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Shock treatment, brain damage, and memory loss: a neurological perspective
Abstract
The author reviews reports of neuropathology resulting from electroconvulsive therapy in experimental animals and humans. Although findings of petechial hemorrhage, gliosis, and neuronal loss were well established in the decade following the introduction of ECT, they have been generally ignored since then. ECT produces characteristic EEG changes and severe retrograde amnesia, as well as other more subtle effects on memory and learning. The author concludes that ECT results in brain disease and questions whether doctors should offer brain damage to their patients.
... While in previous cases symptoms tended to appear in the immediate postictal period (Leniel and Crovitz 1987; Squire 1977 ), in our case, the symptoms appeared 48 hours after treatment, making a causal relationship less convincing. One possible explanation for the delay in the appearance of clinical symptoms is that the memory disturbances displayed here were related to minor brain damage which had developed slowly, causing the clinical symptoms to appear after a period of time (Friedberg 1977). The normal results of CT, eye fundus, LP, other laboratory tests, and the normal neurological examination, ruled out the possibility of anatomic brain injury. ...
... However, none of these tests can definitely exclude brain damage, and only MRI or PET scan can exclude organic brain injury at such an early stage. EEG abnormalities are frequent among patients who have undergone ECT and, as in the case of our patient, these disorders are probably of a functional nature only (Friedberg 1977). ...
Memory-related effects of electroconvulsive therapy (ECT) are known to appear immediately after the treatment. The case of a 39-year-old woman who underwent a course of ECT because of a recurrent major depressive disorder is described. After a symptom-free period of 48 hours, transient amnesia developed. Her condition appeared to be associated with the electroconvulsive therapy, thereby raising questions about its pathogenicity and management.
... Frank, 1990;Kempker, 2000;Andre, 2009) and by social and medical scientists (cf. Friedberg, 1977;Breggin, 1979;Rufer, 1992aRufer, , 2007Lehmann, 2017Lehmann, , 2020Lehmann, , 2022cNewnes, 2018;Robertson & Pryor, 2018;Zinkler et al., 2018). Nor the traumatising long-term effects and despairing states ending in suicidality after electroshocks admitted by the industry, specifically in US instruction manuals by the manufacturer Somatics. ...
Internationally, psychiatrists are increasingly administering electroshocks: in psychiatric hospitals, especially university clinics, and occasionally on an outpatient basis in psychiatric practices. "Referrers" in private practice or in clinics see to it that patients are referred to facilities with electroshock apparatus ready for use. Yet electroshock as a psychiatric treatment measure is highly controversial. Patients, relatives, medical professionals, journalists and lawyers – all want to know: How do electroshocks work? When and to whom do they administer electroshocks? What risks and damages do manufacturers admit to? How did electroshocks come into the world? How are electroshocks administered today? Are there no alternatives to electroshocks? How are patients, relatives and the medical staff informed about the risks of treatment? What responsibility does the manufacturer take for potential damage? The author gives concise answers to short questions. In: Journal of Critical Psychology, Counselling and Psychotherapy (Lancaster)
... Although ECT is an effective treatment for patients with the most severe and treatmentresistant psychiatric disorders, it is has been regarded by some as controversial or stigmatizing, mainly due to misconceptions about how modern ECT is administered, its efficacy, and an exaggerated view of side effects. Misconceptions regarding the clinical conduct of ECT include that it is not effective, or rather works by inducing forgetfulness, or that it leads to brain damage, or that ECT is administered without informed consent [6][7][8][9]. These misconceptions are also reflected in the public opinion [8,10]. ...
Introduction:
Controversy surrounding ECT creates skepticism about the ethics of conducting ECT research. This paper discusses the ethical conduct of clinical research and then focus on the ethics as applied to ECT.
Methods:
PubMed was searched for articles related to the ethical conduct of research and that of ECT research published in English.
Results:
ECT research is ethically justified and should always continue to be conducted with the highest ethical standards. ECT research entails few ethical peculiarities such as involving multiple sessions were capacity to consent can change. It would be unethical not to conduct ECT research.
Conclusion:
ECT research must be based on sound hypotheses in the presence of a clinical equipoise in well-designed studies. ECT studies must select a fair and non-biased sample of participants. It is important that participants represent the broad population of the people that would be receiving ECT for that specific indication. ECT research is ethical; and more research in this field could help decrease stigma and barriers to treatment, and/or reduce side effects and improve efficacy of a potentially life-saving intervention.
... [17] EKT'de ciddi morbidite ve mortalite nadir olmakla birlikte; kalp-damar bozuklukları, oluşmamış, uzamış, gecikmiş ya da yetersiz nöbet, bellek sorunları, kas ağrıları, sağaltımın neden olduğu mani ve konfüzyon, nöbet içi ya da nöbet sonrası deliryum en sık rastlanan yan etkiler olarak sayılabilir. [18,19] EKT'nin beyin hasarına yol açtığı günümüze kadar gösterilememiştir. [20,21] EKT uygulamalarının erken dönemlerinde önemli olanın nöbet oluşturulması olduğu, elektriksel uyarının parametrelerinin klinik duruma etki etmediği yaygın bir düşünceydi. ...
