WILLIAM KARLINER, M.D.
ECT for patients with CNS disease ABSTRACT: Many psychiatric patients with concomitant neurologic disorders can be successfully treated with electroconvulsive treatments (ECT). The selection of patients and the appropriate technique must be made by a psychiatrist experienced in the use of ECT. Untreated mental illness can lead to chronic disability; conversely, careful treatment of such patients may be followed by partial or complete recovery from the mental illness, and improvement in the neurologic symptoms. In the past, ECT for patients with concomitant organic diseases of the central nervous system (CNS) was contraindicated" With the use of the intravenous drip method,2.3 however, it has become feasible to give ECT even to patients with this group of complicating diseases. With the drip method the total amount of ultra-short-acting barbiturates required to induce amnesia is one half to one third the amount necessary for induction when rapid intravenous injections are used. Moreover, the drip method also decreases the amount of succinylcholine chloride required to achieve maximum muscle relaxation. Since the ECT itself causes some transient apnea after the induced seizure, it is imperative to do DECEMBER
1~8'VOL
19·N012
everything possible to keep to a minimum this potentially dangerous post-convulsive condition. Therefore, the decrease in the medication used plus the modified convulsive treatment eliminates most complications. In addition, it is essential to continuously administer oxygen, with and without pressure, for proper ventilation of the lungs until adequate spontaneous respiration is restored. Finally, when the needle is left in situ throughout the treatment with this drip method, one eliminates the necessity of switching from one syringe to the other, thus avoiding vein wall damage. This can also become a "lifeline" for the administration of other necessary drugs should any complication necessi-
tate such action during the course of or following the treatment.
Case histories In 1951 Savitsky and Karliner' successfully treated two multiple sclerosis patients undergoing manicdepressive psychosis. No deleterious effects were noted on the intensity or course of the disseminated sclerosis following these treatments, and there were no signs of the organic mental syndrome or affective lability often seen in patients with multiple sclerosis. There was no significant change in the neurologic status of either of the patients, and one, who had hemiparesis of one year's duration, improved during treatment. Of particular interest to us, was a woman who had become bedridden and incontinent following a manic-depressive episode. When her mental condition improved she was able to walk without a cane (with less ataxia), and regained her bladder control. We attributed the apparent functional improvement in her neurologic condition to the implOvement in her mental status. 781
ECT in CNS disease
Since then I have treated two more patients with multiple sclerosis and concomitant mental illness. One 36-year-old female patient suffered from multiple sclerosis with manic behavior. Even though she was able to ambulate with a cane prior to the commencement of her manic episode, she subsequently could not walk at all; became loud, argumentative, and abusive. She received six ECTs which produced a remarkable change in her behavior. Her affect became appropriate, she could be reasoned with, and she showed insight into her past abnormal behavior. After recovery from her manic episode, she walked with less ataxia. In spite of the improvement in her functional ability, neither a beneficial nor a deleterious effect was noted on the intensity or the course of her multiple sclerosis. The other patient was a 30-year-old female who was suffering from multiple sclerosis and developed a severe unipolar depression which totally disabled her. This patient received five ECTs and her depressed state improved rapidly. No ill effect on her neurologic condition was noted. Cerebrovascular accidents The presence of cerebrovascular accidents complicates the treatment of functional psychoses. Seventeen years after a four-year depressive episode, a 75-year-old woman suffered a recurrence that lasted three years. Some months after her recovery from the second episode her left leg suddenly became weak. Examination confirmed the weakness in the lower leg and revealed increased deep tendon reflexes and a positive Babinski sign. A diagnosis of anterior cerebral artery occlusion was made. 782
