Harold A. Sackeim

Studies of Dosage, Seizure Threshold, and Seizure Duration in ECT

Seizure threshold, defined as the minimal electrical dosage necessary to elicit adequate generalized seizure, was determined throughout the course of electroconvulsive therapy (ECT) in depressed patients randomly assigned to bilateral and right unilateral treatment, with brief pulse, constant current stimulation. In Study 1, it was found that seizure threshold may be more accurately measured using the unit of charge compared to the traditional unit of watt-second. In Study 2, it was found that seizure threshold was associated with seizure duration. Patients with high thresholds had shorter seizure durations. This indicated that the seizure threshold measure assesses in part functional neural activity. In Study 3, it was found that failure for seizure threshold to increase substantially over the course of ECT was associated with poor clinical outcome. In Study 4, it was found that electrical dosage at threshold was not related to magnitude of acute cognitive impairments. This suggested that the degree to which dosage exceeds threshold may be more strongly tied to adverse effects than the absolute dosage administered to patients. Implications of the data are discussed, particularly in relation to a hypothesized link between the anticonvulsant properties of ECT and its mechanism of therapeutic action.

Effects of major depression on estimates of intelligence

This study examined whether patients with major depressive disorder manifest deficits in intelligence during affective episodes and following clinical improvement. WAIS-R scores were contrasted in 100 patients in an episode of major depression with 50 normal controls, matched to the patient sample in terms of demographic variables and estimates of premorbid IQ. The groups were equivalent in verbal IQ, but, in line with previous studies, the depressed patients had a pronounced deficit in performance IQ. A patient subsample was administered the WAIS-R under unlimited time conditions to determine whether the time constraints of performance IQ subtests contributed to the magnitude of the verbal-performance IQ discrepancy. This discrepancy was only slightly reduced with untimed scoring. Subgroups of depressed patients were retested with the WAIS-R within one week (n = 26) or two months (n = 33) following treatment with electroconvulsive therapy. In both subsamples, IQ scores were improved at posttreatment testing relative to pretreatment, but with little change in the verbal-performance IQ discrepancy. These and related findings suggested that a performance IQ deficit is characteristic of depressed patients regardless of affective state.

Effects of depression and ECT on anterograde memory

This study investigated immediate and delayed recognition memory in depressed patients undergoing electroconvulsive therapy (ECT) and in matched, normal controls. At baseline, patients manifested a marked deficit in immediate memory (acquisition), but showed no deficit in delayed memory (retention). When retested 24-36 hr following the seventh ECT, patients showed reductions in both immediate and delayed memory performance. At retesting 4 days, on average, after the ECT course, immediate memory scores returned to baseline levels, but delayed memory performance remained impaired. The findings supported the classic claims that depression is associated with a deficit in the acquisition of information, whereas ECT has a more profound influence on the retention of information. This dissociative pattern could not be viewed as an artifact of task psychometric properties, nor of practice effects in control subjects.

The Efficacy of Electroconvulsive Therapya

A criticism often raised about electroconvulsive therapy (ECT) is that it, like other somatic treatments in psychiatry, has no rational basis.’ We are ignorant of “how” and “why” ECT is so powerful as an antidepressant agent. In the case of ECT, however, this charge, in important respects, is wrong. Largely following the work of Ottosson: for a quarter century it has been accepted that the elicitation of a generalized seizure is essential to the therapeutic process. In depressed patients, chemical or electrical inductions of generalized seizure appear to be equivalent in producing strong therapeutic results.’-5 Using bilateral ECT, Ottosson reported that there was no difference in rates of therapeutic response when a traditional electrical dosage was compared to a more intense, supramaximal dosage.2 Blockade of the seizure discharge with an anticonvulsant medication or the use of subconvulsive electrical dosage is known to be nontherapeutic.2s68 On the basis of this evidence, the most widely accepted view has been that the elicitation of a generalized seizure provides both the necessary and sufficient conditions for the antidepressant properties of the Furthermore, there have been longstanding indications that electrical dosage and/or waveform characteristics are related to the cognitive side effects of ECT.2*”*’2 Configurations requiring greater electrical intensity are generally associated with more profound side effects.” d’Elia and colleagues recently summarized this view, stating: “An optimal therapeutic effect depends on the Occurrence of a generalized, tonic-clonic seizure. . . . On the other hand, supraliminal stimulation does not enhance the therapeutic effect. The organic

