EDITORIAL
Rage Against the (ECT) Machine Keith G. Rasmussen, MD
A
n occasional patient becomes quite angry at electroconvulsive therapy (ECT), claiming “permanent brain damage” and disability. There may be attempts at lawsuits or public defamatory statements about ECT or the practitioner who gave it to them. Such a scenario is obviously upsetting to clinicians, who may be hounded by contacts from the (usually ex-) patient (phone calls, e-mails, letters, items placed on social networking sites, etc) or sued. This is referable not specifically to patients' perceived amount of memory impairment with ECT but rather with how angry they are about it. That is, there are plenty of patients who, especially shortly after a course of treatments, believe that their memory is not working as well as usual but who are not hostile. They are patient enough to give the matter some time and experience improvement in day-to-day ability to recall newly learned information and get on with their lives. However, there is the occasional patient who, for a prolonged period, bitterly complains. Ironically, some of these people spend a great deal of time reading about ECT and become quite fluent in the ECT literature in spite of complaints of “brain damage.” The busy ECT practitioner might expect one of these types of patient to come along during the course of a career. Is there anything to be learned from this “rage against the ECT machine?” Lessons might come under 3 categories. First, is there any psychopathological feature at baseline that might predict such future behavior? Second, is there anything that can be done to prevent it in susceptible individuals? Third, are there any fundamental principles of human psychology at play that might be elucidated by studying peoples' emotional reactions to ECT? Regarding the first issue, I am not aware of any literature addressing predictors of future ECTdirected hostility. Of course, there is a several-decades-old literature on objective cognitive measures during and after ECT as well as on subjective ratings of memory function. However, there seems to be no literature other than personal testimonials on a patient's emotional reaction to their perceived memory impairment, a surprising gap considering how long ECT has been around and how long people have been complaining about it. Furthermore, it would be a relatively easy thing to measure: simply ask ECT patients questions such as “How bothered are you about your experience with ECT's effect on your memory? Are you angry? Do you feel that you have been harmed?” Patients who answer “yes” to these types of questions can then be compared with those who do not on measures such as personality disorders, age, sex, or previous traumatic experiences. I mention the personality and previous trauma issues because I believe that they are relevant to this subject. Patients who evince strong “Cluster B” personality types, particularly narcissism, probably represent a high-risk group for future ECT hostility. Furthermore, patients who have experienced traumas in which they were victimized (eg, childhood sexual abuse, various types of assault) might plausibly be considered high risks for future perceptions of “victimization” by ECT. That is, a person who has been victimized in some way and who has become vigilant in life for perceived threats to personal integrity (eg, many patients with posttraumatic stress disorder) might be more likely to perceive a treatment such as ECT as an assault. Regarding the question of preventive strategies, it is obvious that the standard of care in modern ECT practice is that patients should be given ECT voluntarily, after signing informed consent consisting of information about cognitive effects and, specifically, memory impairment. Interestingly, in this practitioner's approximately 25 years of career doing ECT for a fairly large number of court-ordered patients, this group does not seem to represent a high risk for future bitter ECT complaining. As Abrams1 pointed out, a public forum held at the National Institute of Mental Health some decades ago revealed that the 2 sources of anti-ECT hostility involved patients given it involuntarily (and without court approval) and those not told in advance of possible memory problems. However, even accounting for these 2 elements of modern ECT practice, there are still patients who end up bitterly complaining. One strategy might be to use milder forms of ECT, such as right unilateral ultrabrief pulse technique, but it is not clear that that would prevent ECT hostility, and using such a technique on every patient just to avoid the rare, one-in-hundreds future complainer seems overly defensive. Of course, if during the pre-ECT evaluation process a clinician suspects that the patient may react highly negatively to ECT, then simply not doing the treatment must be considered unless it is emergently needed. From the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. Received for publication June 24, 2014; accepted July 15, 2014. Reprints: Keith G. Rasmussen, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (e‐mail: [email protected]). The author has no conflict of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000171
Journal of ECT • Volume 31, Number 1, March 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
1
Journal of ECT • Volume 31, Number 1, March 2015
Editorial
The third issue regards lessons on human psychology to be learned by studying emotional reactions to ECT. For example, it is possible that transference-related reactions imbued by the symbolic nature of submitting oneself to “electrical stimulation” may, in susceptible individuals, lead to feelings of being victimized. Another profitable line of investigation would be to examine how an initial cognitive response to ECT, in the form of anterograde and retrograde amnesia, may set off a series of cognitive distortions that are self-fulfilling over time, leading to long-standing beliefs about one's own cognition that may be incorrect.