Shortly thereafter, she relapsed into depression, showed agitation, and became preoccupied with selfdestruction. Additional ECTs resulted in marked improvement of her depression. The weakness of the left lower limb as well as the positive neurologic signs disappeared following the treatments. A 58-year-old woman with cerebrovascular disease suffered a severe depression of six months' duration. She had had two such previous episodes, one 18 years before, and another three years before. At the age of 48, she suffered a left hemiparesis which cleared up completely except for a left lower facial weakness. She received five ECTs for the recent depressive episode and made an uneventful recovery. No additional neurologic signs were noted following this course of treatments. A 70-year-old woman who had suffered periodic attacks of atrial fibrillation over a period of three years suffered a myocardial infarct about two months prior to her psychiatric hospitalization and then had a cerebrovascular accident. She became severely depressed and agitated, expressed suicidal thoughts, and was observed striking her head against the wall, stating that no one could help her. In spite of her physical complications, she received 13 ECTs that improved her mental condition with no change in neurologic status. Another 72-year-old woman became depressed for no specific reason. She lost interest in things, ate poorly, and found it difficult to do her usual work. There was no history of any prior attacks of depression. Four years before her depressive episode she suffered a coronary infarct, and three years ago a cerebrovascular accident which re-
sulted in left hemiplegia. This patient had arteriosclerotic heart disease and hypertensive heart disease. Her blood pressure was 210/ 120. She failed to respond to antidepressants and made a suicide attempt by ingesting 22 IOO-mg pentobarbital capsules. Ten days after her recovery from the barbiturate coma, she remained severely agitated and was in a disabling depression. She received five ECTs and her depression improved rapidly, although her neurologic and cardiovascular conditions remained unchanged. Other complications Kalinowskys gave electroshock treatments to a patient undergoing an involutional melancholia; this patient had severe hemiparesis and hemianopia due to a cerebrovascular accident. When her emotional condition improved, her motor weakness and visual impairment became less marked, though there was no objective change in her neurologic status. A 44-year-old woman received 20 ECTs for a paranoid psychosis with auditory hallucinations of two years' duration. She had a history of epilepsy, severe hydrocephalus, spastic paraparesis and bilateral Babinski signs. There was no focal lesion. Following her treatments, the patient's mental condition improved, though no change was observed in her neurologic condition. A 31-year-old epileptic woman who had some residual deformity of her feet due to poliomyelitis, underwent an acute psychotic episode. She became aggressive, overtalkative, expressed grandiose ideas, and felt that people wanted to kill her. After a suicide attempt she received three ECTs, after which she completely recovered PSYCHOSOMATICS
from her psychosis. No ill effect resulted from her treatments and she continued to take her anticonvulsant medication, phenytoin 100 mg, t.i.d. Often, some cases of epileptic cloudy states or rages respond well to a single electroshock treatment. To date. no scientifically valid explanation has been offered for this observation. Head injury Savitsky and Karline ... gave electroconvulsive treatments to patients with a history of moderately severe head injury and concomitant mental disease. One of these patients, a 16-year-old, suffered a cerebral concussion, postconcussion syndrome. and traumatic convergence spasm. Following the accident. she was unable to study or attend school. Eight months after her head injury, the patient developed a paranoid psychosis. She received 18 treatments during a period of six weeks and improved mentally. No neurologic complications ensued. A 27-year-old patient sustained a fracture of the skull in an automobile accident and was unconscious for five days. Following the accident, she became irritable and quarrelsome. and eventually accused members of her family of plotting against her. She stopped seeing her friends and was observed talking to herself and smiling inappropriately. She received 20 ECTs that improved her mental condition. Neurologically, there were no complications. A 24-year-old woman suffered a head injury during an automobile accident and lost consciousness.
