/?~whia/r.\, Rcwurc~h.28. 47-6 I
47
Elsevier
Observed
Behavior
Sleep Deprivation
A.L.
Bouhuys,
Domien
as a Predictor
of the
in Depressed
Patients
G.M.
Beersma,
and Rutger
Received February 5. 1988; revised version received
22. 1988.
November
Response
to
H. van den Hoofdakker
7. 1988; accepted
Decrmhrr
Abstract. Total sleep deprivation
(TSD) in depressive
patients is known to
produce sudden changes in mood, but the factors involved in these mood changes
are poorly understood.
In this study the role of psychomotor
activation was
investigated
by examining
the relationships
between baseline measures
of
activation and subsequent clinical response to TSD. Two methods were used to
assess the degree of activation:
global judgment
(clinical ratings) and direct
observation
and registration
of behavior (ethological
methods). Behavioral and
global assessments
took place I day before TSD during a medication-free
psychiatric interview. The amount of looking displayed during the interview was
negatively correlated with the subsequent clinical response to TSD. while bodyand object-touching
hand movements
showed a positive correlation.
During
switches from speaking turn and at the start of the patients’ speaking turn,
responders
to TSD showed more hand movements
than nonresponders.
No
relation was found between clinical ratings of the degree of psychomotor
activation and the TSD response. Our data suggest that the clinical response to
TSD may be predicted
and therefore
possibly mediated
by dimensions
of
activation. For the detection of these dimensions, behavioral observation appears
to be more suitable than global clinical judgment.
Key Words.
Depression,
sleep deprivation,
psychomotor
activation.
observed
behavior.
About 50 percent of endogenously
depressed patients improve after I night of total
sleep deprivation
(TSD) (Gerner
et al., 1979; Elsenga and van den Hoofdakker,
1987). Unfortunately
subsequent
sleep at the habitual clocktime can be followed by
1983,
substantial
relapse (Gerner et al., 1979; Elsenga and van den Hoofdakker,
1987). Although the clinical effect of sleep deprivation
is usually short-lasting,
the
factors involved
in sudden mood changes are of considerable
interest.
A first
approach
in tracing the factors involved
in sudden mood changes after sleep
deprivation
is studying characteristics
of patients who react to sleep deprivation
and
those who do not. One of the characteristics
already noted in the literature is that
endogenous
depressive patients react better to sleep deprivation
than patients with
1981). Perhaps the
other types of depression
(Rudolf et al., 1977; Fghndrich,
A.L. Bouhuys, Ph.D., is Senior Human Ethologist; Domien G.M. Beersma. Ph.D., is Senior Physicist;
and Rutger H. van den Hoofdakker,
M.D., Ph.D., is Professor of Psychiatry, Department of Biological
Psychiatry, University Psychiatric Clinic, Groningen, The Netherlands. (Reprint requests to Dr. A.L.
University
Psychiatric Clinic, Oostersingel
59, 9713 EZ
Bouhuys, Dept. of Biological Psychiatry,
Groningen, The Netherlands.)
0165-178
I j89jSO3.50
@ 1989 Elsevier Scientific
Publishers Ireland
Ltd.
48
biological
factors involved
in endogenous
depression
trigger the better sleep
deprivation
response. On the level of symptoms,
biological factors seem to have
predictive
value too. Vital symptoms
are reportedly
associated
with clinical
improvement:
the occurrence of diurnal variation in depression (van Scheyen, 1977;
Rudolf and TolIe, 1978; Fahndrich,
1981; Roy-Byrne et al., 1984; Elsenga and van
den Hoofdakker,
1987) sleep disturbances
(Roy-Byrne
et al., 1984) and early
awakening
(Bhanji et al., 1978) have been found to be significantly
related to TSD
response. The relationship
between the severity of depression and the response to
TSD is unclear. Some investigators
have found positive relationships
(Pflug and
TolIe, 1971; Bhanji et al., 1978; Kvist and Kirkegaard,
1980) whereas others have
found no relationship
at all (Rudolf and Tiille, 1978; Duncan et al., 1980).
