Organic Integrity Test (OIT) in Monitoring Drug Effects

Organic Integrity Test (OIT) in Monitoring Drug Effects H. C.

TIEN,

M.S.E.E., M.D.

INTRODUCTION There is an increasing number of patients on psychotropic agents in the world community. Quick, inexpensive and objective tests to monitor dmg effects are needed. And the Organic Integrity Test (011") may answer this need. The orr (Organic Integrity Test) was first published by the author!:! in the AMA Archives of General Ps)'chiatr)' in 1960. In the last decade, the orr has proven itself as a useful psychopharmacologic monitoring test in the treatment of schizophrenias and organic brain disorders. The OIT is a quick (3-minute) test based on colorform perception to measure the brain's capacity for pattern recognition. The Organic Integrity Test (OIT) is a simple binary decision test based on intact form perception. The OIT consists of ten sets of color pictures with three in each set, two of the three pictures sharing a similarity in form and two in color. For example, a blue sweater to 1)(' matched with either a blue suitcase or a red shirt. A normal individual matches by form when requested; that is, he would match sweater with shirt. Whereas, the patient with brain damage will matl'h the blue sweater with the blue luggage. (See Figure I.) The test cluestion of the OIT is simply, "Which two pictures are most alike?", or, "\Vhich two patterns are most similar?" No other information is to be given to the patient. The perfect score for ten correct answers is 100. For each incorrect decision, the subject loses a number of points which are statistically determined and weighted. The normal adult scores an average OIT value of about 80. and 98% of normal adults score an orr value above 50. An OJT score of 50 or less is statistically defined as chromaphilic, indicating reduced capacity for pattern recognition, hence brain dysfunction or damage. The detailed procedure for administering and scoring the test has been given elsewhere by the author!:!'!". The validity and the reliability of the OIT have been confirmed both in Europe and in America by Astrom 1, Engelsmann 4 • Drdkova, and Clark~. The OIT since then has come under more general use to detect organic brain dysfunction in the diagnosis and treatment of mental disorders Dr. Tit>n is Edilor·in·Chi,·f. World Journal of Psy· l'hosynllw~i~. Lansing, Mich. ~1·plt'mLer·Oclobt>r,

1970

by Lin' in 1966, LoS in 1968, Paul" in 1966, Reinehr ll and Golightly in 1968, and Snelbeckerl~ et al. in 1968. Dorfman:' (1967) has used it to demonstrate the reversibility of organic brain syndrome; Hawkins" (1968) in monitoring the treatment of schizophrenia; and Jacobs" (1969) et al. used the OIT in monitoring hyperoxygenation effect on the cognitive function in the aged. The author HI-III has shown that the OIT is useful in other clinical situations. The present paper shows the usefulness of OIT as a monitoring device of drug effects in the routine practice of psychiatry and clinical psychopharmacology. PURPOSE In this paper, the author attempts to show the practical usefulness of the OIT as a daily diagnostic index and therapeutic guide of drug effects on the neuropsychiatric ward of general hospital, where the psychiatric nurse administered the OIT routinely to aid in dmg therapy. The purpose of this paper is, therefore, threefold. First of aIL the orr aids the separation of mental disorders into (A) system function disorders: such as organic brain syndrome. schizophrenia, manic-depressive psychOSiS and other psychoses in which conditions the patients sc:ore low on the OIT (i.e. below 50); and (ll) information disorders: such as psychoneurosis. psychophYSiological disorders. personality disorders and other character disorders in which conditions the patients score high on the OIT (i.e., above 50). Secondly. this paper helps to show how to differentiate the two types of brain dysfunction or damage: (a) that which is reversible with drug therapy as evidenced on the OIT; and (b) that which is unresponsive to drug therapy as shown by a persistent low OIT curve, as in senile brain disease, for example. Thirdly, this paper attempts to further strengthen the validity and the reliability of the orr as an objective test of organicity by a comparative study with the electroencephalogram (EEG):!o. Let us first study the supportive role of the EEG, a more objective, but expensive and time-consuming test, in contrast to the OIT, before describing the actual clinical use of the OIT as a monitory device of drug effects.