Following this accident, marked personality and behavior changes were noted. Three months later she developed a catatonic state, received 20 ECTs and remained symptom-free for five years. No neurologic changes were noted after her treatment was terminated. Many patients with parkinsonian disease7 have received ECT for coincidental mental changes. Often the mental improvement was accompanied by some degree of functional improvement. DelaYS reported a 42-year-old woman who received six ECTs for a depressive reaction. Her depression became worse and five months following the last treatment she had a grand mal seizure. The neurologic re-examination was negative. Immediately after a spinal tap, the patient suffered another grand mal seizure which was accompanied by urinary incontinence. This time she showed right side hyperactive reflexes and an equivocal right side Babinski sign. In addition, she developed acalculia, agraphia, dyslexia, finger agnosia, and right-left disorientation. A second ventriculogram showed changes indicating an expanding lesion of the left parietotemporal region. After removal of a glioma, the patient's mental depression disappeared. Delay stressed that the electroshock, which precipitated the epileptic seizures, made possible early diagnosis and treatment of this brain tumor. Distinguishing symptoms The mental symptoms of general paresis are often indistinguishable from functional psychoses. Some
Dr. Karliner is in the private practice of clinical psychiatry in Westchester County. N. Y. and New York Ci~Y. Reprint requests to him at 20 Franklin Road, Scarsdale, NY
10583. DECEMBER 1978' VOL 19· NO 12
patients are uncooperative or their mental symptoms do not respond to penicillin treatment. In such instances, electroconvulsive therapy may be a definite help. I treated three such patients who were suffering from tertiary syphilis. In addition to approximately 20 million units of penicillin, these patients received from 4 to 20 electroconvulsive shock treatments. All patients improved considerably, with no neurologic complications. With the renewed interest in ECT, it is important to emphasize that many psychiatric patients with complicated neurologic disease can be treated effectively with ECT without aggravating their neurologic condition. In order to achieve this, it is advisable to use the drip method for administering anesthesia and muscle relaxation. These procedures should be undertaken in the company of an anesthesiologist familiar with this method. In addition, continuous and adequate oxygenation with 100% oxygen is essential until the patient begins to breathe spontaneously. 0 REFERENCES 1. savitsky N. Karliner W: Electroshock in the presence of organic disease of the central nervous system. J Hillside Hasp. 2:3, January t953, 2. Kahnowsky LB, Hoch PH: Somatic Treatments in Psychiatry. New York, Grune & Stratton. 1961. pp 147-148. 3. Dell'Aria S, Karhner W: Anesthesiologic considerations in psychiatric convulsive therapy. Behav Neuropsychiatry. 6:6. April-December 1974. 4. savitsky N. Karliner W: Electroshock therapy and mul1iple sclerosis, NY State J Med, 51: 788, 1951. 5. Kalinowsky LB: Die Elektrokrampfbehandlung in ihrer Beziehung Zur Neurolcgie. Monatsschr Psychiatrie Neurologie. Separatum, 117:5-7, 1949, 6. savitsky N. Karliner W: Electroshock in the presence of organic disease of lhe central nervous syslem. J Hillside Hasp. 2:3, January 1953. 7. Kaplan LA, Dennis Freund J: Electroshock therapy in patients with severe organic disease. 11/ Med J, 96:96. February 1949. 8. Delay J: The Sequels of Electroshock. La Prvsse Medicate, 39:533. 1946.
783
ECT for patients with CNS disease ABSTRACT: Many psychiatric patients with concomitant neurologic disorders can be successfully treated with electroconvulsive treatments (ECT). The selection of patients and the appropriate technique must be made by a psychiatrist experienced in the use of ECT. Untreated mental illness can lead to chronic disability; conversely, careful treatment of such patients may be followed by partial or complete recovery from the mental illness, and improvement in the neurologic symptoms. In the past, ECT for patients with concomitant organic diseases of the central nervous system (CNS) was contraindicated" With the use of the intravenous drip method,2.3 however, it has become feasible to give ECT even to patients with this group of complicating diseases. With the drip method the total amount of ultra-short-acting barbiturates required to induce amnesia is one half to one third the amount necessary for induction when rapid intravenous injections are used. Moreover, the drip method also decreases the amount of succinylcholine chloride required to achieve maximum muscle relaxation. Since the ECT itself causes some transient apnea after the induced seizure, it is imperative to do DECEMBER
1~8'VOL
19·N012
everything possible to keep to a minimum this potentially dangerous post-convulsive condition. Therefore, the decrease in the medication used plus the modified convulsive treatment eliminates most complications. In addition, it is essential to continuously administer oxygen, with and without pressure, for proper ventilation of the lungs until adequate spontaneous respiration is restored. Finally, when the needle is left in situ throughout the treatment with this drip method, one eliminates the necessity of switching from one syringe to the other, thus avoiding vein wall damage. This can also become a "lifeline" for the administration of other necessary drugs should any complication necessi-
tate such action during the course of or following the treatment.
