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UBC Theses and Dissertations

An investigation of some neuropsychological, cognitive and behavioral aspects of depression Johnson, Olive Skene 1980

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f l AN I N V E S T I G A T I O N OF SOME N E U R O P S Y C H O L O G I C A L , C O G N I T I V E AND B E H A V I O R A L A S P E C T S OF D E P R E S S I O N b y O L I V E SKENE JOHNSON M . S c , M e m o r i a l U n i v e r s i t y o f N e w f o u n d l a n d , 1976 A D I S S E R T A T I O N SUBMITTED I N P A R T I A L F U L F I L L M E N T OF T H E REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE F A C U L T Y OF GRADUATE S T U D I E S D e p a r t m e n t o f P s y c h o l o g y We a c c e p t t h i s t h e s i s a s c o n f o r m i n g . t o t h e r e q u i r e d s t a n d a r d THE U N I V E R S I T Y OF B R I T I S H COLUMBIA J u l y , 1980 © O l i v e S k e n e J o h n s o n , 1980 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives.. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 A b s t r a c t The purpose of t h i s study was to evaluate Tucker's hypothesis of d i f f e r e n t i a l hemispheric f u n c t i o n i n g i n depression, the v a l i d i t y of Beck's c o g n i t i v e theory and Lewinsohn's b e h a v i o r a l theory of depression f o r c l i n i c a l l y depressed s u b j e c t s , and the r e l a t i o n s h i p between hemi-spheric f u n c t i o n i n g and c o g n i t i v e - b e h a v i o r a l f u n c t i o n i n g throughout a period of h o s p i t a l i z a t i o n f o r depression. A 3 x 2 x 2 x 3 repeated-measures study was conducted w i t h 48 right-handed subjects i n three groups: depressed, normal and p s y c h i a t r i c comparison. Each group contained an.equal number of males and females. To t e s t f o r r i g h t hemisphere f u n c t i o n i n g , subjects were administered a d i c h o t i c s t i m u l a t i o n t e s t (Musical Chords) i n which the l e f t ear ( r i g h t hemisphere) has p r e v i o u s l y proven superior i n normal right-handers. A d i c h o t i c t e s t i n which the r i g h t ear i s normally superior (Word Triads) was administered as a c o n t r o l . A righthemrsphere c o g n i t i v e t e s t (Flags) was a l s o admin-i s t e r e d , w i t h a l e f t hemisphere c o g n i t i v e t e s t (Word Fluency) as a c o n t r o l . A C o g n i t i v e D i s t o r t i o n Question-n a i r e was used to measure depressives' c o g n i t i o n s w i t h i n Beck's typology, and a short v e r s i o n of the Pleasant Events Schedule was used to measure response-contingent p o s i t i v e reinforcement within Lewinsohn's theoret i c a l framework. Patients were tested at admission to h o s p i t a l , 10-13 days l a t e r , and at discharge, i n order to observe changes i n hemispheric, cognitive and behavioral func-tioning, at intervals ranging from severe depression to recovery. On both dichotic tests, depressives f a i l e d to obtain normal ear s u p e r i o r i t i e s at admission to h o s p i t a l , but did so by discharge. Flags scores of depressives were low at each t r i a l , while Word Fluency was unimpaired at any time. These results suggest that two d i f f e r e n t processes, one acute and one chronic, are operating during depression. An acute interhemispheric process apparently affects both hemispheres, producing a break-down i n normal asymmetries for processing mode. With treatment, this acute process abates, and normal asym-metries once again emerge. A second process apparently involves chronic i n h i b i t i o n of certain right hemisphere cognitive functions. This could represent a neurogenic index of psychiatric v u l n e r a b i l i t y within depression-prone i n d i v i d u a l s . Consistent with Beck's cognitive theory, depres-sives demonstrated a high degree of cognitive d i s t o r t i o n at admission to h o s p i t a l . However, since at discharge depressives no longer demonstrated cognitive d i s t o r t i o n , the study provided no evidence that cognitive d i s t o r t i o n i s a c h a r a c t e r i s t i c of depression-prone persons. However, more research i s needed to assess the v a l i d i t y of the i v cognitive d i s t o r t i o n measure employed i n the study. Consistent with Lewinsohn's behavioral theory, depressives demonstrated a low rate of response-contingent posit i v e reinforcement at admission to hospital and increased reinforcement rate by discharge. However, since reinforcement rate of normals dropped across t r i a l s while their mood l e v e l did not, these results do not provide clear support for Lewinsohn's theory. No s i g n i f i c a n t relationship was found between changes i n hemispheric' functioning and changes i n either cognitive d i s t o r t i o n or reinforcement rate. No sex differences were found i n any of the variables under consideration. The necessity for using multiple measures of hemispheric functioning i s discussed, and suggestions for future research are proposed. V Table of Contents page L i s t of Tables v i L i s t of Figures v i i Acknowledgement • v i i i Introduction 1 A Cognitive Theory of Depression 7 A Behavioral Theory of Depression 17 A Neuropsychological Theory of Depression 29 Hemispheric s p e c i a l i z a t i o n - content and mode 29 L a t e r a l s p e c i a l i z a t i o n for emotional processes 31 Lesion data 31 Carotid i n j e c t i o n studies 33 Epilepsy data 34 Studies of p s y c h i a t r i c populations 37 Studies of normals 49 Hemispheric i n t e r a c t i o n theories of emotional functioning 59 Conclusions from the L i t e r a t u r e 66 The Present Study - Design and Measures 69 Hypotheses 79 Method 84 Subjects 84 Procedure 91 Data analysis 93 Results 99 Discussion 138 Reference Notes • I 5 2 References • 154 Appendix A 170 Appendix B 171 Appendix C 178 Appendix D 179 Appendix E 183 Appendix F 184 Appendix G 185 Appendix H 187 Appendix 1 189 Appendix J , 190 v i L i s t of Tables page Table 1 Mean ages of groups 87 Table .12 Mean years of education for groups 87 Table 3 Beck Depression. Inventory - group means 89 Table 4 Beck Depression Inventory - analysis of variance 89 Table 5 Mean number of days between t r i a l s 89 Table 6 Group means for a l l tests 100 Table 7 Zero order c o r r e l a t i o n s - y r s . of education & Flags scores 101 Table 8 Dichotic Musical Chords - group means 101 Table 9 Dichotic Musical Chords - analysis of variance 103 Table 10 Dichotic Musical Chords - simple main e f f e c t s analysis 103 Table 11 Dichotic Musical Chords - comparisons at t r i a l 1 105 Table 12 Dichotic Musical Chords - comparisons across t r i a l s 105 Table 13 Dichotic Musical Chords - subjects' ear advantage at each t r i a l 105 Table 14 Dichotic Word Triads - group means 109 Table 15 Dichotic Word Triads - analysis of variance 110 Table 16 Dichotic Word Triads - simple main e f f e c t s analysis 110 Table 17 Dichotic Word Triads - comparisons at t r i a l 1 112 Table 18 Dichotic Word Triads - comparisons across t r i a l s 112 Table 19 Dichotic Word Triads - subjects' ear advantage at each t r i a l 112 Table 20 Flags t e s t - group means 116 Table 21 Flags t e s t - analysis of variance 117 Table 22 Flags t e s t - main e f f e c t s analysis 117 Table 23 Word Fluency, t e s t - group means 120, Table 24 Word Fluency t e s t - analysis of variance 121 Table 25 Word Fluency t e s t - main e f f e c t s analysis 121 Table 26 Pleasant. Events Schedule - group means 124 Table 27 Pleasant Events Schedule. - analysis of variance 125 Table 28 Pleasant Events Schedule - simple main e f f e c t s analysis 125 Table 29. Pleasant Events Schedule - comparisons at t r i a l 1 128 Table 30 Pleasant Events Schedule - comparisons across t r i a l s 128 Table 31 Cognitive D i s t o r t i o n Questionnaire - group means 129 Table 32 Cognitive D i s t o r t i o n Questionnaire - analysis of variance 131 Table 33 Cognitive D i s t o r t i o n Questionnaire - simple main e f f e c t s analysis 131 Table 34 Cognitive D i s t o r t i o n Questionnaire - comparisons at t r i a l 1 133 Table 35 Cognitive D i s t o r t i o n Questionnaire - comparisons across t r i a l s 133 Table 36 P a r t i a l c o r r e l a t i o n s among improvement scores - Dichotic Chords, Flags, CDQ, PES 135 Table 37 Zero order c o r r e l a t i o n s among improvement scores - Dichotic Chords, Flags, CDQ, PES 135 Table 38 P a r t i a l c o r r e l a t i o n s among improvement scores - BDI, Dich. Chords, Word Triads, Flags 137 Table 39 P a r t i a l c o r r e l a t i o n s among improvement scores - BDI, CDQ, PES 137 v i i L i s t of Figures page Figure 1 Beck Depression Inventory - group means at each t r i a l 90 Figure 2 Dichotic Musical Chords - group means at each t r i a l 104 Figure 3 Dichotic Musical Chords - means for each ear at each t r i a l 107 Figure 4 Dichotic Word Triads - group means at each t r i a l 111 Figure 5 Dichotic Word Triads - means for each ear at each t r i a l 114 Figure 6 Space Perception (Flags) t e s t - means at each t r i a l 118 Figure 7 Word Fluency t e s t - group means at each t r i a l 122 Figure 8 Pleasant Events Schedule - group means at each t r i a l 126 Figure 9 Cognitive D i s t o r t i o n Questionnaire - means at each t r i a l 130 v i i i A c k n o w l e d g e m e n t s T h e w r i t e r w i s h e s t o e x p r e s s h e r a p p r e c i a t i o n t o h e r s u p e r v i s o r , D r . P . D a v i d s o n , f o r h i s p a t i e n c e a n d g u i d a n c e t h r o u g h o u t t h e p r e p a r a t i o n o f ' t h i s d i s s e r -t a t i o n . S p e c i a l t h a n k s a l s o a r e d u e t o D r s . R . C o r t e e n , R . H a r e , D . P a p a g e o r g i s a n d A . T r e i s m a n o f t h e D e p a r t m e n t o f P s y c h o l o g y f o r t h e i r h e l p f u l s u g g e s t i o n s a n d c r i t i c i s m , a n d t o D r . D . C r o c k e t t o f t h e D e p a r t m e n t o f P s y c h i a t r y , H e a l t h S c i e n c e s C e n t e r H o s p i t a l , f o r h i s k n o w l e d g e a n d e n t h u s i a s m . T h e D e p a r t m e n t o f P s y c h i a t r y g e n e r o u s l y f u r n i s h e d s p a c e f o r t h i s r e s e a r c h a n d p e r m i t t e d a c c e s s t o p a t i e n t s , a n d t h e C a n a d i a n M e n t a l H e a l t h A s s o c i a t i o n ( B . C . D i v i s i o n ) p r o v i d e d f u n d i n g f o r w h i c h t h e a u t h o r i s g r a t e f u l . F i n a l l y , t h e w r i t e r w i s h e s t o t h a n k h e r h u s b a n d , D r . R o s s J o h n s o n , a n d h e r c h i l d r e n — M a r c , C h r i s t o p h e r , L i s e , M i c h a e l a n d E r i c a — w i t h o u t w h o s e l o v e a n d g o o d h u m o u r t h i s d i s s e r t a t i o n w o u l d n o t h a v e b e e n p o s s i b l e . I I n t r o d u c t i o n I n r e c e n t y e a r s , t h e p s y c h o l o g i c a l l i t e r a t u r e a d d r e s s i n g d e p r e s s i v e s t a t e s a n d c o n d i t i o n s h a s b u r g e o n e d . M u c h o f t h e i m p e t u s f o r t h e s e p u b l i c a t i o n s i n t h e p a s t d e c a d e h a s come f r o m t h e t h e o r e t i c a l a n d e m p i r i c a l w o r k s o f A a r o n B e c k a n d P e t e r L e w i n s o h n , b o t h o f whom h a v e a d v a n c e d c o n t r o v e r s i a l v i e w s c o n c e r n i n g t h e e t i o l o g y a n d m a i n t e n a n c e o f d e p r e s s i o n . B e c k ( 1 9 6 7 , 1974) h a s p r o p o s e d a c o g n i t i v e t h e o r y o f d e p r e s s i o n w h i c h a t t e m p t s t o a c c o u n t f o r d e p r e s s i v e s t a t e s i n t e r m s o f m a l a d a p t i v e c o g n i t i o n s , w h i l e L e w i n s o h n ( 1 9 7 4 a , 1 9 7 4 b ) h a s a d v a n c e d a b e h a v i o r a l t h e o r y w h i c h a t t r i b u t e s d e p r e s s i o n t o a l o w r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . M o r e r e c e n t l y a n e u r o p s y c h o l o g i c a l t h e o r y o f d e p r e s s i o n h a s b e e n f o r -m u l a t e d b y D o n a l d T u c k e r a t t h e U n i v e r s i t y o f N o r t h D a k o t a . A c c o r d i n g t o T u c k e r ( N o t e 1 ) , d e p r e s s i o n i s t h e p r o d u c t o f h e m i s p h e r i c d y s f u n c t i o n i n v o l v i n g e x t r a o r d i n a r y i n h i b i t i o n o f t h e r i g h t h e m i s p h e r e b y t h e l e f t , a n d h e n c e a d e c r e m e n t i n r i g h t h e m i s p h e r e p e r f o r m a n c e . T h e p r e s e n t s t u d y was d e s i g n e d t o t e s t T u c k e r ' s h y p o t h e s i s c o n c e r n i n g t h e n a t u r e o f h e m i s p h e r i c f u n c t i o n i n g d u r i n g d e p r e s s i o n , b y o b s e r v i n g a s a m p l e o f h o s p i t a l i z e d d e p r e s s i v e s . A v a r i e t y o f s t u d i e s h a v e r e p o r t e d p o o r r i g h t h e m i s p h e r e p e r f o r m a n c e i n d e p r e s s e d i n d i v i d u a l s . H o w e v e r , r e s e a r c h e r s h a v e i n t e r p r e t e d t h i s a s e v i d e n c e o f n e u r o l o g i c a l i m p a i r m e n t r a t h e r t h a n t h e t e m p o r a r y p a t h o l o g i c a l f u n c t i o n i n g o f n e u r o l o g i c a l l y i n t a c t h e m i -s p h e r e s , a s T u c k e r h a s p r o p o s e d . I f T u c k e r i s c o r r e c t , t h e n r i g h t h e m i s p h e r e f u n c t i o n i n g s h o u l d be i m p a i r e d d u r i n g d e p r e s s i o n b u t s h o u l d i m p r o v e a s p a t i e n t s r e c o v e r f r o m a d e p r e s s i v e e p i s o d e . T u c k e r ' s h y p o t h e s i s was t e s t e d b y c o l l e c t i n g d a t a o n h e m i s p h e r i c f u n c t i o n i n g i n t h e same i n d i v i d u a l s a t i n t e r v a l s r a n g i n g f r o m s e v e r e d e p r e s s i o n t o r e c o v e r y . T h e s e c o n d o b j e c t i v e o f t h e s t u d y was t o e x a m i n e t h e r e l e v a n c e o f c o g n i t i v e a n d b e h a v i o r a l f a c t o r s t o g e n u i n e c l i n i c a l d e p r e s s i o n . U n t i l now t h e l i t e r a t u r e r e l a t i n g t o c o g n i t i v e a n d b e h a v i o r a l t h e o r i e s o f d e p r e s s i o n h a s b e e n l a r g e l y d o m i n a t e d b y e x p e r i m e n t a l ( a n a l o g u e ) a n d c a s e s t u d i e s . W h i l e e x p e r i m e n t a l s t u d i e s s h o w i n g t h e i n d u c t i o n o r a l l e v i a t i o n o f d e p r e s s i v e s t a t e s p r o v i d e t h e s t r o n g e s t s u p p o r t t o d a t e f o r d e p r e s s i o n t h e o r i e s ( B l a n e y , 1 9 7 7 ) , t h e s e s t u d i e s h a v e b e e n u n i f o r m l y a n a l o g u e s t u d i e s w h i c h i n d u c e d a r e l a t i v e l y m i l d d e g r e e o f d e p r e s -s i o n . A s B l a n e y ( 1 9 7 7 ) p o i n t s o u t , t h e a s s u m p t i o n t h a t t h e r e i s a c o n t i n u i t y b e t w e e n s u b c l i n i c a l d y s p h o r i a a n d c l i n i c a l d e p r e s s i o n b e c o m e s i n c r e a s i n g l y t e n u o u s a s d e p r e s s i o n b e c o m e s m o r e s e v e r e ; i t i s i m p o r t a n t , t h e r e f o r e , t o e x a m i n e r e i n f o r c e m e n t r a t e a n d c o g n i t i v e d i s t o r t i o n i n s e v e r e l y d e p r e s s e d p o p u l a t i o n s . L e w i n s o h n a n d G r a f ( 1 9 7 3 ) 3 d i d i n c l u d e some p s y c h i a t r i c i n p a t i e n t s i n t h e i r s u b j e c t s a m p l e , b u t t h e s a m p l e a l s o i n c l u d e d o u t p a t i e n t s , s t u d e n t s , a n d v o l u n t e e r s f r o m c o m m u n i t y o r g a n i z a t i o n s a n d o t h e r s o u r c e s . No p r e v i o u s a t t e m p t h a s b e e n made t o s y s t e m a -t i c a l l y m e a s u r e t h e d e g r e e o f c o g n i t i v e d i s t o r t i o n i n c l i n i c a l l y d e p r e s s e d i n d i v i d u a l s w i t h i n B e c k ' s t y p o l o g y a n d t o o b s e r v e how t h e s e m i g h t c h a n g e w i t h r e c o v e r y f r o m d e p r e s s i o n . One p r e v i o u s s t u d y (Hammen a n d K r a n t z , 1976) d i d a t t e m p t t o q u a n t i f y c o g n i t i o n s u s i n g B e c k ' s t y p o l o g y ( s u b j e c t s w e r e a s k e d t o s e l e c t a r e s p o n s e t o a s t o r y t a s k ) , b u t t h e s u b j e c t s w e r e m i l d l y t o m o d e r a t e l y d e p r e s s e d f e m a l e s t u d e n t s . B y e m p l o y i n g a s a m p l e o f h o s p i t a l i z e d d e p r e s s i v e s , t h e p r e s e n t s t u d y a t t e m p t e d t o f i l l a s e r i o u s ! g a p i n t h e l i t e r a t u r e . ^ T h e t h i r d o b j e c t i v e o f t h e s t u d y was t o e x a m i n e t h e r e l a t i o n s h i p among c o g n i t i v e , b e h a v i o r a l a n d n e u r o -p s y c h o l o g i c a l e v e n t s i n d e p r e s s i o n . N u m e r o u s s t u d i e s h a v e s u g g e s t e d t h a t f a u l t y c o g n i t i o n s o r l o w r a t e o f r e i n f o r c e m e n t a r e r e l a t e d t o d e p r e s s i o n . H o w e v e r , i t i s p o s s i b l e t h a t b o t h n e g a t i v e c o g n i t i o n s a n d l o w r e i n f o r c e -m e n t r a t e a r e p r o d u c e d b y t h e t y p e o f h e m i s p h e r i c d y s f u n c -t i o n w h i c h T u c k e r h a s p r o p o s e d a s t h e c a u s e o f d e p r e s s i o n . I f , a s T u c k e r ( N o t e 1) s u g g e s t s , t h e l e f t h e m i s p h e r e t e n d s t o w a r d e m o t i o n a l i n h i b i t i o n a n d c o n s t r i c t i o n , w h i l e t h e "*"After t h e p r e s e n t s t u d y was c o m p l e t e d , K r a n t z a n d Hammen ( 1 9 7 9 ) p u b l i s h e d a s t u d y i n c l u d i n g d a t a f r o m h o s p i t a l i z e d d e p r e s s i v e s ; h o w e v e r , t h e s t u d y d i d n o t m e a s u r e c h a n g e s i n c o g n i t i o n s a f t e r r e c o v e r y f r o m d e p r e s s i o n . 4 right hemisphere tends toward a spontaneous and impulsive expressiveness, then exaggeration of the l e f t hemisphere's contribution to ideation and affe c t (with concomitant i n h i b i t i o n of the right hemisphere's contribution) could be expected to produce a s h i f t toward more negative thinking. Teasdale and Fogarty (1979), having confirmed e a r l i e r findings that depressives have a reduced capacity to retr i e v e pleasant memories, speculated that one aspect of depression may be that there are changes i n the a c c e s s i b i l i t y of thoughts with mood-altering content, such that negative thoughts are r e l a t i v e l y more accessible and p o s i t i v e ones r e l a t i v e l y less accessible. Within Tucker's formulation, this would be the resu l t of increased l e f t hemisphere dominance. Such a s h i f t toward more nega-tive thinking would probably lead to a loss of spontaneity and enthusiasm; consequently the ind i v i d u a l would probably emit fewer behaviors and engage i n fewer p o t e n t i a l l y r e i n f o r c i n g a c t i v i t i e s , thus reducing the opportunities for obtaining pos i t i v e reinforcement. If faulty cogni-tions and low reinforcement rate are related to hemispheric dysfunction, then normalization of hemispheric functioning which might occur with recovery from depression should be accompanied by a decrease i n distorted cognitions and an increase i n reinforcement rate. An additional question of interest i n the study was the relevance of sex differences to the cognitive, behavioral and neuropsychological theories of depression. 5 N u m e r o u s s t u d i e s h a v e shown t h a t f e m a l e s a r e much m o r e l i k e l y t o b e d i a g n o s e d a s d e p r e s s e d ( F l o r - H e n r y , 1 9 7 4 ; S c a r f , 1 9 7 9 ; W e i s s m a n a n d K l e r m a n , 1 9 7 7 ) , b u t t h e r e a r e c o n f l i c t i n g e x p l a n a t i o n s f o r t h i s f i n d i n g . W e i s s m a n a n d K l e r m a n ( 1 9 7 7 ) h a v e r e v i e w e d t h e e v i d e n c e f c r d i f f e r e n t r a t e s a n d v a r i o u s h y p o t h e s e s a d v a n c e d t o a c c o u n t f o r t h i s p h e n o m e n o n . T h e s e i n c l u d e s e x d i f f e r e n c e s i n r e p o r t i n g d i s t r e s s , s o c i a l d i s c r i m i n a t i o n a g a i n s t women, a n d f e m a l e b i o l o g i c a l s u s c e p t i b i l i t y v i a e n d o c r i n e p r o c e s s e s o r a g e n e t i c p r e d i s p o s i t i o n . F l o r - H e n r y ( 1 9 7 6 ) h a s a r g u e d t h a t f e m a l e s a r e s u s c e p t i b l e t o d e p r e s s i o n b e c a u s e t h e y h a v e a " v u l n e r a b l e " r i g h t h e m i s p h e r e . On t h e o t h e r h a n d , a n u m b e r o f f e m i n i s t w r i t e r s ( e . g . C h e s l e r , 1972) h a v e c l a i m e d t h a t p h y s i c i a n s a n d o t h e r p r o f e s s i o n a l s a r e m o r e w i l l i n g t o a s s i g n a d i a g n o s i s o f d e p r e s s i o n t o f e m a l e s , a n d t h e r e f o r e f i n d i n g s o f i n c r e a s e d i n c i d e n c e o f d e p r e s s i o n i n f e m a l e s a r e a r t i f a c t s o f b i a s e d d i a g n o s i n g . H o w e v e r , r e l i a b l e s e x d i f f e r e n c e s h a v e b e e n f o u n d i n b o t h b e h a v i o r a l a n d c o g n i t i v e v a r i a b l e s ( r e v i e w e d i n M a c c o b y a n d J a c k l i n , 1974) a s w e l l a s i n c e r e b r a l h e m i s p h e r i c s p e c i a l i z a t i o n ( r e v i e w e d i n J o h n s o n a n d H a r l e y , 1 9 8 0 ) : I t i s p o s s i b l e , t h e r e f o r e , t h a t h e m i s p h e r i c f u n c t i o n i n g , r e i n f o r c e m e n t r a t e , a n d c o g n i t i v e d i s t o r t i o n may d i f f e r i n d e p r e s s e d men a n d women. By i n c l u d i n g e q u a l n u m b e r s o f m a l e a n d f e m a l e s u b j e c t s a n d o b s e r v i n g t h e m a t v a r i o u s s t a g e s o f a d e p r e s s i v e e p i s o d e , t h e p r e s e n t s t u d y a t t e m p t e d t o s h e d some l i g h t o n t h i s i s s u e . 6 In the l i t e r a t u r e review which follows, studies r e l a t i n g to cognitive and behavioral theories of depression are reported f i r s t , followed by a lengthier review of findings relevant to a neuropsychological theory of depression. 7 A Cognitive Theory of Depression According to Aaron Beck ( 1 9 6 7 , 1 9 7 4 ) , the root of depression i s a negative cognitive set such that the individual's perception and appraisal of himself, of present experience, and of the future, i s negative. Beck ( 1 9 6 7 ) has proposed that depression-prone persons acquire these unfortunate patterns of thought during childhood and adolescence, (1) as a r e s u l t of their i n t e r -actions with the environment, ( 2 ) i n response to others' opinions of them, and ( 3 ) by i d e n t i f i c a t i o n with s i g n i -f i c a n t others such as parents. Thereafter their perception of r e a l i t y i s distorted, such that they tend to construe negatively environmental input regarding them ("I am de f i c i e n t " ) and their present experience ("I am to blame") and to hold negative expectations of future events ("Things w i l l not get be t t e r " ) . The s p e c i f i c d i s t o r t i o n s in which depressives supposedly engage are f i v e : over-generalization, selective abstraction, a r b i t r a r y inference, minimization of positive assets or consequences, and maximization of negative events or consequences (Beck, 1 9 6 7 , 1 9 7 0 ) . Overgeneralization i s defined as drawing a general conclusion on the basis of a single incident: for example, a student might conclude, on the basis of a poor grade 8 o n o n e t e s t , t h a t h e i s s t u p i d . S e l e c t i v e a b s t r a c t i o n i n v o l v e s c o n c e p t u a l i z i n g a n e x p e r i e n c e o n t h e b a s i s o f a n e g a t i v e d e t a i l w h i l e i g n o r i n g o t h e r m o r e s a l i e n t f e a t u r e s o f t h e e x p e r i e n c e : f o r e x a m p l e , a g i r l who was p o p u l a r a t a d a n c e m i g h t r e g a r d t h e e v e n i n g a s a f a i l u r e b e c a u s e s h e was n o t a s k e d b y t h e s c h o o l p r e s i d e n t t o d a n c e . I n a r b i t r a r y i n f e r e n c e , t h e i n d i v i d u a l d r a w s f r o m a n e x p e r i e n c e a n e g a t i v e i n f e r e n c e w h i c h i s u n s u p p o r t e d b y , o r c o n t r a r y t o , t h e e v i d e n c e : a n u n e m p l o y e d m a n , f o r i n s t a n c e , may i n f e r t h a t h e i s i n a d e q u a t e , i n s p i t e o f t h e f a c t t h a t h i s p a s t w o r k r e c o r d i s g o o d a n d h e i s i n r e a l i t y t h e v i c t i m o f a p e r i o d o f h i g h u n e m p l o y m e n t . M a x i m i z a t i o n o f t h e n e g a t i v e a n d m i n i m i z a t i o n o f t h e p o s i t i v e i n v o l v e m a k i n g e r r o r s i n e v a l u a t i o n w h i c h a r e s o g r o s s a s t o c o n s t i t u t e d i s t o r t i o n s ; t h a t i s , a m i n o r n e g a t i v e e v e n t i s e x a g g e r a t e d o u t o f a l l p r o p o r t i o n , w h i l e s i g n i f i c a n t p o s i t i v e a s s e t s a n d a c c o m p l i s h m e n t s a r e m i n i m i z e d o r d i s r e g a r d e d . I n B e c k ' s v i e w , s u c h c o g n i t i o n s p l a y a p r i m a r y r o l e i n t h e d e v e l o p m e n t a n d m a i n t e n a n c e o f d e p r e s s i o n : " ( I n d e p r e s s i o n ) . . . t h e r e i s a p r i m a r y d i s o r d e r o f t h o u g h t w i t h r e s u l t a n t d i s t u r b a n c e o f a f f e c t a n d b e h a v i o r i n c o n s o n a n c e w i t h t h e c o g n i t i v e d i s t o r t i o n s . " ( B e c k , 1 9 6 3 , p . 3 3 2 ) . S i n c e m a l a d a p t i v e c o g n i t i o n s a r e s u p p o s e d l y r e s p o n s i b l e f o r t h e b e h a v i o r a l d e f i c i t s w h i c h t y p i c a l l y c h a r a c t e r i z e t h e d e p r e s s e d i n d i v i d u a l ' s f u n c t i o n i n g , B e c k ' s t h e o r y p r e d i c t s t h a t b e h a v i o r a l d e f i c i t s w i l l 1 9 diminish once cognitions are modified i n a positive d i r e c t i o n (Beck, 1967, 1970). Beck (1967, 1974) has summarized and contributed to the sizeable l i t e r a t u r e showing that depressive states do indeed have cognitive correlates. For example, Beck (1963) compared ambulatory depressed patients seen by i him i n psychotherapy or formal psychoanalysis with a control group of nondepressed patients i n psychotherapy, and found that the verbalizations and self-recorded feelings and thoughts of the depressed patients were characterized , by negative content as well as by a biased ( i . e . negative)' view of neutral events; this was not the case for non-depressed patients. Weintraub, Segal and Beck (1974) tested male undergraduates at Harvard at two-week intervals over a two-month period, and found a r e l a t i o n between sel f - r a t e d depressive states and a story completion test designed to measure the presence of depressed cognitive content. In a c o r r e l a t i o n a l analysis of undergraduates' responses to the Beck Depression Inventory and Jones' I r r a t i o n a l B e l i e f Test, Nelson (1977) found that depression was related most strongly to general i r r a t i o n a l i t y , excessively high self-standards (a need to excel i n a l l endeavours i n order to f e e l worthwhile as a person), f r u s t r a t i o n r e a c t i v i t y (the notion that i t i s t e r r i b l e when things are not the way one would l i k e them to be), anxious overconcern for the future (obsessive worry about possible future misfortunes), and the b e l i e f that i t i s impossible to overcome the influences of past h i s t o r y . 10 The above studies suffer from a number of d e f i -c iencies. In the Beck ( 1 9 6 3 ) study, the experimental group was not homogeneous, since i t included manic-depressives as well as depressives; moreover, three of the diagnostic indicators used f c r inclu s i o n i n the group were pessimism, s u i c i d a l wishes, and excessive s e l f - c r i t i c i s m , so i t i s not surprising that these subjects proved to have nega-tive thoughts and feelings. A weakness i n a l l of the above studies i s that they f a i l e d to show that the content of depressed subjects' cognitions related speci-f i c a l l y to Beck's typology. One study (Hammen and Krantz, 1976) did attempt to relate depressives' cognitions to Beck's c l a s s i f i c a t i o n : depressed and nondepressed women students read b r i e f stories and were asked to select, from several alternatives, the character's l i k e l y response i n each story. The depressed group selected s i g n i f i c a n t l y more responses which were representative of the s p e c i f i c kinds of di s t o r t i o n s i n Beck's typology. However, i n this study, as i n the Weintraub et a l ( 1 9 7 4 ) and Nelson ( 1 9 7 7 ) studies reviewed above, subjects were students who were only mildly to moderately depressed; thus these studies probably provide only limited support for a theory of cl i n i c a l ^ d e p r e s s i o n . Krantz and Hammen ( 1 9 7 9 ) recently published data from 29 c l i n i c a l l y depressed outpatients and 10 inpatients, using the same question-naire as i n the Hammen and Krantz ( 1 9 7 6 ) study. As i n the e a r l i e r study, depressives selected s i g n i f i c a n t l y 11 m o r e s t o r y r e s p o n s e s r e p r e s e n t a t i v e o f B e c k ' s t y p o l o g y . S l i g h t l y s t r o n g e r s u p p o r t f o r B e c k ' s t h e o r y comes f r o m s t u d i e s s u g g e s t i n g t h a t d e p r e s s i v e s t e n d t o s c r e e n m e m o r i e s i n s u c h a way a s t o s u p p r e s s p o s i t i v e o n e s w h i l e f o c u s s i n g o n n e g a t i v e o n e s , o r t h a t t h e y t e n d t o u n d e r -e s t i m a t e t h e g o o d n e s s o f t h e i r p e r f o r m a n c e . L i s h m a n ( 1 9 7 2 ) f o u n d t h a t t h e u s u a l t e n d e n c y t o r e c a l l m o r e p l e a s a n t t h a n u n p l e a s a n t m a t e r i a l was r e d u c e d i n d e p r e s s e d i n p a t i e n t s a n d t h a t t h e y a l s o r e c a l l e d m a t e r i a l o f h i g h e r n e g a t i v e t o n e t h a n d i d o t h e r p a t i e n t s . S i m i l a r l y , L l o y d a n d L i s h m a n ( 1 9 7 5 ) s h o w e d t h a t s e v e r i t y o f d e p r e s s i o n was p o s i t i v e l y c o r r e l a t e d w i t h t h e t e n d e n c y t o r e c a l l u n p l e a -s a n t m a t e r i a l m o r e e a s i l y t h a n p l e a s a n t m a t e r i a l ; s e v e r i t y was i n v e r s e l y r e l a t e d t o t h e s p e e d w i t h w h i c h p l e a s a n t m e m o r i e s w e r e r e c a l l e d . T e a s d a l e a n d F o g a r t y ( 1 9 7 9 ) f o u n d t h a t c o l l e g e s t u d e n t s a l s o r e t r i e v e d u n p l e a s a n t m e m o r i e s m o r e q u i c k l y t h a n p l e a s a n t m e m o r i e s when d e p r e s s e d b u t n o t when h a p p y ; a s i n t h e L l o y d a n d L i s h m a n ( 1 9 7 5 ) s t u d y , d e p t h o f d e p r e s s i o n c o r r e l a t e d w i t h s l o w n e s s o f r e c a l l o f p l e a s a n t e x p e r i e n c e s . N e l s o n a n d C r a i g h e a d ( 1 9 7 7 ) f o u n d t h a t d e p r e s s e d c o l l e g e s t u d e n t s r e c a l l e d l e s s p o s i t i v e a n d m o r e n e g a t i v e f e e d b a c k t h a n n o n d e p r e s s e d s t u d e n t s a n d a l s o s e l f - r e i n f o r c e d l e s s f r e q u e n t l y . F r i e d m a n ( 1 9 6 4 ) s h o w e d t h a t c l i n i c a l l y d e p r e s s e d s u b j e c t s , when a s k e d t o e s t i m a t e how w e l l t h e y h a d d o n e o n t e s t s o f c o g n i t i v e f u n c t i o n i n g , t y p i c a l l y u n d e r e s t i m a t e d t h e i r p e r f o r m a n c e . S i m i l a r l y , B u c h w a l d ( 1 9 7 7 ) f o u n d t h a t 12 c o l l e g e s t u d e n t s w i t h h i g h d e p r e s s i o n s c o r e s t e n d e d t o u n d e r e s t i m a t e t h e n u m b e r o f c o r r e c t r e s p o n s e s t h e y h a d g i v e n o n a m u l t i p l e - c h o i c e t e s t , w h e r e a s s t u d e n t s w i t h l o w d e p r e s s i o n s c o r e s t e n d e d t o e s t i m a t e a c c u r a t e l y o r t o o v e r e s t i m a t e . I n c o n t r a s t t o d e p r e s s i v e s ' t e n d e n c y t o u n d e r -e s t i m a t e t h e g o o d n e s s o f t h e i r p e r f o r m a n c e o n t e s t s , some r e c e n t e v i d e n c e s u g g e s t s t h a t d e p r e s s i v e s a r e a c t u a l l y m o r e a c c u r a t e t h a n n o n d e p r e s s i v e s i n e s t i m a t i n g t h e d e g r e e o f c o n t i n g e n c y b e t w e e n t h e i r r e s p o n s e s a n d o u t c o m e s . A l l o y a n d A b r a m s o n ( 1 9 7 9 ) h a d d e p r e s s e d a n d n o n d e p r e s s e d c o l l e g e s t u d e n t s e s t i m a t e t h e d e g r e e o f c o n t i n g e n c y b e t w e e n t h e i r r e s p o n s e s ( p r e s s i n g o r n o t p r e s s i n g a b u t t o n ) a n d t h e o n s e t o f a g r e e n l i g h t ; a d d i t i o n a l b e h a v i o r a l a n d p r o b a b i l i t y - e s t i m a t e t a s k s a s s e s s e d s u b j e c t s ' b e l i e f s a b o u t c o n t i n g e n c i e s . D e p r e s s e d s t u d e n t s w e r e s u r p r i s i n g l y a c c u r a t e i n a l l c o n d i t i o n s , w h e r e a s n o n d e p r e s s e d s t u d e n t s o v e r e s t i m a t e d t h e d e g r e e o f c o n t i n g e n c y when n o n c o n t i n g e n t o u t c o m e s w e r e f r e q u e n t a n d / o r d e s i r e d , a n d u n d e r e s t i m a t e d t h e d e g r e e o f c o n t i n g e n c y when c o n t i n g e n t o u t c o m e s w e r e u n d e s i r e d . T h i s s u g g e s t s t h a t , w h i l e d e p r e s s i v e s may i n d e e d f o c u s o n t h e n e g a t i v e a s p e c t s o f l i f e , t h e i r p e r -c e p t i o n s c o n c e r n i n g t h e a m o u n t o f c o n t r o l t h e y e x e r t o v e r t h e i r e n v i r o n m e n t may i n f a c t be m o r e r e a l i s t i c t h a n t h o s e ; o 3 : n o n d e p r e s s e d i n d i v i d u a l s , who d i s t o r t s u c h p e r -c e p t i o n s i n a p o s i t i v e d i r e c t i o n . T h e N e l s o n a n d C r a i g h e a d ( 1 9 7 7 ) s t u d y c i t e d a b o v e s u p p o r t s t h i s v i e w : a l t h o u g h 13 depressed students underestimated the amount of positive feedback and. overestimated the amount of negative feedback, they were actually more accurate i n estimating the amount of negative feedback than were nondepressed students. The strongest support to date for Beck's claim that cognitions play a causal role i n depression comes from a group of studies demonstrating that depressed mood can be induced by focussing an individual's attention on negative information or by encouraging a b e l i e f empha-sized by Beck, i . e . a negative view of the s e l f . Velten (1968) had a group of college women read aloud a series of s e l f - r e f e r e n t statements in d i c a t i n g indecision, t i r e d -ness, slowness, unhappiness, i n e f f i c i e n c y , and pessimism; another group read s e l f - r e f e r e n t statements intended to be e l a t i n g . Control groups read neutral statements, or received demand c h a r a c t e r i s t i c s treatments designed to produce simulated e l a t i o n or simulated depression. Pre- and post-treatment self-report and objective behavioral measures, plus post-experimental questionnaire data, a l l supported the conclusion that e l a t i o n and depression treatments had s i g n i f i c a n t l y shifted mood l e v e l i n the predicted directions i n the experimental, but not i n the control, groups. Teasdale and Fogarty (1979), using the same mood induction procedures as Velten (1968), ' successfully induced depressed mood i n college students, as measured by self-report and by a psychomotor measure (speech pause-time). A v e r i l l (1969) had male undergraduates 14 v i e w a s a d f i l m , a c o m e d y f i l m , o r a n e u t r a l f i l m . P s y c h o l o g i c a l r e a c t i o n s ( a s m e a s u r e d b y a d j e c t i v e r a t i n g s c a l e s a n d o p e n - e n d e d q u e s t i o n n a i r e s ) i n d i c a t e d t h a t mood was s i g n i f i c a n t l y d e p r e s s e d b y t h e s a d f i l m a n d e l e v a t e d b y t h e c o m e d y f i l m . D i f f e r e n t p h y s i o l o g i c a l r e a c t i o n s b y t h e two e x p e r i m e n t a l g r o u p s w e r e a l s o o b s e r v e d , w i t h r e s p i r a t o r y c h a n g e s t y p i f y i n g t h e e l a t e d g r o u p a n d c a r d i o v a s c u l a r c h a n g e s t y p i f y i n g t h e d e p r e s s e d g r o u p ; t h e a u t h o r s r e l a t e d t h e l a t t e r f i n d i n g t o a h y p o -t h e s i s c o n c e r n i n g t h e b i o l o g i c a l s i g n i f i c a n c e o f g r i e f . L u d w i g ( 1 9 7 5 ) p r e s e n t e d f e m a l e s t u d e n t s w i t h b o g u s p s y c h o -l o g i c a l t e s t r e s u l t s r e g a r d i n g t h e i r m a t u r i t y a n d c r e a t i v i t y a n d d e s i g n e d t o e i t h e r b o l s t e r t h e i r s e l f - e s t e e m , r e d u c e t h e i r s e l f - e s t e e m , o r h a v e n o i m p a c t o n t h e i r s e l f - e s t e e m . S u b s e q u e n t r e s p o n s e s o n a d j e c t i v e c h e c k - l i s t s , d e p r e s s i o n s c a l e s a n d s e l f - e s t e e m s c a l e s i n d i c a t e d t h a t s e l f - e s t e e m was s i g n i f i c a n t l y a f f e c t e d b y t h e e x p e r i m e n t a l m a n i p u l a t i o n , a n d t h a t mood s h i f t e d f r o m n o n d e p r e s s e d t o d e p r e s s e d f o l l o w i n g r e d u c t i o n i n s e l f - e s t e e m . W h i l e t h e a b o v e f o u r d e p r e s s i o n i n d u c t i o n s t u d i e s p r o v i d e t h e b e s t s u p p o r t t o d a t e f o r B e c k ' s t h e o r y , a l l f o u r a r e a n a l o g u e s t u d i e s . I n d u c i n g a r e l a t i v e l y m i l d d e g r e e o f d e p r e s s i o n i n c o l l e g e s t u d e n t s b y f o c u s s i n g o n n e g a t i v e i n f o r m a t i o n o r g i v i n g n e g a t i v e f e e d b a c k c o n c e r n i n g t h e s t u d e n t s ' p e r s o n a l a t t r i b u t e s i s a l o n g way f r o m s h o w i n g t h a t g e n u i n e c l i n i c a l d e p r e s s i o n i s t h e p r o d u c t o f m a l a d a p t i v e c o g n i t i o n s . 