entered routinely into the patient's medical chart. It is a measure that will help the physician in his de— cision whether or not to attempt shock treatment. This investigation could not establish any dependable relationship between reaction to the adrenergic drug Epineph— rine and behavioral adjustment. Funkenstein's findings have likewise been less conclusive in this respect(ll). He stresses the important element of subjectively experienced anxiety re— ported by schizophrenic patients when subjected to Epinephrine injections. In cases of extremely large blood pressure increase after Epinephrine injection, prognosis following shock treat— ment was reported as poor(ll). This investigator saw no adequate way to measure the subjective elements of the patient's reaction to epinephrine. In only three subjects out of the total group of sixty, did the patient eXpress verbally a feeling of dread. Nevertheless, a routine injection of Epinephrine to newly ad- mitted schiz0phrenic patients may be valuable as a further help in predicting reaction to shock treatment, provided anxiety is evidenced. Lack of such anxiety, however, cannot be assumed to be contra—indicative to Spontaneous improvement, since this in- vestigation could not establish a satisfactory relationship be— (51) tween the blood pressure reaction to Epinephrine and behavioral adjustment. Th,oretical Considerations The literature does not offer a satisfactory eXpla- nation of the autonomic nervous system test's prognostic sig- nificance. Observations of the hypoactivity often encountered in the schizophrenic, emphasizing the inability of the orga- nism to cope with physiological and psychological stressors, actually lack a theoretical structure. The closest approxi- mation to a theoretical structure underlying autonomic nervous system reactivity, comes from the writings of Angyal, Freeman, and Hoshins(2). Their concept of "withdrawal", based upon phy— siological and psychological sluggishness of reaction in schi- zephrenics, does not give, however, a theoretical formulation beyond the observational data. Results of this investigation revealed that while no dependable reaction difference could be obtained between re - covering and non—recovering patients when injected with the adrenergic drug Epinephrine, dependable differences could be obtained when injected with the cholinergic drug Mecholyl Chlo— ride. It is indeed difficult to offer a theoretical formula— tion for this partial failure, due to the fact that no satis— factory theoretical formulation has been encountered that deals with this problem. While acetylcholine, or its synthetic equi— valent Necholyl Chloride, is associated with parasympathetic A \J\ (J V activity, and is held reSponsible for the synaptic transmisflan of nerve currents , hypotheses offered to explain its precise functioning are contradictory.One hypothesis suggests a chemi- cal basis for the transmission of nerve currents across the re- leased acetylcholine at the synapse; another hypothesis assumes that the production of acetylcholine is a function of electro— tonic Spread at the synapse(15). It is most generally accepted that acetylcholine,in its release and subsequent resynthesis, is directly reSponsible for the conduction of nerve currents. Synthesis and breakdown of the cholinergic sti ulant, after a nerve current has passed, is considered pcrt of the metabolic cycle underlying the main— tenance and recovery of nerves. Acetylcholine thus plays a cen- tral role in the choline metabolism of the nerve. The conducthx of impulses and the synaptic transmission of them involves ei— ther chemical or electrotonic Spread. It would appear that an abnormal reaction of the organism to an injected cholinergic agent is related to a faulty metabolic reaction most likely at the nerve synapses. The assumed synthesis and breakdown of the cholinergic agent in the normal Olganism apparently malfunctions in schiz phrenics who do not recover Spontaneously. IrreSpective of whether chemical or electrolytic agents are reSponsible for release of acetylcholine at the syn" apse, authorities are agreed that release of acetylcholine re- ‘ . ,’ sults in parasympathetic stimulation(l§). It has been shown that injection of the synthetic equivalent of acetylcholine will result in similar effects. The sluggishness of body activi- ties, associated with cholinergic stimulation, apparently