Delayed Amnesia and Disorientation After Electroconvulsive Treatment Alexander Grinshpoon, M.D.', Roberto Mester, M.D.2, Baruch Spivak, M.D.3, Yael Berg, M.D.4, Avraham Bleich, M.D.5, Abraham Weizman, M.D.6 'Senior Psychiatrist at Ness-Ziona Mental Health Center, Ness Ziona, 2Director, Ness-Ziona Mental Health Center, Lecturer in Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv,3Senior Resident, Gehah Psychiatric Hospital, Beilinson Medical Center, Petah Tiqva, 4Resident, Ness-Ziona Mental Health Center, 5Senior Lecturer in Psychiatry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, 6Associate Professor in Psychiatry, Director of Research, Gehah Psychiatric Hospital, Beilinson Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv Submitted: November 18, 1992
Accepted: July 22, 1992 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 of48 hours, transient amnesia developed. Her condition appeared to be associated with the electroconvulsive therapy, thereby raising questions about its pathogenicity and management. Key Words: ECT, delayed amnesia
INTRODUCTION
Electroconvulsive therapy (ECT) is a common and effective treatment for major depression. It has been in use for over 50 years and has come into widespread practice during recent decades (Weiner 1984; Weiner 1989). Acute amnestic syndrome is one of the well-known side effects of ECT (Heshe et al 1978). ECT causes memory disturbances, which are anterograde and can be retrograde in 64% of patients (Devanad et al 1991; Freeman and Kendall 1980). The vast majority of acute and subacute cognitive impairments occur in patients treated with bilateral high-dosage (sine wave stimulation) ECT (Devanad et al 1991; Freeman and Kendall 1980). It is generally believed that memory disorders related to or caused by ECT are temporary and reversible (Warren and Croome 1984). Patients may be orientated to self, time and place (Freeman and Kendall 1980) only ten minutes after ECT, although memory disorders, especially retrograde amnesia, may persist for several weeks (12) or even months (Squire 1977). ECT-related memory disturbances tend to appear immediately after the initial stages of the treatment. They increase with the progression of the treatment and J PsychiatrNeurosci, Vol. 17, No. 5, 1992
gradually disappear after treatment is terminated (Squire and Slater 1983; Warren and Croome 1984). There have been no reported cases in which acute memory disturbances appeared some days after completion of the ECT. The case of a patient in whom this occurred is presented and discussed.
CASE REPORT Mrs. D, a 39-year-old woman, had had repeated episodes of unipolar depressive disorder since the age of 20. She had been hospitalized five times because of her depression and, in most instances, her condition had only moderately improved with antidepressant drug therapy. During her last hospitalization, one year prior to the current one, Mrs. D received ECT which had a prompt and positive effect, relieving her almost completely of her crippling symptomatology. Eleven months after her recovery, Mrs. D suffered a relapse of major depressive episode which met DSM-III-R (American Psychiatric Association, 1987) criteria and she was readmitted with symptoms of major depression, melancholic 191
192
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type, with loss of interest in all activities, severe insomnia and anorexia which led to significant weight loss. Because of the severity of her condition, the presence of suicidal thoughts and the previous efficacy of ECT, the treating psychiatrist (A.G.) recommended that ECT be administered. The patient and her family consented to the use of electroconvulsive therapy. No drug treatment was initiated. General physical and neurological examinations did not reveal any abnormalities. Eye fundus examinations were normal. Laboratory tests, including complete blood count, simultaneous multiple analyses 12 (SMA-12), ECG and EEG, were within normal limits. Mrs. D began a series of ECT procedures twice a week, using a Siemens Konvulsator 20775. Pre-medication given one-half hour before each treatment consisted of atropine 0.5 mg (IM). The patient also received 60 mg methohexital