OIT AND EEG The author reports all the adult patients reH5

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Normal: Matches blue sweater with red shirt. (Form response) Organic: Matches blue sweater with blue suitcase. (Chromaphilic response) { Schizophrenic: Matches blue sweater with blue suitcase. (Chromaphilic response) Figure 1. Organic Int'grill Te~t (OTT).

ferred to th EE, I. boraton 01 the am gen 1'.1 ho pital 0 er a period 01 on year (1963- 196..!). The EEC b'adng was obtained ac 'ording to the proc dur 01 the Uni ersity of Michigan I di 'al 'chool EE ; Laboratory. Each EEG was read 1 y th Ie tro ncephaIogl"lph I' and cia sified and . d d 'l: to II e diagno is and d gr e of • bnon-Tlalit) b) the EC Ind x. de is d by Ule auUl r~~. Th EE Index of normulit)· to abnormality rang s [rom 10 to 99. B f I' an EEC i. giv n, Ih EE; te 'hnician als administ red th OTT to each pati nt \ hich score wa J.."llown to th ,I droen . phalogral her and th n the Bnal clinical diagno i was a. certailled about six months later from th att nding ph~'si 'ian or rom th hospital f('con'!s r pres nting the final diagnosi. orne of th Rnal e1iagno es \ ere conllrm d by , 1110p i .• s in br. in tumor I atier ts or admission to stat hospitaL as in chronic schizophr nia or to nursing hom s as in chronic brain syn It·ome. The EE , in li· s • nd IT s or s of Ule four hundred and Rfty- ix pati nts (-156) W I' statistically allalyzt'd according to Ul man, tandard d viatioll, and COlT Iation with re p ct to ag and dia mo 'is :t cording to PA Diagnosti . iVIanualY' 'tatisti 'al re ults anti igniR 'ance te ts ar hown in Table I, amI Tahles 1T and III. I

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E TE T O E eND OIT

Tabl ] shows the 1I1l1mary of comput r I' 'ult. of all dia nasti· groups up n which th one-tailed igniRcanc t sls (t-t ts) \ re p rformed. The tot sts :ho\ cl arl. th organic d sfullction in 'hroni' brain 'vndrom (P < 0.0 0 ) and p . 4<

·ho is (P < O. 2), wh I' a th EEC index sh \V up Ul organic d sfunction ill th ac It brain syntlrom (P < n.o l) chronic brain sYlldrom s (P < O. 05) but I . s igniRcant.Iy in ps ehosi. (P < 0.1). Th 01 is again conRrm d a a test incH ative of brain dama e in th subgroup of 'hroni . brain yndrom due to traum., pH PT• VA, brain tum r. and oUler 1 dis a e of un. Itain au , uch. nile brain dis ase, . rebral arterio cl rosi , and oUler,. Th si niRe. nc t sts show that th OIT i... , better t st of organi brain d . function as in psych 'i lIch a schizophr nia, but th EE is a b tel' t t f abn Imalit)' but not neces arily of organic brain damag invol ing capacit)' for 1< tt rn r cogniti n ab tra ,tion, conc pt forn
olume XI

ORGANIC INTEGRITY TEST

THE OIT TIME-GRAPH

mission OIT score and subsequent ones are charted, like temperature charting of routine nursing procedure. The rise and fall of the OIT scores may be used in monitoring drug therapy. This may best be seen by studying a sample OIT Time-graph. See Figure 2.)

The OIT time-graph is a simple plot with time in hospital days along the abscissa, and the OIT time-graph is begun on every patient, when admitted to the neuro-psychiatric ward. The ad-

TABLE I. A One-Year OIT-EEG Study of All Adults Referred to an EEG Laboratory APA Code 01-09 10-19 20-22 30-39 40 .50-54 60-61 99

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ACE Mean S.D. 37 14 50 17 35 11 35 13 34 14 30 12 20 0 44 16

EEC Mean S.D. 54 22 67 19 51 17 43 16 43 16 52 15 53 0 44 17

OIT Mean S.D. 76 22 25 33 58 24 75 19 70 22 77 12 13 0 72 21

Table II and Table II show the results of the significance tests.

TABLE II. Significance Tests on the Mean OIT Scores Between Normal and Diagnostic Groups

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t-ratio significance t-test between normal & each diagnostic group +0.833 N.S. -8.933 P<0.0005 -2.016 P<0.02 +0.667 N.S. +0.789 N.S. -0.492 N.S.

