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Effect of chlorpromazine (largactil) on Porteus maze performance Quinn, Michael James 1958

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EFFECT OF CHLORPROMAZINE (LARGACTIL) ON PORTEUS MAZE PERFORMANCE by MICHAEL JAMES QUINN B.A., University of B r i t i s h Columbia, 1957 A Thesis submitted i n P a r t i a l Fulfilment of the requirements f o r the degree of MASTER OF ARTS i n the Department of Psychology We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1958 i i ABSTRACT T h i s study was designed to assess the e f f e c t of chlorpromazine, a " t r a n q u i l i z i n g " drug on Porteus Maze Performance, and to f i n d whether such e f f e c t was permanent or t r a n s i t o r y . The drug's e f f e c t on c l i n i c a l b e havior was a l s o e v a l u a t e d . Subjects were 44 a d u l t , male, c h r o n i c p s y c h o t i c s from the Mental H o s p i t a l , B r i t i s h Columbia. Each p a i r was matched e x a c t l y on i n i t i a l Maze s c o r e s and as c l o s e l y as p o s s i b l e f o r age, h o s p i t a l d u r a t i o n , e d u c a t i o n , o c c u p a t i o n , and m a r i t a l s t a t u s . A l l s u b j e c t s : had been diagnosed as s c h i z o p h r e n i c ; had not had chlorpromazine p r e v i o u s l y ; had not been operated on p s y c h o s u r g i c a l l y ; had been h o s p i t a l i z e d f o r at l e a s t t hree y e a r s ; showed no evidence of o r g a n i c b r a i n d i s e a s e . E x perimental s u b j e c t s were s e l e c t e d by random method. The L-M Fergus F a l l s Behavior R a t i n g Scale was used to evaluate c l i n i c a l b e h a v i o r . The experimental group r e c e i v e d 300 mg. d a i l y of chlorpromazine f o r 30 days, and the c o n t r o l group r e c e i v e d 300 mg. d a i l y of placebos f o r the same p e r i o d . Maze scores and Behavior r a t i n g s were obtained f o r each s u b j e c t before medication, d u r i n g medication, and a f t e r m e d i c a t i o n . The r e s u l t s were t r e a t e d s t a t i s t i c a l l y t o f i n d i f there were any s i g n i f i c a n t d i f f e r e n c e s between the two groups. The con-c l u s i o n s were that chlorpromazine had no s i g n i f i c a n t e f f e c t on e i t h e r Maze performance or c l i n i c a l b e h a v i o r . The r e s u l t s were i n the expected d i r e c t i o n but the Maze decrement and the i i c l i n i c a l Improvement a t t r i b u t a b l e to chlorpromazine were too s l i g h t to have s t a t i s t i c a l s i g n i f i c a n c e . I t was t e n t a t i v e l y -concluded: 1. t h a t Maze decrements r e s u l t i n g from chlorproma-z i n e are t r a n s i t o r y ; 2 . t h a t a d e c l i n e i n c l i n i c a l b e havior shown by the c o n t r o l group was due to placebo e f f e c t ; 3. t h a t the maximum e f f e c t s o f chlorpromazine were not achieved due to the composition of the group, the moderate dose, and the short d u r a t i o n of treatment. In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head o f my Department o r by h i s r e p r e s e n t a t i v e . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f Psychology  The U n i v e r s i t y of B r i t i s h Columbia, Vancouver 8, Canada. Date 30 September 1958 i i i TABLE OF CONTENTS Chapter Page I Introduction 1 I I Review of Li t e r a t u r e Concerning C l i n i c a l and Psychological Aspects of Chlorproma-zine Therapy 4 Comparison of Chlorpromazine with Reserpine and Perphenazine 10 Effect of Chlorpromazine on Various Mental Tests 11 Summary of C l i n i c a l Findings on Chlorpromazine 12 I I I The Porteus Maze Test 16 Nature of the Test and i t s Uses 17 Studies Concerning the E f f e c t of Lobotomy on Maze Performance 19 IV Previous Studies of Porteus Maze Performance During Chlorpromazine Therapy 25 V Experimental Design 28 Selection of Subjects 30 Double Bl i n d Technique 32 Matching Procedure 33 Selection of Experimental Group 34 Medication Procedure 35 Rating Scale 36 Intervals Between Measures 37 continued -i v Chapter Page VI Results 39 Composition of the F i n a l Sample 39 The Matching Variables 41 E f f e c t of Medication on Maze Performance 46 Ef f e c t of Medication on Behavior Ratings 51 Summary of Findings 52 VII Discussion 56 VIII Summary and Conclusions 62 References 65 Appendices 69 V TABLES AND FIGURES Table Page I Correlation of Maze Scores with the Different Variables , 42 I I Comparison of Experimental and Control Groups on Variables of Age, Hospital Duration, and Years of Schooling 4 4 I I I Actual and Expected Frequencies of Experimental and Control Subjects i n Two Occupational Levels 45 IV Actual and Expected Frequencies of Experimental and Control Subjects i n Married and Unmarried Categories 45 V Comparison of Maze Scores of Experimental and Control Groups f o r Three Applications of the Maze Test 41 VI Rank Order Correlations Between Raters 52 VII Comparison of Behavior Ratings of Experimental and Control Groups 54 Figures 1. Experimental and Control Groups 1 Means on Three Applications of the Maze Test 47 2. Experimental and Control Groups' Means on Three Behavior Ratings 53 v i LIST OF APPENDICES Appendix Page A Procedure f o r Administering and Scoring the Quantitative Scale of the Porteus Maze Test 69 B The L-M Fergus F a l l s Behavior Rating Scale 77 C Tabulation of Raw Data 82 v i i ACKNOWLEDGEMENTS The writer wishes to express h i s thanks to his sponsor, Professor Edwin S. W. Belyea of the Department of Psychology, University of B r i t i s h Columbia, for his help and guidance throughout the inv e s t i g a t i o n , and to Dr. Douglas T. Kenny of the Department of Psychology, University of B r i t i s h Columbia, for his advice regarding the experimental design and s t a t i s t i c a l treatment of data. He wishes to thank Dr. T. G. Caunt, d i r e c t o r , P r o v i n c i a l Mental Hospital, B r i t i s h Columbia, for permission to carry out the study; Mr. J . Borthwick, chief psychologist, Crease C l i n i c , f o r his assistance during the I n i t i a l phase of the study, and Mr. K. Woolcock, chief pharmacologist, f o r his help with the experimental design. Last but not least he wishes to thank the nurses and aides who participated i n the study as well as the patients who served as subjects. The writer i s g r a t e f u l f o r f i n a n c i a l support f o r t h i s research which was provided from research grant number 201 of the President's Committee on Research of the University of B r i t i s h Columbia. He wishes to thank Poulene Limited f o r supplying a generous quantity of chlorpromazine and placebo tablets f o r use i n t h i s experiment. CHAPTER I INTRODUCTION The purpose of t h i s study was to assess the effects of chlorpromazine,* a " t r a n q u i l i z i n g " drug, on Porteus Maze Performance, and to determine whether such effects were permanent or t r a n s i t o r y . Since the subjects to be studied were mental patients i t was decided also to evaluate the effects of chlor-promazine on c l i n i c a l behavior. The study was designed to use an experimental and a control group i n which each pair of subjects was matched on several variables and i n which the experimental subjects would receive chlorpromazine and the control subjects placebos. t The study was undertaken p a r t l y as a result of the t i m e l i -ness of the topic; namely, that t r a n q u i l i z i n g drugs are being used on an increasing scale i n the treatment of mental i l l n e s s ; and p a r t l y as a result of previous findings. These findings ( 1 2 , 2 2 , 2 8 - 3 3 ) suggested that both chlorpromazine and lobotomy pro-duced a s i g n i f i c a n t decrement i n Porteus Maze performance. This effect of chlorpromazine led Porteus ( 3 0 ) to term i t "pharmacologi-c a l lobotomy." I t s tendency to weaken impulsion and reduce i n i t i a t i v e caused Delay ( 9 ) to draw a s i m i l a r conclusion when he referred to i t as "medicated lobotomy." * This drug has the chemical designation 3-chloro - 1 0 ( 3 -dimethylaminopropyl) phenothiazine hydrochloride ( 2 0 ) . Placebos are composed of a chemically i n e r t substance. 2 The discovery of chlorpromazine i n 1951 was hailed as the beginning of a new era i n psychiatry. The general opinion was that here was a drug that would quiet and soothe the patient without causing stupor or impairment of consciousness. This discovery was followed by the development i n 1954 of reserpine ( 9 ) a drug chemically diff e r e n t from chlorpromazine but s i m i l a r i n i t s c l i n i c a l effects except that i t i s less powerful, slower acting, and less constant. Perphenazine i s a r e l a t i v e l y new drug and l i t t l e research has been done on i t but i t s potency i s reported as 5 to 10 times greater than chlorpromazine ( 2 1 ) . These are but three of several t r a n q u i l i z i n g or neuroleptic drugs now on the market. Of these chlorpromazine i s the best known and the most widely used. A substantial body of l i t e r a -ture has been published related to i t s c l i n i c a l effects and therapeutic value. As an example of the widespread use of chlorpromazine i n the United States i t has been estimated that up to the end of 1955 as many as 4 m i l l i o n patients had had i t prescribed for them ( 2 6 ) . A l l of these drugs act upon the central nervous system. They induce a state of relaxation and calm with a general diminution of somatic functions and i n h i b i -t i o n of psychic e f f i c i e n c y l e v e l . Despite the large body of l i t e r a t u r e relevant to the therapeutic value of neuroleptic drugs the reader i s frequently l e f t with the impression that the results of many of these studies are inconclusive. This i s probably due to the fact 3 that many of them are l i t t l e more than subjective evaluations of the drug's e f f i c a c y . In others, attempts have been made to set up experimental situations with some degree of control over extraneous variables but even here the r e s u l t s , although quanti-f i e d , are often d i f f i c u l t to interpret owing to the lack of an objective c r i t e r i o n f or assessing the drug's effectiveness. Therapeutic value i s usually assessed i n terms of improvement as measured by various rating scales but the scales themselves are seldom described nor the f a l l i b i l i t y of raters taken into consideration. The general impression that emerges from a perusal of the l i t e r a t u r e i s that these drugs are very useful i n the symptomatic treatment of mental i l l n e s s , and that c e r t a i n types of mental patients respond more favourably than others. They do not provide a cure and the percentage of discharges that can be attributed to t h e i r use i s extremely small. In the following section an attempt i s made to review a representative portion of the more important findings concerning the effects of t r a n q u i l i z i n g drugs i n general and chlorpromazine i n p a r t i c u l a r . CHAPTER I I REVIEW OF LITERATURE CONCERNING CLINICAL AND PSYCHOLOGICAL ASPECTS OF CHLORPROMAZINE THERAPY . The development of chlorpromazine i n 1951 by French s c i e n t i s t s was i n i t i a t e d by the search f o r a drug that would induce a state of natural sleep or " a r t i f i c i a l hibernation" without at the same time producing hypnotic or sedative e f f e c t s . Chlorpromazine appeared to possess some of the necessary require-ments, namely, the property of inducing a state of calm and a reduction of tension without stupor. While under i t s influence the patient could be aroused without any apparent loss of con-sciousness or i n t e l l e c t u a l functioning. The method of treatment varies with the nature and i n t e n s i t y of the disease, some ps y c h i a t r i s t s preferring to use chlorpromazine alone while others use i t i n combination with barbiturates and other sedatives to produce prolonged sleep therapy. The dosage varies according to the patient's state and according to i n d i v i d u a l tolerance. I t may range from 25 mg. to 2000 mg. a day but the average seems to be about 300 mg. or 400 mg. d a i l y . The t o t a l d a i l y amount i s usually spread over three or four administrations d a i l y (16). The drug may be administered by mouth or parenterally. When injected i t s use i s somewhat li m i t e d owing to the fact that a smaller dose must be given than when taken o r a l l y and because the solution used i r r i t a t e s the tissues. A high i n i t i a l dose may cause unpleasant 4 5 side effects and a too rapid lowering of dose may bring about relapse or a sudden flareup of pathologic symptoms. For t h i s reason medication i s usually started and terminated gradually. In most cases side effects are harmless and may be al l e v i a t e d or prevented by the use of other drugs or by reducing or termin-ating the dose. Chlorpromazine l i k e other " t r a n q u i l i z e r s " has a depres-sant effect on the nervous system. This sometimes results i n a lowering of blood pressure during the early phase of treatment with possible subsequent f a i n t i n g or p a l p i t a t i o n and shortness of breath. Parkinsonian symptoms such as masklike face, tremor, s a l i v a t i o n , and akinesis have been noted by several investiga-tors (7j 8, 14, 1 6 ). Chlorpromazine i s antiemetic. I t usually produces an increase i n appetite followed by an increase i n weight. Among the more unpleasant side effects have been noted a l l e r g i c affections of the skin and i n some cases jaundice. Some patients develop a peculiar s u s c e p t i b i l i t y of the skin to solar irradiation. The majority of side effects appear to occur during the f i r s t two weeks of medication and most of the compli-cations appear within the second two weeks. Side effects tend to be more intense when the drug i s administered parenterally and when the o r a l doses are high. Drowsiness and lethargy are the most frequently noted side e f f e c t s . Apathy, loss of i n t e r -est i n surroundings, and lack of i n i t i a t i v e are common i n pa-tie n t s who receive intramuscular doses exclusively and when the or a l dose i s 600 to 800 mg. d a i l y ( 6 ) . 6 Chlorpromazine therapy i s not equally e f f e c t i v e with a l l types of mental I l l n e s s . Some of the most dramatic effects are reported to have occurred i n hall u c i n o s i s or delirium r e s u l t i n g from acute schizophrenic episodes or alcohol (14, 42). In such patients hallucinations, delusions, and the need for maximum re s t r a i n t a l l disappeared with i n hours after administration of the drug. Chronic patients require longer treatment and a higher dosage than acute cases, and although a majority of the chronic cases do not respond to the point where complete rehab-i l i t a t i o n i s possible they do show some improvement as evidenced by a reduction of the most serious psychotic manifestations. As evidence of improvement the l i t e r a t u r e frequently c i t e s a reduction i n violence and destruction, and less need for physi-c a l r e s t r a i n t . An important result of such improvement i s the changed atmosphere of the wards and the changed attitudes and behavior of the nursing s t a f f . Resentment, h o s t i l i t y , and nega-tivism give way to f r i e n d l y interest and cooperation which leads to increased in t e r a c t i o n between patients and personnel and to a program of i n d i r e c t psychotherapy. In the treatment of manic-depressive psychoses chlorproma-zine i s more eff e c t i v e with the manic than with the depressive phase. The manic process does not subside as r a p i d l y as the patient's o v e r a c t i v i t y . Depressiyes show l i t t l e improvement with the drug alone but respond better to electro-convulsive therapy i f used i n conjunction with chlorpromazine. 