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A video analysis of the non-verbal behaviour of depressed patients before and after treatment
Journal of Affectwe
Disorder.~, 9 (1985) 63-67
63
Elsevier
JAD 00309
A Video Analysis of the Non-Verbal Behaviour of Depressed Patients Before and After Treatment G. Ulrich’ and K. Harms 2 ’ Department OJ Psychoph_wioloRy and .’ Depcrrtment of Clinical Ps_vchiatrv. Free Unioersit>~of Berlin, D 1000 Berhn (F. R. G.) (Received 4 October, 1984) (Revised. received 11 December, 1984) (Accepted 17 December, 1984)
Summary
Using videotaped interviews of depressive in-patients, which were recorded on day 0 and day 21 of antidepressive pharmacotherapy, the behavioural structure of the syndromal main aspects, retardation and agitation, was analysed. This analysis was done on the basis of non-verbal behaviour only. A factor analysis was carried out on the observational data. Three independent factors, constituting together the clinical picture of endogenous depression, could be defined: one factor of retardation and two different factors of agitation. The importance of such non-verbal analyses for a more differentiated diagnostic evaluation, on the one hand, and to provide more insight into the diagnostic process as such, on the other, is pointed out. Additionally it was found that syndromal complexity decreases in a characteristic manner along with clinical improvement.
Key words:
Antidepressive
phurmacotherupy
- Behaviour
Introduction
The concepts ‘retardation’ (Hemmung) and ‘agitation’ (Agitiertheit), introduced by Kraepelin (1913) as the main syndromal characteristics of depressive syndromes, are still widely used for psychiatric diagnoses. Because of the significance of these concepts for the choice of the proper antidepressive agent (Kielholz 1972; Strian et al.
Address for correspondence: Priv. Doz. Dr. Gerald Ulrich. Freie Universitat Berlin, UniversiWsklinikum Charlottenburg, Abteilung ftir Psychophysiologie, Eschenallee 3. D-1000 Berlin 19, F.R.G. 0165-0327/85/$03.30
@’1985 Elsevier Science Publishers
- Depression
- Treatment
1979; Avery and Silverman 1984) a more refined definition of retardation and agitation seems desirable. Such a definition is also of theoretical importance since it should give deepened insight into the structure of endogenous depression as well as illuminate the diagnostic process itself, i.e., uncover the perceptions which are taken into consideration in making a diagnosis and how these perceptions are weighted. It is certain that the elements which constitute the impression of retardation and agitation are not usually given special attention during the diagnostic process. They only provide diffuse background information which cannot be systematically controlled or relia-
B.V. (Biomedical
Division)
64
bly reconstructed. This is reflected in clinical ratwhere retardation and agitation appear as global. undifferentiated categories of assessment. The uncertainties of the diagnostic process cannot be eliminated by ex cathedra operationalism. but only by careful observation and analysis. Emphasis should be placed on non-verbal behaviour which has not yet been adequately systematically studied. As Kretschmer (1953) put it, many of the terms used in clinical psychiatry suffer from their prescientific metaphoric quality. According to this author, this unsatisfactory condition may be overcome only by a systematic registration and classification of psychomotor phenomena which are based primarily on formal criteria. Video techniques commonly available now allow the analysis of non-verbal behaviour. In a series of investigations on endogenously depressive we have shown how a descriptive patients. videoanalysis of psychopathological behaviour can be developed (Ulrich, 1979, 1980, 1981: Ulrich et al. 1976; Ulrich and Harms 1979). In this study we shall confine ourselves to the following two questions: (1) Which elements or patterns of behaviour are decisive for our judgement of ‘retardation’ or ‘agitation’? (2) Are such patterns of behaviour modified in the course of pharmacotherapy and if so. how? ing scales
Patients
and Methods
