The Effects of Convulsive Therapy on the Excretion of Cortins and Ketosteroids

The Somatic Manifestations of Schizophrenia

There is still no agreement on the aetiology of schizophrenia, or general acceptance of its definition as a “functional psychosis.” There is agreement only on the complexity of the problem presented by an illness which involves every aspect of the personality, and is precipitated by a multiplicity of internal and external causes. This complexity suggests that an approach from many angles, clinical, genetic, sociological, statistical, or even a more remote biological or physiological approach may yield some information of value.

Observations on the Relation Between Insulin Coma Dosage and Prognosis in Schizophrenia

The evidence for somatological differences between various types of schizophrenia and its different stages of severity or chronicity is still scanty and often contradictory. The present investigation mainly concerns itself with endocrinological factors. Kraepelin, already, suggested disturbances in the endocrine system. The incidence of schizophrenia in different age-groups, especially its steep rise at puberty, reaching its peak at 20 in men and 25 in women and the rapid decline of its occurrence after these ages (Haas, 1938), has for a long time pointed to the sex steroids as an important factor in the pathology of this disorder. Hemphill et al. (1944, 1945, 1948) found an atrophy of the testes in many cases of schizophrenia, and considered the severity of the testicular change to be proportional to the severity of the psychosis. They suggest that the testicular lesions are not the cause of schizophrenia, but probably effects of the “pathogenic process” and related to hypothalamic or pituitary function. In confirmation of these findings Hoskins and Pincus (1949) observed the output of androgen in schizophrenics to be significantly lower than in normal men. Sears (1937) made similar observations in females, and found that the blood-œstrin level of female schizophrenics was much lower than in normal women. Possibilities for primary endocrinological factors suggest themselves; the “pathogenic process” can, however, still be primarily a psychological “stress” in this new constellation or a combination of both, or the effect of another central disturbance. Some of our somatological findings can, therefore, tentatively be interpreted as related to or identical with the primary stress or others only as secondary correlates or results, though the present state of our knowledge does not yet allow a final decision as to what is primary and what only secondary. Recent evidence, on the relationship of sex hormones and insulin (Houssay, 1951) suggests that oestrogens have a “sensitizing” and androgens a “desensitizing” effect. An investigation into the insulin sensitivity in clinically different schizophrenic groups and the two sexes expressed in the amount of insulin needed to produce a hypoglycaemic coma should, therefore, throw some light on other endocrinological mechanisms.

Desoxycortone Acetate and Ascorbic Acid in the Treatment of Schizophrenia

During recent years there has been a revival of interest in the possible role of the adrenal cortex in the pathophysiology of schizophrenia.

Cortisone in the Treatment of Schizophrenia

Recent research has given rise to the hope that the secretory products of the adrenal cortex might be useful in the treatment of schizophrenia.

Two main lines of research have stimulated renewed interest in the role of the adrenal cortex in the pathophysiology of schizophrenia. A number of investigations have produced evidence that the responsivity of the adrenal cortex of schizophrenic patients to stress is lower than that of normal controls (Freeman et al., 1944; Hoagland et al., 1946; Pincus and Elmadjian, 1946; Pincus et al., 1949).

Another series of investigations has shown that adrenocortical activity is stimulated by insulin coma therapy, electronarcosis and electroconvulsive therapy (Hemphill and Reiss, 1942; Mikkelsen and Hutchins, 1948; Rees (1949a); Parson et al., 1949).

Cranswick and Hall (1950) reported that desoxycortone acetate and ascorbic acid appeared to be therapeutically valuable in schizophrenia. Rees and King (1951) carried out a controlled investigation on the treatment of schizophrenia with desoxycortone acetate and ascorbic acid, and found no evidence that the method was of any therapeutic value. It was pointed out that the investigation did not preclude the possibility that other products of the adrenal cortex might be therapeutically useful in schizophrenia.

The present paper describes a controlled investigation in the therapeutic value of cortisone administration in schizophrenia.

We are indebted to Dr. Ernest Evans, Consultant Physician, East Glamorgan Hospital, for making available a supply of cortisone for the investigation.

Adrenal Cortical Function and Response to Convulsive Therapy in a Case of Periodic Catatonia

Any patient who shows a regularly recurring change of mental state will be of particular interest to the research worker, for in the recurrence, by acting as his own “control,” the patient provides the best of all comparisons.

Such a patient, a woman aged 39, provided the basis for this work. Usually sensible and well spoken, she would, about every twenty-first day, become confused and incoherent. Convulsive therapy (E.C.T.) always caused an immediate improvement, and within two or three days she was well again. (Previous experience had established that the confusion had little spontaneous tendency to recover.) As she provided this regular cycle, a systematic investigation was made over several months into those aspects more particularly relevant to the effect of E.C.T. on the adenohypophyseal-adrenocortical system, for a previous study (Ashby, 1949) had suggested that E.C.T. might owe its effectiveness to action through this system.