sodium and 30 mg succinylcholine chloride IV immediately before each treatment. Bilateral electrodes were placed fronto-temporally, each with its centre approximately one inch above the midpoint of an imaginary line drawn from the tragus of the ear to the external canthus of the eye. Maximal electrical intensity was 6 units (equivalent to 600 mA peak current intensity), given for four seconds, using the gradual current method of initial glissando and then continuous pulse sequence. ECT was administered while the patient received constant 100% oxygen through a face mask. The clinical picture improved gradually with each treatment. The immediate recovery after each ECT procedure was rapid and uneventful, and no serious or persistent memory disorders were detected beyond the very short post-treatment periods of confusion. During and after each course of ECT, the patient was drugfree and did not drink alcohol or take non-prescription drugs. Twenty-four hours after the fifth treatment, Mrs. D reported feeling well and she appeared to be free of symptoms; no disturbances of awareness, orientation, affect, memory, thought or judgement could be detected by the treating staff. In view of her marked improvement, her psychiatrist granted Mrs. D two days' leave to go home, and she did so immediately. During her first day at home, two days after her last ECT treatment, Mrs. D suddenly disappeared from home; after a while her husband found her wandering inside a nearby bus terminal. Her husband brought her back to the hospital, where she was found to be disoriented to time and place and displayed serious memory disturbances. Mrs. D had serious difficulty learning new information and could not remember events which had taken place even during the previous few days. She had difficulty remembering her name, her age and her address. She was able to recognize her relatives and the treating staff, but was unable to remember their names. The same phenomena occurred in relation to many objects: she was able to recognize them and even use them correctly, but could not identify them even after she had been told what they were called. At the same time, although the patient seemed to be aware of her memory problems, she
VoL 17., No. S., 1992
appeared alert, her thinking processes were well organized, she did not show signs of perceptual disturbances. No delusions could be detected, and she behaved in a calm and cooperative manner. She was diagnosed as having acute amnestic syndrome with signs of disorientation. No abnormalities were found on general physical examination, fundus, blood cell count, urine tests, electrolytes balance, liver function examination and LP. No pathological findings appeared on either the CT or the ECG. The EEG showed delta waves in the fronto-temporal regions. Treatment of this acute condition consisted mainly of supportive psychotherapy and some memory exercises. After two days the patient was well-oriented again. The memory disturbances gradually receded, and after two weeks, completely disappeared. The EEG normalized at a slower pace, and after three months returned to normal.
DISCUSSION The acute transient amnestic syndrome with disorientation in our patient appeared suddenly, 48 hours after the administration of the last of a series of five ECT treatments. No definite organic injury, neurological or otherwise, could be clearly demonstrated by the physical or laboratory tests, apart from the changes in EEG, which will be discussed below. Acute amnestic syndrome, which is found in patients who have undergone ECT, has a clinical picture similar to a variety of conditions, such as grand mal epilepsy, head injuries, diencephalic tumors and Korsakoff's syndrome (Daniel and Crovitz 1986; Trimble and Thompson 1986; Weiner 1989). ECT acts particularly on the temporal lobes and adjacent areas; it appears that it is the resulting neurological impairment which constitutes the principal pathogenic factor of the amnesia and the disorientation which follows the ECT (Warren and Croome 1984). This clinical phenomenon is more common after bilateral ECT (Heshe et al 1978), which was used with this patient. 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).
