Sponsoring Committee: Professor Avrum Ben-Avi (vice Professor Brian E. Tomlinson, on leave), Professor Ernest R. Wood, Professor J. Darrell Barnard and Arnold Schillinger, M.D., Psychiatric Consultant THE DETERMINATION AND EVALUATION OF CHANGES IN PERSONALITY FUNCTIONING OF ELECTROCGNVULSIVE-TREATED SCHIZOPHRENICS STANLEY SAUL SCHWARTZ Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Education of New York University 3 ^ [Thaai* accepted J350 April 28th, 1950 I, Stanley S. Schwartz, hereby guarantee that no part of the dissertation, "The Determination and Evaluation of Changes in Personality Functioning of Electroconvulsive- Treated Schizophrenics," which I have submitted for publi­ cation has been heretofore published and/or copyrighted in the United States of America, except in the case of passages quoted from other published sources; that I am the sole author and proprietor of said dissertation; that the dissertation contains no matter which, if published, will be libelous or otherwise injurious, or infringe in any way the copyright of any other party; and that I will defend, indemnify and hold harmless New York University against all suits and proceedings which may be brought and against all claims which may be made against New York University by reason of the publication of said dissertation. TABLE OF CONTENTS PAGE THE PROBLEM 1 Statement of the Problem 1 Specific Problems 2 Definition of Terms 2 Delimitations 4 Basic Assumption 5 The Need for the Study 5 Summary 9 RELATED LITERATURE 11 Insulin and Metrazol Therapy Studies 12 Electric Shock Therapy Studies 18 Summary 22 PROCEDURE 24 General Statement 24 Description of the Treatment Process 25 The Patient Group 27 Diagnosis 3° Age 32 Educational Level 32 Vocational Background 33 Duration of Illness 33 Previous Treatment 34 Course of Therapy at Northport 35 Patient Group Summarized 3° The Test Battery 37 The Bender-Gestalt Test 39 The Rorschach Test 42 The Word-Association Test 46 The Draw-a-Person Test 49 The Thematic Apperception Test 52 The Color-Form Sorting Test 55 Administration of the Test Battery $8 Treatment of the Data ol Summary 63 PRESENTATION AND DISCUSSION OF TEST RESULTS 64 The Rorschach Test 64 Scoring Procedure 65 Comparison of Pre- and Post-Treatment 76 Records in Terms of Group Data Pre- and Post-Treatment Records Compared in Terms of Monroe Inspection Technique Scoring 82 TABLE OF CONTENTS (continued) CHAPTER PAGE IV PRESENTATION AND DISCUSSION OF TEST RESULTS (continued) The Rorschach Performance of Each Patient Pre- and Post- Treatment and a Clinical Analysis of the Records 88 The Thematic Apperception Test 137 Scoring and Results 137 Adequacy of Stories 137 Responsiveness 141 Personal Reference 141 Interpersonal Interaction 143 Male-Female Identification 146 Dynamic Analysis 147 Needs 150 Effect of Environment 152 Reaction of the Organism 158 Adequacy of Principal Character lo2 Ending 167 The Word-Assoeiation Test 169 Reaction Time 170 Frequency Count 170 Zero Scores 172 Association Disturbances 173 Reproduction Failures 174 The Color-Form Sorting Test 175 Scoring Procedure 17© Results 180 The Draw-a-Person Test l8l Size of Figures 182 First Figure Drawn 185 Position of Figures 185 Rating Scale Comparison 186 Goodenough Scores 190 Judgments of the Figures 192 The Bender-Gestalt Test 205 Comparison of Pathological Indicators 205 Rating Scale Comparison 211 Ratings by Judges 214 Summary 223 V ANALYSIS OF THE DATA 228 The Rorschach Data 228 The Thematic Apperception Test Data 233 The Word-Association Test Data 237 The Color-Form Sorting Test Data 239 The Draw-a-Person Test Data 240 TABLE OF CONTENTS (continued) CHAPTER PAGE V ANALYSIS OF THE DATA (continued) The Bender-Gestalt Test Data 243 Analysis of Individual Patient Data 244 Changes in Personality Functioning with Respect to Age 283 Duration of Illness 284 Sub-diagnosis 285 Previous E.C.T. 286 Summary 288 VI SUMMARY, CONCLUSIONS AND DISCUSSION 29I Summary 291 Conclusions 294 Discussion 295 Future Research Possibilities 297 The Test Battery Approach 297 BIBLIOGRAPHY 299 APPENDIX A B LIST OF TABLES TITLE 1 Background Data of the Patient Group 29 2 Distribution of Schizophrenic Diagnosis of Patient Group 32 3 Distribution of Patients by Age 32 4 Educational Level of Patient Group 32 5 Vocational Level of Patient Group 33 6 Estimated Duration of Illness of Patient Group 34 7 Previous Shock Therapy