We analysed the videotaped interview of 47 in-patients (37 female, 10 male; range: 25-68 years; median: 48 years) with endogenous or involutional depression (ICD No. 296.2 and 296.0, 8th revision) which were recorded before and on day 21 of antidepressive pharmacotherapy. All patients fulfilled the diagnostic criteria suggested by Feighner et al. (1972) for primary depression. The semistructured interviews were conducted by the attending physicians and documented with the AMP system (Scharfetter 1972). The length of the recordings, which was determined by fulfillment of documentational needs, varied only slightly and averaged 520 s. The recordings of the 94 interviews were presented to 2 independent raters 3 times each. An
additional run was needed for the determination of speaking time (ST). First run - graded or alternative assessment of the following aspects. (a) (h) (c) (d) (e) (I”) (g) (h)
Retardation (R) 0-1-2-3-4-5-6-7 Agitation (A) i Reduced eye movements (REM) O-1-2-3 () (no) _ , Reduced facial expression (RFE) Constricted posture (CP) \ (uncertain) Postural reatleasness (PR) 2 (yes) Low vo,cr (LV) i DmGnished prosod) (DP)
The items and the mode of assessment had been found appropriate in an earlier study (Ulrich et al. 1976). Second run ~ registration of certain hand movements as discrete acts. Classification was based on Freedman’s system (1972). (a) Object-focused movements (0). These are speech-related and focused on an object in both of two senses: (1) linked to the object of the speaker’s verbally expressed experience and (2) linked to the effort to reach the listener, the object of presence. Object-focused movements are subdivided into a motor-primacy type (0, ), which is characterized by predominantly gross movements with clear semantic content, and a speech-primacy type (0,), which is characterized by predominantly subtle movements associated mainly to the rhythmic aspects of speaking with no clear semantic function. (b) Discrete body touching (D). Short gestures of embarrassment with a duration less than 3 s and an easily detectable symbolic content (Mahl 1968) mainly directed towards the face or head. Third run - measurement of the duration of
Fig. I. Clawfication Freedman 1972).
of hand
movements
(with
reference
to
continuous body-focused movements (C) (see Fig. 1) with a stop watch. (a) Undirected movements (C”). Both hands are involved in mutual manipulation. (b) Directed movements (C,,). One hand continuously manipulates an object such as: the other hand (Co,); the face or head (CIIF); objects carried on the body (CD+,). In addition the intensity of each sequence of C was evaluated on a 3 degree scale, represented by the scores 1, 2 and 3. To make these measures comparable, we determined the frequency of O-acts per 300 s speaking time (ST) and related the frequency of D-acts and the duration of C-movements to a 600 s period by extrapolation. The durations of the various categories of C were multiplied by their average intensity score. For the first run the ratings of both raters were considered, i.e., if the scores given by the raters differed, we arrived at a decision by discussion. Because of very high interrater-reliability with the data of the second and third run, we relied here only on the data which obtained one of us (K.H.). In order to clarify the structural relationship, we applied the principal component technique of factor analysis. Only factors with an eigenvalue > 1.0 were considered. The data from day 0 and day 21 were evaluated separately. In spite of possible methodical objections, the application of a factor analysis seems to be warranted considering the robustness of the method with regard to the scale of measurement (Borz 1977). Results Six factors were extracted respectively both from the data before and after 21 days of antidepressive medication. These factors account for 79% and 73% of the total variance, respectively. We shall confine our discussion to the factors with high loadings on the indicator variables retardation and agitation after varimax-rotation, as shown in Fig. 2. These factors have a cumulative percentage of 70% and of 66%, respectively of total variance. Fig. 2 shows that, in both interviews, one factor has a close relationship to retardation (the factor R of interview 1 and 2). Two factors load heavily on agitation (the factors A, and A, of interview 1 and 2). A comparison of the factor structures
Factor
loading-I
Factor Percentage “QrlQ”c‘S
-05
0
05
1
-1 -05
I Of
39 0 % R
I
loading -1 -05 0 05 I Factor Percentage Of 38 3 % “orlance
Fig. 2. Retardation
05
1
-1 -05
179 % Interview
Factor
0 II
05
1
13 5 %
2 A,
1 -I*
0 m
A2
-,m IIl
II 140%
factor and agitation
13.8 %
factor R, A.