TABLE III. Significance Tests on the Mean EEG Index Between Normal and Diagnostic Groups APA Code Diagnosis 99 normal 01-09 10-19 20-24 30-39 40 50-54

acute brain syndrome chronic brain syndrome psychosis psychosomatic disorders psychoneurosis personality disorders

Septl'mber.October, 1970

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t-ratio significall(.-e One-tailed t-test between normal & each diagnostic group +2.449 P
PSYCHOSOMATICS

Figure 2 represents the OIT Time-graph of L. ~1., a seventeen-year old girl, who was brought to the hospital by the local sheriff because of "running away from home". She had been under the care of another psychiatrist for a year for behavior disorder. Upon initial testing with OIT, she scored only 18. This places her in the cate-

gory of suHering from a system function disorder, not Originally suspected. Interestingly enough, clinically, she showed no evidence of dissociation, autism, or inappropriateness of affect. Neither did she have any secondary symptoms of hallucinations, delusions of ideas of reference, except episodic ('omplaints of depression. However,

ST. LAWRENCE HOSPITAL Lansing. Michigan

O.I.T. ORGANIC INTEGRIn TEST

CHIEF COMPLAINT: _ "Runni ng Away from Home".

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_ IMPROVED- NO CHANGE_ _ WORSE__ CONDITION ON DISCHARGE: MUCH IMPROVED_X FINAL DIAGNOSIS: Schizo-affect1 ye schi zophreni a COMMENT: LIM. was admitted with the aid of the local sheriff. who picked her up for running away from home. She is an attractive girl. who had been under the care of another psychiatrist for behavior disorder. lhe psychiatrist-in-charge did not expect any different diagnosis. until the first OIl score was obtained. It was 18: And daily OIl testing showed that she was definitely chromaphilic. Clinically. she showed no evidence of schizophrenia. apart from mood changes. With the new diagnosis of sch1zoaffective schixophrenia. she was placed on drug therapy and responded well. SIGNED: l'''lJ~t-.bt-ehaJr.gf. '4.0. Figure 2 418

Volume XI

ORGANIC INTEGRITY TEST

her first low OIT testing placed her in the chromaphilic range. And for a whole week thereafter she was repeatedly tested and she did not score at any time above 50. This is an important diagnostic function of separating her from simple behavioral disorder. The OIT monitoring helped the attending psychiatrist to consider the possibility of a schizo-affective process in this girl. She was placed on chlorpromazine q.Ld. with almost immediate clinical improvement in her attitude and which also reflected on her OIT. Her OIT scores jumped up and down, which patterns \\'as used to guide the drug therapy by adjusting the dosage and by the addition of another drug, trifluoperazine. This OIT time-graph definitely shows the practical use of the OIT in monitoring drug effects. The practical usefulness of the OIT stands up because of its brevity and ease of being given daily by the psychiatric nurse and she can chart the OIT scores like temperature charting independent of the clinical judgment of the psychiatrist, who is ordering or adjusting the drugs for any given patient. DATA COLLECTION The OIT Time-graphs were obtained from 667 patients over a one-year period (1965-1966). Each Time-graph represents the daily OIT monitoring during the entire course of a patient's hospital stay. The first OIT usually represents the admission score and the last OIT usually represents the discharge score. The admission OITs and the discharge OITs have been previously statistically analyzed with regard to age, length of hospital stay, and diagnosis. The results were reported in a previous paper by the author:!1. In this present paper, the author reports the practical use of the OIT as a drug monitoring device. However, we may summarize the previous OIT results of the three major diagnostic groups in Table IV to TABLE IV. OIT Results of Three Major Diagnostic Groups Mean Mean OIT on OIT on Admission Discharge (Before (After Diagnosis N Therapy) Therapy) Normal OIT Range Mean: 78 Range: 50 to 100 Psychoneurosis 167 71 72 Schizophrenia 177 45 60 (All types) Chronic Brain 48 29 31 Syndrome September·October, 1970

