CASE REPORT
Cognitive Behavioral Therapy as a Treatment for Electroconvulsive Therapy Phobia Case Report and Review of Literature Nolan King Hop Wo, MD, RN,* Brendan Guyitt, PhD,† and Richard Owen, MD, FRCP(C)* Background: Electroconvulsive therapy (ECT) can raise feelings of fear and anxiety in our patients. No documented cases of phobia regarding ECT or its treatment were found in the literature. Methods: We present a patient who developed anxiety regarding ECT that was severe enough to be classified as a phobia. She was successfully treated with cognitive behavioral therapy (CBT) for her phobia and was subsequently able to tolerate ECT. We conducted a literature review of ECT phobia, fear, and anxiety using MEDLINE, PsycINFO, and EMBASE. Results: We outlined how CBT, in our specific case, was helpful in treating extreme and unrealistic fears concerning ECT. We could not find a case of phobia related to ECT in the literature; however, both qualitative and quantitative studies illustrate that ECT causes anxiety and fear. Conclusions: Although cases of ECT phobia are rare, feelings of fear and anxiety surrounding ECT are common. The experience of ECT is individualized for each patient, and CBT can be a successful treatment in those who have anxiety related to ECT. Key Words: electroconvulsive therapy (ECT), phobia, cognitive behavioral therapy (CBT), fear, and anxiety (J ECT 2015;31: 273–276)
A
lthough electroconvulsive therapy (ECT) can be anxiety provoking, the literature shows no published reports describing phobia related to ECT. Presented is a case illustrating ECT phobia, which was treated with cognitive behavioral therapy (CBT). This will be followed by a review of literature regarding ECT phobia and fear.
MATERIALS AND METHODS The initial focus of this literature review was ECT phobia, but this was expanded to include fear and panic regarding ECT because of lack of initial results. The search was completed on March 4, 2014, using 3 databases, MEDLINE, PsycINFO, and EMBASE. Articles were limited to those that were published in English within the past 10 years. Search criteria were (ECT) combined with 1 of the following 3 criteria (fear or panic), or (phobic disorders), or (phobia* or fear* or afraid).
RESULTS The described search strategy yielded 13 results, 5 of which were relevant to this review. None of the articles dealt with ECT phobia. Three additional resources were also discovered and incorporated. From the *Department of Psychiatry, The University of Western Ontario; and †London Health Sciences Centre, London, Ontario Canada. Received for publication October 9, 2014; accepted January 13, 2015. Reprints: Nolan King Hop Wo, MD, RN, Department of Psychiatry, London Health Sciences Centre Victoria Campus, Room B8, 800 Commissioners Rd East, London, Ontario, Canada N6A 5W9 (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000221
CASE REPORT The patient was a 45-year-old woman, who was living with family and supporting herself with disability insurance for her mental illness. She was admitted to inpatient psychiatry for ECT following worsening suicidal ideation after completing 80 sessions of CBT over 14 months. She has a history of major depressive disorder, which was previously responsive to 4 courses of ECT in 2004, 2006, 2008, and 2009. She has more than a dozen admissions to inpatient psychiatry and numerous visits to the emergency department. She has a history of bulimia and polysubstance abuse, which were both in remission. She has been prescribed various psychiatric medications for her depression as well as received dialectical behavioral therapy over the past 10 years. Her suicidal ideation started at 5 years old, and she has 15 overdose attempts, one of which left her comatose for a number of days at age 18 years. She has a significant family history of depression. Her medications on admission were escitalopram 30 mg daily, mirtazapine 30 mg daily, quetiapine 450 mg nightly at bedtime (qHS), lorazepam 1 mg qHS, and chloral hydrate 1 g qHS. It should be noted that she had undergone previous medical procedures in the past without incident, including tonsillectomy, internal fixation of a broken bone, and wisdom tooth extraction. As per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria,1 diagnostically she had recurrent major depressive disorder that had remitted on 4 previous courses of ECT. She had a history of sedative, hypnotic, or anxiolytic use disorder, in sustained remission; cannabis use disorder, in sustained remission; and bulimia nervosa, in full remission. She also has a current diagnosis of borderline personality disorder. The previous treatment plan for this patient’s depression was maintenance ECT after she had finished weekly ECT sessions in 2009; however, she was unable to continue treatment because of a fear she developed during her final ECT session. In this final session, during the preoperative preparation, the anesthesiologist had difficulty starting an intravenous line, and so the client waited for a longer period. As she waited, she reported hearing the heart rate monitor steadily increasing and thinking she was going to die of a heart attack, when she was really suffering from a panic attack. This attack was so severe she withdrew her consent to treatment, before she was sedated, and chose to terminate any additional ECT sessions. Following this event, she refused to even discuss the possibility of ECT should her depression and suicidality relapse, despite its proven efficacy. She developed an extreme fear that she would die during ECT, either from a myocardial infarction or the electrical treatment itself. In the interim, between 2009 and 2013, her depression was maintained on medications, but as it was likely she would require ECT in the future, she agreed to CBT sessions with a psychologist with a focus on her phobia of ECT as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.1 She would receive 80 sessions over the year leading up to her hospital admission. Initially, treatment focused on building the therapeutic relationship as the patient had fears of abandonment and, during the