indicates that the factors R and A, are fairly stable compared with factor A,. The coefficient of similarity of the two matrices is 0.85; the retardation factor R shows a similarity of 0.97, and the agitation factors A, and A, show similarities of 0.93 and 0.75. If only loadings > 0.75 are considered, the retardation factor R before and after treatment is characterized by: reduced eye movements (REM); reduced facial expression (RFE); constricted posture (CP); low voice (LV); diminished prosody (DP); diminished speaking time (ST). Some loadings with agitation (A) and with postural restlessness (PR) show that retardation and agitation are not mutually exclusive. The agitation factor A, (before treatment) is characterized by: postural restlessness (PR); discrete body touching (D); continuous body-focused hand movements, directed towards the face or head (C oF). The agitation factor A, (before treatment) is characterized by: continuous body-focused hand
movements,
directed
towards
the
other
hand
(C,,,,). If the variables with lower loading are also considered, the 2 agitation factors differ with respect to the proportions of retardation elements. Factor A> contains more constricted posture (CP) and more low voice (LV) than factor A, and is negatively correlated with object-focused hand movements of the motor-primacy type (0,). Factor A,, on the other hand, is positively correlated with object-focused hand movements of the speech-primacy type (0,). The behavioural patterns corresponding to the 2 agitation factors can be characterized as follow:.. Agitation of the type A, essentially represents a gross motor restlessness involving the whole body. This restlessness expresses itself primarily in numerous distinct hand movements (Cm.. D), reminiscent of the so-called displacement activity of ethologists. The positive correlation with speech-related hand movements (0,) indicates some communicative effort. Agitation of the type AL. in contrast, can be described as constricted restlessness as shown by the relationship to the seemingly opposing elements postural restlessness (PR) and constricted posture (CP): constricted posture is intermingled with a continuous, amorphous hand-to-hand activity near the body (C “, Co,). Altogether the proportion of retardation seems to be higher in type A z than in type A,. A comparison of the factors before and after treatment shows the following. The retardation factor R loses the agitation elements of postural restlessness (PR) and discrete body touching (D); both agitation factors A, and A, lose the retardation elements of reduced facial expression (RFE) and low voice (LV). This separation of retardation and agitation elements suggests that clinical improvement is accompanied by a decrease of syndromal complexity. It is not necessary to discuss all changes between the 2 interviews in factor profiles in detail. However, attention should be paid to agitation factor A z with regard to certain changes of manual activity. In the second interview the loading of continuous undirected hand activity (Co ) disappears. Simultaneously, a previously unrepresented loading on continuous hand activity directed towards objects carried on the body (C,,) appears.
This change suggests that clinical improvement is accompanied by a transformation of an amorphous and purposeless manual activity into a more elaborate and apparently more purposeful manual activity which points to some minor degree of agitation. Discussion Our method yields 3 independent syndromal factors: one factor of retardation and two factors of agitation. The results obtained must, of course, be qualified for the population under observation. In particular one has to take into account the gender differences with regard to the psychomotor behaviour in endogenous depression, i.e., women are more likely to have psychomotor agitation than men (Hamilton 1967; Winokur et al. 1973; Avery and Silverman 1984). Depressive retardation expresses itself primarily in eye movements, facial expression, posture, voice, and speaking time. Remarkably, this factor also shows some agitation elements. This finding is by no means paradoxical; it should be taken as an empirical proof of the clinical observation that just such a combination of psychomotor retardation and agitation features in the endogenous-depressive syndrome (e.g. Hamilton 1960). Depressive agitation can be differentiated into 2 types. Type A, is characterized by gross motor restlessness and abundant hand movements reminiscent of ‘displacement activity’. There is a lower proportion of retardation elements than is present in type A,. Type A, is characterized by a retarded restlessness and continuous hand-to-hand activity near the body. By pointing out such syndromal structures, we hope to have demonstrated convincingly that a systematic analysis of non-verbal behaviour can contribute to a more differentiated diagnostic evaluation. Further investigations will show whether this methodological approach will be able to provide solutions to differential-diagnostic problems and thus lead to a validation of psychiatric classification. A testable hypothesis would be, for instance, that depressive syndromes of various etiology - e.g. neurotic, endogenous or those which occur concurrently with paranoid or organic
psychoses - can be distinguished in this way. Considering the diagnostic process as such, it can be stated that only the simultaneous registration of non-verbal modes of behaviour which are objectively observable and of experiences and feelings which are given only subjectively will allow an estimation of their differential weighting. This is a task for the future. In addition, we found that pharmacotherapy is accompanied by a decrease of syndromal complexity, i.e., a separation takes place of initially interwoven elements of both retardation and agitation, The fact that clinical improvement is also indicated by a transformation of continuous mutual and seemingly purposeless activity of the hands into a more elaborate and goal-directed form of hand movements deserves attention. Diachronic relationships of this kind can be used to evaluate or possibly even objectify clinical response under a pharmacotherapy. References Avery, D. and Silverman, J., Psychomotor retardation and agitation in depression - Relationship to age, sex, and response to treatment, J. Affect. Dis., 7 (1984) 67-76. Borz, J., Lehrbuch der Statistik fur Sozialwissenschaftler, Springer, Berlin, Heidelberg, New York, 1977. Feighner, J.P., Robins, E., Guze, S.B., Woodruff, R.A., Winokur, G. and Munoz, R., Diagnostic criteria for use in psychiatric research, Arch. Gen. Psychiat., 26 (1972) 57-63. Freedman, N., The analysis of movement behavior during the clinical interview. In: A.W. Siegman and B. Pope (I%.), Studies in Dyadic Communication, Pergamon Press, New York, 1972, pp. 153-175.