7 Many excellent descriptions of the " t r a n q u i l ! z i n g " effects of chlorpromazine indicate general agreement that the drug produces a marked change i n "pathological o v e r a c t i v i t y . " However, i n assessing behavioral change, few investigators have specified i n advance the p a r t i c u l a r changes that would denote a reduction of pathological a c t i v i t y . Using a double blind technique Cutler et a l (8) studied the effects of chlor-promazine on pathological a c t i v i t y i n twelve psychotic patients. Twenty-eight s p e c i f i c signs of behavioral o v e r a c t i v i t y were specified i n advance and quantified by actual count of the num-ber of times they appeared per week. Hospital personnel were trained to observe the appearance and record the frequency of pathological symptoms c h a r a c t e r i s t i c of each patient. Inter-observer rank order correlations had a median p of .90. I t was found that 600 mg. per day of chlorpromazine resulted i n a s t a t i s t i c a l l y s i g n i f i c a n t reduction of pathological a c t i v i t y (p *£. .01). However, t h i s reduction i n pathological a c t i v i t y appears to have been achieved at the expense of wakefulness as the patient tended to sleep more while taking the drug. A study by Rees and Lambert (35) based on 150 out-patients with anxiety states suggests that the usefulness of chlorpromazine with t h i s group may be l a r g e l y r e s t r i c t e d to short term symptomatic treatment and management. Marked or moderate improvement was reported for 54- per cent of the group but after a- few weeks two t h i r d s of these relapsed despite con-tinued medication. Assessment of improvement was based on 8 subjective reports by the patient, appearance, behavior, and c l i n i c a l examination. Patients reported a reduction i n anxiety, tension, and apprehension, accompanied by a f e e l i n g of calmness. Feldman et a l (11) carried out an experimental study to assess the effects of chlorpromazine i n the treatment of 22 psychotic patients who were considered "management problems." Most of these patients were schizophrenics and most had f a i l e d to respond favorably to other therapies. Degree of improvement was assessed according to psychiatric evaluations and the Ferguson Rating Scale. Dosage was from 200.to 400 mg. a day fo r three months. Nine out of eleven chlorpromazine patients showed improvement and four of eleven placebo patients improved. There was a low positive c o r r e l a t i o n between the Ferguson scale ratings and the c l i n i c a l evaluations. As found by other i n -vestigators the ward behavior of patients showed a marked change for the better. There was a reduction i n r e s t r a i n t s and seda-t i o n , an improvement i n eating and sleeping and an increase i n adjunctive therapy a c t i v i t i e s . The only side effect of any significance was drowsiness. A review of the following l i t e r a t u r e (2, 4, 8, 10, 38) suggests: A general effect of chlorpromazine i s to reduce ten-sion. Tense, excited schizophrenics respond more favorably to the drug than depressed or less agitated schizophrenics. With prolonged treatment (3 to 6 months) the effects of the drug usually p e r s i s t f o r 2 to 5 months after medication i s terminated. 9 In general, depressed patients do not respond we l l to chlorpro. mazine, and those who do show some improvement usually relapse after the drug i s stopped. Tenenblatt and Spagno (38) carried out a controlled study of the effects of chlorpromazine on 100 negro women patients, a l l of whom were considered disturbed. Their main conclusions are worth quoting: 1. Chlorpromazine i s eff e c t i v e i n the treatment of chronic psychotic patients, since 90$ of the controls remained unchanged as compared to 20% of the patients on chlorpromazine. 2. The age of the patient, duration of i l l n e s s , and previous therapy have no effect on the response to the drug. 3. Chlorpromazine i s not effective i n the treatment of inv o l u t i o n a l psychoses or general paresis. 4. I t i s most ef f e c t i v e i n the treatment of manic and schizophrenic patients, p a r t i c u l a r l y catatonic and paranoid, although the other types showed some response. 5. The most e f f e c t i v e dose and duration of therapy must be determined f o r the i n d i v i d u a l patient by t r i a l and error method, but from a l l indications i f there i s no response after 6 weeks of therapy, there w i l l probably not be any response from prolonging the treatment. In t h i s study l a c t a t i o n (noted by other investigators) occurred i n 36 per cent of the experimental group. An o v e r a l l effect of the project was an increase i n morale of the hospit a l personnel and patients' r e l a t i v e s so that management improved and many more patients were permitted p r i v i l e g e s . This aspect of chlorpromazine therapy has frequently been noted by other observers. 10 These findings may be summarized as follows: Chlorpromazine i s a new drug found to be useful i n the t r e a t -ment of mental i l l n e s s . I t s main therapeutic value i s to reduce tension and anxiety and a l l e v i a t e various psychotic manifestations without causing stupor or unconsciousness. I t a l l e v i a t e s psychotic symptoms but does not a l t e r the underlying problems. Since i t acts as a depressant i t i s more e f f e c t i v e i n reducing o v e r a c t i v i t y than i n r e l i e v i n g depression. Comparison of Chlorpromazine with Reserpine  and Perphenazine Like chlorpromazine, reserpine's action i s i n h i b i t o r y and consists of a reduction of the a c t i v i t y of the central sym-pathetic mechanism (3, 25). Perphenazine i s s i m i l a r to chlorpromazine and has the same effect but i s more potent. The s i t e and mode of action of these drugs i s s t i l l l a r g e l y hypothetical. Chlorpromazine and perphenazine are thought to affect p r i n c i p a l l y the " a l e r t i n g " system of the brain (21). Reserpine i s believed to be mediated, i n part, through the cortex as opposed to the midbrain structures for the other two drugs. Goldman (15) found chlorpromazine more ef f e c t i v e than reserpine i n r e l i e v i n g paranoid symptoms, but neither drug was very e f f e c t i v e i n depressive reactions. There was no clear d i s t i n c t i o n i n effectiveness between the two drugs with schizo-phrenics hospitalized f o r s i x months or less but chlorpromazine was more e f f e c t i v e than reserpine with schizophrenics of longer hospital duration. 11 Kovitz et, a l (17) found chlorpromazine s l i g h t l y more effe c t i v e than reserpine with schizophrenics. Chlorpromazine acts more r a p i d l y than reserpine but i t s side effects are more unpleasant. Both drugs produce e s s e n t i a l l y symptomatic im-provement . Effect of Chlorpromazine on Various Mental Tests Very l i t t l e s i g n i f i c a n t research has been reported i n which psychological tests have been used to assess the effects of chlorpromazine and other " t r a n q u i l i z i n g " drugs. An attempt i s made here to summarize b r i e f l y a few of the more important findings i n t h i s area. Primac et a l (34-) found that chlorpromazine resulted i n a s i g n i f i c a n t lowering of scores on the Continuous Performance Test, a test designed to measure sustained attention. P e t r i e and Le Beau (27) reported that chlorpromazine patients showed no loss on the Wechsler-Bellevue Intelligence Test or the Porteus Maze Test. Lehmann and Hanrahan ( 2 0 ) reported a simi-l a r f i n d i n g . Bair and Herold (4) investigated the effects of chlorpromazine on hyperactive, mentally retarded children. Their r e s u l t s , based on ten matched p a i r s , showed a s i g n i f i c a n t gain of 10.4 I.Q. points f o r the experimental group after 60 days of medication. The control group, which received no medi-cation of any kind, showed no s i g n i f i c a n t change. The measure of i n t e l l i g e n c e used was the Columbia Mental Maturity Scale. Mason-Browne and Borthwiek (21) compared the effects of perphena-zine and chlorpromazine on f i v e separate measures. These 12 measures were designated as Rating Scale, Tapping and Dotting, Wechsler-Bellevue D i g i t Symbol, and D i g i t Span, and the Porteus Maze Test. Their results show that both perphenazine and chlorpromazine patients improved on a l l measures except the Porteus Maze, on which both groups showed a s l i g h t but s t a t i s t i -c a l l y i n s i g n i f i c a n t decrement. The only two tests that showed a s i g n i f i c a n t v a r i a t i o n were Tapping and Dotting, the improve-ment being s i g n i f i c a n t f o r perphenazine but not f o r chlorproma-zine . This review suggests that the findings are not consist-ent as regards the effect of chlorpromazine on various t e s t s . However, the trend appears to be i n the d i r e c t i o n of improvement on most t e s t s . Tests l i k e the Continuous Performance Test and the Porteus Maze appear to be exceptions due perhaps to the s i m i l a r i t y of functions they are supposed to measure. But even here the findings are not unanimous. Studies concerning the effect of chlorpromazine on Porteus Maze performance are reviewed i n Chapter IV. Summary of C l i n i c a l Findings on Chlorpromazine This b r i e f review of current thinking on the c l i n i c a l e f f i c a c y of chlorpromazine may be summarized as follows: Chlorpromazine has the capacity to bring about sedation and quiet without s i g n i f i c a n t impairment of consciousness. Serious side effects are rare and nearly always reve r s i b l e . There i s general agreement that the drug reduces psychomotor 13 a c t i v i t y , assaultiveness, h o s t i l i t y , and negativism; that patients are less r e s t l e s s , more cooperative, and more manage-able. They show considerable reduction i n anxiety, appear to be i n better contact with t h e i r environment, and are less disturbed by t h e i r hallucinations and delusions. This means that some patients, previously inaccessible, become amenable to other therapies such as psychotherapy, occupational therapy, and recreational therapy. Chlorpromazine reduces the need for shock therapy as well as the need for r e s t r a i n t s and seclu-sions. I t appears to be most useful i n the treatment of the paranoid and catatonic schizophrenias, and the manic phase of manic-depressive psychosis but much less e f f e c t i v e i n the t r e a t -ment of deteriorated schizophrenics and agitated depresslves. The age of the patient and the duration of i l l n e s s seem to make l i t t l e difference as f a r as the outcome of chlorpromazine therapy i s concerned, but on t h i s point agreement i s not unani-mous. The effect on the ward i s marked. There i s less annoyance, less antagonism, and i n general an increased f r i e n d -l i n e s s and cooperation between a l l concerned. Neither chlor-promazine nor reserpine nor any of the kno-wn t r a n q u i l i z e r s i s b a s i c a l l y curative, but from the c l i n i c a l point of view they are very useful i n a l l e v i a t i n g various symptoms without produc-ing sedative or hypnotic e f f e c t s . They thus add greatly to the comfort of the patient and of those about him. Most of the l i t e r a t u r e related to the effects of these 14 drugs emphasizes the gain i n " s o c i a l improvement" following or during t h e i r use. However, the c r i t e r i a of Improvement and the methods of assessing i t are often open to question owing to the absence of adequate controls and f a i l u r e to specify the standard that permits the placement of patients i n various "improvement" categories. Considerable s u b j e c t i v i t y and numer-ous i n v a l i d i t i e s are bound to be present when unknown and unstandardized rating methods are used to assess the effects of various drugs. For these reasons many of the reports are equivocal or d i f f i c u l t to i n t e r p r e t . A general opinion among investigators i s that chlorproma-zine leaves a l l i n t e l l e c t u a l functions clear and i n t a c t , and that i t ameliorates disturbing symptoms that are p r i n c i p a l l y dependent on feelings for t h e i r o r i g i n and maintenance. In the investigations reviewed i n t h i s chapter a few have attempted to assess i n t e l l e c t u a l change using various mental tests i n c l u d -ing tests of general i n t e l l i g e n c e such as the Wechsler-Bellevue. The result s appear to be i n general agreement with the above observation that chlorpromazine leaves i n t e l l e c t u a l functioning unimpaired. The Porteus Maze has been used i n several investigations into the effects of chlorpromazine and lobotomy, and i n most cases chlorpromazine and lobotomy patients are reported to have shown a s i g n i f i c a n t decrement i n Maze Performance. This test i s claimed by i t s author to be a test of planning capacity and 15 foresight, two important aspects of i n t e l l e c t u a l functioning. I f t h i s claim i s v a l i d , and i f the findings reported f o r the Maze are substantiated, t h i s would suggest that chlorpromazine may have an adverse effect on these p a r t i c u l a r aspects of i n t e l l e c t u a l functioning. The l i t e r a t u r e r e l a t i n g to the Porteus Maze Test i s reviewed i n the following chapter. CHAPTER I I I THE PORTEUS MAZE TEST The Porteus Maze Test had i t s f i r s t public description at a meeting of the B r i t i s h Association for the Advancement of Science i n Melbourne i n 1914. The test i s a series of p e n c i l -paper maze designs of graduated d i f f i c u l t y ranging from the three year l e v e l to the 17 year l e v e l . Between 1915 and 1924 the test was administered to several thousand children includ-ing mental defectives, normals, c l i n i c cases, selected and unselected school children, representing d i f f e r e n t age le v e l s and d i f f e r e n t socio-economic classes. In these standardization studies the Maze test was validated against the Goddard Revision of the Binet test and l a t e r against the 1916 Revision of the Stanford-Binet. The scoring was revised several times between 1914 and 1933 and i n 1933 a procedure was introduced which pro-vided for a c e i l i n g performance of 17 years. A q u a l i t a t i v e scoring system (Q) pertaining to personal-i t y rather than i n t e l l i g e n c e was introduced i n 1942 but no s i g n i f i c a n t changes were made i n the quantitative scale u n t i l 1955 when the extension series (a p a r a l l e l test) was published. The extension series has no tests below the 7 year l e v e l and Porteus recommends that both series be used i n combination for subjects 14 years and older. When the subject i s less than 14 16 17 years old i t i s recommended that the o r i g i n a l series be used alone according to the procedures published i n 