Specificity of smooth pursuit eye movement and visual fixation abnormalities in schizophrenia : comparison to mania and normal controls

Smooth pursuit eye movements (SPEM) were assessed in 30 schizophrenic patients, 12 lithium-free manic patients, and 20 normal controls. Compared to schizophrenic patients, manic patients evidenced less SPEM impairment in an attention enhancing, sinusoidal target motion condition and had superior performance during a visual fixation condition. SPEM and visual fixation dysfunctions may be more common in schizophrenic than in acutely manic patients, even when the latter are characterized by marked attentional dysfunction, poor interepisode psychosocial functioning, and psychosis.

Perceiver bias in the processing of human faces: neuropsychological mechanisms

Previous research has suggested that in face-to-face contexts perceivers are biased to judge the side of the posers face to their left as more similar to the full face than the side to their right. Traditional explanations of the perceiver bias have presumed that it is a visual field effect, with the side of the posers face falling within the perceivers left visual field dominating impressions of the full face. In this study, five experiments are reported. In the first experiment, the validity of the perceiver bias phenomenon was supported. The remaining experiments examined three alternative accounts of the neuropsychological processes that underlie the perceiver bias. No support was obtained for the visual field explanation, nor for an account of the bias as due to asymmetry in gaze patterns. Support was obtained for an account emphasizing a hemispatial bias in central processing. Despite equivalent intake of information from both sides of space, the brain may differentially weight information as a function of hemispatial origin. Practical and theoretical implications are discussed.

Asymmetry of the face at rest: size, area and emotional expression

In a sample of 53 right-handed, young adult males, asymmetry was examined in the size of 11 facial regions, in total area, and in emotional expression of the face at rest. In the complete sample no evidence was obtained of consistent asymmetry in size of facial regions, in facial area, or in emotional expression. There was, however, an interaction between family history of sinistrality and sighting dominance in facial asymmetry for the pleasantness/unpleasantness of facial expression. The findings suggest that previously established asymmetries in phasic emotional displays are not an outcome of expressive or morphological asymmetries of the face at rest.

Continuation ECT in the management of relapses of major affective episodes

ABSTRACT— Three cases are reported describing the use of continuation ECT. Continuation ECT consisted of six to twelve treatments for about 3 to 6 months after recovery from the index affective episode. Continuation ECT may be indicated in patients with a severe episode of illness, optimal acute response to ECT, and negative response to continuation drug therapy. In such patients, the mostly theoretical risks associated with the procedure may be outweighed by the dangers associated with early relapse.

Morphologic asymmetries of the face: A review ☆

It has been suggested that asymmetries in the morphological properties of the face contribute to or produce asymmetries in facial emotional expression. Over 50 years of research on hard tissue, soft tissue, and facial surface asymmetries is reviewed here. Generally, it appears that if consistent asymmetry characterizes facial morphology, it is extremely small in magnitude or characterizes regions yet to be examined. In contrast, marked homology and asymmetry in regional size and area has been noted often. At present, it does not appear that asymmetry in facial morphology is associated with facial expressive asymmetry, with the latter more likely to be an outcome of functional brain asymmetry.

Effects of predictors of hemispheric specialization on individual differences in hemispheric activation

In two studies predictors of variation in hemispheric specialization--handedness, sex, familial history of sinistrality, writing posture and sighting dominance--were found not to be independent of individual differences in characteristic activation asymmetry. Predominant direction of conjugate lateral eye movements was used to assess activation asymmetry. The lack of independence between these two dimensions of individual difference, predictors of variation in hemispheric specialization and in activation asymmetry, suggests caution in interpreting the results of studies in which one dimension is examined and the other is uncontrolled.