Australian and New Zealand Journal of Psychiatry (1983) 17: 307-318

Review

EVENT=RELATED POTENTIALS IN PSYCHIATRY:

APPROACHES TO RESEARCH AND CLINICAL
AP PLlCAT10 NS
H. G . STAMPFER

This article suggests that the potential usefulness of event-related

potentials in psychiatry has not been fully explored because of the
limitations of various approaches to research adopted to date, and
because the field is still undergoing rapid development. Newer
approaches to data acquisition and methods of analysis, combined
with closer co-operationbetween medical and physical scientists, will
help to establish the practical application of these signals in
psychiatric disorders and assist our understanding of
psychophysiological information processing in the brain. Finally, it is
suggested that psychiatrists should seek to understand these
techniques and the data they generate, since they provide more direct
access to measures of complex cerebral processes than current
clinical methods.

Studies of event-related brain potentials (ERPs) Terminology and Classification

have already resulted in many useful clinical
applications and in a greater understanding of
cerebral activity associated with signal or
information processing. The clinical usefulness of
these potentials has been more evident in the
diagnosis of neurological and sensory impairment,
although various findings suggest that they may
also be of clinical value in psychiatric disorders
and psychophysiological studies in general.
The main concern in this article will be to make
a brief, critical appraisal of the central issues
involved in various approaches to clinical ERP
research and to emphasise developments which
appear to hold greater potential for establishing
clinically relevant ERP measures in psychiatric
disorders. A further aim will be to discuss the uses
that these potentials may have in psychiatry.
For the sake of brevity, the review of the
literature will be selective and focused on what in
this author’s opinion are central issues. Reviews of
various findings and basic methodological issues
already exist (Regan, 1972; Shagass, 1975;
Lehmann, 1979).
An event-related potential is a gross measure of
the brain’s electrical activity which is temporally
linked to some ‘event’, be it the abrupt
presentation of a sensory stimulus, the signalled
anticipation of some occurrence, or the
performance of some task; it is a gross measure of
the electrical activity associated with signal or
information processing and may be considered as
an extension of EEG analysis.
The definition and classification of ERP
components is based mainly on the latency of
major, repeatedly observed voltage deflections, in
relation to a specific stimulation point, although
the polarity, anatomical derivation and the
experimental conditions in which they appear also
influence the terminology (e.g. readiness potential
(RP); contingent negative variation (CNV);
positive wave at 300 ms (P300), sometimes
referred to as ‘decision making wave’).
The terms ‘evoked potential’, ‘evoked response’
and ‘event-related potential’ are sometimes used
synonymously (Cooper, 1981), while some
authors (Groll-Knapp, et a/., 1980) reserve the

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308 EVENT-RELATED
POTENTIALS IN PSYCHlATRY

term ‘event-related potential’ for longer latency
components such as CNV, P300 and DC
potentials which will be discussed later.
The majority of workers connect their
electrodes so that upgoing ERP waves reflect
negative polarity, while the opposite obtains for
the rest. Such lack of standardisation is
regrettable, but also understandable considering
that ERP research is a relatively new and
developing field.
Data Acquisition and Measurement
Raw ERP data are simply segments of scalp-
recorded EEG activity. Studies based on invasive
depth recording have been carried out, but such
methods are seldom justified ethically. The
discussions in this article refer to scalp-recorded
data implicitly, unless stated otherwise.
The basic difference between EEG and ERP
recording is that instead of tracing on-going EEG
activity on paper, EEG epochs of somewhere
between 0.5-1.O-second duration, immediately
following and sometimes preceding a stimulus, are
digitised, stored and added to subsequent epochs
from repeated stimulation before being displayed
as the ERP signal. This enhances the magnitude of
ERP activity relative to background EEG ‘noise’,
and is the so-called averaging technique
commonly used in ERP studies. Hence the
minimum facilities required for carrying out ERP
studies include EEG instrumentation, facilities for
presenting various timed stimuli, analog to digital
converters and computer facilities for processing
and display of data.
The most simple, commonly used measures are
the latency and amplitude of the main deflections
in the ERP signal (see Figure 1).
Many studies have been carried out with only
three electrodes attached. The two ‘active’
electrodes in bipolar configuration are usually
placed over primary sensory areas (e.g. temporal
for auditory and occipital for visual stimuli) and
the third acts as a reference lead. However,
considerable variation is encountered depending
on the type of study being carried out. Different
approaches to data acquisition and analysis will be

t1 STIMULUS
\
\ /
/

-640 0’ + 6 4 0 ‘ (ms)
P R E STIMULUS POST STIMULUS
FIGURE 1 .-Diagram illustrating latency and amplitude measurements of an ERP.