Effects and side effects of electroconvulsive therapy have been a subject of debate since the begininng of its use to treat psychiatric disorders. As its antidepressant mechanism of action have been topic of many researches, many valuable findings were obtained ever since. However, methodological differences and different application protocols limited the accumulation of scientific data. Anticonvulsant effect and elevation of seizure threshold have been taken as outcome measures in many researches although it is still controversial. Some variables of treated disorders also may have affected researches. The aim of this article was to investigate current literature regarding application protocols and mechanism of action of electroconvulsive therapy.
... Although ECT is an effective treatment for patients with the most severe and treatment-resistant psychiatric disorders, it is has been regarded by some as controversial or stigmatizing, mainly due to misconceptions about how modern ECT is administered, its efficacy, and an exaggerated view of side effects. Misconceptions regarding the clinical conduct of ECT include that it is not effective, or rather works by inducing forgetfulness, or that it leads to brain damage, or that ECT is administered without informed consent [6][7][8][9]. These misconceptions are also reflected in the public opinion [8,10]. ...
Introduction: Controversy surrounding ECT creates skepticism about the ethics of conducting ECT research. This paper discusses the ethical conduct of clinical research and then focus on the ethics as applied to ECT.
... ECT is considered the most effective treatment for medication-resistant depression (American Psychiatric Association, 2001). It continues to hold this status in psychiatry even though the damage to the brain and the memory loss have been researched and documented for decades (Breggin, 1998;Calloway, Dolan, Jacoby, & Levy, 1981;Donahue, 2000;Frank, 1990;Friedberg, 1977;Sackeim et al., 2007). Shortly after the ECT course, most patients manifest deficits in retaining newly learned information (anterograde amnesia) and recalling events that occurred in the weeks or months preceding the ECT course (retrograde amnesia; Sackeim et al., 2007). ...
This article reviews historical and current examples of harmful and forced treatments as well as scientific discrimination that have been applied to people diagnosed with mental illness. It discusses anti-psychiatric social action in North America from 1970 to the present. A review of social work's foundations in social justice, empowerment, and person-in-the-environment perspectives highlights the congruencies and communal benefits for both the social work profession and psychiatric-survivor movements. Through this discussion, it is apparent that the professed values of the social work profession are actually more compatible with psychiatric-survivor movements than with any allegiances to the biomedical model of psychiatry.
... Despite this evidence, shock promoters including the Canadian Psychiatric Association and American Psychiatric Association irresponsibly minimize permanent memory loss as a "side effect" or "transient". In a recent position paper, the Canadian Psychiatric Association greatly minimized permanent memory loss claming "a small minority of patients… [have] subjective complaints" and flatly denied brain damage--" [ECT] causes no detectable evidence of irreversible structural brain damage" (Enns & Reiss, 2001) However, in the United States and Ireland, several physicians have publicly called for a ban on electroshock and severely criticized its continued use (Friedberg, 1977;Breggin, 1997;Breeding, 2001;Sterling, 2002;Corry 2008). In sharp contrast, Canadian psychiatrists continue to fraudulently promote 'ECT' as a "safe and effective" or "lifesaving" treatment for depression. ...
... • loss of artistic, musical or creative ability • brain damage (Breggin,1997(Breggin, , 1998Frank,1990Frank, , 2006Friedberg, 1976Friedberg, ,1977Sackeim et al, 2007) ...
... C oncerned professionals and critics of electroconvulsive therapy (ECT) have argued that ECT is causing brain damage. [1][2][3][4] Since the past 2 decades, new evidence for brain plasticity 5 has caused a shift in both preclinical and clinical ECT research from falsifying the "brain damage hypothesis" 6-10 toward exploring ECT's enabling brain (neuro)plasticity effects. ...
Since the past 2 decades, new evidence for brain plasticity has caused a shift in both preclinical and clinical ECT research from falsifying the "brain damage hypothesis" toward exploring ECT's enabling brain (neuro)plasticity effects.
By reviewing the available animal and human literature, we examined the theory that seizure-induced structural changes are crucial for the therapeutic efficacy of ECT.
Both animal and human studies suggest electroconvulsive stimulation/electroconvulsive therapy (ECT)-related neuroplasticity (neurogenesis, synaptogenesis, angiogenesis, or gliogenesis).
It remains unclear whether structural changes might explain the therapeutic efficacy and/or be related to the (transient) learning and memory impairment after ECT. Methods to assess in vivo brain plasticity of patients treated with ECT will be of particular importance for future longitudinal studies to give support to the currently available correlational data.
... The relationship between the amnesic and therapeutic effects has long been a source of controversy. One class of theories has suggested that patients appear to be clinically improved after ECT because they have a global amnesic syndrome and other cognitive side effects (Breggin, 1979;Friedberg, 1977;Miller, 1967). For instance, it has been claimed that manifestation of a "punch drunk," acute confusional state makes patients appear less depressed. ...