Hamilton, M., A rating scale for depression, J. Neurol. Neurosurg. Psychiat., 23 (1960) 56-62. Hamilton, M., Development of a rating scale for primary depressive illness, Brit. J. Sot. Clin. Psychol., 6 (1967) 278-296. Kielholz, P., Diagnostische Voraussetzungen der Depressionsbehandlung. In: P. Kielholz (Ed.), Depressive Zustande, Huber, Bern, 1972, pp. 25-42. Kraepelin, E., Psychiatric, 8th edition, Barth, Leipzig, 1913. Kretschmer, E., Der Begriff der motorischen Schablonen und ihre Rolle in normalen und pathologischen Lebensvorgangen, Arch. Psychiat. 2. Neurol., 190 (1953) l-3. Mahl, G.F., Gestures and body movements in interviews. In: J. Shlien (Ed.), Research in Psychotherapy, Vol. III, American Psychological Association, Washington, DC, 1968, pp. 295-346. Strian, F., Albert, W. and Klicpera, C., Course of depressive mood and psychomotor activation in endogenous depression, Arch. Psychiat. Nervenkr., 227 (1979) 193-200. Ulrich, G., Uber den Zusammenhang videoanalytisch gewonnener Masse des nonverbalen Verhaltens mit selbst eingeschatzter Befindlichkeit, Schweiz. Arch. Neural. Neurochir. Psychiat., 125 (1979) 349-359. Ulrich, G., Verhaltensphysiologische und vigilanztheoretische Aspekte des Handbewegungsverhaltens Depressiver in einer Interviewsituation, Nervenarzt, 51 (1980) 294-301. Ulrich, G., Videoanalyse Depressiver Verhaltensaspekte, Enke, Stuttgart, 1981. Ulrich, G. and Harms, K., Video-analytic study of manual kinesics and its lateralisation in the course of treatment of depressive syndromes, Acta Psychiat. Stand., 59 (1979) 481-492. Ulrich, G., Harms, K. and Fleischhauer, J., Untersuchungen mit einer verhaltensorientierten Schatzskala fur depressive Hemmung und Agitation, Arzneim.-Forsch. (Drug Research), 26 (1976) 1117-1119. Winokur, G., Morrison, J., Clancy, J. and Crowe, R., The Iowa 500 - Familial and clinical findings favor two kinds of depressive illness, Comprehens. Psychiat., 14 (1973) 99-107.
Disorder.~, 9 (1985) 63-67
63
Elsevier
JAD 00309
A Video Analysis of the Non-Verbal Behaviour of Depressed Patients Before and After Treatment G. Ulrich’ and K. Harms 2 ’ Department OJ Psychoph_wioloRy and .’ Depcrrtment of Clinical Ps_vchiatrv. Free Unioersit>~of Berlin, D 1000 Berhn (F. R. G.) (Received 4 October, 1984) (Revised. received 11 December, 1984) (Accepted 17 December, 1984)
Summary
Using videotaped interviews of depressive in-patients, which were recorded on day 0 and day 21 of antidepressive pharmacotherapy, the behavioural structure of the syndromal main aspects, retardation and agitation, was analysed. This analysis was done on the basis of non-verbal behaviour only. A factor analysis was carried out on the observational data. Three independent factors, constituting together the clinical picture of endogenous depression, could be defined: one factor of retardation and two different factors of agitation. The importance of such non-verbal analyses for a more differentiated diagnostic evaluation, on the one hand, and to provide more insight into the diagnostic process as such, on the other, is pointed out. Additionally it was found that syndromal complexity decreases in a characteristic manner along with clinical improvement.