November 1992
DelayedECT-inducedamnesia
193
Our patient was treated with ECT for a depressive illness Devanad DP, Verma AK, Tiruumalasetti F, Sackheim HA which is known to affect memory as a result of emotional (1991) Absence of cognitive impairment after more than withdrawal, lack of interest in the external object world and 100 lifetime ECT treatments. Am J Psychiatry 148:929apathy (Weiner 1989). However, in this case, the memory 932. disorders appeared after the ECT and after the patient's Freeman CPL, Kendall RF (1980) ECT: patients' experidepression had cleared up completely. It seems very unlikely ences and attitudes. Br J Psychiatry 137:8-16. that simple or organic factors played a role in the post-ECT transient amnesia, since there was no laboratory evidence of Friedberg J (1977) Shock treatment, brain damage and memory loss: a neurological perspective. Am J Psychiatry infection, blood sugar fluctuations or other physical causes 134:1010-1013. which could result in a period of lucidity and subsequent transient delirium and memory loss. Heshe J, Roder E, Theilgaard A (1978) Unilateral and bilatIn conclusion, this patient presented with a rare form of eral ECT: a psychiatric and psychological study of therapost-ECT acute amnestic syndrome with disorientation, peutic effect and side effects. Acta Psychiatr Scand which is atypical because the transitory memory disturbance (Suppl): 275-280. appeared more than 48 hours after a course of ECT, during Leniel WF, Crovitz HF (1987) Neuropsychological aspects which time the patient had been symptom-free. of disorientation. Cortex 23:169-187. The possibility of delayed reversible cognitive complications with ECT should be taken into consideration in prepar- Squire LR (1977) ECT and memory loss. Am J Psychiatry 134:997-1001. ing the patient and his or her family for ECT, especially when administered in the outpatient clinic. Close supervision is Squire L, Slater PC (1983) Electroconvulsive therapy and required for outpatients treated with bilateral ECT which is complaints of memory dysfunction: a prospective threeadministrered two or three times a week and also for inpayear follow-up study. Br J Psychiatry 142:1-8. tients who are being treated with the same procedure during Trimble MR, Thompson PJ (1986) Neuropsychological and their weekend leave. behavioral sequelae of spontaneous seizures. Ann N Y Acad Sci 462:284-292. Warren EW, Croome DH (1984) Memory test performance REFERENCES under three different wave forms of ECT for depression. Br J Psychiatry 144:370-375. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Weiner RD (1989) Electroconvulsive therapy. In: Kaplan HI, Sadock B (eds). Comprehensive Textbook of Psychiatry, Revised. Washington, DC: American Psychiatric Press, Volume 2, Fifth Edition. Baltimore, MD: Williams and Inc. Wilkins, pp 1670-1678. Daniel WF, Crovitz HF (1986) Disorientation during electroconvulsive therapy. Ann N Y Acad Sci 462:293- Weiner RD (1984) Does ECT cause brain damage? 306. Behavioral and Brain Science 7:1-53.
Accepted: July 22, 1992 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 of48 hours, transient amnesia developed. Her condition appeared to be associated with the electroconvulsive therapy, thereby raising questions about its pathogenicity and management. Key Words: ECT, delayed amnesia
INTRODUCTION
Electroconvulsive therapy (ECT) is a common and effective treatment for major depression. It has been in use for over 50 years and has come into widespread practice during recent decades (Weiner 1984; Weiner 1989). Acute amnestic syndrome is one of the well-known side effects of ECT (Heshe et al 1978). ECT causes memory disturbances, which are anterograde and can be retrograde in 64% of patients (Devanad et al 1991; Freeman and Kendall 1980). The vast majority of acute and subacute cognitive impairments occur in patients treated with bilateral high-dosage (sine wave stimulation) ECT (Devanad et al 1991; Freeman and Kendall 1980). It is generally believed that memory disorders related to or caused by ECT are temporary and reversible (Warren and Croome 1984). Patients may be orientated to self, time and place (Freeman and Kendall 1980) only ten minutes after ECT, although memory disorders, especially retrograde amnesia, may persist for several weeks (12) or even months (Squire 1977). ECT-related memory disturbances tend to appear immediately after the initial stages of the treatment. They increase with the progression of the treatment and J PsychiatrNeurosci, Vol. 17, No. 5, 1992
gradually disappear after treatment is terminated (Squire and Slater 1983; Warren and Croome 1984). There have been no reported cases in which acute memory disturbances appeared some days after completion of the ECT. The case of a patient in whom this occurred is presented and discussed.