1950 ( 2 9 , 3 0 ) . The procedures used i n administering and scoring the test i n the present study are shown i n Appendix &. These rules may be summarized b r i e f l y as follows: The test consists of eight l e v e l s of d i f f i c u l t y ; years 7> 8 , 9> 1 0 , 1 1 , 1 2 , 14, and Adult. The subject begins with a credit of 6 years of mental age and i s allowed an additional year of mental age f o r each test successfully passed from year 7 through 1 1 . He i s al l o t t e d two years of mental age each for years 1 2 , 14, and Adult. He i s allowed two t r i a l s on each test from year 7 through 1 1 , four t r i a l s each on years 12 and 14, and three t r i a l s on the Adult t e s t . I f he f a i l s a l l the a l l o t t e d t r i a l s on a given test (year l e v e l ) he i s regarded as having f a i l e d that t e s t . Testing i s continued u n t i l two successive f a i l u r e s above 9 years have been recorded or any three f a i l u r e s . When any test i s f a i l e d , e.g. year 1 0 , and the following t e s t , year 1 1 , i s passed, year 11 i s inverted and presented again. I f the inverted form i s passed within the a l l o t t e d number of t r i a l s the subject i s given credit for year 1 1 . I f the inver-ted form i s f a i l e d the subject receives no credit f o r that year l e v e l . The test i s scored by deducting one-half year f o r each unsuccessful t r i a l throughout the series. Nature of the Test and i t s Uses Porteus has consistently claimed that his test i s a measure of planning and foresight, two elements of i n t e l l e c t u a l 18 function that are included i n most d e f i n i t i o n s of i n t e l l i g e n c e . He defines i n t e l l i g e n c e as " . . . the capacity for making planned responses to an increasing range of relevant s t i m u l i . " ( 2 9 , p. 1 0 ) . The Maze test purports to measure both concrete and abstract planning at a simple fundamental l e v e l . I t i s not claimed to be a substitute f o r tests such as the Stanford-Binet (S-B) or the Wechsler-Bellevue (W-B) but a valuable diagnostic supplement. The fact that the i n t e r - c o r r a l a t i o n s between the Maze and numerous other tests are at a r e l a t i v e l y high l e v e l indicates " . . . an extreme c a t h o l i c i t y of r e l a t i o n -ship . . . not shown by any other performance t e s t . . . ." (29> p. 3 2 ) . Porteus reasons that t h i s r e l a tionship can be accounted for by assuming that planning i s a factor common to a l l these t e s t s , a factor which the Maze s p e c i f i c a l l y measures. Tizard ( 3 9 ) notes that of 28 correlations reported between the Porteus Maze and the Stanford-Binet the median r. f o r a narrow chrono-l o g i c a l age range was . 5 4 and the median r. for a wide chrono-l o g i c a l age range was . 6 9 . Sex differences revealed by the Maze led Porteus to conclude that such differences were probably " . . . due to the more temperamental, less i n t e l l e c t u a l t r a i t s involved i n performance." ( 2 9 , p. 3 3 )• This discovery as w e l l as notable differences between the Maze scores of normal sub-jects as opposed to delinquents and psychopaths led to the concept of the Maze as a measure of s o c i a l a d a p t a b i l i t y , and subsequently, to the development of a q u a l i t a t i v e score of social or i n d u s t r i a l capacity. Since the present study i s concerned 1 9 with the quantitative scale only, the Q-scale w i l l not he d i s -cussed. A detailed treatment of the Q-scale i s contained i n the 1950 and 1955 Maze test manuals (29, 30). Studies Concerning the E f f e c t of Lobotomy  on Maze Performance The main evidence f o r the claimed v a l i d i t y of the Maze test as a measure of planning capacity and foresight comes from studies related to the effects of lobotomy (leucotomy) on test performance. The patient's condition following lobotomy i s vari o u s l y described as: emotional childhood, indifference, apathy, mental confusion, lacking i n i n i t i a t i v e , lack of planning and fore-sight, short attention span, et cetera (12, 29, 36, 37)» In contrast to the inadequacy of s o c i a l behavior, as demonstrated by these e f f e c t s , i n t e l l e c t u a l functioning, as measured by most psychological t e s t s , appears to be unimpaired. With few excep-tions performance on the Porteus Maze has declined following psychosurgery. In 1944 Porteus and Kepner (29) reported the pre-operative and post-operative Maze scores for 17 lobotomy patients and 17 controls. The net loss f o r the lobotomy groups was 1.97 years while the control group made an average gain of 1.94 years, t h i s gain being attributed to practice. A follow-up study on another group of 13 psychosurgical patients showed that the average loss was s t i l l 2.2 years several months after the opera-t i o n . Only f i v e of the group showed any improvement over t h e i r 20 i n i t i a l post-operative scores although some of these had had four or f i v e applications of the t e s t . These and s i m i l a r findings led Porteus and Kepner to conclude i n 1944 that " ... lobotomy.patients test 4 years below what might be expected i f ordinary practice effects had operated." (29, p. 80). This value of four years represents the average loss shown by lobotomy patients plus the average gain shown by control sub-je c t s . In a l a t e r i n v e s t i g a t i o n , Porteus and Peters (28), using a larger group (55 lobotomy patients and a control group of 55 unoperated prisoners) confirmed the previous r e s u l t s . The average post-operative loss for the patients was 1.65 years and affected 81 per cent of the group at the f i r s t post-operative or some subsequent testing as against an average gain for the control group of 1.6 years. Allowing for the effects of prac-t i c e , the comparative loss f o r the lobotomy group was 3«25 years. Repeated applications of the test showed that 67.3 per cent of the control group improved t h e i r scores as against 7-3 per cent for the lobotomy cases. In order to determine whether s o c i a l recov-ery was re f l e c t e d i n Maze performance the lobotomy subjects were divided into three groups: 1. unimproved; 2. improved; and 3» those who had recovered s u f f i c i e n t l y to be discharged or placed on long-term parole. Following the operation groups 2 and 3 showed greater i n i t i a l loss than group 1. Repeated applications of the Maze suggested a relationship between degree of s o c i a l recovery and Maze test pattern, namely, a pronounced i n i t i a l 21 loss on the f i r s t post-operative test followed by successive gains up to and beyond the pre-operative l e v e l . The Maze was part of a test battery used i n the exten-sive Columbia-Greystone investigations into the effects of psychosurgery ( 2 2 ) . The Maze was administered to 32 patients divided into a control group of 13 and an experimental group of 1 9 . Both"groups were equated for sex, age, education, I.Q. (W-B), and Maze scores. Each patient received one pre-operative application and three post-operative applications of the Maze t e s t . On the f i r s t post-operative testing the exper-imental group showed an average loss of 1 . 2 1 years while the control group showed a s l i g h t gain. On the t h i r d post-operative t e s t i n g , eight months after the operation, the exper-imental group had recovered t h e i r loss and were s l i g h t l y above t h e i r pre-operative l e v e l but s t i l l below the control group. Sheer, i n reporting the effects of lobotomy on 3 6 patients, states with reference to the Maze: " . . . the data indicated a s i g n i f i c a n t l y greater decrement f o r the operated patients i n the immediate postoperative period than at the 30 or 90 day testing periods." ( 1 9 , p. 6 4 ) . The average Maze loss f o r the t o t a l group of 36 patients examined ten days after the operation was 3*78 years; f or those examined t h i r t y days after the operation the loss was 1 . 8 4 years, and f o r those examined ninety days afterwards the loss was 1 . 9 2 years. As well as confirming previous findings of marked i n i -t i a l loss after the operation followed by gradual improvement 22 these studies showed also that Maze performance varied accord-ing to the severity of the operation. The more anterior the operation the less was the Maze decrement. At the t h i r d Research Conference on psychosurgery held i n New York i n 1951 Landis summed up the s i t u a t i o n as follows: In the battery of tests which was used i n the f i r s t Greystone, the second Greystone, and the New York State Project, we included both the standard Wechsler-Bellevue and the Porteus Maze t e s t . In the test-by-test analysis of the re s u l t s which we obtained, the only i n t e l l i g e n c e test which showed a uniform or almost uniform loss during the f i r s t month after operation compared to the preopera-tive performance on t h i s battery of tests was the Porteus Maze Test. . . . We confirmed his [Porteus] finding that a brain operation on the f r o n t a l lobes gives r i s e to an immediate postoperative loss i n mental age of 1 to 2 years i n some 80 per cent of psychosurgery patients. ( 1 8 , p.109) As these studies progressed i t became apparent that a certain amount of improvement i n Maze performance could be attributed to practice. In the Columbia-Greystone project the experimental group's return to i t s pre-operative l e v e l was interpreted as indicating no permanent loss due to the operation but t h i s i n t e r p r e t a t i o n appears to have been made without due consideration of practice e f f e c t s . I t was t h i s d i f f i c u l t y of determining whether Maze decrements following psychosurgery were permanent or t r a n s i t o r y that prompted Porteus to develop a second series of t e s t s . The extension s e r i e s , published i n 1955 ( 3 0 ) , i s simi-l a r i n design to the standard series except that some of the pathways have been lengthened and the number of blind alleys 23 increased, making the test s l i g h t l y more d i f f i c u l t than the o r i g i n a l . The new series was standardized against the o r i g i -nal using 300 subjects divided into s i x groups of 50 each. The subjects were intermediate and high-school students, 150 of each sex, and represented both r u r a l and urban d i s t r i c t s with a d i s t r i b u t i o n of socio-economic l e v e l . Each group was tested on the same day with the extension applied immediately after the o r i g i n a l . The agreement between the scores on both series of the test was found to be very close. The largest mean difference i n score between the two tests f o r groups of 50 subjects was . 17 of a year. For groups of 100 the largest mean difference was . 0 8 5 of a year, and for the t o t a l group of 300 cases the mean difference was . 0 2 of a year. Porteus points out that while these figures prove the equivalence of the two versions of the test f o r a s p e c i f i c segment of the population only, " . . . there i s good evidence f o r the assumption that the Maze i s less affected by c u l t u r a l l e v e l than any other test i n common use, and c u l t u r a l l e v e l includes education." ( 3 0 , p. 3 D ' Whether the two forms of the test are also equivalent for psychotic subjects has yet to be established. The only studies available i n which both the o r i g i n a l and extension series have been applied to psychotic subjects seem to be those reported by Porteus and Barclay ( 3 2 ) . These are con-sidered i n the following chapter, but fo r the present i t may be noted that i n two of these the controls showed a loss on 24 the extension Maze of 0.10, and 0.04 of a year. In a t h i r d study the controls showed a gain on the extension maze of 0.20 of a year. These observations are reported here merely to suggest that the two forms of the Maze may be less equiva-lent f o r a psychotic than for a "normal" population. In t h i s chapter the l i t e r a t u r e concerning the develop-ment of the Porteus Maze Test and i t s use i n assessing the effects of lobotomy has been reviewed. According to these studies the Maze was found to be consistently sensitive to mental changes induced by psychosurgery. In the following chapter the l i t e r a t u r e concerning the effect of chlorpromazine on Maze performance i s considered. CHAPTER IV PREVIOUS STUDIES OF PORTEUS MAZE PERFORMANCE DURING CHLORPROMAZINE THERAPY While extremely l i t t l e research has been done concern-ing the effects of neuroleptic drugs on Maze performance the available findings suggest a marked p a r a l l e l between chlor-promazine and psychosurgery. Both chlorpromazine and psychosurgery are used to relie v e intractable pain; both reduce anxiety and tension. Terms descriptive of the lobotomy patient's behavior: de-creased v i g i l a n c e , increased somnolence, apathy, indifference, improved appetite, increase i n body weight, are frequently noted i n the l i t e r a t u r e related to chlorpromazine therapy. I f Maze reactions are found to be s i m i l a r following the two methods of treatment then the analogy between psychosurgery and chlorpromazine would be more complete. In a comparison of chlorpromazine and reserpine Gardner et a l (13) reported that 4 out of 9 chlorpromazine patients improved i n Maze scores, 8 out of 10 reserpine patients im-proved, and 2 out of 10 placebo patients improved. In t h i s study the o r i g i n a l series of the Maze appears to have been used before and after treatment so that an indeterminate amount of recovery may have been due to practice e f f e c t s . Four of the W-B subtests that were found to be sensitive to 25 26 drug-induced changes were: Arithmetic, S i m i l a r i t i e s , Vocabu-l a r y , and Picture Completion. No figures are given but a l l the differences reported were said to be s t a t i s t i c a l l y s i g n i f i -cant. Porteus ( 3 D reported the result s of a study based on f i f t e e n male psychotics, and 7 female psychotics i n which both the o r i g i n a l and practice-free Mazes were used. After four months of chlorpromazine therapy the average Maze decrement for the 22 cases was 2 . 0 8 years with over 68 per cent of the group affected. In three l a t e r investigations by Porteus and Barclay ( 3 2 ) both series of the Maze were again used. In the f i r s t of these they found that after s i x weeks of chlorpromazine therapy the experimental group (N = 35) showed a loss of 1 . 8 9 years as against 0 . 1 year f o r the controls (N = 2 5 ) . The difference for the experimental group was s i g n i f i c a n t at the 5 per cent l e v e l . In the second study of t h i s series twenty pairs of sub-jects were matched exactly on pre-medication Maze scores. On the f i r s t post-medication tes t i n g with the practice free Maze the experimental group showed an average loss of 2 . 2 years ( s i g n i f i c a n t at the % l e v e l ) while the controls gained 0 . 