Obviously,
the presence or absence of sleep is related to the course of arousal
(Horne,
1978). The relationship
between primary
dimensions
of emotion
and
dimensions
of arousal such as activation,
stress, and anxiety is widely recognized
(Thayer, 1978; Purcell, 1982; Tellegen, 1985). Consequently,
the above-mentioned
relationships
between mood, sleep, and wakefulness
might be explained
by the
interaction
of sleep and wakefulness
with primary dimensions
of arousal. Such
explanations
can be pursued in various ways. One approach is studying covariation
of mood and arousal variables before, during, and after sleep deprivation.
We will
report on this issue elsewhere
(van den Hoofdakker
et al., 1988). Another
approach-the
focus of the study reported
here-is
to study the predictive
relationship
of arousal variables observed under baseline conditions with the effects
of subsequent
sleep deprivation
on depressive mood.
There are many ways of assessing activational
states. It is very common
for
investigators
to rely on self-reports
of subjective
activation
or external
global
judgments
(Dermer and Berscheid,
1972; Hoddes, 1972; Thayer, 1978). Another
approach is the direct observation
and measurement
of all kinds of patient behaviors
(Maser, 1984; Ulrich and Harms, 1985; Bouhuys, 1985; Bouhuys et al. 1988). Both
approaches
are used in the present study.
Several authors have suggested that ethological methods could be usefully applied
in psychiatry
(cf. Hutt, 1970; Ekman and Friesen, 1974; McGuire and Fairbanks,
1977; Kramer and McKinney,
1979). For instance,
ethological
theories on the
biological function of behavior (McGuire and Essock-Vitale,
1981) territorial and
agonistic behavior (Singh et al., 1981a, 19816) and attachment
behavior (Bowlby,
1969) are applied in psychiatry. Moreover, the nonobtrusive
observation
of various
types of behavior in naturalistic
situations
has been a useful tool in the clinical
evaluation
of depressed patients (Polsky and McGuire,
1979, 1980; Rosen et al.,
1980; Fisch, 1983; Fossi et al., 1984; Lyons and Rosen, 1985; Ulrich and Harms,
1985; Ellgring,
1986); in the differentiation
between
various
diagnostic
and
nonpsychiatric
groups (Hinchliffe et al., 1975; Rutter and Stephenson,
1972; Jones
and Pasna, 1979); and in the search for predictors
of improvement
in depressed
patients (Ranelli and Miller, 1981; Bouhuys et al., 1987a, 19876, 1988).
In the ethological
procedure used in the present study, a group of behaviors is
defined, and the durations of these behaviors are then scored from videotape for an
objective quantification.
The video recordings
are made during a conversation
between the patient and the psychiatrist,
an interaction
in which they influence each
49
other’s behavior (Matarazzo
and Wiens, 1967; Natale, 1976; Scherer and Rogers,
1980). Thus, the patient’s behaviors
are studied in relation to the psychiatrist’s
behaviors.
The categories of behavior observed are mainly chosen on the basis of earlier
reported relationships
with activation
in depressive and nondepressive
groups. For
instance, the frequency of body touching is positively related to anxiety or agitation
(Ekman
and Friesen,
1974; Ulrich and Harms,
1979, 1985); speaking
time is
negatively
related and pausing time is positively
related to retardation,
i.e., the
slowing down of cognitive processes and motoric behavior (Greden et al., 1981;
Bouhuys and Mulder-Hajonides,
1984); the frequency of gesticulation
is negatively
related to retardation
(Ulrich and Harms, 1985); the duration of looking is negatively
correlated both to arousal (Gale et al., 1975, 1978; Kleinke and Pohlen, 1986) and
retardation
(Bouhuys,
1985). Because of the emphasis placed on motoric aspects in
concepts like agitation and retardation,
we studied all kinds of movements, including
head movements and leg movements.