CASE REPORT Mrs. D, a 39-year-old woman, had had repeated episodes of unipolar depressive disorder since the age of 20. She had been hospitalized five times because of her depression and, in most instances, her condition had only moderately improved with antidepressant drug therapy. During her last hospitalization, one year prior to the current one, Mrs. D received ECT which had a prompt and positive effect, relieving her almost completely of her crippling symptomatology. Eleven months after her recovery, Mrs. D suffered a relapse of major depressive episode which met DSM-III-R (American Psychiatric Association, 1987) criteria and she was readmitted with symptoms of major depression, melancholic 191
192
Journal of Psychiatry & Neuroscience
type, with loss of interest in all activities, severe insomnia and anorexia which led to significant weight loss. Because of the severity of her condition, the presence of suicidal thoughts and the previous efficacy of ECT, the treating psychiatrist (A.G.) recommended that ECT be administered. The patient and her family consented to the use of electroconvulsive therapy. No drug treatment was initiated. General physical and neurological examinations did not reveal any abnormalities. Eye fundus examinations were normal. Laboratory tests, including complete blood count, simultaneous multiple analyses 12 (SMA-12), ECG and EEG, were within normal limits. Mrs. D began a series of ECT procedures twice a week, using a Siemens Konvulsator 20775. Pre-medication given one-half hour before each treatment consisted of atropine 0.5 mg (IM). The patient also received 60 mg methohexital sodium and 30 mg succinylcholine chloride IV immediately before each treatment. Bilateral electrodes were placed fronto-temporally, each with its centre approximately one inch above the midpoint of an imaginary line drawn from the tragus of the ear to the external canthus of the eye. Maximal electrical intensity was 6 units (equivalent to 600 mA peak current intensity), given for four seconds, using the gradual current method of initial glissando and then continuous pulse sequence. ECT was administered while the patient received constant 100% oxygen through a face mask. The clinical picture improved gradually with each treatment. The immediate recovery after each ECT procedure was rapid and uneventful, and no serious or persistent memory disorders were detected beyond the very short post-treatment periods of confusion. During and after each course of ECT, the patient was drugfree and did not drink alcohol or take non-prescription drugs. Twenty-four hours after the fifth treatment, Mrs. D reported feeling well and she appeared to be free of symptoms; no disturbances of awareness, orientation, affect, memory, thought or judgement could be detected by the treating staff. In view of her marked improvement, her psychiatrist granted Mrs. D two days' leave to go home, and she did so immediately. During her first day at home, two days after her last ECT treatment, Mrs. D suddenly disappeared from home; after a while her husband found her wandering inside a nearby bus terminal. Her husband brought her back to the hospital, where she was found to be disoriented to time and place and displayed serious memory disturbances. Mrs. D had serious difficulty learning new information and could not remember events which had taken place even during the previous few days. She had difficulty remembering her name, her age and her address. She was able to recognize her relatives and the treating staff, but was unable to remember their names. The same phenomena occurred in relation to many objects: she was able to recognize them and even use them correctly, but could not identify them even after she had been told what they were called. At the same time, although the patient seemed to be aware of her memory problems, she
VoL 17., No. S., 1992
appeared alert, her thinking processes were well organized, she did not show signs of perceptual disturbances. No delusions could be detected, and she behaved in a calm and cooperative manner. She was diagnosed as having acute amnestic syndrome with signs of disorientation. No abnormalities were found on general physical examination, fundus, blood cell count, urine tests, electrolytes balance, liver function examination and LP. No pathological findings appeared on either the CT or the ECG. The EEG showed delta waves in the fronto-temporal regions. Treatment of this acute condition consisted mainly of supportive psychotherapy and some memory exercises. After two days the patient was well-oriented again. The memory disturbances gradually receded, and after two weeks, completely disappeared. The EEG normalized at a slower pace, and after three months returned to normal.