2 years over t h e i r pre-medication scores. In the t h i r d i n v e s t i g a t i o n the Maze was applied three times to unmatched groups of 21 experimental and 21 control subjects. The standard Maze was applied before medication, 27 the extension Maze during medication, and the extension Maze inverted ( i . e . rotated 180 degrees) at a s t i l l l a t e r stage of medication. On the f i r s t post-medication testing the experi-mental group showed an average loss of 1.5 years as against a loss for the controls of 0.04 years. On the second post-medication testing (extension Maze inverted) the experimental group was 2.09 years below i t s pre-medication l e v e l while the control group had exceeded i t s pre-medication score by 1.07 years. The results of t h i s i n v e s t i g a t i o n show that prolonged use of the drug widens rather than decreases the gap between experimental and control patients, at least as regards Maze scores. The l i t e r a t u r e reviewed i n t h i s chapter represents the only available studies published to date that have been con-cerned p r i m a r i l y with the effects of chlorpromazine on Maze performance. Although the studies are few i n number and the samples small the implications of the findings are clea r . They are that chlorpromazine affects the central nervous system i n a manner si m i l a r to c e r t a i n types of psycho-surgery. This effect of chlorpromazine i s refl e c t e d i n reduced a b i l i t y to perform the Porteus Maze Test, which i s claimed to be a v a l i d measure of planning capacity and foresight. The present thesis stems from the foregoing studies. This thesis i s that chlorpromazine, administered to psychotic patients, can be expected to produce a d e f i c i t i n the Maze per-formance of the majority, and at the same time an improvement i n t h e i r c l i n i c a l behavior. CHAPTER V EXPERIMENTAL DESIGN This study i s designed to provide an answer to the following questions: 1. Does chlorpromazine produce a s i g n i f i c a n t decrement i n Porteus Maze performance? 2. I f i t does produce such a decrement i s t h i s decrement permanent or transitory? 3« Does chlorpromazine produce s i g n i f i c a n t improvement i n c l i n i c a l behavior? In an attempt to answer these questions the study makes use of experimental and control groups i n which each pair of subjects i s matched exactly on pre-medication Maze scores and as closely as possible on several other variables. The experimental method thus employed i s known as the "matched pairs" method (1). The l o g i c of t h i s experimental design as described by Andrews (1) and Townsend (40) and as applicable to the present inves t i g a t i o n may be summarized as follows:-: Pairs of subjects are selected so that the members of each pair are comparable i n a l l respects believed to be related to the performance of a given task (e.g. Maze performance). Using random methods one member of each pai r i s assigned to either the experimental or control group. The experimental group i s given some kind of treatment which i t i s believed w i l l 28 29 influence i t s performance of the task i n question. (In the present study the experimental treatment i s chlorpromazine and the task i s Maze performance.) The control group may or may not be given some kind of treatment but i n either event i t i s assumed that whatever i s done or happens to the control group w i l l also have been done or w i l l have happened to the experimental group. Thus the "treatment" of the experimental group i s the only independent variable that distinguishes i t from the control group. In other words the control group serves as the base l i n e against which the experimental group's performance, under the experimental condition, i s compared. The two groups are then given the same task and i f t h e i r mean performance d i f f e r s s i g n i f i c a n t l y t h i s difference i s assumed to be due to the influence of the experimental treatment on the experimental group. In the present study an attempt i s made to exercise more r i g i d control over the experimental procedure and to more c l e a r l y define the sample used than has been reported i n previ-ous studies of the same problem. In b r i e f , the i n v e s t i g a t i o n proceeded along the follow-ing l i n e s : Subjects were selected according to c e r t a i n pre-determined c r i t e r i a . Each subject received three applications of the Porteus Maze Test: 1. before medication; 2 . after 30 days on medication; and 3* after 30 days without medication. Medication means either chlorpromazine or placebo treatment. P r i o r to the start of medication subjects were matched exactly 30 on i n i t i a l Maze scores and as closely as possible f o r age, hospital duration, education, occupation, and marital status. When matching was completed subjects were assigned by a random method to either the experimental or the control group. Each subject's c l i n i c a l behavior was assessed on the L-M Fergus-Falls Behavior Rating Scale (23) at approximately the same time and i n the same order as his Maze behavior. The results were analyzed s t a t i s t i c a l l y and p r o b a b i l i t y values of 5 per cent were regarded as s i g n i f i c a n t . Selection of Subjects A l l the subjects i n t h i s study were selected from a group of male chronic psychotics at the P r o v i n c i a l Mental Hospital, B r i t i s h Columbia. Since the purpose of the study was to assess the effects of chlorpromazine on Maze performance certain c r i t e r i a had to be met i n the selection of subjects. I t was reasoned that i f any s i g n i f i c a n t changes were evident after treatment, factors other than the treatment that might have contributed to such change would have to be controlled. Such factors might include the nature of the i l l n e s s , the effects' of previous therapies and fluctuations of psychotic mood. The i n i t i a l c r i t e r i a f o r the selection of subjects was as follows: The study would include only those patients; 1. who had not been operated on psychosurgically, 2. who had not had previous medication ( t r a n q u i l i z e r s ) , 3« who had been 31 diagnosed as schizophrenic, 4. who had been hospitalized f o r at least three years. Psychosurgery and medication were ruled out because previous investigations had shown that these treatments de-pressed Maze scores. Schizophrenia i s a broad c l a s s i f i c a t i o n including several sub-categories, most of which are repres-ented i n the present sample. The main purpose served i n selecting schizophremics was to rule out organic disease and various brain syndromes any or a l l of which might have pro-duced changes i n the patient's condition over a period of time thereby contaminating the f i n a l r e s u l t s . I t was reasoned that patients who had been hospitalized f o r a minimum of three years would be r e l a t i v e l y stable as f a r as changes i n the psychotic process were concerned, so that i f s i g n i f i c a n t changes did occur during the inv e s t i g a t i o n , the p r o b a b i l i t y that they were due to the treatment would be increased. Further, such patients could no longer be regarded as acute cases since they would have had ample oppor-tu n i t y to benefit from other therapies. The present sample was selected from s i x d i f f e r e n t wards. The wards may be roughly divided into three l e v e l s , each representing a stage of progress i n the patient's recov-ery. One l e v e l may be conceived as a r e h a b i l i t a t i o n l e v e l , representing the highest stage of progress, i n which most of the patients have regular h o s p i t a l jobs and ground p r i v i l e g e s . 32 The second l e v e l represents a lesser stage of progress with fewer patients having regular r e s p o n s i b i l i t i e s or freedom of the grounds. The t h i r d l e v e l houses mainly "deterior-ated" patients who are incapable of assuming even minor r e s p o n s i b i l i t i e s and who are constantly under supervision. The i n i t i a l screening procedure i n selecting these subjects consisted of obtaining from the chief psychiatric nurse i n each ward the names of patients who were not receiv-ing medication and who, as f a r as he could determine, had not received medication previously. Approximately 400 names were obtained i n t h i s manner. Following t h i s i n i t i a l screen-ing each name was checked against the patient's c l i n i c a l record for evidence of previous medication, psychosurgery, or organic disease. I f evidence for any of these was found, that patient was excluded from the study. At the same time, other information needed to match the experimental and control subjects was obtained from the record, information such as date of admission, age, occupation,education, and marital status. Subsequently, 192 patients were found who met the essential c r i t e r i a . A l l the pertinent information was entered on a 5 x 8 card which bore the patient's name, hospi-t a l number, and ward number. Double Blind Technique The psychological effects of giving a mental patient a p i l l or increased attention are not too w e l l known. The patient may assume or be t o l d that the p i l l w i l l do him good, 33 and i n some cases placebo patients do show a marked change i n behavior either favorable or unfavorable. The nursing s t a f f ' s knowledge of what a c e r t a i n p i l l or other method of treatment i s supposed to do undoubtedly influences not only i t s perception of the patient receiving the treatment but i n d i r e c t l y the patient's reaction to the treatment. This being the case i t was decided to reduce such effects as f a r as possible by using what has come to be known as the "double b l i n d " technique. With t h i s technique the control group receives a placebo tablet i d e n t i c a l i n s i z e , shape, and color, to the chlorpromazine tablets received by the experimental subjects. Even the containers and method of administration are i d e n t i c a l so that no i n d i v i d u a l d i r e c t l y involved i n the study knows which patient receives the placebo and which the drug. Each ward contained both experimental and control subjects whose i d e n t i t y remained a secret u n t i l completion of the project. The d e t a i l s of how t h i s was achieved are given i n the section below describing the medica-t i o n procedure. Matching Procedure An attempt was made to administer the o r i g i n a l Maze to the 192 patients who were regarded as suitable for the study. Some of these refused to attempt the t e s t ; others t r i e d but the results were meaningless; s t i l l others were bed-patients or otherwise p h y s i c a l l y incapacitated. A few had been trans-ferred to d i f f e r e n t units of the Hospital; released on parole; 34 or were undergoing other forms of therapy. Eventually, the number was reduced to some 140 patients for whom Maze scores were obtained. An attempt was then made to match these 140 patients exactly on i n i t i a l Maze scores and as c l o s e l y as possible on age, hosp i t a l duration, education, occupation, and marital status. The purpose of matching was to reduce the influence of factors other than chlorpromazine on the c r i t e r i o n scores. I t was not known d e f i n i t e l y to what extent these variables correlated with Maze performance but i t was assumed that i f both experimental and control subjects were r e l a t i v e l y equal i n these respects then any s i g n i f i c a n t change following medi-cation could be attributed to medication with a greater degree of confidence than would otherwise be the case. The matching procedure resulted i n a further reduction of the sample to 80 subjects who were matched as indicated above. Selection of the Experimental Group When matching was completed the names were l i s t e d i n pairs and the l i s t presented to an i n d i v i d u a l not involved i n the study. This person was instructed to assign at random a code number from 1 to 80 to each name. The same person then transferred each pair of code numbers to a blank sheet of paper and gave i t to the investigator. At the same time t h i s i n d i -v idual sealed the coded l i s t of names i n an envelope. This coded l i s t was not seen by the investigator or by any person d i r e c t l y Involved i n the study u n t i l the inve s t i g a t i o n was completed. The l i s t of code numbers (without names), each number representing a subject, was used by the investigator to select the experimental group by entering a table of random numbers. The sealed l i s t of coded names and the ran-domly selected l i s t of code numbers were then presented to the chief pharmocologist at the Hospital with appropriate instructions f o r t h e i r i n t e r p r e t a t i o n and use i n assigning patients to the chlorpromazine and placebo groups. Medication Procedure; Chlorpromazine and placebo tablets each weighing 25 mg. and s u f f i c i e n t f o r the period of medication were placed i n i d e n t i c a l i n d i v i d u a l containers, and each container l a b e l l e d with the patient's name and the word " L a r g a c t i l . " The word " L a r g a c t i l " was considered necessary to enable the nursing s t a f f to di s t i n g u i s h the present project from other medica-t i o n programs then i n progress. The decision to continue medication f o r t h i r t y days was made because of the l i m i t e d time available f or the completion of the investigation. I t was decided to l i m i t the dose to 300 mg. d a i l y since t h i s was the dosage employed by Porteus and Barclay (32) and was re-garded as a more or less routine amount. The fact that the tablets were i n 25 mg. size made t h i s dose convenient to ad-minister. I t was the opinion of the nursing s t a f f and the c l i n i c a l d i rector that the more tablets a patient had to take the more reluctant he would be to cooperate. As i t was, the 36 patient was expected to take a t o t a l of 12 tablets d a i l y . The medication was carried out i n a routine manner. Under medical supervision the nursing s t a f f administered chlorpromazine and placebo tablets i n equal amounts four times d a i l y . The patient received 75 mg. i n the morning, 75 mg. at noon, 75 mg. at night, and 75 mg. again just before going to bed. The dose was gradually increased from 100 mg. on the f i r s t day to the maximum of 300 mg. on the fourth day. On the 3 3 r d day of medication the dose was abruptly terminated without any tapering o f f . Rating Scale The Rating Scale used to assess behavioral change i n th i s study i s shown i n Appendix B. Commenting upon the r e l i a -b i l i t y of t h i s Scale the authors, Meyer and Lucerno, (23, 24) report agreements between raters of from Q7% to 92%. They report a positive rank order c o r r e l a t i o n of . 9 2 between two male raters who rated 20 patients and a positive c o r r e l a t i o n of . 