15 Beck ( 1 9 6 7 , 1 9 7 0 ) has described s p e c i f i c treatment formulations consistent with the cognitive model of depression. Treatment i s aimed at the systematic modifica-tion of faulty patterns of thinking. Clients are f i r s t taught to i d e n t i f y their "automatic thoughts" and then to challenge th e i r v a l i d i t y and a l t e r those cognitions which are distorted or dysfunctional. Gradually the c l i e n t ' s underlying assumptions are also examined and modified. Recently three controlled treatment studies have been reported, in d i c a t i n g the successful application of such an approach to the treatment of depression: Shaw ( 1 9 7 7 ) found that moderately depressed students treated by Beck's methods showed a s i g n i f i c a n t l y greater reduction i n depression (as measured by the Beck Depression Inventory and by two c l i n i c a l r a t ing scales) than did a behavior modification group treated by Lewinsohn's methods, a non-directive therapy group, and a waiting l i s t control group. Taylor and Marshall ( 1 9 7 7 ) , also working with moderately depressed students, found that cognitive therapy and behavior therapy were both e f f e c t i v e i n reducing depression (as measured by the Beck Depression Inventory and an abbreviated form of the MMPI depression scale), but a treatment that combined both strategies was more e f f e c t i v e than either alone. A possible explana-tion for the superiority of cognitive therapy shown by the f i r s t study but not the second i s the sample charac-t e r i s t i c s of the former: Shaw's subjects were a l l young, 16 i n t e l l i g e n t students from middle-class families; i t i s possible that such subjects were more amenable to cognitive therapy than to other kinds of therapy. The t h i r d study i n this group compared cognitive therapy to pharmacotherapy (imipramine) i n the treatment of moderately to severely depressed outpatients: Rush, Beck, Kovacs and Hollon ( 1 9 7 7 ) reported that 79% of the cognitive therapy group, compared to 23% of the pharmacotherapy group, showed marked improvement or complete remission of symptoms (as measured; by the Beck Depression Inventory and c l i n i c a l rating scales); moreover, while 68% of the pharmacotherapy group re-entered treatment for depression within six months, only 16% of the cognitive therapy patients did so. A l l of the above three studies assumed that depres-sion i n the cognitive therapy group diminished because fault y cognitions had been modified. However, none of the studies actually measured changes i n cognitive d i s t o r t i o n (within Beck's typology) over the course of therapy. It i s not clear, therefore, that the success which has been reported for cognitive treatments i s due to an actual reduction of cognitive d i s t o r t i o n i n those treated. 17 A B e h a v i o r a l T h e o r y o f D e p r e s s i o n A c c o r d i n g t o L e w i n s o h n ( 1 9 7 4 a , 1 9 7 4 b ) d e p r e s s i o n i s d u e t o a n i n d i v i d u a l ' s l o w r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . I t i s i m p o r t a n t t o n o t e t h a t L e w i n s o h n i s n o t r e f e r r i n g t o r e i n f o r c e m e n t p e r s e , b u t r a t h e r t o r e i n f o r c e m e n t w h i c h i s g i v e n c o n t i n g e n t u p o n t h e i n d i v i d u a l ' s e m i s s i o n o f a r e s p o n s e . T h e t o t a l a m o u n t o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t i s a s s u m e d t o b e a f u n c t i o n o f ( 1 ) t h e n u m b e r o f e v e n t s t h a t a r e r e i n f o r c i n g f o r t h e i n d i v i d u a l , ( 2 ) t h e a v a i l a b i l i t y o f r e i n f o r c e m e n t i n t h e e n v i r o n m e n t , a n d ( 3 ) t h e n u m b e r o f e m i t t e d r e s p o n s e s w h i c h a r e a b l e t o e l i c i t r e i n f o r c e m e n t . T h u s , i n d i v i d u a l s may r e c e i v e o n l y a l o w r a t e o f r e s p o n s e - c o n t i n g e n t r e i n f o r c e m e n t l e a d i n g t o d e p r e s s i o n i f few e v e n t s a r e r e i n f o r c i n g f o r t h e m , o r i f few r e i n f o r c i n g e v e n t s a r e a v a i l a b l e i n t h e i r p a r t i c u l a r e n v i r o n m e n t s , o r i f , d u e t o t h e i r l a c k o f s o c i a l s k i l l s , t h e y i n f r e q u e n t l y make r e s p o n s e s w h i c h w o u l d b e r e i n f o r c e d . Qrrote d e p r e s s i v e b e h a v i o r s h a v e b e e n e l i c i t e d , t h e y a r e s u p p o s e d l y m a i n t a i n e d b y p r o c e s s e s s u c h a s a v e r s i v e f e e d b a c k a n d s o c i a l i s o l a t i o n . I t c a n b e s e e n t h a t L e w i n s o h n , c o n t r a r y t o B e c k , a s s i g n s a p r i m a r y p o s i t i o n t o t h e r o l e o f o v e r t b e h a v i o r s 18 i n t h e g e n e s i s o f d e p r e s s i o n ; t h a t i s , t h e c o g n i t i v e m a n i f e s t a t i o n s o f d e p r e s s i o n a r e a s s u m e d t o be a p r o d u c t o f m a l a d a p t i v e o v e r t b e h a v i o r p a t t e r n s , a n d w o u l d be e x p e c t e d t o i m p r o v e o n c e s c h e d u l e s o f r e i n f o r c e m e n t a n d o v e r t b e h a v i o r p a t t e r n s a r e m o d i f i e d . L e w i n s o h n e x p l i c i t l y s t a t e s t h a t d e p r e s s i v e c o g n i t i o n s a r e " s e c o n d a r y e l a b o r a -t i o n s o f t h e f e e l i n g o f d y s p h o r i a , w h i c h i n t u r n i s p r e -sumed t o b e t h e c o n s e q u e n c e o f a l o w r a t e o f ( r e s p o n s e -c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . ) " ( L e w i n s o h n , 1 9 7 4 b , p . 1 6 9 . ) L e w i n s o h n a n d h i s c o - w o r k e r s h a v e p u b l i s h e d a c o n s i d e r a b l e n u m b e r o f s t u d i e s i n s u p p o r t o f a " r a t e o f r e i n f o r c e m e n t " m o d e l o f d e p r e s s i o n . S e v e r a l s t u d i e s , f o r e x a m p l e , h a v e d e m o n s t r a t e d a c o r r e s p o n d e n c e b e t w e e n mood l e v e l a n d a m o u n t o f e n j o y a b l e a c t i v i t y i n w h i c h s u b j e c t s a r e i n v o l v e d . S i n c e p a r t i c i p a t i o n i n p l e a s a n t a c t i v i t i e s i s a s s u m e d t o b e a m e a s u r e o f c u r r e n t r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t , t h e s e s t u d i e s h a v e b e e n i n t e r p r e t e d a s d e m o n s t r a t i o n s o f a n a s s o c i a t i o n b e t w e e n r e i n f o r c e m e n t r a t e a n d i n t e n s i t y o f d e p r e s s i o n . F o r e x a m p l e , L e w i n s o h n a n d L i b e t ( 1 9 7 2 ) h a d c o l l e g e s t u d e n t s r a t e t h e i r d a i l y moods o n a D e p r e s s i o n A d j e c t i v e C h e c k L i s t a n d a l s o i n d i c a t e t h e n u m b e r o f p l e a s a n t a c t i v i t i e s e n g a g e d i n e a c h d a y f o r t h i r t y d a y s ; a s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n mood a n d p l e a s a n t a c t i v i t y s c o r e s c o m p u t e d o v e r t h i r t y d a y s f o r i n d i v i d u a l s u b j e c t s . T h i s p r o c e d u r e was r e p l i c a t e d b y 19 Lewinsohn and Graf ( 1 9 7 3 ) with a sample including a wider range of ages and socioeconomic backgrounds; again a s i g n i f i c a n t c o r r e l a t i o n between mood and pleasant a c t i -v i t i e s was found. MacPhillamy and Lewinsohn ( 1 9 7 4 ) c l a s s i -f i e d 120 subjects as depressed, psychiatric controls, or normal controls, according to MMPI and c l i n i c a l rating c r i t e r i a ; as predicted, the depressed group scored s i g n i f i c a n t l y lower than the control groups on a c t i v i t y l e v e l , amount of obtained pleasure, and potential for being reinforced by a wide v a r i e t y of events. Lewinsohn and MacPhillamy ( 1 9 7 4 ) asked over 700 subjects i n age groups ranging from 18 to 7 0 + , and including depressed, nondepressed p s y c h i a t r i c , and normal control groups, to rate 320 pleasant a c t i v i t i e s and events for frequency of occurrence during the past month and for subjective e n j o y a b i l i t y ; the depressed and the e l d e r l y both reported s i g n i f i c a n t l y fewer pleasant events and i n addition the depressed group reported less subjective e n j o y a b i l i t y ; therefore depressives had the lowest o v e r a l l reinforcement rate. O'Hara and Rehm ( 1 9 7 9 ) divided females who responded to a newspaper advertisement into depressed and nonde-pressed groups on the basis of their Beck Depression Inventory scores; those with higher BDI scores experienced more pleasant a c t i v i t i e s over a 28-day period, while those with low BDI scores experienced more unpleasant a c t i v i t i e s . MacPhillamy and Lewinsohn ( 1 9 7 2 , 1976) reported that self-reports on the schedule which has been most 20 f r e q u e n t l y u s e d t o m e a s u r e p a r t i c i p a t i o n i n p l e a s a n t a c t i v i t i e s ( t h e P l e a s a n t E v e n t s S c h e d u l e ) t e n d e d t o a g r e e w i t h o b s e r v a t i o n s o f b o t h t r a i n e d a n d n a t u r a l o b s e r v e r s . H o w e v e r , a s n o t e d e a r l i e r , d e p r e s s e d i n d i v i d u a l s t e n d t o u n d e r e s t i m a t e t h e f r e q u e n c y o f p l e a s a n t e v e n t s w h i l e n o n d e p r e s s e d i n d i v i d u a l s s o m e t i m e s o v e r e s t i m a t e s u c h e v e n t s ; t h u s t h e r e l a t i o n s h i p b e t w e e n mood l e v e l a n d o c c u r r e n c e o f p l e a s a n t e v e n t s r e p o r t e d b y L e w i n s o h n a n d h i s c o - w o r k e r s m a y , a t l e a s t t o some e x t e n t , h a v e b e e n i n f l u e n c e d b y t h e t e n d e n c y t o u n d e r e s t i m a t e p l e a s a n t e x p e r i e n c e s when d e p r e s s e d a n d t o o v e r e s t i m a t e t h e m when h a p p y . I t h a s a l s o b e e n s u g g e s t e d t h a t a s k i n g i n d i v i d u a l s t o s e l f - m o n i t o r p l e a s a n t e v e n t s m i g h t i t s e l f p r o d u c e m o r e p o s i t i v e m o o d , s i n c e i t w o u l d r e q u i r e t h e m t o a t t e n d s e l e c t i v e l y t o s u c h e v e n t s . O ' H a r a a n d Rehm ( 1 9 7 9 ) t e s t e d t h i s h y p o t h e s i s b y a s k i n g f e m a l e v o l u n t e e r s t o m o n i t o r p l e a s a n t a n d u n p l e a s a n t e v e n t s f o r 28 d a y s ; c o n t r o l s m o n i t o r e d b o t h k i n d s o f e v e n t s o r n e i t h e r . C l a s s o f e v e n t m o n i t o r e d was n o t f o u n d t o i n f l u e n c e m o o d , a s m e a s u r e d b y a d e p r e s s i o n a d j e c t i v e c h e c k l i s t , t h u s s u g g e s t i n g t h a t s e l f - m o n i t o r i n g o f e v e n t s i s n o t a s i g n i f i c a n t l y r e a c -t i v e p r o c e s s . F u c h s a n d Rehm ( 1 9 7 7 ) h a v e s u g g e s t e d t h a t t h e a b i l i t y t o s e l f - m o n i t o r a c c u r a t e l y may b e i m p a i r e d i n d e p r e s s e d i n d i v i d u a l s ; t h u s l o w a c t i v i t y l e v e l s r e p o r t e d b y d e p r e s s i v e s c o u l d r e p r e s e n t i n a c c u r a t e s e l f - m o n i t o r i n g r a t h e r t h a n few a c t i v i t i e s . R e g a r d l e s s o f t h e i r a b i l i t y t o a c c u r a t e l y m o n i t o r 21 a n d r e c a l l r e i n f o r c i n g e v e n t s , h o w e v e r , d e p r e s s e d i n d i v i -d u a l s d o a p p a r e n t l y e m i t f e w e r b e h a v i o r s t h a n n o r m a l s : S h a f f e r a n d L e w i n s o h n ( N o t e 2) e x a m i n e d t h e i n t e r p e r s o n a l b e h a v i o r s o f s p o u s e s i n t h e homes o f d e p r e s s e d a n d n o n d e p r e s s e d p e r s o n s , a n d f o u n d t h a t d e p r e s s e d p e r s o n s e m i t t e d f e w e r b e h a v i o r s t h a n d i d n o r m a l c o n t r o l s . B e c a u s e o f t h i s , t h e r e w e r e f e w e r o p p o r t u n i t i e s f o r d e p r e s s e d s p o u s e s t o b e r e i n f o r c e d . S u p p o r t f o r L e w i n s o h n ' s t h e o r y h a s b e e n i n f e r r e d f r o m s u c c e s s - o r - f a i l u r e f e e d b a c k s t u d i e s s h o w i n g t h a t r e d u c i n g t h e r a t e o f p o s i t i v e r e i n f o r c e m e n t ( i . e . s u c c e s s -r a t e f e e d b a c k ) i n d u c e s a m o r e n e g a t i v e m o o d . F o r e x a m p l e , W e n e r a n d Rehm ( 1 9 7 5 ) f o u n d t h a t when n o r m a l n u r s i n g a n d h i g h s c h o o l s t u d e n t s w e r e g i v e n 20% o r 80% s u c c e s s - r a t e f e e d b a c k o n p r e d i c t i o n s o f m o s t common w o r d a s s o c i a t e s , t h e 20% g r o u p r e p o r t e d s i g n i f i c a n t l y h i g h e r d e p r e s s i o n l e v e l s t h a n d i d t h e 80% g r o u p . M i l l e r a n d S e l i g m a n ( 1 9 7 3 ) , w h i l e t e s t i n g t h e " l e a r n e d h e l p l e s s n e s s " t h e o r y o f d e p r e s s i o n , f o u n d t h a t d e p r e s s e d a n d n o n d e p r e s s e d c o l l e g e s t u d e n t s d i d n o t d i f f e r o n i n i t i a l p r e d i c t i o n s o f p e r f o r m a n c e ; h o w e v e r , f o l l o w i n g n e g a t i v e f e e d b a c k c o n c e r n i n g t h e i r p e r f o r m a n c e , d e p r e s s e d s t u d e n t s f e l t l e s s o p t i m i s t i c a b o u t t h e i r f u t u r e s u c c e s s t h a n d i d n o n d e p r e s s e d s t u d e n t s . S i m i l a r l y , Hammen a n d K r a n t z ( 1 9 7 6 ) s h o w e d t h a t d e p r e s s e d a n d n o n d e p r e s s e d f e m a l e s t u d e n t s t a k i n g p a r t i n a b o g u s " t h e r a p e u t i c t a l e n t t e s t " d i d n o t i n i t i a l l y d i f f e r i n s e l f - r a t i n g s o r i n p r e d i c t i o n s 22 o f t h e i r p e r f o r m a n c e ; h o w e v e r , f o l l o w i n g n e g a t i v e f e e d -b a c k c o n c e r n i n g p e r f o r m a n c e , t h e d e p r e s s e d women e v a l u a t e d t h e m s e l v e s m o r e n e g a t i v e l y a n d a l s o l o w e r e d t h e i r e x p e c -t a t i o n s f o r f u t u r e p e r f o r m a n c e s i g n i f i c a n t l y m o r e t h a n d i d t h e n o n d e p r e s s e d women. U n f o r t u n a t e l y , n e i t h e r o f t h e a b o v e two s t u d i e s a s s e s s e d d e p r e s s i o n l e v e l f o l l o w i n g f e e d b a c k . P r k a c h i n , C r a i g , P a p a g e o r g i s a n d R e i t h ( 1 9 7 7 ) f o u n d t h a t , i n t h e a b s e n c e o f n e g a t i v e f e e d b a c k , d e p r e s s e d p a t i e n t s ' p r e d i c t i o n s o f p e r f o r m a n c e d i d n o t d i f f e r f r o m p r e d i c t i o n s o f n o n d e p r e s s e d g r o u p s . T h e p r o b l e m w i t h e x p e r i m e n t s r e l a t i n g f e e d b a c k o f s u c c e s s o r f a i l u r e t o d e p r e s s i o n l e v e l i s t h a t t h e m a j o r i m p a c t o f s u c h f e e d b a c k may be o n s e l f - e s t e e m , a n d t h u s t h e s e s t u d i e s w o u l d s u p p o r t a c o g n i t i v e t h e o r y r a t h e r t h a n a b e h a v i o r a l o n e . T h e W e n e r a n d Rehm ( 1 9 7 5 ) s t u d y , f o r e x a m p l e , w h i l e p u r p o r t i n g t o b e a t e s t o f L e w i n s o h n ' s h y p o t h e s i s c o n c e r n i n g t h e o r i g i n s o f d e p r e s -s i o n , t o l d s u b j e c t s t h a t t h e i r s u c c e s s r a t e r e f l e c t e d t h e i r s o c i a l i n t e l l i g e n c e ; s i n c e t h i s w o u l d p r o b a b l y e n c o u r a g e a m o r e n e g a t i v e v i e w o f t h e s e l f , t h e s t u d y may i n f a c t h a v e b e e n a t e s t o f B e c k ' s t h e o r y . L e w i n s o h n h a s e m p h a s i z e d t h e r o l e o f p o o r s o c i a l s k i l l s i n r e d u c i n g t h e a m o u n t o f r e i n f o r c e m e n t t h a t d e p r e s s i v e s a r e a b l e t o o b t a i n . C o n s e q u e n t l y a n u m b e r o f s t u d i e s h a v e f o c u s s e d o n t h e i m p o r t a n c e o f s o c i a l s k i l l s d e f i c i t s i n d e p r e s s i o n , d e f i n i n g s o c i a l s k i l l s a s t h e a b i l i t y t o e m i t b e h a v i o r s t h a t a r e r e i n f o r c e d b y 23 o t h e r s a n d n o t t o e m i t b e h a v i o r s t h a t a r e p u n i s h e d b y o t h e r s ( L e w i n s o h n , W e i n s t e i n a n d S h a w , 1 9 6 9 ) . L i b e t a n d L e w i n s o h n ( 1 9 7 3 ) t e s t e d t h e h y p o t h e s i s t h a t d e p r e s s e d p e r s o n s a r e g e n e r a l l y l e s s s o c i a l l y s k i l l f u l b y c o m p a r i n g some i n t e r p e r s o n a l b e h a v i o r s o f d e p r e s s i v e s a n d c o n t r o l s ; d e p r e s s i v e s w e r e f o u n d t o be l o w e r o n a n u m b e r o f b e h a v i o r s d e f i n e d a s o p e r a t i o n a l m e a s u r e s o f s o c i a l s k i l l , i n c l u d i n g n u m b e r o f a c t i o n s e m i t t e d , r a t e o f p o s i t i v e r e a c t i o n s e m i t t e d , " i n t e r p e r s o n a l r a n g e " ( t h e n u m b e r o f i n d i v i d u a l s w i t h whom a p e r s o n i n t e r a c t s ) , a n d " a c t i o n l a t e n c y " ( t h e a m o u n t o f t i m e e l a p s e d b e f o r e r e a c t i n g t o a n o t h e r ' s a c t i o n s ) . I n t h e s t u d i e s c i t e d b e l o w , i t h a s b e e n r e p o r t e d t h a t d e p r e s s i v e s t a l k l e s s , r e s p o n d m o r e s l o w l y a n d l e s s p r e d i c t a b l y t o o t h e r s ' v e r b a l i z a t i o n s , a r e l e s s l i k e l y t o e n c o u r a g e o t h e r s t o s p e a k , a r e l e s s s k i l l f u l i n n o n v e r b a l c o m m u n i c a t i o n , a n d a r e m o r e l i k e l y t o e v o k e n e g a t i v e r e a c t i o n s f r o m o t h e r s , t h a n a r e n o n d e p r e s s e d i n d i v i d u a l s . A r o n s o n a n d W e i n t r a u b ( 1 9 6 7 ) f o u n d t h a t v e r b a l p r o d u c t i v i t y ( i . e . n u m b e r a n d l e n g t h o f s p o n t a n e o u s u t t e r a n c e s ) o f d e p r e s s e d p a t i e n t s was s i g n i f i c a n t l y l e s s d u r i n g a t e n - m i n u t e i n t e r v a l t h a n was t h a t o f n o r m a l , c o n t r o l s . H i n c h l i f f e , L a n c a s h i r e a n d R o b e r t s ( 1 9 7 1 ) c o m p a r e d d e p r e s s e d p a t i e n t s t o s u r g i c a l c o n t r o l s a n d a l s o f o u n d t h a t t h e n u m b e r o f w o r d s p r o d u c e d p e r m i n u t e was s i g n i f i c a n t l y l e s s f o r t h e d e p r e s s i v e s . L e w i n s o h n , W e i n s t e i n a n d A l p e r ( 1 9 7 0 ) f o u n d t h a t d e p r e s s e d c o l l e g e u n d e r g r a d u a t e s i n s m a l l g r o u p t h e r a p y s e t t i n g s n o t o n l y 24 e m i t t e d f e w e r p o s i t i v e r e a c t i o n s t o w a r d o t h e r s b u t a l s o e l i c i t e d f e w e r v e r b a l b e h a v i o r s f r o m o t h e r s , t h a n d i d n o n d e p r e s s e d s u b j e c t s . R o s e n b e r r y , W e i s s a n d L e w i n s o h n ( N o t e 3) h a d d e p r e s s e d s u b j e c t s l i s t e n t o t a p e - r e c o r d e d s p e e c h e s a n d p r e s s a b u t t o n t o i n d i c a t e when t h e y w o u l d n o r m a l l y s a y o r d o s o m e t h i n g t o m a i n t a i n r a p p o r t w i t h t h e s p e a k e r ; d e p r e s s i v e s r e s p o n d e d l e s s p r e d i c t a b l y t h a n n o n d e p r e s s i v e s a n d d e m o n s t r a t e d l o n g e r l a t e n c i e s i n r e s p o n d i n g , t h u s i n d i c a t i n g p o o r e r s o c i a l c o m p e t e n c e i n m a i n t a i n i n g c o n v e r s a t i o n a l r a p p o r t . P r k a c h i n e t a l ( 1 9 7 7 ) f o u n d t h a t v i d e o t a p e d f a c i a l e x p r e s s i o n s o f d e p r e s s e d p a t i e n t s e x p o s e d t o a v e r s i v e , p l e a s a n t a n d n e u t r a l s t i m u l i w e r e s i g n i f i c a n t l y m o r e d i f f i c u l t t o j u d g e t h a n w e r e e x p r e s s i o n s o f p s y c h i a t r i c a n d n o r m a l c o n t r o l s , s u g g e s t i n g t h a t d e p r e s s i v e s a r e a l s o d e f i c i e n t i n n o n v e r b a l c o m m u n i c a t i o n b e h a v i o r . C o y n e ( 1 9 7 6 ) r e p o r t e d t h a t t e l e p h o n e c o n v e r s a t i o n s w i t h d e p r e s s e d i n d i v i d u a l s e v o k e d f e e l i n g s o f h o s t i l i t y , r e j e c t i o n , d e p r e s s i o n a n d a n x i e t y i n n o r m a l s u b j e c t s , a f i n d i n g w h i c h s u p p o r t s t h e n o t i o n t h a t d e p r e s s i v e s r e l a t e t o o t h e r s i n a way t h a t r e d u c e s t h e l i k e l i h o o d o f t h e i r b e i n g r e w a r d e d . H o w e v e r , l i k e s t u d i e s d e m o n s t r a t i n g a r e l a t i o n b e t w e e n l o w a c t i v i t y l e v e l . a n d d e p r e s s i o n , s t u d i e s r e l a t i n g s o c i a l s k i l l s d e f i c i t s t o d e p r e s s i o n may m e r e l y b e d e s -c r i b i n g t h e d e p r e s s e d i n d i v i d u a l ' s way o f i n t e r a c t i n g w i t h h i s e n v i r o n m e n t r a t h e r t h a n e l u c i d a t i n g t h e c a u s a l a n t e c e d e n t s o f a d e p r e s s i v e e p i s o d e . One s t u d y w o u l d 25 appear to suggest that a depressive episode i s not more l i k e l y i n those with d e f i c i e n t s o c i a l s k i l l s : Tanner, Weissman and Prusoff ( 1 9 7 5 ) rated patients' " s o c i a l adjustment" after recovery from a depressive episode, and two months l a t e r retrospectively compared the scores of the 33 women who had relapsed with those of a matched group of 33 who had not relapsed. They found no differences. However, the study can be c r i t i c i z e d both for comparing subjects who had a l l previously been depressed fend may a l l , therefore, have been d e f i c i e n t i n s o c i a l s k i l l s ) , and also for not determining whether a drop i n s o c i a l effectiveness occurred during the two-month period between the time of measuring s o c i a l adjustment and the time of relapse. Moreover, the indices of s o c i a l adjustment used i n the study refer more to community adjustment (e.g. work performance, family attachment) than to the kind of interpersonal functioning implied by Lewinsohn's d e f i n i t i o n of s o c i a l s k i l l s . What i s r e a l l y needed to support the behavioral theory of depression i s a demonstration that a drop i n reinforcement rate precipitates a plunge into depression. However, as Blaney ( 1 9 7 7 ) points out, i t i s v i r t u a l l y impossible to compare the amount of reinforcement that a person receives before and after the onset of depression; therefore i t i s extremely d i f f i c u l t to investigate the major hypothesis of Lewinsohn's theory. One study (Paykel, Myers, Dienelt et a l , 1969) did survey the 26 l i f e e v e n t s o f t h e p r e c e d i n g s i x m o n t h s f o r 185 d e p r e s s e d s u b j e c t s a n d a m a t c h e d g r o u p o f n o r m a l c o n t r o l s , a n d f o u n d t h a t d e p r e s s e d s u b j e c t s i n g e n e r a l h a d e x p e r i e n c e d m o r e s t r e s s f u l a n d u n d e s i r a b l e e v e n t s d u r i n g t h e p e r i o d , a n d m o r e e v e n t s i n v o l v i n g l o s s e s o r " e x i t s f r o m t h e s o c i a l f i e l d " ( e . g . s e p a r a t i o n , d i v o r c e , d e a t h ) . I n o r d e r f o r t h e s e f i n d i n g s t o s u p p o r t t h e L e w i n s o h n t h e o r y , h o w e v e r , i t w o u l d be n e c e s s a r y t o show t h a t s u c h l o s s e s a c t u a l l y p r o d u c e d a d r o p i n r e i n f o r c e m e n t r a t e f o r t h e i n d i v i d u a l . T h e two s t u d i e s w h i c h h a v e r e l a t e d mood l e v e l t o a p r e -c e d i n g c h a n g e i n a c t i v i t y l e v e l h a v e f a i l e d t o f i n d a r e l a t i o n b e t w e e n t h e t w o : L e w i n s o h n a n d L i b e t ( 1 9 7 2 ) a n d L e w i n s o h n a n d G r a f ( 1 9 7 3 ) c o m p u t e d c r o s s - l a g g e d c o r r e l a t i o n s b e t w e e n a c t i v i t y l e v e l o n o n e d a y a n d mood l e v e l o n e o r two d a y s l a t e r ; n e i t h e r s t u d y f o u n d t h a t a c h a n g e i n a c t i v i t y l e v e l r e l a t e d t o a c h a n g e i n mood l e v e l a d a y o r two l a t e r , a l t h o u g h t h i s may b e b e c a u s e t h e i n t e r v a l was t o o s h o r t . L e w i n s o h n (1974b) h a s o u t l i n e d a t r e a t m e n t p r o g r a m i n v o l v i n g t h e a p p l i c a t i o n o f r e i n f o r c e m e n t t h e o r y t o t h e t r e a t m e n t o f d e p r e s s i o n . T h e a i m i s t o r e s t o r e a n a d e q u a t e s c h e d u l e o f p o s i t i v e r e i n f o r c e m e n t b y i n c r e a s i n g b o t h s o c i a l s k i l l s a n d i n v o l v e m e n t i n p l e a s a n t a c t i v i t i e s . B y t h e u s e o f t e c h n i q u e s s u c h a s b e h a v i o r r e h e a r s a l a n d m o d e l l i n g , c l i e n t s a r e t r a i n e d t o e m i t b e h a v i o r s t h a t a r e l i k e l y t o b e r e i n f o r c e d ; a s w e l l , v e r b a l c o n t r a c t s a n d a c t i v i t y s c h e d u l e s a r e u s e d t o e n g a g e c l i e n t s i n i n t r i n s i -c a l l y r e w a r d i n g a c t i v i t i e s . I n t h e p a s t few y e a r s a n u m b e r o f c a s e r e p o r t s d e s c r i b i n g t h e s u c c e s s f u l a p p l i c a t i o n o f s u c h t e c h n i q u e s h a v e a p p e a r e d i n t h e l i t e r a t u r e ; h o w e v e r , o n l y a s m a l l n u m b e r o f c o n t r o l l e d s t u d i e s h a v e b e e n r e p o r t e d : Two s t u d i e s c i t e d e a r l i e r ( S h a w , 1 9 7 7 ; T a y l o r a n d M a r s h a l l , 1977) c o m p a r e d b e h a v i o r t h e r a p y t o c o g n i t i v e t h e r a p y . Two o t h e r s t u d i e s h a v e c o m p a r e d b e h a v i o r t h e r a p y t o o t h e r t h e r a p i e s w h i c h d i d n o t i n c l u d e c o g n i t i v e t h e r a p y , a n d f o u n d b e h a v i o r a l t r e a t m e n t t o b e s u p e r i o r : M c L e a n , O g s t o n a n d G r a u e r ( 1 9 7 3 ) u s e d a n o p e r a n t p r o g r a m c a r r i e d o u t i n home p r a c t i s e s e s s i o n s w i t h t h e c l i e n t ' s s p o u s e , t o m o d i f y t h e c l i e n t ' s s o c i a l s k i l l s ( i . e . h e r v e r b a l i n t e r a c t i o n s t y l e s ) i n o r d e r t o e n a b l e h e r t o o b t a i n m o r e p o s i t i v e r e i n f o r c e m e n t f r o m h e r f a m i l y . A c o m p a r i s o n g r o u p r e c e i v e d a v a r i e t y o f t r a d i t i o n a l t r e a t m e n t s f o r d e p r e s s i o n ( g r o u p o r i n d i v i d u a l t h e r a p y o r a n t i d e p r e s s a n t m e d i c a t i o n o r some c o m b i n a t i o n o f t h e s e . ) T h e e x p e r i -m e n t a l g r o u p , b u t n o t t h e c o m p a r i s o n g r o u p , showed s i g n i f i c a n t c h a n g e s i n t a r g e t b e h a v i o r s , mood r a t i n g s , a n d v e r b a l c o m m u n i c a t i o n s t y l e . M o r e r e c e n t l y , M c L e a n a n d H a k s t i a n ( 1 9 7 9 ) c o m p a r e d d e p r e s s e d o u t p a t i e n t s r e c e i v i n g t e n w e e k s o f b e h a v i o r t h e r a p y , p s y c h o t h e r a p y , d r u g t h e r a p y o r r e l a x a t i o n t h e r a p y . B e h a v i o r t h e r a p y , w h i c h i n v o l v e d g r a d u a t e d i n c r e a s e s i n b e h a v i o r a l p r o d u c -t i v i t y a n d d a i l y p r a c t i s e i n s o c i a l i n t e r a c t i o n a n d c o m m u n i c a t i o n s k i l l s , p r o v e d s u p e r i o r t o o t h e r t h e r a p i e s o n n i n e o f t e n o u t c o m e m e a s u r e s a t t h e e n d o f t r e a t m e n t , 28 and marginally superior at three-month followup. However, since the so-called behavior therapy procedures deployed i n the study also included cognitive s e l f - c o n t r o l tech-niques designed to avoid "negative introspective habits", i t i s obvious that the therapy was not purely behavioral. Moreover, neither of these studies actually measured reinforcement rate over the course of therapy. Therefore, these studies do not provide strong support for Lewinsohn's theory. 29 A Neuropsychological Theory of Depression Tucker and his associates (Tucker, Note 1; Tucker, Roth and Shearer, Note 5) have recently proposed a neuro-psychological theory of depression. According to this theory, depression i s the product of psychopathological dysfunction involving an extraordinary degree of i n h i b i -t ion exerted by the l e f t hemisphere on the more primary and spontaneous capacities of the r i g h t hemisphere. Hemispheric s p e c i a l i z a t i o n — c o n t e n t and mode: Since Sperry (1964) f i r s t reported his dramatic findings with " s p l i t - b r a i n " p a t i e n t s — s e v e r e e p i l e p t i c s whose corpus callosum had been severed and whose is o l a t e d hemispheres could therefore be studied s e p a r a t e l y — s t u d i e s concerning the specialized functions of the two cerebral hemispheres have p r o l i f e r a t e d . An i n i t i a l focus was the delineation of cognitive and perceptual functions for which each hemisphere i s prepotent. Several researchers reported that u n i l a t e r a l brain lesions produced d i f f e r e n t d e f i c i t s , depending on the side of injury (Benton and Van A l l e n , 1968; L u r i a , 1966; Milner, 1967, 1971). However, since the s p e c i f i c i t y ccf lesions i s often dubious, claims that lesions are u n i l a t e r a l can be misleading (Todd, Coolidge and Satz, 1977). Nonetheless, the same asymmetry i n f u n c t i o n a l a b i l i t i e s o f t h e h e m i s p h e r e s was o b s e r v e d i n h e m i s p h e r e c t o m y c a s e s ; s i n c e s u c h c a s e s i n v o l v e t h e r e m o v a l o f a n e n t i r e h e m i s p h e r e , u n i l a t e r a l i t y i s n o t i n d o u b t . I n g e n e r a l s u c h c a s e s s h o w e d t h a t n o n - l a n g u a g e f u n c t i o n s w e r e b a s i c a l l y u n a f f e c t e d f o l l o w i n g l e f t h e m i -s p h e r e c t o m y , w h i l e l a n g u a g e a b i l i t i e s ( e . g . s p e e c h , r e a d i n g , w r i t i n g ) w e r e g r o s s l y i m p a i r e d o r d i s r u p t e d . C o n v e r s e l y , r i g h t h e m i s p h e r e c t o m y p r o d u c e d i m p a i r e d v i s u o s p a t i a l a b i l i t i e s , w h i l e s p e e c h a n d o t h e r l a n g u a g e f u n c t i o n s w e r e u n a f f e c t e d ( S e a r l e m a n , 1 9 7 7 ) . S t u d i e s o f n o r m a l s c o n f i r m e d t h e s e f u n c t i o n a l a s y m m e t r i e s , d e m o n -s t r a t i n g t h a t t h e l e f t h e m i s p h e r e o f n o r m a l r i g h t h a n d e r s e x c e l s i n l a n g u a g e a n d m a t h e m a t i c s t a s k s w h i l e t h e r i g h t h e m i s p h e r e i s s u p e r i o r i n h a n d l i n g s p a t i a l - p e r c e p t u a l r e l a t i o n s h i p s , m u s i c a l t o n e p a t t e r n s , a n d o t h e r n o n v e r b a l s t i m u l i ( B o r o d a n d G o o d g l a s s , 1 9 8 0 b ; B u c h s b a u m a n d F e d i o , 1 9 7 0 ; D a r w i n , 1 9 7 5 ; F i l b e y a n d G a z z a n i g a , 1 9 6 9 ; G o r d o n , 1 9 7 0 , 1 9 7 8 ; K i m u r a , 1 9 6 1 , 1 9 6 4 , 1 9 6 7 ; S h a i , G o o d g l a s s a n d B a r t o n , 1 9 7 2 ) . W h i l e i t i s c l e a r from^s.u.ch s t u d i e s t h a t e a c h h e m i -s p h e r e i s p r e p o t e n t f o r c e r t a i n k i n d s o f c o g n i t i o n , o t h e r s t u d i e s h a v e shown t h a t e a c h h e m i s p h e r e may a l s o p a r t i -c i p a t e i n f u n c t i o n s f o r w h i c h t h e o p p o s i t e h e m i s p h e r e i s s u p e r i o r : f o r e x a m p l e , l e f t h e m i s p h e r e i n v o l v e m e n t h a s b e e n shown i n t h e r y t h m i c a s p e c t s o f m u s i c ( B e v e r a n d C h i a r e l l o , 1 9 7 4 ; G o r d o n , 1 9 7 0 ) , w h i l e r i g h t h e m i s p h e r e a b i l i t i e s i n c l u d e r u d i m e n t a r y l a n g u a g e s k i l l s ( S e a r l e m a n , 31 1 9 7 7 ) . R e c e n t l y , t h e r e f o r e , r e s e a r c h o n f u n c t i o n a l h e m i s p h e r i c s p e c i a l i z a t i o n h a s f o c u s s e d l e s s o n t h e c o n t e n t o f i n f o r m a t i o n b e i n g p r o c e s s e d a n d m o r e o n t h e u n i q u e p r o c e s s i n g mode f o r w h i c h e a c h h e m i s p h e r e i s s p e c i a l i z e d . T h i s a p p r o a c h t o f u n c t i o n a l a s y m m e t r y h a s r e c e i v e d t h e b e s t s u p p o r t f r o m t h e r e s e a r c h t o d a t e . N u m e r o u s s t u d i e s h a v e now s u g g e s t e d t h a t t h e l e f t h e m i -s p h e r e i s s p e c i a l i z e d f o r a n a n a l y t i c , s e q u e n t i a l , t i m e -d e p e n d e n t mode Of i n f o r m a t i o n p r o c e s s i n g , a n d t h a t t h e r i g h t i s s p e c i a l i z e d f o r a h o l i s t i c , i n t e g r a t i v e , t i m e -i n d e p e n d e n t mode o f i n f o r m a t i o n p r o c e s s i n g ( C a r m o n , 1 9 7 8 ; G o r d o n , 1 9 7 8 ; K i n s b o u r n e , 1 9 7 4 ; L e v y , 1 9 6 9 , 1 9 7 4 a , 1 9 7 4 b ; M i l l s a n d R o l l m a n , 1 9 8 0 ; N e b e s , 1 9 7 3 ; O r n s t e i n , J o h n s t o n e , H e r r o n e t a l , 1 9 8 0 ; Semmes, 1 9 6 8 ; S c h w a r t z , N o t e 1 4 ; S p e r r y , G a z z a n i g a a n d B o g e n , 1 9 6 9 ; T o m l i n s o n - K e a s e y a n d K e l l y , 1 9 7 9 ; T u c k e r , 1 9 7 6 ; V e r o f f , 1 9 7 8 ; W i l l i s , W h e a t l e y a n d M i t c h e l l , 1 9 7 9 . ) L a t e r a l s p e c i a l i z a t i o n f o r e m o t i o n a l p r o c e s s e s : T h e r e i s a l s o e v i d e n c e s u g g e s t i n g t h a t e m o t i o n a l p r o c e s s e s a r e r e l a t e d t o h e m i s p h e r i c a s y m m e t r y . Some o f t h i s e v i d e n c e comes f r o m s t u d i e s o f b r a i n - i n j u r e d , n e u r o -s u r g i c a l a n d e p i l e p t i c p a t i e n t s , w h i l e o t h e r e v i d e n c e comes f r o m o b s e r v a t i o n s o f p s y c h i a t r i c a n d n o r m a l p o p u -l a t i o n s . (1) L e s i o n d a t a : E a r l y c l i n i c a l o b s e r v a t i o n s o f t h e e f f e c t s o f u n i l a t e r a l b r a i n damage w e r e among t h e f i r s t r e p o r t s 32 r e l a t i n g d i f f e r e n t emotional reactions to the l e f t and r i g h t brain. Forty years ago Goldstein (1939) noticed that l e f t brain-damaged patients frequently manifested what he c a l l e d "catastrophic" reactions (outbursts of anxiety and despair i n the face of demonstrated f a i l u r e s ) , while almost t h i r t y years ago Denny-Brown, Meyer and Horenstein (1952) observed that patients with lesions of the right hemisphere were often characterized by i n d i f -ference reactions. However, these were incidental obser-vations; i t was not u n t i l some twenty years l a t e r that such phenomena were investigated systematically: Gainotti (1972) administered a battery of neuropsychological tests to 80 l e f t and 80 right brain-damaged patients of compar-able age and education, i n order to observe their reactions when d i f f i c u l t y was experienced. The left-damage group s i g n i f i c a n t l y more often reacted with behaviors deemed to denote a depressive-catastrophic reaction (crying, cursing, declaring incapacity, emphasizing f a i l u r e , refusing to continue, etc.) while the right-damage group s i g n i f i c a n t l y more often reacted with indifference or denial (laughing at f a i l u r e s , inappropriately joking, minimizing d e f i c i t s , denying i l l n e s s , a t t r i b u t i n g hemiplegia to medication, etc.) Unfortunately, no normal or patient control groups were used i n the study. Gainotti (1972) and Wexler (1980) have both postulated that the reactions observed i n brain-damaged patients could r e f l e c t a b a s i c a l l y normal response to serious cognitive d e f i c i t s . 