does not occur in schizophrenics who have a poor prognosis. The question arises why this may be so. It is generally agreed that physiological reactions on the part of the schizophrenic are either more variable or underactive. As the synthetic equi— valent of acetylcholine is injected into the schizophrenic with poor prognosis, an overreaction on part of the organism’ occuni It may secrete an adrenaline like substance to counter— act the agent which would ordinarily aggravate hypoactivity. Thus, increase of blood pressure is a function of the organism‘s attempt to counteract the aggravating action of the choliner— gic sti ulant. Future research will have to determine whether such an adrenaline like substance is actually secreted by pa- tients that suffer from schizophrenia and who are not sponta- neously improving. Another possible explanation of the action of hecholyl Chloride is that in certain patients the effects of such stimu— lation may imitate the adrenergic pattern. As the organism attempts to meet Optimal internal conditions, its reaction sen. sitivity undergoes a change in the direction of reducing stress that cholinergic hypoactivity would entail. It is felt that the approach used by Funkenstein(ll), and extended in the present investigation, contains implica- tions which may produce substantial changes in our conception of the behavioral disorders. It appears to cut across beha- vioral symptom categories, and may represent a more funda— mental psychobiological orientation. It brings about a change in our thinking with regard to pathological reaction types, a recasting of our concepts in the direction of stress and an- xiety as related not only to psychodynamic, but also to phy— siodynamic frames of reference. Psychologists and physiolo- gists will have to work in closer harmony, in order to coor- dinate research projects designed to investigate the processes involved in behavior malfunctioning. Implications for Further Research o A coordinated psychophysiological approach to the problems inherent in adjustment patterns appears to be most desirable. This approach can be conveniently subdivided into four major areas: a) The investigation of reaction types. While this will for some time to come require the assumptions .of psychiatric classification, it is felt that it ultimately will cut across symptom classification inherent in present day thinking. b) Investigations designed to ascertain the changes that occur in body chemistry as a function of adrenergic and cholinergic sthnulation. It may well be that upon such findings will rest the ulti ate eXplanation of why some patients react adrenergically to cholinergic stimulation. Is it a function of an adrenaline like substance increase in the organism, or a function of the cholinergic drug effecting adrenergic like (55) reactions? 0) Investigations of central nervous system re- actions to stimulation of the autonomic nervous system. Hill electroenbephalographic changes occur as a function of auto— nomic nervous system sti ulation, and will these changes differ in relation to the patient's Specific autonomic nervous system reaction? This investigator is at present attempting such a research project at the Traverse City State hoopital, in coor— dination with members of the electroencephalographic research team. d) Additional attempts to relate specific physiological reactions, such as blood preSeure change as a function of autonomic nervous system stimulants, to a series of psycholo— gical testsi These attempts should be Specifically directed at the prognostic implications inherent in projective tech- niques, and their relationship to physiological factors. SUHIARX Recent investigations have disclosed that a Specific autonomic nervous system reaction, blood pressure change after the injection of adrenergic and cholinergic drugs, is related to success or failure of shock treatments of schiZOphrenic pa— tients(ll,12,13,l#). The purpose of this study was to investigate the re— lationship between autonomic nervous system reSponses after the injection of adrenergic and cholinergic drugs, and the behavio— ral adjustment, change, and outcome of a group of schizophrenic patients. It was felt that this should help to reduce part of the arbitrariness in the selection of patients for Shock treat- ment. The three general hypotheses around which this study was structured were: 1. A significant relationship can be established be- tween the quality of behavioral adjustment in schiZOphrenic pa— tients, and characteristic blood pressure changes after inject— ion of the adrenergic drug Epinephrine Hypochloride, and the cholinergic drug Hecholyl Chloride. 