An Autobiographical Memory Interview (AMI) was administered to 75 depressed inpatients and 16 nondepressed controls. Patients were randomized to 1 of 4 forms of electroconvulsive therapy (ECT) that varied in electrode placement and stimulus intensity. Short-term retrograde amnesia was assessed during the week following the randomized phase. Bilateral ECT produced more marked deficits than right unilateral ECT. At a 2-mo follow-up, persistent amnesic deficits were related to having received a second ECT course and, to a lesser extent, bilateral ECT during the randomized phase. The magnitude of clinical improvement was not associated with amnesia scores at either time point. There were no differential amnesic effects as a function of the affective valence of memories. It appears that retrograde amnesia for autobiographical information after ECT and mood congruence effects on recall are independent phenomena. The magnitude and persistence of retrograde amnesia is related to how ECT is performed and not to changes in clinical state or the affective valence of memories. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
... The energy model also predicts that adding energy to the field will distort the structure of awareness to a degree dependent on the amount of energy added. We can see this with electrical stimulation such as that used in electroconvulsive therapy, which at low levels causes conscious sensations, at higher levels seizures, unconsciousness and amnesia (Friedberg, 1977). Incidentally, similar interference occurs when energy is transferred to the skull and brain by a blow on the head. ...
Much of neuroscience is currently dominated by an information processing metaphor which is largely conceptualized in discrete terms. An alternative metaphor conceptualizes information flow as continuous. A qualitative set of hypotheses based on this metaphor, the energy model, is described here. This model considers information transfer in terms of the flow of an abstract variable, energy, between points in a field comprising the extent of the nervous system. Although extremely simple, it generates some intriguing consequences. In particular, it provides a useful way in which to look at consciousness. Traditional problems of consciousness, such as qualia and the unity of consciousness, are briefly addressed, and outlines are sketched of the answers given by the energy model.
... But we might well ask ourselves whether we, as doctors sworn to the Hippocratic Oath, should be offering it. (Friedberg, 1977(Friedberg, , p.1013 These sentiments have been strongly echoed by service users: 'It is not justifiable to give people something that harms their brains and gives them an epileptic fit on the NHS. ...
... Evidence that the adverse effects of ECT are not imaginary or subjective' is provided by studies documenting brain damage (Breggin, 1984;Frank, 1978;Friedberg, 1976;1977;Sterling 2000). In what is best described as a diatribe against "the old myth about ECT and brain damage" Shorter & Healy (2007) cite (amid studies of convulsive therapies prior to ECT or of ECT on animals) just one human ECT study (Coffey et al., 1991). ...
To review the literature on the efficacy of electroconvulsive therapy [ECT], with a particular focus on depression, its primary target group.
PsycINFO, Medline, previous reviews and meta-analyses were searched in an attempt to identify all studies comparing ECT with simulated-ECT [SECT].
These placebo controlled studies show minimal support for effectiveness with either depression or 'schizophrenia' during the course of treatment (i.e., only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group, of any benefits beyond the treatment period. There are no placebo-controlled studies evaluating the hypothesis that ECT prevents suicide, and no robust evidence from other kinds of studies to support the hypothesis.
Given the strong evidence (summarised here) of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.
Enlistment of brain (cerebrum) signals can be arranged by a few techniques, for example, invasive and non-invasive. On the off chance that the biosensor is inserted in the cerebrum, at that point, the invasive procedure, has the advantage of high-frequency parts will estimate clearly and exact, yet because of wellbeing dangers and a few moral angles, they are essentially utilized in animal experimentations. If there should arise an occurrence of non-invasive technique, the surface electrodes are made available at the outer portion of the cerebrum, as per 5 to 15 global norms and standards. This application technique is substantially more likely utilized on people (human beings) since it doesn’t jeopardize them because of the implantation, however, it has the detriment, that the deliberate signals are noisier. This noisy signal can be removed by using a digital filter, named: Finite Impulse Response (FIR). In the previous years, a few electroencephalography headsets have been created not just for clinical use, which is worked from own batteries to guarantee versatile use. Presently some across the board Electroencephalography headsets are being presented, which are additionally reasonable for accomplishing one of a kind created Brain-Computer Interface. This kind of Headsets can be developed with the architecture of the Internet of Robotic Things (IoRT), where it can analyse the incoming electroencephalographic signals for corresponding actions of human beings. These recordings can be sent to the remote area and stored in the server through Bluetooth or Wi-fi mediums using the Gateway.
Magnetic brain stimulation used as a method of psychological interventions in the treatment of diseases. This method functions used in the treatment of clinical disorder such as speech and movement disorders caused by stroke, tinnitus, Parkinson's disease, nervous tics. Applications in the field of psychological therapy, it is possible to stimulate specific brain area involved in certain mental illnesses including schizophrenia. Proven scientific results based on magnetic stimulation of the brain showed: this way, cure diseases such as addiction, depression, bipolar disorder, obsessive-compulsive disorder. On the other hand, this method is one of the ways of studying the brain function. In the method by the law of electromagnetic induction, induced currents varying shapes and winding, in the brain. The advantage of this method is that brain stimulation has the least pain and discomfort. Magnetic stimulation of the brain in terms of pulse split into three categories: single pulse, pulse magnetic stimulation pair repeatedly. Research has shown the procedure to increase or reduce brain excitability and plasticity. It also has a significant effect in the treatment of mental illness.
The current book chapter deals with a thorough literature survey on different Internet-of-Things applications. These applications are mainly dealing with acquisition and processing of electroencephalogram signals. The chapter starts with giving a thorough idea about how these signals can be acquired and what are the signal parameters needed to be measured for successful implementation of electroencephalography based human-computer interactive devices. Then the chapter focuses on different feature extraction methods for the signals. Lastly, the chapter gives a thorough understanding of different application domains related to brain-computer interfacing.