The resulting objective assessments of behaviors, probably representing activational states, are compared to global clinical judgments
of the response to TSD.
Methods
Subjects
and Design.
Seventeen
endogenously
depressed
hospitalized
patients
were
observed during interviews with the same male psychiatrist
in which the severity of the
depression
was assessed using the 21-item Hamilton Rating Scale for Depression (HRSD)
(Hamilton,
1967). The average baseline HRSD score was 31.7 (SD = 6.5; range = 23.7-46.7).
The group consisted of I5 females and 2 males with a mean age of 49.1 (SD = 14.6) years.
They were drug free for at least 3 days before the start of these interviews. Patients were
included if they were diagnosed
by an experienced
psychiatrist
as suffering from a major
depressive disorder according to DSM-III
criteria (Spitter and Williams, 1982) and had an
HRSD score 3 16. During the interviews, which were all conducted between 9 and I I a.m.,
the HRSD score was assessed by two independent
raters (the mean was taken in this study).
Interrater reliability was 0.97 (Kendall concordance
coefficient; n = 29) (Siegel, 1956).
The patients were deprived of sleep during the night following the interview. They took part
in a study designed to determine
whether clomipramine
could potentiate
the antidepressant effect of TSD (Elsenga and van den Hoofdakker,
19836). Before TSD (but after the
interviews), they received either 50 mg clomipramine
or placebo at 6 p.m. in a randomized
order. On the day following TSD, 50 mg clomipramine was given at 8 a.m and 6 p.m. The day
before and after TSD self-ratings
of depression
(Befindlichkeitsskala
[Bf-s]; von Zerssen,
1976) were obtained at 9 a.m. and 5 p.m. The response to TSD was defined as the difference
between the averaged depression scores before and after TSD. It ranged from 25 to -8 in the
present study. A difference score of at least 6 points on the Bf-s was considered
a positive
response to TSD. Nonresponders
had a difference score < 6. Nine patients responded to TSD
with a mean change of depression
of 12.2 (SD = 5.7; range = 7-25). Eight patients were
nonresponders
and showed an average difference in depression of 0.0 (SD = 4.5; range = -8 to
5). For more details of the design of this study, see Elsenga and van den Hoofdakker (1983h).
Clinical
Activation Measures. Retardation
and agitation (items 8 and 9 on the HRSD)
were taken as a quantitative clinical estimate of the patients’ activational state. The interrater
reliabilities of these items were 0.79 and 0.90, respectively (Kendall concordance
coefficient).
The means obtained by the two raters for the baseline scores are I .2 (SD = 0.9) for retardation
and I .3 (SD = I. I) for agitation
50
Observational
Measures.
The interviews were recorded on videotape together with a time
code. Two cameras were placed so that both persons could be viewed frontally, using a split
screen technique. The patient and the psychiatrist were seated under an angle of I35 degrees
and with a distance from head to head of about I .20 m. Various behavioral categories were
scored from videotape. Each behavior (e.g., looking) corresponded
to a button of an eventrecording system. When the patient started looking (toward the psychiatrist),
the observer
pushed the corresponding
button and when looking stopped, the observer released that
button. These moments of change in behavior were digitally coded to a precision of 0.2 set and
stored for computer analysis. All behaviors were scored continuously
during the first I.5 min
of the interviews.
Registration
from the videotape was carried out in different runs with
preservation
of temporal relationships.
The following categories of behaviors were recorded.
I Sound production: speech.
2. Looking: looking in the direction of the head of the partner in the conversation.
3. Head movements: (a) Yes-nodding;
assessed on the basis of the content
of the
conversation
and a relatively high frequency of nodding per time unit. (b) No-shaking.
(c)
Head movements: all movements not described under (a) and (b).