9 4 between two female raters who rated the same patients. The Scale consists of eleven categories, each category being divided into f i v e statements descriptive of mental patients' behavior. Values range from 1 for very retarded or abnormal behavior to 5 for r e l a t i v e l y normal behavior. One advantage of t h i s scale i s that the descriptive terms are e a s i l y under-stood by psychiatric aides and nurses. In the present in v e s t i g a t i o n i t was arranged to have the 37 same pair of raters on each ward rate the same given patients throughout the study. The raters were selected on the basis of experience and t r a i n i n g . Most of the twelve raters chosen were graduates of the hospital's t r a i n i n g program for nurses. A few had had equivalent t r a i n i n g elsewhere. Only one of the raters had been employed at t h i s hospital f o r less than a year but he was adequately trained and had had previous experience with mental patients. P r i o r to the week for which a Rating was required, each rater was provided with a mimeographed i n s t r u c t i o n sheet and an appropriate number of rating sheets. An attempt was made to ensure that raters understood what was required and to im-press upon them the necessity to work independently. The Rating Scale was modified s l i g h t l y to meet the requirements of the present study. One of the eleven categories was l e f t out as being irrelevant ("F" response to e l e c t r i c or i n s u l i n therapy), and another ("E" response to doctors, s o c i a l workers, psychologists) could have been excluded as i t was never used. I t was f e l t that one important advantage of having nurses rather than more highly trained personnel do the rating stemmed from the fact that the former were i n closer contact with the pa-tient s and hence th e i r evaluations were l i k e l y to be more r e l i a b l e . Interval between Measures A l l the Maze tests were administered and scored by the same person p a r t l y out of necessity and p a r t l y as a method of 38 c o n t r o l l i n g the influence of d i f f e r e n t examiners on test r e s u l t s . The procedure used i n administration and scoring was that recommended In the Maze Test Manual published i n 1955 (30). This procedure has been summarized and i s shown i n Appendix A. The f i r s t Maze scores ( O r i g i n a l Series) were obtained during the three weeks immediately preceding the start of medi-cation. The second Maze scores (Extension Series) were ob-tained during the f i n a l three days of medication. These three days were additional to the t h i r t y day period of medication previously decided upon so that no patient received less than t h i r t y days medication. The t h i r d set of Maze scores (Exten-sion Inverted) was obtained after a l l subjects had been without medication of any kind f o r from 30 to 33 days. No aspect of the q u a l i t a t i v e scale was considered i n t h i s study. Each patient was tested i n his own ward and an attempt was made to standardize external conditions as much as possible by always testing i n the same place. However, t h i s was not always possi-ble. In order to derive some estimate of rater r e l i a b i l i t y two ratings were obtained f o r each patient p r i o r to the st a r t of medication. The i n t e r v a l between these two ratings was two weeks. The patient's i n i t i a l r ating score or behavioral l e v e l was based on the second of these two ratings. The next rating assessed the patient's ward behavior f o r the l a s t ten days of medication, and the f i n a l rating assessed i t for the week follow-ing the end of the no-medication period. CHAPTER VI RESULTS The experiment was designed so as to rule out, as f a r as possible, factors other than the medication that might he assumed to influence subsequent Maze performance and c l i n i c a l behavior. Since the groups were cl o s e l y equated before medi-cation began by pairing subjects, i t could reasonably be assumed that any s i g n i f i c a n t differences observed between them during medication could be attributed to the pharmacological effects of chlorpromazine, since there were no grounds for assuming that placebo treatment had any pharmacologic effect on either Maze performance or c l i n i c a l behavior. Composition of the F i n a l Sample The size of the f i n a l sample which completed the project was reduced to 22 matched p a i r s , a somewhat greater loss than had been anticipated. These losses occurred as follows. F i f -teen patients refused to take the t a b l e t s ; four were trans-ferred to a diff e r e n t unit of the hosp i t a l during the f i r s t week of medication; two developed subjectively unpleasant side effects during the second and t h i r d weeks of medication and refused to continue, and two developed side effects severe enough to warrant t h e i r withdrawal from the s tudy. Just p r i o r to the start of medication i t was discovered that one patient 39 40 had received chlorpromazine previously and another was due for nine days' leave during the t h i r d week of medication. Both of these patients were excluded from further study. The remainder were allowed to continue and t h e i r Maze scores and l a t i n g scores were recorded but since they were unmatched t h e i r r e s u l t s were not included i n any of the calculations other than the i n i t i a l estimate of Rater r e l i a b i l i t y . I t i s of interest to note that most of the patients who refused medication were from the better wards and hence r e l a -t i v e l y well adjusted to t h e i r environment. Some refused on the grounds that they did not need " p i l l s " , others did not "believe i n doctors", and s t i l l others "had no time." Refusal to take the drug by mouth could have been met by administering i s parenterally but i t was f e l t that t h i s would have interfered with the purpose of the i n v e s t i g a t i o n because parenteral administration necessitates a smaller dose and results i n more pronounced side e f f e c t s . Another reason why parenteral administration was not considered feasible was that i t would have revealed to the patient, the nursing s t a f f , and the examiner, which patient was receiving chlorpromazine and which patient was not. This would have defeated the purpose of placebo control which, though Porteus (31) questions i t s value as a control device, was the best available under the present circumstances. The composition of t h i s f i n a l sample of 44 patients i s shown i n Appendix C. The mean score for the t o t a l group of 44 41 patients on the pre-medication Maze testw'as 12.88 years. The mean age was 56.43 years with a range of from 33 to 78 years. The average length of time spent i n the hospital was 15.43 years with a range of from 3 to 28 years. The mean educational l e v e l was 6.38 years of schooling with a range of from 3 to 14 years. Only 7 out of the 44 patients had had ten or more years of formal schooling. Over 75 per cent of the group was classed as unmarried, and as regards occupa-t i o n a l l e v e l over 81 per cent may be considered as u n s k i l l e d . The Matching Variables Since i t was not possible to match each pai r exactly on a l l the variables i t was decided to compute the c o r r e l a t i o n between Maze scores (on which they were exactly matched), and each of the other variables to f i n d i f there was any s i g n i f i -cant c o r r e l a t i o n between them. The results are shown i n Table I . Table I shows that there i s no s i g n i f i c a n t c o r r e l a t i o n between Maze scores and any of the other variables. A l l the correlations are positive but too low to have s t a t i s t i c a l s i g -nificance. The one variable which might be expected to correlate s i g n i f i c a n t l y with Maze scores i s education, which correlates only .28. The only variable for which a measure of relationship with Maze scores could not be computed was occupational l e v e l . For t h i s variable the appropriate s t a t i s t i c a l measure of i t s 42 TABLE I CORRELATION OF MAZE SCORES WITH THE DIFFERENT VARIABLES Variable N Mean S D Correlation with Maze Scores Age Hospital Duration 44 44 Years of Schooling 44 M a r i t a l Status 56.43 15.43 6.38 11.6 7-37 2.85 44 + .041 + .15 + .281 + .189 * Point b i s e r i a l c o r r e l a t i o n relationship with Maze scores i s chi square but t h i s value could not be computed owing to the fact that several of the expected frequencies are less than 5? a value below which chi square i s not recommended. In the present case some of the expected frequencies are too small even when ce r t a i n categories of occu-pational l e v e l are combined or eliminated. However, f a i l u r e to overcome t h i s d i f f i c u l t y i s not con-sidered too important owing to the fact that such a large per-centage of the group i s uniform as regards occupation. I t should be pointed out also that i n the c l i n i c a l record the patient's occupation i s stated simply as farmer, logger, miner, et cetera. In the present study the investigator a r b i t r a r i l y divided these 43 occupations into three l e v e l s : s k i l l e d , semi-skilled, and u n s k i l l e d . Most of the patients seemed to f i t best into the unskilled category but i t i s recognized that others may not necessarily agree with t h i s c l a s s i f i c a t i o n . Over 90 per cent of the patients used i n t h i s study might well be placed i n the unskilled category without d i s t o r t i n g the data contained i n t h e i r c l i n i c a l records. When a l l the data had been collected and tabulated, the key to the i d e n t i t y of the experimental and the control groups was revealed to the investigator. The mean scores of both groups on the Maze test and Behavior Ratings, as we l l as on the d i f f e r e n t variables, were compared and t- t e s t s of the s i g -nificance of the mean differences computed. A comparison of the two groups i n terms of age, length of h o s p i t a l i z a t i o n , and years of schooling i s shown i n Table I I . These results show that no s i g n i f i c a n t differences exist between the two groups on these three variables. Mean differences as large or larger than those obtained could be expected to occur more than 40 per cent of the time as a re s u l t of sampling f l u c -tuation. Chi square was computed f o r the variable of occupational l e v e l . The results are shown i n Table I I I . The chi square for t h i s variable was computed according to a method proposed by Yates (41) which makes i t possible to compute chi square when the expected frequencies i n some of the c e l l s i s less than f i v e . But since t h i s method i s applicable only to a 4 - c e l l TABLE II. COMPARISON OF EXPERIMENTAL AND CONTROL GROUPS ON VARIABLES OF AGE, HOSPITAL DURATION, AND YEARS OF SCHOOLING Measure Exper. Group Control Group M D i f f . SEMD t df P Mean SD Mean SD Age 5 6 . 8 11.09 5 6 . 5 1 1 . 7 0 + 0 . 3 0 . 9 8 0 . 3 0 6 21 > . 7 Hospital Duration 16.04 6 . 8 5 14 .81 7 . 9 8 +1.23 1 . 4 7 O .836 21 > .4 Y ©ell's of Schooling 6 . 3 5 2 . 3 9 6 . 8 0 2 . 2 2 -0.45 0 . 5 7 O.789 21 y> .4 N = 22 pairs of subjects 6 TABLE I I I ACTUAL AND EXPECTED FREQUENCIES OF EXPERIMENTAL AND CONTROL SUBJECTS IN TWO OCCUPATIONAL LEVELS Occupational Experimental Control  Level Actual Expected Actual Expected Total Unskilled 19 1 7 - 8 3 16 1 7 . 0 9 35 Semiskilled and S k i l l e d 3 4 . 0 9 5 3 . 9 0 8 Total 22 2 1 . 9 2 21 2 0 . 9 9 43 Degrees of freedom = 1 Chi square = . 2 2 2 P > . 5 * * * * * TABLE IV ACTUAL AND EXPECTED FREQUENCIES OF EXPERIMENTAL AND CONTROL SUBJECTS IN MARRIED AND UNMARRIED CATEGORIES Ma r i t a l Experimental Control  Status Actual Expected Actual Expected Total Married 5 5 . 5 6 5 . 5 11 Unmarried 17 1 6 . 5 16 1 6 . 5 33 Total 22 2 2 . 0 22 2 2 . 0 44 Degrees of freedom - 1 Chi square - . 120 P > . 7 46 contingency table two of the categories, semi-skilled and s k i l l e d , are combined i n Table I I I . With one degree of free-dom the value of chi square equals 0 . 2 2 2 , a value which could be expected more than 50 per cent of the time as a res u l t of sampling f l u c t u a t i o n . In other words the discrepancy between observed and expected frequencies i s not s i g n i f i c a n t . The chi square for marital status was computed accord-ing to the usual method since the smallest expected frequency was 5 or greater. With one degree of freedom the obtained chi square of 0 . 1 2 0 could be expected more than 70 per cent of the time as a result of sampling f l u c t u a t i o n . The results are shown i n Table IV. Effect of Medication on Maze Performance The following terms are used to describe the results of the Maze tests and Behavior ratings. The term "pre-medication" (pre-med.) refers to Maze scores and Behavior r a t -ings obtained before the start of chlorpromazine and placebo treatment. The term "medication" (med.) refers to Maze scores and ratings obtained during chlorpromazine and placebo t r e a t -ment. And the term "post-medication" (post-med.) refers to Maze scores and ratings obtained 30 to 33 days after chlorpro-mazine and placebo treatment had been terminated. The Maze performance of both groups i s sho\vn graphically i n Figure 1 . As t h i s graph shows, the experimental group's Maze d e f i c i t during medication was s l i g h t l y greater than that shown by the controls. i l s o , the experimental group's post-47 medication recovery was s l i g h t l y i n excess of the controls' recovery. These changes suggest that chlorpromazine may have produced a s l i g h t decrement i n Maze performance. The experi-mental group's post-medication recovery suggests also that with the present subjects the effect of chlorpromazine on Maze performance was tr a n s i t o r y . Figure 1. Experimental and  Control Groups' Means on Three Applications of The Maze Test On the basis of the findings reported by Porteus (3D and Porteus and Barclay (32), that chlorpromazine depressed Maze scores, i t had been hypothesized that the experimental group's Maze performance would be s i g n i f i c a n t l y poorer than 48 that of the control group during medication. The r e s u l t s , shown i n Table V on the following page, show that the Maze performance of both groups declined during medication. The d e f i c i t was s l i g h t l y greater for the experimental group: the actual mean difference between the two groups was 0.47 of a year. This difference i s s t a t i s t i c a l l y i n s i g n i f i c a n t , the p r o b a b i l i t y being greater than 2.% (P > .25) that a difference as large or larger would occur as a result of sampling v a r i a -b i l i t y . In terms of the l o g i c of the experiment these r e s u l t s o f f e r no evidence that chlorpromazine had any s i g n i f i c a n t effect on Maze performance. Subjects were matched before medi-cation and randomly assigned to experimental and control groups on the assumption that subsequent s i g n i f i c a n t differences between them, i f any, could be accounted f o r only i n terms of the effect of chlorpromazine. The Maze performance of the two groups did not d i f f e r s i g n i f i c a n t l y on either the medica-t i o n or post-medication t e s t s . Both changed i n the same direc-t i o n . Thus both groups l o s t during medication and recovered on the post-medication Maze t e s t . The Maze d e f i c i t shown by both groups during medication could have been due to any one of several factors or a combination of these factors, e.g. the psychological effects of being given a p i l l or of increased attention. This d e f i c i t could have been due also to the greater d i f f i c u l t y of the extension Maze. In any event, i t must be assumed that the same factor or factors affected both TABLE V COMPARISON OF MAZE SCORES OF EXPERIMENTAL AND CONTROL GROUPS FOR THREE APPLICATIONS OF THE MAZE TEST Maze Exper. Gp. Cont. Gp. M D i f f . SEMD t df P Mean SD Mean SD 3 . 1 2 0 . 0 0 2 . 6 0 - 0 . 4 7 0 . 7 1 0 . 6 6 2 21 y . 2 5 3 . 3 1 + 0 . 2 8 0 . 7 9 0 . 3 5 4 21 p> . 7 N = 22 pairs of subjects Pre-med. 1 2 . 8 8 3 . 1 2 1 2 . 8 8 Maze M ^ ' m 8 d ^ 3 . l 6 s . 3 . 2 3 1 2 . 