In the decade or so after the introduction of electroconvulsive therapy (ECT), scattered reports of neuropathological changes found among people who died after treatment began to appear. Such reports, combined with laboratory studies purporting to show neurological damage in experimental animals and the demonstration of memory changes (particularly retrograde amnesia) after ECT treatment, have suggested to some that ECT must somehow result in physical damage to the brain. Although such concerns still appear to influence popular attitudes toward ECT, use of modern technique does not appear to be commonly associated with any evidence of central nervous system damage.
Die EKT stellt weltweit eine sehr sichere, hochwirksame und relativ nebenwirkungsarme Behandlung bei schweren psychischen Erkrankungen dar. Trotzdem wird sie außerhalb eines engen Kreises von psychiatrischen Fachkollegen und Betroffenen häufig als überkommen angesehen und mit Zwangsmaßnahmen assoziiert. Irrationale Vorbehalte verhindern den evidenzbasierten Einsatz. Tatsächlich hat sich die EKT durch kontinuierliche Innovationen zu einer modernen medizinischen Maßnahme entwickelt. Sie sollte deshalb als selbstverständlicher Bestandteil der psychiatrischen Versorgung integriert werden. In den deutschsprachigen Ländern nimmt die Akzeptanz der Methode in den letzten Jahrzehnten allmählich zu. Steigende Behandlungszahlen machen deutlich, dass Ärzte und Patienten sich zunehmend von ideologischen Barrieren befreien. Ziel ist es, die Kontroverse um die EKT darzustellen, Erklärungsmodelle anzubieten und Strategien aufzuzeigen, um die Verzerrungen in der öffentlichen Wahrnehmung zu korrigieren.
The electroconvulsive therapy (ECT) probably just from beginning of its clinical applying provokes numerous fears and oppositions - both part of medical milieu, as and of the public opinion. These are connected with potential side effects - mainly cognitive nature. Not to overestimating are also irrational apprehensions before image of current passing by a patient's head, that it has executed convulsions in time of ECT treatment without of drug modification. The paper presents cardinal objections and reason of controversies what the electroconvulsive treatment arouse up to today. The effectiveness, as also the safety, of electroconvulsive therapy are the most important counterargument.
Migraine with aura is considered as an etiologic factor in ischemic cerebrovascular disorders. While, intracerebral hemorrhage occurs in rare instances during or after migraine attack. A thirty-four year-old female patient has migraine without aura for ten years with a frequency of 3-4 attacks monthly. She underwent electroconvulsive therapy for seven times in the psychiatry department because of obsessive-compulsive disorder a week ago. Following a migraine attack a left hemiparesis syndrome occurred, and computed tomography, which was performed at the same day, revealed a right parietal lobar hematoma. In this paper, lobar hemorrhage in a young patient and its etiologic causes in relation to migraine and/or electroconvulsive therapy were discussed.
When properly administered for appropriate indications, electroconvulsive therapy (ECT) is a safe and effective treatment for several severe mental disorders. Nonetheless, ECT is referred to as the “controversial” treatment and is subjected to regulatory legislation and even banning unheard of for other standard treatments. Histories of clinical practice, litigation, cinematic portrayal of ECT, popular and professional literature, and antipsychiatric ideologies that contributed to visceral misperceptions of ECT and the perceived need for increased legal regulation are briefly summarized. The practice of ECT has been affected not only by negative imagery, but also by a passionate anti-ECT movement, the ultimate goal of which is to abolish the use of ECT altogether. After a capsular history of ECT legislation, a more extensive account of the extreme regulatory law in Texas is explained. This is followed by the more moderate and typical approach of Missouri. Rational approaches to ECT legislation would include (a) providing no more statutory regulation than is applied to treatments with comparable risks and benefits and (b) ensuring that any legislation provides adequate informed consent based on fact and reason and protects the patient's autonomy rights as is done for psychotropic medication, while it supports availability of ECT for individuals who would benefit. Paracelsus said the difference between a medicine and a poison is the dose. ECT, like other modern treatments, is safe and effective when used properly.
Electroconvulsive therapy is the most effective treatment for endogenous depression. Possible adverse effects include confusion, memory loss, headache, hypotension, and tachycardia. We describe a 22-year-old woman treated for unconsciousness four hours after electroconvulsive therapy. She had no history of recent head trauma, hypertension or cerebrovascular symptoms. Complete blood count, platelet count, prothrombin and partial thromboplastin time were normal. Multiple intracerebral hemorrhages were seen on computed tomography. This unusual finding has not been reported previously.
Despite misgivings, ECT is a highly effective treatment for refractory depression, severe mania, some acute psychotic illnesses, and catatonic conditions.