4. Baclcc+~annc~/ behaviors: emitted to encourage the partner or to show him or her one is
listening; encouragement
could be vocal (“hm hm . . . yes, yes”) and/or nonvocal (yes-nodding).
5. Hand movements: (a) Body-touching hod movements. Movements by which the subject
touches parts of the body, such as touching or rubbing the hair or the face, manipulating
the
fingers, etc. (b) O&ec,t-touching handmovements.
Movements by which any object within reach
is manipulated
(e.g., plucking or rubbing a handbag, the chair, or an adornment).
(c) Gestures.
Movements intimately linked to the rhythm and/or the content of the speech.
6. f~;r movement.s: all movements of the legs.
The mean
= 0.7 I-0.99).
interrater
reliability
(kappa)
1968) for all scores
(Cohen,
was 0.89 (range
Data Analysis.
Two methods were used in the analysis of the organization
of behavior.
Method
1. This method was developed to study behavior in relation to the core elements
of
the interview: the vocalizations and the intermediate
pauses (see Bouhuys and Alberts, 1984).
Logically, four types of pauses can be distinguished.
There are pauses within the speech of
either partner (speech pauses) and pauses that are followed by switches in speaking turn
(switching pauses). The procedure is visualized in Fig. la.
Fig. 1. Illustration of methods
a)
SPEECH
SPEECH
PAUSE
PAT-PAT
PATIENT
d----ym
PSYCHIATRIST
SWITCHING
PAUSE
PAT-PSYCH
r-----7
I
--I
L-J
PAUSE
PSYCH-PSYCH
C‘___,’
SWITCHING
PAUSE
PSYCH-PAT
b)
SPEECH
SPEECH
PATIENT
PSYCHIATRIST
I
-
I
j
L_________d
A
I
I
I
I
I
+
:___..____-J
B
!
I
,
I
t
I
I
I____--:
A
51
The analysis focuses on these four types of pauses. The last half of a vocalization.
the
following pause, and the first half of a vocalization following that pause are defined as the unit
of analysis. Such a sequence is also called an episode. Fig. I h shows the four types of episodes
(A, B, C, and D).
The analysis is designed to describe the temporal distribution
of other behaviors relative to
the temporal
structure of the episodes.
Because episodes may be very different in their
temporal structure, a method was used to normalize the various durations of the various parts
of the episodes. Fig. 2 demonstrates
this normalization
procedure. Step “a” in Fig. 2 shows
four episodes of the same type with different lengths. For these four episodes, the mean
duration oj’cwh.~ugmenr of the episode was calculated (i.e., of the two speech fragments and
of the pause). Thts was done for each type of episode for the total group of patients. Step “b”
calculated how many 0.2 set epochs (0.2 is the resolution of the analysis) are represented
by
that mean. In the example in Fig. 2 the number of 0.2 set epochs amounts to N I = 3, N2 = 3,
and N3 = 2. In this way, a new time axis (step “c”) was calculated consisting of eight (i.e., 3 + 3
+ 2) 0.2 set epochs. Step “d” adjusted each episode to this new time axis (i.e., each episode
fragment was divided into N I, N2, and N3 epochs, respectively). The fragments of an episode
were thus expanded or contracted.
Fig. 2. Four episodes of different durations (each composed of consecutive
speech-pause-speech
fragments) illustrating the normalization procedure
SpWCtl
pZ3U-3~
speech
step d
steta b
i
8
i
Nl
;
0
1
N2
:N3!
I
;
i:
u
0.2 sec.
*top c
The distribution
of other behavior was then studied with respect to this newly calculated
time axis. For each epoch (now with an averaged duration of 0.2 set), the number of times this
other behavior occurred was calculated for each patient and expressed as a percentage of the
total number of episodes per patient. Fig. 3 shows the framework of the presentation
of these
distributions.