33 However, Gasparrine, Satz, Heilman et a l (1978) compared MMPI scores of l e f t and right brain-damaged patients and also examined them with a battery of cognitive tests from the WAIS; they found that l e f t hemisphere damage led to an increase i n the patient's scores on the MMPI depression scale, while right hemisphere damage did not lead to abnormal scores; there were no differences i n performance on the cognitive tests between r i g h t - and left-hemisphere groups. (2) Carotid i n j e c t i o n studies: Intracarotid artery i n j e c t i o n studies have also reported d i f f e r e n t emotional reactions, depending on the side of the i n j e c t i o n . A number of I t a l i a n researchers (Perria, Ros.adini and Rossi, 1961; Rossi and Rosadini, 1967; Terzian, 1964) have reported that a s i g n i f i c a n t proportion of patients receiving u n i l a t e r a l carotid i n j e c t i o n of sodium amytal to determine speech l a t e r a l i -zation p r i o r to surgery showed a severe emotional reaction as the anaesthetic was wearing o f f : a dramatic depressive-catastrophic reaction more frequently followed p a r t i a l recovery from l e f t hemisphere sedation and an inappro-priate euphoric response followed p a r t i a l recovery from ri g h t hemisphere sedation. The amytal i n j e c t i o n results have been questioned by Milner (1967), who found no difference between the emotional reactions i n 104 patients following i n j e c t i o n of either right or l e f t hemisphere. She related the emotional reaction to the temperament 34 of the patient, although Rossi and Rosadini (1967) reported that both depression and e l a t i o n frequently occurred i n the same subject, only by changing the side of the i n j e c t i o n . While neither Milner nor the I t a l i a n researchers could account for their divergent r e s u l t s , i t i s possible that either drug dose or extent of brain damage was responsible: Milner's standard dose was 200 mg. of 10% amytal solution while Rossi and Rosadini's was 100-200 mg. of 5% solution. An early report by Alema, Rosadini and Rossi (1961) suggested that the presence or absence of l a t e r a l i z e d emotional reactions may depend on the extent of brain damage: i n an examina-tion of patients receiving carotid i n j e c t i o n , l a t e r a l i z e d a f f e c t i v e responses were seen almost always i n patients with no brain damage, seen only on the intact side i n patients with u n i l a t e r a l damage, and ra r e l y seen i n cases of diffuse or b i l a t e r a l damage. (Reasons for using the amytal procedure on patients without brain damage are not reported.) (3) Epilepsy data: A recent study of outpatients with u n i l a t e r a l temporal lobe epilepsy (Bear and Fedio, 1977) also related d i f f e r e n t emotional q u a l i t i e s to l a t e r a l i z e d processes: In an e f f o r t to determine whether d i s t i n c t behavioral p r o f i l e s characterized right versus l e f t temporal e p i l e p t i c s , eighteen behavioral t r a i t s were assessed by two equivalent true-false questionnaires, one completed 35 b y t h e p a t i e n t h i m s e l f d u r i n g n o n - p a r o x y s m a l s t a t e s a n d t h e o t h e r c o m p l e t e d b y a l o n g - t i m e o b s e r v e r o f t h e p a t i e n t . S t e p w i s e d i s c r i m i n a n t a n a l y s i s a n d f a c t o r a n a l y s i s o f t h e r e s u l t s s h o w e d t h a t p a t i e n t s w i t h r i g h t t e m p o r a l f o c i e x h i b i t e d d e n i a l ( i . e . t h e y s i g n i f i c a n t l y u n d e r -r e p o r t e d d e p r e s s i o n a n d d i s s o c i a l b e h a v i o r s , c o m p a r e d t o o b s e r v e r s ' e v a l u a t i o n s o f them) w h i l e t h o s e w i t h l e f t t e m p o r a l f o c i , c o m p a r a b l e i n a l l s a m p l e d c h a r a c t e r i s t i c s , d e m o n s t r a t e d a c a t a s t r o p h i c o v e r - e m p h a s i s o f s e l f - r e p o r t e d d e p r e s s i o n a n d d i s s o c i a l b e h a v i o r s ( o b s e s s i o n a l i s . m , a n g e r , d e p e n d e n c e , p u n i t i v e m o r a l i s m , e t c . ) N e i t h e r o f t h e s e b e h a v i o r a l p r o f i l e s w e r e f o u n d i n n o r m a l a n d p a t i e n t g r o u p s ; h o w e v e r , a c o n t r o l g r o u p w i t h s e i z u r e f o c i i n o t h e r s i t e s was n o t i n c l u d e d i n t h e s t u d y . T h u s l e s i o n , a m y t a l a n d e p i l e p s y s t u d i e s h a v e a l l r e p o r t e d d e p r e s s i v e - c a t a s t r o p h i c r e a c t i o n s f o l l o w i n g l e f t h e m i s p h e r e damage o r s e d a t i o n , a n d i n d i f f e r e n c e , d e n i a l a n d / o r e u p h o r i a r e a c t i o n s f o l l o w i n g ' r i g h t h e m i -s p h e r e damage o r s e d a t i o n . S i n c e damage o r s e d a t i o n o f a h e m i s p h e r e s h o u l d d e c r e a s e t h a t h e m i s p h e r e ' s f u n c t i o n i n g a n d a l l o w t h e o t h e r h e m i s p h e r e t o b e c o m e m o r e d o m i n a n t , a s t r a i g h t f o r w a r d i n t e r p r e t a t i o n o f t h e o b s e r v a t i o n o f i n c r e a s e d d e p r e s s i o n f o l l o w i n g l e f t h e m i s p h e r e i n j u r y o r s e d a t i o n i s t h a t t h e r i g h t h e m i s p h e r e t e n d s t o w a r d d e p r e s -s i v e a f f e c t . H o w e v e r , T u c k e r , R o t h a n d S h e a r e r ( N o t e 5) a r g u e t h a t t h e s e o b s e r v a t i o n s c o u l d a l s o b e t a k e n t o r e f l e c t a n e x a g g e r a t i o n o f t h e l e f t h e m i s p h e r e ' s c o n t r i b u t i o n t o 36 a f f e c t and personality, since damage or sedation might have the e f f e c t of preventing that hemisphere from receiving i t s normal i n h i b i t i o n from the right hemisphere. The observation that the amytal reactions occurred several minutes after the i n j e c t i o n , i . e . after the i n i t i a l u n i l a t e r a l sedative effects had cleared, would support this i n t e r p r e t a t i o n : If the depressive reaction were a product of the unaffected right hemisphere, i t would be more reasonable to expect i t to occur when the l e f t hemi-sphere i s f u l l y sedated; i t s occurrence af t e r the i n i t i a l sedative effects have cleared suggests instead that i t i s the product of an u n i n h i b i t i e d l e f t hemisphere. A study by H a l l , H a l l and Lavoie ( 1 9 6 8 ) also supports an "exaggera-t i o n " hypothesis: Rorschach responses were used to s t a t i s t i c a l l y contrast, with a high degree of separation ( p < \ 0 0 1 ) , the ideational style of right-handed patients who had w e l l - l o c a l i z e d l e f t brain lesions with that of right-handed patients who had w e l l - l o c a l i z e d right brain lesions. The thinking of l e f t damaged patients was found to be i n h i b i t e d and constricted, while that of right damaged patients was expansive and u n c r i t i c a l l y innovative; patients with midline or b i l a t e r a l lesions showed neither of these ideational patterns. The authors interpreted these observations as suggesting that damage exaggerates a hemisphere's normal contribution to personality func-tions. In support of this "exaggeration" inter p r e t a t i o n , the authors note that the right damaged, but not the l e f t d a m a g e d , g r o u p d i s p l a y e d a m a r k e d t e n d e n c y t o w a r d h o l i s t i c r e s p o n s e s a n d a v i v i d n e s s o f i m a g i n a l i d e a t i o n , b o t h o f w h i c h a r e b e l i e v e d t o b e c h a r a c t e r i s t i c s o f r i g h t h e m i s p h e r e f u n c t i o n i n g . P e r s o n a l i t y c h a n g e s i n t e m p o r a l l o b e e p i l e p t i c s a l s o s u p p o r t a n e x a g g e r a t i o n h y p o t h e s i s : C i t i n g e v i d e n c e t h a t t e m p o r a l l o b e e p i l e p s y i n v o l v e s t h e p r o g r e s s i v e d i s i n h i b i t i o n o f t h e t e m p o r a l l o b e l i m b i c s y s t e m , M a n d e l l ( 1 9 7 9 ) n o t e s t h a t p a t i e n t s w i t h l e f t t e m p o r a l l o b e e p i l e p s y g r a d u a l l y m a n i f e s t d y s p h o r i c a n d d e p r e s s i v e p e r s o n a l i t y f e a t u r e s w h i l e t h o s e w i t h r i g h t t e m p o r a l l o b e e p i l e p s y g r a d u a l l y m a n i f e s t h y s t e r i c a l , i m p u l s i v e a n d h y p o m a n i c p e r s o n a l i t y f e a t u r e s ; t h e s e c h a n g e s a r e p r e s u m a b l y d u e t o t h e p r o g r e s s i v e d i s i n h i b i t i o n o f t h e a f f e c t e d l o b e . A c c o r d i n g t o a n i n t e r p r e t a t i o n o f e x a g g e r a t i o n o f n o r m a l f u n c t i o n t h e n , t h e l e s i o n , a m y t a l a n d e p i l e p s y s t u d i e s r e v i e w e d a b o v e w o u l d s u g g e s t a p r e d o m i n a t e l y l e f t h e m i s p h e r e c o n t r i b u t i o n t o d e p r e s s i v e a f f e c t a n d i d e a t i o n , a n d a p r e d o m i n a t e l y r i g h t h e m i s p h e r e c o n t r i b u t i o n t o f e e l i n g s o f e u p h o r i a , i n d i f f e r e n c e a n d / o r d e n i a l . A l t e r n a t i v e l y , t h e s e d a t a c o u l d b e i n t e r p r e t e d a s s u g ^ g e s t i n g t h a t damage o r s e d a t i o n t o o n e h e m i s p h e r e u p s e t s t h e n o r m a l b a l a n c e e x i s t i n g b e t w e e n t h e h e m i s p h e r e s , a n d t h a t s u c h a c h a n g e i n i n t e r h e m i s p h e r i c b a l a n c e i s r e l a t e d t o e x t r e m e e m o t i o n a l r e a c t i o n s . ( 4 ) S t u d i e s o f p s y c h i a t r i c p o p u l a t i o n s : I t i s o b v i o u s t h a t i n f e r e n c e s d r a w n f r o m 38 . o b s e r v a t i o n s o f p a t i e n t s w i t h b r a i n p a t h o l o g y a r e d i f f i c u l t a n d r i s k y , s i n c e t h e a c t u a l e f f e c t s o f t h e p a t h o l o g y a r e u n k n o w n . I t i s i n t e r e s t i n g , t h e r e f o r e , t h a t s t u d i e s o f p s y c h i a t r i c p o p u l a t i o n s w i t h n o k n o w n b r a i n p a t h o l o g y h a v e a l s o y i e l d e d d a t a r e l a t i n g e m o t i o n a l p r o c e s s e s t o l a t e r -a l i z e d b r a i n f u n c t i o n s . T y p i c a l l y a d e c r e m e n t i n l e f t h e m i s p h e r e p e r f o r m a n c e h a s b e e n o b s e r v e d i n s c h i z o p h r e n i a a n d a d e c r e m e n t i n r i g h t h e m i s p h e r e p e r f o r m a n c e i n d e p r e s -s i o n . T h e s e o b s e r v a t i o n s come f r o m n e u r o p s y c h o l o g i c a l a s s e s s m e n t s t u d i e s a n d f r o m e x p e r i m e n t a l s t u d i e s u s i n g t a c h i s t o s c o p i c p r e s e n t a t i o n s , d i c h o t i c l i s t e n i n g , a n d e l e c t r o p h y s i o l o g i c a l m e a s u r e s . F l o r - H e n r y a n d Y e u d a l l ( 1 9 7 3 ) s u b j e c t e d 35 d e p r e s s e d p a t i e n t s a n d 28 p s y c h o p a t h s r e f e r r e d c o n s e c u t i v e l y f o r n e u r o p s y c h o l o g i c a l t e s t i n g t o a t e s t b a t t e r y c o n s i s t i n g o f 25 i n d i c a t o r s o f l o c a l i z e d a n d l a t e r a l i z e d c e r e b r a l d y s f u n c t i o n ; b l i n d n e u r o p s y c h o -l o g i c a l i n t e r p r e t a t i o n s s h o w e d t h a t a d i a g n o s i s o f p s y c h o -p a t h y was c o r r e l a t e d w i t h d o m i n a n t ( i . e . l e f t ) f r o n t o -t e m p o r a l d y s f u n c t i o n w h i l e a d i a g n o s i s o f d e p r e s s i o n was c o r r e l a t e d w i t h n o n d o m i n a n t ( i . e . r i g h t ) d y s f u n c t i o n . A n a l y s i s o f WAIS s u b t e s t s c o n f i r m e d t h e s e l a t e r a l i t y e f f e c t s , p s y c h o p a t h s e x h i b i t i n g a d e c r e m e n t o f V e r b a l I . Q . ( a s m e a s u r e d b y t h e V o c a b u l a r y a n d S i m i l a r i t i e s s u b -t e s t s ) a n d d e p r e s s i v e s a d e c r e m e n t o f P e r f o r m a n c e I . Q . ( a s m e a s u r e d b y t h e O b j e c t A s s e m b l y a n d B l o c k D e s i g n s u b -t e s t s . ) U n f o r t u n a t e l y , t h e s t u d y d i d n o t i n c l u d e a n o r m a l c o n t r o l g r o u p ; m o r e o v e r , t h e f i n d i n g o f d o m i n a n t h e m i s p h e r e 39 d y s f u n c t i o n i n p s y c h o p a t h s h a s b e e n q u e s t i o n e d b y H a r e (1979), who f o u n d n o s u c h e v i d e n c e when h e g a v e c r i m i n a l p s y c h o p a t h s a t a c h i s t o s c o p i c r e c o g n i t i o n t a s k d e s i g n e d t o m e a s u r e v i s u a l f i e l d s u p e r i o r i t y f o r w o r d s . A p o s s i b l e e x p l a n a t i o n f o r t h i s i n c o n s i s t e n c y i s t h a t p a t i e n t s i n t h e F l o r - H e n r y a n d Y e u d a l l (1973) s t u d y h a d a l l b e e n r e f e r r e d f o r n e u r o p s y c h o l o g i c a l a s s e s s m e n t s a n d t h u s t h e s a m p l e was b i a s e d . I n a l a t e r s t u d y , F l o r - H e n r y (1976) d i d u s e a n o r m a l c o n t r o l g r o u p i n c o m p a r i n g 35 s c h i z o p h r e n i c s a n d 4 0 a f f e c t i v e s ( m a n i c s , d e p r e s s i v e s a n d s c h i z o a f f e c -t i v e s ) o n t h e same n e u r o p s y c h o l o g i c a l t e s t b a t t e r y e m p l o y e d i n t h e p r e v i o u s s t u d y . D o u b l e - b l i n d a n a l y s i s o f t h e r e s u l t s f o u n d t h a t s c h i z o p h r e n i c s w e r e i m p a i r e d , r e l a t i v e t o n o r m a l s , o n t e s t s o f l e f t h e m i s p h e r e f u n c t i o n i n g ; a f f e c t i v e s w e r e i m p a i r e d , r e l a t i v e t o n o r m a l s , o n t e s t s o f r i g h t h e m i s p h e r e f u n c t i o n i n g . A r e c e n t s t u d y b y T a y l o r , G r e e n s p a n a n d A b r a m s (1979) a l s o c o m p a r e d s c h i z o p h r e n i c s , a f f e c t i v e s ( m a n i c s a n d d e p r e s s i v e s ) , a n d n o r m a l s . S u b j e c t s w e r e a d m i n i s t e r e d a m o d i f i c a t i o n o f t h e H a l s t e a d - W e p m a n A p h a s i a S c r e e n i n g T e s t a n d t h e t e s t was s c o r e d f o r e r r o r s a s s o -c i a t e d w i t h v a r i o u s b r a i n a r e a s . W h i l e s c h i z o p h r e n i c s made m o r e t o t a l e r r o r s a n d a l s o m o r e n o n d o m i n a n t p a r i e t a l e r r o r s t h a n b o t h n o r m a l s a n d a f f e c t i v e s , t h e y d i f f e r e d m o s t f r o m b o t h o t h e r g r o u p s i n t h e f r e q u e n c y w i t h w h i c h t h e y made e r r o r s a s s o c i a t e d , w i t h d o m i n a n t t e m p o r a l / t e m p o r a l p a r i e t a l p e r f o r m a n c e . A f f e c t i v e s made m o r e t o t a l a n d d o m i n a n t p a r i e t a l e r r o r s t h a n n o r m a l s , b u t d i f f e r e d 4 0 m o s t f r o m n o r m a l s i n t h e f r e q u e n c y w i t h w h i c h t h e y made e r r o r s a s s o c i a t e d w i t h n o n d o m i n a n t p a r i e t a l p e r f o r m a n c e . G o r d o n ( N o t e 6) g a v e a b a t t e r y o f l e f t a n d r i g h t h e m i -s p h e r e t e s t s t o 12 d e p r e s s e d a n d 15 s c h i z o p h r e n i c p a t i e n t s , a n d f o u n d t h a t t h e d e p r e s s e d g r o u p p e r f o r m e d n o r m a l l y o n l e f t h e m i s p h e r e t e s t s b u t p o o r l y o n r i g h t h e m i s p h e r e t e s t s , w h i l e t h e r e v e r s e was t r u e f o r a l l 15 s c h i z o p h r e n i c s . Two o f t h e d e p r e s s e d g r o u p w e r e b i p o l a r a f f e c t i v e s ; when t h e s e two p a t i e n t s s u b s e q u e n t l y b e c a m e m a n i c , t h e i r p e r f o r m a n c e o n r i g h t h e m i s p h e r e t e s t s was n o r m a l w h i l e t h e i r p e r f o r m a n c e o n l e f t h e m i s p h e r e t e s t s was i m p a i r e d . F i n d i n g s f r o m s e v e r a l e x p e r i m e n t a l s t u d i e s a r e c o n s i s t e n t w i t h t h e a b o v e d a t a : B e a u m o n t a n d D i m o n d ( 1 9 7 3 ) f o u n d t h a t s c h i z o p h r e n i c s , c o m p a r e d t o n o r m a l s , w e r e d e f i c i e n t i n m a t c h i n g p a i r s o f l e t t e r s p r e s e n t e d t a c h i s t o s c o p i c a l l y t o t h e l e f t h e m i s p h e r e b u t n o t d e f i -c i e n t i n m a t c h i n g p a i r s o f d i g i t s a n d a b s t r a c t s h a p e s p r e s e n t e d t o t h e r i g h t h e m i s p h e r e . G u r ( 1 9 7 8 ) r e p o r t e d t h a t r i g h t - h a n d e d s c h i z o p h r e n i c s , c o m p a r e d t o m a t c h e d n o r m a l c o n t r o l s , s h o w e d n o r m a l r i g h t - h e m i s p h e r e s u p e r i o r i t y f o r a s p a t i a l t a s k ( d o t l o c a t i o n ) p r e s e n t e d t a c h i s t o -s c o p i c a l l y b u t f a i l e d t o show n o r m a l l e f t - h e m i s p h e r e s u p e r i o r i t y o n a v e r b a l t a s k ( s y l l a b l e s ) , s u g g e s t i n g l e f t h e m i s p h e r e d y s f u n c t i o n i n p r o c e s s i n g v e r b a l i n f o r -m a t i o n . I n a s e c o n d s t u d y , G u r ( 1 9 7 8 ) o b s e r v e d s c h i z o -p h r e n i c s ' l a t e r a l e y e m o v e m e n t s ( L E M s ) , w h i c h h a v e b e e n h y p o t h e s i z e d t o r e f l e c t a c t i v a t i o n o f t h e h e m i s p h e r e 41 c o n t r a l a t e r a l t o t h e d i r e c t i o n o f t h e g a z e ( B a k a n , 1968; K i n s b o u r n e , 1973). I n r e s p o n s e t o q u e s t i o n s o f a v e r b a l , s p a t i a l , o r e m o t i o n a l n a t u r e , s c h i z o p h r e n i c s made m o r e r i g h t L E M s t h a n c o n t r o l s , r e g a r d l e s s o f q u e s t i o n t y p e . G u r c o n c l u d e d f r o m t h e s e two s t u d i e s t h a t s c h i z o p h r e n i a i s a s s o c i a t e d w i t h l e f t h e m i s p h e r e o v e r a c t i v a t i o n a s w e l l a s d y s f u n c t i o n . S c h w e i t z e r , B e c k e r a n d W e l s h (1978) a l s o o b s e r v e d L E M s i n s c h i z o p h r e n i c s when t h e l a t t e r r e f l e c t e d o n s p a t i a l - n o n e m o t i o n a l , v e r b a l - n o n e m o t i o n a l , s p a t i a l - e m o t i o n a l a n d v e r b a l - e m o t i o n a l m a t e r i a l : S c h i z o -p h r e n i c s p r o d u c e d s i g n i f i c a n t l y m o r e r i g h t - L E M s o v e r a l l t h a n d e p r e s s i v e s a n d n o r m a l s , s u g g e s t i n g t h a t t h e y u s e t h e l e f t h e m i s p h e r e i n g e n e r a l m o r e o f t e n t h a n o t h e r s when i n i t i a t i n g t h o u g h t . S c h i z o p h r e n i c s a l s o m o r e f r e q u e n t l y i n i t i a t e d t h o u g h t o n s p a t i a l - e m o t i o n a l m a t e r i a l i n t h e i r l e f t h e m i s p h e r e ( a s i n f e r r e d f r o m r i g h t w a r d L E M s ) ; t h i s was i n c o n t r a s t t o d e p r e s s i v e s a n d n o r m a l s , who i n i t i a t e d t h o u g h t o n s u c h m a t e r i a l m o r e f r e q u e n t l y i n t h e i r r i g h t h e m i s p h e r e ( a s i n f e r r e d f r o m l e f t w a r d L E M s ) . T h e s e f i n d i n g s w e r e c o n f i r m e d b y S c h w e i t z e r (1979); who i n a d d i t i o n f o u n d t h a t d e p r e s s i v e s i n i t i a t e d r e f l e c t i v e t a s k s i n g e n e r a l i n t h e i r r i g h t h e m i s p h e r e m o r e o f t e n t h a n s c h i z o p h r e n i c s a n d n o r m a l s ; t h e r e s u l t s w e r e i n t e r -p r e t e d a s e v i d e n c e f o r l e f t h e m i s p h e r e d i s t u r b a n c e i n s c h i z o p h r e n i a a n d r i g h t h e m i s p h e r e d i s t u r b a n c e i n d e p r e s -s i o n . H o w e v e r , s i n c e L E M s h a v e n o t b e e n c l e a r l y r e l a t e d t o h e m i s p h e r e a s y m m e t r y , i n f e r e n c e s c o n c e r n i n g h e m i s p h e r i c 42 functioning based on LEMs are questionable: In a c r i t i c a l review of LEM research, Ehrlichman and Weinberger (1978) noted several conceptual and methodological ambiguities i n LEM studies and also concluded that the evidence from such studies i s equivocal, since only nine of eighteen studies they reviewed found more right or l e f t LEMs in response to l e f t hemisphere or right hemisphere questions. Using dichotic l i s t e n i n g procedures usually employed to discriminate u n i l a t e r a l temporal lobe lesions ( i . e . c l i c k pairs at threshold l e v e l s , and dichotic words and s y l l a b l e s ) , Yozawitz and Bruder (Note 7) observed that right-handed patients with a f f e c t i v e disorders demonstrated poor l e f t ear (right hemisphere) performance, compared to normals. Gruzelier and Venables (1974) measured electrodermal responses i n both hands of three groups— schizophrenics, depressives and subjects with various personality disorders (there was no normal comparison group). Response amplitudes i n schizophrenics were lower on the l e f t hand than on the r i g h t , while the opposite was true for depressives; hand differences i n the personality disorder group were not s i g n i f i c a n t . Since, however, there i s disagreement about whether the electrodermal response i s mediated i p s i l a t e r a l l y (Luria and Homskaya, 1970) or c o n t r a l a t e r a l l y (Myslobodsky and Horesh, 1978), i t i s not clear whether reduced response on one hand suggests dysfunction of the hemisphere i p s i l a t e r a l or co n t r a l a t e r a l to that hand. It can be seen that studies of psychiatric populations 43 generally report a performance decrement i n depressives which i s s p e c i f i c to the right hemisphere. If this decrement i s the resu l t of suppression of right hemisphere functions by an overactive l e f t hemisphere, as Tucker suggests, then i t would be consistent with depressed mood, within the inter p r e t a t i o n of the les i o n , amytal and epilepsy data advanced e a r l i e r (which suggested a l e f t hemisphere tendency toward depressive af f e c t and there-fore a drop i n mood l e v e l with an exaggeration of l e f t hemisphere tendencies.) Flor-Henry (1976) has proposed that altered brain function i n psychiatric populations i s evidence of neurologic dysfunction. A l t e r n a t i v e l y , other researchers (Bakan, 1976; Tucker et a l , Note 5; Urstad, 1979) have suggested that psychiatric states may r e f l e c t the patho-l o g i c a l functioning of neurologically intact hemispheres. Some empirical support for the l a t t e r hypothesis comes from studies of cerebral blood flow, from studies reporting a s h i f t i n EEG asymmetry or l a t e r a l i z e d auditory discrimination i n schizophrenics following treatment, and from studies reporting an asymmetrical improvement i n performance by depressives following electroconvulsive treatment. Franzen and Ingvar (1975) compared cerebral blood flow i n normals and psychiatric patients and found that the l e f t hemisphere of schizophrenics had highest flow 44 in post-central regions and lowest in precentral regions, while the opposite was true for the l e f t hemisphere of normals, organics and chronic alcoholics. Since cerebral blood flow is apparently regulated by the metabolic activity of the neurons (Ingvar and Lassen, 1975), the rate of flow mirrors regional functional levels in the brain. Franzen and Ingvar (1975) concluded, there-fore, that "the primary disorder in schizophrenics is not caused by a loss of function, but by an abnormal distribution of function within a brain with an intact morphology and metabolism" (p. 211). Additional support for the notion of pathological functioning of intact hemispheres in psychiatric states comes from data pointing to an actual shift in lateralized function following some type of treatment intervention: Serafetinides (1972) measured the mean integrated amplitude from right and le f t parietal-occipital regions of the EEG in chronic female schizophrenics (handedness not reported) after a 12-week period without medication, and again after placebo or treatment with varying amounts of chlorpromazine. By examining voltage in each side over time, he observed a significant voltage increase in the le f t (but not right) side following treatment with 690 mg. of chlorpromazine per day, but no significant increase in the placebo group. Although the laterality shift was a minority occurrence (14 out of 31 patients), i t was in agreement with c l i n i c a l outcome, the 14 patients 45 who improved being those with s i g n i f i c a n t l y higher l e f t side than right side voltage. D'Elia, Jacobsson, von Knorring et a l (1977) also observed a s h i f t i n l a t e r a l i z e d EEG a c t i v i t y i n hospitalized schizophrenics after four weeks of treatment with antipsychotic medication. On four EEG v a r i a b l e s — w i t h i n - p a t i e n t variance i n the alpha band (7.5-13.5 Hz), mean integrated amplitude i n the alpha band, within-patient variance on the global EEG (.5-25 Hz) and mean integrated amplitude on the global EEG—the l e f t / r i g h t hemisphere r a t i o shifted from >1 (greater on l e f t ) before treatment to < 1 (greater on r i g h t — the t y p i c a l normal pattern) after treatment. However, the study lacked both a normal and a placebo control group, and the handedness of the subjects i s not given; moreover, the data analysis appears to be inadequate (multiple t-tests for comparing scores obtained before and after treatment.) Nevertheless, the s h i f t in alpha r a t i o was reported i n another study with fewer shortcomings: Urstad (1979) tested right-handed normal and psychotic subjects (diagnosis not reported) and found less alpha i n the l e f t temporal lobe than i n the r i g h t temporal lobe of a l l normals tested, whether they were reading, l i s t e n i n g to music with eyes closed, or resting with eyes closed and eyes open. He inferred that this r e f l e c t e d normal l e f t hemisphere dominance i n right-handed in d i v i d u a l s . In a l l psychotics tested there was less alpha i n the right temporal lobe than i n the l e f t across a l l tested conditions; moreover, 46 o n c e p a t i e n t s w e r e n o l o n g e r p s y c h o t i c , t h e i r l e f t - r i g h t a l p h a r a t i o was r e v e r s e d t o t h e same p a t t e r n a s ' n o r m a l s . W h i l e t h i s i s a n i n t e r e s t i n g f i n d i n g , t h e s m a l l n u m b e r o f s u b j e c t s w h o s e a l p h a p a t t e r n r e v e r s e d (5 o u t o f 10) a n d t h e l a c k o f a p l a c e b o g r o u p p r e c l u d e s s t r o n g i n f e r e n c e s . A l a r g e r s a m p l e (19 s u b j e c t s ) was u s e d b y G r u z e l i e r a n d Hammond ( 1 9 7 6 ) i n a s t u d y o f t h e l a t e r a l i t y e f f e c t s o f c h l o r p r o m a z i n e o n r i g h t - h a n n d e d s c h i z o p h r e n i c s c o m p a r e d t o n o r m a l c o n t r o l s . I n a n A - B - A d e s i g n , p a t i e n t s w e r e a s s e s s e d a f t e r s e v e r a l w e e k s o n t h e d r u g , r e t e s t e d a f t e r a f o u r - w e e k p l a c e b o p e r i o d , a n d a g a i n f o u r w e e k s a f t e r t h e d r u g was r e i n s t a t e d . I n a t a s k i n v o l v i n g a u d i t o r y d i s -c r i m i n a t i o n o f t o n e d u r a t i o n s w i t h e i t h e r e a r ( i n w h i c h n o r m a l s do b e t t e r w i t h r i g h t e a r ) , d r u g d o s e l e v e l c o r r e -l a t e d s i g n i f i c a n t l y w i t h s u p e r i o r r i g h t e a r p e r f o r m a n c e . ( S i n c e e a r d i f f e r e n c e s c o r e s w e r e u s e d i n t h i s a n a l y s i s , p a r t i a l c o r r e l a t i o n s w o u l d h a v e b e e n m o r e a p p r o p r i a t e . ) D u r i n g t h e p l a c e b o p h a s e , r i g h t ( b u t n o t l e f t ) e a r p e r -f o r m a n c e d e t e r i o r a t e d , i n d i c a t i n g p o o r e r l e f t h e m i s p h e r e p e r f o r m a n c e w i t h o u t t h e d r u g ; t h i s d e f i c i t t e n d e d t o r e v e r s e when t h e d r u g was r e i n s t a t e d ( h o w e v e r , t h e a u t h o r r e p o r t s a s i g n i f i c a n c e l e v e l o f . 0 6 ) . T h e s e l a t e r a l i t y e f f e c t s w e r e c o n s i s t e n t w i t h c l i n i c a l o b s e r v a t i o n s t h a t t h e p e r i o d o f g r e a t e s t p s y c h i a t r i c d e t e r i o r a t i o n o c c u r r e d d u r i n g t h e p l a c e b o p h a s e ; h o w e v e r , n u r s i n g s t a f f d o i n g t h e c l i n i c a l r a t i n g s w e r e n o t b l i n d t o t h e e x p e r i m e n t a l p r o c e d u r e , h e n c e t h e i r r a t i n g s may h a v e b e e n b i a s e d . 47 A c r i t i c i s m of several of the above studies ( d ' E l i a et a l , 1977; Urstad, 1979; Gruzelier and Hammond, 1976) i s that their data analysis involved a comparison of right side and l e f t side scores. Such comparisons do not take into account differences i n o v e r a l l performance and they are therefore not unbiased; use of a " l a t e r a l i t y score" would have been preferable (Marshall, Caplan and Holmes, 1975). Four studies have used neuropsychological assess-ment, EEG analysis, or dichotic l i s t e n i n g , to observe changes associated with electroconvulsive treatments for depression. In a study of u n i l a t e r a l ECT, Kronfol, Hamsher, Digire et a l (1978) observed a s p e c i f i c right hemisphere performance decrement (as measured by neuropsychological assessment) in right-handed depressed patients p r i o r to ECT, and also observed a decline i n l e f t hemisphere cognitive functioning following l e f t - s i d e d ECT and an improvement i n three out of four tests of right hemisphere cognitive functioning following right-sided ECT. (The exception was a f a c i a l recognition test. However, Benton £1980] has shown that the l e f t hemisphere may also participate i n f a c i a l percep-tion and memory; hence f a c i a l recognition i s not always a right hemisphere task.) Where ECT a l l e v i a t e d depression (as measured by a s i g n i f i c a n t drop i n depression scale scores), there was a performance improvement i n tests sensitive to right hemisphere function; no such improvement occurred i n tests sensitive to l e f t hemisphere function. 48 This occurred whether ECT was delivered to the right or l e f t side, a finding which suggests that right hemisphere cognitive performance i s s p e c i f i c a l l y affected i n depres-sion. Goldstein, Filskov, Weaver et a l ( 1 9 7 7 ) also used neuropsychological assessment (Halstead-Reitan battery) to observe the impact of nondominant ECT i n depressed patients. In contrast to Kronfol et a l ( 1 9 7 8 ) , they found that signs _of right hemisphere impairment increased after ECT. However, this finding may; be unreliable, since these patients were a r e l a t i v e l y old group (average age 52) and many of them had received either b i l a t e r a l ECT or u n i l a t e r a l dominant ECT i n the past; generalized as well as l a t e r a l i z e d d e f i c i t s were evident pre-treatment, suggesting the pos-s i b i l i t y of generalized brain impairment, possibly due to cerebral vascular disorders related to age. D'Elia and Perris ( 1 9 7 3 ) analyzed the EEG amplitude of right-handed depressed patients before and after they received b i l a t e r a l ECT and concluded that, because of a s i g n i f i c a n t increase in the variance of the amplitude on the l e f t side after ECT, the l e f t hemisphere i s primarily affected i n depression. However, the c o e f f i c i e n t of v a r i a t i o n , which i s the more usual index of v a r i a b i l i t y (Flor-Henry, 1976) did not d i f f e r on either side pre- or post-treatment, nor did the l e f t -r i g h t r a t i o of the mean integrated amplitude. Marjerrison, James and Reichert ( 1 9 7 5 ) replicated their study and found a b i l a t e r a l , not u n i l a t e r a l , increase i n variance after b i l a t e r a l ECT; therefore they questioned the D'Elia and 49 P e r r i s ( 1 9 7 3 ) c o n c l u s i o n o f l e f t h e m i s p h e r e d y s f u n c t i o n i n d e p r e s s i o n . S t r a u s s , M o s c o v i t c h a n d O l d s ( N o t e 1 3 ) , i n a s t u d y d o n e c o n t e m p o r a n e o u s l y w i t h t h e p r e s e n t s t u d y , u s e d d i c h o t i c s t i m u l a t i o n t o m e a s u r e h e m i s p h e r i c a s y m m e t r y i n r i g h t - h a n d e d f e m a l e d e p r e s s i v e s b e f o r e a n d a f t e r r e c e i v i n g n o n - d o m i n a n t u n i l a t e r a l E C T . P r i o r t o E C T , s u b j e c t s d e m o n s t r a t e d r e d u c e d e a r a s y m m e t r y i n s t e a d o f t h e n o r m a l p a t t e r n o f r i g h t e a r s u p e r i o r i t y i n d i c h o t i c l i s t e n i n g t o s p e e c h s y l l a b l e s ; f o l l o w i n g E C T , a l l b u t o n e p a t i e n t s h o w e d a s u p e r - a s y m m e t r y , d u e t o a s i g n i f i c a n t r i g h t e a r e l e v a -t i o n a n d l e f t e a r s u p p r e s s i o n , t h e o v e r a l l l e v e l o f p e r f o r -m a n c e r e m a i n i n g u n c h a n g e d . T h e s e e x t r e m e a s y m m e t r i e s p e r s i s t e d a t 3 - m o n t h f o l l o w - u p , when p a t i e n t s c o n t i n u e d t o r e p o r t e l e v a t e d m o o d . ( A l t h o u g h n o d e p r e s s i o n s c a l e s w e r e u s e d , t h e o n e p a t i e n t who f a i l e d t o show t h e e a r c h a n g e s a f t e r E C T was a l s o t h e o n l y o n e n o t j u d g e d b y p h y s i c i a n s t o b e c l i n i c a l l y i m p r o v e d . ) T h e a b o v e s t u d i e s w h i c h show a n a c t u a l s h i f t i n l a t e r a l i z e d f u n c t i o n f o l l o w i n g t r e a t m e n t i n t e r v e n t i o n f o r d e p r e s s i o n s u g g e s t t h a t a t t r i b u t i n g p o s i t i v e o r n e g a t i v e e m o t i o n t o e i t h e r h e m i s p h e r e a l o n e may b e a n o v e r s i m p l i f i -c a t i o n . R a t h e r , t h e s e s t u d i e s c o u l d i n d i c a t e t h a t t h e e f f e c t o f t r e a t m e n t was t o a d j u s t t h e f u n c t i o n a l b a l a n c e b e t w e e n t h e two h e m i s p h e r e s , t h e r e b y r e s t o r i n g t h e i n d i v i -d u a l t o e m o t i o n a l h e a l t h . ( 5 ) S t u d i e s o f n o r m a l s : S t u d i e s o f n o r m a l s a l s o s u g g e s t t h a t e m o t i o n a l 50 processes are related to hemispheric asymmetry. For example, f a c i a l asymmetry during emotional expression has been reported i n several studies which used bisected photographs of posed expressions; the halves were assembled into l e f t - l e f t and r i g h t - r i g h t composites: which subjects rated for in t e n s i t y of expression. Campbell ( 1 9 7 8 ) and Sackeim, Gur and Saucy ( 1 9 7 8 ) found left-facedness ( i . e . more intense emotional expression on the l e f t side of the photographed faces) for both males and females when expres-sing both positive and negative expressions, while Strauss and Kaplan (Note 15) found left-facedness only for females on sad poses, and Knox (Note 16) found no s i g n i f i c a n t l e f t - r i g h t differences. These inconsistencies may be due to methodological problems: composites may be of d i f f e r e n t widths, which would aff e c t apparent i n t e n s i t y ; composites exclude natural asymmetry i n t r i n s i c to some expressions, e.g. snarling; posed expressions may not be the same as those produced when subjects actually experience emotions (Borod and Caron, 1 9 7 9 ) . To avoid these problems, Borod and Caron ( 1 9 7 9 ) videotaped subjects producing f a c i a l expressions while imagining themselves i n positive and negative emotional situations described for them by the experimenter. Subsequent ratings of the tapes found that right-handed, but not left-handed, subjects were s i g n i -f i c a n t l y l e f t - f a c e d for the production of both positive and negative emotions. The authors concluded that the f a c i a l expression of emotion i s mediated by the right 51 h e m i s p h e r e i n r i g h t - h a n d e d p e r s o n s . F o u r o t h e r s t u d i e s h a v e c o n c l u d e d t h a t t h e r i g h t h e m i s p h e r e i s a l s o m o r e i n v o l v e d i n e m o t i o n a l e x p e r i e n c e o r i n t h e p e r c e p t i o n a n d e v a l u a t i o n o f e m o t i o n a l s t i m u l i . A l l f o u r , h o w e v e r , h a v e m e t h o d o l o g i c a l o r c o n c e p t u a l p r o b -l e m s . S c h w a r t z , D a v i d s o n a n d M a e r ( 1 9 7 5 ) r e p o r t e d t h a t e m o t i o n a l q u e s t i o n s p o s e d t o n o r m a l r i g h t - h a n d e d s t u d e n t s r e s u l t e d i n b o t h m o r e l e f t w a r d a n d f e w e r r i g h t w a r d e y e m o v e m e n t s t h a n d i d n o n e m o t i o n a l q u e s t i o n s ; t h e s e i n c r e a s e d t e n d e n c i e s w e r e a c c e n t u a t e d when e m o t i o n a l q u e s t i o n s a l s o i n v o l v e d s p a t i a l m a n i p u l a t i o n ( w h i c h w o u l d r e q u i r e r i g h t h e m i s p h e r e p r o c e s s i n g ) a n d a t t e n u a t e d when e m o t i o n a l q u e s -t i o n s a l s o i n v o l v e d v e r b a l m a n i p u l a t i o n ( w h i c h w o u l d r e q u i r e l e f t h e m i s p h e r e p r o c e s s i n g ) . T h e a u t h o r s c o n -c l u d e d , t h e r e f o r e , t h a t t h e r i g h t h e m i s p h e r e i s m o r e a c t i v a t e d i n e m o t i o n . H o w e v e r , t h e c o n t e n t v a l i d i t y o f t h e q u e s t i o n s was n o t a s s e s s e d ; m o r e o v e r , s i g n i f i c a n t i n t e r a c t i o n s w e r e e x a m i n e d w i t h t - t e s t s i n s t e a d o f b y a n a l y s i s o f s i m p l e m a i n e f f e c t s . T u c k e r , R o t h , A r n e s o n e t a l ( 1 9 7 7 ) r e p l i c a t e d a n d e x t e n d e d t h e s e f i n d i n g s w i t h u n d e r g r a d u a t e s i n a n o t h e r w i t h i n - s u b j e c t s p r o c e d u r e w h i c h v a r i e d n o t o n l y t h e e m o t i o n a l n a t u r e o f t h e q u e s t i o n c o n t e n t , b u t a l s o t h e e m o t i o n a l t o n e o f t h e e x p e r i m e n t a l s i t u a t i o n ( n e u t r a l o r s t r e s s f u l ) . I n a s t a t e a n x i e t y q u e s t i o n n a i r e c o m p l e t e d f o r t h e two c o n d i t i o n s , s u b j e c t s r e p o r t e d s i g n i -f i c a n t l y m o r e a n x i e t y f o r t h e s t r e s s c o n d i t i o n . A s w i t h t h e S c h w a r t z e t a l s t u d y , t h e r e w e r e m o r e l e f t w a r d e y e movements to emotional than to non-emotional questions (the questions were drawn from the Schwartz et a l study and again content v a l i d i t y was not assessed); the tendency toward leftward eye movements was accentuated i n the stress condition so that stress and emotional content combined produced a greater number of leftward movements than any other condition. The authors concluded that right hemisphere ac t i v a t i o n i s increased by stress. However, since the handedness of the students i s not reported, i t i s not clear which hemisphere was presumably more activated by the greater number of leftward movements. An additional methodological problem i n both of the above studies i s their reliance on l a t e r a l eye movements as indicators of hemispheric ac t i v a t i o n , when, as noted e a r l i e r , LEMs have not been c l e a r l y related to hemisphere asymmetry. Safer and Levanthal (1977) had normal right-handed undergraduates l i s t e n with l e f t or right ear to tape-recorded passages varying both i n emotional tone of voice (happy, angry or neutral) and i n nature of content (positive, negative, or neutral.) When passages were heard by the l e f t ear, subjects primarily used emotional tone of voice cues to rate them, whereas when heard by the right ear, passages were rated primarily according to the nature of their content. The authors concluded that these results r e f l e c t e d l e f t hemisphere superiority for analytic processing and right hemisphere superiority i n the perception and evaluation of emotional s t i m u l i . However, since the right 53 h e m i s p h e r e i s s u p e r i o r f o r t o n a l ( p i t c h ) p r o c e s s i n g ( M i l n e r , 1 9 6 2 ) , i t i s p o s s i b l e t h a t t h e r i g h t h e m i s p h e r e was r e s -p o n d i n g t o v o i c e t o n e s r a t h e r t h a n t o t h e e m o t i o n a l c o n t e n t c o n v e y e d b y t h e s p e a k e r . T h e same c r i t i c i s m a p p l i e s t o a s t u d y b y C a r m o n a n d N a c h s o n ( 1 9 7 