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 H.G . STAMPFER
discussed in greater detail below. This outline is
intended only to provide a basic orientation to
what is involved for readers not familiar with
these techniques.
Functional Significance of ERP Components
Certain components of the E R P vary
systematically with the physical parameters of the
stimulus and depend upon the structural integrity
of the sensory receptors and pathways, but are
relatively impervious to transient changes in the
subject’s psychophysiological state. Such
components have been termed ‘exogenous’,
‘obligatory’ or, simply, ‘evoked’.
They consist of the early components occurring
within 50 ms of the stimulus, regardless of the
stimulus modality. The brain stem responses,
which occur within 10 ms of the stimulus, are
especially stable and stimulus bound. By contrast,
the later components are more sensitive to
subjective states. The perceptual experience of a
stimulus depends not only on its physical
characteristics but also on the psychophysiological
state of the experiencing subject, such as his or her
level of alertness, direction of attention, memories
of relevant past experiences, expectations and
motivation. The late components occurring after
200 ms are the most susceptible to such
psychological influences. They are often referred
to as ‘emitted’ or ‘endogenous’ potentials, since
the dominant influence in their development is the
subject’s psychophysiological state. Included in
this category are slow potential changes such as
CNV, RP, P300 and direct current (DC) shifts.
It is customary to make a broad latency
classification of ERPs into what are generally
termed ‘early’, ‘middle’ and ‘late’ potentials,
although authors vary somewhat in their latency
specifications and nomenclature (Oades, 1982;
Spohn and Patterson, 1979; Gibson, 1980).
Ivanitsky (1980) has proposed that in terms of
biophysical detection theory, perception results
from an interaction of sensorial and nonsensorial
factors and, on the basis of his findings, has
suggested that the ERP can be divided into three
parts corresponding to three broad stages of signal
processing; the first, lasting approximately
100 ms, he suggests is associated with the analysis
of the physical and biological characteristics of the
stimulus; the second, occurring approximately
between 100-200 ms, he suggests is associated with
the synthesis of the physical and biological
characteristics of the stimulus; and the third,
commencing after approximately 200 ms, he
suggests is associated with the decision stage of
perception (see Figure 2).
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309
Notwithstanding various differences in latency,
nomenclature and interpretation, there is general
agreement on what seems intuitively obvious,
namely that the sequence of ERP components
grossly corresponds to sequential stages of signal
or information processing which, in turn, reflect
the influence of different anatomical or functional
systems arranged hierarchically in the brain.
Disciplinary Interest in ERP Components
To some extent the hypothesised significance of
different latency components is already reflected
by a division of disciplinary interest. In the case of
auditory-evoked potentials for example, otologists
are mainly interested in the very early ‘cochlear’
components occurring within 2 ms. Neurologists
have been more interested in brain stem and
middle latency components which can provide
useful diagnostic evidence. Psychiatrists and
psychologists have been more interested in the
later components which are more susceptible to
psychological influence. Of course the functional
relationship between early and late components is
still poorly understood and one needs to be
cautious about interpreting ‘pathological changes’
in later ERP components without having studied
the earlier components. In psychiatric studies, it
seems wise to avoid premature bias towards
working only with selected ERP components, and
to remember that the boundaries between early,
middle and late components are only loosely
defined.
Why Study ERPs in Psychiatric Disorders?
Various answers can be given to this question. The
most common, simple and optimistic rationale can
be stated as follows:
an ERP is a measurable signal of brain activity
which is clearly linked to some sensory/perceptual
event;
there is evidence that different components of this
signal reflect the activity of different anatomical/
functional systems associated with sensory/
perceptual experience;
psychiatric disorders, especially the psychoses,
show prominent perceptual disturbances;
hence the study of ERPs may provide laboratory
indices of clinical phenomena, and may also help
to explain the pathophysiological changes
underlying those clinical phenomena.
The optimistic viewpoint was summarised by
Regan in 1972, when he wrote: ‘At the present
time, therefore, EP recording offers unique
possibilities for advancing our understanding of
the neurophysiological basis of mental life and its
malfunctions in psychiatric illness.’
310 EVENT-RELATED
POTENTIALS IN PSYCHIATRY

While newer techniques, such as Positron large amounts of information of obscure

Emission Tomography (PET) and Nuclear
Magnetic Resonance (NMR) scans have come into
operation since then, most ERP researchers still
believe that ERPs will find practical usefulness in
psychiatry. Also ERP techniques are very safe,
noninvasive, not stressful to the subject and
relatively inexpensive.
Less optimistic views have been expressed
concerning the usefulness of these studies which
might be seen as ‘harmless methods for gathering
significance’ (Shagass, 1976). Some people
speculate that ERPs would contain about as much
useful information about brain functioning, as a
microphone, held six inches away from a
computer, would reveal about the functioning of
the computer.
Attempts will be made to examine these
different viewpoints in greater detail before
reaching a final conclusion as to the *Dossible
utility i f these potentials in psychiatry.