give us a bird's eye view of the therapeutic effects as reflected on the OIT. Table IV shows a clear summary of (1) Psychoneurosis group (N = 167) represents information disorder, and therefore, its OIT mean (M = 71) before therapy is about the same as it is after therapy (M = 72) (Le., within normal range); whereas, the schizophrenia group (N = 177, M = 45) and the chronic brain syndrome group (N = 48, M = 24) represent system function disorders, and their admission OIT means are below normal range before therapy. Furthermore, the discharge OIT mean (M = 31) of the chronic brain syndrome group remained essentially unchanged after therapy, whereas the discharge OIT mean (M 60) of the schizophrenia group came within the normal OIT range, indicative of improvement after therapy. The usefulness of monitoring drug effects lies, therefore, with the fact that the OIT scores mayor may not change under drug therapy depending on the various diagnoses.

=

OIT MONITORING Drug Therapy in Various Diagnoses (a) Psychoneurosis. Figure 3 represents the Time-graph of a patient, B. F., a thirty-five old female suffering from depression. Clinically, she was clinging and demanding. The attending psychiatrist tried various drugs, as shown on the Time-graph. It can be seen clearly that on admission, the patient scored an OIT of 85 and on discharge she scored 80, which would indicate that her primary problems are in the areas of information disorder rather than system function disorder. Her personal conflicts involving her childhood and her marriage could not be revealed by the OIT curve. The drugs might have reduced her anxiety to some extent but would not alter her intact system function insofar as the OIT could show. Her OIT Time-graph should be compared with Figure 2, which showed the teenaged girl with apparent behavior disorder, but her low OIT scores led to the consideration of a system function disorder, which responded to drug therapy. In this respect the OIT is a very useful test in separating the psychoneurotic patient from a schizo-affective patient who shows no overt psychotic symptoms, except the low OIT curve, like other patients with schizophrenia. Such patients should be treated with appropriate drugs as in schizophrenia. (See Figure 3.) (b) Paranoid Schizophrenia. Figure 4 shows the OIT Time-graph of a twenty-four year old man 449

ORGANIC INTEGRITY TEST

admitted in acutely psychotic state. His admission OIT was 13, and he was obviously inappropriate and felt persecuted. He was immediately placed on thiordazine 100 mgm. q.i.d. for two weeks without benefits, even when thioridazine was increased to 150 mgm. q.i.d. He continued in his bizarre and delusional manner. On the fifteenth

day, the attending psychiatrist discontinued thioridazine and placed him on chlorpromazine 300 mgm., spansule, t.i.d. Within three days, his OIT scores jumped from 13 to 30, to 50 and to 90. Clinically, he became rational and his OIT scores stayed stable around 95. On the day of discharge, he even scored 100 on the OlT. (See Figure 4.)

B.F. Age 35

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Volume XI

ORGANIC INTEGRITY TEST

(c) Chronic Undifferentiated Schizophrenia.Figure 5 represents the 011' monitoring in drug therapy of a case of chronic undiflereniated schizophrenia. This 011' time-graph actually is a continuation graph of a patient, V.A., who did not respond to a course of electroconvulsive therapy (Eel') under the working diagnosis of involutional depression. Her 011' scores stayed around 50, indicating a system function disorder. Her ECT was discontinued on November 18th, and she was placed on drug therapy a week later. At first, she received trifluoperazine 2 mgm. g.Ld., to which she did not respond. And then, the attending psychiatrist added thioridazine 100 mgm. q.i.d. and also without eH·ects. Her 011' scores progressively went down from 55 to 23, at which point her thioridazine was discontinued. She was placed on a new drug, chlorprothixene 100 mgm. q.Ld. and within two days, her 011' jumped to .'50, and to 65 and from that point on, her 011' scores continued to rise to 80. And she was discharged two weeks later on maintenance dose of chlorprothixene 100 mgm. q.i.d. (See Figure .'5. ) (d) Acute Brain Syndrome with Psychosis. Figure 6 is the 011' time-graph of a fifty-year old lady, who was brought in from the streets because