Case histories In 1951 Savitsky and Karliner' successfully treated two multiple sclerosis patients undergoing manicdepressive psychosis. No deleterious effects were noted on the intensity or course of the disseminated sclerosis following these treatments, and there were no signs of the organic mental syndrome or affective lability often seen in patients with multiple sclerosis. There was no significant change in the neurologic status of either of the patients, and one, who had hemiparesis of one year's duration, improved during treatment. Of particular interest to us, was a woman who had become bedridden and incontinent following a manic-depressive episode. When her mental condition improved she was able to walk without a cane (with less ataxia), and regained her bladder control. We attributed the apparent functional improvement in her neurologic condition to the implOvement in her mental status. 781
ECT in CNS disease
Since then I have treated two more patients with multiple sclerosis and concomitant mental illness. One 36-year-old female patient suffered from multiple sclerosis with manic behavior. Even though she was able to ambulate with a cane prior to the commencement of her manic episode, she subsequently could not walk at all; became loud, argumentative, and abusive. She received six ECTs which produced a remarkable change in her behavior. Her affect became appropriate, she could be reasoned with, and she showed insight into her past abnormal behavior. After recovery from her manic episode, she walked with less ataxia. In spite of the improvement in her functional ability, neither a beneficial nor a deleterious effect was noted on the intensity or the course of her multiple sclerosis. The other patient was a 30-year-old female who was suffering from multiple sclerosis and developed a severe unipolar depression which totally disabled her. This patient received five ECTs and her depressed state improved rapidly. No ill effect on her neurologic condition was noted. Cerebrovascular accidents The presence of cerebrovascular accidents complicates the treatment of functional psychoses. Seventeen years after a four-year depressive episode, a 75-year-old woman suffered a recurrence that lasted three years. Some months after her recovery from the second episode her left leg suddenly became weak. Examination confirmed the weakness in the lower leg and revealed increased deep tendon reflexes and a positive Babinski sign. A diagnosis of anterior cerebral artery occlusion was made. 782
Shortly thereafter, she relapsed into depression, showed agitation, and became preoccupied with selfdestruction. Additional ECTs resulted in marked improvement of her depression. The weakness of the left lower limb as well as the positive neurologic signs disappeared following the treatments. A 58-year-old woman with cerebrovascular disease suffered a severe depression of six months' duration. She had had two such previous episodes, one 18 years before, and another three years before. At the age of 48, she suffered a left hemiparesis which cleared up completely except for a left lower facial weakness. She received five ECTs for the recent depressive episode and made an uneventful recovery. No additional neurologic signs were noted following this course of treatments. A 70-year-old woman who had suffered periodic attacks of atrial fibrillation over a period of three years suffered a myocardial infarct about two months prior to her psychiatric hospitalization and then had a cerebrovascular accident. She became severely depressed and agitated, expressed suicidal thoughts, and was observed striking her head against the wall, stating that no one could help her. In spite of her physical complications, she received 13 ECTs that improved her mental condition with no change in neurologic status. Another 72-year-old woman became depressed for no specific reason. She lost interest in things, ate poorly, and found it difficult to do her usual work. There was no history of any prior attacks of depression. Four years before her depressive episode she suffered a coronary infarct, and three years ago a cerebrovascular accident which re-
sulted in left hemiplegia. This patient had arteriosclerotic heart disease and hypertensive heart disease. Her blood pressure was 210/ 120. She failed to respond to antidepressants and made a suicide attempt by ingesting 22 IOO-mg pentobarbital capsules. Ten days after her recovery from the barbiturate coma, she remained severely agitated and was in a disabling depression. She received five ECTs and her depression improved rapidly, although her neurologic and cardiovascular conditions remained unchanged. Other complications Kalinowskys gave electroshock treatments to a patient undergoing an involutional melancholia; this patient had severe hemiparesis and hemianopia due to a cerebrovascular accident. When her emotional condition improved, her motor weakness and visual impairment became less marked, though there was no objective change in her neurologic status. A 44-year-old woman received 20 ECTs for a paranoid psychosis with auditory hallucinations of two years' duration. She had a history of epilepsy, severe hydrocephalus, spastic paraparesis and bilateral Babinski signs. There was no focal lesion. Following her treatments, the patient's mental condition improved, though no change was observed in her neurologic condition. A 31-year-old epileptic woman who had some residual deformity of her feet due to poliomyelitis, underwent an acute psychotic episode. She became aggressive, overtalkative, expressed grandiose ideas, and felt that people wanted to kill her. After a suicide attempt she received three ECTs, after which she completely recovered PSYCHOSOMATICS
from her psychosis. No ill effect resulted from her treatments and she continued to take her anticonvulsant medication, phenytoin 100 mg, t.i.d. Often, some cases of epileptic cloudy states or rages respond well to a single electroshock treatment. To date. no scientifically valid explanation has been offered for this observation. Head injury Savitsky and Karline ... gave electroconvulsive treatments to patients with a history of moderately severe head injury and concomitant mental disease. One of these patients, a 16-year-old, suffered a cerebral concussion, postconcussion syndrome. and traumatic convergence spasm. Following the accident. she was unable to study or attend school. Eight months after her head injury, the patient developed a paranoid psychosis. She received 18 treatments during a period of six weeks and improved mentally. No neurologic complications ensued. A 27-year-old patient sustained a fracture of the skull in an automobile accident and was unconscious for five days. Following the accident, she became irritable and quarrelsome. and eventually accused members of her family of plotting against her. She stopped seeing her friends and was observed talking to herself and smiling inappropriately. She received 20 ECTs that improved her mental condition. Neurologically, there were no complications. A 24-year-old woman suffered a head injury during an automobile accident and lost consciousness.