Concern remains among many that electroconvulsive therapy (ECT) causes "brain damage." This ambiguous term presumably refers to lesions that could, in principle, be observed either grossly or microscopically in postmortem studies, and the assertion that it occurs appears to be based largely on old reports with dubious relevance to modern practice. Fortunately, using modern technique, ECT is so safe that mortality around the time of treatment is extraordinarily rare and as a result there has been little opportunity for postmortem examination of individuals who had recently had ECT. We report a case in which postmortem brain examination was performed roughly a month after the patient's last treatment.
toabstract thinking and judgment. The ECT-induced persistent brain dysfunction was global. In addition to the loss of autobiographical memories, the most marked cognitive injury occurred in “retention of newly learned information,” “simple reaction time,” and most tragically, “global cognitive status” or overall mental function. In other words, the patients continued to have trouble learning and remembering new things, they were slower intheir mental reaction times, and they were mentally impaired across a broad range of faculties. Probably to disguise the wide swath of devastation, the Sackeim study did not provide the percentages of patients affl icted with persistent cognitive defi cits; but all of the mul- tiple tests were highly significant (p< .0001 on 10 of 11 tests and p< .003 on the 11th). Also, the individual measures correlated with each other. This statistical data indicates that a large percentage of patients were significantly impaired.
Initially, this paper briefly introduces the work of my colleague, Nina Farhi, who was a highly respected psychoanalytic psychotherapist in London and who sadly died last year. After her death, I was invited to discuss both her paper, “The Hands of the Living God,” and the three commentaries by North American analysts, all published in this issue. As part of my commentary, I provide an appreciative yet critical discussion of the way Farhi uses the term “intersubjectivity.” I argue that there is a need for paternal function or a third position to be found in the mind of the analyst in the later phases of work with deeply disturbed patients. I also contribute to the hypothetical debate about whether or not experiences in the womb can be subject to analytic work, using the Lacanian concept of the “Real” and Piontelli's work on fetal and child observation. After this, I explore some of the ways Lacan revised drive theory and discuss these in relation to psychic devolution in later life, essential aloneness and creative human destiny. Finally, I look at how Farhi's paper's posthumous publication may have affected the commentary.
Electroconvulsive treatment (ECT) is increasingly used in North America and there are attempts to promote its further use world-wide. However, most controlled studies of efficacy in depression indicate that the treatment is no better than placebo with no positive effect on the rate of suicide. ECT is closed-head electrical injury, typically producing a delirium with global mental dysfunction (an acute organic brain syndrome). Significant irreversible effects from ECT are demonstrated by many studies, including: (1) Inventories of autobio- graphic and current events memories before and after ECT; (2) Retrospective subjective observations on memory; (3) Autopsy studies of animals and some of humans. ECT causes severe and irreversible brain neuropathology, including cell death. It can wipe out vast amounts of retrograde memory while producing permanent cognitive dysfunction. Contemporary ECT is more dangerous since the current doses are larger than those employed in earlier clinical and research studies. Elderly women, an especially vulnerable group, are becoming the most common target of ECT. Because of the lopsided risk/benefit ratio, because it is fundamentally traumatic in nature, because so many of the patients are vulnerable and unable to protect themselves, and because advocates of ECT fail to provide informed consent to patients - ECT should be banned.
The rapid growth of psychotherapeutic movements in recent years has led to a free market. Vast numbers of psychotherapists of different theoretical persuasions are now on offer. While such a choice has its obvious advantages, it creates bewildering confusions in the minds of potential clients. How can the clients tell which psychotherapist or psychotherapeutic entepise to opt for? How can they know whether they have made an appropriate choice? How do they know which therapy works best under which conditions? Are there a set of criteria laid down which might guide the client in making a judicious choice? Can they be assured that after a senes of agreed sessions, they will get better? These are extremely serious issues. The paper discusses the practical and ethical implications underlying these issues and offers specific suggestions and guidelines as to how the clients might safeguard their own interests when it comes to choosing an appropriate psychotherapist.
After reaching the verge of obsolescence, electroconvulsive therapy (ECT) is once again on the increase. There remains, however, no sound theoretical basis for its use. By 1948 at least 50 different theories had been proposed to account for the workings of ECT. Today there are numerous more. Further, there is no good evidence for its therapeutic effectiveness. Although some studies show what are claimed to be positive results, others show significant amount of relapse, even with severe depression (the disorder against which ECT is supposed to be most effective), while even other studies show ECT to have little more effect than a placebo. Finally, there is much evidence for ECTs damaging effects, particularly to cognitive functioning like memory, general intelligence level, and perceptual abilities, and quite possibly to brain functioning. Some studies even suggest that the alleged therapeutic effects of ECT are essentially the effects of organic brain damage. The question, then, is why, despite these problems, does ECT continue to be used? ECTs salient features suggest an answer here. These are the features of dehumanization, power, control, punishment, and others, all of which can be traced back to the fear of deviant psychotic behavior.
Neuromodulation techniques have been part of psychiatry since the introduction of electroconvulsive therapy over 60 years
ago, but their applications remain controversial. In particular, they are disregarded for their invasiveness, risk of changing
personal identity or resemblance to early psychosurgery. Here we show that stringent ethical analyses are hampered rather
than facilitated by these concepts and issues. Instead, ethical implications of neuromodulation techniques are more productively
analyzed by use of widely shared ethical criteria that, in addition, can easily be applied to empirical evidence and thus
allow to turn from speculative, rhethoric to evidence-based ethics. This will be shown for each neuromodulation technique,
namely electroconvulsive therapy (ECT), psychiatric repetitive transcranial magnetic stimulation (rTMS) and psychiatric deep-brain
stimulation (DBS). We will argue that each neuromodulation technique has to be thoroughly assessed for its benefit, harm and
respect of the patient’s will. However, not only the application per se needs special ethical attention, but also their perception
and portrayal in the public. This analysis will prepare the ground for ethically justified, empirically comprehensive neuromodulation
in the highly vulnerable population of psychiatric patients and allow stringent future societal discussions about its legitimation.