PERCEPTION

Sensitivity Criterion
Prychophysics index index
of pIrcep t tan

Evoked
potential

Sensory stage Stage of synthesis Decision stage

Analysis of the Synthesis

Brain
physical charac- of the physical
Informational Decision
teristics of the and biological
processing making
stimulus characteristics
of the stimulus
1 1 I
Sensation

mwc 0 50 100 150 200 250 300

1
F I G U R E2.-(Taken from lvanitsky (1980)). Diagrammatic representation of the hypothesised three
periods of perception associated with ERP activity.

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 H.G. STAMPFER
Approaches to Clinical ERP Research
According to Shagass (1976), ‘The investment in
measuring scalp-recordable signals is based on the
assumption that their statistical characteristics
reflect clinically relevant attributes of the myriad
phenomena taking place in the neuronal
populations contributing to the recording. To
determine relevance, t h e psychiatric
electrophysiologist seeks correlations between
electrophysiological and clinical phenomena, even
though, to perform this task, he must be able to
tolerate not knowing exactly what his raw
electrophysiological data mean. If he were to put a
moratorium o n his work until basic
neurophysiological research explained the surface
signals, there would be no body of information to
which the explanations could be applied.’
Shagass here has implied a seemingly neat
division of labour; ‘correlative’ clinical research
and ‘explanatory’ basic research. There are
potential pitfalls in adopting this approach to
clinical ERP research. The division of labour
suggested by Shagass might make good sense if
ERP measures were reliably established.
However, there is still considerable controversy as
to what measurements should be made. This
applies especially to the later ERP components
which are often selectively studied in psychiatric
disorders and psychophysiological studies in
general. For example Basar (1980) has argued that
‘not the peak or amplitudes of the gross response
but the slope changes and frequency behaviour of
the ERPs are relevant in the study of brain-evoked
potentials ’.
It will be argued that to avoid expending a great
deal of effort establishing correlations which are
intrinsically doubtful, clinical ERP researchers
must give some ‘basic’ thought to methods of data
acquisition and analysis. The clinical researcher
has to experiment with different approaches to
optimise the chances of finding relevant
correlations, otherwise he might as well put a
moratorium on his work, at least until reliable
measures have been established. To make a simple
measure like amplitude (and even this is not as
simple as it may seem) and set about trying to
establish large correlations may simply not be
worth the effort. It would be better to give some
basic thought to what an ERP signal might
represent so that more meaningful measurements
may be developed and explored. Saito’s (1981)
advice is very apposite here: ‘The key to avoid
meaningless analysis and proceed to successful
result seems to be the adequate co-operation
between medical and engineering professionals,
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31 1
taking initiatives on each side and not invading the
other’s area.’
Unless a psychiatrist researcher has had special
training in signal analysis, it is vitally important to
work in close collaboration with electronics and
engineering professionals to avoid reducing the
information to simplistic, irrelevant correlations.
Walter (1981) captured the nub of the matter when
he wrote: ‘Struggling with this unpleasant
ambiguity of the brain’s outputs has made me
realise that this problem is only a small, though
representative, part of a larger scientific problem;
when is reductionism a poor scientific strategy? I
suggest that brain research is a branch of science
where reductionism is often a poor strategy.’
The main findings of ERP studies in psychotic
disorders, up to 1975, have been summarised by
Shagass (1975). Most of the findings have been
described in terms of latency and amplitude
changes, although there is mention of ‘less after
rhythm’, ‘wave shape variability’ and duration of
activity. The findings based on these measures
suggest abnormal ERP activity in affective and
schizophrenic disorders, but fail to provide
definite indices of specific clinical features or
diagnoses. One can only speak of ‘tendencies’ to
certain ERP abnormalities and ‘probable’
differences between schizophrenic and affective
disorders.
Various explanations are possible for this
frequently found ‘overlap’ between normal and
psychiatric, and between different diagnostic
groups. There may have been considerable clinical
and pathophysiological heterogeneity such that
group data analyses reduce the significance of
these changes; alternatively, the approaches to
data acquisition and analysis may have been too
crude o r faulty t o permit significant
discrimination; finally, the experimental test
(excluding problems of poor design) and the
nature of the data obtained may simply have
failed to expose or reflect the disturbance, in the
same way that a test meal and glucose tolerance
curve will fail to expose or reflect the presence of
osteoarthritis, all other things being equal. Each