8 8 50 groups, and the pharmacological effect of chlorpromazine was i n s u f f i c i e n t i n comparison to d i s t i n g u i s h the experimental from the control group to a s i g n i f i c a n t degree. For the post-medication test the extension series was inverted, i . e . , i t was the medication test rotated 180 degrees i n front of the subject. The recovery shown by both groups i n t h i s a p p l i c a t i o n of the Maze could also have been due to several unknown factors such as termination of medication, i n -creased f a m i l i a r i t y with the testing s i t u a t i o n , or practice e f f e c t . In the studies reported by Porteus and Barclay (32) conclusions were based on a comparison of the experimental group's Maze performance before and during chlorpromazine therapy, and s i m i l a r comparisons f o r the control group. The mean difference between the experimental and control groups was not reported. While t h e i r i n t e r p r e t a t i o n of t h e i r f i n d -ings appears to be correct, because the control group showed an increment i n Maze score while the experimental group showed considerable d e f i c i t , they appear to have overlooked the basic l o g i c of the experiment employing a control group. It i s of interest to note that, i f the l o g i c employed by Porteus and Barclay (32) was applied i n the present experi-ment, a f a l s e conclusion might be arrived at. The mean difference f o r the controls between pre-medication and medica-t i o n Maze scores was -0.75 of a year, which i s found to be s t a t i s t i c a l l y i n s i g n i f i c a n t ( P > . 1 ) . For the experimental group the mean difference was -1.22 years, which yie l d s a t = I.876, and employing the appropriate one-tailed test ( P ^ . . 0 5 ) . From these values one might therefore conclude that (a) the placebo had no s i g n i f i c a n t effect upon the con-t r o l group, but (b) the chlorpromazine s i g n i f i c a n t l y depressed the Maze scores of the experimental subjects. From the discussion above i t w i l l be evident that such a conclusion i s not v a l i d l y supported by the data, and that such treatment i s not appropriate. Effect of Medication on Behavior Ratings The extent to which raters agreed i n t h e i r evaluations of patients• behavior p r i o r to the start of medication had been determined by computing the rank order c o r r e l a t i o n between raters. The resul t s are shown i n Table VI. Two independent ratings were obtained for each patient throughout the i n v e s t i -gation on the assumption that the average of two estimates was more r e l i a b l e than either estimate taken alone. The co r r e l a -tions shown i n Table VI are i n f a i r l y close agreement with those reported by the authors of the Scale,(23> 24). In obtaining ratings a given patient was rated by the same pair of raters throughout the study. Previous findings provided a basis f o r hypothesizing s i g n i f i c a n t improvement i n the experimental group's c l i n i c a l 52 TABLE VI BANK ORDER CORRELATIONS BETWEEN RATERS FOR RATINGS OBTAINED APPROXIMATELY TWO WEEKS APART AND BEFORE THE START OF MEDICATION Correlations Ward Raters N F i r s t Rating Second Rating 1 M-W 10 +.822 ••'.652 2 H-P 10 +.849 +.597 3 G-P 14 +.910 +.930 4 B-W 22 +.922 +.847 5 C-F 15 +.945 +.812 6 W-P 7 +.822 +.715 behavior during medication. The same findings suggested also that no s i g n i f i c a n t change could be expected i n the control group. m a •H •¥> CO U O •H & X5 CD cq Exper. Group Cont. Group Pre-med Med. Post-med, Figure 2. Experimental and Control Groups' Means on Three Behavior Ratings 53 The behavior ratings of both groups are shown graphi-c a l l y i n Figure 2. As t h i s graph indicates the groups were not equated on the pre-medication r a t i n g , the control group's mean being s l i g h t l y higher than that of the experimental group. During medication the experimental group improved s l i g h t l y while the controls worsened. On the post-medication rating the experimental group was unchanged from i t s previous l e v e l while the controls improved over t h e i r previous l e v e l . These results are tabulated i n Table VII on the follow-ing page. The mean difference between the two groups of 0.13 of a point on the pre-medication r a t i n g was not s i g n i f i -cant (P > .3). The mean difference on the medication r a t i n g . was 0.16 of a point (P > .3), and the mean difference on the post-medication rating was 0.08 of a point (P>.6). In other words the two groups did not d i f f e r s i g n i f i c a n t l y on any of the ratings. Summary of Findings The findings concerning the effects of chlorpromazine on Maze performance and c l i n i c a l behavior may be summarized as follows: There were no s i g n i f i c a n t differences between the experimental and control groups on any of the Maze tests or Behavior ratings. As regards the Maze, both groups showed a loss during medication and subsequent recovery after medication. As regards c l i n i c a l behavior the experimental group improved s l i g h t l y during medication and the controls TABLE VII COMPARISON OF BEHAVIOR RATINGS OF EXPERIMENTAL AND CONTROL GROUPS Rating Exper. Gp. Cont. Gp. Mean SD Mean SD D i f f . SE D df. Pre-med 3 > 2 1 0 # 6 5 3 < 3 4 0 # ? 2 _ G # 1 3 Rating Rating 3 , 2 8 0 , 6 9 3 * 1 2 °* 9 2 * 0 # l 6 R a t i n g ^ 3 , 2 8 0 , 6 8 3 , 3 6 °' 9 6 " 0 ' ° 8 0.14 0.928 0.18 0.19 0.888 0.421 21 21 21 > -3 > -3 > .6 N = 22 pairs of subjects 55 worsened but the mean difference between the groups was not s t a t i s t i c a l l y s i g n i f i c a n t . Within the terms and l i m i t a t i o n s of the study the re s u l t s o f f e r no evidence that chlorpromazine had any s i g n i f i c a n t effect on either Maze performance or c l i n i c a l behavior. CHAPTER VII DISCUSSION The present findings o f f e r no evidence that chlorpro-mazine had any s i g n i f i c a n t effect on Maze performance. P r i o r to medication subjects were matched exactly on Maze scores and as c l o s e l y as possible f o r age, h o s p i t a l duration, educa-t i o n , occupation, and ma r i t a l status. In addition, a l l subjects were males and a l l had been diagnosed as schizophren-i c . Subjects were allocated to the experimental and control groups by reference to a table of random numbers and a double b l i n d procedure obscured the i d e n t i f i c a t i o n of every i n d i v i d u a l within a p a r t i c u l a r group. S t a t i s t i c a l analysis showed that the differences between the two groups on the variables of age, hospital duration, education, occupation, and marital status, were a l l i n s i g n i f i c a n t . In a l l these respects, then, the two groups were r e l a t i v e l y equal. I t could reasonably be assumed that they were r e l a t i v e l y equal also on ce r t a i n other variables such as physical health, and adjustment to environment. I t may be taken, then, that the two groups were equiva-lent with regard to any factors that might be expected to influence subsequent Maze performance. In order to e s t a b l i s h that chlorpromazine resulted i n a s i g n i f i c a n t Maze decrement i t would be necessary to show that the experimental, group's Maze 56 57 performance was s i g n i f i c a n t l y worse, during medication, than the control group's Maze performance during the same period. S i m i l a r l y , i n order to e s t a b l i s h that the effects of chlor-promazine on Maze performance were either permanent or t r a n s i -tory i t would be necessary to show that the experimental group's post-medication Maze Performance was either s i g n i f i -cantly worse than or equal to that of the controls on the same te s t i n g . Analysis of the re s u l t s show that the differences between the experimental and control groups were not s t a t i s t i -c a l l y s i g n i f i c a n t either on the medication or post-medication Maze t e s t s . I t i s concluded, therefore, that i n the present invest i g a t i o n chlorpromazine did not produce a s i g n i f i c a n t decrement i n Maze performance. The fact that the control group showed a maze d e f i c i t of 0.75 of a year on the medication Maze test suggests that the extension series may be more d i f f i c u l t f o r a psychotic population than previous studies indicate. Porteus and Barclay (32) report three studies i n which the extension Maze was applied after the o r i g i n a l Maze to psychotic subjects being employed as controls. In two of these studies the controls showed a Maze decrement of 0.10, and 0.04 of a year, and i n the t h i r d they showed a gain of 0.20 of a year. Com-pared with these figures, the Maze decrement shown by the control group i n the present study i s quite large. Within the l o g i c of the present experiment i t must be assumed that a 58 s i m i l a r decrement would be shown by the experimental subjects had chlorpromazine been administered. As regards the gains shown by both groups on the post-medication Maze test I t appears possible that these were due to practice effect including increased f a m i l i a r i t y with the testing s i t u a t i o n . Again, with reference to the findings of Porteus and Barclay (32), i n one of the studies mentioned t h e i r subjects were given a t h i r d application of the Maze (the extension series inverted). In t h i s case the controls showed a gain of 1.11 years over t h e i r previous l e v e l on the non-inverted extension form, and a gain of 1.07 years over t h e i r o r i g i n a l Maze or pre-medication l e v e l . In view of these considerations i t i s possible that the post-medication improvement i n Maze performance shown by experimental and control subjects i n the present i n v e s t i g a t i o n was l a r g e l y due to practice e f f e c t . Turning now to a consideration of the Behavior rat i n g s , the results o f f e r no evidence that chlorpromazine had any s i g n i f i c a n t effect on c l i n i c a l behavior. A comparison of the mean rating scores of experimental and control groups showed that they did not d i f f e r s i g n i f i c a n t l y on either the pre-medication, the medication, or the post-medication ratings. An i n t e r e s t i n g development concerns the control group's worsening of behavior during medication, and i t s post-medication recovery. In t r y i n g to account f o r these changes 59 several p o s s i b i l i t i e s suggest themselves. One obvious d i f f i c u l t y i n trying to obtain an accurate evaluation of c l i n i c a l behavior i s the f a l l i b i l i t y of ra t e r s . Another, d i f f i c u l t y i s the s e n s i t i v i t y of the measuring instrument. I f a p a r t i c u l a r category or statement should appear ambiguous the rater's evaluation i s l i k e l y to be made at random. The same resu l t i s l i k e l y i f a rater has no clear idea how a patient behaves r e l a t i v e to a given category. Another con-sideration, perhaps the most important, concerns "placebo ef f e c t . " When a patient i s given a p i l l he assumes or i s t o l d i t w i l l do him good. An expectation i s thus created, not only i n the patient but i n the nursing s t a f f as w e l l , which, i f i t i s not f u l f i l l e d , may w e l l lead to re s u l t s opposite to those intended. I f the anticipated improvement i s not e v i -dent the patient may assume he i s beyond help and his behavior may actu a l l y worsen. The r a t e r , also anticipating improve-ment i n the patient and not finding i t , may conclude that behavior has either worsened or not improved. In either case the r e s u l t i s l i k e l y to be a lower r a t i n g . I t i s con-ceivable that any or a l l of these factors may have operated to produce a decline i n the control group's c l i n i c a l behavior i n the present study. The fact that the patient was required to take twelve tablets d a i l y may have strengthened t h i s e f f e c t . The i n i t i a l expectations of the experimental subjects were, of course, indistinguishable from those of the control group 60 but for the experimental group the expectations were met to some extent at l e a s t . The physiological effects of chlor-promazine such as i n i t i a l somnolence, increased appetite, and antiemesis, would constitute evidence of the drug's e f f i c a c y . Thus, as f a r as the patient was concerned the p i l l s were doing him some good. This change, while less evident to the rat e r than to the patient, might not be s u f f i c i e n t to produce a marked c l i n i c a l improvement but i t would s a t i s f y c e r t a i n expectations and thus tend to prevent a decline or worsening of behavior. In any event, i t i s concluded that, i n the present i n -vestigation, chlorpromazine had no s i g n i f i c a n t effect on c l i n i c a l behavior, while placebo medication did result i n a worsening of behavior. The fact that these result s do not confirm previous findings may perhaps be accounted f o r i n terms of the composi-t i o n of the sample, the dose, and duration of treatment. The l i t e r a t u r e on the c l i n i c a l e f f i c a c y of chlorpromazine suggests that chronic and deteriorated schizophrenics respond less r e a d i l y to moderate doses of chlorpromazine and short duration of treatment than do certain other psychotic patients. More-over, previous findings indicate a wide v a r i a t i o n i n i n d i v i d u a l reactions to the drug, some patients not responding at a l l even with prolonged treatment. The present sample was comprised of chronic schizophrenics some of them deteriorated, and most of them of long standing. 61 The dose, 300 mg. a day, while the same as that administered by Porteus and Barclay (32) must be regarded as quite moderate fo r these p a r t i c u l a r patients. The duration of treatment was br i e f — somewhat shorter than that reported by Porteus and Barclay (32). In view of these considerations i t i s conceiv-able that i n the present study the maximum effects of the drug were not achieved. However, t h i s i s only a suggestion that might be explored further. I t i s equally possible that these patients would not manifest a much greater change even i f the dose were increased and the duration of treatment prolonged. CHAPTER VIII SUMMARY AND CONCLUSIONS A review of the l i t e r a t u r e concerning the c l i n i c a l e f f i c a c y of chlorpromazine suggested that the drug i s useful i n the symptomatic treatment of c e r t a i n types of mental i l l -ness. The l i t e r a t u r e concerning the Porteus Maze Test was also reviewed, and t h i s suggested that chlorpromazine, l i k e psychosurgery, produces a s i g n i f i c a n t decrement i n Maze per-formance. The present study was designed, then, to f i n d what effects chlorpromazine has on Maze Performance, and whether such effects are permanent or t r a n s i t o r y . In addition, i t was decided to assess the effects of chlorpromazine on c l i n i c a l behavior by using a Behavior Ratihg Scale. The subjects were 22 pairs of adult, male, chronic psychotics from the Mental Hospital, B r i t i s h Columbia. Each pair was matched exactly on i n i t i a l Maze scores and as c l o s e l y as possible f o r age, ho s p i t a l duration, education, occupation, and marital status. 