2. A significant relationship can be established be— tween Spontaneous behavioral changes and characteristic blood pressure changes following hecholyl Chloride injection. 3. A significant relationship can be shown between (57) characteristic blood pressure changes after the injection of Kecholyl Chloride and outcome of institutionalization. Sixty schizophrenic patients, first admissions to the Traverse City State HOSpital, were selected on the basis of an undiSputed diagnosis of schizophrenia, without organic disturbances and without mental deficiency. These patients did not receive any Shock treatment during a two months period of behavioral observation. The tool used to investigate behavioral adjustment was the Gardner Behavior Chart, a five point scale instrument, that possesses face validity and good reliability. Behavior ratings were obtained weekly for eight weeks by two sums of nurses and attendants. Blood _ressure readings were obtained in the follow. ing manner: 1. Determination of basal blood pressure by having patients rest in a supine position for a period of fifteen mi- nutes. 2. Blood pressure readings after an inhavenous injection of a saline solution in order to determine possible fluctua— tions due to psychological stress.3. Blood pressure readings every fifteen seconds for a period of seven to eight minutes following intravenous Epinephrine injections.4. Blood pressure readings every thirty seconds for six minutes, followed by rea— dings every one minute for a total of twenty—five minutes after intramuscular injection of Mecholyl Chloride. The maximum increase and decrease of blood pressure as a function of the injections were recorded. The relationship of blood pressure reactions to the adrenergic drug Epinephrine Hypochloride and behavioral ad— justment was not found to be statistically significant. Findings with regard to the cholinergic drug Mecho- lyl Chloride supported the three major hypotheses. A signi— ficant relationship was established between increase of blood pressure following Mecholyl Chloride injection and poor beha— vioral adjistment, with an r of —.527. A significant relation— ship between decrease of blood pressure following Mecholyl Chloride injection and good behavioral adjustment was estab- lished, with an r of .425. Using t tests, mean differences were determined between first and eighth week behavior ratings for those subjects with the fifteen highest and fifteen lowest blood pressure reactions to Hecholyl Chloride. A t of 3.063, significant at the less than one percent level of confidence in the direction of behavioral decrement was obtained for the fifteen highest blood pressure increases. A t of 1.818, signi— ficant at the less than five percent level of confidence in the direction of behavioral improvement was obtained for the fiftmn largest blood pressure decreases. Behavior ratings were signifi— cantly different for the first week and eighth week of behavio— ral observation, for the fifteen largest blood pressure increa— ses and decreases.These differences were in the expected diredthm. \ (59) A follow—up study, five months after the initial emperiment, revealed that out of the original group of sixty patients, thirty-two had been discharged on parole, while nineteen were institutionalized; nine were of indeterminate status and were not included. The relationship between hos- pital status and blood pressure reaction after the injection of Mecholyl Chloride was investigated by a Chi Square analy— sis. A Chi Square of 5.68 was obtained and found to be signi— ficant at the .01 — .02 levels of confidence. Prolonged in— stitutionalization is related to an abnormal blood pressure reaction after the injection of Mecholyl Chloride, while a normal reaction tends to be associated with early hOSpital dis- charge. It has been demonstrated that reaction sensitivity of the autonomic nervous system, as indicated by blood pressure changes after the injection of a cholinergic drug, is a valu— able tool in the prediction of behavioral adjustment and Spon- taneous behavioral changes. It also helps in predicting the status of patients with regard to