of these possibilities will now be examined in
greater detail. Emphasis will be given to various
strategies which might help to provide more
discriminative findings.
Clinical Variability
T h e clinical p r o b l e m involved in
electrophysiological research can be illustrated by
taking the diagnosis of schizophrenia as an
example.
312 EVENT-RELATED
POTENTIALS
The clinical heterogeneity of schizophrenia is
well recognised and ‘since the days of Kraepelin,
two contrasting tendencies - one towards
dividing the clinical group of the schizophrenias
into a number of independent entities and another
towards including a great variety of syndromes
under the common nosological rubric of
schizophrenia - have existed side by side, but
neither has succeeded in definitely resolving the
problem of the definition of the boundaries of this
group of conditions’ (WHO, 1981).
Even if more homogeneous subgroups are
selected (e.g. DSM I11 paranoid, residual) there
are invariably further differences in the
prominence and severity of symptoms, and the
researcher does not know in advance which of
these symptoms, singly or in combination, might
affect selected ERP measures. Hence, it becomes
imperative to use a reliable instrument for
measuring the clinical features pregent at the time
of recording, irrespective of what broad or sub-
diagnostic group is selected initially. The
correlations based on clinical features evident at
the time of recording may be more revealing than
those based on diagnosis.
The Present State Examination (PSE)
developed by Wing (1970) has helped greatly to
standardise the definition and measurement of
psychiatric symptoms and signs, and is the type of
instrument required for clinical
electrophysiological research. The format of the
PSE facilitates computer processing of the data,
and the CATEGO programs are available to
provide diagnostic classification. Clinical
electrophysiologists will be less interested in the
CATEGO diagnoses initially. For reasons
outlined above, it is more important to
standardise the definition and measurement of
clinical features. For example, it may turn out that
the significant electrophysiological findings
correlate with CATEGO, DSM I11 or RDC
diagnostic criteria for schizophrenia, suggesting a
similar fundamental disturbance, but they may
also correlate only with particular clinical features
common to categorically distinct diagnoses,
suggesting a common state disturbance.
A p a r t f r o m heterogeneity in o v e r t
symptomatology, there are further clinical
differences due to current and past treatment, age
and sex. Furthermore, there is evidence to suggest
that age and sex differences can occur in
psychiatric groups when they are absent in
normals (Shagass et al., 1972, 1974). All such
clinical variables may contribute to reduce the
significance of findings, unless careful
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IN PSYCHIATRY
consideration is given to control measures and
methods of analysis.
Inter- and Intra-subject ERP Variability
There is evidence to suggest that both EEG and
ERP characteristics are determined to a significant
extent by genetic influences (Davis and Davis,
1936; Lennox et al., 1945; Dustman and Beck,
1965; Lewis et al., 1972) although conflicting
opinions have been expressed about the degree of
intra-subject variability of ERP measures under
similar experimental conditions. Oades (1982
op.cit., p69) and Ciganek (1969) both emphasise
inter- and intra-subject variability, whereas
Maryutina (1 980) maintains that ‘visual-evoked
responses (ERs) in adults have individual
configurations rather constant for each person.
Individual features are also present in ER
dynamics in situations when attention is either
attracted to or distracted from the stimulus’.
More studies are needed to answer the different
questions pertaining to inter- and intra-subject
ERP variability and identity, especially in normal
subjects. The findings from such studies might
help to provide subtle classifications of both
normal and clinical ERP data. Certain ERP
components or measures might be genetically
determined and associated with different
‘cognitive styles’. For present purposes, however,
reports of both inter- and intra-subject variability
should caution researchers against making large
number cross-sectional comparisons on the basis
of one or two measures. Significant differences
may be entirely lost. It might be a better strategy
to take smaller, well-selected and documented
clinical and control groups and study the
individuals in greater depth, on several occasions
and with varied measures. More relevant findings
and groupings may emerge with this approach.
Choosing Relevant ERP Measures
Different authors (Farber, 1980; Sviderskaja,
1980; Walter, 1981) have emphasised that the
brain is an active system which synthesises or
integrates its many inputs and outputs, and that
ERP measures should therefore reflect its system
characteristics. In this context, it becomes
necessary to consider what methods of data
acquisition and analysis would be adequate to
reflect these characteristics. Such considerations
have particular relevance to studies of the later
ERP components, where there is evidence of a
greater convergence of system influences and