Key words:
Antidepressive
phurmacotherupy
- Behaviour
Introduction
The concepts ‘retardation’ (Hemmung) and ‘agitation’ (Agitiertheit), introduced by Kraepelin (1913) as the main syndromal characteristics of depressive syndromes, are still widely used for psychiatric diagnoses. Because of the significance of these concepts for the choice of the proper antidepressive agent (Kielholz 1972; Strian et al.
Address for correspondence: Priv. Doz. Dr. Gerald Ulrich. Freie Universitat Berlin, UniversiWsklinikum Charlottenburg, Abteilung ftir Psychophysiologie, Eschenallee 3. D-1000 Berlin 19, F.R.G. 0165-0327/85/$03.30
@’1985 Elsevier Science Publishers
- Depression
- Treatment
1979; Avery and Silverman 1984) a more refined definition of retardation and agitation seems desirable. Such a definition is also of theoretical importance since it should give deepened insight into the structure of endogenous depression as well as illuminate the diagnostic process itself, i.e., uncover the perceptions which are taken into consideration in making a diagnosis and how these perceptions are weighted. It is certain that the elements which constitute the impression of retardation and agitation are not usually given special attention during the diagnostic process. They only provide diffuse background information which cannot be systematically controlled or relia-
B.V. (Biomedical
Division)
64
bly reconstructed. This is reflected in clinical ratwhere retardation and agitation appear as global. undifferentiated categories of assessment. The uncertainties of the diagnostic process cannot be eliminated by ex cathedra operationalism. but only by careful observation and analysis. Emphasis should be placed on non-verbal behaviour which has not yet been adequately systematically studied. As Kretschmer (1953) put it, many of the terms used in clinical psychiatry suffer from their prescientific metaphoric quality. According to this author, this unsatisfactory condition may be overcome only by a systematic registration and classification of psychomotor phenomena which are based primarily on formal criteria. Video techniques commonly available now allow the analysis of non-verbal behaviour. In a series of investigations on endogenously depressive we have shown how a descriptive patients. videoanalysis of psychopathological behaviour can be developed (Ulrich, 1979, 1980, 1981: Ulrich et al. 1976; Ulrich and Harms 1979). In this study we shall confine ourselves to the following two questions: (1) Which elements or patterns of behaviour are decisive for our judgement of ‘retardation’ or ‘agitation’? (2) Are such patterns of behaviour modified in the course of pharmacotherapy and if so. how? ing scales
Patients
and Methods
We analysed the videotaped interview of 47 in-patients (37 female, 10 male; range: 25-68 years; median: 48 years) with endogenous or involutional depression (ICD No. 296.2 and 296.0, 8th revision) which were recorded before and on day 21 of antidepressive pharmacotherapy. All patients fulfilled the diagnostic criteria suggested by Feighner et al. (1972) for primary depression. The semistructured interviews were conducted by the attending physicians and documented with the AMP system (Scharfetter 1972). The length of the recordings, which was determined by fulfillment of documentational needs, varied only slightly and averaged 520 s. The recordings of the 94 interviews were presented to 2 independent raters 3 times each. An
additional run was needed for the determination of speaking time (ST). First run - graded or alternative assessment of the following aspects. (a) (h) (c) (d) (e) (I”) (g) (h)
Retardation (R) 0-1-2-3-4-5-6-7 Agitation (A) i Reduced eye movements (REM) O-1-2-3 () (no) _ , Reduced facial expression (RFE) Constricted posture (CP) \ (uncertain) Postural reatleasness (PR) 2 (yes) Low vo,cr (LV) i DmGnished prosod) (DP)
The items and the mode of assessment had been found appropriate in an earlier study (Ulrich et al. 1976). Second run ~ registration of certain hand movements as discrete acts. Classification was based on Freedman’s system (1972). (a) Object-focused movements (0). These are speech-related and focused on an object in both of two senses: (1) linked to the object of the speaker’s verbally expressed experience and (2) linked to the effort to reach the listener, the object of presence. Object-focused movements are subdivided into a motor-primacy type (0, ), which is characterized by predominantly gross movements with clear semantic content, and a speech-primacy type (0,), which is characterized by predominantly subtle movements associated mainly to the rhythmic aspects of speaking with no clear semantic function. (b) Discrete body touching (D). Short gestures of embarrassment with a duration less than 3 s and an easily detectable symbolic content (Mahl 1968) mainly directed towards the face or head. Third run - measurement of the duration of
Fig. I. Clawfication Freedman 1972).