prolonged hospitalization versus early hospital discharge. Ln] 0 }_J 3 KO V's—v ‘1- ‘ -:- aw—v , i: 1.51;; (fl; 5:51, _— Annval, A., and Blackman, Y. Vestibular reactivity in schizophrenia. Arch. Neurdl. & P€"Ch193., lQLO, ’1 / /f'3 M L / 2“”, 01].." “1-200 Aneysl, A., Ereeman, 3., and Eoskins, B. C. Physio— logic eSpects of schizophrenic withdrawal. Arch. our— 9 yr L. O K ' ol. ; Pr c-iet., lQSO, uL, oil—o2o. Bellsk, L. Dementia Presser. The nest decade's york 1 and present status. A review end evaluation. Sew ’ork: Grzne & Stratton, lCLE. Blevler, E. “0”P1tj° FrescoV or the 6 “our of schizo— phrenias. flew fork: Internstion l Um1 vs -rSi “ti s Press, "are. '1", “)V. Ca.non V. B. The wisdom of the body. Sew Y rh: N U Iorton, 1932. Cohen, L. 5., end Fiecnvo J. lets bolic, cardiovascular, and bio— chemical chances associated with experimentally induced hzcertnrr01c1si in schiZOphrenia. EndocrinolOQyL 1935. 22, 5% -553 of autonomic blood pres— ence on the wechs ler— 1pwolis shed Ph. D. Thesis (‘50 Ficca, S. C. The relations' sure types and subjects' per Bellevue and Rorschach test. 1 Pennsylvania State University, 1 O nip fl .1‘. io-r U1 Freeman, G. L., ar1d Kat Hoff, E. T Individual differences in physiolooical reactions to stimulation and their re— lations to other measures of enotionelity. J. Er:er Psvchol.4_1942, 31 , 537—537 Freeman, G. L., and Pathmen, J. H. PhysiOlosica resc- tions of psychotics to er Vt rimentally induced disflace_ ment. Ager. g;_Ps"c hiet. C1”/l” 109 >=;-L12 Freeman, 3., end Carmichael, H. T. A pharmaco— dynamic investigation of the autonomic nervous system in schizo— phrenia. Arch. Negro;L g Psychiet., 1935, 22¢_3”3— 353. F4 \ .) (Cl) FLnkens tein, D. J. Autonomic nervous e} ste.'n c10n~es folloninr electric shock therapy. J. Yerv.1ent. Dis., lots, 138 Moe—422. ‘v ’1 u - e D. 3., “reenblatt, m., Root, o., and Solo— mo., 5 C. Psycho-physioloricel study of mentally ill 9 8 Changes in the reactions to Epinejhrine an- yl Chloride after electric shock treatment. ' Amer. Q;_Psvchiet.,_1§A9/l950, 106, 113—121. Funkenstein, D. 3., -"eer31n t, 3., and Solomon, 3. An autonomic nervous system test of procnostic Si nifi- cance in relation to electroshock treatment. PEVChosom. Med., 1952, 1L 317_362. 1' v Funkenstein, D.n., Greenblatt, M., and Solomon, E. C. Autonomic chances pare lelin~ psvcr ol ocic C1a‘een in men— tally ill patients. J. Yerv. nest. Dieéj 1151, 11b, 1-13. }_J Goodman, L. 3., ant Gilman, A. The rhar: colonicel besis thern’erticsL 3 textbook 9:_:hrr ecolo~v, toricc loo" 3 and there“ atics for Lhyeicizns and medical students. New York, The nacmillan Company, lSLl. foacland, H. Metabolic and physioloric disturbances in the pchhosee. ‘13 27th annual conference _: the lilbenk Kem~ oriai Fund. New York: Harper, 1950. Hoskins, R, C. Oxynen meta bolisn in schiZOphre nia. Arch; leurol. §,Ps3chiatLL1937,,:oL l2ol-1270. Eoskins, Y. C. The biolo f schigophrenia. Jew York: W. V. Horton & Co., 19L6. Kantor, R. E., Vallner, J. 1., end Hinder, C. L. Pro— 0659 and reactive schiZOphrenie. . Con: lt. Psvcfigl., LEVSY, D. Hens Selye and a unitary concept of cisease. arit. J Sci 19 2, 1 157—1e3, ncadot A. Anxiety, concrete thinkine, and blood pressure chances in schizophrenia. Unpublished Ph. D. Thesis, Llarva qrd University, 1950. D.) ( t7 Meadov, A., and Funkenstein, D. H. The relationshi; Of abstract thinkinm to the autonomic nervous s ste; in schiZOphrenia. In Eoch, P. and Zuoin, J. (st.) iilfiElQfl of Psycholo~icel Tects _9 EEZPEEEEEIn Jew York: Grune & Stratton, 1952. YV‘ nolatt, 1., Funkenstein D. n., and Sol— anD ty for abstrac- esponse to auto- 1 l'.‘ fif‘2 firs-f? ' ‘.' -.- v, J/ -/--'U0 1 c ‘ renia anfi physiolo~ic31 . J. fierv. HentL DisLL £953, .’ Pincus, G., and Hose and, n. Adrenal cortical rGSponses to stress in normal men and in those with personality dis- ... ' -- ‘_ o '_ . ,' VI. : I oraers, Arc“. J. {fichint., 19b9/1950, 0o, Cal—c50. Pincus, G., Hos~lend, T., Freeman, E., Elnodjian, F., and Romanoff, L. P. A study of pituitary-adrenocortical func- tion in normal and psychotic nan. Psycnoron. Lied.I lélfi, 1.1;, flux—101. Rubin, n. A. Effect of hyperventilation on electro— encephalorran of scniZOphrenic subjects. Arch. Heurol. —.‘.~ .‘ . fir 'n . n k (‘I'l C‘ ’«F , ,»... 