Received by Patient Group 35 8 Electroconvulsive Treatments Administered to Patient Group 36 9 Interval Between Pre-Test and First Treatment 59 10 Interval Between Final Treatment and Post- Test 59 11 Tests Taken by Each Patient Before and After Therapy 61 12 Comparison of Composite Rorschach Scores, Pre- and Post-Treatment 7,71 13 Comparison of Monroe Inspection Scores 83 14 Areas of Disturbance on Monroe Inspection, Pre- and Post-Treatment 84 15 Comparison of Disturbance Indicators in Monroe Inspection Scoring of Rorschach Records 85 16 Direction of Change of Functioning in Monroe Areas 87 Rorschach Summaries, Pre- and Post- Treatment of Patients #1-20 0-1 LIST OF TABLES (continued) TABLE NO. TITLE PAGE 36 Pre- and Post-Treatment Evaluation of Adequacy of T.A.T. Stories 139 37 Number of Words in T.A.T. Stories, Pre- and Post-Treatment, Compared 142 38 Comparison of Personal References, Interpersonal Interactions, and Unusual Male-Female Identification in the T.A.T. Stories 144 Dynamic Analysis of the T.A.T. Stories; 39 I. Needs 151 40 II. Effect of Environment A.Frustrating 153 41 B.Helpful 154 42 C.Neutral 155 43 Effect of the Environment on the Indi­ vidual Compared, Pre- and Post-Treatment 157 Dynamic Analysis of the T.A.T. Stories; 44 III. Reaction of the Organism to the Environment A. Neurotic Symptoms 159 45 B. Reactions of Self- Sufficiency 160 46 Adequacy of the Principal Character Compared, Pre- and Post-Treatment 163 Dynamic Analysis of the T.A.T. Stories; 47 IV. Adequacy of the Principal Character A. Not Adequate - Maladjusted 164 48 B. Adequate - Adjusted 166 V. Ending 168 49 LIST OP TABLES (continued) TITLE PAGE Comparison of Pre- and Post-Treatment Word-Association Test Scoring 171 Performance on Color-Form Sorting Test, Pre- and Post-Treatment 178 Comparison of Size of Drawings Pre- and Post-Treatment I83 Comparison of Positions of Figures, Pre- and Post-Treatment 186 Rating Scale Values of Drawings, Pre- and Post-Treatment 189 Goodenough Scoring of Draw-a-Person Figures Compared 191 Pathological Indicators in Bender-Gestalt Records Compared 209 Comparison of Areas of Disturbance in Bender-Gestalt Records 210 Comparison of Bender-Gestalt Ratings, Pre- and Post-Treatment 213 Preferences of Judges on the Design- by-Design Rating 215 Preferences of Judges on the Over-All Rating 216 Effect of Age on Over-All Change in Personality Functioning 284 Effect of Duration of Illness on Over- 285 All Change in Personality Functioning Effect of Sub-Diagnosis on Over-All Change in Personality Functioning 286 Effect of Previous Electroconvulsive Treatment on Over-All Change in Personality Functioning 287 LIST OF FIGURES FIGURE NO. TITLE PAGE I - II Male Drawings of Patient #1 195-196 III - IV Male Drawings of Patient #5 197-198 V - VI Female Drawings of Patient #5 199-200 VII - VIII Male Drawings of Patient #15 201-202 IX - X Female Drawings of Patient #15 203-204 XI - XII Bender Designs of Patient #12 217-218 XIII - XIV Bender Designs of Patient #14 219-220 XV - XVI Bender Designs of Patient #15 221-222 CHAPTER I THE PROBLEM Statement of the Problem The purpose of this investigation is to determine and evaluate the changes in personality functioning of schizo­ phrenic patients who have undergone a course of electroconvul- sive therapy in a neuropsychiatric hospital. The convulsive, and particularly the electroeonvulsive, therapies have become, since their modern introduction in 1933- 1935 by Sakel, Von Meduna, and Cerletti and Bini'*', the thera­ peutic mainstay of those engaged in the treatment of the major mental disorders. Continued application of these techniques has resulted because empirical findings, on the whole, indicate ben­ eficial results. What results in the personality functioning of the psychotic individual who has received a course of such 2 therapy is not particularly well-understood, however. The present study is concerned with the application of psychological techniques in a clinical setting with the end in view of measuring and evaluating changes in personality function- In this paper the terms "electroeonvulsive therapy11 (ECT) and "electro-shock therapy" (EST) will be used synonymously. 1. L. B. Kalinowsky and P. H. Hoch, Shock Treatments and Other Somatic Procedures in Psychiatry, pp. 1-6. 2. H. L. Gordon, "Fifty Shock Therapy Theories," The Military Surgeon, 103, (November, 1948), pp. 397-401.