The abscissa represents
the time course of the four types of episodes. The
hatched columns refer to the speech of the partners in the dialogue. Which partner is speaking
is indicated above each of the columns. The widths of the columns correspond
to the number
of 0.2 set epochs, calculated according to the normalization
method described above. The
widths of the intervals between the columns (within an episode) represent the pauses and again
correspond to the number of 0.2 set epochs. Only episodes with a speech duration between 0.4
52
and IO set and a pause duration between I and 3 set are considered. The occurrence of other
behavior (in this example, looking) during the given episodes is indicated along the ordinate in
terms of the relative number of episodes during which this behavior occurred. Data from
patients with fewer than IO episodes of a specific type were excluded from further analysis.
This method has been applied to relatively frequently occurring behaviors (i.e., looking,
head movements, object and body touching, and gestures).
Method 2. In contrast to method I, method 2 does not concern time relationships
between
behaviors.
Instead, the total durations
of all behaviors, their frequencies,
and their mean
durations were analyzed.
Statistics. Spearman rank correlations
were calculated between the observational
and the
clinical variables. Thus, no arbitrary cutting points had to be chosen in the continuum of the
distribution
of a variable. However, some behaviors occurred in a relatively low number of
patients. In these cases, comparisons
between groups (the responders and the nonresponders)
were made using the Mann-Whitney
U test (Siegel, 1956). The occasions are indicated in the
text. In all instances, two-tailed tests are applied.
Results
Speech-Pause
Analysis. The following patient behaviors were analyzed: looking,
head movements,
object and body touching, and gestures. For each 0.2 set point of
the distribution
of these behaviors, rank correlations
were calculated between the
amount
of the behaviors
and the clinical response to TSD. Results are only
presented for those behaviors that show significant relationships
to clinical change at
some moments in the speech-pause sequences.
Looking. Fig. 3 shows the distribution
of looking over the various speech-pause
fragments in responders and nonresponders
to TSD. Because the level of looking by
the psychiatrist
is very high (about 90%) in this particular
interview situation,
looking by the patients in the direction of the psychiatrist
may be interpreted
as
looking to each other. Significant correlations
are indicated by asterisks. During the
day preceding TSD, patients who later responded
to this intervention
showed a
lower level of looking than patients who did not respond, especially during the turn
switch in speaking from patient to psychiatrist.
Hand movements. Fig. 4 shows the distribution
of body touching over the
various speech-pause
fragments in responders and nonresponders
to TSD. Patients
who responded to TSD displayed a higher level of body touching than patients who
did not respond. Differences between responders and nonresponders
most markedly
occurred during switches of speaking turns.
Fig. 5 shows the distribution
of object-touching
hand movements.
Responders
displayed
higher
amounts
of this behavior
while talking
to the
nonresponders
did, while differences
vanished
at other time points
Total Durations,
psychiatrist
than
in the analysis.
Mean Durations, and Frequencies. Total durations,
mean
durations,
and frequencies of behaviors, when analyzed irrespective of the timing of
these behaviors
in relation to speaking and pausing, are shown in Table 1. The
averaged values of the observed baseline behaviors are shown for TSD responders
and nonresponders.
The rank correlations
between the observed baseline parameters
and the subsequent
clinical response are also depicted. The frequencies
of body
touching and object touching were significantly
and positively correlated with the
clinical response to TSD (both r = 0.492, n = 17, p < 0.05).
53
Fig. 3. Amount of looking of patients in relation to speech-pause-speech
sequences during baseline interviews 1 day before total sleep deprivation
96 looking
-.
responders
O----•
nonresponders
l
patients
to TSD
to TSD
pe.05
psych
80
Pay
8
a*
80
PI
TIME
.1
Hatched columns: speech of patients (pat) or psychiatrist (psych). Area between hatched columns: pauses.
Responders to total sleep deprivation (TSD): n = 9; nonresponders to TSD: n = 13.*: Significant correlation between
baseline behavior and subsequent clinical response to TSD.