Electroconvulsive Therapy (ECT) practitioners and anti-ECT activists have divergent interpretations of both the treatment and its history. Despite claims by ECT opponents that practitioners do not acknowledge memory side effects, the published literature on the procedure demonstrates psychiatrists' awareness of this issue. And though current ECT practitioners claim that memory side effects were mostly the result of outmoded methods, investigators continue to publish studies that indicate ongoing memory problems. This article explores the conflict between pro- and anti-ECT groups around the issue of memory side effects in the broader context of changes in American psychiatry and society.
Electroconvulsive therapy (ECT) is becoming primarily a tool for treating major depressive illness, where there is substantial evidence for its success. The use of ECT to treat schizophrenia, mania and other conditions has markedly decreased, reflecting the development of effective drug treatment. Recommended indications for ECT are suicidal patients and those who refuse to eat or who are otherwise seriously disturbed or unmanageable. ECT is also indicated when chemotherapy has or is likely to fail or is contraindicated because of cardiac difficulties or pregnancy. ECT compares favorably with chemotherapy in terms of safety and effectiveness. The only absolute contraindication is raised intracranial pressure. Unilateral electrode placement using brief pulse current minimizes post treatment confusion and memory impairment.
Objective: The aim of this study was to determine the frequency of ECT use, the features of patients who underwent ECT treatment, short term treatment response to ECT, differences in efficacy and complications between modified and unmodified ECT, and the rate of complications among inpatients in a university hospital setting in-between 1990 to 2001. Method: Three hundred eighty four patients (183 men, 201 women) who had been hospitalized in Cukurova University Faculty of Medicine Psychiatry Service between 1990 and 2001 and received ECT were included in the study. The sociodemographic features, DSM diagnosis, ECT indications, the features of ECT course, complications and clinical response rate were recorded and evaluated. Results: During a 12 year period, 14.4% of inpatients received ECT as a part of their treatment. Among these patients 44.8% were treated with a diagnosis of psychotic disorder, whereas 49% treated for affective disorder and 6.3% for other diagnoses. Patients received an average of 7.8 bilateral ECT treatment and 82.3% of them showed moderate to marked improvement after ECT treatment. There were no differences between responders and non-responders to ECT with regards to age, sex, number and type of ECT treatment, hospitalization period and complication rate. Only variable showing significant difference was the presence of an axis II disorder. Forty six percent of patients developed a complication as a result of ECT. The most common complications observed were memory disturbances and confusion, all of which disappeared three weeks after the last round of ECT. Discussion and Conclusion: The results of this study confirmed the results of previous studies indicating the short term-efficacy, safety and reliability of ECT among psychiatric patients in all age groups.
Computerized tomography (CT) is a new neuroradiologic tool that is an extremely sensitive and noninvasive procedure for investigating many neurologic disorders. Essentially, it measures alterations in tissue density and associated displacement and distortion. It is extremely sensitive in detecting hemorrhage and edema, the two pathologic changes most often ascribed to ECT. The administration of 10 ECTs over 45 minutes to a suicidal patient afforded the opportunity to perform a CT scan before and after ECT in a clinical situation that would be particularly likely to produce an abnormality if such changes were common after ECT. The absence of any CT changes following administration of multiple ECT to a patient who demonstrated the typical post-ECT amnestic syndrome suggests that the basis of the amnestic-confusional syndrome depends on functional subcellular or synaptic changes, and that ECT does not produce hemorrhages or edema in the brain.
Despite widespread belief that violence begets violence, methodological problems substantially restrict knowledge of the long-term
consequences of childhood victimization. Empirical evidence for this cycle of violence has been examined. Findings from a
cohort study show that being abused or neglected as a child increases one's risk for delinquency, adult criminal behavior,
and violent criminal behavior. However, the majority of abused and neglected children do not become delinquent, criminal,
or violent. Caveats in interpreting these findings and their implications are discussed in this article.
Although the safety and efficacy of electroconvulsive therapy (ECT) is acknowledged by most, concern has repeatedly been expressed that the treatment may have some lasting effects on the brain. To study potential morphological changes, 22 patients with a history of ECT were submitted to a detailed clinical evaluation and a brain CT scan examination. Age- and sex-matched control subjects comprised a group of comparable patients, none of whom had received ECT, and a second control group of healthy volunteers. Patients had larger ventricle/brain ratios and cortical "atrophy" scores than normal controls, but no association was found between these radiological measures and a previous history of ECT. Hence, the present data are consistent with recent reports that affective disorders may be associated with enlarged brain ventricles, although the clinical significance of such findings remains unclear. In line with previous investigations age correlated significantly with cortical "atrophy" scores and ventricle/brain ratios for all subjects. Statistical tests of correlations between duration of illness, previous psychotropic drug exposure and CT scan appearances were mainly inconclusive.