2:. F54. ic‘t ‘ ’ 17.72) 1“,) 9L l‘"97“’0 Scnrader, P. J., and Robinson, H. F. An evaluation of yrs-frontal lobot my throu~n ward behavior observation with tne @arine: Behavior Charts. J. Abngrq. Soc; PsycholL, ~-_.l adaptation syndrome and t; lin. Enoggrin., l3k6, é» ll Wilcox, E. n. The Gardner Behavior Chart. nner. . Psv_ 1942, 0- E7A_Eco. 4';— APPIIDII Name of Institution GARDNER BEHAVIOR CHART analysis of the continued care cases. The period rated at one time usually should not Last Name First Name This behavior chart was developed in a state hospital for mental diseases and is Egrlticulaily :prglicable to the periodic behavior can t n ours nor more t n 6 months. A conscientious nurse with a little supervision at the start can rate a patient fairly reliably if she consults her colleagues regarding those aspects of the patient's behavior which she is not in a position to observe herself. Key to Ratings In rating the patient’s work consider the characteristics in relation to the particular task or tasks at which he is now occupied. If in doubt, put a question mark and add explanatory comments. Make use of all information available. 1. Attention to Personal Appearance. -1 — Untidy— Wets or soils or both. Indicate which. , 0 - None— Slobbers his clothes and neither washes nor changes his clothes unless forced to. l — Poor— Does not slohber, but is untidy in general appearance and is physically rather dirty. 2 — Fair— Washes up an average amount and keeps his clothes tidy. 3 — Good — Keeps himself clean and neat most of the time. Takes some pride in his appearance. 4— Extra Good - Very particular about being physically clean and about having his clothes clean and neat, and if possible, pressed. 2. Sleep. 0 — None— Seems to be awake day and night. 1 — Poor — Awake frequently during night, sleeps very lightly. 2 — Fair — Usually sleeps most of the night, but is occasionally restless. 3 — Good — Sleeps soundly all night, unless there is considerable commotion. 4 — Extra Good — A heavy sleeper. seldom disturbed by noises. 3. Appetite. 0 — None — Has to be tube fed. 1 — Poor — Eats very little, but will eat more when spoon fed. 2 — Fair — Eats a moderate amount when encouraged — usually leaves food on his plate after one helping. 3 — Good — Eats one large serving regularly. 4 — Extra Good — Usually asks for second or third belpings. 4. Sociability. 0 -— None — Never talks or plays with others. Always seclusive. 1 — Poor — Almost always seclusive, will occasionally speak to others. but never joins in games. 2 — Fair - Converses with others a fair amount and may occasionally join in games. 3 — Good — Us sally found talking or playing with others. 4 -- Extra Good— Takes an active interest in others. Talks and plays freely with both patients and employees as opportunity arises. 5. Activity Control. 0 — None — Acutely restless. Stays in bed or in a chair scarcely five minutes at a time, or has prolonged periods of running to and fro. l — Poor — Quite restless. Prolonged restlessness, though will stay in bed or in a chair for half hour periods. Stirred up by newcomers in the room or by commotion. 2 — Fair— Restless. Frequently moving about but does not run about. Will stay in bed or in a chair frequently for considerable periods. 3 — Good — Slightly restless at times but most of the time moves about only according to the demands of the situation. 4 — Extra Good — Not restless. No excess unnecessary activity. x - Underactive- Slow and sometimes motionless. y — Motionless — Frequently and for considerable periods motionless. 6. Noise Disturbance Control. 0 - None— Acutely disturbed. noisy most of the time, shouting. banging doors, etc. 1 — Poor— Rather noisy at times or a little noisy most of the time. 2 - Fair— Quiet most of the time, but moderately noisy occasionally, or frequent low mutterings. 3 — Good — Never causes noisy disturbance. 4 — Extra Good — Very quiet. P. H. W. 9.'88 '; Rem Wilcox. Paul l-i.: The Gardner Behavior Chart. Hutton Press, lnc.. Gardner, Mass. Am. J. Psychiat., 98:870-080. Hay 1942. ' BEHAVIOR CHART i ,3” it. 5‘ Last Name First Name No. Age on Adm. Occupation and Comments Hours of Work. Daily BEHAVIOR CHART oEeZ Powwow 55:38qu again—m 63253 0:34 darn—«Eon humoameU Jae? out—SM am nowauomoou «aegis—um flow 9 10 ll 12 l3 14 15 16 17'18 19 20 21 22 5.5995 «c 9.30 3.330 32.33.3300 3.5.30 nomaoh. sauce ssz .ossoo brace batman ouflomm< 7. 10. ll. 12. l3. 14. 15. Key to Ratings (continued) Temper Control. 