Clinical Activation
Measures in Relation to Clinical Change. No significant
correlations
were found between the degree of retardation
or agitation, as measured
the day before TSD, and the later change of severity of depression
in response to
TSD (r = -0.050 and r = 0.334, respectively).
In addition, the baseline severity of
depression
(i.e., the baseline
HRSD score and the 9 a.m. Bf-s score) was not
significantly
related to TSD response (baseline HRSD: r = -0.313; 9 a.m. Bf-s score:
r = -0.215). The degree of retardation
was negatively correlated with the degree of
agitation (r = -0.678, n = 17, p < 0.01).
Outcome Predicting Behavior in Relation to Retardation
and Agitation.
Hand movements are thought to be associated with activational
states. In the current
patient group, we studied this association only for the variables predicting outcome.
In 63% of the moments at which positive correlations
between body touching and
response to TSD were found (see Fig. 4), body touching was also significantly
related
to the degree of retardation
(i.e., a negative correlation).
At 37.3% of the rest of the
moments shown in Fig. 4, the percentage of body touching was correlated with the
degree of retardation
and not with the response to TSD. In 100% of the moments at
which object touching
was positively
correlated
with the TSD response,
this
54
Fig. 4. Amount of body touching of patients in relation
speech sequences during baseline interview
%bodytouching
patients
to speech-pauseto
.-a
responders
O----•
norresponders
I
TSD
lo TSD
PC.05
60
*: Significant correlation; responders: n = 9; nonresponders:
n = 6.
behavior was also related to the degree of agitation (Fig. 5). At 0.7% of the rest of the
moments, body touching was also positively correlated with agitation. Moreover, the
total frequency of object-touching
hand movements over the 15 min of the interview,
which was positively correlated
with TSD response, was also positively correlated
with the degree of agitation (I = 0.579, n = 17, p < 0.05). Looking variables were
related neither to the degree of retardation
nor to the degree of agitation.
Effect of Clomipramine
on TSD Response. The psychometric
and ethological
data were collected under drug-free conditions.
TSD response was measured when
patients were receiving either placebo or clomipramine.
Treatment condition did not
significantly
affect the clinical response to TSD: the mean change as measured in
Bf-s units for the eight patients in the placebo group was 5.5 (SD = 6.6) while that
for the nine patients in the clomipramine
group was 7.6 (SD = 9.4) (Mann-Whitney
U test, p > 0.45).
Discussion
Quantitative
aspects of behaviors
observed during medication-free
related to subsequent
clinical response to total sleep deprivation
interviews
(TSD).
are
The
55
frequency and duration of body touching (Table I and Fig. 4), respectively, and the
frequency
of object touching (Table I) were positively related to TSD response,
whereas the duration
of looking (Fig. 3) was negatively
related to this response.
Globally judged (psychomotor)
activation was not predictive of TSD response.
The relatively large number of correlations
calculated
in the current study will
have produced type 1 statistical errors. Although our results cannot be compared
with other studies
examining
relationships
between
response
to TSD and
observations
of behavior
at baseline,
they are, as far as relationships
between
activational
concepts and observable
behaviors are concerned,
to a large extent in
agreement with findings reported by others (see below).
Patients treated with TSD in combination
with clomipramine
did not differ in
their response to TSD from patients treated with TSD and placebo. Thus, the
response to TSD does not appear to be significantly
confounded
by treatment
effects.
Different investigators
have different theoretical orientations
toward the concept
of arousal
or activation.