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 Maze scores and any of the matching variables, nor did the two groups d i f f e r s i g n i f i c a n t l y on any of the matching variables. The experimental group was given 300 mg. of chlorpromazine d a i l y f o r t h i r t y days, and the control group received 300 mg. of placebo t a b l e t s d a i l y f o r t h i r t y days. A double b l i n d 62 63 technique was used, the i d e n t i f i c a t i o n of i n d i v i d u a l subjects being thus obscured. Maze scores and Behavior ratings were obtained f o r each subject before medication, during medication, and after medication. The o r i g i n a l Maze was applied before medication, the extension Maze during medication, and the extension Maze inverted af t e r medication. M l subjects i n a given ward, e.g. Ward 1, were rated independently on c l i n i c a l behavior by the same pair of rat e r s , e.g. raters M and W, throughout the in v e s t i g a t i o n . Raters H and P rated the sub-jects i n Ward 2, and so on f o r the rest of the wards. The average of these two ratings was taken as i n d i c a t i v e of the subject's c l i n i c a l behavior. The r e s u l t s of the Maze tests and the Behavior ratings were treated s t a t i s t i c a l l y to evalu-ate the significance of the mean differences between the two groups. I t was hypothesized that chlorpromazine would produce a s i g n i f i c a n t decrement i n Maze performance and a s i g n i f i c a n t improvement i n c l i n i c a l behavior. However, since there were no s i g n i f i c a n t differences between the experimental and con-t r o l groups on any of the Maze tests or Behavior ratings t h i s hypothesis was considered untenable. Both experimental and control groups showed a decrement i n Maze performance during medication and an improvement following termination of medica-t i o n . The loss shown during medication and subsequent recovery after medication may have been due to any one of several factors such as the psychological effects of being experimental subjects, greater d i f f i c u l t y of the extension 64 Maze, and practice e f f e c t . I t i s therefore very u n l i k e l y that the decrease i n Maze performance of the experimental group was due to the effect of chlorpromazine. During medication the experimental group's c l i n i c a l behavior improved very s l i g h t l y while that of the controls worsened considerably. I t was speculated that the changes observed f o r the controls during medication may have been due to placebo e f f e c t . In view of these findings i t i s concluded that chlorpromazine has no s i g n i f i c a n t effect on either Maze performance or c l i n i c a l behavior. Since these r e s u l t s appear to contradict previous f i n d -ings, two possible explanations are suggested. One Is that i n the present i n v e s t i g a t i o n the maximum effects of chlorpro-mazine may not have been achieved owing to the composition of the sample, the moderate dose, and the short duration of treatment. The other i s that chlorpromazine was r e l a t i v e l y i n e f f e c t i v e f o r the present subjects, and that even with Increased dosage and prolonged treatment s i g n i f i c a n t l y greater change would not occur. These considerations suggest the need for further studies. 65 REFERENCES 1 Andrews, T. G., ( E d i t o r ) , Methods of Psychology. New York: John Wiley & Sons, 1948, 8-12. 2 Azima, H., and Ogle, W. Effects of l a r g a c t i l i n mental syndromes. Canad. M.A.J.. 1954, 71, 116-21. 3 Azima, H. The use of chlorpromazine and reserpine i n psychological disorders i n general practice. Canad. M.A.J.. 1956, 74, 929-31. 4 Ba i r , H.V., and Herold, William. E f f i c a c y of chlorpro-mazine i n hyperactive mentally retarded children. A.M.A. Arch. Neurol. Psvchiat., 1955, 74, 363-64. 5 Bower, W.H. Chlorpromazine i n psychotic i l l n e s s . New England J . Med.. 1954, 251, 689-92. 6 Courvoisier, S. Pharmacodynamic basis f o r the use of chlorpromazine i n psychiatry. J . c l i n . exp. Psycho-path, and Quart. Rev. Psychiat. Neurol.. 1956. 17. 2 F _ 7 Cohen, I r v i n . Undesirable effects and c l i n i c a l t o x i c i t y of chlorpromazine. J . c l i n . exp. Psychopath, and  Quart. Rev. Psvchiat. Neurol.. 1956. 17. 153-63. 8 Cutler, Robert P., Monroe, Jack J . , and Anderson, Thomas E. Effects of " t r a n q u i l i z e r s " upon pathological a c t i v i t y i n psychotic patients. A.M.A. Arch. Neurol.  Psvchiat.. 1957, 77, 616-22. 9 Delay, John, and Deniker, P i e r r e . Chlorpromazine and neuroleptic treatments i n psychiatry. J . c l i n . exp.  Psychopath, and Quart. Rev. Psychiat. Neurol.. 1956. 17, 19-24. 10 Elkes, J . , and Elkes, C. Effect of chlorpromazine on the behavior of chr o n i c a l l y overactive psychotic patients. B r i t , med. J . . 1954, 2, 560-65. 11 Feldman, P.E., Lacy, B.S., and Walker, A.E. A controlled, b l i n d study of effects of thorazine on psychotic behavior. B u l l menninger C l i n . . 1956, 20, (1), 25-47. 12 Freeman, Walter, and Watts, James. Pre f r o n t a l lobotomy. Amer. J . Psvchiat.. 1954, 99, 798-806. 66 13 Gardner, M.J., Hawkins, H.M., Judah, L.N., and Murphree, O.D. Objective measurement of psyc h i a t r i c changes produced by chlorpromazine and reserpine i n chronic schizophrenia. Psychiat. res. Rep.. American psychi-a t r i c Association, 1955, 77-83. 14 Goldman, Douglas. Chlorpromazine treatment of h o s p i t a l -ized psychotic patients. J . c l i n . exp. Psychopath, and  Quart. Rev. Psychiat. Neurol.. 1956. 17. 45-56. 15 Goldman, Douglas. Comparison of c l i n i c a l effects of chlorpromazine and reserpine i n psychotic patients. Amer. J . med. S c i . . 1957, 233, 137-44. 16 K i e l h o l z , P. and Lobhardt, F. Treatment of mental d i s -orders with chlorpromazine. J . c l i n . exp. Psychopath,  and Quart. Rev. Psychiat. Neurol.. 1956. 17. 38-44. 17 Kovitz, B., Carter, J.T., and Addison, W.P. A comparison of chlorpromazine and reserpine i n chronic psychosis. A.M.A. Arch. Neurol. Psychiat.. 1955, 74, 567-71. 18 Landis, C , i n Proc. Third Res. Conf. Psvchosurg., New York, N.Y., Oct. 1951. Fred A. Mettler (Chairman), Winfred Overhasler ( E d i t o r ) . U.S. Dept. Health, E duc, and Welfare. 19 Lehmann, H.E., and Hanrahan, G.E. Chlorpromazine: New i n h i b i t i n g agent for psychomotor excitement and manic states. A.M.A. Arch. Neurol. Psychiat.. 1954, 71, 227-37. 21 Mason-Browne, N.L., and Borthwick, J.W. Effect of perphenazine (Trilafon) on modification of crude con-sciousness. P i s . Nerv. System. 1957, 18 (8), 300-306. 22 Mettler, Fred A., (Ed.) Columbia-Greystone Associates. Selective p a r t i a l ablation of the f r o n t a l Cortex. New York: Paul B. Haeber, 1949, 195-200. 23 Meyer, B i l l T., and Lucerno, Rubel J . A behavior r a t i n g scale suitable f or use i n mental ho s p i t a l s . J . c l i n .  Psychol.. 1951, 7, 250-54. 24 Meyer, B i l l T., and Lucerno, Rubel J . A v a l i d a t i o n study of the L-M Fergus F a l l s behavior r a t i n g scale. J . c l i n . Psvchol.. 1953, 9, 192-95. 25 Noce, R.H., Williams, D.B., and Rapaport, W. Reserpine (Serpasil) i n the management of the mentally i l l and mentally retarded: preliminary report. J . Amer. med.  Ass.. 1954, 156, 821-24. 67 26 Overholser, Winfred. Has chlorpromazine inaugurated a new era i n mental hospitals? J . c l i n . exp. Psychopath* and Quart. Rev. Psychiat. Neurol.. 1956, 17. 197 - 2 0 1 . 27 P e t r i e , Asenath, and Le Beau, Jacques. Psychologic changes i n man after chlorpromazine and ce r t a i n types of brain surgery. J . C l i n . exp. Psychopath, and Quart. Rev. Psychiat. Neurol.. 1956, 17. 170-79. 2 8 Porteus, S.D., and Peters, Henry N. Maze Test v a l i d a t i o n and psychosurgery. Gen, psychol. Monogr., 1 9 4 7 , 3 6 , 1 - 8 6 . 29 Porteus, S.D., The Porteus maze Test and Inte l l i g e n c e . Palo A l t o , C a l i f o r n i a : P a c i f i c Books, 1 9 5 0 . 30 Porteus, S.D., The maze Test: Recent advances. Palo A l t o , C a l i f o r n i a : P a c i f i c Books, 1 9 5 5 . 31 Porteus, S.D., Maze test reactions after chlorpromazine. J. consult. Psychol., 1 9 5 7 , 2 1 , 15-21. 32 Porteus, S.D., and Barclay, John E. A further note on chlorpromazine: Maze reactions. J . consult. Psychol,., 1 9 5 7 , 21, 297-99. 33 Porteus, S.D., Sp e c i f i c behavior changes following chlorpromazine. J . consult. Psychol.. 1 9 5 7 , 21, 2 5 7 - 6 3 . 34 Primac, Daniel W., Mlrsky, A l l a n F., and Rosvold, H.Enger. Effe c t s of c e n t r a l l y acting drugs on two tests of brain damage. A.M.A. Arch. Neurol. Psvchiat., 1 9 5 7 , 7 7 , 3 2 8 - 3 2 . 35 Rees, W. Li s f o r d and Lambert, C a r l . The value and l i m i t a -tions of chlorpromazine i n the treatment of anxiety states. J . ment. S c i . , 1 9 5 5 , 1 0 1 , 834-40. 36 Robinson, M.F., Freeman, W., and Watts, J.W. Personality changes of psychosurgery. Proc. F i r s t Res, conf.  Psychosurg., Fred H. Mettler (Chairman), Newton Bigelow ( E d i t o r ) . New York, 1949. Public Health Service Pub l i c a t i o n No. 1 6 , 1 9 5 1 . 3 7 Schrader, P.J., and Robinson, M.F. An evaluation of prefrontal lobotomy through ward behavior. J . abnorm.  soc. Psychol., I 9 4 5 , 40, 60-69• 68 38 Tenenblatt, Sarah Shtoffer and Spagno, Anthony. A con-t r o l l e d study of chlorpromazine therapy i n chronic psychotic patients. J . c l i n . exp. Psychopath, and  Quart. Rev. Psychiat. Neurol.. 1956, 17. 81-92. 39 Tizard, J . The Porteus Maze Test and Inte l l i g e n c e : A c r i t i c a l survey. B r i t . J . , educ. Psychol.. 1951, 21, 172-85. 40 Townsend, J.C., Introduction to experimental method. New York: McGraw-Hill, 1953, 58-62. 41 Wert, James B., Neidt, Charles 0., and Ahmann, J . Stanley. S t a t i s t i c a l methods i n educational and psychological  Research. New York: Appleton-Century Crofts, Inc., 1 9 ^ 154-55. 42 Winkleman, W.W., J r . Chlorpromazine i n the treatment of neuropsychiatry disorders. J . Amer. med. Ass.. 1954, 155, 18-21. A P P E N D I C E S APPENDIX A PROCEDURE FOR ADMINISTERING AND SCORING THE QUANTITATIVE SCALE OF THE PORTEUS MAZE TEST The procedures given i n the 1950 (29) and 1955 (30) Manuals f o r testing adults do not appear to be e x p l i c i t enough to avoid some confusion. This confusion seems to arise p a r t l y from the fact that the Maze test may be scored on both a quantitative and a q u a l i t a t i v e scale. A quanti-ta t i v e score may be derived from a q u a l i t a t i v e score, but the reverse i s not the case, since a quantitative score i s based on only two kinds of errors whereas the q u a l i t a t i v e score i s based on at leas t s i x kinds of errors. The present study i s concerned only with the quantita-t i v e scale as applied to abnormal adults and the procedures outlined below are based on the 1955 manual. The instructions issued i n 1950, which have reference to the o r i g i n a l series only, s t i l l apply when the subject being tested i s under 14 years of age. The rules published i n 1955 and outlined below apply to both series of the t e s t . The test consists of 8 leve l s of graduated d i f f i c u l t y ^ Years V I I , V I I I , IX, X, XIV X I I , XIV., and Adult. The follow-ing directions f o r administration are given i n the manual (30). 70 1. With a l l subjects 14 years or older begin with the VII year l e v e l . (There are no tests below the VII year l e v e l i n the extension series.) 2. Give 2 t r i a l s i n each test through year XI, 4 t r i a l s each i n years XII and XIV, and 3 t r i a l s i n the Adult t e s t . 3. When a given year l e v e l i s f a i l e d i n a l l the a l l o t t e d t r i a l s and the one immediately following i t i s passed w i t h i n the a l l o t t e d number of t r i a l s , invert the l a t t e r and score the worse performance. To "invert" means to rotate the test blank 180 degrees and present as a new t e s t . For example, i f year IX i s f a i l e d i n both t r i a l s , and year X i s passed i n one or two t r i a l s , invert year X and present as a new t e s t . I f the inverted test i s f a i l e d no credit i s given for that year l e v e l . The purpose of t h i s procedure i s to reduce the p r o b a b i l i t y of a chance success following a f a i l u r e . 4. Discontinue the test after 2 successive f a i l u r e s above year IX or after any 3 f a i l u r e s . 5. Give the Adult test i f there are no successive f a i l u r e s above year IX or i n the absence of any 3 f a i l u r e s . In the 1955 manual (30) the I n i t i a l i n structions are given i n terms of driving a car. While t h i s i s appropriate for normal subjects, the method poses several problems when used with seriously disturbed mental pa t i e n t s . Many adult psychotics of long standing have never driven a car and they may use t h i s as an excuse f o r not attempting the t e s t . Others 71 may take the suggestion quite l i t e r a l l y and become so pre-occupied with imaginary stop signs, speeding, and d r i v i n g on the right and wrong side of the road that they lose sight of the goal and either f a i l to complete the maze or take an ex-ceedingly long time to do so. Because a l l t h i s can be very confusing to a mental patient, as well as time consuming, i t seemed advisable to exclude the idea of a vehicle from the i n i t i a l i n s t r u c t i o n s . Another point worth noting, and not mentioned i n the manual, i s that of using pencils without erasers. Many psychotic subjects, as soon as they become aware of an error, attempt to erase i t and then continue as i f nothing had hap-pened. The practice of eliminating erasers saves time and makes scoring easier and more accurate, and was therefore adopted. The i n i t i a l procedure adopted with psychotic adults was as follows: Begin with the VII year t e s t . (In the case of primi-t i v e , deaf, or l i n g u i s t i c a l l y handicapped subjects, the V and VI year tests of the o r i g i n a l series may be used for demonstration purposes.) After some degree of rapport has been established place the test blank before the subject with the p r i n t towards him. The horizontal l i n e s should be roughly perpendicular to his w r i t i n g arm. The subject's v i s u a l acuity should be considered, I.e. i f he o r d i n a r i l y wears glasses he should wear them when he 72 attempts the t e s t . The examiner should keep the fingers of one hand pressed against the top of the test blank to prevent i t being rotated. At the same time he should be careful not to cover any part of the design with h i s fingers or unintentionally indicate an e x i t . Say to the subject: " I want you to suppose that these are streets and a l l the l i n e s are s o l i d stone walls. Take your p e n c i l and start here (indicate entrance), and f i n d your way out to here (indicate e x i t i n VII year test only). But you have to be careful because some of these are dead-end streets and i f you go into one you w i l l be stuck and won't be able to get out. You can stop anywhere and look as long as you l i k e , but don't l i f t your pencil u n t i l you are r i g h t outside, and be sure not to bump into any of the walls. This i s how you do i t . Start here and make a mark l i k e t h i s , r i g h t down the middle of the street, around the corner, and so on u n t i l you come out here." The examiner draws a l i n e slowly and c a r e f u l l y from the entrance arrow and around the f i r s t corner, being sure to keep i n the middle of the printed l i n e s and making a right-angle turn. He should make sure he has the subject's attention. The