3 ) , w h i c h r e p o r t e d t h a t s u b j e c t s m o r e a c c u r a t e l y j u d g e d t h e a f f e c t i v e q u a l i t y o f n o n l a n g u a g e e m o t i o n a l human v o c a l i z a t i o n s when t h e s e w e r e h e a r d b y t h e l e f t e a r . L e y a n d B r y d e n ( 1 9 7 9 ) h a v e p o i n t e d o u t t h a t t h e r i g h t h e m i s p h e r e may be b e t t e r s u i t e d t o p e r c e i v e a n d e v a l u a t e e m o t i o n a l s t i m u l i b e c a u s e d o i n g s o e n t a i l s a n i n t e g r a t i o n o f s t i m u l u s i n f o r m a t i o n f r o m a v a r i e t y o f s o u r c e s a n d a c r o s s s p a c e a n d t i m e ; s i n c e t h e r i g h t h e m i s p h e r e i s a p p a r e n t l y s p e c i a l i z e d f o r s u c h g e s t a l t p r o c e s s i n g , i t s h o u l d p r o c e s s e m o t i o n a l s t i m u l i m o r e e f f i c i e n t l y . I n t h e same v e i n , S a f e r a n d L e v a n t h a l ( 1 9 7 7 ) h a v e n o t e d t h a t e m o t i o n s a r e o f t e n a c c o m p a n i e d b y , o r a s s o c i a t e d w i t h , i m a g e r y , w h i c h i s b e l i e v e d t o be p r i m a r i l y a r i g h t h e m i s p h e r e f u n c t i o n . T h u s t h e r i g h t h e m i s p h e r e ' s r e p o r t e d s u p e r i o r i t y f o r p r o c e s s i n g c e r t a i n e m o t i o n a l s t i m u l i may r e l a t e t o t h e p r o c e s s i n g demands a s s o c i a t e d w i t h s u c h s t i m u l i r a t h e r t h a n t o t h e i r e m o t i o n a l c o n t e n t p e r s e . I n c o n t r a s t t o s t u d i e s w h i c h a t t r i b u t e e m o t i o n a l e x p e r i e n c e t o t h e r i g h t h e m i s p h e r e a r e f i v e E E G s t u d i e s w i t h n o o b v i o u s m e t h o d o l o g i c a l p r o b l e m s , w h i c h s u g g e s t t h a t b o t h h e m i s p h e r e s a r e i n v o l v e d i n e m o t i o n a l e x p e r i e n c e , a n d t h a t i t i s t h e p a r t i c u l a r f u n c t i o n a l b a l a n c e b e t w e e n t h e h e m i s p h e r e s t h a t d e t e r m i n e s e m o t i o n a l s t a t u s . A l l f i v e studies report asymmetrical changes i n hemispheric functioning during the experience of strong positive or negative emotion. Harman and Ray ( 1 9 7 7 ) recorded right and l e f t hemisphere EEG power from temporal s i t e s before and during e l i c i t a t i o n of positive and negative emotions i n normal right-handed students, when the students r e c a l l e d v i v i d emotionally negative and posi t i v e memories. In separate analysis of variance for each side, i t was found that the l e f t hemisphere became more active than usual i n strong negative a f f e c t i v e states and less active than usual i n strong positive ones; no s i g n i f i c a n t changes in r ight hemisphere act i v a t i o n were observed. Ehrlichman and Weiner (Note 8) compared the amount of activation i n l e f t and r i g h t temporal lobe during r e c a l l of negative or p o s i t i v e a f f e c t by normal right handers; a s h i f t to greater l e f t than right hemisphere act i v a t i o n occurred during r e c a l l of negative a f f e c t , while a s h i f t to greater right than l e f t hemisphere act i v a t i o n occurred during r e c a l l of positive a f f e c t . More recently, three EEG studie have recorded from brain regions other than the temporal regions, and also reported asymmetrical changes i n a c t i v a -tion during strong emotional states: Davidson (Note 9) and Davidson, Schwartz, Saron, Bennett and Goleman (Note 10) had normal subjects view t e l e v i s i o n programs and record their emotional responses by continuous pressure on a response lever, while their EEG data was recorded from anterior and posterior s i t e s within each hemisphere; 55 i n a s e c o n d e x p e r i m e n t , n o r m a l s u b j e c t s g e n e r a t e d p o s i t i v e a n d n e g a t i v e t h o u g h t s , f e e l i n g s a n d i m a g e s a b o u t t h e i r p a s t o r f u t u r e w h i l e t h e same k i n d o f E E G d a t a was c o l l e c t e d . T h e r e s u l t s s h o w e d t h a t t h e p a r i e t a l r e g i o n o f r i g h t h e m i -s p h e r e b e c a m e m o r e a c t i v e t h a n t h a t o f t h e l e f t d u r i n g b o t h p o s i t i v e a n d n e g a t i v e e m o t i o n s , w h i l e i n f r o n t a l r e g i o n s t h e r i g h t b e c a m e m o r e a c t i v e t h a n t h e l e f t d u r i n g n e g a t i v e a f f e c t a n d t h e l e f t m o r e a c t i v e t h a n t h e r i g h t d u r i n g p o s i t i v e a f f e c t . T u c k e r , S t e n s l i e , R o t h e t a l ( 1 9 7 9 ) r e c o r d e d f r o m a v a r i e t y o f b r a i n s i t e s ( l e f t a n d r i g h t f r o n t a l , c e n t r a l , p a r i e t a l a n d o c c i p i t a l ) w h i l e d e p r e s s e d a n d e u p h o r i c moods w e r e i n d u c e d i n r i g h t - h a n d e d s t u d e n t s b y d i r e c t s u g g e s t i o n a n d b y h a v i n g t h e s t u d e n t s r e c a l l a s t r o n g e m o t i o n a l l y p o s i t i v e o r n e g a t i v e m e m o r y ; s t r e n g t h o f mood was s e l f - r a t e d d u r i n g d e b r i e f i n g . T h e r e s u l t s s h o w e d r e l a t i v e s y m m e t r y d u r i n g t h e e u p h o r i a c o n d i t i o n ( w h i c h was n o t d i f f e r e n t f r o m t h e n e u t r a l c o n d i t i o n p r e c e d i n g mood i n d u c t i o n ) , b u t a s h i f t t o w a r d m o r e a c t i v a t i o n i n r i g h t t h a n i n l e f t f r o n t a l l o b e d u r i n g d e p r e s s i o n . T h i s was c o n s i s t e n t w i t h t h e D a v i d s o n e t a l ( N o t e 10) f i n d i n g f o r n e g a t i v e e m o t i o n s , b u t n o t c o n s i s t e n t w i t h t h e i r f i n d i n g o f a s y m m e t r y i n f r o n t a l l o b e s d u r i n g p o s i t i v e a f f e c t . T h i s i n c o n s i s t e n c y may b e d u e t o t h e d i f f i c u l t y i n i n d u c i n g e u p h o r i a r e p o r t e d b y T u c k e r e t a l ( 1 9 7 9 ) , h e n c e l a c k o f s u f f i c i e n t l y p o w e r f u l p o s i t i v e e m o t i o n t o p r o d u c e f r o n t a l a s y m m e t r y . I t may a l s o b e d u e t o t h e f a c t t h a t D a v i d s o n e t a l ( N o t e 10) e x a m i n e d m e a n s w i t h i n c o n d i t i o n s o f p o s i t i v e 56 or negative emotion, while Tucker et a l ( 1 9 7 9 ) used analysis of variance comparisons pertaining to the differences between euphoric and depressive mood conditions, thus interpretation of the l a t t e r ' s data deals more properly with the r e l a t i v e effects of euphoric versus depressive mood conditions. Two other studies of normals, which did not involve EEG recordings, also concluded that emotional experience i s related to the functional balance between the hemi-spheres: Dimond, Farrington and Johnson ( 1 9 7 6 ) had normal right-handed students view b r i e f cine films chosen to pro-voke d i f f e r e n t kinds of emotional response. The films were projected to either both hemispheres (free viewing) or to one hemisphere only (via special contact lenses which r e s t r i c t e d v i s u a l input to right or l e f t hemisphere). Films were judged s i g n i f i c a n t l y more unpleasant and h o r r i f i c when projected to right hemisphere alone than when pro-jected to either l e f t hemisphere alone or to both hemi-spheres. The authors concluded, therefore, that under normal conditions, negative emotion i s inh i b i t e d by the l e f t hemisphere. When such i n h i b i t i o n i s prevented (by stimulating only the right hemisphere), the functional balance between the hemispheres changes, producing a s h i f t toward more negative emotional experience. Tucker, Antes, Stenslie et a l ( 1 9 7 8 ) examined auditory attentional bias and l a t e r a l eye movement in high versus low t r a i t anxiety subjects ( a l l right-handed students). They found high 57 t r a i t anxiety (as measured by the Spielberger Question-naire) to be associated with a right ear attentional bias (more tones judged louder i n right ear) while no bias for either ear was found i n low-anxiety subjects. High anxiety also correlated s i g n i f i c a n t l y with a lower incidence of l e f t l a t e r a l eye movements and a higher incidence of nonlateral ones (in response to the r e f l e c t i v e questions of Schwartz et a l , 1 9 7 5 ) . The authors inferred from this that the l e f t hemisphere becomes overactive (hence more tones judged louder i n right ear) and the right hemi-sphere becomes underactive (hence fewer l e f t eye movements) in subjects who experience high t r a i t anxiety. However, in addition to the c r i t i c i s m that LEMs have not been c l e a r l y linked to hemispheric a c t i v a t i o n , i t i s d i f f i c u l t to reconcile the conclusion that high t r a i t anxiety i s associated with an underactive right hemisphere with the Tucker et a l ( 1 9 7 7 ) conclusion that right hemisphere ac t i v a t i o n i s increased by state anxiety. On the other hand, the conclusion of l e f t hemisphere overactivation i n anxiety i s consistent with EEG studies reporting increased l e f t temporal lobe a c t i v a t i o n during negative a f f e c t . It i s obviously extremely d i f f i c u l t , from studies of normal subjects, to draw conclusions concerning which hemisphere contributes what to p a r t i c u l a r emotional states. What these studies do consistently suggest, however, (excluding those with obvious methodological or conceptual problems), i s that d i f f e r e n t emotional states are r e f l e c t e d 58 i n d i f f e r e n t p a t t e r n s o f f u n c t i o n a l a s y m m e t r y . W h i l e t h e f i v e E E G s t u d i e s a p p e a r t o b e i n c o n s i s t e n t i n i m p l i c a t i n g r i g h t o r l e f t h e m i s p h e r e i n n e g a t i v e e m o t i o n , i t m u s t b e r e m e m b e r e d t h a t i n c r e a s e d a c t i v a t i o n i n a p a r t i c u l a r b r a i n r e g i o n c o u l d r e p r e s e n t e i t h e r e x c i t a t o r y o r i n h i b i t o r y a c t i v i t y . T h u s f i n d i n g s o f i n c r e a s e d a c t i v a t i o n i n l e f t t e m p o r a l l o b e d u r i n g n e g a t i v e a f f e c t ( E h r l i c h m a n a n d W i e n e r , N o t e 8 ; H a r m a n a n d R a y , 1977) a r e n o t n o t n e c e s s a r i l y a t v a r i a n c e w i t h f i n d i n g s o f i n c r e a s e d a c t i v a t i o n i n r i g h t f r o n t a l l o b e d u r i n g n e g a t i v e a f f e c t ( D a v i d s o n , N o t e 9 ; D a v i d s o n e t a l , N o t e 1 0 ; T u c k e r e t a l , 1 9 7 9 ) : t h e f o r m e r c o u l d r e p r e s e n t e x c i t a t o r y a c t i v i t y w h i l e t h e l a t t e r c o u l d r e p r e s e n t i n h i b i t o r y a c t i v i t y , o r t h e c o n v e r s e c o u l d be t r u e . S i n c e t h e f r o n t a l l o b e s h a v e b e e n i m p l i -c a t e d i n i n h i b i t o r y f u n c t i o n s , T u c k e r e t a l ( 1 9 7 9 ) h a v e s p e c u l a t e d t h a t t h e i n c r e a s e d f r o n t a l l o b e a c t i v i t y o b s e r v e d b y t h e m a n d b y D a v i d s o n e t a l ( N o t e 10) d u r i n g n e g a t i v e a f f e c t c o u l d r e p r e s e n t i n t r a h e m i s p h e r i c i n h i b i t i o n . B y c o n t r a s t , l e f t t e m p o r a l l o b e a c t i v a t i o n d u r i n g n e g a t i v e a f f e c t c o u l d r e p r e s e n t i n t e r h e m i s p h e r i c i n h i b i t i o n . A t t h e p r e s e n t t i m e s u c h p r o p o s a l s a r e p u r e l y s p e c u l a t i v e . A l l t h a t c a n be s a f e l y i n f e r r e d f r o m t h e a b o v e s t u d i e s i s t h a t f u n c t i o n a l a s y m m e t r y a p p e a r s t o b e r e l a t e d t o e m o t i o n a l p r o c e s s e s i n n o r m a l s u b j e c t s . T h i s h a s i m p o r t a n t i m p l i c a t i o n s f o r T u c k e r ' s h e m i s p h e r i c i n t e r a c t i o n t h e o r y o f e m o t i o n a l f u n c t i o n i n g , d i s c u s s e d b e l o w . 59 Hemispheric int e r a c t i o n theories of emotional functioning Tucker et a l (Note 5) argue that i t i s i n s u f f i c i e n t and probably misleading to question which emotion i s l a t e r a l i z e d i n which hemisphere, since, i n their view, i t i s the inte r a c t i o n between the hemispheres which i s the c r u c i a l determinant i n the individual's psychological status. Thus, attempting to i s o l a t e the emotional pro-pensities of either hemisphere singly i s f r u i t l e s s , since one hemisphere's status i n any emotional configuration i s at least i n part dependent upon influences from the other hemisphere. Somewhat similar views have been advanced by both Bakan (1976) and Galin (1974), both of whom have proposed theories of emotional functioning i n which the l e f t hemisphere exerts i n h i b i t o r y influences upon the more primary and spontaneous capacities of the right hemisphere. Bakan (1976) has suggested that a breakdown i n the l e f t hemisphere's i n h i b i t o r y functions may be relevant to psychosis: C i t i n g evidence suggesting that the right hemi-sphere i s predominantly involved i n sexual arousal and in dreaming, Bakan has speculated that i n schizophrenia the usual i n h i b i t i o n of the right hemisphere has broken down, possibly due to a defective corpus callosum, so that right hemisphere experience i s no longer confined to REM sleep; hence the "dreamlike r e a l i t y (of the right hemisphere) s p i l l s over into (the schizophrenic's) waking l i f e " (Bakan, 1976, p. 68). Galin (1974) has drawn a 60 p a r a l l e l between the psychological operations of the r i g h t and l e f t hemispheres and the primary and secondary process functions, respectively, of. psychoanalytic theory: Noting that i n s p l i t -brain patients the mental process of one hemisphere i s inacces-s i b l e to deliberate conscious r e t r i e v a l by the other, and that the isolated right hemisphere can apparently sustain emotional responses and goals d i f f e r e n t from those of the l e f t , Galin has hypothesized that i n normal individuals unpleasant or con-f l i c t i n g events i n the r i g h t hemisphere become functionally disconnected from the verbal l e f t hemisphere by i n h i b i t i o n across the cerebral commissures. The hypothesis thus suggests a neurophysiological basis for psychological repression and an anatomical locus for unconscious mental events. In support of this hypothesis, Galin notes that s p l i t - b t a i n patients do not experience their obvious duality; s i m i l a r l y , i n functional d i s -connection the i n d i v i d u a l would be unaware of repressed r i g h t hemisphere events. Tucker's i n t e r a c t i o n a l theory of hemispheric c o n t r i -butions to psychological processes suggests that the development of l a t e r a l s p e c i a l i z a t i o n has resulted i n hemispheres which are not only d i f f e r e n t , but opposite from each other: The opposition between the two sides of the brain results i n a d i a l e c t i c a l i n t e r a c t i o n : the optimal configuration of human neuro-psychological organization i s not seen as a dichotomous usage of one side or the other, but a synergic l e v e l of integration which arises out of the i n t r i n s i c opposition of the two hemispheres' d i f f e r e n t i a t e d forms of structuring experience and behavior. (Tucker et a l , Note 5 , p. 7 ) . 61 A p p l y i n g t h i s d i a l e c t i c a l v i e w t o e m o t i o n a l f u n c -t i o n i n g , T u c k e r ( N o t e 1) p r o p o s e s t h a t t h e l e f t h e m i s p h e r e i s i n v o l v e d i n e m o t i o n a l i n h i b i t i o n a n d c o n s t r i c t i o n , w h i l e t h e r i g h t i s i n v o l v e d i n s p o n t a n e o u s a n d i m p u l s i v e e x p r e s s i v e n e s s . T h e l e f t h e m i s p h e r e ' s " d o m i n a n t " f u n c t i o n s a r e e f f e c t e d l a r g e l y t h r o u g h i n h i b i t i o n o f t h e m o r e p r i m a r y e m o t i o n a l r e s p o n s i v i t y o f t h e r i g h t . W i t h i n t h i s f r a m e w o r k , i t i s n o t a m a t t e r o f o n e h e m i s p h e r e b e i n g m o r e " e m o t i o n a l " t h a n t h e o t h e r , n o r o f o n e h e m i s p h e r e c o n t r o l l i n g n e g a t i v e e m o t i o n a n d t h e o t h e r c o n t r o l l i n g p o s i t i v e e m o t i o n . A s T u c k e r e t a l ( N o t e 5 , p . 11) c o m m e n t , A v a r i e t y o f p r i m i t i v e , s y n c r e t i c , a n d s p o n -t a n e o u s e m o t i o n a l r e s p o n s e s w i t h p r i m a r y e l a b o r a t i o n w i t h i n t h e r i g h t h e m i s p h e r e c o u l d be q u i t e a v e r s i v e t o t h e i n d i v i d u a l ; t h e i n h i b i t i o n , a n d p o t e n t i a l l y t h e d i f f e r e n t i a -t i o n , o f s u c h p r i m a r y a f f e c t i v e a r o u s a l b y t h e l e f t h e m i s p h e r e c o u l d r e s u l t i n a n a f f e c -t i v e s t a t e w h i c h i s m o r e p o s i t i v e . T h i s s o r t o f i n t e r a c t i o n may p e r t a i n t o t h e f i n d i n g s o f D i m o n d e t a l ( 1 9 7 6 ) ( w h i c h s u g g e s t e d t h a t t h e l e f t h e m i s p h e r e i n h i b i t s n e g a t i v e e m o t i o n a s s o c i a t e d w i t h t h e r i g h t h e m i s p h e r e . ) I n d e p r e s s i o n , s a y s T u c k e r , t h e l e f t h e m i s p h e r e ' s i n h i b i t o r y t e n d e n c i e s b e c o m e m o r e d o m i n a n t , w h i l e f u n c t i o n s o f t h e r i g h t b e c o m e s u p p r e s s e d . T u c k e r e t a l ( N o t e 5) t e s t e d t h i s h y p o t h e s i s b y c o m p a r i n g t h e d e g r e e o f h e m i s p h e r i c a c t i v a t i o n a n d t h e p e r f o r m a n c e c a p a c i t y o f e a c h h e m i s p h e r e d u r i n g a d e p r e s s i v e mood s t a t e a n d a e u p h o r i c mood s t a t e , e a c h i n d u c e d h y p n o -t i c a l l y i n n o r m a l r i g h t - h a n d e d c o l l e g e s t u d e n t s . A r i t h -m e t i c a n d i m a g e r y t a s k s p r o v i d e d m e a s u r e s o f l e f t a n d r i g h t hemisphere performance during the mood states; a dichotic l i s t e n i n g task provided a measure of auditory attentional bias in d i c a t i n g greater ac t i v a t i o n of one hemisphere over the other (subjects judged i n which ear a tone presented simultaneously to both ears sounded louder). The results showed a transient s h i f t i n hemi-spheric function concomitant with a transient a l t e r a t i o n of the individual's emotional state. S p e c i f i c a l l y , the right hemisphere was more activated i n euphoria and the l e f t more activated i n depression. Moreover, performance on the right hemisphere task (imagery) was s i g n i f i c a n t l y poorer i n depression than i n euphoria, while performance on the l e f t hemisphere task (arithmetic) was exactly the same i n both mood states. Unfortunately, the study has several methodological flaws: there was no neutral control condition; no objective measures of depression and euphoria were obtained before or after the hypnotic induction; performance on the imagery task was rated by degree of self-reported vividness and thus the impact of the depressed mood could have been upon subjects' ratings of the images rather than upon the quality of the images themselves. Tucker argues that his theory of depression i s not necessarily at variance with the view that depression i s a biochemical disorder which responds to antidepressant medications: Glick, Jerussi and Zimmerberg (1977) reported on studies showing asymmetry i n dopamine content of nigro-s t r i a t a l systems i n normal rats, suggesting asymmetry i n 63 the number of receptor s i t e s for this neurotransmitter. Oke, K e l l e r , Mefford and Adams ( 1 9 7 8 ) recently demonstrated that norepinephrine has a strongly l a t e r a l i z e d d i s t r i -bution i n the human thalamus: In the most posterior region, the l e f t hemisphere i s r i c h i n norepinephrine, whereas i n the somatosensory input area (more anterior) the right hemisphere has a higher concentration of this catechol-amine, and i n the most anterior regions there i s very l i t t l e l a t e r a l i z a t i o n at a l l . Thus i t i s possible that antidepressants may stimulate one hemisphere more than the other, helping to restore a functional balance between the two hemispheres. Relevant to this are two double-bl i n d controlled studies by Vogel, Thompson, Thurmond and Rivers ( 1 9 7 3 ) and Vogel, Thurmond, Gibbons, Sloan, Boyd and Walker ( 1 9 7 5 ) : Noting that several antidepressants disrupt REM sleep, which has been proposed as a predomi-nantly right hemisphere process (Bakan, Note 1 1 ) , these researchers speculated that the antidepressant mechanism of the drugs resides i n their capacity to reduce REM sleep, thus creating REM "pressure" i n the waking state, which increases right hemisphere a c t i v a t i o n . They found that disrupting REM sleep of endogenously depressed patients s i g n i f i c a n t l y reduced depression l e v e l ; disrupting non-REM sleep i n such patients had no e f f e c t . Evidence from ECT studies suggests that the e f f e c t of non-dominant u n i l a t e r a l ECT may also be a restoration of the functional balance between the two hemispheres: 64 A l t h o u g h some s t u d i e s ( A b r a m s , 1 9 7 2 ; C o s t e l l o , B e l t o n , A b r a a n d D u n n , 1 9 7 0 ; d ' E l i a a n d R a o t m a , 1975) c l a i m t h a t n o n -d o m i n a n t E C T , w h i l e p r o d u c i n g f e w e r s i d e e f f e c t s s u c h a s p o o r r e c a l l a n d r e l e a r n i n g , h a s n o g r e a t e r a n t i d e p r e s s i v e e f f e c t t h a n o t h e r m o d e s o f E C T , m o s t s t u d i e s c o m p a r i n g E C T m o d e s h a v e a v a r i e t y o f m e t h o d o l o g i c a l p r o b l e m s ( s e e d ' E l i a a n d R a o t m a , 1 9 7 5 , a n d C o h e n , P e n i c k a n d T a r t e r , 1974) i n c l u d i n g t h e a b s e n c e o f a n o - E C T c o n t r o l g r o u p . T h e o n e s t u d y w i t h a d e q u a t e m e t h o d o l o g y i n c l u d i n g a n o - E C T c o n t r o l g r o u p f o u n d t h a t u n i l a t e r a l n o n - d o m i n a n t E C T was a m o r e e f f e c t i v e a n t i d e p r e s s a n t t h a n e i t h e r o f t h e o t h e r two m o d e s o f E C T ( C o h e n e t a l , 1 9 7 4 ) . F r o m t h i s i t w o u l d f o l l o w t h a t t h e n o n - d o m i n a n t ( i . e . r i g h t ) h e m i s p h e r e i s c r i t i c a l l y i n v o l v e d i n d e p r e s s i o n , s i n c e t h e m a j o r i t y o f u n i l a t e r a l l y i n d u c e d s e i z u r e s i m p l i c a t e t h e s t i m u l a t e d s i d e m o r e t h a n t h e u n s t i m u l a t e d s i d e , b o t h a t t h e m o t o r a n d n e u r o p h y s i o -l o g i c a l l e v e l s ( d ' E l i a a n d P e r r i s , 1 9 7 0 ) . I t seems l i k e l y t h a t s t i m u l a t i n g t h e r i g h t h e m i s p h e r e h e l p s t o r e s t o r e a m o r e e q u i t a b l e f u n c t i o n a l b a l a n c e b e t w e e n t h e two h e m i s p h e r e s . S i n c e T u c k e r ' s n e u r o p s y c h o l o g i c a l t h e o r y o f d e p r e s s i o n h a s o n l y r e c e n t l y b e e n a d v a n c e d , i t h a s n o t y e t b e e n s u b -j e c t e d t o c r i t i c a l e v a l u a t i o n w i t h c l i n i c a l l y d e p r e s s e d s u b j e c t s . T u c k e r e t a l ' s ( N o t e 5) f i n d i n g t h a t a s h i f t i n h e m i s p h e r i c f u n c t i o n i n g c o r r e s p o n d e d t o a s h i f t i n e m o t i o n a l s t a t e i n n o r m a l s u b j e c t s i s i n t r i g u i n g , b u t a s n o t e d e a r l i e r , t h e s t u d y h a s a n u m b e r o f m e t h o d o l o g i c a l f l a w s ; m o r e o v e r , i t s r e l e v a n c e t o c l i n i c a l l y d e p r e s s e d p o p u l a t i o n s , 65 l i k e the experimental studies of Beck's and Lewinsohn's hypotheses, i s uncertain. One attempt (Burtle, 1976) to t r a i n four depressed patients i n the use of v i s u a l imagery to encourage right hemispere processing did produce a s i g n i f i c a n t decrease i n depression l e v e l . While such a finding coud suggest new options for the treatment of depression, the smallness of the sample and the lack of objective measures of imagery production i n the study preclude anything more than speculation at the present time. 66 Conclusions from the Literature From the foregoing review, i t can be seen that Beck's, Lewinsohn's, and Tucker's theories are each con-sistent with a considerable body of data reported i n the psychological and neuropsychological l i t e r a t u r e . In support of Beck's cognitive theory, several studies have shown that depressive states have negative cognitive correlates, that depressives tend to screen information i n a negative way, and that depressed mood can be induced in normals by focussing attention on negative information or by reducing self-esteem. Two studies have demonstrated that cognitive therapy i s e f f e c t i v e i n a l l e v i a t i n g depres-sion. However, i t has not been shown that depression-prone persons have a negative cognitive set which renders them vulnerable to depression, nor has i t been shown that the cognitions of c l i n i c a l l y depressed persons relate to Beck's typology. Lewinsohn's behavioral theory i s supported by studies showing that depressive states have behavioral correlates, including reduced p a r t i c i p a t i o n i n enjoyable a c t i v i t i e s , emission of fewer behaviors, and emission of ''"The Krantz and Hammen (1979) study, reporting data from c l i n i c a l l y depressed patients, was published after the present study was completed. a v a r i e t y o f s o c i a l l y u n s k i l l f u l b e h a v i o r s , a l l o f w h i c h w o u l d p r o b a b l y r e d u c e t h e i n d i v i d u a l ' s r a t e o f r e s p o n s e -c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . H o w e v e r , i t h a s n o t b e e n shown t h a t s e v e r e l y d e p r e s s e d i n d i v i d u a l s h a v e e x -p e r i e n c e d a d r o p i n r e i n f o r c e m e n t r a t e , o r t h a t a n i n c r e a s e i n r e i n f o r c e m e n t r a t e c o r r e s p o n d s t o a n e l e v a t i o n o f mood l e v e l i n s u c h i n d i v i d u a l s . S u p p o r t i n g T u c k e r ' s t h e o r y t h a t a s y m m e t r i c a l h e m i s p h e r i c p r o c e s s e s r e l a t e t o d e p r e s s i o n a r e t h e l e s i o n , a m y t a l a n d e p i l e p s y s t u d i e s w h i c h r e p o r t a d e p r e s s i v e -c a t a s t r o p h i c r e a c t i o n f o l l o w i n g u n i l a t e r a l h e m i s p h e r i c i n s u l t o r s e d a t i o n . Two s t u d i e s s u g g e s t i n g t h a t damage may e x a g g e r a t e a h e m i s p h e r e ' s c o n t r i b u t i o n t o p e r s o n a l i t y p r o c e s s e s p o i n t t o a p r e d o m i n a n t l y l e f t h e m i s p h e r e c o n t r i -b u t i o n t o d e p r e s s i v e a f f e c t a n d i d e a t i o n . S e v e r a l s t u d i e s o f n o r m a l s l e n d a d d i t i o n a l s u p p o r t t o t h e n o t i o n t h a t d e p r e s s i o n i s r e l a t e d t o f u n c t i o n a l a s y m m e t r y . W h i l e t h e s e s t u d i e s a r e i n c o n s i s t e n t i n l o c a l i z i n g n e g a t i v e e m o t i o n u n i l a t e r a l l y , t h e y d o s u p p o r t t h e h y p o t h e s i s t h a t c h a n g e s i n f u n c t i o n a l a s y m m e t r y o c c u r when t h e i n d i v i d u a l e x p e r i e n c e s d e p r e s s i v e a f f e c t . C o n s i s t e n t w i t h T u c k e r ' s h y p o t h e s i s t h a t r i g h t h e m i s p h e r e f u n c t i o n s a r e s u p p r e s s e d d u r i n g d e p r e s s i o n i s t h e f i n d i n g , i n a v a r i e t y o f n e u r o p s y c h o l o g i c a l a n d e x p e r i m e n t a l s t u d i e s , o f a s p e c i f i c r i g h t h e m i s p h e r e p e r f o r m a n c e d e c r e m e n t i n d e p r e s s i v e s . T u c k e r ' s c l a i m t h a t a l t e r e d b r a i n f u n c -t i o n i n g i n p s y c h i a t r i c p o p u l a t i o n s r e p r e s e n t s t h e d i f f e r -e n t i a l o p e r a t i o n o f n e u r o l o g i c a l l y i n t a c t h e m i s p h e r e s i s supported by several studies showing a s h i f t i n cerebr asymmetry i n schizophrenics following pharmacotherapy, and by two studies showing an asymmetrical improvement i n performance by depressives following ECT. 69 T h e P r e s e n t S t u d y - D e s i g n a n d M e a s u r e s B l a n e y ( 1 9 7 7 ) h a s c o m m e n t e d o n t h e n e e d f o r l o n g i -t u d i n a l r e s e a r c h t o s u p p l e m e n t e x i s t i n g e x p e r i m e n t a l s t u d i e s . I n s u c h r e s e a r c h , v a r i a b l e s p o s i t e d a s i m p o r t a n t i n t h e d e v e l o p m e n t o f d e p r e s s i o n w o u l d b e m o n i t o r e d o v e r t i m e , a n d t h e f o c u s w o u l d b e o n t h e s e q u e n c i n g among t h e m , p a r t i c u l a r l y w i t h r e s p e c t t o c h a n g e s p r e c e d i n g t h e o n s e t o f c l i n i c a l d e p r e s s i o n . H o w e v e r , s u c h r e s e a r c h p o s e s a n u m b e r o f d i f f i c u l t i e s : t h e t i m e - l a g b e t w e e n c a u s e a n d e f f e c t c o u l d b e l e n g t h y a n d / o r q u i t e v a r i a b l e ; a v e r y l a r g e s a m p l e w o u l d b e r e q u i r e d , s i n c e t h e r e i s n o way o f k n o w i n g i n a d v a n c e w h a t p o r t i o n o f a p o p u l a t i o n w i l l b e c o m e d e p r e s s e d ; m o r e o v e r , s u c h r e s e a r c h w o u l d be e x t r e m e l y e x p e n s i v e . G i v e n t h e s e p r o b l e m s , a n d t h e d i f f i c u l t i e s i n o b t a i n i n g t r u s t w o r t h y d a t a i n r e t r o s p e c t i v e s t u d i e s ( B r o w n , 1 9 7 4 ; B r o w n , S k l a i r , H a r r i s a n d B i r l e y , 1 9 7 3 ) , i t a p p e a r s u n l i k e l y t h a t a d e f i n i t i v e t e s t b e t w e e n t h e c o g n i t i v e , b e h a v i o r a l ; a n i d n e u r o p s y c h o l o g i c a l t h e o r i e s r e g a r d i n g t h e c a u s e o f d e p r e s s i o n w o u l d be c o n d u c t e d , i f i n d e e d s u c h a t e s t w e r e p o s s i b l e . What is_ p o s s i b l e , h o w e v e r , i s a m o d i f i e d l o n g i t u d i n a l s t u d y w h i c h w o u l d e x a m i n e d e p r e s s e d i n d i v i d u a l s a n d t h e n o b s e r v e c h a n g e s w h i c h may o c c u r i n t h e s e i n d i v i d u a l s a s t h e y r e c o v e r f r o m d e p r e s s i o n . 70 This approach was the one adopted i n the present study. While the primary focus of the study was an inves-t i g a t i o n of Tucker's theory of pathological hemispheric functioning i n depression, the study was also able, by employing .a sample of hospitalized depressives, to examine the relevance of cognitive and behavioral factors to genuine c l i n i c a l depression. In addition, the study was able to explore a possible relationship between hemispheric functioning on the one hand and cognitive and behavioral functioning on the other. The study employed a normal comparison group and a psychiatric comparison group of hos p i t a l i z e d schizo-phrenics. Both males and females were included i n equal numbers i n each group, i n order to observe possible sex differences i n the events being monitored. The sample was r e s t r i c t e d to right-handed subjects because hemispheric asymmetry has been shown to be more variable i n left-handed persons (Davis and Wada, 1 9 7 7 ; Milner, 1 9 7 5 ; Searleman, 1 9 7 7 ) . Since i t has been shown that a questionnaire i s a v a l i d and r e l i a b l e method for assessing lateral preference (Coren and Porac, 1 9 7 8 ) , handed-ness was assessed by a hand preference questionnaire (Appendix A) consisting of eight items shown to coordinate with manual s k i l l (Annett, 1970) and also to possess good r e l i a b i l i t y and v a l i d i t y (Raczkowski, Kalat and Nebes:,": 1 9 7 4 ) . Only subjects consistently right-handed for a l l eight items were recruited. 71 M e a s u r e s u s e d i n t h e s t u d y i n c l u d e d t e s t s o f b o t h r i g h t a n d l e f t h e m i s p h e r e f u n c t i o n i n g , a s w e l l a s c o g n i -t i v e t e s t s o f b o t h h e m i s p h e r e s . F o l l o w i n g i s a d e s c r i p -t i o n o f e a c h o f t h e s e t e s t s a n d t h e r a t i o n a l e f o r i t s i n c l u s i o n : 1. D i c h o t i c M u s i c a l C h o r d s T e s t . T h i s t e s t was u s e d t o a s s e s s r i g h t h e m i s p h e r e f u n c t i o n i n g . S i n c e c o n t r a l a t e r a l s e n s o r y p r o j e c t i o n s f r o m t h e e a r s t o t h e h e m i s p h e r e s a r e s t r o n g e r a n d m o r e d i r e c t t h a n i p s i l a t e r a l o n e s ( R o s e n z w e i g , 1951), when a s o u n d i s h e a r d b y o n e e a r t h e r e i s a s l i g h t t e n d e n c y f o r t h e c o n t r a l a t e r a l h e m i s p h e r e t o r e s p o n d m o r e t h a n t h e i p s i l a t e r a l o n e ( B r o a d b e n t , 1954). T h i s t e n d e n c y i s a c c e n t u a t e d when two d i f f e r e n t m e s s a g e s a r e p r e s e n t e d s i m u l t a n e o u s l y , o n e t o e a c h e a r , a s i n : d i c h o t i c p r e s e n t a t i o n s t h r o u g h b i l a t e r a l e a r p h o n e s . I n t h i s s i t u a t i o n t h e c o n t r a l a t e r a l p a t h w a y s t e n d t o o c c l u d e i m p u l s e s a r r i v i n g a l o n g t h e i p s i l a t e r a l p a t h w a y s , p r o d u c i n g a f u n c t i o n a l a s y m m e t r y w h i c h a c c e n t u -a t e s t h e n o r m a l e a r a s y m m e t r y ( D a r w i n , 1975). T h u s , m a t e r i a l i s t y p i c a l l y r e p o r t e d b e s t when p r e s e n t e d t o t h e e a r c o n t r a l a t e r a l t o t h e h e m i s p h e r e w h i c h i s p r e p o t e n t f o r p r o c e s s i n g t h e p a r t i c u l a r k i n d o f i n f o r m a t i o n p r e s e n t e d . E v i d e n c e t h a t d i c h o t i c l i s t e n i n g i s i n d e e d a r e f l e c t i o n o f b r a i n l a t e r a l i t y i s b a s e d o n i t s c o r r e s p o n d e n c e w i t h Wada t e s t s t i m u l i ( B o r o d a n d G o o d g l a s s , 1 9 8 0 a ) , a n d o n i t s c o r r e s p o n d e n c e w i t h d e g r e e o f d y s p h a s i a f o l l o w i n g l e f t -a n d r i g h t - s i d e d E C T ( G e f f e n , T r a u b a n d S t i e r m a n , 1 9 7 8 ) . 72 S t u d i e s o f r i g h t - h a n d e d i n d i v i d u a l s h a v e d e m o n -s t r a t e d a r i g h t h e m i s p h e r e s u p e r i o r i t y f o r p r o c e s s i n g h o l i s t i c , i n t e g r a t i v e , t i m e - i n d e p e n d e n t m a t e r i a l , i n c l u -d i n g m u s i c a l c h o r d s ( G o r d o n , 1 9 7 0 , 1 9 7 8 ) ; t h e r e f o r e f a i l u r e t o o b t a i n a l e f t e a r s u p e r i o r i t y f o r d i c h o t i c a l l y p r e s e n t e d c h o r d s i n n o r m a l r i g h t - h a n d e d s u b j e c t s c o u l d s u g g e s t a f a i l u r e i n n o r m a l p r o c e s s i n g b y t h e i r r i g h t h e m i s p h e r e . T h e m u s i c a l c h o r d s t a p e e m p l o y e d i n t h i s s t u d y was a c o p y o f a s t e r e o t a p e p r e p a r e d b y D r . H . W. G o r d o n o f t h e U n i v e r s i t y o f P i t t s b u r g h ( G o r d o n , 1 9 7 8 ) . T h e t a p e c o n s i s t s o f f o u r p r a c t i s e s e t s a n d 24 t e s t s e t s o f m u s i c a l c h o r d s p l a y e d o n a n e l e c t r i c o r g a n . I n e a c h s e t two d i f f e r e n t c h o r d s a r e p r e s e n t e d d i c h o t i c a l l y ; s u b s e q u e n t l y t h e y m u s t b e p i c k e d o u t f r o m a s e r i e s o f f o u r c h o r d s , e a c h o f w h i c h i s h e a r d s i m u l t a n e o u s l y i n b o t h e a r s , a n d two o f w h i c h h a v e n o t b e e n h e a r d d i c h o t i c a l l y . E a c h c h o r d s t i m u l u s l a s t s . 2 . 5 s e c o n d s , s e p a r a t e d f r o m t h e n e x t c h o r d b y a n i n t e r v a l o f 1 .5 s e c o n d s . S e t s a r e s e p a r a t e d b y 1 0 - s e c o n d i n t e r v a l s . A t t h e c o n c l u s i o n o f a s e t , t h e s u b j e c t u s e s a n a n s w e r s h e e t t o m a r k two n u m b e r e d s p a c e s c o r r e s p o n d i n g t o t h e c o r r e c t two c h o r d s . T h e p r o c e d u r e i s r e p e a t e d u n t i l a l l s e t s h a v e b e e n h e a r d a n d r e s p o n d e d t o . T h e s c o r e i s t h e n u m b e r o f c h o r d s c o r r e c t l y i d e n t i f i e d f o r e a c h e a r , f o r a maximum p o s s i b l e o f 24 c h o r d s f o r e a c h e a r . 2 . D i c h o t i c W o r d T r i a d s . T h i s t e s t was u s e d t o a s s e s s l e f t h e m i s p h e r e f u n c t i o n i n g . S t u d i e s o f r i g h t - h a n d e d s u b j e c t s h a v e d e m o n s t r a t e d a l e f t h e m i s p h e r e s u p e r i o r i t y f o r p r o c e s s i n g s e q u e n t i a l , t i m e - d e p e n d e n t i n f o r m a t i o n , i n c l u d i n g s t r i n g s o f w o r d s ( B r y d e n , 1 9 6 7 ; K i m u r a , 1 9 6 4 , 1 9 6 7 ) ; t h e r e f o r e f a i l u r e t o o b t a i n a r i g h t e a r s u p e r i o r i t y f o r w o r d t r i a d s i n r i g h t - h a n d e d s u b j e c t s c o u l d s u g g e s t a f a i l u r e i n n o r m a l p r o c e s s i n g b y t h e i r l e f t h e m i s p h e r e . T h e w o r d t r i a d s t a p e e m p l o y e d i n t h i s s t u d y was a c o p y o f a s t e r o t a p e p r e p a r e d b y D r . F . S p e l l a c y o f t h e D e p a r t m e n t o f P s y c h o l o g y , U n i v e r s i t y o f V i c t o r i a , a n d r o u t i n e l y i n c l u d e d i n t h e n e u r o p s y c h o l o g i c a l b a t t e r y u s e d a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t e r P s y c h i a t r i c U n i t . T h e t a p e c o n s i s t s o f 22 s e t s o f w o r d s , s e p a r a t e d b y 1 0 - s e c o n d i n t e r v a l s . E a c h s e t i s c o m p r i s e d o f t h r e e o n e - s y l l a b l e w o r d p a i r s i n s u c c e s s i o n . E a c h p a i r b e g i n s w i t h t h e same l e t t e r o f t h e a l p h a b e t . W o r d s a r e m a t c h e d f o r a c o u s t i c l e n g t h , a n d n o w o r d i s p r e s e n t e d m o r e t h a n o n c e . A t t h e c o n c l u s i o n o f a s e t , t h e s u b j e c t r e p e a t s a l o u d a s many o f t h e w o r d s i n t h e s e t a s h e c a n r e c a l l . T h e p r o c e d u r e i s r e p e a t e d u n t i l a l l s e t s h a v e b e e n h e a r d a n d r e s p o n d e d t o . T h e s c o r e i s t h e n u m b e r o f w o r d s c o r r e c t l y r e c a l l e d f o r e a c h e a r , f o r a maximum p o s s i b l e o f 66 w o r d s f o r e a c h e a r . 