variation due to changes in psychophysiological
state. Sviderskaja has stated that ‘The
 H.G . STAMPFER
phenomenon of spatial synchronisation is being
used more widely as a criterion of functional
condition and activity of the brain because the
analysis of EEG, derived from several cortical
points, appears to be not sufficiently informative
to understand principles of organisation of
bioelectrical activity, which is essentially a
systematic process’. The same would apply to
ERP measures which have been derived from
‘raw’ EEG data. There may be various
deficiencies in ERP measures which have been
derived from data recorded from only one or a
few electrode placements, as they might fail to
reflect the perhaps more important spatio-
temporal characteristics of the response. NMR,
PET and regional blood flow (RBCF) studies have
already demonstrated interesting spatio-temporal
dynamics of cerebral activity during various
‘mental’ performances, and it might be precisely
these dynamics that are altered in disorders such
as schizophrenia. It would seem very important,
therefore, to incorporate a greater number of
electrode placements than has usually been the
case in psychiatric ERP studies. A reasonable
starting point would be the standard 10-20
placements used in routine clinical EEG
recordings. Lehmann and Skrandies (1980) used
47 channel recordings!
Apart from trying to understand more complex
spatio-temporal dynamics, the well-recognised
hemispheric asymmetries of brain functioning
should warrant at least bilateral electrode
placements, especially in the light of evidence to
suggest a differential hemispheric involvement in
psychopathology (Flor-Henry, 1974).
The use of multichannel recordings and spatio-
temporal mapping techniques (Duffy, 1981) may
help to extract more relevant ERP measures from
ERPs obtained with ‘averaging’, which is still one
of the most popular techniques used today. Figure
3 illustrates spatio-temporal maps of averaged
auditory-evoked potentials. The examples were
taken from studies being carried out in the
author’s laboratory,
The following sections will make reference to
more technical and mathematical issues of ERP
research. Attempts have been made to reduce
specific details to a minimum and to emphasise the
central issues in generally comprehensible terms.
Limitations of the Averaging Technique
The basic aim of ‘averaging’ is to increase the
ratio of wanted signals to unwanted ‘noise’.
Occasionally, the ERP response is large enough to
be distinguishable from the background EEG with
only one stimulus presentation. Most of the time,
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313
however, it is too small to be distinguished clearly
and lies ‘buried’ invisibly in the EEG. Because
ERP changes are time-locked to some specific
trigger point, it is possible to enhance the relative
magnitude of the ERP response by repeated
summation of pre- and post-stimulus EEG
epochs. Any unsynchronised ‘noise’ will cancel
proportionally as the square root of the number of
summations, whereas the time-locked ERP
response will add together and increase in relative
magnitude. Thus, if 100 post-stimulus epochs are
added together and divided by 100, the signal-to-
noise ratio will have improved by a factor of 10.
Somewhere between 50-100 epochs are usually
averaged to obtain the middle and late potentials,
whereas about 10o0 epochs are necessary to obtain
the very small brain stem potentials occurring
within 10 ms.
The validity of the averaging technique is based
on a number of assumptions, namely: identical
stimuli, identical responses and random stationary
background EEG which is not correlated with the
ERP response. These assumptions have been
questioned by different authors (Sayers, 1974;
Squires and Donchin, 1976; Basar, 1980; Van der
Tweel et al., 1980) who have discussed the
limitations of a ‘linear’ technique like averaging,
when dealing with non-linear irregularities of
brain function. The analysis of single-evoked
response will avoid any distortion resulting from
averaging, and provide additional information on
the inter-stimulus variation.
Basar (1980) has raised what seems to be the
central issue in more general terms: ‘Do we have
the right to consider the spontaneous activity of
the brain always as a background noise in the
sense of ideal communication theory? . . . The
spontaneous activity is not simply a noise, but is a
kind of controller which affects the production of
signals (or at least, which affects the conduction
of signals) in the brain.’ Basar’s opinion gains
support from the work of Sayers, who found that
‘effective stimuli act by synchronising or
controlling the phases of spectral components of
the spontaneous EEG activity already present’.
The notion that the ERP response is a
consequence of a reorganisation of the
spontaneous EEG activity triggered by some
‘event’ is intuitively more appealing than other
interpretations which treat the background
activity as ‘unwanted noise’ - it incorporates the
system characteristics of brain activity and should
result in more meaningful analysis of ERP
changes. In this sense, the averaging technique
may be an example of reductionism being a ‘poor
scientific strategy’.
3 14 EVENT-RELATED
POTENTIALS IN PSYCHIATRY

