Analyzing Non-verbal Behavior Throughout Recovery in a Sample of Depressed Patients Receiving Deep Brain Stimulation Pubblico
McCall, McCall (Spring 2018)
Abstract
Background. Traditional assessments of depression involve scales based on verbal report. Such
scales are used as measures of efficacy in studies of deep brain stimulation (DBS) as a treatment
for major depression. These scales lack detailed measurement of non-verbal behavior, despite
evidence that non-verbal behavior can provide a window into the unconscious and involuntary
physical manifestations of depression. Traditional scales thus may not be sufficient in
understanding the recovery of DBS patients as they learn to understand normal negative
emotions as transient rather than chronic.
Purpose. This study examines non-verbal behavior in a sample of patients receiving DBS over
the first 6 months of treatment. The purpose of this study is to uncover groups of related nonverbal
behaviors and investigate the relationship between non-verbal behaviors and verbal selfreport
scales at different phases of recovery.
Methods. Clinical interviews of twelve DBS patients were analyzed at three time points (1 week
pre-operative, ~3 months, and 6 months after start of stimulation), using an ethogram to assess
the frequencies of 42 non-verbal behaviors. Beck Depression Inventory (BDI) and Hamilton
Depression Rating Scale (HDRS) were also collected at all time points.
Results. Factor analysis groups non-verbal behaviors into three factors: react, engage/fidget, and
disengage. Two-way repeated measures ANOVA shows that scores on the three factors change
differently from each other over time. Mixed effects modelling provides evidence that the
frequency of non-verbal behaviors related to reactivity and engagement increase as BDI score
decreases. Lastly, the non-verbal behavior displayed at ~3 months is more similar to that at 6
months than pre-op.
Conclusion. Non-verbal behavior is a rich source of information about clinical states that cannot
be contained by omnibus psychomotor scores on traditional depression rating scales. This study
affirms the usefulness of assessment of non-verbal behavior, particularly during transitional
phases in which patients re-learn to discriminate transient from chronic negative affect.
Table of Contents
Table of Contents
Purpose and rationale………………………………..………………………................. 1
Hypothesis…………………………………………………………...……………………. 2
Introduction………………………………………………………………………………… 3
Major depressive disorder and treatment resistance………………………………….. 3
Neurobiology of depression…………………………………………………………........ 5
Deep brain stimulation…………………………………………………………………..... 6
Hamilton Depression Rating Score and Beck Depression Inventory………………… 8
Psychomotor symptoms of depression………………………………………………...... 9
The rough patch……………………………………………………………………………. 11
The analysis of non-verbal behavior……………………………………………………... 12
Ethnography and psychiatry…………………………………………………...…............. 13
Methods……………………………………………………………………………………… 17
Patients………………………………………………………………………………………. 17
Surgery and treatment phases………………………………………………………......... 17
Clinical assessment and time points………………………………………………………. 18
Ethogram…………………………………………………………………………………….. 18
Collection of non-verbal behavior data………………………………………………….... 19
Data analysis………………………………………………………………………………... 19
Results……………………………………………………………………………................. 24
Ethogram…………………………………………………………………………................. 24
Factor analysis……………………………………………………………………………..... 24
Treatment Rating Scores…………………………………………………………………… 24
Non-verbal behavior factors over time……………………………………………………. 25
Association between BDI and non-verbal factor scores………………………………… 26
Association between HDRS-17 and non-verbal factor scores…………………………. 28
Association between BDI and individual non-verbal behavior scores…………………. 29
Discussion……………………………………………………………………………………. 31
The ethogram……………………………………………………………………………....... 31
Factor analysis………………………………………………………………………............ 32
Non-verbal behavior factors over time……………………………………………………. 33
Association between BDI and non-verbal factor scores ……………………………...... 34
HDRS-17 and BDI……………………………………………………………………………37
The behaviors within the factors…………………………………………………………... 38
Importance for clinical assessment and future directions………………………………..40
Limitations………………………………………………………………………………........ 42
Conclusion ……………………………………………………………………………………44
References……………………………………………………………………………………59
Tables and Figures
Table 1. Ethogram……………………………………………………………………………........... 46
Table 2. Factor scores scaled with mean of zero…………………………………………........... 47
Figure 1. Location of the electrodes implanted during DBS surgery ………………………...... 48
Figure 2. Average BDI scores every 2 weeks for the first 6 months of stimulation………….... 49
Figure 3. Correlation plot of non-verbal behavior scores using Pearson Correlations………... 50
Figure 4. Diagram of factor loadings generated from confirmatory factor analysis………........ 51
Figure 5. Non-verbal factor scores over time………………………………………………........... 52
Figure 6. BDI by non-verbal factor score over time…………………………………………......... 53
Figure 7. HDRS-17 by non-verbal factor score over time……………………………………....... 54
Supplementary Table 1. Factor loadings based on exploratory factor analysis………………... 55
Supplementary Table 2. P-values of pairwise comparisons using paired t-tests…………........ 56
Supplementary Figure 1. BDI by individual behavior scores over time…………………............ 57
Supplementary Figure 2. Pause, illustrative gesture, and head to the side scores over time... 58
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