3 . S p a c e T h i n k i n g ( F l a g s ) T e s t . , T h i s t e s t was u s e d t o a s s e s s p e r f o r m a n c e i n a r i g h t h e m i s p h e r e c o g n i t i v e t a s k . T h e t e s t m e a s u r e s t h e a b i l i t y t o v i s u a l i z e a r i g i d c o n f i g u r a t i o n , i . e . a f i g u r e i n w h i c h t h e r e i s n o i n t e r n a l m o v e m e n t when i t s p o s i t i o n i s s h i f t e d , when t h e f i g u r e i s moved into d i f f e r e n t positions. This a b i l i t y was i d e n t i -f i e d i n early factor analytic studies as one of the primary "space thinking" factors (Thurstone and Thurstone, 1941); i t s existence has since been confirmed i n a number of factor analytic studies (reviewed i n McGee, 1979). Other studies have shown that the right hemisphere i s superior for such vi s u o s p a t i a l manipulations and that such manipulations are d i f f i c u l t or impossible for persons with impaired r i g h t hemisphere (reviewed i n Nebes, 1978, and i n DeRenzi, 1978). There i s also electrophysiological evidence for increased r i g h t hemisphere a c t i v a t i o n during the performance of a mental rotation s p a t i a l task (Krynicki, Note 4). The Flags test (Thurstone and J e f f r e y , 1956) consists of two practise items and 21 test items. Each item presents a f l a g at the l e f t and six other flags at the right which represent a d i f f e r e n t position of either the same or the opposite side of the f l a g at the l e f t . The subject responds by c i r c l i n g either "S" or "0" under-neath each f l a g to indicate same or opposite side. He i s given f i v e minutes to complete as many items as possible. The score i s the number right minus the number wrong, for a maximum of 126. 4. Word Fluency Test. This test was used to assess performance i n a l e f t hemisphere cognitive task. The test comes from an aphasia battery (Spreen and Benton, 1969) and i s a measure of l e f t hemisphere cognitive functioning, since i n almost a l l normal right handers the l e f t hemi-sphere i s responsible for speech production (reviewed i n 75 S e a r l e m a n , 1977). T h e s u b j e c t i s a l l o w e d o n e m i n u t e t o g e n e r a t e a s many w o r d s a s p o s s i b l e b e g i n n i n g w i t h t h e l e t t e r F , f o l l o w e d b y s e p a r a t e o n e - m i n u t e p e r i o d s f o r g e n e r a t i n g w o r d s b e g i n n i n g w i t h t h e l e t t e r s A a n d S s u c -c e s s i v e l y . W o r d - g e n e r a t i o n p e r i o d s a r e s e p a r a t e d b y o n e - m i n u t e r e s t i n t e r v a l s . T h e s c o r e f o r t h e t e s t i s t h e sum o f a l l a d m i s s i b l e w o r d s f o r t h e t h r e e l e t t e r s . A c o r r e c t i o n i s made f o r e d u c a t i o n l e v e l a s f o l l o w s : 12-15 y e a r s o f e d u c a t i o n , a d d 0; 8-11 y e a r s o f e d u c a t i o n , a d d 4; b e l o w 8 y e a r s o f e d u c a t i o n , a d d 9. T h e r e m a i n i n g two t e s t s i n t h e b a t t e r y r e l a t e d t o t h e b e h a v i o r a l a n d c o g n i t i v e t h e o r i e s o f d e p r e s s i o n : 5. P l e a s a n t E v e n t s S c h e d u l e . T h i s t e s t was u s e d t o a s s e s s c u r r e n t r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . I t i s a s h o r t e r v e r s i o n o f t h e o r i g i n a l PES ( M a . c P h i l l a m y a n d L e w i n s o h n , 1972), w h i c h l i s t e d 320 a c t i v i t i e s a n d e v e n t s shown t o b e s o u r c e s o f p l e a s u r e f o r a w i d e v a r i e t y o f p e o p l e . M a c P h i l l a m y a n d L e w i n s o h n (1972, 1976) r e p o r t t h a t s u b j e c t s ' s e l f - r e p o r t s o n t h e P E S t e n d t o a g r e e w i t h t h e o b s e r v a t i o n s o f b o t h n a t u r a l a n d t r a i n e d o b s e r v e r s . A l t h o u g h o t h e r s t u d i e s ( F r i e d m a n , 1964; B u c h w a l d , 1977) h a v e s u g g e s t e d t h a t d e p r e s s e d i n d i v i d u a l s t e n d t o u n d e r e s t i m a t e t h e f r e q u e n c y o f p l e a s a n t e v e n t s a n d t h e r e f o r e P E S s c o r e s may b e b i a s e d , t h e PES was s e l e c t e d f o r t h e p r e s e n t s t u d y f o r two r e a s o n s : F i r s t , many p r e v i o u s s t u d i e s h a v e m e a s u r e d r e i n f o r c e m e n t r a t e w i t h t h e P E S a n d t h e r e f o r e f o r c o m p a r i s o n p u r p o s e s 76 t h e PES was a l s o u s e d i n t h e p r e s e n t s t u d y ; s e c o n d l y , t h e r e s t r i c t i o n s i m p o s e d b y h o s p i t a l r o u t i n e a n d n u r s i n g s t a f f w o r k l o a d s made i t i m p o s s i b l e t o o b t a i n o b j e c t i v e m e a s u r e s o f b e h a v i o r a l f u n c t i o n i n g o n t h e w a r d s . T h e s h o r t e r 4 9 - i t e m v e r s i o n o f t h e PES ( L e w i n s o h n a n d G r a f , 1 9 7 3 ; L e w i n s o h n a n d A m e n s o n , 1978) was u s e d i n t h e p r e s e n t s t u d y b e c a u s e c o m p l e t i o n o f t h e 3 2 0 - i t e m v e r s i o n was deemed t o be t o o t a x i n g f o r i n p a t i e n t s , who t i r e e a s i l y a n d h a v e d i f f i c u l t y c o n c e n t r a t i n g . I t e m s i n t h e s h o r t e r v e r s i o n a r e t h o s e f o u n d b y L e w i n s o h n a n d G r a f ( 1 9 7 3 ) t o c o r r e l a t e m o s t o f t e n w i t h f e e l i n g g o o d . A r e c e n t s t u d y b y L e w i n s o h n a n d A m e n s o n ( 1 9 7 8 ) s u p p o r t e d t h e c o n s t r u c t v a l i d i t y o f t h e s e e v e n t s a s m e a s u r e s o f r e i n f o r c e m e n t p o t e n t i a l a n d showed t h a t t h e s e i t e m s d i s c r i m i n a t e e s p e c i a l l y w e l l b e t w e e n d e p r e s s e d a n d n o n d e p r e s s e d p e r s o n s . A l o w a c t i v i t y s c o r e c a n r e s u l t f r o m (1) a r e s t r i c t e d r a n g e o f a c t i v i t i e s , ( 2 ) f e w e r r e p l i c a t i o n s o f c h o s e n a c t i v i t i e s , o r ( 3 ) l e s s s u b j e c t i v e p l e a s u r e b e i n g d e r i v e d f r o m a c t i v i t i e s . T h e r e f o r e s u b j e c t s a r e a s k e d t o i n d i c a t e ( a ) how o f t e n t h e y h a v e p a r t i c i p a t e d i n e a c h a c t i v i t y d u r i n a c e r t a i n t i m e p e r i o d ( i n t h e p r e s e n t s t u d y , t h e t i m e p e r i o was t h e p r e v i o u s w e e k ) a n d ( b ) how e n j o y a b l e , o n a s c a l e o f 0 t o 2 , t h e y w o u l d r a t e e a c h a c t i v i t y i n w h i c h t h e y p a r t i c i p a t e d (0 = n o t p l e a s a n t , 1 = somewhat p l e a s a n t , 2 = v e r y p l e a s a n t ) . F r e q u e n c y a n d e n j o y a b i l i t y r a t i n g s a r e c o m b i n e d i n a m u l t i p l i c a t i v e f u n c t i o n t o p r o d u c e a measure of "amount of pleasure", which i s a reasonable approximation of obtained reinforcement (MacPhillamy and Lewinsohn, 1976). 6. Cognitive D i s t o r t i o n Questionnaire (Appendix D). This questionnaire, developed by the author for this study, was used to assess the presence of cognitive d i s -t o r t i o n . Beck (1967, 1974) has argued that the biased perceptions of depressed persons are characterized by a dysphoric quality, as d i s t i n c t from cognitive d i s t o r t i o n s of such other psychopathological groups as manic or paranoid persons. The present questionnaire, therefore, contained items designed to i d e n t i f y cognitions which are both depressive and distorted, and which represent s p e c i f i c instances of the categories i d e n t i f i e d by Beck: selective abstraction, overgeneralization, a r b i t r a r y inference, minimization of p o s i t i v e assets or consequences, and maximization of the negative. Content v a l i d i t y of the depressed-distorted items was assessed by independent judges' ratings: Ten c l i n i c a l psychologists working i n a. psychiatric hospital evaluated the s u i t a b i l i t y of the items as examples of the Beck categories of cognitive d i s t o r t i o n , and also rated each item as negative or not negative. Only items unanimously judged to be negative and also to be suitable examples of the Beck categories were retained; these t h i r t y items were embedded randomly i n t h i r t y positive or neutral items so as to avoid response bias. The question-naire was administered to 88 college students i n order to assess r e l i a b i l i t y : s p l i t - h a l f r = . 9 4 , test-retest r = . 8 4 ( i n i t i a l test x = 3 . 4 , S.D. = 3 . 8 2 ; retest x = 2 . 3 6 , S.D. = 3 . 4 4 ) . A subject rates each item on the questionnaire as True or False for him at that time. Hi score i s the t o t a l number of depressed-distorted items marked True, for a maximum possible score of 3 0 . 79 Hypotheses The f i r s t objective of the study was to i n v e s t i -gate Tucker's hypothesis concerning hemispheric dysfunc-tion i n depression. Tucker (Note 1) has proposed that during depression a functional override by the l e f t hemisphere produces a decrement i n right hemisphere performance. Thus, i n a dichotic l i s t e n i n g task for which the l e f t ear (right hemisphere) i s normally superior, i . e . musical chords, depressives should demonstrate a reduced l e f t ear superiority, compared to nondepressed subjects. Moreover, i f , as Tucker proposes, the decrement in right hemisphere performance i s not related to neurologic impair-ment, right hemisphere performance should recover as patients recover from their depression. Thus depressives should show an increase i n l e f t ear superiority for dichotic chords while other subjects should not. The f i r s t hypothesis, therefore, i s : 1. The depressed group at admission w i l l demonstrate less l e f t ear superiority i n  the Dichotic Chords test than comparison  groups, and only depressives w i l l show an increase i n l e f t ear superiority by  discharge. 80 If impaired right hemisphere performance i n depres-sion also affects cognitive a b i l i t i e s for which that hemisphere i s superior, then depressives should i n i t i a l l y perform poorly on the Flags test as well. Moreover, they should improve their Flags scores as they recover from depression. The second hypothesis, therefore, i s : 2. The depressed group w i l l i n i t i a l l y obtain  lower scores than comparison groups on  the Flags test and only depressives w i l l  show a s i g n i f i c a n t increase i n Flags  scores by discharge. Tucker's theory does not speculate concerning the impact .on l e f t hemisphere performance of that hemisphere's supposed overactivation i n depression. However, to control for the p o s s i b i l i t y that the l e f t hemisphere may also be affected during depression, tests of l e f t hemisphere func-tioning were also included. Since neuropsychological and experimental studies suggest right but not l e f t hemisphere dysfunction i n depression, i t i s not expected that the depressed group w i l l be impaired, r e l a t i v e to comparison groups, on the Dichotic Word Triads test or on the Word Fluency test. The second objective of the study was to examine the relevance of cognitive and behavioral factors to genuine c l i n i c a l depression. If Lewinsohn's behavioral theory i s v a l i d for c l i n i c a l populations, depressives should i n i t i a l l y obtain lower scores than nondepressed 81 groups on a measure of response-contingent positive reinforcement ( i . e . the Pleasant Events Schedule). More-over, depressives should obtain an increase i n r e i n f o r c -ment rate as the depression l i f t s . The t h i r d hypothesis, therefore, i s : 3. The depressed group w i l l i n i t i a l l y obtain  lower scores than comparison groups on  the Pleasant Events Schedule and w i l l  s i g n i f i c a n t l y increase their PES scores  by discharge. If Beck's cognitive theory of depression i s v a l i d for c l i n i c a l populations, then depressives should i n i t i a l l y manifest a larger number of cognitive d i s t o r t i o n s which r e f l e c t Beck's typology of depressed-distorted cognitions (as measured by the Cognitive D i s t o r t i o n Questionnaire). Since Beck has argued that a negative cognitive set i s c h a r a c t e r i s t i c of depression-prone i n d i v i d u a l s , Beck might predict that such indidivuals would continue to demon-strate cognitive d i s t o r t i o n even afte r recovery from a depressive episode. However, i n the present study i t i s hypothesized that cognitive d i s t o r t i o n i s related to hemispheric dysfunction; therefore such d i s t o r t i o n should decrease as hemispheric functioning normalizes with recovery from depression. The fourth hypothesis, there-fore, i s : 4. The depressed group w i l l i n i t i a l l y obtain  higher scores than comparison groups on 82 the Cognitive D i s t o r t i o n Questionnaire  and w i l l s i g n i f i c a n t l y decrease their CDQ  scores by discharge. The t h i r d objective of the study was to examine the relationship between hemispheric functioning and both cognitive d i s t o r t i o n and reinforcement rate. I t i s expected that an improvement i n right hemisphere func-tioning w i l l be accompanied by an improvement ( i . e . a decrease) i n cognitive d i s t o r t i o n as well as an improve-ment i n rate of response-contingent positive reinforcement. The f i f t h and sixth hypotheses, therefore, are: 5. There w i l l be a s i g n i f i c a n t positive c o r r e l a -tion between depressives' improvement scores  on the Dichotic Chords test and th e i r  improvement scores on the Cognitive Distor-tion Questionnaire. 6. There w i l l be a s i g n i f i c a n t positive c o r r e l a -tion between depressives' improvement scores  on the Dichotic Chords test and their  improvement scores on the Pleasant Events  Schedule. If improved right hemisphere performance also extends to cognitive a b i l i t i e s for which the right hemi-sphere i s normally superior, then pos i t i v e correlations should also obtain between improvement i n Flags test scores and improvement ( i . e . a decrease) i n cognitive 83 d i s t o r t i o n a n d i n r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t . T h e s e v e n t h a n d e i g h t h h y p o t h e s e s , t h e r e -f o r e , a r e : 7. T h e r e w i l l b e a s i g n i f i c a n t p o s i t i v e  c o r r e l a t i o n b e t w e e n d e p r e s s i v e s ' i m p r o v e - m e n t s c o r e s i n t h e F l a g s t e s t a n d t h e i r  i m p r o v e m e n t s c o r e s i n t h e C o g n i t i v e  D i s t o r t i o n Q u e s t i o n n a i r e . 8 . T h e r e w i l l be a s i g n i f i c a n t p o s i t i v e  c o r r e l a t i o n b e t w e e n d e p r e s s i v e s ' i m p r o v e -m e n t s c o r e s i n t h e F l a g s t e s t a n d t h e i r  i m p r o v e m e n t s c o r e s i n t h e P l e a s a n t E v e n t s  S c h e d u l e . S i n c e t h e r e i s n o r e l i a b l e e v i d e n c e o f l e f t h e m i -s p h e r e i m p a i r m e n t i n d e p r e s s i o n a n d t h e r e f o r e n o r e a s o n t o e x p e c t a c h a n g e i n p e r f o r m a n c e o n l e f t h e m i s p h e r e t e s t s ( D i c h o t i c W o r d T r i a d s a n d W o r d F l u e n c y ) a s p a t i e n t s r e c o v e r f r o m d e p r e s s i o n , n o s i g n i f i c a n t c o r r e l a t i o n s w e r e p r e d i c t e d b e t w e e n (1) c h a n g e s i n s c o r e s o n l e f t h e m i s p h e r e t e s t s ( i . e . D i c h o t i c W o r d T r i a d s a n d W o r d F l u e n c y ) a n d ( 2 ) c h a n g e s i n s c o r e s o n e i t h e r t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e o r t h e P l e a s a n t E v e n t s S c h e d u l e . M e t h o d S u b j e c t s S u b j e c t s i n t h e d e p r e s s e d g r o u p w e r e s i x t e e n p a t i e n t s a d m i t t e d t o t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t e r P s y c h i a t r i c U n i t w i t h a d i a g n o s i s o f M a j o r D e p r e s s i v e D i s o r d e r a s d e f i n e d i n t h e D S M - I I I ( D i a g n o s t i c a n d S t a t i s t i c a l M a n u a l o f M e n t a l D i s o r d e r s , A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n , 1/15/78 D r a f t ) . S e e A p p e n d i x B f o r t h e r e l e v a n t s e c t i o n s o f t h e D S M - I I I . S u b j e c t s i n t h e n o r m a l c o m p a r i s o n g r o u p w e r e s i x t e e n e m p l o y e e s o n s t a f f a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t e r w i t h n o known p s y c h i a t r i c i l l n e s s o r p h y s i c a l c o n d i t i o n t h a t c o u l d a f f e c t p e r f o r m a n c e . T h e s e i n c l u d e d j a n i t o r i a l a n d o f f i c e s t a f f , n u r s e s , p s y c h i -a t r i c a s s i s t a n t s a n d s u p e r v i s o r y p e r s o n n e l . T h e y w e r e n o t p a i d t o p a r t i c i p a t e , b u t w e r e i n f o r m e d a b o u t t h e i r i n d i v i d u a l p e r f o r m a n c e s a t t h e c o n c l u s i o n o f t h e s t u d y . S u b j e c t s i n t h e p s y c h i a t r i c c o m p a r i s o n g r o u p w e r e s i x t e e n p a t i e n t s a d m i t t e d t o t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t e r P s y c h i a t r i c U n i t ( a ) w i t h a d i a g n o s i s o f S c h i z o p h r e n i c D i s o r d e r a s d e f i n e d i n t h e D S M - I I I 1/15/78 D r a f t , (b) who d i d n o t m e e t t h e c r i t e r i a f o r S c h i z o a f f e c t i v e D i s o r d e r ( D S M - I I I 1/15/78 D r a f t ) , a n d ( c ) w h o s e f i r s t h o s p i t a l a d m i s s i o n o c c u r r e d d u r i n g t h e 85 p a s t f i v e y e a r s . ( T h i s was i n t e n d e d t o e x c l u d e c h r o n i c s c h i z o p h r e n i c s , w h o s e r e p e a t e d h o s p i t a l i z a t i o n s c o u l d c o n s i t u t e a c o n f o u n d i n g v a r i a b l e . ) H a l f o f e a c h g r o u p w e r e m a l e s a n d h a l f w e r e f e m a l e s . A l l s u b j e c t s w e r e r e q u i r e d t o m e e t t h e f o l l o w i n g c r i t e r i a : 1. N a t i v e l a n g u a g e E n g l i s h . 2. A g e n o t l e s s t h a n 20 o r m o r e t h a n 5 0 . 3 . N o t s u f f e r i n g f r o m a l c o h o l i s m o r f r o m d r u g - i n d u c e d p s y c h o s i s . 4 . No k n o w n b r a i n d a m a g e . 5 . No h i s t o r y o f p s y c h o s u r g e r y . 6 . N o t r e c e i v i n g e l e c t r o c o n v u l s i v e t h e r a p y . 7. No a p p a r e n t m e n t a l d e f i c i e n c y . 8 . No s e l f - r e p o r t e d h e a r i n g i m p a i r m e n t . 9 . R i g h t h a n d e d . I n f o r m a t i o n c o n c e r n i n g t h e f i r s t s e v e n a b o v e i t e m s was o b t a i n e d f r o m t h e p a t i e n t s ' h o s p i t a l r e c o r d s a n d , i n t h e c a s e o f n o r m a l s , b y d i r e c t q u e s t i o n i n g . S i n c e a l l s u b j e c t s w e r e f i r m l y r i g h t - h a n d e d a n d w r o t e w i t h s t r a i g h t r a t h e r t h a n i n v e r t e d h a n d , i t was a s s u m e d t h a t a l l s u b j e c t s h a d t h e i r d o m i n a n t h e m i s p h e r e c o n t r a l a t e r a l t o t h e i r p r e f e r r e d h a n d ( L e v y a n d R e i d , 1976) P a t i e n t - s u b j e c t s w e r e r e c r u i t e d i n t h e f o l l o w i n g w a y : P r i m a r y t h e r a p i s t s a t t h e h o s p i t a l w e r e b r i e f e d b y t h e e x p e r i m e n t e r a n d a s k e d t o i d e n t i f y p a t i e n t s a d m i t t e d c o n s e c u t i v e l y t o t h e h o s p i t a l who met t h e i n c l u s i o n c r i t e r i a a n d w h o , i n t h e t h e r a p i s t ' s j u d g m e n t , s a t i s f i e d t h e D S M - I I I c r i t e r i a f o r e i t h e r M a j o r D e p r e s s i v e D i s o r d e r o r S c h i z o p h r e n i c ( b u t n o t S c h i z o a f f e c t i v e ) D i s o r d e r . T h i r t y - n i n e p a t i e n t s w e r e a s k e d t o p a r t i c i p a t e . O f t h e s e , two s c h i z o p h r e n i c s a n d o n e d e p r e s s i v e r e f u s e d . One s c h i z o p h r e n i c w i t h d r e w f r o m t h e s t u d y a f t e r t h e f i r s t 86 t e s t i n g s e s s i o n ; a n o t h e r p r o v e d t o h a v e b r a i n damage ( o n t h e b a s i s o f n e u r o p s y c h o l o g i c a l e x a m i n a t i o n i n h o s p i t a l ) a n d was t h e r e f o r e d r o p p e d f r o m t h e s t u d y a f t e r t h e s e c o n d t e s t i n g s e s s i o n . One d e p r e s s e d p a t i e n t l e f t t h e h o s p i t a l ( a g a i n s t m e d i c a l a d v i c e ) a f t e r o n e t e s t i n g s e s s i o n ; a n o t h e r d e p r e s s e d p a t i e n t b e g a n r e c e i v i n g E C T a f t e r t h e f i r s t t e s t i n g s e s s i o n a n d was t h e r e f o r e d r o p p e d f r o m t h e s t u d y . A l l o t h e r p a t i e n t s — 1 6 d e p r e s s i v e s a n d 16 s c h i z o p h r e n i c s , t o t a l l y 82% o f t h o s e a s k e d t o p a r t i c i p a t e o r 88% o f t h o s e who h a d a t l e a s t o n e t e s t i n g s e s s i o n — c o m p l e t e d a l l t e s t i n g s e s s i o n s . V o l u n t a r y c o n s e n t was o b t a i n e d a n d r e c o r d e d i n t h e p a t i e n t ' s c h a r t , w i t h a s i g n e d s t a t e m e n t b y t h e p a t i e n t t h a t t h e n a t u r e o f t h e r e s e a r c h h a d b e e n e x p l a i n e d t o h i m a n d t h a t h i s a n o n y m i t y i n a n y s u b s e q u e n t p u b l i c a t i o n o f r e s u l t s h a d b e e n a s s u r e d ( A p p e n d i x C ) . P a t i e n t s w e r e t o l d s i m p l y t h a t t h e y w e r e t a k i n g p a r t i n a s t u d y d e s i g n e d t o d e s c r i b e t h e i r f u n c t i o n i n g o v e r t h e s p a n o f t h e i r h o s p i t a l i -z a t i o n a n d t h a t t h i s w o u l d i n v o l v e t h e c o m p l e t i o n o f v a r i o u s p s y c h o l o g i c a l t e s t s . C o n f i d e n t i a l i t y was e n s u r e d , a n d p a t i e n t s w e r e a s s u r e d t h a t t h e i r t e s t r e s u l t s w o u l d n o t b e s h a r e d w i t h a n y o t h e r s t a f f member a n d w o u l d h a v e n o b e a r i n g o n t h e i r t r e a t m e n t p r o g r a m o r d i s c h a r g e p l a n s . T a b l e s 1 a n d 2 d e p i c t mean a g e s a n d y e a r s o f e d u c a t i o n f o r t h e t h r e e g r o u p s . A n a l y s i s o f v a r i a n c e o n age y i e l d e d a s i g n i f i c a n t g r o u p d i f f e r e n c e , F ( 2 , 4 7 ) = 3 . 2 3 , p < . 0 4 9 . C o m p a r i s o n s among means ( N e w m a n - K e u l s t e s t ) 87 Males Females A l l subjects Table 1 Mean Ages of Groups Depressed Schizophrenic Normal 3 6 . 2 5 2 3 . 6 3 3 2 . 2 5 3 8 . 7 5 3 4 . 1 3 3 2 , 7 5 3 7 . 5 0 2 8 . 8 8 3 2 . 5 0 Males Females A l l subjects Range: Table 2 Mean Years of Education Depressed Schizophrenic 1 1 . 2 5 1 0 . 7 5 1 1 . 0 0 7-16 yrs 1 1 . 6 2 1 2 . 0 0 1 1 . 8 1 9 - 1 6 yrs. Normal 1 3 . 6 3 1 3 . 7 5 1 3 . 6 9 1 0 - 1 8 yrs 88 showed that depressives were s i g n i f i c a n t l y older than schizophrenics, p ^ . 0 5 ; neither patient group was s i g n i -f i c a n t l y d i f f e r e n t i n age from normals. Analysis of variance on education also yielded a s i g n i f i c a n t group difference, F ( 2 , 4 7 ) = 6 . 1 7 , p < . 0 0 4 . Mean comparisons (Newman-Keuls) showed that normals had s i g n i f i c a n t l y more education than both depressives, p < . 0 1 , and schizophrenics, p « « . 0 5 . Although depressed subjects were selected on the basis of psychiatric diagnosis, the Beck Depression Inven-tory (Beck, 1972) was used for confirmation of this and for confirmation of recovery from depression at discharge. (See Appendix E for a description of the BDI.) Table 3 shows mean BDI scores for the three groups at the three assessment times, and Figure 1 displays them graphically. Beck and Beamesderfer ( 1 9 7 4 ) recommend using a high cutting score on the BDI C > 2 1 ) to minimize false positives when attempting to i d e n t i f y a pure group of depressives for research purposes. It i s reassuring, therefore, that i n the present study no depressed subject i n i t i a l l y scored below 2 1 , and the average for the group was much higher ( 3 1 . 8 8 ) . Analysis of variance on BDI scores with Groups and Sex as between subjects factors and T r i a l s as a within subjects factor yielded s i g n i f i c a n t main effects for Groups, F ( 2 , 4 2 ) = 5 0 . 3 4 , p < . 0 0 1 , and for T r i a l s , F ( 2 , 8 4 ) = 7 4 . 0 1 , p - < . 0 0 1 , as well as a s i g n i f i c a n t Groups x T r i a l s i n t e r a c t i o n , F ( 4 , 8 4 ) = 3 1 . 0 8 , p < . 0 0 1 . The e f f e c t for Sex was not s i g n i f i c a n t . These results are summarized 89 Table 3 Mean scores on the Beck Depression Inventory on admission 1 0 - 1 3 days l a t e r at discharge 'Normals were tested at interv a l s spaced to coincide with those for patients. Depressed Schizophrenic Normal" 3 1 . 8 8 1 4 . 5 0 2 . 0 6 1 7 . 8 1 1 0 . 1 9 1 . 6 9 7 . 0 0 6 . 5 0 1 . 5 6 Table 4 Analysis of variance for the Beck Depression Inventory Source SS df MS F £ Groups 7038 . 5 0 2 3519 . 2 5 5 0 . 3 4 . 0 0 1 Sex 52 . 5 6 1 52 . 5 6 < 1 . 3 9 1 Groups x Sex 197 .17 2 98 . 5 8 1 . 4 1 . 2 5 5 S-WITHIN 2936 . 0 6 42 69 .91 T r i a l s 2985 . 5 0 2 1492 .75 7 4 . 0 1 . 0 0 1 Groups x T r i a l s 2508 . 0 0 4 627 . 0 0 3 1 . 0 8 . 0 0 1 Sex x T r i a l s 22 .17 2 11 . 0 8 < 1 . 5 7 9 Gr. x Sex x Tr. 84 . 6 7 4 , 2 1 .17 1 . 0 5 . 3 8 7 CS-WITHIN 1694 . 3 6 84 20 .17 Table 5 Mean number of days between t r i a l s T r i a l 1-2 T r i a l s 2 - 3 T r i a l s 1-3 Depressed x 1 1 . 1 2 1 5 . 1 5 2 6 . 2 5 s.d. 1 . 2 6 5 . 3 6 5 . 5 9 Schizophrenic x 1 1 . 8 8 1 6 . 8 1 2 8 . 6 9 s.d. 1 . 3 6 8 . 3 4 8 . 9 7 Normal x 1 1 . 2 5 1 7 . 0 0 2 8 . 2 5 s.d. 1 . 0 9 1 . 8 2 1 . 4 8 9 0 Figure 1 Beck Depression Inventory - group means at each t r i a l 91 i n T a b l e 4 . P o s t h o c c o m p a r i s o n s o f B D I s c o r e s (Newman-K e u l s t e s t ) s h o w e d t h a t o n a d m i s s i o n d e p r e s s i v e s s c o r e d s i g n i f i c a n t l y h i g h e r t h a n b o t h n o r m a l s a n d s c h i z o p h r e n i c s , p * < . 0 1 , a n d t h a t t h e i r s c o r e s d r o p p e d s i g n i f i c a n t l y b e t w e e n e a c h p a i r o f t r i a l s , p < . 0 1 . S c h i z o p h r e n i c s ' s c o r e s a l s o d r o p p e d a c r o s s t r i a l s , w h i l e n o r m a l s ' s c o r e s d i d n o t c h a n g e . A t d i s c h a r g e , s c o r e s o f b o t h p a t i e n t g r o u p s , w h i l e s t i l l h i g h e r t h a n s c o r e s o f n o r m a l s ( p < . 0 1 ) , w e r e w i t h i n t h e " n o n d e p r e s s e d " r a n g e o f t h e B D I , i . e . < 1 0 ( ( B e c k e t a l , 1 9 6 1 ; B e c k a n d B e a m e s d e r f e r , 1 9 7 4 ) . P r o c e d u r e P a t i e n t s w e r e i n d i v i d u a l l y t e s t e d 1-3 d a y s a f t e r a d m i s s i o n , 1 0 - 1 3 d a y s l a t e r , a n d a t d i s c h a r g e , w h i c h was a p p r o x i m a t e l y f o u r w e e k s a f t e r a d m i s s i o n . N o r m a l s w e r e i n d i v i d u a l l y t e s t e d a t i n t e r v a l s s p a c e d t o c o i n c i d e w i t h t h o s e f o r p a t i e n t s . T a b l e 5 shows t h e mean n u m b e r o f d a y s b e t w e e n t e s t i n g s e s s i o n s f o r e a c h g r o u p . T e s t i n g t o o k p l a c e i n a q u i e t r o o m a t t h e h o s p i t a l r e s e r v e d f o r r e s e a r c h p u r p o s e s . S u b j e c t s s a t a t a d e s k f a c i n g a w a l l , w i t h t h e e x p e r i m e n t e r s e a t e d o f f t o o n e s i d e . H a l f t h e m a l e s a n d h a l f t h e f e m a l e s i n e a c h g r o u p w e r e t e s t e d b y t h e a u t h o r ; t h e r e m a i n d e r w e r e t e s t e d b y a r e s e a r c h a s s i s t a n t t r a i n e d b y t h e a u t h o r . F o l l o w i n g c o m p l e t i o n o f t h e B D I , s u b j e c t s w e r e a d m i n i s t e r e d t h e r e s e a r c h b a t t e r y i n t h e f o l l o w i n g o r d e r : C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e , P l e a s a n t E v e n t s 92 Schedule, Word Fluency, F l a g s , D i c h o t i c Word T r i a d s , D i c h o t i c M u s i c a l Chords. I t took approximately one hour to administer the b a t t e r y to each normal subject. Subjects i n the comparison groups were tested at any time of the day or evening, whenever they were a v a i l a b l e ; depressed p a t i e n t s were normally tested i n the afternoon or e a r l y evening to c o n t r o l f o r d i u r n a l v a r i a t i o n s common i n depression. Because of complaints of f a t i g u e and i n a b i l i t y to concentrate, i t was sometimes necesssary to break the i n i t i a l t e s t i n g session i n t o two or more shorter periods fo r p a t i e n t - s u b j e c t s . For the d i c h o t i c l i s t e n i n g t e s t s , tapes were played on a portable stereo cassette tape player (Sears Model 19282) wi t h stereo headphones. Equal volume f o r the two channels on a t e s t tape was ensured by observing the output on an o s c i l l o s c o p e during recording from the o r i g i n a l tape to the t e s t tape. Equal balance between the stereo headphones was ensured by t e s t i n g the output from each headphone on a sound l e v e l meter. For the word t r i a d s tape two males and two females tested by each experimenter i n each group began w i t h the l e f t stereo headphone on the l e f t ear and the r i g h t headphone on the r i g h t ear; the other two males and two females tested by each experimenter i n each group s t a r t e d i n the reversed p o s i t i o n s . A f t e r the eleventh t r i a l , the headphones were reversed on a l l su b j e c t s . The d u r a t i o n of the t e s t was approximately f i v e minutes. (See Appendix F f o r t e s t i n s t r u c t i o n s . ) For 93 t h e c h o r d s t a p e , t h e p r o c e d u r e was t h e same a s f o r t h e w o r d s t a p e e x c e p t t h a t h e a d p h o n e s w e r e r e v e r s e d a f t e r t h e t w e l f t h t r i a l . T h e d u r a t i o n o f t h e c h o r d s t e s t was a p p r o x i m a t e l y t w e n t y m i n u t e s . ( S e e A p p e n d i x G f o r t e s t i n s t r u c t i o n s . ) D a t a A n a l y s i s I n o r d e r t o e x a m i n e d i f f e r e n c e s o v e r t i m e i n a l l d e p e n d e n t v a r i a b l e s , s e p a r a t e 3 x 2 x 2 x 3 r e p e a t e d -m e a s u r e s a n a l y s e s o f v a r i a n c e w e r e p e r f o r m e d f o r e a c h t e s t i n t h e b a t t e r y , w i t h G r o u p s , S e x a n d E x p e r i m e n t e r s a s b e t w e e n s u b j e c t s f a c t o r s a n d T r i a l s a s a w i t h i n s u b j e c t s f a c t o r . E x p e r i m e n t e r s was i n c l u d e d a s a f a c t o r b e c a u s e two e x p e r i m e n t e r s a d m i n i s t e r e d t h e t e s t b a t t e r y ; t h e r e f o r e i t was n e c e s s a r y t o e x a m i n e t h e p o s s i b i l i t y o f d i f f e r e n t i a l e x p e r i m e n t e r e f f e c t s . B e c a u s e o f t h e n u m b e r o f a n a l y s e s i n v o l v e d , a f a i r l y s t r i n g e n t s i g n i f i c a n c e c r i t e r i o n l e v e l was a d o p t e d , i . e . p - < . 0 1 , i n o r d e r t o c o n t r o l f o r T y p e I e r r o r ( K e p p e l , 1 9 7 3 , p p . 8 7 - 8 8 ) . W h i l e t h e r e l a t i v e c o s t s o f T y p e I a n d T y p e I I e r r o r s i s o f t e n d e b a t a b l e ( K i r k , 1 9 6 8 , p p . 3 1 - 3 2 ; W i n e r , 1 9 6 2 , 1 2 - 1 3 ) , i t was deemed i m p o r t a n t i n t h e p r e s e n t s t u d y t o r e d u c e t h e r i s k o f f a l s e p o s i t i v e s i n o r d e r n o t t o r e p o r t " f a l s e f a c t s " i n t h e a r e a o f h e m i s p h e r i c s p e c i a l i -z a t i o n a t t h e p r e s e n t s t a g e o f k n o w l e d g e i n t h e a r e a . T h e a s s u m p t i o n o f h o m o g e n e i t y o f v a r i a n c e was t e s t e d i n a l l d e p e n d e n t v a r i a b l e s b y H a r t l e y ' s F t e s t R J J max f o r r e p e a t e d - m e a s u r e s d e s i g n s ( W i n e r , 1 9 6 2 , p . 3 0 5 ) , w h i c h 94 involves the r a t i o of largest to smallest within-group variance, compared to a c r i t i c a l F value. This test max i s more conservative than tests of homogeneity described by B a r t l e t t and Scheffe, and therefore more appropriate i n a study where Type I error was of concern. For variables i n which assumptions of homogeneous variance proved untenable, i t could be inferred that the assumption of homogeneous covariance might also be vio l a t e d (McCall and Appelbaum, 1 9 7 3 ) . Therefore, a l l effects i n that analysis were tested according to the Geisser-Greenhouse Conserva-tive F procedure (Winer, 1 9 6 2 , pp. 306 and 3 4 0 ) , i n which the degrees of freedom for numerator and denominator are each divided by r - 1 (r = the number of levels of the repeated f a c t o r ) . This procedure i s more conservative than variance-covariance matrix procedures described by Box and others. If the observed F value was s i g n i f i c a n t after the Geisser-Greenhouse correction, then i t could be assumed that the results would also be s i g n i f i c a n t under the conventional procedure, notwithstanding hetero-geneity (McCall and Appelbaum, 1 9 7 3 ) . When analysis of variance yielded a s i g n i f i c a n t i n t e r a c t i o n , simple main effects analyses were conducted to determine i t s locus. The error term used to test the simple main eff e c t of Groups at each t r i a l was the within-c e l l "heterogeneous" error term advocated by Winer, 1 9 6 2 , p. 3 4 0 , which i s a composite of MSC r , - ^ - and ' r ' ^ S-Withm M^DS-Within weighted by their respective degrees of 95 freedom, i . e . S S g / w + S S p s / w  dfS/W = dfDS/W This term i s more conservative than error terms advocated by some other authors (e.g. Keppel, 1973) and therefore more appropriate i n the present study, where a number of analyses are involved. The error term used to test the simple main effects of T r i a l s for each group was M S D g ^ £ t j ^ n (Winer, 1962, p. 340). When analysis of simple main effects revealed group differences at admission to hospital ( T r i a l 1), posthoc comparisons of group means were conducted to determine the nature of those differences. Where simple main effects analysis revealed differences across t r i a l s for a group, comparisons across t r i a l s were also conducted, to examine changes i n performance by that group between admission and discharge. A l l posthoc comparisons were conducted using the Newman-Keuls test (Winer, 1962, pp. 309-10). This test was chosen because i t reduces the l i k e l i h o o d of capi-t a l i z i n g on chance differences by providing a protection l e v e l lower l i m i t of l-o£ for a l l ordered sets of means regardless of how many steps apart they are. For analysis of the dichotic tests, raw scores were converted to " l a t e r a l i t y scores" which t h e o r e t i c a l l y have the least bias for o v e r a l l performance (Marshall, Caplan and Holmes, 1975). Ear preference i n dichotic tests has commonly been measured either by r i g h t - l e f t difference scores ( i . e . the difference i n correct responses on right and l e f t sides) or by comparison of right and l e f t ear scores. However, these approaches do not take into account differences i n o v e r a l l performance. In a review of 45 d i f f e r e n t dichotic l i s t e n i n g experiments, Harshman and Krashen ( 1 9 7 2 ) showed that r i g h t - l e f t d i f f e r -ence scores were negatively correlated with t o t a l accuracy. An alternative practise i s to use proportion of correct (POC), which i s correct responses on the right side divided by t o t a l correct responses, or proportion of error (POE), which i s errors on the l e f t side divided by t o t a l errors. However, both POC and POE have been shown to correlate with o v e r a l l accuracy; moreover, POC i s con-strained above accuracies of 50% ( i . e . i t cannot assume any value i n i t s range at accuracies above 5 0 % ) , while POE i s constrained at accuracies below 50% (Marshall et a l , 1 9 7 5 ) . In the present study, an "unconstrained" l a t e r a l i t y score representing the l e v e l of ear superiority i n each in d i v i d u a l for each dichotic test, regardless of the individual's accuracy, was obtained by the following formulas (Marshall et a l , 1 9 7 5 ) : R . - L correct correct Total correct f o r ^ c u r a c y < 50% for accuracy ^ 5 0 % and R . - L correct correct Total errors A positive score derived from the above formulas indicates a right ear advantage while a negative score indicates a l e f t ear advantage. Although this l a t e r a l i t y measure 9 7 w o u l d be d i s t o r t e d a t v e r y e x t r e m e s c o r e s , e . g . p e r f e c t o r z e r o s c o r e s f o r e i t h e r e a r , t h i s was n o t a p r o b l e m i n t h e p r e s e n t s t u d y , w h e r e a l m o s t a l l s c o r e s f o r b o t h r i g h t a n d l e f t e a r f e l l w i t h i n t h e r a n g e l e a s t s e n s i t i v e t o d i s t o r t i o n , i . e . b e t w e e n t h e f i r s t a n d t h i r d q u a r t i l e s o f p o s s i b l e s c o r e s . T h e o n l y e x c e p t i o n s w e r e 6 o u t o f 288 D i c h o t i c C h o r d s s c o r e s (48 f o r e a c h e a r a t e a c h t r i a l ) a n d 12 o u t o f 288 D i c h o t i c W o r d s s c o r e s ; a l l o t h e r e a r s c o r e s w e r e w i t h i n t h e r a n g e l e a s t s e n s i t i v e t o d i s t o r t i o n w i t h t h e l a t e r a l i t y m e a s u r e e m p l o y e d i n t h e s t u d y . I n o r d e r t o e x a m i n e r e l a t i o n s h i p s among c h a n g e s o v e r t i m e i n (1) h e m i s p h e r i c f u n c t i o n i n g , ( 2 ) d e g r e e o f c o g n i t i v e d i s t o r t i o n , a n d ( 3 ) r a t e o f r e s p o n s e - c o n t i n g e n t p o s i t i v e r e i n f o r c e m e n t , p a r t i a l c o r r e l a t i o n a n a l y s e s o f r e l e v a n t i m p r o v e m e n t s c o r e s w e r e c o n d u c t e d . I m p r o v e m e n t s c o r e s w e r e d i f f e r e n c e s c o r e s , i . e . T r i a l 3 - T r i a l 1. W h e r e a v a r i a b l e p r o d u c e d n e g a t i v e d i f f e r e n c e s c o r e s ( e . g . a d r o p i n c o g n i t i v e d i s t o r t i o n b e t w e e n T r i a l 1 a n d T r i a l 3 ) , T r i a l 1 a n d T r i a l 3 s c o r e s w e r e r e f l e c t e d s o t h a t i m p r o v e -m e n t s c o r e s w e r e a l w a y s p o s i t i v e . P a r t i a l c o r r e l a t i o n s w e r e c o m p u t e d among i m p r o v e m e n t , s c o r e s f o r t h e . D i c h o t i c C h o r d s t e s t , t h e F l a g s t e s t , t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e a n d P l e a s a n t E v e n t s S c h e d u l e , c o n t r o l l i n g i n e a c h a n a l y s i s f o r b o t h i n i t i a l s c o r e s . I n o r d e r t o d e t e r m i n e w h e t h e r c h a n g e s i n t e s t s c o r e s b e t w e e n a d m i s s i o n a n d d i s c h a r g e w e r e r e l a t e d t o m e d i c a t i o n , a d d i t i o n a l p a r t i a l c o r r e l a t i o n a n a l y s e s w e r e 98 c o n d u c t e d f o r b o t h d e p r e s s i v e s a n d s c h i z o p h r e n i c s . C o r r e l a t i o n s b e t w e e n m e d i c a t i o n s c o r e s a n d i m p r o v e m e n t s c o r e s f o r a l l d e p e n d e n t v a r i a b l e s w e r e o b t a i n e d , c o n t r o l l i n g f o r T r i a l 1 s c o r e s . M e d i c a t i o n s c o r e s w e r e d e r i v e d i n t h e f o l l o w i n g w a y : f o r d e p r e s s i v e s , t h e amount o f t r i c y c l i c a n t i d e p r e s s a n t s t a k e n d u r i n g e a c h o f t h e t h r e e w e e k s p r e c e d i n g t h e t h r e e t r i a l s w e r e a v e r a g e d f o r e a c h p a t i e n t , y i e l d i n g a r o u g h a p p r o x i m a t i o n o f h i s a v e r a g e m e d i c a t i o n d u r i n g t h e o v e r a l l p e r i o d o f t e s t i n g . F o r s c h i z o p h r e n i c s , who r e c e i v e d a v a r i e t y o f n e u r o l e p t i c s , a v e r a g e m e d i c a t i o n was c o n v e r t e d t o a c e r t a i n n u m b e r o f " m e d i c a t i o n u n i t s " b y s e t t i n g d o s e e q u i v a l e n t s , e . g . 