of "running nude". Her initial 011' was 38 and it dropped to 13 despite the fact that she was placed on chlorpromazine 25 mgm. q.i.d. She was then maintained on ehlorprothixene on trial basis without benefits and her 011' even dropped to 13 after thirteen days on chlorprothixene. On the thirteenth day, chlorprothixene was discontinued. And she was then placed on thioridazine 50 mgm. q.Ld. and she showed good response and improvement thereafter. Later on, her diagnosis eonfirmed that her psyehotic behavior was due to an acute brain syndrome due to cerebrovascular insufficiency. On the twenty-ninth day of admission, her 011' again abruptly dropped to 25, at which time she was placed on isoxsuprine 10 mgm. q.Ld. to increase cerebral circulation. From then on she remained stable and her 011' scores stayed at about .'58. She was discharged on the forty-second day as much improved. She was maintained on thioridazine 50 mgm. q.Ld., isoxsuprine 10 mgm. q.i.d. Her 011' was 89, one year later on an office check-up visit. On this check-up, she complained of some depression and was given methylphenidate .5 mgm. t.i.d., as a mild antidepressant. This 011' Time-graph is interesting in the respect that an organic brain sydrome is reversible and sometimes the psychotic symptoms could obscure the diagnosis. (See Figure 6.)

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PSYCHOSOMATICS tained, as his OIT scores jumped up and down around the 50 mark line, indicating confused behavior and perception. Subsquently, his EEG showed slow delta waves, diffusely for the entire brain. At this point, his chlorpromazine was increased to 100 mgm. q.i.d. and he showed some improvement. And his OIT scores stayed around 70, and then progressively went down. His clinical picture was also unstable. He was given

(e) Sub-acute Organic Brain S}'ndrome. Figure 7 represents the OIT Time-graph of a patient, who suffered from an automobile accident with brain concussion without objective neurological signs. This fifty-one year old man admitted because of confusion after an automobile accident, scored 18 on his admission OIT. He improved a great deal when placed on chlorpromazine 25 mgm. q.i.d. However, the improvement was not sus-

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'. Volume XI

ORGANIC INTEGRITY TEST additional trifluoperazine, 2 mgm. q.i.d. with some improvement. However, eventually his OIT scores fluctuated very closely around 48. Clinically, he showed definite impairment of memory, judgment, orientation and intellectual functioning. Because of the lcvcling-off of his OIT scores around 48. he \\',IS dis~harged to a nursing home for ulIltinued care as a case of subacute organic brain syndrome. (See Figure 7.) (f) Chronic Brain Syndrome Without Psychosis. Fi!!ure 8 is the orr time-graph of a patient sufferlllg from chro:lil' brain syndrome due to cerebral arteriosclerosis. The patient is a seventy-four year old woman, who was admitted because of being "nervous and on edge" and with a great deal of psychosomatic complaints. \Vhen she was given the OlT, she scored 13, which persisted for ten days without any change. This kind of low, tlat orr cmvc is often seen in chronic brain syndronH'. However, because of her somatic complaints and "nervousness", she was given chlorpromazine 10 mgm. q.i.d. and then it was increased to 25 mgm. <].i.d., without much effect. She was still disoriented with respect to time, place and person and continued to have her physical complaint~, but her orr peaked to 41 on the twelfth day. However, clinically she was confused even lIIore so and that her score jumped to 41 was probably due to her random response to the OIT. After the chloropromazine was discontinued, she wa~ put on thioridazine 25 mgm. q.i.d., and she became relatively less confused, but her

OIT returned to 13 on a low, flat curve. This kind of low, flat curve is often seen in chronic brain syndrome. She was sent home with the advice of continuous supervised care or a convalescent home. (See Figure 8). (g) Death, Figure 9 represents the incomplete OIT time-graph of a seventy-two year old patient, who came in the hospital because of uncooperativeness. No OIT score could be obtained for two weeks. Finally, with much persuasion, the psychiatric nurse obtained a single OIT score of 27 for the graph. Before another OIT could be obtained the patient suddenly died, cause unknown. DISCUSSION Every little solid evidence is helpful in a field so fraught with subjectivity and inponderables as clinical psychiatry and psychopharmacology. This is the little extra objective evidence the author sought for the OIT with the EEC. The OIT as supported by the EEC truly measures a general organic brain dysfunction or damage, transient or chronic, reversible or otherwise. Nonetheless, there is no substitute for clinical observation and diagnosis and evaluation. To emphaSize this point, the author would like to repeat his earlier observation in making the OIT available for large scale clinical use, namely, "The reliance on a Single test without clinical correlation is ahnost always hazardous. To help to determine the fate of another individual with the use of an isolated test score, is akin to witchcraft. False positives and