of hand
movements
(with
reference
to
continuous body-focused movements (C) (see Fig. 1) with a stop watch. (a) Undirected movements (C”). Both hands are involved in mutual manipulation. (b) Directed movements (C,,). One hand continuously manipulates an object such as: the other hand (Co,); the face or head (CIIF); objects carried on the body (CD+,). In addition the intensity of each sequence of C was evaluated on a 3 degree scale, represented by the scores 1, 2 and 3. To make these measures comparable, we determined the frequency of O-acts per 300 s speaking time (ST) and related the frequency of D-acts and the duration of C-movements to a 600 s period by extrapolation. The durations of the various categories of C were multiplied by their average intensity score. For the first run the ratings of both raters were considered, i.e., if the scores given by the raters differed, we arrived at a decision by discussion. Because of very high interrater-reliability with the data of the second and third run, we relied here only on the data which obtained one of us (K.H.). In order to clarify the structural relationship, we applied the principal component technique of factor analysis. Only factors with an eigenvalue > 1.0 were considered. The data from day 0 and day 21 were evaluated separately. In spite of possible methodical objections, the application of a factor analysis seems to be warranted considering the robustness of the method with regard to the scale of measurement (Borz 1977). Results Six factors were extracted respectively both from the data before and after 21 days of antidepressive medication. These factors account for 79% and 73% of the total variance, respectively. We shall confine our discussion to the factors with high loadings on the indicator variables retardation and agitation after varimax-rotation, as shown in Fig. 2. These factors have a cumulative percentage of 70% and of 66%, respectively of total variance. Fig. 2 shows that, in both interviews, one factor has a close relationship to retardation (the factor R of interview 1 and 2). Two factors load heavily on agitation (the factors A, and A, of interview 1 and 2). A comparison of the factor structures
Factor
loading-I
Factor Percentage “QrlQ”c‘S
-05
0
05
1
-1 -05
I Of
39 0 % R
I
loading -1 -05 0 05 I Factor Percentage Of 38 3 % “orlance
Fig. 2. Retardation
05
1
-1 -05
179 % Interview
Factor
0 II
05
1
13 5 %
2 A,
1 -I*
0 m
A2
-,m IIl
II 140%
factor and agitation
13.8 %
factor R, A.
indicates that the factors R and A, are fairly stable compared with factor A,. The coefficient of similarity of the two matrices is 0.85; the retardation factor R shows a similarity of 0.97, and the agitation factors A, and A, show similarities of 0.93 and 0.75. If only loadings > 0.75 are considered, the retardation factor R before and after treatment is characterized by: reduced eye movements (REM); reduced facial expression (RFE); constricted posture (CP); low voice (LV); diminished prosody (DP); diminished speaking time (ST). Some loadings with agitation (A) and with postural restlessness (PR) show that retardation and agitation are not mutually exclusive. The agitation factor A, (before treatment) is characterized by: postural restlessness (PR); discrete body touching (D); continuous body-focused hand movements, directed towards the face or head (C oF). The agitation factor A, (before treatment) is characterized by: continuous body-focused hand
movements,
directed
towards
the
other
hand
(C,,,,). If the variables with lower loading are also considered, the 2 agitation factors differ with respect to the proportions of retardation elements. Factor A> contains more constricted posture (CP) and more low voice (LV) than factor A, and is negatively correlated with object-focused hand movements of the motor-primacy type (0,). Factor A,, on the other hand, is positively correlated with object-focused hand movements of the speech-primacy type (0,). The behavioural patterns corresponding to the 2 agitation factors can be characterized as follow:.. Agitation of the type A, essentially represents a gross motor restlessness involving the whole body. This restlessness expresses itself primarily in numerous distinct hand movements (Cm.. D), reminiscent of the so-called displacement activity of ethologists. The positive correlation with speech-related hand movements (0,) indicates some communicative effort. Agitation of the type AL. in contrast, can be described as constricted restlessness as shown by the relationship to the seemingly opposing elements postural restlessness (PR) and constricted posture (CP): constricted posture is intermingled with a continuous, amorphous hand-to-hand activity near the body (C “, Co,). Altogether the proportion of retardation seems to be higher in type A z than in type A,. A comparison of the factors before and after treatment shows the following. The retardation factor R loses the agitation elements of postural restlessness (PR) and discrete body touching (D); both agitation factors A, and A, lose the retardation elements of reduced facial expression (RFE) and low voice (LV). This separation of retardation and agitation elements suggests that clinical improvement is accompanied by a decrease of syndromal complexity. It is not necessary to discuss all changes between the 2 interviews in factor profiles in detail. However, attention should be paid to agitation factor A z with regard to certain changes of manual activity. In the second interview the loading of continuous undirected hand activity (Co ) disappears. Simultaneously, a previously unrepresented loading on continuous hand activity directed towards objects carried on the body (C,,) appears.