Following this accident, marked personality and behavior changes were noted. Three months later she developed a catatonic state, received 20 ECTs and remained symptom-free for five years. No neurologic changes were noted after her treatment was terminated. Many patients with parkinsonian disease7 have received ECT for coincidental mental changes. Often the mental improvement was accompanied by some degree of functional improvement. DelaYS reported a 42-year-old woman who received six ECTs for a depressive reaction. Her depression became worse and five months following the last treatment she had a grand mal seizure. The neurologic re-examination was negative. Immediately after a spinal tap, the patient suffered another grand mal seizure which was accompanied by urinary incontinence. This time she showed right side hyperactive reflexes and an equivocal right side Babinski sign. In addition, she developed acalculia, agraphia, dyslexia, finger agnosia, and right-left disorientation. A second ventriculogram showed changes indicating an expanding lesion of the left parietotemporal region. After removal of a glioma, the patient's mental depression disappeared. Delay stressed that the electroshock, which precipitated the epileptic seizures, made possible early diagnosis and treatment of this brain tumor. Distinguishing symptoms The mental symptoms of general paresis are often indistinguishable from functional psychoses. Some
Dr. Karliner is in the private practice of clinical psychiatry in Westchester County. N. Y. and New York Ci~Y. Reprint requests to him at 20 Franklin Road, Scarsdale, NY
10583. DECEMBER 1978' VOL 19· NO 12
patients are uncooperative or their mental symptoms do not respond to penicillin treatment. In such instances, electroconvulsive therapy may be a definite help. I treated three such patients who were suffering from tertiary syphilis. In addition to approximately 20 million units of penicillin, these patients received from 4 to 20 electroconvulsive shock treatments. All patients improved considerably, with no neurologic complications. With the renewed interest in ECT, it is important to emphasize that many psychiatric patients with complicated neurologic disease can be treated effectively with ECT without aggravating their neurologic condition. In order to achieve this, it is advisable to use the drip method for administering anesthesia and muscle relaxation. These procedures should be undertaken in the company of an anesthesiologist familiar with this method. In addition, continuous and adequate oxygenation with 100% oxygen is essential until the patient begins to breathe spontaneously. 0 REFERENCES 1. savitsky N. Karliner W: Electroshock in the presence of organic disease of the central nervous system. J Hillside Hasp. 2:3, January t953, 2. Kahnowsky LB, Hoch PH: Somatic Treatments in Psychiatry. New York, Grune & Stratton. 1961. pp 147-148. 3. Dell'Aria S, Karhner W: Anesthesiologic considerations in psychiatric convulsive therapy. Behav Neuropsychiatry. 6:6. April-December 1974. 4. savitsky N. Karliner W: Electroshock therapy and mul1iple sclerosis, NY State J Med, 51: 788, 1951. 5. Kalinowsky LB: Die Elektrokrampfbehandlung in ihrer Beziehung Zur Neurolcgie. Monatsschr Psychiatrie Neurologie. Separatum, 117:5-7, 1949, 6. savitsky N. Karliner W: Electroshock in the presence of organic disease of lhe central nervous syslem. J Hillside Hasp. 2:3, January 1953. 7. Kaplan LA, Dennis Freund J: Electroshock therapy in patients with severe organic disease. 11/ Med J, 96:96. February 1949. 8. Delay J: The Sequels of Electroshock. La Prvsse Medicate, 39:533. 1946.
783