0— None— Flies 03 the handle at every little thing. , l -— Poor— Loses temper easily, but can be handled, if done with care. 2 — Fair — Usually controls his temper, but has spells of irritability. 3 — Good - Seldom loses his temper, except occasionally when bothered. ‘4— Euro Good — Very seldom loses temper, even with provocation. Combativeness Control. 0— N‘one— Is continually violent, attacking or fighting. Must be restrained or under sedation to protect others. 1 — Poor— Assaults patients and/or nurses nearly every day. 2 —— Fair— Occasionally assaultive. 3 — Good — Never strikes except in self-defence. 4 — Extra Good— If attacked, attempts to protect self without hurting the attacker. Care of Property. 0 — None —- Destructive of furniture and clothing much of the time, or steals constantly. l — Poor —- Occasionally destructive of furniture and clothing, or will sometimes steal. 2 — Fair —- Usually takes care of clothes, never destroys furniture. but will occasionally do minor damage to clothing, 0. g. pulls buttons OH, or occasionally steals food. 3 - Good — Never intentionally damages furniture or clothing. Makes no petty thefts. 4 —- Extra Good — Always very careful about furniture, clothing, etc. Will assist in protecting property when asked. Self-entertainment, including reading, writing, handicraft, or solitaire. Score and insert letters indi- cating the entertainment, r, w, h, and s. . 0 -- None— Absolutely idle or destructively occupied when not forced to work or play. 1 -— Poor -— Only occasionally entertains self constructively except when urged to. 2 — Fair — Entertains self of his own accord a moderate amount, but content to be absolutely idle for considerable periods. 3 —- Good —- Usually entertains self in spare moments, but occasionally allows himself to be idle. 4 — Em Good — Always entertaining himself constructively when not working or mingling with others. Cooperation in Routine. 0 — None — Is resistive to all routine procedures. Must be dressed and undressed and bathed by the nurses. 1 — Poor — Will not move in routine unless the nurse takes him by the arm, when he will go without special resistance. Never responds to calls. 2 — Fair— Will move to meals or to bed or bathe, etc., if called individually, but not when the group is called. 3 — Good -— Moves according to the group routine when others take the initiative. 4 — Euro Good —- Fits in with the routine very well. Goes to bed or to meals or bathes promptly on schedule without waiting for the rest of the crowd to lead the way. Work Capacity. 0— None— Entirely unable to learn this type of work, even after repeated instruction and demonstration. l -— Poor — Learns this type of work with difficulty and never is able to do it well. 2 —- Fair— Learns rather slowly, but in time gains considerable skill. 3 — Good — Gets the idea quickly, and acquires skill quickly. 4 — Extra Good — Gets the idea quickly without detailed instructions and does the task well from the start. Work Initiative When Alone. 0 — None— Stops immediately, unless continually supervised or with other patients. 1 — Poor— Makes only a little effort when not continually supervised or with other patients. 2 — Fair— Makes an average efl'ort when alone, but must be started. 3 — Good — Can be expected to work well when not closely watched but may require starting. 4 — Extra Good — Takes full interest and drives his work when alone. Needs but a minimum of supervision. Work Initiative When Closely Supervised. 0 — None— Refuses to work while closely supervised or while with other patients. 1 — Poor — Makes little efl'ort when closely supervised or while with other patients. 2 — Fair — Does fairly well when closely supervised or while with other patients. 3 — Good — Works well while closely supervised or while with other patients. 4 — Euro Good — Takes full interest, drives his work when closely supervised or with other patients. Willingness to Follow Directions. 0 — None— Refuses to do the task assigned. 1 — Poor- Does task assigned, but insists on doing it his own way. 2 — Fair— Does task assigned, prefers to do it his own way,,but does it as directed if closely supervised. 3 — Good — Gladly (or willingly) does task as directed. 4 — Euro Good — Very careful to do a task just as directed, and if in doubt, asks for further instructions. FT“: "-2": “I“ 4}. I.~_r ;.‘f '.-‘-‘ Rad'JJ‘Ti was... Mi... Oct 19 55 "'iiiififlfiafljfififiuflfilifiiffiiljiiguflflfifii‘wEs 3 030