Journal of ECT • Volume 31, Number 4, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
273
Journal of ECT • Volume 31, Number 4, December 2015
Hop Wo et al
first month of therapy, was unable to discuss ECT without severe anxiety. Despite possessing insight into the necessity of ECT, she was too fearful of the procedure to consider it an option. Exploration of the cause of the phobia included the idea that she would die secondary to a myocardial infarction. A theme of loss of control was also identified and addressed throughout the course of therapy. Other factors that increased her anxiety were difficulty tolerating the wait time immediately before the procedure and travel to the hospital where her final ECT session had occurred. In addition, she described posttraumatic stress disorder (PTSD) symptoms regarding her final ECT session including nightmares, intrusive thoughts, and ruminating about the incident. Other factors that increased the number of sessions needed included the severity of both her depressive and anxiety symptoms and the fact that her exposure therapy required a medicalized environment (eg, as opposed to going into a supermarket between sessions when treating social phobia). To address this last point, we tried the use of imaginal exposure with a script of the ECT event that the client could use at home as an adjunct to the in vivo exposure. The client, however, could not tolerate this technique as her anxiety increased to such a degree that it became unhelpful. After clarifying the core issues and fully validating her previous experiences, sessions were spent educating the patient on the physiology of normal anxiety and panic responses. In regard to cognitive treatment, the evidence for and against dying while receiving ECT, the client’s fear of memory loss from ECT, and the reinterpretation of an increased heart rate as a sign of stress and not a cardiac event were covered. Time was spent challenging and processing ideas of self-worthlessness, suicidal ideation, and being a burden to family members as these factors significantly reduce the patient’s ability to engage with therapy and exposure work. In regard to exposure therapy, systematic desensitization was chosen as the framework. The progression of graduated exposure therapy included using exercise to increase heart rate, having a heart rate monitor in the room, connecting the heart rate monitor to her finger, looking at the monitor as it displayed her heart rate, listening to the monitor noise, exposing herself to a physical examination room, laying in a hospital bed, and exposing herself to the ECT suite. Each of these steps was broken down into smaller increments and repeated many times. The goal of creating a new
ECT experience for the client was paramount in this work. Examples of her progress are illustrated in Figures 1 and 2. After a year of CBT sessions, the patient, her family, and the care team decided she would be admitted to hospital as her depression and suicidal thoughts had worsened to the point where ECT should be initiated. Acknowledging this, CBT sessions were tailored to focus on distress and anxiety tolerance techniques to cope with the upcoming ECT. Techniques included acknowledging she would feel anxious and learning to accept the anxiety without trying to overcontrol it, progressive muscle relaxation, deep breathing, counting for distraction, positive self-talk and focusing on safe aspects of the situation, challenging negative thoughts, and talking with staff in the ECT suite to increase her level of perceived control and involvement. During her first 4 ECT treatments, her psychologist accompanied her into the suite and stood next to her for support and to cue strategy use; during the next 2 sessions, he attended the procedure but stood in the corner out of sight of the patient. After the first 6 sessions were completed, the patient could tolerate the procedure without the psychologist present. Between ECT sessions, she continued to have feelings of anxiety, including patterns of restless sleep the preceding night. One other measure taken to further reduce the patient’s anxiety was to have her undergo ECT at a facility that was different than where she had her initial panic attack in 2009. She also received 1 g of chloral hydrate prior to her treatments. In total, the patient received 14 ECT sessions over 7 weeks, before agreeing to maintenance ECT. Her treatment successfully caused her suicidal thoughts to abate and her depression to remit. She is currently debriefing with her psychologist and psychiatrist, while receiving maintenance ECT.