FIGURE 3(a).-Examples of spatio-temporal voltage mapping of ERP activity. The figures show voltage
iso-contour lines 248 ms after a click has been presented to the left ear. Figure 3(a) also shows the activity
in a normal, healthy volunteer.

FIGURE
3(b).-Abnormal activity, maximally abnormal in the right temporal region, associated with an
A-V malformation in that area.

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 H.0.STAMPFER
Once the background activity is no longer
considered merely as ‘noise’, it follows that a
more sophisticated approach to data acquisition
and analysis is required. First, it becomes
necessary to record EEG before as well as after the
stimulus in order to understand the generation of
the ERP. Second, it will require more detailed
signal analysis techniques to understand the kind
of changes that have occurred: phase, frequency
and amplitude changes as well as various auto-
and cross-correlations and coherency
measurements must be made and analysed. The
benefit of such an approach may be to produce
more relevant ERP measures and clinical
correlations.
Theoretical and practical problems involved in
choosing a suitable approach to ERP research
should emphasise that the clinical researcher
cannot ignore basic questions while searching for
clinical correlations. This applies especially to
research in psychiatric disorders which may be
reflected in ERP changes that are more subtle than
those due to more obviously localised ‘hardware’
lesions found in neurological diseases. The major
psychoses may indeed be manifest as functional
system disturbances at the level of brain electrical
activity, such that the relevant ERP measures
should reflect the brain’s system characteristics.
Walter (1981) emphasised that the brain is a
synthesising system and maintains that ‘to undo a
synthesis is to analyse; speaking mathematically, it
is to perform an inverse operation’. Ideally then,
the analysis of the ERP should reflect its genesis
or synthesis. Of course, the most advanced,
sophisticated techniques of analysis will never be
able to analyse fully a synthesis which is only
partially and indirectly reflected in the raw data -
and this is no doubt a limitation of scalp-recorded
EEG data. The problem then is to find measures
which extract the maximum useful information
from any given type of study. Thus, whilst simple
measures, like latency and amplitude, have
already resulted in useful clinical applications of
the early ERP components, it will probably be
necessary to incorporate more varied and detailed
time domain, frequency domain and spatio-
temporal measures before similar applications can
be found for the later components.
Surface Ripples - Depth of Information?
The enormous three-dimensional complexity of
the brain might lead one to pessimistic views
concerning the possibility of ever finding useful
ERP measures in psychiatric disorders - scalp
recordings seem rather limited two-dimensional
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315
samples of brain activity even if a large number of
electrodes are used, and even if the allegedly more
informative magnetoencephalographic detectors
(Reite et al., 1976) are used. It might be argued
that the ERP, like the EEG, can only indicate
more gross ‘neurological’ disorders.
Theoretically, it might be argued that the rather
limited bandwidth of most EEG recordings
(70 Hz) does not contain enough information to
analyse the complex processes involved. Whilst
such doubts are justified to some extent, there is
also reason to be more optimistic. First, ERP
changes reflect brain activity linked specifically to
sensory and/or cognitive processes. Hence, they
are more selective functional markers than routine
EEG recordings. Second, even though the ERP is
undoubtedly a ‘gross’ measure, it may
nevertheless reflect relevant measures of more
‘macroscopic’ levels of functional organisation in
the brain. It may be that ‘the situation (of
neurodynamics) is superficially very similar to that
which obtains in statistical mechanics, as it applies
t o the relation between macroscopic
thermodynamic quantities and the underlying
microscopic description in terms of the complete
specification of the states of all the individual
atoms or molecules . . . These are first that we
could not, even if we knew all the necessary
parameters, actually solve in detail the 1010 or
more coupled neuronal “equations of motion”
necessary to follow the state of the system in detail
as a function of time. Second, that there exists a
simpler “macroscopic” level of description which
is really our main ultimate object of interest so
that we do not wish, even if we could, to follow
the “microscopic” state in detail but merely wish
to use it to understand the time development of
the macroscopic state’ (Griffith, 1971).
Different studies (Creutzfeldt et al., 1966;
Lopes da Silva et al., 1970; Verzeano, 1973) have
demonstrated significant correlations between the
scalp-recorded gross response and the statistical
‘group’ behaviour of cortical and sub-cortical
neurons, even though individual neurons may
show unpredictable correlations. This applies
especially to ERP components associated with
higher levels of information processing.
These findings suggest, first, that potentially
meaningful relationships do exist between the
surface-recorded gross response and the