DISCUSSION The acute transient amnestic syndrome with disorientation in our patient appeared suddenly, 48 hours after the administration of the last of a series of five ECT treatments. No definite organic injury, neurological or otherwise, could be clearly demonstrated by the physical or laboratory tests, apart from the changes in EEG, which will be discussed below. Acute amnestic syndrome, which is found in patients who have undergone ECT, has a clinical picture similar to a variety of conditions, such as grand mal epilepsy, head injuries, diencephalic tumors and Korsakoff's syndrome (Daniel and Crovitz 1986; Trimble and Thompson 1986; Weiner 1989). ECT acts particularly on the temporal lobes and adjacent areas; it appears that it is the resulting neurological impairment which constitutes the principal pathogenic factor of the amnesia and the disorientation which follows the ECT (Warren and Croome 1984). This clinical phenomenon is more common after bilateral ECT (Heshe et al 1978), which was used with this patient. 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).
November 1992
DelayedECT-inducedamnesia
193
Our patient was treated with ECT for a depressive illness Devanad DP, Verma AK, Tiruumalasetti F, Sackheim HA which is known to affect memory as a result of emotional (1991) Absence of cognitive impairment after more than withdrawal, lack of interest in the external object world and 100 lifetime ECT treatments. Am J Psychiatry 148:929apathy (Weiner 1989). However, in this case, the memory 932. disorders appeared after the ECT and after the patient's Freeman CPL, Kendall RF (1980) ECT: patients' experidepression had cleared up completely. It seems very unlikely ences and attitudes. Br J Psychiatry 137:8-16. that simple or organic factors played a role in the post-ECT transient amnesia, since there was no laboratory evidence of Friedberg J (1977) Shock treatment, brain damage and memory loss: a neurological perspective. Am J Psychiatry infection, blood sugar fluctuations or other physical causes 134:1010-1013. which could result in a period of lucidity and subsequent transient delirium and memory loss. Heshe J, Roder E, Theilgaard A (1978) Unilateral and bilatIn conclusion, this patient presented with a rare form of eral ECT: a psychiatric and psychological study of therapost-ECT acute amnestic syndrome with disorientation, peutic effect and side effects. Acta Psychiatr Scand which is atypical because the transitory memory disturbance (Suppl): 275-280. appeared more than 48 hours after a course of ECT, during Leniel WF, Crovitz HF (1987) Neuropsychological aspects which time the patient had been symptom-free. of disorientation. Cortex 23:169-187. The possibility of delayed reversible cognitive complications with ECT should be taken into consideration in prepar- Squire LR (1977) ECT and memory loss. Am J Psychiatry 134:997-1001. ing the patient and his or her family for ECT, especially when administered in the outpatient clinic. Close supervision is Squire L, Slater PC (1983) Electroconvulsive therapy and required for outpatients treated with bilateral ECT which is complaints of memory dysfunction: a prospective threeadministrered two or three times a week and also for inpayear follow-up study. Br J Psychiatry 142:1-8. tients who are being treated with the same procedure during Trimble MR, Thompson PJ (1986) Neuropsychological and their weekend leave. behavioral sequelae of spontaneous seizures. Ann N Y Acad Sci 462:284-292. Warren EW, Croome DH (1984) Memory test performance REFERENCES under three different wave forms of ECT for depression. Br J Psychiatry 144:370-375. American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Weiner RD (1989) Electroconvulsive therapy. In: Kaplan HI, Sadock B (eds). Comprehensive Textbook of Psychiatry, Revised. Washington, DC: American Psychiatric Press, Volume 2, Fifth Edition. Baltimore, MD: Williams and Inc. Wilkins, pp 1670-1678. Daniel WF, Crovitz HF (1986) Disorientation during electroconvulsive therapy. Ann N Y Acad Sci 462:293- Weiner RD (1984) Does ECT cause brain damage? 306. Behavioral and Brain Science 7:1-53.