DISCUSSION Electroconvulsive therapy phobia, as illustrated by the case presentation, has not been previously described in the literature. What has been described were lesser feelings of anxiety and fear surrounding ECT. This article focuses on literature within the past decade. One important article, which was cited numerous times and therefore included despite being published in 1999, focused on identifying negative themes related to the psychological effects
FIGURE 1. Comparing subjective units of distress with time, over a 6-week period for select CBT sessions. This portion of the exposure therapy was centered around a standard vitals machine (VM).
274
www.ectjournal.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 4, December 2015
CBT as Treatment for ECT Phobia
FIGURE 2. Comparing subjective units of distress with time, over a 4-week period for select CBT sessions. This portion of the exposure therapy was centered around having the patient inside a clinical examination room.
of ECT.2 This qualitative study, involving 20 subjects, produced 4 themes: humiliation, worthlessness, fear, and shame. The experience of 2 subjects drew parallels with previous childhood abuse, and they associated ECT with further psychological trauma. Fisher3 reviewed both quantitative and qualitative literature regarding the psychological experience of ECT with a goal of finding areas to make improvements. The review found that although there were no specific articles on PTSD and ECT, non-ECT medical procedures can produce PTSD symptoms, which in turn lead to decreased compliance. The article highlighted 4 areas that should be addressed in hopes of improving compliance among ECT patients. The 4 areas of focus were addressing feelings of powerlessness, acknowledging the patient’s experience, listening nonjudgmentally, and providing an opportunity to debrief after completion of ECT sessions. Fisher’s review also highlighted the importance of taking the time to formulate a patient’s psychological makeup, with an example of being mindful of a patient with trauma history. Such a patient might be more likely to frame the ECT experience as abusive, rather than therapeutic in nature. Our case example supported the idea that ECT can also be associated with PTSD symptoms as the patient developed nightmares, intrusive thoughts, and ruminations about her experience. Debriefing was made available to the patient by her psychologist in regard to giving and receiving feedback as her ECT sessions progressed. Chakrabarti et al4 reviewed 75 articles for their literature review to focus on the knowledge, experiences, and attitudes of patients undergoing ECT. Common negative themes uncovered were that patients felt poorly informed about the process, and a third of people felt coerced into treatment. Common worries were the possibility of permanent brain damage or permanent memory loss. In regard to the magnitude of fear and anxiety that ECT provoked, 50% to 95% of patients thought ECT was no more fearful than having a tooth extraction by a dentist. In contrast to this, half of studies found that the fear and anxiety surrounding ECT were more than should be expected for a procedure of this type. This finding was supported by Rajagopal et al,5 who looked at patients and families in Northern India and found that despite more than 50% of patients and families satisfied with ECT, one third of patients continued to be afraid after the procedure. It is therefore important to remember that families can be important allies in encouraging patients to continue with ECT therapy.6
Koopowitz et al7 used a qualitative study to explore the subjective experience of ECT. Four themes that emerged were fear of ECT, worries regarding memory loss, positive experiences, and suggestions from patients. Fear of ECT ranged from nervousness associated with any type of medical procedure to PTSD symptoms including nightmares occurring 3 years after ECT. Worries included death, personality changes, and brain damage. One suggestion was to decrease perioperative waiting times, as some patients noticed their anxiety worsened as they waited for ECT. This was echoed by the patient in our case study who expressed increased anxiety in proportion to waiting time. Another suggestion was to create a separate procedure area to deliver ECT with a goal to alleviate the possibility of having patients receiving ECT misconstrue the distress associated with other medical procedures as having originated from ECT.7 Acknowledging patients’ fears regarding ECT, as was done with our patient, has also been found to be beneficial in helping to alleviate their anxieties.8 Interestingly, a preliminary study in 2003 found that animal-assisted therapy involving a 15-minute visit with a dog prior to receiving ECT therapy was helpful in reducing a feeling of fear, but not a feeling of anxiety.9 This suggests that animal-assisted therapy may also be a viable option in regard to a reduction in fear surrounding ECT treatments.