This change suggests that clinical improvement is accompanied by a transformation of an amorphous and purposeless manual activity into a more elaborate and apparently more purposeful manual activity which points to some minor degree of agitation. Discussion Our method yields 3 independent syndromal factors: one factor of retardation and two factors of agitation. The results obtained must, of course, be qualified for the population under observation. In particular one has to take into account the gender differences with regard to the psychomotor behaviour in endogenous depression, i.e., women are more likely to have psychomotor agitation than men (Hamilton 1967; Winokur et al. 1973; Avery and Silverman 1984). Depressive retardation expresses itself primarily in eye movements, facial expression, posture, voice, and speaking time. Remarkably, this factor also shows some agitation elements. This finding is by no means paradoxical; it should be taken as an empirical proof of the clinical observation that just such a combination of psychomotor retardation and agitation features in the endogenous-depressive syndrome (e.g. Hamilton 1960). Depressive agitation can be differentiated into 2 types. Type A, is characterized by gross motor restlessness and abundant hand movements reminiscent of ‘displacement activity’. There is a lower proportion of retardation elements than is present in type A,. Type A, is characterized by a retarded restlessness and continuous hand-to-hand activity near the body. By pointing out such syndromal structures, we hope to have demonstrated convincingly that a systematic analysis of non-verbal behaviour can contribute to a more differentiated diagnostic evaluation. Further investigations will show whether this methodological approach will be able to provide solutions to differential-diagnostic problems and thus lead to a validation of psychiatric classification. A testable hypothesis would be, for instance, that depressive syndromes of various etiology - e.g. neurotic, endogenous or those which occur concurrently with paranoid or organic
psychoses - can be distinguished in this way. Considering the diagnostic process as such, it can be stated that only the simultaneous registration of non-verbal modes of behaviour which are objectively observable and of experiences and feelings which are given only subjectively will allow an estimation of their differential weighting. This is a task for the future. In addition, we found that pharmacotherapy is accompanied by a decrease of syndromal complexity, i.e., a separation takes place of initially interwoven elements of both retardation and agitation, The fact that clinical improvement is also indicated by a transformation of continuous mutual and seemingly purposeless activity of the hands into a more elaborate and goal-directed form of hand movements deserves attention. Diachronic relationships of this kind can be used to evaluate or possibly even objectify clinical response under a pharmacotherapy. References Avery, D. and Silverman, J., Psychomotor retardation and agitation in depression - Relationship to age, sex, and response to treatment, J. Affect. Dis., 7 (1984) 67-76. Borz, J., Lehrbuch der Statistik fur Sozialwissenschaftler, Springer, Berlin, Heidelberg, New York, 1977. Feighner, J.P., Robins, E., Guze, S.B., Woodruff, R.A., Winokur, G. and Munoz, R., Diagnostic criteria for use in psychiatric research, Arch. Gen. Psychiat., 26 (1972) 57-63. Freedman, N., The analysis of movement behavior during the clinical interview. In: A.W. Siegman and B. Pope (I%.), Studies in Dyadic Communication, Pergamon Press, New York, 1972, pp. 153-175.
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