Synopsis
Using computed tomography, lateral ventricular size was studied in a sample of 112 institutionalized chronic schizophrenic patients (selected from 510 cases to investigate the correlates of the defect state and intellectual decline and the effects of insulin, electroconvulsive and neuroleptic treatment), and compared with matched groups of non-institutionalized schizophrenics, patients with first schizophrenic episodes, institutionalized and non-institutionalized patients with primary affective disorder, and neurotic out-patients. Age was significantly correlated ( P < 0·0002) with lateral ventricular size, but the institutionalized schizophrenic patients had significantly larger ( P < 0·025) lateral ventricles than the neurotics when age was taken into account. Ventricular enlargement was unrelated to past physical treatment (neuroleptics, insulin coma and electroconvulsive therapy).
Within the group of institutionalized schizophrenic patients few correlates of ventricular enlargement were identified; thus in this population increased ventricular size was not clearly associated with the features of the defect state (negative symptoms and intellectual impairment). however, there was a curvilinear (inverted-U) relationship between intellectual function and ventricular size was significantly related to absence of hallucinations, impairment of social behaviour, inactivity and the presence of abnormal involuntary movements.
The findings confirm that structural brain changes do occur in chronic schizophrenia, but illustrate some of the difficulties in elucidating the clinical significance of ventricular enlargement. Lateral not bimodal; the relationship to particular features of the disease is complex and likely to emerge only in studies with a large sample size.
This report documents a unique case, in which over 1,250 ECTs produced no observable gross or histological sign of brain damage. The patient was an 89 year-old female with chronic psychiatric illness; neuropathological examination revealed a healthy CNS, in spit of the massive ECT exposure, and there was no sign of oxygen deficiency in spite of numerous, repeated anaesthesia inductions and seizures for each of the many courses of treatment.
The main contention of this paper is that some of the transient side-effects of electroconvulsive therapy on human memory resemble, in kind if not in degree, those more severe and chronic learning defects that are known to appear as an incidental result of temporal lobectomy in man. If this claim can plausibly be supported it would imply a pressing need for the more systematic study of other modes of therapeutically effective ECT that would interfere as little as possible with the normal activity of those parts of the human brain that are essential for adequate learning and memory function.
Prolonged electroencephalographic seizures were induced by the intravenous injection of bicuculline (0.5 to 1.4 mg/kg) in adolescent Papio papio, while they were paralyzed and artificially ventilated on air or oxygen. Physiological monitoring revealed an initial increase in cerebral blood flow. Arterial oxygen tension remained steady or decreased slightly. Rectal temperature rose, but did not exceed 40.0 C.
Electroconvulsive therapy is a complex treatment which involves at least three factors: (1) introduction of a quantity of electrical current into the brain; (2) rapidly induced loss of consciousness, and (3) motor convulsion. It is the aim of this study to determine experimentally the extent to which each of these components contributes to the therapeutic effectiveness of the over-all treatment. Although ECT is extensively used in the treatment of the mentally ill, it has never been firmly established whether it is the electrical current itself, or the motor convulsion, or the resulting unconsciousness which is the major therapeutic factor of the treatment; or whether the entire treatment complex is necessary.
The literature abounds in statistical and case reports comparing various forms of shock treatment, but few controlled studies have been done, especially with regard to the specific aim of this investigation (i. e., to determine the therapeutic efficacy of certain
Daily electrical stimulation of the amygdala in Senegalese baboons (Papio papio) resulted in the development of generalized convulsive seizures focal onset through five distinct clinical stages in an average of 72 days. The chronologic pattern of electroclinical features suggested that vertical intrahemispheric ictal dissemination was of primary importance in the progressive seizure development. Some animals developed spontaneous recurrence of both partial complex and primary generalized seizures. The kindling preparation in P. papio represents a unique model of human epilepsy with its secondary generalized convulsive seizure development, spontaneously recurrent partial and primary generalized seizures in the background of predisposed epileptogenic susceptibility.
Epileptic seizures were induced in 13 adolescent baboons (Papio papio and P. cynocephalus) by the intravenous administration of allylglycine (350 to 630 mg/kg body weight). In 8 animals the seizures were brief, recurred 6 to 63 times in 2 to 11 hr and were followed by neurological recovery. In 5 animals a period of status epilepticus supervened. Recurrent seizures were associated with progressive hypoglycemia. Status epilepticus produced hyperpyrexia. Cerebral pathology was studied after peraortic perfusion fixation of the brain. Sequences of 6 to 26 seizures occurred without any pathological sequelae. Short survivals (usually following status epilepticus) were associated with the appearance of ischemic cell change selectively in neurons of the hippocampus (h 1 and h 3 to h 5) and neocortex (pyramidal neurons of the third and fifth layers). Long survivals (7 to 42 days) were associated with neuronal loss and gliosis in the vulnerable regions of the hippocampus. These lesions apparently correspond to an early stage in the development of Ammon's horn sclerosis (mesial temporal sclerosis).
Verbal and nonverbal memorization skills were tested before and after electroconvulsive shocks to the left, right, or both
cerebral hemispheres of neurologically normal patients. As predicted, decrements for the left-hemisphere—shocked group were
larger on the verbal than nonverbal tasks, while the reverse was true for the right-hemisphere—shocked group. Largest decrements
on both tasks were shown by the bilaterally shocked group.