Some assume that the experience
of activation
is
unidimensional
and parallels the physiological
arousal continuum
postulated
by
Lindsley (cf. Dermer and Berscheid, 1972). Others question the unidimensionality
of
activation
(Thayer, 1967, 1970; Bohlin and Kjellberg,
1973). Recent research has
examined
different dimensions
of arousal in relation to information-processing
Fig. 5. Amount of object touching of patients in relation to speech-pausespeech sequences during baseline interviews
4
responders to TSD
%object touching
l
a--- -0
patients
nonesponders
t
pat
psych
psych
to TSD
p<.05
pat
12
8
a
*: Significant difference between responders (n = 9) and nonresponders (n = 8) (Mann-Whitney U test)
pat
56
theory (Sanders, 1977; Knott and Lapierre, 1987) or the theories of emotion (Russell,
1980; Purcell, 1982). In psychiatry,
concepts of activational
states are global and
nonspecific.
Retardation,
for example, refers to cognitive processes as well as to
observable
behavior.
These different
aspects do not necessarily
relate to one
particular
dimension
of activation.
Moreover, the weights given to the constituent
aspects of the concept of retardation
tend to be unclear and not explicit. Greden and
Carroll (198 I) emphasized the need for objective instrumentation
and monitoring
procedures
in experimental
paradigms
capable of isolating and quantifying
the
contribution
of individual
components
of retardation.
We think that studying
observable behavior may be one answer to this need. It may reveal novel dimensions
of activation
and may be more sensitive to therapeutic
outcome than the global
concepts of activation
common in psychiatry (i.e., retardation
and agitation).
The
results of the current study support this presumption:
observable
behaviors were
related to treatment response, whereas global judgments
of psychomotor
activation
were not.
What role do the types of behavior that predicted improvement
after TSDnamely,
looking and hand movements-play
in an interaction,
and with what
concepts are they related?
In normal
individuals,
looking
provides
information,
regulates
interaction,
expresses intimacy, and exercises social control (Kendon,
1967; Kleinke, 1986). An
additional
interesting feature of gaze behavior is its relation to arousal. Under some
conditions,
gaze can result in heightened physiological
responses. Electroencephalographic (EEG) arousal was found to be higher for direct than for averted gaze (Gale
et al., 1975, 1978) and Kleinke and Pohlen (1971) reported that heart rate was
significantly
higher for subjects in the gaze condition than for subjects in the no-gaze
condition
(see Kleinke [1986] for a review). One of the difficulties in this type of
research is the discrimination
between behavior expressing an underlying
state and
behavior serving the regulation
of that state. Being looked at, for instance, may
increase the level of arousal, and in this case looking may be interpreted
as an
expression of arousal; but simultaneously
or subsequently
looking away may lower
this arousal level, and in that case looking may be considered a tool in the regulation
of arousal. The second possibility
finds support in studies on the relationships
between embarrassment
and looking: embarrassed
(and consequently
activated)
people look away from the person who provokes their embarrassment
(Kleinke,
1986). Accordingly,
it is very difficult to decide on the basis of amounts of looking
how looking should be interpreted
in relation to arousal. The process character of
these phenomena
must be taken into account. Hence, apart from serving functions in
the interaction,
looking may serve the regulation
of or be an expression
of the
arousal state of an individual.
Our data are not conclusive in this respect.
Hand movements
have also been associated with activational
states during an
interaction.
When assessed in a normal population,
this relation is more unequivocal
than the relation between arousal and looking. Body touching can express the degree
of anxiety or arousal in normal subjects (Mahl, 1968; Barroso et al., 1978; Harrigan,
1985) or the degree of uncertainty
encountered
in communication
(Sousa-Posa
and
Rohrberg,
1977; Harrigan,
1985). Monti et al. (1984) found in both psychiatric
patients
and healthy controls
positive correlations
between
amounts
of self-
SD
53.6
16.6
Object touching
Gesturing
1. p < 0.05.