CONCLUSIONS Although little is documented concerning ECT phobia, anxiety and fear surrounding ECT are common. Our case illustrates an individual who subsequently developed a phobia to ECT in the context of fears that she would die either of ECT itself or of a cardiac event. This irrational fear led her to refuse ECT as a treatment option despite acknowledging this was her best choice for recovery. Weekly CBT sessions, over a year, prepared her to tolerate ECT when it was eventually required. This literature review focuses on fear and anxiety in ECT. It found that fear and anxiety often occur in medical procedures. However, there is a heightened level of fear and anxiety associated with ECT, which occurs in one third to one half of patients and families. This fear ranges from the anxiety similar to experiencing a tooth extraction to PTSD symptoms. Predisposing factors for developing anxiety regarding ECT may include previous
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
275
Journal of ECT • Volume 31, Number 4, December 2015
Hop Wo et al
psychological trauma, not being fully educated about ECT, and having longer wait times from the time the patient enters the hospital to when they receive their treatment. Thus, it is important to recognize that some patients may need more support to participate in ECT and that therapy focused on the ECT experience itself may be necessary. At a minimum, we must take the time to listen to our patients, acknowledge their individual experiences, and provide an opportunity for debriefing. ACKNOWLEDGMENTS The authors thank Sandra McKeown for her assistance with the literature search. REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing; 2013:197–202.
276
www.ectjournal.com
2. Johnstone L. Adverse psychological effects of ECT. J Ment Health. 1999;8:69–85. 3. Fisher P. Psychological factors related to the experience of and reaction to electroconvulsive therapy. J Ment Health. 2012;21:589–599. 4. Chakrabarti S, Grover S, Rajagopal R. Electroconvulsive therapy: a review of knowledge, experience and attitudes of patients concerning the treatment. World J Biol Psychiatry. 2010;11:525–537. 5. Rajagopal R, Chakrabarti S, Grover S. Satisfaction with electroconvulsive therapy among patients and their relatives. J ECT. 2013;29:283–290. 6. McCall WV. You win. J ECT. 2008;24:243. 7. Koopowitz LF, Chur-Hansen A, Reid S, et al. The subjective experience of patients who received electroconvulsive therapy. Aust N Z J Psychiatry. 2003;37:49–54. 8. Fox HA. Patients’ objections to electroconvulsive therapy. J ECT. 2009;25:288. 9. Barker SB, Pandurangi AK, Best AM. Effects of animal-assisted therapy on patients’ anxiety, fear, and depression before ECT. J ECT. 2003;19:38–44.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cognitive Behavioral Therapy as a Treatment for Electroconvulsive Therapy Phobia Case Report and Review of Literature Nolan King Hop Wo, MD, RN,* Brendan Guyitt, PhD,† and Richard Owen, MD, FRCP(C)* Background: Electroconvulsive therapy (ECT) can raise feelings of fear and anxiety in our patients. No documented cases of phobia regarding ECT or its treatment were found in the literature. Methods: We present a patient who developed anxiety regarding ECT that was severe enough to be classified as a phobia. She was successfully treated with cognitive behavioral therapy (CBT) for her phobia and was subsequently able to tolerate ECT. We conducted a literature review of ECT phobia, fear, and anxiety using MEDLINE, PsycINFO, and EMBASE. Results: We outlined how CBT, in our specific case, was helpful in treating extreme and unrealistic fears concerning ECT. We could not find a case of phobia related to ECT in the literature; however, both qualitative and quantitative studies illustrate that ECT causes anxiety and fear. Conclusions: Although cases of ECT phobia are rare, feelings of fear and anxiety surrounding ECT are common. The experience of ECT is individualized for each patient, and CBT can be a successful treatment in those who have anxiety related to ECT. Key Words: electroconvulsive therapy (ECT), phobia, cognitive behavioral therapy (CBT), fear, and anxiety (J ECT 2015;31: 273–276)
A
lthough electroconvulsive therapy (ECT) can be anxiety provoking, the literature shows no published reports describing phobia related to ECT. Presented is a case illustrating ECT phobia, which was treated with cognitive behavioral therapy (CBT). This will be followed by a review of literature regarding ECT phobia and fear.
MATERIALS AND METHODS The initial focus of this literature review was ECT phobia, but this was expanded to include fear and panic regarding ECT because of lack of initial results. The search was completed on March 4, 2014, using 3 databases, MEDLINE, PsycINFO, and EMBASE. Articles were limited to those that were published in English within the past 10 years. Search criteria were (ECT) combined with 1 of the following 3 criteria (fear or panic), or (phobic disorders), or (phobia* or fear* or afraid).