examiner indicates the e x i t i n the VII year test but i n no other t e s t . I f the subject, i n any other t e s t , asks where the exi t i s or complains that there i s no e x i t , he should be t o l d , gently but f i r m l y , that there i s only one way out and he must f i n d i t himself. These i n s t r u c -tions should be given slowly and c l e a r l y with the examiner 73 s i t t i n g opposite the subject and with a f a i r l y narrow table between them. In subsequent tests the examiner indicates the s t a r t -ing point and says: " s t a r t here and f i n d your way out." No further elaboration or r e p e t i t i o n of instructions should be given with the exception of the warning against l i f t i n g the p e n c i l , which i s not a quantitative error. As soon as an error i s made the test blank should be withdrawn and a new one substituted. However, before the blank i s withdrawn the subject should be informed of his error i f he has not already discovered i t for himself. In no case, however, should the correct pathway be pointed out nor should the subject be allovred to continue or return to a new route after making an error. An important r e s t r i c t i o n and one that i s d i f f i c u l t to enforce with psychotic subjects i s to prevent pre-tracing of the Maze. This should not be mentioned to the subject u n t i l i t occurs spontaneously at which time the examiner places h i s hand over the design and warns against i t . Enforcement of the rule against l i f t i n g the p e n c i l helps to prevent pre-tracing. With some subjects i t may be necessary to repeat these two rules ( i . e . against l i f t i n g the p e n c i l , and pre-tracing) several times throughout a t e s t . There are only two kinds of errors which are scored i n the quantitative scale: 74 1. An error occurs when the subject crosses an imagi-nary l i n e at the entrance to a dead-end street to the extent of at least one-sixteenth (1/16) of an inch. 2. An error occurs when the subject crosses a l i n e to an opening instead of pursuing the proper course, or when he crosses a l i n e to an adjacent correct pathway, instead of following the o r i g i n a l pathway to i t s proper e x i t or turning point. O r d i n a r i l y , the i n i t i a l i nstructions may not be repeated i f the application of the extension follows immediately or within a year of giving the o r i g i n a l . But an exception to t h i s rule may be made i n the case of psychosurgical patients or patients on medication to whom the o r i g i n a l i s given before treatment and the extension after treatment. I t i s then permis-s i b l e to repeat the instructions f o r the second or t h i r d a p p l i -cations of the Maze i f the subject says he does not remember the t e s t . In the 1950 (29) manual test ages were calculated by adding c r e d i t s to a basic score. In the 1955 (30) manual the procedure i s to deduct one-half year f o r every unsuccessful t r i a l . The results are the same but the l a t t e r method i s much simpler. The scoring procedure now i s as followsJ 1. Take as maximum credit 17 years i f the adult test i s passed and deduct one-half year f o r each unsuccessful t r i a l throughout the ser i e s . 75 2. Take as maximum cre d i t 15 years (a) i f the adult test i s f a i l e d or (b) i f i t i s not counted because of previous f a i l u r e s . In either case (a) or case (b) deduct one-half year f o r each unsuccessful t r i a l i n a l l tests p r i o r to the adult l e v e l . In the adult test no cre d i t i s given or deduction made. 3« Take as maximum cre d i t the highest test passed and deduct one-half year f o r each unsuccessful t r i a l i n a l l tests p r i o r to and including the highest test passed. The procedure f o r administering the quantitative scale to psychotic adults may be summarized as follows: 1. With subjects 14 years or older begin with the VII year t e s t . 2. Allow two t r i a l s i n each test through year XI, four t r i a l s each i n years XII and XIV, and three t r i a l s i n the adult t e s t . 3. When a test i s f a i l e d , and the test immediately following i t i s passed, invert the l a t t e r and score the worse performance. 4. Continue testing u n t i l two successive f a i l u r e s above year IX or any three f a i l u r e s have been recorded. 5. Administer and score the adult test i f there are no successive f a i l u r e s above year IX or i n the absence of any three f a i l u r e s . 6. A t r i a l i s f a i l e d as soon as a quantitative error 76 i s made. A quantitative error consists of (a) entering a b l i n d a l l e y to the extent of 1/16 of an inch, (b) cross-ing a l i n e to an opening, or crossing a l i n e and proceed-ing along an adjacent pathway instead of pursuing the proper course. 7. Take as maximum credit (a) 17 years, or (b) 15 years, or (c) the highest test passed, according to the instructions given above. The scoring method re s u l t s i n a test age or mental age. To convert these into I.Q.'s, 14 years should be used as the d i v i s o r f o r cases at that age or above. The foregoing procedure i s to be used with both the o r i g i n a l and the extension series but i t should be noted that i t applies only to the quantitative scale and to a s p e c i f i c population, namely, psychotic adults. APPENDIX B The L-M Fergus F a l l s Behavior Rating Scale 77 PROCEDURE FOR SCORING BEHAVIOR RATING SCALE Each category consists of f i v e separate statements and each statement i s given a weighted value as follows: 1 f o r the f i r s t statement, which represents the poorest behavior; 2 f o r the second, which represents a type of behavior superior to 1, and so on up to 5 for the f i f t h statement, which represents behavior that i s r e l a t i v e l y normal. The rater places a check mark beside the statement he considers represents a given patient's behavior i n a p a r t i c u l a r category, or beside more than one statement i f he deems i t necessary. The weighted value or values are then summed and the average taken as indi c a -t i v e of the patient's behavior i n a given category, e.g. A (work). A quantitative value of from 1 to 5 i s thus obtained f o r each category on which a patient i s rated. Some patients may be rated on a l l eleven categories; others may be rated on fewer than eleven. In the present study, for example, no patient was receiving e l e c t r i c or i n s u l i n therapy hence no subject was rated on that category (E). Certain other patients did not work or took no part i n recreational or occupational therapy and so could not be rated on these categories. The ratings obtained on each category are summed and the average of these i s taken as representing the patient's c l i n i c a l behavior. 78 INSTRUCTIONS FOR FILLING OUT BEHAVIOR RAT TNT. SHP.F.T At the top of the Behavior Rating Sheet write i n the patient's name and. number, the ward, and your own name. Below you w i l l f i n d ten di f f e r e n t groups of descriptions of a p a r t i c u l a r type of behavior. Place a check (X) by the des-c r i p t i o n that comes closest to t e l l i n g how t h i s p a r t i c u l a r patient has behaved for . I f the patient's behavior has changed i n t h i s period, then check the description which t e l l s how the patient has behaved most of the time. I f the patient's behavior i s evenly divided, then check two descriptions (or more, i f necessary). Look at each group of descriptions separately, do not t r y to give an  o v e r a l l impression at any time because, as you well know, a cert a i n patient may be a very good worker but he may not speak at a l l . I f you f e e l that you don't know enough about a ce r t a i n b i t of behavior (example, you haven't seen the patient eat) then leave that part out, i t i s f a r more important to have true des-crip t i o n s than to have many descriptions. There w i l l be other descriptions that you w i l l have to leave out. (Examples: i f patient i s n ' t getting i n s u l i n or e l e c t r i c treatments, you can't rate that p a r t i c u l a r patient. I f patient i s bedridden, he can't be rated f o r amount of a c t i v i t y . ) APPENDIX B L-M Fergus F a l l s Behavior Rating Sheet Patient's Name A. WORK Number Ward Rater C. RESPONSE TO OTHER PATIENTS Does no work - refuses -"extremely n e g a t i v i s t i c ; Does a l i t t l e work with a l o t "of urging. Constant supervision i s necessary. May have a regularly assigned "job—and supervision may be necessary. Enthusiastic p a r t i c i p a t i o n i n " a l l types of work - asks for work. Normal interest i n work - i . e . , "interested i n some kinds of work more than others ( w i l l do other kinds than main interest I f c a l l e d upon to do so). B. RESPONSE TO MEALS Has to have special attention, "as eats too much, spoon fed or tube fed. Eats by s e l f , i s sloppy—may need coaxing. Eats by s e l f using k n i f e , fork "and spoon properly. May show some finickyness. Passes and asks for things to be "passed, but w i l l not carry on table conversation. Would not stand out among normal "people for eating habits. Stays a l l alone or may s t r i k e out at other patients. W i l l be with other patients only fo r a short while and with urging. Some signs of friendliness - speaks to patients - may have a f r i e n d . Some spontaneity i n making contacts with other patients. May i n i t i a t e play or work of a s o c i a l r e l a t i v e l y high order type. (Card game, washing dishes) Helpfulness expressed toward other p a t i e n t s — o r non-hostile recognition of t h e i r being mentally i l l and making allowances. D. RESPONSE TO PSYCHIATRIC AIDES AND NURSES Negativistic - h o s t i l e (can include s t r i k i n g ) - doesn't do anything requested. W i l l do a few things i f asked or pushed - shows no open h o s t i l i t y . W i l l do most things when asked - w i l l ask f o r simple things - "I want my tooth-brush." Extremely cooperative — w i l l do anything when asked. Normal give and take rel a t i o n s h i p . Speaks spontaneously to nurses about things of not immediate importance, (weather, baseball games, etc.) •o 2 E. RESPONSE TO DOCTORS, SOCIAL WORKERS, PSYCHOLOGISTS. Hostile Passively n e g a t l v i s t l c (would rather not have anything to do with them but w i l l not r e s i s t ) . W i l l speak when spoken to. Seeks advice. Understands, accepts, and asks for therapy. F. RESPONSE TO ELECTRIC OR INSULIN THERAPY Ho s t i l e , etc. Anxious, apprehensive, but not overly h o s t i l e . Passively accepts. Accepts p o s i t i v e l y — ( M a y say, "I f e e l better a f t e r " ) . Asks f o r , understands necessity f o r . G. OCCUPATIONAL THERAPY AND RECREA-TIONAL THERAPY (WALKS DON'T COUNT) -•• Does not participate at a l l -n e g a t i v i s t i c - h o s t i l e . Participates with urging for short periods. Participates when asked -some spontaneity. Shows i n t e r e s t — p a r t i c i p a t e s i n a l l types wholeheartedly without discriminating very much between dif f e r e n t types - looks forward t o . G. continued Interested i n many varied a c t i v i t i e s -normal s e l e c t i v i t y ( l i k e s some kinds more than others.) H. ATTENTION TO DRESS AND PERSON Has to be dressed - needs special attention of one kind or another. Dresses s e l f but i s sloppy. Some Interest i n looks - f a i r l y neat. Carets about looks and dress; w i l l ask for shaving equipment etc., inconsistently. (Not an o v e r a l l balance.) Normal (for culture) - would not stand out i n a crowd. I. PSYCHOMOTOR ACTIVITY (NOT INCLUDING GOING TO THE BATHROOM, OR MEALS) Stays i n one place unless pushed, or hyperactive, (seclusion necessary, etc.) _ Moves around a l i t t l e (one chair to another) or i f hyperactive, the a c t i v i t y i s not of a type making seclusion or other r e s t r i c t i o n s necessary. Some a c t i v i t y r e s u l t i n g from the influence of the i l l n e s s (moves around because voices say to) and some purposeful behavior. S t i l l moves around a l i t t l e fast or a l i t t l e slow. Normal a c t i v i t y - would not stand out among normal people. 8 J . SPEECH Mute or speaks a l o t but i t doesn't make sense. A few words that make sense ("yes" or "no") Speaks i n short clear sen-tences, "can I have my toothbrush." Speaks normally except a l i t t l e fast or slow. Speaks normally. K. TOILET BEHAVIOR Untidy anytime during the day and/or more than twice a week nig h t l y . Untidy once or twice a week night l y - brushes teeth and washes only when tol d to do so. Not untidy - t o i l e t behavior somewhat sloppy - brushes teeth and washes once a day without being t o l d . T o i l e t behavior normal except for being too neat or too much time spent at one thing or occasionally sloppy. T o i l e t behavior normal. 3 0 0 H APPENDIX C Tabulation of Raw Data P a i r •a +> £3 CO S H •H O fH F* CP - P p. d X o W o il II W O Porteus Maze Score Behavior Rating Pre-medication Maze .Scores Medication Maze Scores Post-medication Maze Scores Pre-medication Ratings Medication Ratings Post-medication Ratings CD W) < Hospital Duration Years of Schooling Occupation * T J CD T J «H CD t-i •H t-i !-, ca co a II II a CO Diagnosis ** 16.5 16.5 16.5 2.9 3-3 3.2 48 7 8 1 S U 16.5 16.5 16.5 2.9 2.6 2.7 44 9 10 1 s U 16.5 15.0 17.0 3.4 3.3 3.5 50 19 11 1 s D 16.5 12.5 15.0 4.4 4.4 4.3 53 7 8 1 M P 16.5 15.5 15.5 2.3 2.2 2.3 64 20 3 3 M D 16.5 15.5 14.5 3.7 4.0 6.7 67 24 6 1 M P 15.5 14.5 14.5 2.7 2.7 2.8 45 11 5 1 S S 15.5 16.0 16.5 2.6 2.7 3.2 41 3 9 1 s U 15.5 10.5 13.0 3.8 3.7 3.4 59 20 3 1 s S 15.5 17.0 16.0 4.4 4.4 4.5 65 21 4 1 s P 15.5 16.0 16.5 2.2 2.0 2.3 47 18 11 1 M S 15.5 10.5 13.4 2.2 1.9 2.3 45 23 12 2 s U 15.5 9.0 13.0 3.2 3.3 3.3 66 5 8 3 M D 15.5 10.0 15.5 4.3 4.5 4.6 66 7 4 1 S U 15.0 9.0 15.5 3.4 3.5 3.6 65 7 5 1 s S 15.0 12.5 10.0 3.3 3.0 2.8 58 16 5 1 s U 14.5 9.0 8.0 3.5 3.6 4.1 48 16 10 1 . M D 14.5 12.5 13.5 3.2 3.1 3.3 46 19 6 1 s TJ 14.5 17.0 16.0 2.9 3.4 3.3 42 16 7 1 s P 14.5 12.5 16.0 3.5 3.9 4.4 47 10 9 2 s U 14.5 11.5 12.0 2.4 2.5 2.3 58 19 4 . 1 s P 14.5 13.0 11.0 2.0 2.1 1.9 59 17 6 1 M U 14.0 15.0 16.0 3.9 4.0 3.6 74 20. i 6 1 s P 14.0 13.5 15.0 3.7 3.1 4.1 75 28 6 1 s C 13.5 15.5 17.0 4.7 4.9 4.9 73 10 8 1 s P 13.5 11.5 16.5 4.2 4.2 3.8 72 16 5 1 M U 12.5 9.5 12.0 2.7 2.8 2.8 61 24 5 3 s U 12.5 12.5 15.0 3.9 3.4 3.6 60 5 8 1 s U 10.5 11.5 15.0 3.0 3.2 3.7 67 26 6 1 M U 10.5 13.5 10.5 3.4 3.5 3.6 76 20 6 1 s P 10.5 7.5 io.5 2.5 2.3 2.4 40 7 7 1 s D 10.5 9.0 6.5 2.5 2.7 2.6 33 10 5 3 s D 10.5 6.0 9.0 2.9 2.9 2.8 60 6 4 1 s c 10.5 11.5 11.0 4.1 3.8 3.8 54 3 5 ? M p 10.0 7.0 8.5 4.2 4.1 "~ 3.8 78 24 5 1' s s 10.0 12.0 16.5 3.9 3.6 3.7 69 18 10 2 s s 9.5 12.5 16.5 3.7 3.9 4.4 56 11 00 1 s p 9.5 9.5 8.0 2.6 2.6 2.5 59 7 14 3 M D 8.0 10.5 9.0 3.7 3.5 3.4 55 24 5 1 s S 8.0 7.0 9.0 2.5 1.8 2.4 51 24 6 1 s D 7.5 8.0 9.5 2.9 3.1 3.0 41 19 6 1 s U 7.5 9.5 9.0 3.0 3.0 3.2 34 11 6 1 s P 7.0 10.0 9.0 3.7 3.9 3.3 55 24 0 1 s D 7.0 9.0 8.5 3.5 2.7 2.8 59 28 4 1 s U Matching Variables 1 E 1 C E 2 C 3 E  J C E 4 C * E 5 c k E he n E 7 c 8 E C 9 E   C 10 E C E 11 C 12 E C E 13 c 14 E C E 15 c 16 c E 17 c E 18 c E 19 C 20 21 22 E C E E C * 1 = Unskilled 2 = Semi-skilled 3 = S k i l l e d ** u P D S D Undifferentiated Schizophrenia Paranoid Schizophrenia Deteriorated Schizophrenia Simple Schizophrenia Catatonic Schizophrenia oo 

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