100 m g . c h l o r p r o m a z i n e , 75 m g . t h i o r i d a z i n e , 2 m g . f l u p h e n a z i n e ( R o t e n b e r g , 1 9 7 7 ) , e q u a l t o o n e m e d i c a t i o n u n i t . 99 R e s u l t s G r o u p means f o r a l l d e p e n d e n t v a r i a b l e s a r e s u m -m a r i z e d i n T a b l e 6 . T h e r e w e r e n o s i g n i f i c a n t e f f e c t s f o r e i t h e r S e x o r E x p e r i m e n t e r s i n a n y o f t h e a n a l y s e s . S i n c e t h e mean a g e o f s c h i z o p h r e n i c s was s i g n i f i -c a n t l y l o w e r t h a n t h a t o f d e p r e s s e d s u b j e c t s , z e r o o r d e r c o r r e l a t i o n s w e r e c o m p u t e d b e t w e e n a g e a n d s c o r e s o n e a c h o f t h e d e p e n d e n t v a r i a b l e s . T h e o n l y c o r r e l a t i o n t o r e a c h s i g n i f i c a n c e a t t h e . 0 1 l e v e l was t h a t b e t w e e n age a n d n o r m a l s ' T r i a l 1 s c o r e s o n t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e ( r = - . 6 6 , p < . 0 0 3 ) . S i n c e t h e n o r m a l g r o u p h a d a h i g h e r mean e d u c a t i o n l e v e l t h a n b o t h p a t i e n t g r o u p s , z e r o o r d e r c o r r e l a t i o n s w e r e a l s o c o m p u t e d b e t w e e n y e a r s o f e d u c a t i o n a n d s c o r e s o n e a c h o f t h e d e p e n d e n t v a r i a b l e s . None o f t h e s e c o r r e l a -t i o n s was s i g n i f i c a n t . B e c a u s e e d u c a t i o n l e v e l c o u l d a f f e c t p e r f o r m a n c e o n c o g n i t i v e t a s k s , t h e c o r r e l a t i o n b e t w e e n e d u c a t i o n a n d s c o r e s o n t h e F l a g s t e s t a r e o f p a r t i c u l a r i n t e r e s t ( t h e W o r d F l u e n c y t e s t p r o v i d e d a c o r r e c t i o n f o r e d u c a t i o n ) . T h e r e f o r e , c o r r e l a t i o n s b e t w e e n y e a r s o f e d u c a t i o n a n d F l a g s s c o r e s a r e d i s p l a y e d i n T a b l e 7. H y p o t h e s i s 1 p r e d i c t e d t h a t , i n a c c o r d a n c e w i t h T u c k e r ' s n e u r o p s y c h o l o g i c a l t h e o r y o f d e p r e s s i o n , d e p r e s -s i v e s a t a d m i s s i o n t o h o s p i t a l w o u l d o b t a i n a s m a l l e r 100 Table 6 Group Means for a l l Tests T r i a l 1 T r i a l 2 T r i a l 3 Depr. Schiz. Norm. C.D.Q. x 18.00 6.56 0.56 s.d. 6.74 5.66 0.73 Depr. Schiz. Norm. 11.19 5.88 0.69 8.20 6.56 0.79 Depr. Schiz. Norm. 4.13 3.56 0.31 3.59 1.69 0.48 P.E.S. x 206.06 1156.69 922.50 s.d. 105.78 1385.59 595.46 * 497.63 1067.94 680.06 361.79 1424.94 377.31 668.19 928.31 562.31 367.69 1256.52 295.95 WORD FL. x 42.63 37.81 39.63 s.d. 14.02 10.45 10.24 49.19 41.69 48.56 13.34 13.50 9.02 52.38 43.25 55.69 15.63 10.67 13.68 FLAGS x 39.75 36.88 47.81 s.d. 3.86 7.33 7.09 42.88 41.63 52.00 4.99 6.60 8.54 45.13 44.88 58.25 6.71 7.80 6-81 R WORDS x 23.94 25.44 35.81 s.d. 4.89 6.99 9.04 27.50 29.31 37.19 4.84 4.53 6.59 30.50 29.94 37.25 5.27 3.61 6.68 L WORDS x 24.50 24.88 25.38 s.d. . 8.09 5.39 8.15 26.56 25.81 28.94 6.59 4.87 7.35 25.00 24.50 31.00 5.90 5.05 6.77 L.S. (words) * x -0.02 0.00 0.21 s.d. 0.18 0.19 0.16 0.03 0.06 0.14 0.15 0.10 0.12 0.10 0.10 0.11 0.13 0.11 0.09 R CHORDS x 13.69 11.63 13.38 s.d. 2.47 2.90 1.09 13.25 H.94 13.56 1.73 2.47 1.71 12.44 13.31 13.75 2.53 2.36 1-77 L CHORDS x 12.75 14.06 15.13 s.d. 2.67 2.57 1.63 13.63. 13.31 15.06 2.00 1.99 1.34 15.94 11.75 14.13 2.21 1.95 1-41 L.S. (chords) * x 0.06 -0.11 -0.08 s.d. 0.17 0.20 0.10 -0.02 -0.05 -0.08 0.11 0.20 0.07 -0.18 0.07 "0.02 0.16 0.17 0.11 *L.S. = Laterality Score. Positive scores negative scores = right ear advantage; = l e f t ear advantage. 101 Table 7 Zero order correlations between years of education and Flags scores Depressed Schizophrenic Normal T r i a l 1 .3554 .0955 .3095 (p=.088) (p=.363) (P=.122) T r i a l 2 .1091 .0155 .0035 (p=.240) (P=.477) (p=.495) T r i a l 3 -.0432 -.1338 .0498 (P=.437) (p=.311) (p=.427) Table 8 Mean l a t e r a l i t y scores for the Dichotic Musical Chords test T r i a l 1 T r i a l 2 T r i a l 3 x s.d. x" s.d. x" s.d. Depressed 0.06 (0.17) -0.02 (0.11) -0.18 (0.16) Schizo. -0.11 (0.20) -0.05 (0.20) 0.07 (0.17) Normal -0.08 (0.10) -0.08 (0.07) -0.02 (0.11) 102 l e f t ear advantage i n the Dichotic Chords test and only depressives would show a s i g n i f i c a n t increase i n l e f t ear advantage by discharge. Means and S.D.s for each group at each t r i a l are shown i n Table 8 . The n u l l hypothesis of homogeneity of variance for the Dichotic Chords data was not rejected: observed F = 4 . 4 5 . c r i t i c a l J max ' max(3,15) = 4 . 9 0 , p < . 0 1 ; therefore an analysis of variance was conducted. Results of this analysis are summarized i n Table 9 and group means at each t r i a l are depicted graphically i n Figure 2 . The only s i g n i f i c a n t e f f e c t i n this analysis was the Groups x T r i a l s i n t e r a c t i o n , F ( 4 , 7 2 ) = 1 0 . 4 4 , p < . 0 0 1 . Analysis of simple main effects for Groups at each t r i a l (Table 10) revealed s i g n i f i c a n t group d i f -ferences at admission ( T r i a l 1) , F ( 2 , 1 0 8 ) = 8 . 7 6 , p < . 0 0 1 , and at discharge ( T r i a l 3 ) , F ( 2 , 1 0 8 ) = 1 0 . 7 6 , p< : . 0 0 1 . Analysis of simple main effects of T r i a l s for each group showed that scores of depressives changed s i g n i f i c a n t l y across t r i a l s , F ( 2 , 7 2 ) = 1 3 . 9 4 , p < . 0 0 1 ; schizophrenics' scores also changed across t r i a l s , F ( 2 , 7 2 ) = 5 . 9 6 , p « £ . 0 1 ; scores of normals did not change. Posthoc comparisons of groups at T r i a l 1 showed that, on admission to h o s p i t a l , depressives demonstrated less l e f t ear superiority than both normals and schizo-phrenics (Table 1 1 ) . Comparisons across t r i a l s for depres-sives and schizophrenics showed that scores of depressives changed s i g n i f i c a n t l y between each pair of t r i a l s , moving from a right ear advantage at T r i a l 1 to a l e f t ear advantage Table 9 Analysis of variance on l a t e r a l i t y scores for the Dichotic Musical Chords test 103 Source Groups Sex Groups x Sex Experimenters Groups x Exp. Sex x Exp. Gr. x Sex x Exp, S-WITHIN T r i a l s _ . Groups x T r i a l s Sex x T r i a l s Gr. x Sex x Tr. Exp. x T r i a l s Gr. x Exp. x Tr, Sex x Exp. x Tr., Gr. x Sex x Exp, DS-WITHIN x Tr, SS df MS F £ 0 . 0 2 5 2 0 . 0 1 3 . 4 8 . 6 2 2 0 . 0 0 0 1 0 . 0 0 0 . 0 1 . 9 1 4 0 . 0 5 0 2 0 . 0 2 5 . 9 7 . 3 8 9 0 . 0 1 0 1 0 . 0 1 0 . 3 7 . 5 4 9 0 . 1 0 7 2 0 . 0 5 4 2 . 0 6 . 1 4 2 0 . 0 3 1 1 0 . 0 3 1 1 .19 . 2 8 3 0 . 0 9 6 2 0 . 0 4 8 1 . 8 5 .172 0 . 9 3 7 36 0 . 0 2 6 0 . 0 0 7 2 0 . 0 0 3 .15 . 8 6 1 0 . 9 0 9 4 0 . 2 2 7 1 0 . 4 4 . 0 0 1 * 0 . 1 2 3 2 0 . 0 6 2 2 . 8 3 . 0 6 6 0 . 0 7 1 4 0 . 0 1 8 . 8 2 .517 0 . 0 0 2 2 0 . 0 0 1 . 0 6 . 9 4 5 0 . 1 8 3 4 0 . 0 4 6 2 . 1 1 . 0 8 9 0 . 0 9 6 2 0 . 0 4 8 2 . 2 1 .117 0 . 1 3 3 4 0 . 0 3 3 1 . 5 3 . 2 0 3 1 . 5 6 7 72 0 . 0 2 2 *meets c r i t e r i o n l e v e l set for the study Table 10 Analysis of simple main effects for the Dichotic Musical Chords test Source SS df MS F £ GROUPS: at T r i a l 1 . 4 0 6 5 2 . 2 0 3 3 8 . 7 6 . 0 0 1 * at T r i a l 2 . 0 2 8 2 2 . 0 1 4 1 1 n. s. at T r i a l 3 . 4 9 9 1 2 . 2 4 9 6 1 0 . 7 6 . 0 0 1 * W-CELL 2 . 5 0 4 0 108 . 0 2 3 2 TRIALS: Depressed . 6 1 3 3 2 . 3 0 6 7 1 3 . 9 4 . 0 0 1 * Schizo. . 2 6 2 1 L .1311 5 . 9 6 . 0 1 * Normal . 0 3 9 9 2 . 0 2 0 0 1 n. s . DS-WITHIN 1 . 5 6 7 0 72 . 0 2 2 0 *meets c r i t e r i o n l e v e l set for the study 104 * +scores -scores = right ear advantage = l e f t ear advantage 105 T a b l e 11 C o m p a r i s o n s o f mean l a t e r a l i t y s c o r e s a t T r i a l 1 o n t h e D i c h o t i c M u s i c a l C h o r d s t e s t C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e D e p r . v s . N o r m . . 1 4 0 0 * . 0 8 9 6 D e p r . v s . S c h i z o . . 1 6 9 0 * . 1 0 2 8 S c h i z o . v s . N o r m . . 0 2 7 5 . 0 8 9 6 * p < . 0 1 T a b l e 12 C o m p a r i s o n s o f mean l a t e r a l i t y s c o r e s a c r o s s t r i a l s f o r t h e D i c h o t i c M u s i c a l C h o r d s t e s t C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e D e p r . T 1 - T 2 . 1 1 5 0 * . 0 8 0 3 T 2 - T 3 . 1 6 0 6 * . 0 8 0 3 T 1 - T 3 . 2 7 5 6 * . 0 9 1 4 S c h i z o . T 1 - T 2 . 0 6 1 3 . 0 8 0 3 T 2 - T 3 . 1 1 6 8 * . 0 8 0 3 T 1 - T 3 . 1 7 8 1 * . 0 9 1 4 * p < . 0 1 D e p r . (n=16) S c h i z o . (n=16) N o r m a l (n=16) T a b l e 13 Number o f s u b j e c t s a t e a c h t r i a l w i t h a r i g h t , l e f t , o r n o e a r a d v a n t a g e o n t h e D i c h o t i c M u s i c a l C h o r d s t e s t T r i a l 1 R i g h t L e f t N o n e 6 4 6 6 10 0 0 12 4 ' T r i a l 2 Right Left None 7 7 2 4 11 1 1 11 4 T r i a l 3 Right Left None 2 13 1 10 5 1 3 10 3 106 a t s u b s e q u e n t t r i a l s ( T a b l e 1 2 ) . S c o r e s o f s c h i z o p h r e n i c s a l s o c h a n g e d s i g n i f i c a n t l y b e t w e e n a d m i s s i o n a n d d i s -c h a r g e , b u t i n a d i r e c t i o n o p p o s i t e t o t h a t o f d e p r e s s i v e s ; a l t h o u g h t h e d i f f e r e n c e b e t w e e n T r i a l 1 a n d 2 was n o t s i g n i f i c a n t , d i f f e r e n c e s b e t w e e n o t h e r p a i r s o f t r i a l s w e r e ( T a b l e 1 2 ) . N o r m a l s d i d n o t c h a n g e a c r o s s t r i a l s , d e m o n s t r a t i n g c o n s i s t e n t l y t h e l e f t e a r a d v a n t a g e p r e v i o u s l y r e p o r t e d f o r t h i s t e s t . T h e s e r e s u l t s s u p p o r t H y p o t h e s i s 1: d e p r e s s i v e s i n i t i a l l y s h o w e d s i g n i f i c a n t l y l e s s l e f t e a r s u p e r i o r i t y t h a n b o t h c o m p a r i s o n , g r o u p s , a n d w e r e t h e o n l y g r o u p t o s i g n i f i c a n t l y i n c r e a s e l e f t e a r s u p e r i o r i t y b e t w e e n a d m i s s i o n a n d d i s c h a r g e . T a b l e 13 shows t h e n u m b e r o f s u b j e c t s i n e a c h g r o u p who o b t a i n e d a r i g h t o r l e f t e a r a d v a n t a g e a t e a c h t r i a l . I t c a n be s e e n t h a t i n . t h e d e p r e s s e d g r o u p o n l y f o u r s u b j e c t s i n i t i a l l y d e m o n s t r a t e d a l e f t e a r a d v a n t a g e , w i t h t h e r e m a i n i n g t w e l v e s u b j e c t s s h o w i n g e i t h e r a r i g h t e a r a d v a n t a g e o r n o d i f f e r e n c e b e t w e e n e a r s . B y d i s c h a r g e , h o w e v e r , t h i r t e e n o f t h e s i x t e e n d e p r e s s e d s u b j e c t s s h o w e d a l e f t e a r a d v a n t a g e . S i n c e s c o r e s o f b o t h t h e p a t i e n t g r o u p s c h a n g e d s i g n i f i c a n t l y b e t w e e n a d m i s s i o n a n d d i s c h a r g e , g r o u p means f o r e a c h e a r s e p a r a t e l y w e r e p l o t t e d i n o r d e r t o g r a p h t h e d i r e c t i o n o f c h a n g e i n e a c h e a r ' s a c c u r a c y o v e r t i m e . A s F i g u r e 3 s h o w s , d e p r e s s i v e s ' l e f t e a r a c c u r a c y i n c r e a s e d s h a r p l y b e t w e e n a d m i s s i o n a n d d i s c h a r g e , w h i l e t h e i r r i g h t e a r a c c u r a c y d e c r e a s e d . I n c o n t r a s t , s c h i z o p h r e n i c s 107 16 .5 •• 16 .0 • • CD 15 .5 • H <U • H 15 .0 4-1 C 0) T3 14 .5 • H >^ i—l 14 .0 - • 4—' o cu 13 .5 o o 13 .0 • • CO }-l 12 .5 O O 12 .0 •, O !-i 11 .5 • • CD 11 e .0 •-i-J1 10 .5 10 .0 N (L ear) S (L^^ear) D (L ear) D (R ear) 1 T r i a l 1 1 T r i a l 2 1 T r i a l 3 Figure 3 Dichotic Musical Chords - means for each ear at each t r i a l D = Depressives N = Normals S = Schizophrenics Right ear Left ear 108 i n c r e a s e d t h e i r r i g h t e a r a c c u r a c y a n d d e c r e a s e d t h e i r l e f t e a r a c c u r a c y b e t w e e n a d m i s s i o n a n d d i s c h a r g e . ( S c h i z o p h r e n i c s ' r e s u l t s a r e d i s c u s s e d i n A p p e n d i x H . ) I t was n o t e x p e c t e d t h a t d e p r e s s i v e s w o u l d p e r f o r m d i f f e r e n t l y f r o m c o m p a r i s o n g r o u p s o n D i c h o t i c W o r d T r i a d s . M e a n s a n d S . D . s f o r e a c h g r o u p a t e a c h t r i a l a r e shown i n T a b l e 1 4 . T h e n u l l h y p o t h e s i s o f h o m o g e n e i t y o f v a r i a n c e f o r t h e D i c h o t i c W o r d s d a t a was n o t r e j e c t e d : o b s e r v e d F = 1 . 5 1 , c r i t i c a l F = 4 . 9 0 , p<C . 0 1 ; t h e r e f o r e a n max ' max 5 ^ ' a n a l y s i s o f v a r i a n c e was c o n d u c t e d . R e s u l t s o f t h i s a n a l y s i s a r e s u m m a r i z e d i n T a b l e 15 a n d g r o u p m e a n s a r e . . 2 d e p i c t e d i n F i g u r e 4 . T h e o n l y s i g n i f i c a n t e f f e c t was t h e G r o u p s x T r i a l s i n t e r a c t i o n , F ( 4 , 7 2 ) = 6 . 4 3 , p ^ . 0 0 1 . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f G r o u p s a t e a c h t r i a l ( T a b l e 16) f o u n d s i g n i f i c a n t g r o u p d i f f e r e n c e s a t T r i a l 1, F ( 2 , 1 0 8 ) = 1 3 . 7 9 , p - C . O O l ; t h e r e w e r e n o s i g n i f i c a n t d i f f e r e n c e s a t s u b s e q u e n t t r i a l s . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f T r i a l s f o r e a c h g r o u p f o u n d t h a t t h e d e p r e s s e d g r o u p c h a n g e d s i g n i f i c a n t l y a c r o s s t r i a l s , F ( 2 , 7 2 ) = 6 . 5 3 , p ^ . 0 1 ; c h a n g e s i n t h e c o m p a r i s o n g r o u p s f a i l e d t o r e a c h t h e . 0 1 l e v e l o f s i g n i f i c a n c e . P o s t h o c c o m p a r i s o n s o f g r o u p s a t T r i a l 1 showed t h a t n o r m a l s d e m o n s t r a t e d g r e a t e r r i g h t e a r s u p e r i o r i t y t h a n b o t h d e p r e s s i v e s a n d s c h i z o p h r e n i c s ( T a b l e T X 7 ^ ) . C o m p a r i s o n s a c r o s s t r i a l s 2 • • B e c a u s e o f t h e . 0 1 c r i t e r i o n l e v e l a d o p t e d f o r t h i s s t u d y , t h e S e x m a i n e f f e c t a n d t h e Sex. x T r i a l s i n t e r a c t i o n e f f e c t w e r e n o t s i g n i f i c a n t . H o w e v e r , s i n c e s e x d i f -f e r e n c e s w e r e o f i n t e r e s t i n t h e s t u d y , t h e s e e f f e c t s a r e e x a m i n e d a n d d i s c u s s e d i n A p p e n d i x I . 109 Table 14 Mean l a t e r a l i t y scores for the Dichotic Word Triads test T r i a l 1 T r i a l 2 T r i a l 3 x s.d. x s.d. x s.d. Depressed: -0.02 (0.18) 0.03 (0.15) 0.10 (0.13) Schizo.: 0.00 (0.19) 0.06 (0.10) 0.10 (0.11) Normal: 0.21 (0.16) 0.14 (0.12) 0.11 (0.09) 110 Table 15 Analysis of variance on l a t e r a l i t y scores for the Dichotic Word Triads test Source SS df MS F £ Groups 0.373 2 0 .186 5.08 .011 Sex. 0.190 1 0 .190 5.07 .029 Groups x Sex 0.105 2 0 .053 1.43 .252 Experimenter 0.006 1 0 .006 0.16 .695 Groups x Exp. 0.005 2 0 .003 0.07 .931 Sex x Exp. 0.130 1 0 .130 3.54 .068 Gr. x Sex x Exp. • 0.030 2 0 .015 0.41 .668 S-WITHIN 1.323 36 0 .037 T r i a l s 0.043 2 0 .021 2.13 .127 Groups x T r i a l s . 0.258 4 0 .064 6.43 .001* Sex x T r i a l s 0.061 2 0 .031 3.06 .053 Gr. x Sexx Tr. 0.012 4 0 .003 0.30 .880 Exp. x T r i a l s 0.003 2 0 .001 0.13 .883 Gr. x Exp. x Tr. 0.065 4 0 .016 1.63 .176 Sex x Expp. x Tr. 0.013 2 0 .006 0.64 .531 Gr. x Sex x Exp. x Tr . 0.027 4 0 .007 0.67 .617 DS-WITHIN 0.722 72 0 .010 "meets the c r i t e r i o n l e v e l set for the study. Table 16 Analysis of simple main effects for the Dichotic Word Triads test Source SS df MS F £ GROUPS: at T r i a l 1 at T r i a l 2 at T r i a l 3 W-CELL 0.524 0.107 0.000 2.045 2 2 . 2 108 0.262 0.053 0.000 0.019 13.79 2.79 < 1 .001* n. s. n. s . TRIALS: Depressed Schizophrenic Normal DS-WITHIN 0.131 0.081 0.089 0.722 2 2 2 72 0.065 0.041 0.044 0.010 6.53 4.05 4.43 .01* .025 .025 *meets the c r i t e r i o n l e v e l set for the study. T r i a l 1 T r i a l 2 T r i a l 3 Figure 4 Dichotic Word Triads - group means at each t r i a l ? * + scores = right ear advantage - scores = l e f t ear advantage 112 T a b l e 17 C o m p a r i s o n s o f mean l a t e r a l i t y s c o r e s a t t r i a l 1 o n t h e D i c h o t i c W o r d T r i a d s t e s t C o m p a r i s o n D e p r . v s . N o r m . D e p r . v s . S c h i z o . S c h i z o . v s . N o r m . *p <.0l M e a n d i f f , . 2 3 4 4 * . 0 2 8 1 . 2 0 6 3 * C r i t i c a l N - K V a l u e . 0 1 2 3 . 1 0 6 9 . 1 0 6 9 T a b l e 18 C o m p a r i s o n s o f mean l a t e r a l i t y s c o r e s a c r o s s t r i a l s o n t h e D i c h o t i c W o r d T r i a d s t e s t C o m p a r i s o n D E P R . T 1 - T 2 T 2 - T 3 T 1 - T 3 * p < . 0 1 M e a n d i f f , . 0 5 0 7 . 0 7 6 2 * . 1 2 6 9 * C r i t i c a l N - K V a l u e . 0 5 4 1 . 0 5 4 1 . 0 6 1 5 T a b l e 19 Number, o f s u b j e c t s a t e a c h t r i a l w i t h a r i g h t , l e f t o r n o e a r a d v a n t a g e o n t h e D i c h o t i c W o r d T r i a d s t e s t D e p r . (n=16) S c h i z o . (n=16) N o r m a l (n=16) T r i a l 1 R i g h t L e f t N o n e 6 7 15 9 8 1 1 1 0 T r i a l 2 R i g h t L e f t N o n e 7 12 14 9 3 2 0 1 0 T r i a l 3 R i g h t L e f t N o n e 14 12 15 2 4 0 0 0 113 (Table 18) showed that depressives s i g n i f i c a n t l y increased r i g h t ear superiority between T r i a l s 2 - 3 and 1 - 3 ; the difference between T r i a l s 1-2 was not s i g n i f i c a n t . Changes across t r i a l s for schizophrenics and normals were not s i g n i f i c a n t at the . 0 1 l e v e l . These results were contrary to expectation, for the depressed group did perform d i f f e r e n t l y from comparison groups on this test of l e f t hemisphere functioning, and only showed the normal pattern of ear preference after recovery from depression. Table 19 shows, the number of. subjects who demonstrated a right or l e f t ear advantage at each t r i a l . It can be seen that only six of the depressed group i n i t i a l l y demonstrated a right ear advantage, the remaining ten obtaining either a l e f t ear advantage or no ear difference. By discharge, however, fourteen of the sixteen depressed subjects showed a normal right ear advantage. As with Dichotic Chords, group means for right and l e f t ear on the Dichotic Word Triads test were plotted in order to graph changes i n each ear's accuracy over time (Figure 5 ) . Although the change i n l a t e r a l i t y scores across t r i a l s was not s i g n i f i c a n t for schizophrenics or nor-mals at the c r i t e r i o n l e v e l adopted for this study, means for these groups were also plotted for comparison. As Figure 5 shows, depressives increased their right ear accuracy but did not change i n l e f t ear accuracy. Hypothesis 2 predicted that at admission depres-sives would obtain lower scores than comparison subjects 114 T3 0) 4- 1 5- i O a a> u o OJ S-I o o CO T3 S-i O & C H O S-i OJ e 40 39 38 37 36 35 34 33 32 + 31 30 29 28 27 26 25 24 23 22 21 + 20 N (R ear) .,-*• N (L ear) S (R ear (R ear) -D (L ear) *S (L ear) T r i a l 1 T r i a l 2 T r i a l 3 Figure 5 Dichotic Word Triads - means for each ear at each t r i a l D N S = Depressives = Normals = Schizophrenics Right ear Left ear 1 o n t h e F l a g s t e s t a n d o n l y d e p r e s s i v e s w o u l d show a s i g n i f i c a n t i n c r e a s e i n s c o r e s b y d i s c h a r g e . M e a n s a n d S . D . s f o r e a c h g r o u p a t e a c h t r i a l a r e shown i n T a b l e 2 0 . T h e n u l l h y p o t h e s i s o f h o m o g e n e i t y o f v a r i a n c e f o r t h e F l a g s d a t a was n o t r e j e c t e d : o b s e r v e d F = 4 . 4 4 . ° J max c r i t i c a l / F ( 3 , 1 5 ) = 4 . 9 0 , p ^ . 0 1 : t h e r e f o r e a h a n a l y s i s m a x v 5 7 J t- s J o f v a r i a n c e was c o n d u c t e d . R e s u l t s o f t h i s a n a l y s i s a r e s u m m a r i z e d i n T a b l e 21 a n d g r o u p m e a n s a r e d i s p l a y e d i n F i g u r e 6 . T h e m a i n e f f e c t f o r G r o u p s was s i g n i f i c a n t , F ( 2 , 3 6 ) = 1 9 . 5 8 , p < . 0 0 1 , a s w e l l a s t h e m a i n e f f e c t f o r T r i a l s , F ( 2 , 7 2 ) = 5 6 . 5 7 , p < . 0 0 1 . No o t h e r e f f e c t s w e r e . . 3 s i g n i f i c a n t a t t h e . 0 1 l e v e l . A n a l y s i s o f t h e m a m e f f e c f o r G r o u p s s h o w e d t h a t s c o r e s o f d e p r e s s i v e s w e r e s i g n i -f i c a n t l y l o w e r t h a n t h o s e o f n o r m a l s , F ( l , 3 6 ) = 2 5 . 2 1 , p < . 0 0 1 , b u t n o t d i f f e r e n t f r o m t h o s e o f s c h i z o p h r e n i c s , w h o s e s c o r e s w e r e a l s o l o w e r t h a n n o r m a l s ' , F ( l , 3 6 ) = 3 3 . 0 1 , p < . 0 0 1 . A n a l y s i s o f t h e m a i n e f f e c t f o r T r i a l s s h o w e d t h a t a l l g r o u p s made s i g n i f i c a n t g a i n s b e t w e e n e a c h p a i r o f t r i a l s : f o r T r i a l s 1 - 2 , F ( l , 7 2 ) = 2 9 . 0 2 , p < . 0 0 1 ; f o r T r i a l s 2 - 3 , F ( l , 7 2 ) = 2 7 . 5 4 , p < . 0 0 1 ; f o r T r i a l s 1 - 3 , F ( l , 7 2 ) = 1 1 3 . 1 0 , p < . 0 0 1 . T h e s e r e s u l t s a r e s u m m a r i z e d i n T a b l e 2 2 . R e s u l t s f o r t h e F l a g s t e s t o n l y p a r t i a l l y s u p p o r t H y p o t h e s i s 2. W h i l e d e p r e s s i v e s d i d o b t a i n l o w e r s c o r e s a t a d m i s s i o n t h a n n o r m a l s , t h e i r p e r f o r m a n c e was n o t 3 . . . . . . T h e i n t e r a c t i o n s i n v o l v i n g S e x w e r e n o t s i g n i f i c a n t a t t h e . 0 1 l e v e l . T h e s e a r e e x a m i n e d a n d d i s c u s s e d i n A p p e n d i x J . 116 Depressed: Schizo.: Normal: Table 20 Mean Flags test scores at each t r i a l T r i a l 1 x s.d. 39:75 (3.86) 36.88 (7.33) 47.81 (7.09) T r i a l 2 x s.d. 42.88 (4.99) 41.63 (6.60) 52.00 (8.54) T r i a l 3 x s.d. 45.13 (6.71) 44.88 (7.80) 58.25 (6.81) 117 Table 21 Analysis of variance for Source SS Groups 3806 .75 Sex. 33 .00 Groups x Sex 786 .00 Experimenters 193 .75 Groups x Exp. 170 .75 Sex x Exp. 1 .00 Gr. x Sex x Exp. 735 .50 S-WITHIN 3498 .81 T r i a l s 1512 .25 Groups x T r i a l s 121 .75 Sex x T r i a l s 68 .75 Gr. x Sex x Tr. 22 .00 Exp. -x T r i a l s 1 .25 Gr. x Exp. x Tr. 104 .25 Sex x Exp. x Tr. 7 .50 Gr. x Sex x Exp. x Tr. 24 .25 DS-WITHIN 962 .44 *meets the c r i t e r i o n l e v e l set the Flags test df MS F 2 1093.38 19.58 .001* 1 33.00 0.34 .564 2 393.00 4.04 .026 1 193.75 1.99 .167 2 85.38 0.88 .424 1 1.00 0.01 .920 2 367.75 3.78 .032 36 97.19 2 756.13 56.57 .001* 4 30.44 2.28 .069 2 34.38 2.57 .083 4 5.50 0.41 .800 2 0.63 0.05 .954 4 26.06 1.95 .111 2 3.75 0.28 .756 4 6.06 0.45 .769 72 13.37 for the study. Table 22 Analysis of main effects for the Flags test Source S_S df MS F £ GROUPS * Depr. vs. Norm. 2450.26 1 2450.26 25.21 .001* Depr. vs. Schizo. 51.04 1 51.04 ^ 1 n.s. Schizo. vs. Norm. 3208.59 1 3208.59 33.01 .001* S-WITHIN 3498.81 36 97.19 TRIALS: T r . ' l v s . Tr. 2 388.01 1 388.01 29.02 .001* Tr. 2 vs. Tr. 3 368.17 1 368.17 27.54 .001* Tr. 1 vs. Tr. 3 1512.09 1 1512.09 113.10 .001* DS-WITHIN 962.44 72 13.37 *meets the c r i t e r i o n l e v e l set for the study. 118 F i g u r e 6 Space P e r c e p t i o n ( F l a g s ) t e s t - group means a t each t r i a l 119 d i f f e r e n t from that of schizophrenics. Moreover, although depressives did improve steadily between admission and discharge, a similar improvement was demonstrated by both of the comparison groups, suggesting a strong practise e f f e c t for this t e s t . Depressives 1 low scores were due to t h e i r making more errors than normals, as well as completing fewer items on the test: At T r i a l 1, depressives averaged 7 . 4 errors compared to 4 . 3 for normals; at T r i a l 2 , 7 . 8 compared, to 3 . 7 for normals; at T r i a l 3 , 7 . 0 compared to 3 . 4 for normals. Schizophrenics made a large number of errors at each t r i a l : at T r i a l 1, mean errors were 1 6 . 3 ; T r i a l 2 , 1 5 . 2 ; T r i a l 3 , 1 2 . 5 . It was not expected that depressives would be impaired, r e l a t i v e to comparison subjects, on the Word Fluency test. Means and S.D.s for each group at each t r i a l are shown in Table 2 3 . The n u l l hypothesis of homogeneity of variance was not rejected: observed F = 3 . 1 1 , c r i t i c a l F ( 3 , 1 5 ) = 4 . 9 0 , p < . 0 1 ; therefore max ' max 5 ' ' v ' an analysis of variance was conducted. Results of this analysis are summarized i n Table 24 and means at each t r i a l are graphed i n Figure 7. The only s i g n i f i c a n t e f f e c t was that for T r i a l s , F ( 2 , 7 2 ) = 2 2 . 2 5 , p « < . 0 0 1 . Analysis of this e f f e c t (Table 25) showed that a l l groups made s i g n i f i c a n t gains between admission and discharge: T r i a l s 1 - 2 , F ( l , 7 2 ) = 1 6 . 7 8 , p < . 0 0 1 ; T r i a l s 1 - 3 , F ( l , 7 2 ) = 4 3 . 6 6 , p - ^ . 0 0 1 ; the difference between T r i a l s 2 - 3 was not s i g n i f i c a n t . Since depressives were not impaired, r e l a t i v e to other groups, 1 2 0 T a b l e 23 M e a n s c o r e s o n t h e W o r d F l u e n c y t e s t a t e a c h t r i a l T r i a l 1 T r i a l 2 T r i a l 3 x s . d . x s . d . x s . d . D e p r e s s e d 4 2 . 6 3 ( 1 4 . 0 2 ) 4 9 . 1 9 ( 1 3 . 3 4 ) 5 2 . 3 8 ( 1 5 . 6 3 ) S c h i z o . : 3 7 . 8 1 ( 1 0 . 4 5 ) 4 1 . 6 9 ( 1 3 . 5 0 ) 4 3 . 2 5 ( 1 0 . 6 7 ) N o r m a l 3 9 . 6 3 ( 1 0 . 2 4 ) 4 8 . 5 6 ( 9 . 0 2 ) 5 5 . 6 9 ( 1 3 . 6 8 ) 121 Table 24 Analysis of variance for the Word Fluency test Source SS df MS F £ Groups 1610 .50 2 805.25 2. 11 .136 Sex 458 .50 1 458.50 1. 20 .280 Groups x Sex 1411 .75 2 705.88 1. 85 .172 Experimenters 158 .25 1 158.25 0. 42 .524 Groups x Exp. 168 .50 2 84.25 0. 22 .803 Sex x Exp. 243 .00 1 24.3.00 0. 64 .430 Gr. x Sex x Exp. 64 .75 2 32.38 0. 09 .919 S-WITHIN 13732 .63 36 381.46 T r i a l s 2654 .00 2 1327.00 22. 25 .001* Groups x T r i a l s 460 .50 4 115.13 1. 93 .115 Sex x T r i a l s 126 .00 2 63.00 1. 06 .353 Gr. x S e x x Tr. 45 .00 4 11.25 0. 19 .944 Exp. x T r i a l s 27 .75 2 13.88 0. 23 .793 Gr. x Exp. x Tr. 136 .00 4 34.00 0. 57 .685 Sex x Exp. x Tr. 2 .25 2 1.13 0. 02 .981 Gr. x Sex x Exp. x Tr 95 .00 4 23.75 0. 40 .809 DS-WITHIN . 4294 .63 72 59.65 *meets the c r i t e r i o n l e v e l set for the study. Table 25 Analysis of the t r i a l s main e f f e c t for the Word Fluency test Source SS df MS F £ T r i a l 1 vs. T r i a l 2 1001.04 1 1001.04 16.78 .001* T r i a l 2 vs. T r i a l 3 376.04 1 376.04 6.30 .025 T r i a l 1 vs. T r i a l 3 2604.17 1 2604.17 43.66 .001* DS-WITHIN 4294.63 72 59.65 *meets the c r i t e r i o n l e v e l set for the study. — • , // , — T r i a l 1 T r i a l 2 T r i a l 3 Word Fluency -Figure 7 group means at each t r i a l 123 t h e r e s u l t s w e r e a s e x p e c t e d . H y p o t h e s i s 3 p r e d i c t e d t h a t , i n a c c o r d a n c e w i t h L e w i n s o h n ' s b e h a v i o r a l t h e o r y o f d e p r e s s i o n , d e p r e s s i v e s a t a d m i s s i o n w o u l d o b t a i n l o w e r s c o r e s t h a n n o r m a l s a n d s c h i z o p h r e n i c s o n t h e P l e a s a n t E v e n t s S c h e d u l e , a n d w o u l d i n c r e a s e t h e i r s c o r e s b y d i s c h a r g e . M e a n s a n d S . D . s f o r e a c h g r o u p a t e a c h t r i a l a r e shown i n T a b l e 2 6 . I n s p e c t i o n o f t h e d a t a i n d i c a t e d t h a t t h i s was n o t a u s e f u l t e s t f o r s c h i z o p h r e n i c s , who e x h i b i t e d a v e r y l a r g e a m o u n t o f v a r i a n c e ; f o r e x a m p l e , o n e s c h i z o p h r e n i c s u b j e c t ' s s c o r e , was c l o s e t o 5 , 0 0 0 a t e a c h t r i a l , w h e r e a s a n o t h e r s u b j e c t i n t h i s g r o u p s c o r e d 65 o n t h e f i r s t t r i a l a n d u n d e r 200 a t s u b s e q u e n t t r i a l s . I t was d e c i d e d , t h e r e f o r e , t o e x c l u d e s c h i z o p h r e n i c s f r o m t h e a n a l y s i s . T h e n u l l h y p o t h e s i s o f h o m o g e n e i t y o f v a r i a n c e f o r t h e PES d a t a ( e x c l u d i n g s c h i z o -p h r e n i c s ) was n o t r e j e c t e d : o b s e r v e d F = 1 . 0 4 , c r i t i c a l r J max ' F ( 2 , 1 5 ) = 4 . 0 7 , p < . 0 1 ; t h e r e f o r e a n a n a l y s i s o f v a r i a n c e was c o n d u c t e d . R e s u l t s o f t h i s a n a l y s i s a r e s u m m a r i z e d i n T a b l e 27 a n d d i s p l a y e d i n F i g u r e 8 . O n l y t h e G r o u p s x T r i a l s i n t e r a c t i o n e f f e c t was s i g n i f i c a n t , F ( 2 , 4 8 ) = 2 1 . 7 9 , p < . 0 0 1 . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f G r o u p s a t e a c h t r i a l r e v e a l e d s i g n i f i c a n t g r o u p d i f f e r e n c e s a t e a c h t r i a l , p < . 0 0 1 ( T a b l e 2 8 ) : f o r T r i a l 1, F ( l , 7 2 ) = 4 6 . 4 7 ; f o r T r i a l 2 , F ( l , 7 2 ) = 2 4 . 5 6 ; f o r T r i a l 3 , F ( l , 7 2 ) = 2 5 . 5 6 . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f T r i a l s f o r d e p r e s s i v e s a n d n o r m a l s showed t h a t s c o r e s o f b o t h g r o u p s c h a n g e d s i g n i f i c a n t l y a c r o s s t r i a l s : f o r d e p r e s s i v e s , F ( l , 4 8 ) = 2 7 . 3 4 , p < . 0 0 1 ; 124 Table 26 Mean scores on the Pleasant Events Schedule at each t r i a l T r i a l 1 T r i a l 2 T r i a l 3 x s.d. x s.d. x s.d. Depr.: 206.06 (105.78) 497.63 (361.79) 668.19 (367.69) Schizo.: 1156.69 (1385.59) 1067.94 (1424.94) 928.31 (1256.52) Normal: 922.50 (595.46) 680.06 (377.31) 562.31 (295.95) 125 Table 27 Analysis of variance for the Pleasant Events Schedule, excluding data from schizophrenics Source SS df MS F £ Groups 1676928 .00 1 1676928 .00 4 .70 .040 Sex. 468 .00 1 468 .00 .00 .971 Groups x Sex 357216 .00 1 357216 .00 1 .00 .327 Experimenters 25220 .00 1 25220 .00 .07 .793 Groups x Exp. 190816 .00 1- 190816 .00 .54 .472 Sex x Exp. 158760 .00 1 158760 .00 .45 .511 Gr. x Sex x Exp. 160400 .00 1 160400 .00 .45 .509 S-WITHIN 8556880 .00 24 356536 .63 T r i a l s 41580 .00 2 20790 .00 .33 .724 Groups x T r i a l s 2785280 .00 2 1392640 .00 21 .79 .001* Sex x T r i a l s 65796 .00 2 32898 .00 .52 .601 Gr. x Sexx Tr. 129108 .00 2 64554 .00 1 .01 .372 Exp. x T r i a l s 68256 .00 2 34128 .00 .53 .590 Gr. x Exp. x Tr. 117068 .00 2 58534 .00 .92 .407 Sex x Exp. x Tr. 11236 .00 2 5618 .00 .09 .916 Gr. x Sex x Exp. x Tr. 17536 .00 2 8768 .00 .14 .872 DS-WITHIN 3068192 .00 48 63920 .66 *meets the c r i t e r i o n l e v e l set for the study. Table 28 Analysis of simple main effects for the Pleasant Events Schedule, excluding data from schizophrenics Source SS df MS GROUPS: at T r i a l 1 at T r i a l 2 at T r i a l 3 W-CELL 7502670.30 1 3964794.80 1 4127356.80 1 11625072.00 72 7502670.30 3964794.80 4127356.80 161459.33 46.47 24.56 25.56 ,001* ,001* ,001* TRIALS: Depressed Normal DS-WITHIN 1747519.00 1 1079339.00 1 3068192.00 48 1747519.00 1079339.. 00 63920.66 27.34 16.89 ,001* 001* *meets the c r i t e r i o n l e v e l set for the study. Figure 8 Pleasant Events Schedule - group means at each t r i a 127 f o r n o r m a l s , F ( l , 4 8 ) = 1 6 . 8 9 , p * - . 0 0 1 ( T a b l e 2 8 ) . C o m p a r i s o n o f n o r m a l s a n d d e p r e s s i v e s a t T r i a l 1 s h o w e d t h a t d e p r e s -s i v e s s c o r e d s i g n i f i c a n t l y l o w e r t h a n n o r m a l s ( T a b l e 2 9 ) . C o m p a r i s o n s a c r o s s t r i a l s ( T a b l e 30) s h o w e d t h a t d e p r e s s i v e s ' s c o r e s i n c r e a s e d s i g n i f i c a n t l y b e t w e e n e a c h p a i r o f t r i a l s , w h i l e n o r m a l s ' s c o r e s d r o p p e d b e t w e e n T r i a l s 1-2 a n d 1 - 3 , w i t h t h e d i f f e r e n c e b e t w e e n T r i a l s 2 - 3 n o t s i g n i f i c a n t . T h e s e r e s u l t s c o u l d b e i n t e r p r e t e d a s p r o v i d i n g p a r t i a l c o n f i r m a t i o n o f H y p o t h e s i s 3 , f o r d e p r e s s i v e s a t a d m i s s i o n d i d o b t a i n l o w e r s c o r e s o n t h e PES t h a n n o r m a l s , a n d d e p r e s -s i v e s w e r e t h e o n l y g r o u p w h o s e s c o r e s i n c r e a s e d s i g n i f i c a n t l y b y d i s c h a r g e . H o w e v e r , s i n c e t h e s c o r e s o f n o r m a l s d r o p p e d s i g n i f i c a n t l y a c r o s s t r i a l s , t h e s e r e s u l t s m u s t b e i n t e r -p r e t e d c a u t i o u s l y . A n a l t e r n a t i v e i n t e r p r e t a t i o n i s t h a t c h a n g e s i n t h e s c o r e s o f d e p r e s s i v e s a n d n o r m a l s r e p r e s e n t r e g r e s s i o n t o w a r d t h e m e a n . T h e i m p l i c a t i o n s o f t h i s a r e e l a b o r a t e d i n t h e D i s c u s s i o n s e c t i o n . H y p o t h e s i s 4 p r e d i c t e d t h a t a t a d m i s s i o n d e p r e s -s i v e s w o u l d o b t a i n h i g h e r s c o r e s t h a n c o m p a r i s o n g r o u p s o n t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e a n d b y d i s c h a r g e d e p r e s s i v e s w o u l d show a s i g n i f i c a n t d r o p i n CDQ s c o r e s . M e a n s a n d S . D . s f o r e a c h g r o u p a t e a c h t r i a l a r e shown i n T a b l e 3 1 , a n d m e a n s a r e g r a p h e d i n F i g u r e 9 . When t h e n u l l h y p o t h e s i s o f h o m o g e n e i t y o f v a r i a n c e was t e s t e d o n t h e CDQ d a t a , t h e h y p o t h e s i s was r e j e c t e d : o b s e r v e d F = ' J r u max 4 7 5 . 1 6 , c r i t i c a l 'F ( 3 , 1 5 ) = 4 . 9 0 , p ^ . 0 1 . A c c o r d i n g t o t h e a n a l y s i s o f v a r i a n c e f o r t h e CDQ d a t a ( T a b l e 3 2 ) , T a b l e 29 C o m p a r i s o n o f mean s c o r e s f o r n o r m a l s a n d d e p r e s s i v e s o n t h e P l e a s a n t E v e n t s S c h e d u l e a t t r i a l 1 C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e D e p r . v s . N o r m a l 7 1 6 . 4 4 * 4 0 6 . 3 9 * p « * . 0 1 T a b l e 30 C o m p a r i s o n o f m e a n s c o r e s f o r n o r m a l s a n d d e p r e s s i v e s a c r o s s t r i a l s o n t h e P l e a s a n t E v e n t s S c h e d u l e C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e D e p r . : T 1 - T 2 2 9 1 . 5 7 * 1 4 8 . 8 8 T 2 - T 3 1 7 0 . 5 6 * 1 4 8 . 8 8 T 1 - T 3 4 6 2 . 1 3 * 1 6 9 . 5 2 N o r m a l : T 1 - T 2 2 4 2 . 4 4 * 1 4 8 . 8 8 T 2 - T 3 1 1 7 . 7 5 1 4 8 . 8 8 T 1 - T 3 3 6 0 . 1 9 * 1 6 9 . 5 2 * p « < . 0 1 129 Table 31 Mean scores for the Cognitive D i s t o r t i o n Questionnaire at each t r i a l T r i a l 1 T r i a l 2 T r i a l 3 X s .d. X s .d. X s.d. Depressed: 1 8 . 0 0 (6 . 7 4 ) 1 1 . 1 9 (8 . 2 0 ) 4 . 1 3 ( 3 . 5 9 ) Schizo.: 6 . 5 6 (5 . 6 6 ) 5 . 8 8 (6 . 5 6 ) 3 . 5 6 ( 1 . 6 9 ) Normal: 0 . 5 6 (0 . 7 3 ) 0 . 6 9 (0 . 7 9 ) 0 . 3 1 ( 0 . 4 8 ) 130 Figure 9 Cognitive D i s t o r t i o n Questionnaire - group means at each t r i a l Table 32 Analysis of variance for the Cognitive D i s t o r t i o n Questionnaire Source SS df MS F £ Groups 2684 .63 2 1342.31 26 .22 .001* Sex. 79 .51 1 79.51 1 .55 .221 Groups x Sex 155 .10 2 77.55 1 .52 .234 Experimenters 4 .34 1 4.34 .09 .773 Groups x Exp. 287 .93 2 143.97 2 .81 .073 Sex x Exp. 2 .01 1 .2.01 .04 .844 Gr. x Sex x Exp. 209 .18 2 104.59 2 .04 .144 S-WTTHIN 1842 .89 36 51.19 T r i a l s 786 .54 2 393.27 43 .94 .001* Groups x T r i a l s 833 .83 4 208.46 23 .29 .001* Sex x T r i a l s 1 .27 2 0.63 .07 .932 Gr. x Sex x Tr. 53 .44 4 13.36 1 .49 .213 Exp. x T r i a l s 25 .02 2 12.51 1 .40 .254 Gr. x Exp. x Tr. 23 .53 4 5.88 .66 .624 Sex x Exp. x Tr. 21 .51 2 10.76 1 .20 .307 Gr. x Sex x Exp. x Tr . 