‘macroscopic’ activity of cortical and sub-cortical
neurons, and second, that single neuron and ERP
studies provide complementary information. It
would appear, therefore, that the ‘surface ripples’
of an ERP do reflect a ‘depth’ of potentially
useful information.
316 EVENT-RELATED
POTENTIALS
I N PSYCHIATRY
Selecting Suitable Experimental Tests
The choice of experimental test will obviously
depend upon the kind of ERP study being carried
out. The selection of revealing tests may be
relatively straightforward if one is merely
investigating the integrity of primary sensory
pathways: simple clicks, flashes and peripheral
nerve stimulation may be adequate to elicit useful
information. Beyond this level of testing,
however, the situation becomes more difficult.
Considering the clinically obvious disturbances
of information processing in acute mania and
schizophrenia, it might be expected that
‘neurological’-type ERP changes would also be
found in these disorders. Whilst there is some
evidence to suggest that this might be the case
(Spohn and Patterson, 1979), clinically useful
changes have not been identified’ as yet, and
cynical observers might say that if some
fundamental state or trait disturbance existed at
this level, there would have been more conclusive
evidence by now. However, simple sensory stimuli
might yet reveal clinically useful information if
more comprehensive data are acquired and if
more sophisticated techniques of analysis are
used.
The use of more complex sensory and cognitive
performance tests immediately introduces more
variables into a problem already containing many
unknowns. Yet this may be necessary to reveal the
more subtle and complex ERP changes in
psychiatric disorders. Simple stimuli may simply
fail to elicit revealing ERP changes, whereas tests
of sensory discrimination and attention, for
example, might elicit such changes, especially in
the later ERP components.
When it comes to choosing a test, the researcher
is literally faced with an open-ended number of
possibilities and, like a child in a candy store,
might find it difficult to make a choice.
Probably the most fruitful approach will be to
proceed along rational lines, such as selecting
some test in order to test hypotheses based on
established clinical facts. For example,
considering the prominence of auditory perceptual
disturbances and the evidence of difficulties in
maintaining ‘segmental sets’ in schizophrenia
(Shakow, 1962), it would seem reasonable to
design an experiment in which auditory ERPs are
recorded while the subject is engaged in
distinguishing different ‘sets’ of audition. Such a
study has been carried out by Callaway et al.
(1965) who have reported significant findings.
Unfortunately, because the field of ERP research
is still developing rapidly, studies are often not
replicated and hence produce isolated findings
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without contributing to a body of well-established
facts.
Standardisation of recording techniques,
experimental tests and methods of analysis is
clearly desirable in that it facilitates comparisons
of findings from different laboratories. However,
it seems to this author that this sort of stability will
not be attained until the newer approaches have
been explored more fully and until the origins and
genesis of these signals are better understood. New
technology and new techniques make the grass
look truly greener at the developing edges, which
tends to encourage a less orderly, although not
necessarily a less rational, or fruitful approach.
In general, it is suggested that a battery of
different tests be used in the same way that a
battery of tests is used in psychological
neuropsychiatric assessment. It may be that
relevant ERP changes will become evident only
when the results of different tests are compared.
Furthermore, such ‘screening’ may help to isolate
tests and measures which are more likely to show
relevant clinical correlations. These tests can then
be pursued at greater depth. In psychiatric studies,
it is important to include tests of cognition, such
as sensory discrimination and attention, in order
to establish profiles of ERP changes associated
with higher mental activity.
Clinical and Research Applications of ERPs
The main general areas to which ERP techniques
have been applied include the following:
evaluation of the integrity of sensory pathways:
auditory, visual, somatosensory, olfactory,
gustatory. (Olfactory and gustatory ERPs are still
largely at the experimental stage whereas the
clinical application of auditory, visual and
somatosensory ERPs has already been firmly
established);
detection and localisation of neurological lesions
and psychiatric disorders;
finding ERP correlates of pharmacological agents
and actions;
finding ERP correlates of neuroanatomical and
psychophysiological developmental stages, and
hence finding objective measures for neurometric
assessment of developmentalAearning disorders;
genetic studies which may reveal genetic identity
of ERP components and may help to isolate
genetic markers for various neuropsychiatric
disorders;
general psychophysiological studies which seek to
find electrophysiological correlates of higher
mental activity.
It will readily be appreciated that there may be
 H.G . STAMPFER
considerable overlap of interest between the