RESULTS The described search strategy yielded 13 results, 5 of which were relevant to this review. None of the articles dealt with ECT phobia. Three additional resources were also discovered and incorporated. From the *Department of Psychiatry, The University of Western Ontario; and †London Health Sciences Centre, London, Ontario Canada. Received for publication October 9, 2014; accepted January 13, 2015. Reprints: Nolan King Hop Wo, MD, RN, Department of Psychiatry, London Health Sciences Centre Victoria Campus, Room B8, 800 Commissioners Rd East, London, Ontario, Canada N6A 5W9 (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000221
CASE REPORT The patient was a 45-year-old woman, who was living with family and supporting herself with disability insurance for her mental illness. She was admitted to inpatient psychiatry for ECT following worsening suicidal ideation after completing 80 sessions of CBT over 14 months. She has a history of major depressive disorder, which was previously responsive to 4 courses of ECT in 2004, 2006, 2008, and 2009. She has more than a dozen admissions to inpatient psychiatry and numerous visits to the emergency department. She has a history of bulimia and polysubstance abuse, which were both in remission. She has been prescribed various psychiatric medications for her depression as well as received dialectical behavioral therapy over the past 10 years. Her suicidal ideation started at 5 years old, and she has 15 overdose attempts, one of which left her comatose for a number of days at age 18 years. She has a significant family history of depression. Her medications on admission were escitalopram 30 mg daily, mirtazapine 30 mg daily, quetiapine 450 mg nightly at bedtime (qHS), lorazepam 1 mg qHS, and chloral hydrate 1 g qHS. It should be noted that she had undergone previous medical procedures in the past without incident, including tonsillectomy, internal fixation of a broken bone, and wisdom tooth extraction. As per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria,1 diagnostically she had recurrent major depressive disorder that had remitted on 4 previous courses of ECT. She had a history of sedative, hypnotic, or anxiolytic use disorder, in sustained remission; cannabis use disorder, in sustained remission; and bulimia nervosa, in full remission. She also has a current diagnosis of borderline personality disorder. The previous treatment plan for this patient’s depression was maintenance ECT after she had finished weekly ECT sessions in 2009; however, she was unable to continue treatment because of a fear she developed during her final ECT session. In this final session, during the preoperative preparation, the anesthesiologist had difficulty starting an intravenous line, and so the client waited for a longer period. As she waited, she reported hearing the heart rate monitor steadily increasing and thinking she was going to die of a heart attack, when she was really suffering from a panic attack. This attack was so severe she withdrew her consent to treatment, before she was sedated, and chose to terminate any additional ECT sessions. Following this event, she refused to even discuss the possibility of ECT should her depression and suicidality relapse, despite its proven efficacy. She developed an extreme fear that she would die during ECT, either from a myocardial infarction or the electrical treatment itself. In the interim, between 2009 and 2013, her depression was maintained on medications, but as it was likely she would require ECT in the future, she agreed to CBT sessions with a psychologist with a focus on her phobia of ECT as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.1 She would receive 80 sessions over the year leading up to her hospital admission. Initially, treatment focused on building the therapeutic relationship as the patient had fears of abandonment and, during the
Journal of ECT • Volume 31, Number 4, December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
273
Journal of ECT • Volume 31, Number 4, December 2015
Hop Wo et al
first month of therapy, was unable to discuss ECT without severe anxiety. Despite possessing insight into the necessity of ECT, she was too fearful of the procedure to consider it an option. Exploration of the cause of the phobia included the idea that she would die secondary to a myocardial infarction. A theme of loss of control was also identified and addressed throughout the course of therapy. Other factors that increased her anxiety were difficulty tolerating the wait time immediately before the procedure and travel to the hospital where her final ECT session had occurred. In addition, she described posttraumatic stress disorder (PTSD) symptoms regarding her final ECT session including nightmares, intrusive thoughts, and ruminating about the incident. Other factors that increased the number of sessions needed included the severity of both her depressive and anxiety symptoms and the fact that her exposure therapy required a medicalized environment (eg, as opposed to going into a supermarket between sessions when treating social phobia). To address this last point, we tried the use of imaginal exposure with a script of the ECT event that the client could use at home as an adjunct to the in vivo exposure. The client, however, could not tolerate this technique as her anxiety increased to such a degree that it became unhelpful. After clarifying the core issues