17 .86 4 4.47 .50 .737 DS-WITHIN 644 .36 72 8.95 *meets the c r i t e r i o n l e v e l set for the study. Table 33 Analysis of simple main effects for the Cognitive D i s t o r t i o n Questionnaire Source GROUPS: at T r i a l 1 at T r i a l 2 at T r i a l 3 W-CELL TRIALS: Depressed Schizo. Normal DS-WITHIN *meets the c r i t e r i o n l e v e l set for the study. SS df MS 2511.38 882.05 135.55 2487.25 2 2 2 108 1255.69 441.03 67.77 23.03 54.52 19.15 2.94 .001* .001* n. s. 1540.29 79.05 1.17 644.36 2 2 2 72 770.15 39.53 0.59 8.95 86.05 4.42 1 .001* .025 n. s. 132 b o t h t h e m a i n e f f e c t f o r G r o u p s a n d t h e m a i n e f f e c t f o r T r i a l s w e r e s i g n i f i c a n t , a s was t h e G r o u p s x T r i a l s i n t e r s a c t i o n : f o r G r o u p s , F ( 2 , 3 6 ) = 2 6 . 2 2 , p - * . 0 0 1 ; f o r T r i a l s , F ( 2 , 7 2 ) = 4 3 . 9 4 , p " * . 0 0 1 ; f o r G r o u p s x T r i a l s , F ( 4 , 7 2 ) = 2 3 . 2 9 , p ^ . 0 0 1 . B e c a u s e t h e h y p o t h e s i s o f h o m o g e n e i t y o f . v a r i a n c e was r e j e c t e d , t h e G e i s s e r - G r e e n h o u s e C o n s e r v a t i v e F p r o c e d u r e was u s e d t o t e s t t h e G r o u p s x T r i a l s i n t e r a c t i o n e f f e c t . T h e n u l l h y p o t h e s i s o f n o i n t e r a c t i o n was r e j e c t e d : o b t a i n e d F ( 4 , 7 2 ) = 2 3 . 2 9 , c r i t i c a l F ( 2 , 3 6 ) = 5 . 2 6 , p < . 0 1 . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f G r o u p s a t e a c h t r i a l ( T a b l e 33) s h o w e d t h a t g r o u p s d i f f e r e d s i g n i f i c a n t l y a t T r i a l s 1 a n d 2 b u t n o t a t T r i a l 3 : f o r T r i a l 1, F ( 2 , 1 0 8 ) = 5 4 . 5 2 , p - C . 0 0 1 ; f o r T r i a l 2 , F ( 2 , 1 0 8 ) = 1 9 . 1 5 , p * . 0 0 1 . A n a l y s i s o f s i m p l e m a i n e f f e c t s o f T r i a l s f o r e a c h g r o u p ( T a b l e 33) s h o w e d t h a t s c o r e s o f t h e d e p r e s s e d g r o u p c h a n g e d s i g n i f i c a n t l y a c r o s s t r i a l s , F ( 2 , 7 2 ) = 8 6 . 0 5 , p < . 0 0 1 ; c h a n g e s i n s c h i z o p h r e n i c s ' s c o r e s f a i l e d t o r e a c h s i g n i f i c a n c e a t t h e . 0 1 l e v e l ; n o r m a l s d i d n o t c h a n g e a c r o s s t r i a l s . P o s t h o c c o m p a r i s o n s o f g r o u p m e a n s a t T r i a l 1 s h o w e d t h a t d e p r e s s i v e s s c o r e d h i g h e r t h a n b o t h n o r m a l s a n d s c h i z o -p h r e n i c s ; s c h i z o p h r e n i c s a l s o s c o r e d h i g h e r t h a n n o r m a l s ( T a b l e 3 4 ) . C o m p a r i s o n s a c r o s s t r i a l s ( T a b l e 35) s h o w e d t h a t d e p r e s s i v e s o b t a i n e d p r o g r e s s i v e l y l o w e r s c o r e s o n t h e CDQ a t e a c h s u c c e s s i v e t r i a l . T h e s e r e s u l t s s u p p o r t H y p o t h e s i s 4 , s i n c e o n a d m i s s i o n d e p r e s s i v e s d i d d e m o n s t r a t e a s i g n i f i c a n t l y g r e a t e r d e g r e e o f c o g n i t i v e d i s t o r t i o n t h a n r b o t h s c h i z o p h r e n i c s a n d n o r m a l s 133 T a b l e . 3 4 C o m p a r i s o n s o f m e a n t r i a l 1 s c o r e s o n t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e D e p r . v s . N o r m . 1 7 . 4 4 * 4 . 5 4 D e p r . v s . S c h i z o . 1 1 . 4 4 * 3 . 9 8 S c h i z o . v s . N o r m . 6 . 0 0 * 3 . 9 8 * p * * . 0 1 T a b l e 35 C o m p a r i s o n s a c r o s s t r i a l s o f m e a n s c o r e s of. d e p r e s s i v e s o n t h e C o g n i t i v e D i s t o r t i o n Q u e s t i o n n a i r e C o m p a r i s o n M e a n d i f f . C r i t i c a l N - K V a l u e T 1 - T 2 6 . 8 1 * 1 . 6 1 T 2 - T 3 7 . 0 6 * 1 . 6 1 T 1 - T 3 1 3 . 8 7 * 1 . 8 4 * p < £ . 0 1 134 (although schizophrenics' scores were also elevated), and by discharge depressives' scores had dropped s i g n i f i c a n t l y while those of other subjects had not. It was hypothesized that improvement i n right hemi-sphere functioning would be accompanied by an improvement ( i . e . a drop) i n distorted cognitions and also by an improve-ment i n reinforcement rate. Therefore Hypotheses 5 to 8 i n c l u s i v e predicted s i g n i f i c a n t p o s i t i v e correlations between improvement scores for: a) Dichotic Chords and CDQ (Hypothesis 5 ) ; b) Dichotic Chords and PES (Hypothesis 6 ) ; c) Flags and CDQ (Hypothesis 7 ) ; d) Flags and PES (Hypothesis 8 ) . Table 36 summarizes the p a r t i a l correlations obtained between the relevant improvement scores. It can be seen that none of Hypotheses 5 to 8 was supported by these r e s u l t s : When i n i t i a l scores were controlled for, an increase i n l e f t ear superiority on the Dichotic Chords test between admission and discharge was not s i g n i f i c a n t l y related to either a drop i n distorted cognitions or to an increase i n response-contingent positive reinforcement; nor was an increase i n Flags test scores s i g n i f i c a n t l y related to either a decrease i n cognitive d i s t o r t i o n or to an increase i n reinforcement rate. Moreover, there was no s i g n i f i c a n t c o r r e l a t i o n between changes i n PES scores and changes i n CDQ scores. For comparison, zero order p a r t i a l correlations are also presented (Table 3 7 ) . It can be seen that, even when i n i t i a l scores were not controlled for, the only c o r r e l a t i o n to reach significance 135 Table 36 P a r t i a l correlations among improvement scores for the Dichotic Chords test, the Flags test, the Cognitive D i s t o r t i o n Questionnaire and the Pleasant Events Schedule DICH. CHORDS: FLAGS C.D.Q, Depr. Schizo. Normal Depr. Schizo. Normal Depr. Schizo. Normal C.D.Q. .1822 (p-.267) .1422 (p-.314) .1005 (p=.366) .0830 (p=.389) .2521 (p=.192) .1805 (p=.268) P.E.S. .1431 (p-.313) .2815 (p=.165) .3618 (p=.102) .0557 (p=.425) .4701 (p=.045) .0266 (p-.464) .4024 (p=.077) .1034 (p=.362) .4217 (p=.067) Table 37 Zero order correlations among improvements scores for the Dichotic Chords test,.the Flags test, the Cognitive D i s t o r t i o n Questionnaire and the Pleasant Events Schedule C, .D.Q • P, .E.S • DICH. CHORDS: Depr. Schizo. Normal .4503 .1562 .3088 <P= (P= (P= .04) .282) .122) .0042 .2084 .2573 (P= (P= (P= .494) .219) .168) FLAGS: Depr. Schizo. Normal .0806 .1704 .2665 <P= (P-(P= .383) .264) .159) .0522 .5515 .0415 (P= (P= (P= .424) .013) .439) C.D.Q. Depr. Schizo. Normal .4806 .0352 .6844 (P= (P= (P= .030) .449) .002) 136 b e y o n d t h e . 0 1 l e v e l was t h a t b e t w e e n a d r o p i n CDQ s c o r e s a n d a d r o p i n PES s c o r e s f o r n o r m a l s . I n o r d e r t o e x a m i n e t h e r e l a t i o n s h i p b e t w e e n s e l f -r e p o r t e d d e p r e s s i o n a n d n e u r o p s y c h o l o g i c a l c h a n g e s , p a r t i a l c o r r e l a t i o n s b e t w e e n i m p r o v e m e n t s c o r e s f o r t h e B D I a n d i m p r o v e m e n t s c o r e s f o r t h e two d i c h o t i c t e s t s w e r e o b t a i n e d . A s T a b l e 38 s h o w s , n e i t h e r o f t h e s e was s i g n i f i c a n t . T h e c o r r e l a t i o n b e t w e e n i m p r o v e m e n t s c o r e s f o r t h e B D I a n d t h e F l a g s t e s t i s a l s o s h o w n . L i k e t h e B D I , t h e CDQ a n d P E S c o u l d b e r e g a r d e d a s s e l f - r e p o r t m e a s u r e s o f d e p r e s s i o n . T o s e e w h e t h e r i m p r o v e -m e n t i n B D I s c o r e s r e l a t e d t o i m p r o v e m e n t s c o r e s f o r t h e CDQ o r P E S , p a r t i a l c o r r e l a t i o n s among t h e s e i m p r o v e m e n t s c o r e s w e r e o b t a i n e d . W h i l e t h e s e r e l a t i o n s h i p s w e r e f a i r l y h i g h , t h e y f a i l e d t o r e a c h t h e . 0 1 c r i t e r i o n l e v e l r e q u i r e d f o r t h e s t u d y ( s e e T a b l e 3 9 ) . When m e d i c a t i o n s c o r e s w e r e c o r r e l a t e d w i t h i m p r o v e -m e n t s c o r e s o n d e p e n d e n t v a r i a b l e s ( c o n t r o l l i n g f o r i n i t i a l s c o r e s o n t h e s e v a r i a b l e s ) , n o n e o f t h e p a r t i a l c o r r e -l a t i o n s r e a c h e d s i g n i f i c a n c e , i n d i c a t i n g t h a t m e d i c a t i o n was n o t s i g n i f i c a n t l y r e l a t e d t o i m p r o v e m e n t i n a n y d e p e n d e n v a r i a b l e f o r e i t h e r p a t i e n t g r o u p . 137 Table 38 P a r t i a l correlations between improvement scores for the Beck Depression Inventory, and improvement scores for the dichotic tests and the Flags test DICHOTIC CHORDS DICHOTIC WORD TRIADS FLAGS B.D.I. -.1347 .0956 .0351 (P=.323) (p=.372) (p=.453) Table 39 P a r t i a l correlations between improvement scores for the Beck Depression Inventory ? and improvement scores for the Cognitive D i s t o r t i o n Questionnaire and the Pleasant Events Schedule C.D.Q. P.E.S. B.D.I. .5870 (p=.014) -.4493 (p=.054) 138 D i s c u s s i o n T u c k e r h a s h y p o t h e s i z e d t h a t , d u r i n g d e p r e s s i o n , r i g h t h e m i s p h e r e f u n c t i o n s a r e s u p p r e s s e d b y a n o v e r a c t i v e l e f t h e m i s p h e r e . R e s u l t s o f t h e c o g n i t i v e t e s t s u s e d i n t h i s s t u d y w o u l d a p p e a r t o s u p p o r t t h i s h y p o t h e s i s , f o r s e v e r e l y d e p r e s s e d p a t i e n t s p e r f o r m e d w e l l o n a l e f t h e m i -s p h e r e c o g n i t i v e t e s t ( W o r d F l u e n c y ) b u t w e r e i m p a i r e d o n a r i g h t h e m i s p h e r e c o g n i t i v e t e s t ( F l a g s ) . ^ H o w e v e r , t h e r e s u l t s o f t h e d i c h o t i c t e s t s i n d i c a t e t h a t T u c k e r ' s h y p o t h e s i s i s i n a d e q u a t e , f o r t h e s e r e s u l t s showed t h a t b o t h h e m i s p h e r e s w e r e a f f e c t e d d u r i n g d e p r e s s i o n , n e i t h e r d e m o n s t r a t i n g i t s n o r m a l s u p e r i o r i t y f o r p r o c e s s i n g i n t h e mode f o r w h i c h i t i s s p e c i a l i z e d . M o r e o v e r , w i t h r e c o v e r y f r o m d e p r e s s i o n , n o r m a l e a r p r e f e r e n c e s e m e r g e d , s u g g e s t i n g a r e t u r n t o n o r m a l a s y m m e t r i c a l p r o c e s s i n g s u p e r i o r i t i e s f o r b o t h h e m i s p h e r e s . T h i s i s c o n s i s t e n t w i t h two s t u d i e s d o n e c o n t e m p o r a n e o u s l y w i t h t h e p r e s e n t s t u d y : S t r a u s s e t a l ( N o t e 13) f o u n d t h a t , p r i o r t o t r e a t m e n t , h o s p i t a l -i z e d d e p r e s s i v e s f a i l e d t o show t h e e x p e c t e d e a r a s y m m e t r y f o r d i c h o t i c s p e e c h s y l l a b l e s ( i . e . r i g h t e a r - l e f t h e m i -s p h e r e s u p e r i o r i t y ) , b u t r e g a i n e d n o r m a l a s y m m e t r y u p o n r e c o v e r y f r o m d e p r e s s i o n f o l l o w i n g E C T . S i m i l a r l y , W e x l e r S i n c e s c h i z o p h r e n i c s w e r e a c o m p a r i s o n g r o u p i n t h e p r e s e n t s t u d y , t h e i r r e s u l t s a r e n o t e l a b o r a t e d h e r e . R e s u l t s r e l a t e d t o h e m i s p h e r i c f u n c t i o n i n g i n s c h i z o -p h r e n i c s a r e d i s c u s s e d i n A p p e n d i x H . 139 and Heninger ( 1 9 8 0 ) found that ear asymmetry on a dichotic words test increased as depressed patients recovered; they interpreted this as i n d i c a t i n g that i n acute psychiatric i l l n e s s there i s a breakdown i n the interhemispheric i n h i b i t i o n that normally mediates cerebral l a t e r a l i t y . Since neither of these studies also employed a dichotic task for which the right hemisphere i s normally superior, they were unable to observe the return to l e f t ear-right hemisphere superiority i n a right hemisphere task, as i n the present study. It i s tempting to speculate that the changes i n depressed subjects' performance on the dichotic tests were due to improved motivation or to learning which took place with repeated administrations of the same dichotic tests. However, such explanations appear u n l i k e l y , for i n the dichotic words test improvement occurred only i n right ear scores, while i n the dichotic chords test there was improvement only i n l e f t ear scores.' The dichotic findings lend support to Tucker's claim that altered brain functioning during depression i s a reversible phenomenon; however, the continued poor performance of depressives on the Flags test, even after recovery from depression, indicates that right hemisphere cognitive d e f i c i t s , which have also been reported i n previous studies of depressives (Flor-Henry, 1 9 7 6 ; Gordon, Note 6 ; Kronfol et a l , 1978) may be chronic. These results suggest that two d i f f e r e n t processes, one acute and one 140 c h r o n i c , may b e o p e r a t i n g d u r i n g d e p r e s s i o n . A n a c u t e i n t e r h e m i s p h e r i c p r o c e s s a p p a r e n t l y a f f e c t s b o t h h e m i -s p h e r e s , p r o d u c i n g a b r e a k d o w n i n * n o r m a l a s y m m e t r i e s f o r p r o c e s s i n g m o d e . W i t h t r e a t m e n t , t h i s a c u t e p r o c e s s a b a t e s , a n d n o r m a l a s y m m e t r i e s o n c e a g a i n e m e r g e . A s e c o n d p r o c e s s a p p a r e n t l y i n v o l v e s c h r o n i c ( i n t r a h e m i s p h e r i c ? ) i n h i b i t i o n o f c e r t a i n r i g h t h e m i s p h e r e c o g n i t i v e f u n c t i o n s . T h i s c o u l d r e p r e s e n t a n i n d e x o f p s y c h i a t r i c v u l n e r a b i l i t y w i t h i n d e p r e s s i o n - p r o n e i n d i v i d u a l s . H o w e v e r , s i n c e d e p r e s s i v e s h a d l e s s e d u c a t i o n t h a n n o r m a l s i n t h e s t u d y , r e s u l t s o f t h e F l a g s t e s t m u s t b e i n t e r p r e t e d w i t h c a u t i o n . S i n c e n o s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n e d u c a -t i o n l e v e l a n d s c o r e s o n a n y o f t h e d e p e n d e n t v a r i a b l e s , i n c l u d i n g t h e F l a g s t e s t , i t seems u n l i k e l y t h a t d i f f e r -e n c e s i n e d u c a t i o n w e r e r e s p o n s i b l e f o r t h e r e s u l t s r e p o r t e d h e r e . N o n e t h e l e s s , a t t h e p r e s e n t t i m e t h e s e r e s u l t s c a n be r e g a r d e d o n l y a s t e n t a t i v e . t. T h e p a t t e r n o f c o g n i t i v e a b i l i t i e s d i s p l a y e d b y d e p r e s s i v e s i n t h e s t u d y , i . e . g o o d v e r b a l a b i l i t y a n d p o o r s p a t i a l a b i l i t y , i s t h e same a s t h a t shown b y d e p r e s s e d s t u d e n t s who o b t a i n e d g o o d a r i t h m e t i c ( l e f t h e m i s p h e r e ) s c o r e s a n d p o o r i m a g e r y ( r i g h t h e m i s p h e r e ) s c o r e s i n t h e T u c k e r e t a l ( N o t e 5) s t u d y . L e v y ( 1 9 6 9 ) h a s p r o p o s e d t h a t s u c h a p a t t e r n o f c o g n i t i v e a b i l i t i e s c o u l d b e d u e t o i n t r a h e m i s p h e r i c i n h i b i t i o n b e c a u s e o f " c o g n i t i v e c r o w d i n g " . She h a s a r g u e d t h a t g r e a t e r h e m i s p h e r i c s p e c i a l i z a t i o n f o r c o g n i t i v e a b i l i t i e s ( i . e . l a n g u a g e 141 i n l e f t h e m i s p h e r e , s p a t i a l a b i l i t y i n r i g h t h e m i s p h e r e ) f a c i l i t a t e s s p a t i a l c o m p e t e n c e . F i n d i n g t h a t n o r m a l l e f t -h a n d e r s ( i n whom l a n g u a g e f u n c t i o n s a r e m o r e f r e q u e n t l y b i l a t e r a l l y r e p r e s e n t e d ) h a d s u p e r i o r v e r b a l a b i l i t y a n d i m p a i r e d s p a t i a l a b i l i t y , L e v y ( 1 9 6 9 ) p r o p o s e d t h a t v e r b a l f u n c t i o n s i n s u c h i n d i v i d u a l s i m p i n g e o n r i g h t h e m i s p h e r e a r e a s n o r m a l l y r e s e r v e d f o r s p a t i a l f u n c t i o n s i n m o r e c l e a r l y l a t e r a l i z e d p e r s o n s . T h e r e i s some e v i d e n c e s u g g e s t i n g t h a t d e p r e s s i v e s may a l s o h a v e l a n g u a g e b i l a t e r a l l y m e d i a t e d : Hommes a n d P a n h u y s e n ( 1 9 7 1 ) r e p o r t e d t h a t h o s p i t a l i z e d d e p r e s s i v e s ( t e n r i g h t h a n d e r s a n d o n e l e f t h a n d e r ) w i t h n o n e u r o l o g i c a l i m p a i r m e n t s s h o w e d b i l a t e r a l r e p r e s e n t a t i o n o f l a n g u a g e f u n c t i o n a s d e t e r m i n e d b y t h e Wada s o d i u m a m y t a l t e c h n i q u e a p p l i e d o n s e p a r a t e o c c a s i o n s t o e a c h h e m i s p h e r e ; m o r e o v e r , d e p t h o f d e p r e s s i o n was s i g n i f i c a n t l y c o r r e l a t e d w i t h l a c k o f c e r e b r a l d o m i n a n c e f o r l a n g u a g e . T h e s t u d y a l s o f o u n d a l a c k o f a s y m m e t r y f o r e m o t i o n a l p r o c e s s e s : b o t h r i g h t a n d l e f t h e m i s p h e r e a m y t a l i n j e c t i o n s i n d u c e d e u p h o r i c r e s p o n s e s i n t h e s e d e p r e s s e d p a t i e n t s . T h e n o t i o n o f b i l a t e r a l l a n g u a g e c o m p e t e n c e i n r i g h t - h a n d e d p e r s o n s i s n o t n e c e s s a r i l y a t v a r i a n c e w i t h c o n s i s t e n t r e p o r t s i n t h e l i t e r a t u r e t h a t a l m o s t a l l r i g h t h a n d e r s a r e l e f t h e m i s p h e r e d o m i n a n t f o r s p e e c h p r o d u c t i o n . J u s t a s c e r t a i n r e s e a r c h e r s h a v e a r g u e d t h a t h a n d e d n e s s i s d i s t r i b u t e d a l o n g a c o n t i n u u m r a t h e r t h a n d i c h o t o m o u s l y ( A n n e t t , 1 9 7 0 ) , o t h e r s h a v e p r o p o s e d t h a t t h e r e a r e d e g r e e s o f h e m i s p h e r i c d o m i n a n c e f o r v a r i o u s f u n c t i o n s ( M a r s h a l l 142 et a l , 1 9 7 5 ; Shankweiler, Note 17; Zangwill, 1 9 6 7 ) . It i s recognized that the right hemisphere of normal right handers does have language c a p a b i l i t y (Moscovitch, 1 9 7 6 ; Searleman, 1 9 7 7 ; Zangwill, 1 9 6 7 ) , although under normal conditions this i s generally far less than that of the l e f t hemisphere. However, as Searleman ( 1 9 7 7 ) has observed, there i s a need to d i s t i n g u i s h between language production and language comprehension: While language production i s t y p i c a l l y controlled by the l e f t hemisphere, the high degree of l e f t ear accuracy by normal right handers i n dichotic l i s t e n i n g to speech stimuli suggests that language compre-hension may be b i l a t e r a l i n normal right handers (Searleman, 1 9 7 7 ) . Sodium amytal studies and findings with s p l i t -brain patients also suggest that language comprehension may be b i l a t e r a l : Right-handed subjects have shown indications of language comprehension even when they are incapable of speech during anesthetization of the l e f t hemisphere with sodium amytal (Branch, Milner and Rasmussen, 1 9 6 4 ; Terzian, 1 9 6 4 ; Wada and Rasmussen, 1 9 6 0 ) , and s p l i t -brain subjects have indicated (by s i g n a l l i n g with their l e f t hand) that they comprehend words projected to the separated right hemisphere (Gordon, Note 1 8 ) . Moreover, under certain circumstances, the right hemisphere can apparently assume a more v i t a l role- i n language processing: for example, patients with l e f t hemisphere lesions commonly obtain low right ear scores and elevated l e f t ear (right hemisphere) scores i n dichotic language tasks (Cullen, B e r l i n and Hughes, 1 9 7 4 ) . This has been interpreted as 143 i n d i c a t i n g t h a t r i g h t h e m i s p h e r e l a n g u a g e c a p a b i l i t y i s n o r m a l l y s u p p r e s s e d b y a d o m i n a n t l e f t h e m i s p h e r e ; when s u c h d o m i n a n c e i s n o l o n g e r p o s s i b l e ( d u e , i n t h e s e c a s e s , t o i n j u r y t o t h e l e f t h e m i s p h e r e ) , t h e r i g h t h e m i s p h e r e i s a b l e t o a s s u m e a g r e a t e r r o l e i n l a n g u a g e p r o c e s s i n g ( P e t t i t a n d N o l l , N o t e 1 2 ) . K i n s b o u r n e ( 1 9 7 1 ) c o n c l u d e d t h a t r i g h t h e m i s p h e r e l a n g u a g e p r o d u c t i o n i s a l s o s o m e -t i m e s s u p p r e s s e d b y t h e l e f t h e m i s p h e r e : f i n d i n g t h a t i n r i g h t - h a n d e d s t r o k e p a t i e n t s w i t h a p h a s i a , a m y t a l s e d a t i o n o f t h e l e f t h e m i s p h e r e a few d a y s a f t e r t h e s t r o k e h a d n o e f f e c t o n s p e e c h w h i l e s e d a t i o n o f t h e r i g h t h e m i -s p h e r e a b o l i s h e d s p e e c h , h e c o n c l u d e d t h a t t h e a p h a s i c s p e e c h o r i g i n a t e d i n t h e r i g h t h e m i s p h e r e a n d r e p r e s e n t e d r i g h t h e m i s p h e r e l a n g u a g e a b i l i t y w h i c h h a d b e e n r e l e a s e d when t h e l e f t h e m i s p h e r e was d a m a g e d b y s t r o k e . I t i s p o s s i b l e t h a t t h e r i g h t h e m i s p h e r e may a l s o a s s u m e a m o r e v i t a l r o l e i n l a n g u a g e p r o c e s s i n g d u r i n g d e p r e s s i o n : I f d e p r e s s i o n - p r o n e p e r s o n s a r e c h a r a c t e r i z e d b y a g r e a t e r t e n d e n c y t o w a r d b i l a t e r a l l a n g u a g e p r o c e s s i n g , t h i s t e n d e n c y may b e e x a g g e r a t e d b y s t r e s s , when p e r s e v -e r a t i v e r u m i n a t i o n b e g i n s t o d o m i n a t e t h e i n d i v i d u a l ' s m e n t a l c o n t e n t . A s l a n g u a g e b e c o m e s i n c r e a s i n g l y b i l a t e r -a l l y m e d i a t e d , t h e r i g h t h e m i s p h e r e may b e c o m e m o r e l i k e a l e f t h e m i s p h e r e , i . e . m o r e s p e c i a l i z e d f o r p r o c e s s i n g m a t e r i a l o f a s e q u e n t i a l , a n a l y t i c , t i m e - d e p e n d e n t n a t u r e . T h e l a r g e n u m b e r o f d e p r e s s e d s u b j e c t s i n t h e p r e s e n t s t u d y ( e l e v e n o u t o f s i x t e e n ) who i n i t i a l l y s h o w e d a l e f t 144 ear (right hemisphere) superiority for processing dichotic word triads would support this interpretation. (By contrast, a majority of depressed subjects did not show a right ear superiority for processing dichotic chords). Having found that depressives showed b i l a t e r a l language representation and no u n i l a t e r a l s p e c i a l i z a t i o n for a f f e c t following amytal i n j e c t i o n , Hommes and Panhuysen ( 1 9 7 1 ) posed the question whether depression reduces cerebral dominance patterns, or an a t y p i c a l pattern of cerebral dominance predisposes to depression. Results of the present study indicate that "cerebral dominance" should be defined more s p e c i f i c a l l y . These results could suggest that an a t y p i c a l pattern of cerebral dominance for cogni-tive functions predisposes to a breakdown i n cerebral dominance patterns for processing mode and to depressed mood. A l t e r n a t i v e l y , the onset of depressed mood may upset the delicate balance between the hemispheres, causing a breakdown i n normal dominances for processing mode. It i s not possible, from these r e s u l t s , to choose between these alternatives; more research i s needed to elucidate the sequence of events i n depression. On the Pleasant Events Schedule, the schizophrenic group exhibited a very large amount of variance. Thus i t appears that the PES i s not a useful means of assessing reinforcement rate i n schizophrenics. When this group was excluded from the analysis, i t became apparent that depres-sives at admission to hospital were receiving s i g n i f i c a n t l y 145 less response-contingent positive reinforcement (as measured by the PES) than were normals. This would be consistent with Lewinsohn's behavioral theory of depres-sion, as would the fact that only depressives increased t h e i r PES scores between admission and discharge, sug-gesting that recovery from depression was accompanied by an increase i n reinforcement rate. However, the drop i n normals' PES scores across t r i a l s presents a problem i n interpreting these r e s u l t s . It i s possible that normals habituated to the test with repeated administration; this would be consistent with the experience of both experi-menters that normals were the only group i n which subjects complained of boredom when completing the PES at T r i a l s 2 and 3. However, since the results for normals and depres-sives could a l t e r n a t i v e l y represent regression toward the mean, i t i s not possible to draw conclusions from this study concerning the relat i o n s h i p between reinforcement rate and depression. It may be that the PES i s a schedule that should not be administered repeatedly to the same subjects. On the Cognitive D i s t o r t i o n Questionnaire, depressed patients scored higher than both control groups at admission. This i s consistent with Beck's cognitive theory. With treatment, depressives decreased their CDQ scores, and at discharge they no longer displayed an abnormal degree of cognitive d i s t o r t i o n . This could suggest that a nega-tive cognitive set i s not, as Beck argues, a chronic feature 146 of depression-prone persons. However, since the CDQ is a new instrument, i t i s possible that i t i s not a v a l i d measure of the s p e c i f i c cognitive d i s t o r t i o n s described by Beck. It could instead be another means of measuring depression, similar to the Beck Depression Inventory. More research i s needed to assess the CDQ's v a l i d i t y for measuring the nature and magnitude of cogni-tive d i s t o r t i o n within Beck's typology. Contrary to expectations, no systematic relationship was found between improvement i n hemispheric functioning i n depressives and either an increase i n their obtained posi t i v e reinforcement (as measured by the PES) or a decrease i n their distorted thinking (as measured by the CDQ). This could suggest that neuropsychological changes are not related to the cognitive and behavioral changes which occur i n a depressive episode, possibly because depression i s multiply-determined. It i s also possible that a l l three kinds of changes merely describe depression rather than causing i t . A l t e r n a t i v e l y , the scores for in d i v i d u a l subjects may have changed at d i f -ferent rates i n each variable and thus no systematic rela t i o n s h i p between sets of changes could be observed. This could also explain why no s i g n i f i c a n t c o r r e l a t i o n was found between BDI improvement scores and dichotic test improvement scores. Since the l a t t e r probably r e f l e c t e d physiological changes occurring with recovery from depres-sion, their lack of relationship with self-report measures of depression i s consistent with many previous studies which have shown that physiological measures (e.g. of anxiety) were uncorrelated with self-report measures (Bernstein, 1 9 7 6 ; Lacey, 1 9 6 7 ) , possibly because of indi v i d u a l differences i n the lag between physiological events and the experiences which they produce. N o 1 s i g n i f i c a n t sex effects were found on any of the dependent variables; thus the study provides no evidence for sex differences ih<the cognitive, behavioral and neuropsychological events examined here. Medication was found to be not related to improve-ment between admission and discharge for either patient group on any of the dependent variables. This could be because several patients i n the study received no medica-tion at a l l while others were on a variety of d i f f e r e n t medication schedules, with some patients increasing their dosage across t r i a l s and others decreasing t h e i r s . Suggestions for future research Since the research at this time i s exploratory, the dichotic r e s u l t s reported here can be regarded only as provisional findings. More research i s needed to confirm or disconfirm the finding of abnormal dominance patterns i n depressives and a return to normal patterns after recovery from depression. The importance of using two kinds of dichotic tests i n future research, one for which each hemisphere i s superior, and the importance of using cognitive tests as well as tests of processing mode, 148 are well i l l u s t r a t e d i n the present study. Had this study, l i k e most previous studies, employed only one dichotic test, quite d i f f e r e n t (and probably erroneous) inferences would have been drawn from the r e s u l t s . The same would be true i f only cognitive or dichotic tests had been used. The decrease i n right ear superiority for normals, with repeated administrations of the dichotic words test, i s i n t r i g u i n g . Although this e f f e c t did not reach s i g n i -ficance i n the present study because of the stringent c r i t e r i o n l e v e l adopted, the phonomenon deserves further exploration. There appear to be no previous studies reporting the r e s u l t of s e r i a l administration of dichotic tests to normal subjects. The question of whether poor s p a t i a l s k i l l i n depressives represents a chronic index of psychiatric v u l n e r a b i l i t y also needs to be explored further. While the Flags and Word Fluency tests appear to be s a t i s f a c t o r y measures of right and l e f t hemisphere cognitive capacity, i t would probably be advisable i n future research to employ separate groups representing d i f f e r e n t levels of depression, in order to obviate practise effects which were apparent in the present study on both of these tests. A l t e r n a t i v e l y , alternate forms of each test could be used at each t r i a l , involving d i f f e r e n t l e t t e r stimuli for each administra-tion of the Word Fluency test and d i f f e r e n t f l a g stimuli for each administration of the Flags test, assuming that the d i f f e r e n t forms were t r u l y equal. It would also be 149 preferable to employ alternate forms of the dichotic tests i f i t were possible to devise alternate forms which were equated on a l l parameters. In studying h o s p i t a l i z e d depressives, i t i s obviously important to include a hospitalized comparison group. Unfortunately, the hospital at which the present study was done did not have a non-psychiatric patient population, and since using a comparison group from another hospital could have introduced other confounds, i t was decided to use schizophrenics as a psychiatric comparison group. However, this proved to be less than s a t i s f a c t o r y : f i r s t , schizophrenics whose f i r s t h o s p i t a l i z a t i o n was within the past f i v e years, as i n the present study, generally tend to be younger than depressives, and this was also true i n this study; second, as the Beck Depression Inventory scores showed, the schizophrenic group were also somewhat depressed and therefore not well suited as a comparison group i n a study of depression; t h i r d , schizophrenics exhibited a large amount of variance on some of the tests. If future studies could obtain a non-psychiatric hospitalized comparison group, such as surgical patients, such problems could probably be avoided. It would also be useful, i n studying depressives, to select subjects who are either on no medication or on a common schedule of medication. The v a r i e t y of medication regimes for depressed patients i n the present study, made i t impossible to relate medication to an improvement i n 150 any of the dependent variables; thus i t was impossible to speculate, for example, concerning the probable impact of medication on neurotransmitter production and how this might relate to changes i n hemispheric functioning. The PES was used to measure reinforcement rate i n the present study i n order to f a c i l i t a t e comparison of these results with previous PES results for nonhospitalized populations. While the association between mood and PES scores i n the present sample i s i n agreement with previous PES results for nonhospitalized depressives, there are d i f f i c u l t i e s i n interpreting the.present r e s u l t s . One problem—the p o s s i b i l i t y of regression toward the mean—has already been noted. An additional problem i s the p o s s i b i l i t y that depressives 1 low PES scores at admis-sion to hospital and high PES scores at discharge were a product of the tendency to underestimate pleasant occurrences when depressed and to overestimate (or estimate more accurately) when happy (Buchwald, 1977). The use of behavioral observation to measure depressed patients' p a r t i c i p a t i o n i n re i n f o r c i n g events would avoid these problems. While behavioral observation was not possible i n the present study, i t s use i n future research might help to resolve the issue of underestimation vs. under-p a r t i c i p a t i o n . F i n a l l y , the present study indicates that dichotic l i s t e n i n g may be a useful c l i n i c a l tool as well as a research t o o l . If c l i n i c i a n s were to use dichotic l i s t e n i n g as 151 a r o u t i n e a s s e s s m e n t t o o l , t h i s m i g h t h e l p t o e l u c i d a t e t h e s e q u e n c e b e t w e e n d e p r e s s e d mood a n d a b r e a k d o w n i n n o r m a l h e m i s p h e r i c d o m i n a n c e p a t t e r n s f o r p r o c e s s i n g m o d e . A t t h e same t i m e c l i n i c i a n s m i g h t be a b l e t o d e t e c t mood c h a n g e e a r l y i n o r d e r t o i n t e r v e n e b e f o r e d e p r e s s i o n l e v e l b e c o m e s s e v e r e . A s w e l l , d i c h o t i c l i s t e n i n g c o u l d b e u s e d t o m o n i t o r t h e r a p e u t i c e f f i c a c y i n d e p r e s s e d p a t i e n t s . I f f u t u r e r e s e a r c h s h o u l d d e t e r m i n e t h a t t h e t e n d e n c y t o e n g a g e b o t h h e m i s p h e r e s i n l a n g u a g e p r o c e s s i n g i s a f e a t u r e o f d e p r e s s i o n - p r o n e p e r s o n s , t h i s c o u l d s u g g e s t new t r e a t m e n t o p t i o n s t o a u g m e n t t h e c o g n i t i v e a n d b e h a v i o r a l t r e a t m e n t s c u r r e n t l y i n u s e . N e u r o p s y c h o -l o g i c a l t r e a t m e n t w o u l d b e a i m e d a t r e d u c i n g l i n g u i s t i c -a n a l y t i c p r o c e s s i n g w h i l e e n c o u r a g i n g i n c r e a s e d n o n v e r b a l p r o c e s s i n g , i n a n a t t e m p t t o r e s t o r e t h e f u n c t i o n a l b a l a n c e b e t w e e n t h e two h e m i s p h e r e s . T h e " t h o u g h t - s t o p p i n g " p r o c e d u r e s o u t l i n e d b y W o l p e a n d L a z a r u s ( 1 9 6 6 ) w o u l d p r o b a b l y h e l p t o d e c r e a s e t h e t e n d e n c y t o w a r d c o v e r t v e r b a l i z a t i o n , w h i l e i m a g e r y o r m u s i c e x e r c i s e s m i g h t b e u s e f u l i n i n c r e a s i n g n o n v e r b a l p r o c e s s i n g . 152 Reference Notes 1. Tucker ? D. M. D i a l e c t i c a l processes i n emotion and hemispheric function. Paper presented to the International Neuropsychological Society, Minneapolis, February, 1978. 2. Shaffer, M. & Lewinsohn, P. M. Interpersonal behaviors i n the home of depressed versus nondepressed psy c h i a t r i c and normal controls: A test of several hypotheses. Paper presented at the annual meeting of the Western Psychological Association, San Francisco, A p r i l , 1971. 3. Rosenberry, C , Weiss, R. L. & Lewinsohn, P. M. 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N e u r o p s y c h o l o g i a , 1 9 7 7 , 1 5 , 6 9 7 - 7 0 0 . 168 Tucker, D. M., Stenslie, C . E . j R o t h , R._S. & Shearer, S. L. Right f r o n t a l lobe a c t i v a t i o n and right hemisphere performance decrement during a depressed mood. Archives of General Psychiatry, 1979, i n press. Urstad, H. Hemispheric dominance: A temporal lobe s h i f t i n psychotic behavior. Acta Psychiatrica Scandinavica, 1979, i n press. Velten, E. A laboratory task for induction of mood states. Behavior Research and Therapy, 1968, _6, 473-482. Veroff, A. E. A st r u c t u r a l determinant of hemispheric pro-cessing of p i c t o r i a l material. Brain and Language, 1978 Vogel, G. W. , Thompson, E., Thurmond, A. & Rivers, B. The eff e c t of REM deprivation on depression. Psychosomatics, 1973, 14, 104-107. Vogel, G. W. , Thurmond, A., Gibbons, P., et a l . REM sleep reduction effects on depression syndromes. Archives  of General Psychiatry, 1975, 32, 765-777. Wada, J. & Rasmussen, T. Intracarotid i n j e c t i o n of sodium amytal for the l a t e r a l i z a t i o n of cerebral speech domi-nance: Experimental and c l i n i c a l observations. Journal of Neurosurgery, 1960, J-7, 266-282. Weintraub, M., Segal, R. M. & Beck, A. T. An investigation of cognition and affe c t i n the depressive experiences of normal men. Journal of Consulting and C l i n i c a l  Psychology, 1974, 42, 911. Weisman, M. M. & Klerman, G. L. Sex differences and the epidemiology of depression. Archives of General  Psychiatry, 1977, 34, 98-111. : Wener, A. E. & Rehm, L. P. Depressive a f f e c t : A test of behavioral hypotheses. Journal of Abnormal Psychology, 1975, 84, 221-227. Wexler, B. E. Cerebral l a t e r a l i t y and psychiatry: a review of the l i t e r a t u r e . American Journal of Psychiatry, 1980, 137, 279-291. Wexler,. B. E. & Heninger, G. R. Alterations i n cerebral l a t e r a l i t y i n acute psychotic i l l n e s s . Archives of  General Psychiatry, 1980, i n press. W i l l i s , S. G., Wheatley, G. H. & M i t c h e l l , 0. R. Cerebral processing of s p a t i a l and verbal-analytic tasks: An EEG study. Neuropsychologia, 1979, J_7, 473-484. 169 W i n e r , B . J . S t a t i s t i c a l P r i n c i p l e s i n E x p e r i m e n t a l D e s i New Y o r k : M c G r a w - H i l l , 1962. W o l p e , J . & L a z a r u s , A . A . B e h a v i o r T h e r a p y T e c h n i q u e s . New Y o r k : P e r m a g o n , 1 9 6 6 . Z a n g w i l l , 0 . L . S p e e c h a n d t h e m i n o r h e m i s p h e r e . A c t a  P s y c h i a t r i c a S c a n d i n a v i c a , 1 9 6 7 , 6 7 , 1 0 1 3 - 1 0 2 0 . 170 A p p e n d i x A HANDEDNESS Q U E S T I O N N A I R E W h i c h h a n d w o u l d y o u u s e f o r t h e f o l l o w i n g a c t i v i t i e s ? C i r c l e R i f y o u w o u l d u s e t h e r i g h t h a n d . C i r c l e L i f y o u w o u l d u s e t h e l e f t h a n d . C i r c l e E i f y o u w o u l d u s e e i t h e r h a n d . 