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September.()ctober, 1970

453

PSYCHOSOMATICS

false negatives are probably always with us in any test we can devise." This is certainly true with the OIT. In order not to rely on all individual test score for diagnosis or therapy, the author further extended the use of the OIT by designing the OIT timegraph, as a daily monitoring device for drug therapy. The OIT time-graph reduces false positives and negatives. \Vhen used in conjunction with clinical observation. the OIT timegraph may suggest a diagnosis, previously unsuspected by the clinician. For example, as we have seen in the case of L.M. (see figure 2) that she had a schizo-affective process, which was evident only with the help of the OlT time-graph. The OIT time-graph has, therefore, become a useful tool to guide drug therapy because it reduces guesswork or the number of trials and errors. Of course, in managing a great number of patients under drug therapy in mental hospitals or in state institutions, time is of essence. And as the number of available psychotropic agents increases and the number of patients on drugs multiplies, we simply need a quick, inexpensive and time-saving test to monitor drug effects objectively. Only with objectivity, we can increase our therapeutic capacity to be judicious, appropriate and rational in drug therapy. And in this paper the author tries to show that the Organic Integrity Test (OlT) and the OlT time-graph may answer this need.

In our rational drug therapy, guided by the OIT, we cannot forget that we are psychotherapists, as well as chemotherapists, and above all, we are human beings like our patients, "fellow sufferers in the same darkness, actors in the same tragedy with ourselves." As Bertrand Russell had so well put, "And so, when their day is over, when their good and their evil have become eternal by the immortality of the past, be it ours to feel that, where they suffered, where they failed, no deed of ours was the cause ..." In our role as therapists, we can do our best for our fellow patients by using drugs without forgetting psychotherapy, and while doing psychotherapy without forgetting drugs. Finally, the author would like to comment on the last case (see figure 9). There are limitations to psychopharmacology, as the last OIT timegraph attests, when the OIT score suddenly reached the zero-minus of death. Psychopharmacology doesn't confer immortality! And besides, it has many other limitations. And the OIT timegraph has many limitations also, while it may disclose probable system function disorders, but it gives us little information about the patient's worries, fears, jealousies, frustrations and angers in his life. However, the OIT, in its Simplicity, separates system function disorders from information disorders and in so dOing, it point~ to the sensible union of drug therapy with psychotherapy in the

TIME IN DAYS

454

Volume XI

ORGANIC INTEGRITY TEST

new development of psychiatric thought: the science of psychosynthesis. SUMMARY The Organic Integrity Test (OIT) has proven itself as a useful test in monitoring drug effects. The validity and reliability of the OIT have been independently confinned by several authors in the last decade (1960-1970). However, the author felt that the OIT still needed a different type of confinnation of its validity as a test of organicity, independent of other psychological tests and clinical judgments. The author has, therefore, chosen the electroencephalogram (EEG) for this purpose. A one-year EEG-OIT correlation study on 456 adult patient~ was undertaken. The data including the age, EEG abnormality index, OIT score, and clinical diagnosis of each patient were processed at the Computer Center of Michigan State University. The significance tests (t-test) revealed that the OIT is a better test in detecting organic brain dysfunction such as psychosis (e.g. schizophrenia) than the EEG. The overall OIT-EEG correlation (r = -0.39) would indicate that the OIT is a useful test. The effective psychotropic agents (e.g. chlorpromazine, thioridazine, etc.) can reverse the low OIT scores in schizophrenias, involutional psychosis and other organic brain disorders. In therapy, the author also introduces the OIT time-graph and shows how this testing can best be done with daily OIT scores in monitoring drug effects. And the OIT time-graphs can be used profitably to monitor drug therapy as the author has shown in 667 patients on the neuropsychiatric ward of a general hospital, with a variety of diagnoses. In sum, the OIT timegraph is applicable to all neuropsychiatric patients as a daily diagnostic and therapeutic index. Data collection was done at the EEG Laboratory of St. Lawrence Hospital. and data processing at the Com· puter Center. Michigan State University. East Lansing, Michigan. The OIT Test cards and manual are now available from Psychodiagnostic Test Company, Box 528, East Lansing, Michi~an 48823.