and fully validating her previous experiences, sessions were spent educating the patient on the physiology of normal anxiety and panic responses. In regard to cognitive treatment, the evidence for and against dying while receiving ECT, the client’s fear of memory loss from ECT, and the reinterpretation of an increased heart rate as a sign of stress and not a cardiac event were covered. Time was spent challenging and processing ideas of self-worthlessness, suicidal ideation, and being a burden to family members as these factors significantly reduce the patient’s ability to engage with therapy and exposure work. In regard to exposure therapy, systematic desensitization was chosen as the framework. The progression of graduated exposure therapy included using exercise to increase heart rate, having a heart rate monitor in the room, connecting the heart rate monitor to her finger, looking at the monitor as it displayed her heart rate, listening to the monitor noise, exposing herself to a physical examination room, laying in a hospital bed, and exposing herself to the ECT suite. Each of these steps was broken down into smaller increments and repeated many times. The goal of creating a new
ECT experience for the client was paramount in this work. Examples of her progress are illustrated in Figures 1 and 2. After a year of CBT sessions, the patient, her family, and the care team decided she would be admitted to hospital as her depression and suicidal thoughts had worsened to the point where ECT should be initiated. Acknowledging this, CBT sessions were tailored to focus on distress and anxiety tolerance techniques to cope with the upcoming ECT. Techniques included acknowledging she would feel anxious and learning to accept the anxiety without trying to overcontrol it, progressive muscle relaxation, deep breathing, counting for distraction, positive self-talk and focusing on safe aspects of the situation, challenging negative thoughts, and talking with staff in the ECT suite to increase her level of perceived control and involvement. During her first 4 ECT treatments, her psychologist accompanied her into the suite and stood next to her for support and to cue strategy use; during the next 2 sessions, he attended the procedure but stood in the corner out of sight of the patient. After the first 6 sessions were completed, the patient could tolerate the procedure without the psychologist present. Between ECT sessions, she continued to have feelings of anxiety, including patterns of restless sleep the preceding night. One other measure taken to further reduce the patient’s anxiety was to have her undergo ECT at a facility that was different than where she had her initial panic attack in 2009. She also received 1 g of chloral hydrate prior to her treatments. In total, the patient received 14 ECT sessions over 7 weeks, before agreeing to maintenance ECT. Her treatment successfully caused her suicidal thoughts to abate and her depression to remit. She is currently debriefing with her psychologist and psychiatrist, while receiving maintenance ECT.
DISCUSSION Electroconvulsive therapy phobia, as illustrated by the case presentation, has not been previously described in the literature. What has been described were lesser feelings of anxiety and fear surrounding ECT. This article focuses on literature within the past decade. One important article, which was cited numerous times and therefore included despite being published in 1999, focused on identifying negative themes related to the psychological effects
FIGURE 1. Comparing subjective units of distress with time, over a 6-week period for select CBT sessions. This portion of the exposure therapy was centered around a standard vitals machine (VM).
274
www.ectjournal.com
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 4, December 2015
CBT as Treatment for ECT Phobia
FIGURE 2. Comparing subjective units of distress with time, over a 4-week period for select CBT sessions. This portion of the exposure therapy was centered around having the patient inside a clinical examination room.
of ECT.2 This qualitative study, involving 20 subjects, produced 4 themes: humiliation, worthlessness, fear, and shame. The experience of 2 subjects drew parallels with previous childhood abuse, and they associated ECT with further psychological trauma. Fisher3 reviewed both quantitative and qualitative literature regarding the psychological experience of ECT with a goal of finding areas to make improvements. The review found that although there were no specific articles on PTSD and ECT, non-ECT medical procedures can produce PTSD symptoms, which in turn lead to decreased compliance. The article highlighted 4 areas that should be addressed in hopes of improving compliance among ECT patients. The 4 areas of focus were addressing feelings of powerlessness, acknowledging the patient’s experience, listening nonjudgmentally, and providing an opportunity to debrief after completion of ECT sessions. Fisher’s review also highlighted the importance of taking the time to formulate a patient’s psychological makeup, with an example of being mindful of a patient with trauma history. Such a patient might be more likely to frame the ECT experience as abusive, rather than therapeutic in nature. Our case example supported the idea that ECT can also be associated with PTSD symptoms as the patient developed nightmares, intrusive thoughts, and ruminations about her