1. t o w r i t e R L E 2. t o t h r o w a b a l l t o h i t a t a r g e t R L E 3 . t o h o l d a r a c k e t t o h i t a b a l l R L E 4 . t o h o l d a m a t c h when s t r i k i n g i t R L E 5 . t o u s e a hammer R L E 6 . t o u s e a t o o t h b r u s h R L E 7. t o u s e s c i s s o r s R L E 8 . t o d e a l p l a y i n g c a r d s R L E 171 Appendix g from the Diagnostic and S t a t i s t i c a l Manual of Mental Disorders, American P s y c h i a t r i c Association, 1/15/78 Draft MAJOR DEPRESSIVE DISORDER Diagnostic c r i t e r i a A. One or more Depressive Episodes B. Has never had a Manic Episode Depressive Episode D i f f e r e n t i a l diagnosis. Organic A f f e c t i v e Syndrome (e.g., influenza), Substance-induced Organic A f f e c t i v e Syndromes (e.g., due to hypertensive agent, reserpine), Progressive idiopathic.and M u l t i - i n f a r c t Dementias, Schizophrenia, S c h i z o a f f e c t i v e Disorder, Chronic Depressive and Cyclothymic Disorders, Adjustment Disorder with Depressed Mood, Separation Anxiety Disorder, Uncomplicated Bereavement. Diagnostic c r i t e r i a . A. Dysphoric mood or loss of i n t e r e s t or pleasure i n a l l or almost a l l usual a c t i v i t i e s and pastimes. The dysphoric mood i s charac-t e r i z e d by symptoms such as the following: depressed, sad, blue, hopeless, low, down i n the dumps, i r r i t a b l e , worried. The disturbance must be prominent and r e l a t i v e l y p e r s i s t e n t but not nece s s a r i l y the most dominant symptom. I t does not include momentary s h i f t s from one dysphoric mood to another dysphoric mood, e.g., anxiety to depression to anger, such as are seen i n states of acute psychotic turmoil. B. At l e a s t four of the following symptoms: (1) Poor appetite or weight loss or increased appetite or weight gain (change of one l b . a week or ten l b s . a year when not d i e t i n g ) . (2) Sleep d i f f i c u l t y or sleeping too much. (3) Loss of energy, f a t i g a b i l i t y , or tiredness. (4) Psychomotor a g i t a t i o n or retardation (but not mere subjective f e e l i n g s of restlessness or being slowed down.) (5) Loss of i n t e r e s t or pleasure i n usual a c t i v i t i e s , or decrease in sexual drive (do not include i f l i m i t e d to a period when delusional or h a l l u c i n a t i n g ) . .172 (6) F e e l i n g s o f s e l f - r e p r o a c h o r e x c e s s i v e o r i n a p p r o p r i a t e g u i l t ( e i t h e r may b e d e l u s i o n a l ) . (7) C o m p l a i n t s o r e v i d e n c e o f d i m i n i s h e d a b i l i t y t o t h i n k o r c o n c e n t r a t e s u c h a s s l o w e d t h i n k i n g , o r i n d e c i s i v e n e s s ( d o n o t i n c l u d e i f a s s o c i a t e d w i t h o b v i o u s f o r m a l t h o u g h t d i s o r d e r . ) (8) R e c u r r e n t t h o u g h t s o f d e a t h o r s u i c i d e , o r a n y s u i c i d a l b e h a v i o r , i n c l u d i n g t h o u g h t s o f w i s h i n g t o b e d e a d . C . T h e p e r i o d o f i l l n e s s h a s h a d a d u r a t i o n o f a t l e a s t o n e w e e k f r o m t h e t i m e o f t h e f i r s t n o t i c e a b l e c h a n g e i n t h e i n d i v i d u a l ' s u s u a l c o n d i t i o n . D . N o n e o f t h e f o l l o w i n g w h i c h s u g g e s t s S c h i z o p h r e n i a i s p r e s e n t . (1) D e l u s i o n s o f b e i n g c o n t r o l l e d o r t h o u g h t b r o a d c a s t i n g , i n s e r t i o n , o r w i t h d r a w a l . (2) H a l l u c i n a t i o n s o f a n y t y p e t h r o u g h o u t t h e d a y f o r s e v e r a l d a y s o r i n t e r m i t t e n t l y t h r o u g h o u t a o n e w e e k p e r i o d u n l e s s a l l o f t h e c o n t e n t i s c l e a r l y r e l a t e d t o d e p r e s s i o n o r e l a t i o n . (3) A u d i t o r y h a l l u c i n a t i o n s i n w h i c h e i t h e r a v o i c e k e e p s u p a r u n n i n g c o m m e n t a r y o n t h e i n d i v i d u a l ' s b e h a v i o r s o r t h o u g h t s a s t h e y o c c u r , o r t w o o r m o r e v o i c e s c o n v e r s e w i t h e a c h o t h e r . (4) A t some t i m e d u r i n g t h e p e r i o d o f i l l n e s s h a d d e l u s i o n s o r h a l l u c i n a t i o n s f o r m o r e t h a n o n e m o n t h i n t h e a b s e n c e o f p r o m i n e n t a f f e c t i v e ( m a n i c o r d e p r e s s i v e ) s y m p t o m s ( a l t h o u g h t y p i c a l d e p r e s s i v e d e l u s i o n s , s u c h a s d e l u s i o n s o f g u i l t , s i n , p o v e r t y , n i h i l i s m , o r s e l f - d e p r e c a t i o n o r h a l l u c i n a t i o n s o f s i m i l a r c o n t e n t a r e p e r m i t t e d ) . (5) P r e o c c u p a t i o n w i t h a d e l u s i o n o r h a l l u c i n a t i o n t o t h e r e l a t i v e e x c l u s i o n o f o t h e r s y m p t o m s o r c o n c e r n s ( o t h e r t h a n d e l u s i o n s o f g u i l t , s i n , p o v e r t y , n i h i l i s m , o r s e l f - d e p r e c a t i o n , o r h a l l u c i n a t i o n s w i t h s i m i l a r c o n t e n t ) . (6) M a r k e d f o r m a l t h o u g h t d i s o r d e r i f a c c o m p a n i e d b y e i t h e r b l u n t e d o r i n a p p r o p r i a t e a f f e c t , d e l u s i o n s o r h a l l u c i n a t i o n s o f a n y t y p e , o r g r o s s l y d i s o r g a n i z e d b e h a v i o r . E . N o t d u e t o a n y O r g a n i c M e n t a l D i s o r d e r . F . N o t s u p e r i m p o s e d o n S c h i z o p h r e n i a , R e s i d u a l s u b t y p e . G . E x c l u d e s U n c o m p l i c a t e d B e r e a v e m e n t f o l l o w i n g l o s s o f a l o v e d o n e i f a l l o f t h e f e a t u r e s a r e c o m m o n l y s e e n i n m e m b e r s o f t h e i n d i v i -d u a l ' s s u b c u l t u r a l g r o u p i n s i m i l a r c i r c u m s t a n c e s . 173 M a n i c E p i s o d e  D i a g n o s t i c c r i t e r i a . A . One o r m o r e d i s t i n c t p e r i o d s w i t h a p r e d o m i n a n t l y e l e v a t e d , e x p a n s i v e o r i r r i t a b l e m o o d . T h e e l e v a t e d o r i r r i t a b l e mood m u s t b e a p r o m i n e n t p a r t o f t h e i l l n e s s a n d r e l a t i v e l y p e r s i s t e n t a l t h o u g h i t may a l t e r n a t e w i t h d e p r e s s i v e m o o d . Do , n o t i n c l u d e i f m o o d c h a n g e i s a p p a r e n t l y d u e t o s u b s t a n c e i n t o x i c a t i o n . B . I f mood i s e l e v a t e d o r e x p a n s i v e , a t l e a s t f o u r o f t h e f o l l o w i n g s y m p t o m c a t e g o r i e s m u s t b e d e f i n i t e l y p r e s e n t t o a s i g n i f i c a n t d e g r e e ( f i v e i f m o o d i s o n l y i r r i t a b l e ) . (1) M o r e a c t i v e t h a n u s u a l — e i t h e r s o c i a l l y , a t w o r k , s e x u a l l y , o r p h y s i c a l l y r e s t l e s s . (2) M o r e t a l k a t i v e t h a n u s u a l o r f e l t a p r e s s u r e t o k e e p t a l k i n g . (3) F l i g h t o f i d e a s o r s u b j e c t i v e e x p e r i e n c e t h a t t h o u g h t s a r e r a c i n g . (4) I n f l a t e d s e l f - e s t e e m ( g r a n d i o s i t y , w h i c h may b e d e l u s i o n a l ) . (5) D e c r e a s e d n e e d f o r s l e e p . (6) D i s t r a c t i b i l i t y , i . e . , a t t e n t i o n i s t o o e a s i l y d r a w n t o u n i m p o r t a n t o r i r r e l e v a n t e x t e r n a l s t i m u l i . (7) E x c e s s i v e i n v o l v e m e n t i n a c t i v i t i e s w i t h o u t r e c o g n i z i n g t h e h i g h p o t e n t i a l f o r p a i n f u l c o n s e q u e n c e s , e . g . , b u y i n g s p r e e s , s e x u a l i n d i s c r e t i o n s , f o o l i s h b u s i n e s s i n v e s t m e n t s , r e c k l e s s d r i v i n g . C . T h e p e r i o d o f i l l n e s s i s c l e a r l y d i s t i n g u i s h e d f r o m u s u a l f u n c t i o n i n g a n d t h e a f f e c t i v e d i s t u r b a n c e i s s u s t a i n e d f o r a t l e a s t o n e w e e k ( o r a n y d u r a t i o n i f h o s p i t a l i z e d ) . D . H a s n o n e o f t h e f o l l o w i n g s c h i z o p h r e n i c - l i k e s y m p t o m s . ( N o t e : B e c a u s e a s i n g l e s y m p t o m i s g i v e n s u c h d i a g n o s t i c s i g n i f i c a n c e , i t s p r e s e n c e s h o u l d b e c l e a r l y e s t a b l i s h e d . ) S y m p t o m s f r o m C r i t e r i o n A f o r S c h i z o p h r e n i a , w h i c h a r e i n d i c a t i v e  o f S c h i z o a f f e c t i v e D i s o r d e r , i n t h e c o n t e x t o f a n a f f e c t i v e s y n d r o m e . (1) D e l u s i o n s o f c o n t r o l : E x p e r i e n c e s h i s t h o u g h t s , a c t i o n s , o r f e e l i n g s a s i m p o s e d o n h i m b y some e x t e r n a l f o r c e . (2) T h o u g h t b r o a d c a s t i n g : E x p e r i e n c e s h i s t h o u g h t s , a s t h e y o c c u r , a s b e i n g b r o a d c a s t f r o m h i s h e a d i n t o t h e e x t e r n a l w o r l d s o t h a t o t h e r s c a n h e a r t h e m . (3) T h o u g h t i n s e r t i o n : E x p e r i e n c e s t h o u g h t s , w h i c h a r e n o t h i s o w n , b e i n g i n s e r t e d i n t o h i s m i n d ( o t h e r t h a n b y G o d ) . (4) T h o u g h t w i t h d r a w a l : B e l i e f t h a t t h o u g h t s h a v e b e e n r e m o v e d f r o m h i s h e a d , r e s u l t i n g i n a d i m i n i s h e d n u m b e r o f t h o u g h t s r e m a i n i n g . 174 (5) Auditory h a l l u c i n a t i o n s i n which either a voice keeps up a running commentary on the i n d i v i d u a l ' s behavior or thoughts as they occur, or two or more voices converse with each other. (6) Auditory h a l l u c i n a t i o n s on several occasions with content having no apparent r e l a t i o n to depression or e l a t i o n , and not l i m i t e d to one or. two words. Other symptoms that indicate S c h i z o a f f e c t i v e Disorder i n the context of an a f f e c t i v e syndrome. (7) Preoccupation with a delusion or h a l l u c i n a t i o n to the r e l a t i v e exclusion of other symptoms or concerns (other than delusions of g u i l t , s i n , poverty, n i h i l i s m , or self-deprecation, or h a l l u c i n a t i o n s with s i m i l a r content). (8) Delusions (or hallucinations) which were concurrent with the a f f e c t i v e syndrome, p e r s i s t i n g for at l e a s t one month aft e r the complete r e s o l u t i o n of the a f f e c t i v e disturbance. E. Not due to any Organic Mental Disorder. F. Not superimposed on Schizophrenia. SCHIZOPHRENIC DISORDERS D i f f e r e n t i a l diagnosis. Organic Mental Disorders, Paranoid Disorders, S c h i z o a f f e c t i v e and A f f e c t i v e Disorders ( e s p e c i a l l y Manic Disorder), Schizophreniform Disorder, A t y p i c a l Psychosis, Obsessive Compulsive Disorder, F a c t i t i o u s I l l n e s s with Psychological Symptoms, A t y p i c a l Somatoform Disorder, Personality Disorders, s u b c u l t u r a l l y supported r e l i g i o u s b e l i e f s or experiences, Mental Retardation, No Mental Disorder ( d i f f e r e n t i a t e d from Schizophrenia i n Remission). Diagnostic c r i t e r i a . A. C h a r a c t e r i s t i c schizophrenic symptoms. At l e a s t one symptom from any of the following 10 symptoms was present during an active phase of the i l l n e s s (because, a single symptom i s given such diagnostic s i g n i f i c a n c e , i t s presence should be c l e a r l y established.): C h a r a c t e r i s t i c delusions (1) Delusions of being c o n t r o l l e d : Experiences his thoughts, actions, or fe e l i n g s as imposed on him by some external force. (2) Thought broadcasting: Experiences his thoughts, as they occur, as being broadcast from h i s head into the external world so that others can hear them. (3) Thought i n s e r t i o n : Experiences thoughts, which are not his own, being inserted into h i s mind (other than by God). 175 (4) Thought withdrawal: B e l i e f that thoughts have been removed from his head, r e s u l t i n g i n a diminished number of thoughts remaining. (5) Other bizarre delusions (patently absurd, f a n t a s t i c or implausible). (6) Somatic, grandiose, r e l i g i o u s , n i h i l i s t i c or other delusions without persecutory or jealous content. (7) Delusions of any type i f accompanied by h a l l u c i n a t i o n s of any type. C h a r a c t e r i s t i c h a l l u c i n a t i o n s (8) Auditory h a l l u c i n a t i o n s i n which either a voice keeps up a running commentary on the i n d i v i d u a l ' s behaviors or thoughts as they occur, or two or more voices converse with each other. (9) Auditory h a l l u c i n a t i o n s on several occasions with content having no apparent r e l a t i o n to depression or e l a t i o n , and not l i m i t e d to one or two words. Other c h a r a c t e r i s t i c symptoms (10) Either incoherence, derailment (loosening of a s s o c i a t i o n s ) , marked i l l o g i c a l i t y , or marked poverty of content of speech— i f accompanied by either blunted, f l a t or inappropriate a f f e c t , delusions or h a l l u c i n a t i o n s , or behavior that i s grossly disorganized or catatonic. During the active phase of the i l l n e s s , the symptoms in A have been associated with s i g n i f i c a n t impairment i n two or more areas of routine d a i l y functioning, e.g., work, s o c i a l r e l a t i o n s , s e l f - c a r e . C h r o n i c i t y: Signs of the i l l n e s s have lasted continuously for at l e a s t s i x months at some time during the person's l i f e and the i n d i v i d u a l now has some signs of the i l l n e s s . The s i x month period must include an active phase during which there were symptoms from A with or without a prodromal or r e s i d u a l phase, as defined below. Prodromal phase: A clear d e t e r i o r a t i o n i n functioning not due to a primary disturbance i n .mood.or to substance abuse, and involving at l e a s t two of the symptoms noted below. Residual phase: Following the active phase of the i l l n e s s , at l e a s t two of the symptoms noted below, not due to a primary d i s -turbance i n mood or to substance abuse. Prodromal or Residual Symptoms (a) S o c i a l i s o l a t i o n or withdrawal. (b) Marked impairment i n ro l e functioning as wage-earner, student, homemaker. 176 ( c ) M a r k e d l y e c c e n t r i c , o d d , o r p e c u l i a r b e h a v i o r ( e . g . c o l l e c t i n g g a r b a g e , t a l k i n g t o s e l f i n c o r n f i e l d o r s u b w a y , h o a r d i n g f o o d ) . (d) I m p a i r m e n t i n p e r s o n a l h y g i e n e a n d g r o o m i n g . (e ) B l u n t e d , f l a t , o r i n a p p r o p r i a t e a f f e c t . ( f ) S p e e c h t h a t i s t a n g e n t i a l , d i g r e s s i v e , v a g u e , o v e r e l a b o r a t e , c i r c u m s t a n t i a l , o r m e t a p h o r i c a l . (g) O d d o r b i z a r r e i d e a t i o n , o r m a g i c a l t h i n k i n g , e . g . s u p e r s t i -t i o u s n e s s , c l a i r v o y a n c e , t e l e p a t h y , " s i x t h s e n s e , " " o t h e r s c a n f e e l my f e e l i n g s , " o v e r v a l u e d i d e a s , i d e a s o f r e f e r e n c e , o r s u s p e c t e d d e l u s i o n s . (h) U n u s u a l p e r c e p t u a l e x p e r i e n c e s , e . g . , r e c u r r e n t i l l u s i o n s , s e n s i n g t h e p r e s e n c e o f a f o r c e o r p e r s o n n o t a c t u a l l y p r e s e n t , s u s p e c t e d h a l l u c i n a t i o n s . E x a m p l e s : S i x m o n t h s o f p r o d r o m a l s y m p t o m s w i t h o n e w e e k o f s y m p t o m s f r o m A ; n o p r o d r o m a l s y m p t o m s w i t h s i x m o n t h s o f s y m p t o m s f r o m A ; n o p r o d r o m a l s y m p t o m s w i t h t w o w e e k s o f s y m p t o m s f r o m A a n d s i x m o n t h s o f r e s i d u a l s y m p t o m s ; s i x m o n t h s o f s y m p t o m s f r o m A , a p p a r e n t l y f o l l o w e d b y s e v e r a l y e a r s o f c o m p l e t e r e m i s s i o n , w i t h o n e w e e k o f s y m p t o m s i n A i n c u r r e n t e p i s o d e . D . T h e f u l l d e p r e s s i v e o r m a n i c s y n d r o m e ( c r i t e r i a A a n d B o f D e p r e s s i v e o r M a n i c E p i s o d e ) i s e i t h e r n o t p r e s e n t , o r i f p r e s e n t , d e v e l o p e d a f t e r a n y p s y c h o t i c s y m p t o m s . E . N o t d u e t o a n y O r g a n i c M e n t a l D i s o r d e r . S C H I Z O A F F E C T I V E D I S O R D E R D i f f e r e n t i a l d i a g n o s i s . A f f e c t i v e D i s o r d e r , S c h i z o p h r e n i a , S c h i z o -p h r e n i f o r m D i s o r d e r . D i a g n o s t i c c r i t e r i a . A . H a s a d e p r e s s i v e o r m a n i c s y n d r o m e ( o r m i x t u r e o r r a p i d a l t e r n a t i o n ) o f a t l e a s t o n e w e e k ' s d u r a t i o n : C r i t e r i a A a n d B o f D e p r e s s i v e E p i s o d e o r M a n i c E p i s o d e . B . H a s a t l e a s t o n e o f t h e f o l l o w i n g n i n e s y m p t o m s ( b e c a u s e a s i n g l e s y m p t o m i s g i v e n s u c h d i a g n o s t i c s i g n i f i c a n c e , i t s p r e s e n c e s h o u l d b e c l e a r l y e s t a b l i s h e d ) : 177 Symptoms from C r i t e r i o n A of Schizophrenia, which are i n d i c a t i v e of S c h i z o a f f e c t i v e Disorder i n the context, of an a f f e c t i v e syndrome; (1) Delusions of c o n t r o l : Experiences his thoughts, actions, or f e e l i n g s as imposed on him by some external force. (2) Thought broadcasting: Experiences h i s thoughts, as they occur, as being broadcast from h i s head into the external world so that others can hear them. (3) Thought i n s e r t i o n : Experiences thoughts, that are not h i s own, being inserted into his mind (other than from God). (4) Thought withdrawal: B e l i e f that thoughts have been removed from h i s head, r e s u l t i n g i n a diminished number of thoughts remaining. (5) Auditory h a l l u c i n a t i o n s in which either a voice keeps up a running commentary on the i n d i v i d u a l ' s behavior or thoughts as they occur, or two or more voices converse with each other. (6) Auditory h a l l u c i n a t i o n s on several occasions with content having no apparent r e l a t i o n to depression or e l a t i o n , and not l i m i t e d to one or two words. Other symptoms that indicate S c h i z o a f f e c t i v e Disorder i n the  context of an a f f e c t i v e syndrome: (7) Preoccupation with a delusion or h a l l u c i n a t i o n to the r e l a t i v e exclusion of other symptoms or concerns, with content having no apparent r e l a t i o n to depression or e l a t i o n . (8) Delusions (or hallucinations) that were concurrent with the a f f e c t i v e syndrome, p e r s i s t i n g for at l e a s t one month aft e r the complete res o l u t i o n of the a f f e c t i v e disturbance. (9) Repeated instances of incoherence or derailment, unless con-current with manic syndrome. C. Depressive or manic syndrome overlaps temporally to some degree with the symptoms Jin B. The depressive or manic syndrome must precede or develop at the same time as the symptoms i n B. D. Duration of i l l n e s s at l e a s t one week from the time of the f i r s t noticeable change in the i n d i v i d u a l ' s usual condition. E. Not due to any Organic Mental Disorder. 178 Appendix C CONSENT FORM I hereby v o l u n t a r i l y consent to p a r t i c i p a t e i n a research study under the d i r e c t i o n of Olive Johnson, M.Sc, psychologist on ward Two West, Health Sciences Center Psychiatric Unit. The nature of this research has been explained to me and I understand that I w i l l be required to complete certain psychological tests, including questionnaires and l i s t e n i n g to tape-recorded sounds. If I do not wish to p a r t i c i p a t e i n this study, I understand that my decision w i l l i n no way a f f e c t the standard of treatment and care I w i l l receive i n h o s p i t a l . I further understand that I am free to withdraw from this study at any time, and that my withdrawal w i l l i n no way af f e c t the standard of treatment and care I w i l l receive. I have been informed that test scores w i l l not be i d e n t i f i e d as mine, except to the researcher, without my written permission. In addition, my i d e n t i t y w i l l not be revealed i n any publication or report r e s u l t i n g from this research. Signed: (Patient) (Witness: Primary Therapist) (Date) 179 Appendix D Q U E S T I O N N A I R E Are the following statements True or False for you? If a statement i s True, mark T a f t e r i t . I f a statement i s False, mark F after i t . 1. When people compliment me, I can t e l l they don't know what I'm r e a l l y l i k e . 2. I compete as s u c c e s s f u l l y as most other people. 3. Considering how boring and unattractive I am, i t ' s no wonder the opposite sex i s n ' t interested in me. 4. Nothing I do seems to turn out r i g h t . 5. When I have an e s p e c i a l l y good day, I f e e l r e a l l y s a t i s f i e d . 6. I'm the kind of person that people l i k e to talk to. 7. If I haven't been able to solve my problems by now, I'm probably never going to. 8. When I forget someone's name, i t reminds me that I'm inadequate i n most s o c i a l s i t u a t i o n s . 9. Not being able to sleep i s t e r r i b l e and makes me f e e l that I ' l l never be able to sleep well again. 10. The world i s a better place with me i n i t . 11. F a i l i n g doesn't mean I should qu i t t r y i n g . 12. Considering the kind of person I am, i t would be s u r p r i s i n g i f things didn't turn out w e l l . 13. I can t e l l that the opposite sex finds me a t t r a c t i v e . 14. Losing out in a competition reminds me what a loser I am. 15. There are dozens of things I enjoy doing. T or F QUESTIONNAIRE (Page 2) 16. When I phone somebody who says she's too busy to ta l k , I can t e l l she's t r y i n g to avoid me. 17. Seeing other people working hard makes me think how lazy and helpless I am. 18. The way things have gone for me l a t e l y makes me f e e l I ' l l never be happy again. 19. When people are f r i e n d l y I know i t ' s because I'm nice to be with. 20. I'm f a i r l y competent i n what I do. 21. Every time something goes wrong i t reminds me what a f a i l u r e I am. 22. I t ' s pleasant to be alone sometimes. 23. Even i f I have a pretty good day, I know that tomorrow w i l l be bad again. 24. Not making a go of something doesn't mean I'm useless 25. I wasn't able to get the love I wanted because I'm not a lovable person myself. 26. Not reaching the goals I had set for myself makes me r e a l i z e how inadequate I am. 27. A l l things considered, my l i f e i s pretty good. 28. S o c i a l gatherings give me a chance to use my good s o c i a l s k i l l s . 29. People usually f i n d me nice to be around. 30. The people I know best would be better o f f without me 31. A person l i k e me deserves to be happy. 32. I f I have an argument with someone, I r e a l i z e afterward that I'm incapable of loving people. 33. Losing out in a competition doesn't mean I'm a l o s e r . 34. Most things I do turn out pretty w e l l . 35. When people are l a t e for an appointment with me, I can t e l l they don't r e a l l y want to see me. 181 Q U E S T I O N N A I R E ( P a g e 3) 36. I a l w a y s f a i l a t e v e r y t h i n g , s o t h e r e ' s n o u s e i n t r y i n g a n y m o r e . 37. T h i n k i n g a b o u t t h e f u t u r e i s e n j o y a b l e b e c a u s e I k n o w t h i n g s a r e g o i n g t o g e t b e t t e r . 38. C o n s i d e r i n g t h e k i n d o f p e r s o n I a m , i t ' s n o t r e a l l y s u r p r i s i n g t h a t t h i n g s h a v e t u r n e d o u t s o b a d l y . 39. S i t t i n g home a l o n e m a k e s me f e e l m i s e r a b l e a n d I r e a l i z e I ' l l p r o b a b l y a l w a y s b e t h a t w a y . 40. A p e r s o n l i k e me d o e s n ' t d e s e r v e t o b e h a p p y . 41. I h a n d l e m y s e l f q u i t e w e l l w i t h o t h e r s . 42. When I s e t a g o a l f o r m y s e l f , I u s u a l l y e x p e c t t o r e a c h i t . 43. E v e n w h e n I m a n a g e t o d o s o m e t h i n g r i g h t , I ' m b o u n d t o m e s s i t u p t h e n e x t t i m e . 44. H a v i n g a n a r g u m e n t d o e s n ' t m e a n I ' m a n u n l o v i n g p e r s o n . 45. H e a r i n g a b o u t o t h e r p e o p l e ' s p l a n s m a k e s me t h i n k how b l e a k my own f u t u r e i s . 46. E v e n w h e n p e o p l e a r e f r i e n d l y I s t i l l f e e l u n w a n t e d . 47. When I p l a n t o d o s o m e t h i n g o u t d o o r s a n d i t r a i n s , I d o n ' t b l a m e m y s e l f f o r p i c k i n g a b a d d a y . 48. When my o p i n i o n s a r e c h a l l e n g e d , i t g i v e s me a c h a n c e t o s h o w w h a t I k n o w . 49. When I ' m a t a s o c i a l g a t h e r i n g a n d s o m e o n e d o e s n ' t s h o w a n i n t e r e s t i n m e , I f e e l b o r i n g a n d i n f e r i o r . 50. I k n o w t h a t I ' m a p e r s o n w o r t h l o v i n g . 51. When s o m e o n e i n a u t h o r i t y c r i t i c i z e s m e , I f e e l l i k e I ' v e r e a l l y b e e n c l o b b e r e d . 52. One m i s t a k e d o e s n ' t m e a n I ' m s t u p i d . 53. H e a r i n g a b o u t o t h e r p e o p l e ' s p l a n s m a k e s me t h i n k how n i c e my o w n f u t u r e i s . 54. T h i n g s t h a t u s e d t o b e e a s y t o d o a r e now a l m o s t i m p o s s i b l e b e c a u s e I ' m s o i n c o m p e t e n t . 182 Q U E S T I O N N A I R E ( P a g e 4) 55. H a v i n g p r o b l e m s now d o e s n ' t m e a n I ' l l a l w a y s h a v e t h e m . 56. A l l t h e p r a i s e i n t h e w o r l d d o e s n ' t make u p f o r a c r i t i c i s m o f my p e r f o r m a n c e . 57. A s a l e s c l e r k may g i v e me p o o r s e r v i c e , b u t t h a t d o e s n ' t m e a n h e t h i n k s I ' m a n o b o d y . 58. When t h i n g s d o n ' t r u n s m o o t h l y a t h o m e , I k n o w i t ' s b e c a u s e I ' m a p o o r o r g a n i z e r . 59. R e c e i v i n g a c o m p l i m e n t m a k e s me f e e l g o o d . 60. When s o m e b o d y q u e s t i o n s my o p i n i o n s , I k n o w t h e y t h i n k I ' m s t u p i d . A p p e n d i x E B e c k D e p r e s s i o n I n v e n t o r y T h e B e c k D e p r e s s i o n I n v e n t o r y ( B D I ) i s a s e l f -r e p o r t m e a s u r e , t h e i n t e r n a l c o n s i s t e n c y a n d v a l i d i t y o f w h i c h h a s b e e n w e l l d o c u m e n t e d ( B e c k a n d B e a m e s d e r f e r 1 9 7 4 ) . T h e r e a r e 21 g r o u p s o f s t a t e m e n t s r e p r e s e n t i n g 21 c a t e g o r i e s o f symptoms a n d a t t i t u d e s . E a c h g r o u p c o n s i s t s o f a s e r i e s o f f o u r o r f i v e s e l f - e v a l u a t i v e s t a t e -m e n t s r a n k e d t o r e f l e c t t h e r a n g e o f s e v e r i t y o f t h e symptoms f r o m n e u t r a l t o m a x i m a l s e v e r i t y . T h e s u b j e c t i s i n s t r u c t e d t o r e a d e a c h g r o u p o f s t a t e m e n t s , p i c k o u t t h e o n e f r o m e a c h g r o u p t h a t b e s t d e s c r i b e s t h e way h e f e e l s t h a t d a y , a n d c i r c l e t h e n u m b e r b e s i d e t h a t s t a t e m e n t . A n u m e r i c a l v a l u e o f 0 - 3 i s a s s i g n e d t o e a c h s t a t e m e n t , y i e l d i n g a maximum p o s s i b l e s c o r e o f 6 2 . 184 Appendix F Instructions on Dichotic Word Triads Tape You are going to hear several sets of words. In each set, three pairs of words w i l l be spoken i n both ears at the same time. One member of a pair w i l l be heard i n your l e f t ear and the other member of a pair i n your ri g h t ear. Lis t e n c a r e f u l l y so that after each set of six words you can report the words you remember. I w i l l repeat: In each set you w i l l hear a s t r i n g of three words i n your right ear and at the same time a s t r i n g of three words i n your l e f t ear. Listen c a r e f u l l y so that af t e r each set you can t e l l me as many words as you remember. You can report the words you heard i n whatever order you l i k e . Do you have any questions? If so, please raise your hand. (pause) The test w i l l begin i n a few seconds. As soon as the f i r s t three pairs of words are said, report them aloud. Then l i s t e n for the next set of three pairs and report those words, and so on. There are twenty-two sets of words, with a ten-second i n t e r v a l between sets to give you time to report what you heard. The f i r s t set w i l l begin i n ten seconds. 185 Appendix G Instructions on Dichotic Musical Chords Tape You are going to hear some musical chords played on an e l e c t r i c organ. F i r s t you w i l l hear two test chords, a d i f f e r e n t one i n each ear, at the same time. Then you w i l l hear four more chords i n succession, each chord played i n both ears at the same time. Only two of these four chords are the same as the two test chords. Your job i s to t e l l which two of these four chords are the same as the two test chords you heard f i r s t . Check the spaces on your answer sheet corresponding to the correct two chords. I w i l l repeat that: F i r s t you w i l l hear two d i f -ferent test chords simultaneously, one i n each ear. Then you w i l l hear.four more chords, one after the other. You must pick out two of these four chords which match the o r i g i n a l two test chords. On your answer sheet check two of the numbers 1, 2, 3, 4, depending on which two numbers - correspond to the two correct chords. If you have any questions, please raise your hand. (pause) We w i l l begin with four practise t r i a l s . L i s t e n c a r e f u l l y ; here comes the f i r s t practise trials-*-Here i s the second practise trials-*- Here i s the th i r d practise t r i a l : - Here i s the fourth practise t r i a l : If you have any questions, please raise your hand. (pause) 186 Dichotic Chords tape instructions (Page 2) The test i t s e l f w i l l now begin. There w i l l be twenty-four groups of chords with a ten-second pause after each group to give you time to mark your answers. Lis t e n c a r e f u l l y , the f i r s t set w i l l begin i n ten seconds. 187 A p p e n d i x H H E M I S P H E R I C F U N C T I O N I N G I N S C H I Z O P H R E N I C S S c h i z o p h r e n i c s p e r f o r m e d p o o r l y o n b o t h c o g n i t i v e t e s t s ( F l a g s a n d W o r d F l u e n c y ) , a l t h o u g h o n t h e W o r d F l u e n c y t e s t t h e d i f f e r e n c e b e t w e e n s c h i z o p h r e n i c s a n d o t h e r g r o u p s d i d n o t r e a c h s i g n i f i c a n c e . On b o t h o f t h e d i c h o t i c t e s t s , s c h i z o p h r e n i c s i n i t i a l l y d e m o n s t r a t e d p o o r r i g h t e a r ( l e f t h e m i s p h e r e ) p e r f o r m a n c e ; t h i s i s c o n s i s t e n t w i t h n u m e r o u s s t u d i e s w h i c h h a v e s u g g e s t e d l e f t h e m i s p h e r e d y s f u n c t i o n i n s c h i z o -p h r e n i a . W i t h t r e a t m e n t , s c h i z o p h r e n i c s showed a n i n c r e a s e d r i g h t e a r ( l e f t h e m i s p h e r e ) a d v a n t a g e o n b o t h d i c h o t i c t e s t s , a l t h o u g h t h e i n c r e a s e f o r D i c h o t i c W o r d s was s i g n i f i -c a n t o n l y a t t h e . 0 2 5 l e v e l . T h e s e r e s u l t s c o u l d s u g g e s t t h a t t h e i m p a c t o f t r e a t m e n t i n s c h i z o p h r e n i a may b e p r i m a r i l y u p o n l e f t h e m i s p h e r e f u n c t i o n i n g . T h e s h i f t t o w a r d l e f t h e m i s p h e r e d o m i n a n c e i s c o n s i s t e n t w i t h s t u d i e s r e v i e w e d e a r l i e r , s h o w i n g a s h i f t i n l a t e r a l i z e d E E G a c t i v i t y f o l -l o w i n g d r u g t r e a t m e n t o f s c h i z o p h r e n i c s . T h e a b n o r m a l r i g h t e a r s u p e r i o r i t y f o r D i c h o t i c C h o r d s shown b y s c h i z o p h r e n i c s a t d i s c h a r g e r a i s e s t h e p o s s i b i l i t y t h a t p e r s o n s v u l n e r a b l e t o s c h i z o p h r e n i a may h a v e a n a t y p i c a l p a t t e r n o f f u n c t i o n a l h e m i s p h e r i c s p e c i a l i -z a t i o n s u c h t h a t t h e l e f t h e m i s p h e r e i s d o m i n a n t f o r n o n v e r b a l a s w e l l a s v e r b a l p r o c e s s i n g . T h i s was t h e c o n -c l u s i o n d r a w n b y S c h w e i t z e r e t a l ( 1 9 7 8 ) a n d S c h w e i t z e r ( 1 9 7 9 ) , 188 who f o u n d t h a t s c h i z o p h r e n i c s p r o d u c e d m o r e r i g h t w a r d L E M s t h a n c o n t r o l s when t h i n k i n g a b o u t s p a t i a l m a t e r i a l , t h u s s u g g e s t i n g t h a t " t h e l e f t h e m i s p h e r e o f s c h i z o p h r e n i c s i n a p p r o p r i a t e l y a c c e p t s m a t e r i a l o r d i n a r i l y d e s t i n e d t o be p r o c e s s e d b y t h e r i g h t h e m i s p h e r e o f n o r m a l s " ( S c h w e i t z e r , 1 9 7 9 , p . 7 2 3 ) . I f s o , t h i s c o u l d o v e r l o a d t h e l e f t h e m i -s p h e r e a n d c h r o n i c a l l y r e d u c e i t s c o g n i t i v e e f f i c i e n c y : t h e g e n e r a l l y p o o r p e r f o r m a n c e o f s c h i z o p h r e n i c s o n W o r d F l u e n c y i n t h e p r e s e n t s t u d y , e v e n a t d i s c h a r g e , w o u l d s u p p o r t t h i s h y p o t h e s i s . A l t e r n a t i v e l y , s i n c e b o t h W o r d F l u e n c y a n d F l a g s w e r e t i m e d t e s t s , t h e p o o r s h o w i n g b y s c h i z o p h r e n i c s o n t h e s e t e s t c o u l d s i m p l y h a v e b e e n d u e t o l a c k o f m o t i v a t i o n o r a t t e n t i o n a n d / o r p s y c h o m o t o r r e t a r d a t i o n . 189 A p p e n d i x I D I C H O T I C WORD T R I A D S T E S T S e x m a i n e f f e c t ( p < . 0 2 9 ) M e a n s M a l e s 0 . 1 1 8 F e m a l e s 0 . 0 4 6 . A s t h e a b o v e s h o w s , m a l e s . a s a g r o u p d e m o n s t r a t e d a g r e a t e r r i g h t e a r a d v a n t a g e t h a n f e m a l e s a s a g r o u p . T h i s i s i n a g r e e m e n t w i t h p r e v i o u s f i n d i n g s w i t h d i c h o t i c a l l y — p r e s e n t e d v e r b a l m a t e r i a l ( L a k e a n d B r y d e n , 1 9 7 6 ) , a n d i s c o n s i s t e n t w i t h s t u d i e s s u g g e s t i n g g r e a t e r h e m i s p h e r i c s p e c i a l i z a t i o n i n m a l e s t h a n i n f e m a l e s ( r e v i e w e d i n J o h n s o n a n d H a r l e y , 1 9 8 0 ) . S e x x T r i a l s e f f e c t ( p < . 0 5 3 ) M e a n s T r i a l 1 T r i a l 2 T r i a l 3 M a l e s 0 . 1 1 0 0 . 1 3 2 0 . 1 1 2 F e m a l e s 0 . 0 1 7 0 . 0 2 2 0 . 0 9 7 A s t h e a b o v e t a b l e s h o w s , f e m a l e s a s a g r o u p i n c r e a s e d t h e i r r i g h t e a r a d v a n t a g e a c r o s s t r i a l s , w h i l e m a l e s a s a g r o u p d i d n o t . H o w e v e r , a s t h e t a b l e b e l o w s h o w s , t h e i n c r e a s e d r i g h t e a r a d v a n t a g e . f o r f e m a l e s was d u e . e n t i r e l y t o f e m a l e s i n t h e p a t i e n t g r o u p s ; n o r m a l f e m a l e s a c t u a l l y , d e c r e a s e d t h e i r r i g h t e a r a d v a n t a g e a c r o s s t r i a l s . M o r e o v e r , m a l e s i n t h e p a t i e n t g r o u p s a l s o i n c r e a s e d t h e i r r i g h t e a r a d v a n t a g e a c r o s s . t r i a l s , b u t t h i s was o f f s e t f o r m a l e s a s a g r o u p b y t h e s u b s t a n t i a l , d e c r e a s e i n r i g h t e a r a d v a n t a g e o f n o r m a l m a l e s . T h u s . i n b o t h p a t i e n t g r o u p s b o t h s e x e s i n c r e a s e d r i g h t e a r a d v a n t a g e b e t w e e n a d m i s s i o n a n d d i s c h a r g e ; i n t h e n o r m a l g r o u p b o t h s e x e s d e c r e a s e d r i g h t e a r a d v a n t a g e a c r o s s t r i a l s . T h i s d r o p i n r i g h t e a r a d v a n t a g e f o r n o r m a l s i s d i s c u s s e d i n t h e D i s c u s s i o n s e c t i o n . M e a n s T r i a l 1 T r i a l 2 T r i a l 3 D E P R . M a l e s F e m a l e s 0 . 0 5 0 - 0 . 0 9 7 0 . 1 1 9 - 0 . 0 6 5 0 . 1 5 2 0 . 0 5 4 S C H I Z O . M a l e s F e m a l e s 0 . 0 4 5 - 0 . 0 3 6 0 . 1 2 6 0 . 0 0 1 0 . 0 9 5 0 . 1 1 4 NORMAL M a l e s F e m a l e s 0 . 2 3 6 0 . 1 8 5 0 . 1 5 0 0 . 1 3 0 0 . 0 9 0 0 . 1 2 5 190 Appendix J FLAGS TEST Groups x Sex x Experimenters e f f e c t (p<.032) As the table below shows, when depressives were tested by Experimenter I, males scored higher; when depressives were tested by Experimenter I I , females scored higher. The opposite was true for schizophrenics tested by each experimenter. In normals, males scored higher regardless of experimenter. Means for each Sex i n each Group EXPERIMENTER I EXPERIMENTER II Males Females Males Females Depressed 44.65 42.42 38.67 44.58 Schizophrenic 39.08 48.33 40.33 36.75 Normal 57.33 47.90 55.58 49.92 Groups x Sex e f f e c t (p<.026) As the table below shows, females i n both patient groups scored higher than males, while i n the normal control group males scored higher than females. Means Males Females Depressed 41.67 43.50 Schizophrenic 39.71 42.54 Normal 56.46 48.92 Since males have r e l i a b l y been shown to have superior.spatial a b i l i t y (Maccoby and J a c k l i n , 1974; Fairweather, 1976), the f a i l u r e of male psychiatric patients to demonstrate this s uperiority i s intriguing.. Several studies have suggested that female brains are less c l e a r l y l a t e r a l i z e d than male brains (reviewed i n Johnson and Harley, 198Q), and Levy (1969) has argued that superior s p a t i a l a b i l i t y i nmales i s due to their greater degree of hemispheric s p e c i a l i z a t i o n . If so, then right hemisphere cognitive d e f i c i t s associated with depression could be expected to be greater i n depressed males than i n depressed females, who may have some s p a t i a l c a p a b i l i t y i n the unaffected l e f t hemisphere. A l t e r n a t i v e l y , since females have been shown to use verbal mediation i n nonverbal tasks more than males do (McGlone and Kertesz, 1973), i t i s possible that female patients r e l i e d more on verbal a b i l i t y ? . w h i c h was r e l a t i v e l y unimpaired, than did male depressives. 

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