DRUG NOMENCLATURE

=

Benztropine Mesylate Cogentin (Merck Sharp & Dohme) Chlordiazepoxide Librium
= =

=

=

September·October. 1970

REFERENCES

1. Astrom, J.: Organic Integrity Test in Clinical Use. Nord. Psykiat. T., 2:160-169. 1963. 2. Clark, Gaius, D., M.D.: Pre·Employment Psychiatric Screening Test. General Motors 26th Medical Conference, Pittsburgh. Penn.• April, 1964. 3. Dorfman, Wilfred. M.D.: Is There a "Reversible" Chronic Brain Syndrome? Psychosomatics, Volume VIII. September·October. 1967. 4. Engelsmann, F., and Drdkova, S.: Organic In. tegrity Test. Czechoslovak Journal 0/ Psychology. 2: 1964. 5. Hawkins, D. R.. M.D., Chiossone, Francesco. M.D., Furfaro, Frank, Runyon. Richard P., Ph.D.: Schizo. phrenia: Response to Intensive Hospital Treatment as Monitored by the HOD and OIT Tests. Pre. sented at Fordham Univ.. Conference on Schizo. phrenia, January 13. 1968. 6. Jacobs, E. A., Winter, P. M.• Alvins, H. J., Small, S. M.: Hyperoxygenation Effect on Cognitive Func. tioning in the Aged. New Eng. J. Med.• 181 :753-758, 1969. 7. Lin, James Ying: The Clinical Use of the Organic Integrity Test as a Color·Form Preception Test with the Juvenile Delinquents. Doctor's thesis, Univer. sity of Oklahoma (Norman, Okla.), 1966. (DA 27:2139B) 8. 1.0, W. H.: Organic Integrity Test. Mental Health Association 0/ Hong Kong Newsletter, 5-6, October. 1968. 9. Paul, Gerald T.: Differential Performances of Chron. ic Schizophrenics and Organics on the Organic In· tegrity Test. Newsl. Res. PsychoL. 8:10 N '66. 10. Raines, G. N., Ed.: Diagnostic and Statistical Man. ual: Mental Disorders. Washington: American Psy· chiatric Association, 1958. 11. Reinehr, Robert c.. and Golightly, Carole: The Re· lationship Between the Bender Gestalt and the Organic Integrity Test. Percept. and Motor Skills 27:427·300 1968. (PA 43·5579). 12. Snelbecker, Glen E., Sherman, Lewis J.. and Schwaag. Eugene, Jr.: Validation Study of the Organic Integrity Test. Percept. and Motor Skills. 1968. 13. Tien, H. c.: Organic Integrity Test. Arch. Gen. Psychiat. 3:43-52, 1960. 14. Tien, H. c., and Clark, G. D.: Organic Integrity Test Confirmed. Am. J. Psychiat.• 121 :257·261, 1964. 15. Tien. H. C. and Williams, M. W.: Organic Integrity Test in Children. Arch. Gen. Psychiat.• 1965. 16. Tien. H. c.: Use of the Organic Integrity Test (OIT) with Children Who Cannot Read. Amer. J. Psychiat.• 1966. 17. Tien, H. C. and Clark. G. D.: OIT as a Routine Neuropsychiatric Screening Test. Michigan Med.• 66:302·307, 1967. 18. Tien, H. c.: The AEIOU&Y Method of Reading: Theory and Technique. J. Special Ed.. 1 :223-24(), 1967. 19. Tien, H. c.: Organic Integrity Test (OIT) as an Empirical Guide in the Treatment of Schizophrenia. Brit. J. Psychiat., 512:871·875, July. 1968. 20. Tien, H. C.: The Routine Use of Or~anic Inte~ity Test (OIT) in an EEG Laboratory, Electroencephalo. ~raph.y and Clin. Neurophysiol., 1969. 26:110-116. 21. Tien, H. C.: Pattern Recognition in Mental Disorders and the Organic Integrity Tests (OIT). Psychoso· matics. Vol. X, January·February, 1969. 22. Tien, H. c.: The Electroencephalography of Hyper· ventilation. J1Torld J. Psychosynth.• Vol. 1, No.2: 62·72. October, 1969. 455