387.9
ments
Body touching
186.2
38.7
47.2
45.4
18.6
288.5
120.6
24.2
22.2
71.3
82.5
185.1
50.1
20.2
20.1
229.8
-147
250
381
155
-101
-282
-375
190
501.7
r
226.2
102.1
Mean SD
Nonresponders
148.8
151.6
21.4
21.3
No-shaking
Headmove-
22.6
246.5
113.7
16.5
307.6
258.6
Yes-nodding
Nonlooking
Looking
Nonspeaking
Speaking
Responders
Total duration (set)
20.1
51.0
82.7
130.4
24.4
17.8
65.7
25.8
25.8
25.3
57.9
22.2
112.1
27.0
24.1
21.6
79.5
39.4
20.7
20.6
51.3
492'
-175
34.0
492'
-019
-084
-306
-282
21.8
25.6
35.2
16.0
12.5
34.0
r
042
48.4
183.0
Mean
SD
56.5
SD
191.7
Mean
Nonresponders
Responders
Frequency
1.7
1.0
4.9
1.4
0.8
0.7
36.2
4.1
3.9
1.3
Mean
2.1
0.9
2.0
0.9
0.2
0.2
46.6
2.0
2.5
0.5
SD
Responders
1.0
1.4
5.0
1.1
0.9
0.9
6.1
7.3
4.1
1.2
Mean
0.7
1.1
3.5
0.3
0.3
0.4
4.7
5.1
1.7
0.4
SD
Nonresponders
r
172
075
-120
169
184
(n=16)
-342 (n=l6)
-188 (n =16)
310
-220
-111
Mean duration (set)
Table 1. Baseline means and standard deviations of behavioral parameters in responders and nonresponders to
total sleep deprivation (TSD): Spearman rank correlations between observed behavior and subsequent clinical
response to TSD
5x
manipulation
and measures of arousal (i.e., heart rate) in a situation provoking high
social anxiety. Some findings in depressed populations
support these observations.
Ekman and Friesen (1974) found a positive correlation
between anxiety and the
duration
of self-adaptors
(i.e., the categories body touching plus object touching of
the current study). Ulrich and Harms (1979, 1985) found comparable
relationships
in
depressed
patients
for parameters
equivalent
to body touching
(e.g., mutual
manipulation
of both hands, manipulation
of the face or head). They consistently
found that the frequency of body-focused
movements (with a duration > 3 set) was
positively
correlated
with agitation,
whereas the frequency
of gesticulation
was
negatively correlated with retardation.
Such a negative correlation
was also found
for the duration of gesticulation
(Bouhuys. 1985).
Thus,
the main findings
in depressed
populations
are that body-focused
movements
are positively related to agitation (Ulrich and Harms, 1979, 1985) and
anxiety (Ekman and Friesen, 1974), and that gesticulation
is negatively correlated
with retardation
(Ulrich and Harms, 1979, 1985; Bouhuys, 1985). Our findings on
gesticulation
are in line with these earlier studies. The frequency of object touching in
our subjects was positively correlated with agitation and accords with the results of
Ekman and Friesen (1974). The amount of body touching (Fig. 4, speech pause
analysis) was negatively correlated with retardation
and not with agitation, as one
would expect from earlier findings.
Retardation
and agitation
are, according to
Hamilton (1967), not mutually exclusive categories. On the other hand, considering
the descriptions
given by Hamilton of agitation and retardation,
one would expect
negative correlations
between retardation
and agitation. Indeed, in the current study
retardation
and agitation were negatively correlated, indicating that they have much
variance in common. This negative correlation
may account for our finding that the
duration
of body touching
was significantly
related to retardation
and not to
agitation.
In conclusion,
behaviors
predictive
of improvement
appear to be related to
concepts of activation.
Consequently,
the mood change occurring during and after
TSD may be mediated
by dimensions
of arousal.
The finding that observed
behaviors
rather than global clinical assessments
of activation
are predictive
of
therapeutic
response to TSD is promising.
It may indicate that these behaviors refer
to novel and relevant aspects of the multidimensional
concept of activation,
or that
they are more sensitive to therapeutic
events than global arousal measures. The
current approach,
using direct observation
and registration
of behavior, may open
new theoretical perspectives.
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