experience. Debriefing was made available to the patient by her psychologist in regard to giving and receiving feedback as her ECT sessions progressed. Chakrabarti et al4 reviewed 75 articles for their literature review to focus on the knowledge, experiences, and attitudes of patients undergoing ECT. Common negative themes uncovered were that patients felt poorly informed about the process, and a third of people felt coerced into treatment. Common worries were the possibility of permanent brain damage or permanent memory loss. In regard to the magnitude of fear and anxiety that ECT provoked, 50% to 95% of patients thought ECT was no more fearful than having a tooth extraction by a dentist. In contrast to this, half of studies found that the fear and anxiety surrounding ECT were more than should be expected for a procedure of this type. This finding was supported by Rajagopal et al,5 who looked at patients and families in Northern India and found that despite more than 50% of patients and families satisfied with ECT, one third of patients continued to be afraid after the procedure. It is therefore important to remember that families can be important allies in encouraging patients to continue with ECT therapy.6
Koopowitz et al7 used a qualitative study to explore the subjective experience of ECT. Four themes that emerged were fear of ECT, worries regarding memory loss, positive experiences, and suggestions from patients. Fear of ECT ranged from nervousness associated with any type of medical procedure to PTSD symptoms including nightmares occurring 3 years after ECT. Worries included death, personality changes, and brain damage. One suggestion was to decrease perioperative waiting times, as some patients noticed their anxiety worsened as they waited for ECT. This was echoed by the patient in our case study who expressed increased anxiety in proportion to waiting time. Another suggestion was to create a separate procedure area to deliver ECT with a goal to alleviate the possibility of having patients receiving ECT misconstrue the distress associated with other medical procedures as having originated from ECT.7 Acknowledging patients’ fears regarding ECT, as was done with our patient, has also been found to be beneficial in helping to alleviate their anxieties.8 Interestingly, a preliminary study in 2003 found that animal-assisted therapy involving a 15-minute visit with a dog prior to receiving ECT therapy was helpful in reducing a feeling of fear, but not a feeling of anxiety.9 This suggests that animal-assisted therapy may also be a viable option in regard to a reduction in fear surrounding ECT treatments.
CONCLUSIONS Although little is documented concerning ECT phobia, anxiety and fear surrounding ECT are common. Our case illustrates an individual who subsequently developed a phobia to ECT in the context of fears that she would die either of ECT itself or of a cardiac event. This irrational fear led her to refuse ECT as a treatment option despite acknowledging this was her best choice for recovery. Weekly CBT sessions, over a year, prepared her to tolerate ECT when it was eventually required. This literature review focuses on fear and anxiety in ECT. It found that fear and anxiety often occur in medical procedures. However, there is a heightened level of fear and anxiety associated with ECT, which occurs in one third to one half of patients and families. This fear ranges from the anxiety similar to experiencing a tooth extraction to PTSD symptoms. Predisposing factors for developing anxiety regarding ECT may include previous
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
275
Journal of ECT • Volume 31, Number 4, December 2015
Hop Wo et al
psychological trauma, not being fully educated about ECT, and having longer wait times from the time the patient enters the hospital to when they receive their treatment. Thus, it is important to recognize that some patients may need more support to participate in ECT and that therapy focused on the ECT experience itself may be necessary. At a minimum, we must take the time to listen to our patients, acknowledge their individual experiences, and provide an opportunity for debriefing. ACKNOWLEDGMENTS The authors thank Sandra McKeown for her assistance with the literature search. REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Publishing; 2013:197–202.
276
www.ectjournal.com
2. Johnstone L. Adverse psychological effects of ECT. J Ment Health. 1999;8:69–85. 3. Fisher P. Psychological factors related to the experience of and reaction to electroconvulsive therapy. J Ment Health. 2012;21:589–599. 4. Chakrabarti S, Grover S, Rajagopal R. Electroconvulsive therapy: a review of knowledge, experience and attitudes of patients concerning the treatment. World J Biol Psychiatry. 2010;11:525–537. 5. Rajagopal R, Chakrabarti S, Grover S. Satisfaction with electroconvulsive therapy among patients and their relatives. J ECT. 2013;29:283–290. 6. McCall WV. You win. J ECT. 2008;24:243. 7. Koopowitz LF, Chur-Hansen A, Reid S, et al. The subjective experience of patients who received electroconvulsive therapy. Aust N Z J Psychiatry. 2003;37:49–54. 8. Fox HA. Patients’ objections to electroconvulsive therapy. J ECT. 2009;25:288. 9. Barker SB, Pandurangi AK, Best AM. Effects of animal-assisted therapy on patients’ anxiety, fear, and depression before ECT. J ECT. 2003;19:38–44.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