In this study it has been demonstrated that under environmental conditions wherein opportunity for activity was available there is an improvement in the social performance of chronic schizophrenic patients treated with ECT, nonconvulsive stimulation under Pentothal, and Pentothal alone. The improvement does not vary significantly with the various types of treatment. ECT was the most difficult treatment to give owing to the apprehension shown by the patients. Although there was a change in all the social qualities discussed this was significant only as regards the increase in activity of the patients both actively and passively and in the interest the staff felt they showed in their environment. Three patients who were incontinent of feces became continent. The only significant change in the patients' psychosis was that all 30 were demonstrably hallucinating at the end of the experiment. It is felt that this may well be an indirect effect of the treatment in that the patients were participating more in a r...
Two cases have been described in which irreversible histological changes in the brain may have been caused by preceding heavy electro-convulsive treatment. The changes consisted mainly of a proliferation of the marginal glia and of the glia of the white matter. They were thus similar to the pathological lesions known to occur in idiopathic epilepsy but they were not accompanied by loss of nerve cells in the cornu Ammonis or in the cerebellar cortex.
The changes were mild in spite of an unusually heavy shock treatment. It is emphasized that even such slight changes are by no means common after this form of tretment.
1. The brains of 4 patients who died following electroshock treatment were studied. 2. A massive intraventricular hemorrhage was found in one. The other 3 had petechial hemorrhages, particularly in the periaqueductal gray matter and brainstem. 3. Only 1 case could be considered a cerebral death, the other 3 dying of cardiac failure. 4. The literature on animal experiments and reports on human beings are reviewed and discussed. 5. If the individual being treated is well physically, most of the neuropathological changes are reversible. If, on the other hand, the patient has cardiac, vascular, or renal disease, the cerebral changes, chiefly vascular, may be permanent.
A recent court case (16) exposed many of the problems that confront the psychiatrist called upon to perform electroplexy.
In particular it revealed that in 1957, nearly 20 years after E.C.T. had first been used for the treatment of mental disorder, no uniform technique had yet been evolved. The medical witnesses were unable to agree on the use of muscle relaxants or mechanical restraint, but were agreed that there were certain risks attendant upon the use of electroplexy, especially the risk of fractures and the risk to life. It was argued that had the plaintiff received a relaxant drug he might not have sustained bilateral acetabular fractures, but might have suffered an even worse disaster, namely death.
Four fatalities are reviewed: 1. Cerebral hemorrhage, 2. Coronary occlusion, 3. Aspiration pneumonia and 4. Pulmonary embolism. Two other complications are also reviewed, one a result of ECT and the other an incidental complication; namely, rupture of an abdominal viscus and acute suppurative appendicitis.
Kalinowsky(2) states that coronary complications may arise following ECT. He states that cerebral hemorrhage has not occurred in his experience. Kalinowsky(3) also states intestinal ruptures have occurred as has pulmonary embolism from pelvic thrombosis.
Clinically, the occurrence of the described unusual complications following the use of ECT over a 3-year period in one institution has resulted in a broadening of the staff's education and experience in this field and have tested their mettle in coping with these complications.
However, in spite of the fact that complications do arise, the value of this form of treatment is in no way disputed.
THIS study was made to evaluate any unilateral or focal effects that might be the result of unilateral placement of stimulating electrodes in electric convulsion therapy. If the passage of the electric current is localized dependent on placement of the stimulating electrodes, it should be possible to demonstrate such localization by observation of the nature of the convulsion produced and by electroencephalographic recordings. Accordingly, extensive clinical, psychologic, electroencephalographic and neurologic studies have been made. This paper is concerned with the electroencephalographic findings in relation to the type of convulsion obtained and to the improvement manifested by the patient.MATERIAL AND METHODS
The choice of patients for the entire study considered only the patient's ability to cooperate adequately for electroencephalograms and psychologic evaluation. All subjects were men, mostly between the ages of 20 and 30, the commonest diagnosis being paranoid schizophrenia. Patients with other classifications of schizophrenia, as well as manic-depressive
Five groups of Maccacus rhesus monkeys were subjected to 32-100 electrically induced convulsions with currents of 90 volts and duration of current flow of 0.3 sec. and 0.5 sec.; two different sized electrodes were used. The following findings were observed in animals sacrificed at varying intervals (from ½ hour up to 1½ years) following the last induced convulsion.
Functional and morphologic changes mostly related to the vascular system as indicated by increased permeability of the blood vessel walls (distension of the perivascular spaces surrounded at times by mild reactive glia proliferation, or compound granular corpuscles, and particularly diapedesis of blood elements).
The neuronal changes were mostly of the reversible type. When more intense and more frequently repeated current and longer duration of current were applied, occasional minute petechial hemorrhages resulted. This seems to support the contention that the degree of the lesions is somewhat proportional to the intensity of the electric current, the duration of the current flow and, to a lesser extent, the number of shocks.
The histologic alterations were more pronounced and more frequently observed in the areas traversed by the main path of the current.
In comparing some of the neuronal changes in experimental animals with the same occurrence in the control group, one must not only evaluate the qualitative changes but also the quantitative ones.
Differing somewhat from reports in human material, our conclusions are derived from the study of numerous blocks and at times of a whole hemisphere serially sectioned of experimental material, thus allowing detection of changes which may escape a more cursory investigation in human material.
Functional vasomotor changes may be at the base of the favorable therapeutic results reported in human cases. Reversible histometabolic and structural changes as well as permanent structural damage may be at the base of the more or less transitory mental symptoms of the organic reaction type which follow, at times, electroshock therapy.