separate areas listed above.
Specific applications of ERP techniques within
each of these broad areas are too numerous to be
listed here and for practical purposes are limited
only by the interest of different researchers in the
many and various problems subsumed, for
example under ‘learning disabilities’ or ‘detection
and localisation of neurological lesions’.
The most firmly established applications in
current medical practice include the evaluation of
sensory pathways and the detection of
neurological lesions. One of the advantages of
using ERP techniques is that they do not require a
cooperative subject and, hence, may be
particularly useful in testing young children and
adults who are unable to cooperate for various
reasons, e.g. because of dissociative reactions and
stuporous states. Some psychiatrists might think
that even if these tests are of clinical value, they
would be used more by neurologists than
psychiatrists. This, of course, depends upon the
interest and attitude of the psychiatrist who may,
for example, think it worth while to measure
ERPs in dissociative reactions even if he has made
a firm diagnosis on clinical grounds and even if it
seems unlikely that there exists any underlying
organic disorder. Such tests may reveal
unsuspected brain lesions and may also help to
answer questions as to whether dissociative
reactions are associated with demonstrable
physiological changes that cannot be ‘faked’ by
normal people (Levy and Mushin, 1973). Such
findings would add new insights to notions of
‘psychological’ defence mechanisms and altered
or alternate states of consciousness in general, e.g.
hypnosis, catatonia, depressive stupor.
ERP techniques occupy a prominent place in
the field of neurometrics where researchers are
rapidly establishing the clinical usefulness of ERP
and other electrophysiological techniques. The
interested reader is strongly advised to read the
work of John et al. (1977) who found that ‘a
remarkable feature of these findings (ERP studies)
is that information processing in children with a
particular type of learning disability seems to
reflect a general operational defect, independent
of the specific information content of the input,
revealed as a distinctive spatiotemporal pattern’.
Such objective measures would have obvious
value in child and adult psychiatry and may help
to overcome the cultural limitations of
psychometric tests. These workers concluded that
‘neurometric methods may serve to provide
criteria for the efficacy of interventions, whether
pharmacological or behavioural, in a wide variety
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317
of diseases and dysfunctions, including
neurological disease, senile deterioration, learning
disability, psychosis, mental retardation, drug
addiction and malnutrition. The amount of
damage and rate of recovery from perinatal
trauma, head injury and stroke may be
quantitatively evaluated and followed by
neurometrics’.
The hope of many psychiatric researchers in the
field is that objective measures of mental illness
will be found, especially in affective and
schizophrenic disorders. Such measures may or
may not correlate with existing descriptive/
phenomenological classifications, but may
provide more useful criteria for general and sub-
classifications; more useful in the sense that they
may help to distinguish more fundamentally
relevant pathological groupings which, in turn,
may permit a more objective approach to the
selection of medication; to the evaluation of
various methods of treatment, and for the
selection of subjects for various research
enterprises.
It should be emphasised that ERP techniques,
even when more fully developed, will no doubt
remain one among many different tests used to
evaluate brain function, but as such will hopefully
make a valuable contribution.
The extent to which both established and
potential applications of ERPs will find a place in
psychiatry will clearly depend upon what
psychiatrists deem to be the province of their
specialty and upon what emphasis they give to
different aspects within this province, and
psychiatrists often find it difficult to achieve clear
consensus on such questions. It is suggested that
psychiatrists should not avoid a more active
interest and involvement in rapidly developing
techniques which can increase our understanding
of brain function and behaviour. ERPs in general
constitute one such technique. It has often been
said that the brain represents the last frontier of
human enquiry and as such would seem to occupy
a central position in the specialty of psychiatry.
ERPs can be construed as phenomena at the
interface between microscopic electrochemical
activity and macroscopic behaviour, and should
therefore be particularly interesting t o
psychiatrists.
Acknowledgements
Special thanks are given to Professor G. A.
German, whose helpful comments and criticism
were greatly appreciated. Special thanks are also
given to Professor G. Fenton, D. S. Brown and D.
F. Isele, whose thought-provoking contributions
318 EVENT-RELATED IN PSYCHIATRY
POTENTIALS
to our discussions about evoked potentials were
much appreciated.
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H. G. STAMPFER, MA.. B.s., F.R.A.N.Z.C.P.
Lecturer,
University Department of Psychiatry,
Queen Elizabeth I1 Medical Centre,
Shenton Park,
Perth, Western Australia 6009.