Clinical, Biochemical and Physiological Studies in Cases of Recurrent Schizophrenia

During the clinical observation of a female patient suffering from recurrent schizophrenic attacks, it was noticed that each psychotic episode was associated with the appearance of acne, and also that during remissions the patient showed an unusual craving for salt. These observations, together with the automatic disturbances characteristic of the onset of attacks, suggested that the adrenal cortex might play a part in the metabolic changes in this type of case, particularly the changes in nitrogen balance which have been demonstrated by Gjessing (1932, 1938). The work here reported was therefore primarily concerned with investigating the possible relationship between adrenal cortex activity and nitrogen metabolism in two patients of this type.

An Investigation of the Adrenocortical Response of Mental Patients to E.C.T. and Insulin Hypoglycaemia

Somatic disturbances in schizophrenia include metabolic, circulatory and endocrine changes frequently associated with disorders of the pituitary gland and adrenal cortex. Depression of the metabolic rate is often severe (Hoskins, 1932), the systolic blood-pressure is sometimes as low as 80 mm. Hg (Hoskins, 1934; Rheingold, 1939; Shattock, 1950), and the pulse pressure only a few millimetres. Peripheral vascular deficiency and atrophy of the tissues (Bleuler, 1920; Mapother, 1924; Minski, 1937; Shattock, 1950), asthenia and various cutaneous changes are common; amenorrhoea is almost the rule.

It is remarkable that these disturbances are reversible, and that they are relieved or greatly alleviated during mental remission. Physical health is restored during a spontaneous remission, and a gradual improvement can be observed during a course of insulin comas. Sometimes a dramatic recovery follows electroconvulsion when this initiates a mental remission; somatic improvement is then rapid and the vascular deficiency may be relieved within a few hours (Shattock, 1950). Unfortunately these remissions are often brief, and as relapses become more frequent after repeated treatment, physical and mental deterioration may be noticeable a few days after the initial improvement. The point of interest is a concordance of physical and mental changes, and not the therapeutic value of E.C.T. used as an adjunct to insulin treatment or as a means of moderating extreme restlessness in chronic patients.

Activators and inhibitors of hexokinase in human blood

The endocrine system is one of the foremost links in the psychosomatic relationship, and its special significance in the study of mental disease needs no emphasis. Compared with our knowledge of the chemistry and basic functions of the hormones very little is known about their more intimate mechanisms of action. It has been possible to assign to some hormones the function of controlling the rate of specific metabolic processes, but whether they do so by a direct reaction with a component of one or more enzyme systems or indirectly by influencing the mutual accessibility of enzyme and substrate is still a matter of discussion. The latter mechanism would depend on a spatial organization involving membrane barriers, phase boundaries or similar discontinuities and, in fact, many hormonal effects which can be demonstratedin vitrowith the aid of intact or sliced tissues disappear when the structural organization of the cell is destroyed. It is, however, well to remember that synthetic and other energy-consuming reactions were believed until recently to depend on the integrity of the cellular organization, but when some insight was gained into the mechanism of biological energy transformation and the function of labile phosphate bonds in these processes, it was possible to demonstrate many such reactions in homogeneous systems. Similarly, the interactions of hormones and enzymes may require the intervention of unstable mediators, and control of these factors might allow their reconstruction in cell-free extracts. In any case, it is more satisfying to account for the great specificity of hormonal action on the basis of a chemical reaction with specific enzymes than by a mechanism leading to predominantly physical changes.

A theory of convulsive therapy in endogenous depression: significance of hypothalamic functions

The repeated induction of seizures (convulsive therapy) relieves the symptoms of severe depressive mood disorders, particularly those accompanied by vegetative symptoms. Neuroendocrine abnormalities characterize patients with endogenous depression, and the abnormalities are reversed by convulsive therapy. Tests of neuroendocrine functions provide criteria for the classification of such cases, and probably will be useful in defining suitable cases for convulsive therapy. We postulate that the antidepressant efficacy of convulsive therapy results from the increased release and more widespread cerebral distribution of hypothalamic peptides with behavioral effects. Such a hypothesis provides a basis for clinical trials of centrally active peptides in cases of endogenous depression, and for studies of neuroendocrine functions as predictors of outcome in convulsive therapy.

The mode of action of electro-convulsive therapy

How electro-convulsive therapy (E.C.T.) acts, what is the chain of cause and effect from the electrical application to the clinical improvement, are questions whose answers are as uncertain as ever, in spite of the importance of such knowledge to psychiatry and in spite of the researches of nearly twenty years. The experiments reported in this paper are an attempt to elucidate the links of one possible chain. What are the possibilities? I shall review them briefly, restricting the review to the physiological and biochemical aspects and omitting any reference to the psychological or psycho-analytical.