2
www.ectjournal.com
My general point here is that the ECT field would benefit from the study of emotional reactions to the ECT experience as a separate domain because there probably is more to this issue than mere objectively measured memory performance or subjectively assessed memory capability. REFERENCE 1. Abrams R. Electroconvulsive Therapy. 4th ed. New York, NY: Oxford University Press; 2002.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rage Against the (ECT) Machine Keith G. Rasmussen, MD
A
n occasional patient becomes quite angry at electroconvulsive therapy (ECT), claiming “permanent brain damage” and disability. There may be attempts at lawsuits or public defamatory statements about ECT or the practitioner who gave it to them. Such a scenario is obviously upsetting to clinicians, who may be hounded by contacts from the (usually ex-) patient (phone calls, e-mails, letters, items placed on social networking sites, etc) or sued. This is referable not specifically to patients' perceived amount of memory impairment with ECT but rather with how angry they are about it. That is, there are plenty of patients who, especially shortly after a course of treatments, believe that their memory is not working as well as usual but who are not hostile. They are patient enough to give the matter some time and experience improvement in day-to-day ability to recall newly learned information and get on with their lives. However, there is the occasional patient who, for a prolonged period, bitterly complains. Ironically, some of these people spend a great deal of time reading about ECT and become quite fluent in the ECT literature in spite of complaints of “brain damage.” The busy ECT practitioner might expect one of these types of patient to come along during the course of a career. Is there anything to be learned from this “rage against the ECT machine?” Lessons might come under 3 categories. First, is there any psychopathological feature at baseline that might predict such future behavior? Second, is there anything that can be done to prevent it in susceptible individuals? Third, are there any fundamental principles of human psychology at play that might be elucidated by studying peoples' emotional reactions to ECT? Regarding the first issue, I am not aware of any literature addressing predictors of future ECTdirected hostility. Of course, there is a several-decades-old literature on objective cognitive measures during and after ECT as well as on subjective ratings of memory function. However, there seems to be no literature other than personal testimonials on a patient's emotional reaction to their perceived memory impairment, a surprising gap considering how long ECT has been around and how long people have been complaining about it. Furthermore, it would be a relatively easy thing to measure: simply ask ECT patients questions such as “How bothered are you about your experience with ECT's effect on your memory? Are you angry? Do you feel that you have been harmed?” Patients who answer “yes” to these types of questions can then be compared with those who do not on measures such as personality disorders, age, sex, or previous traumatic experiences. I mention the personality and previous trauma issues because I believe that they are relevant to this subject. Patients who evince strong “Cluster B” personality types, particularly narcissism, probably represent a high-risk group for future ECT hostility. Furthermore, patients who have experienced traumas in which they were victimized (eg, childhood sexual abuse, various types of assault) might plausibly be considered high risks for future perceptions of “victimization” by ECT. That is, a person who has been victimized in some way and who has become vigilant in life for perceived threats to personal integrity (eg, many patients with posttraumatic stress disorder) might be more likely to perceive a treatment such as ECT as an assault. Regarding the question of preventive strategies, it is obvious that the standard of care in modern ECT practice is that patients should be given ECT voluntarily, after signing informed consent consisting of information about cognitive effects and, specifically, memory impairment. Interestingly, in this practitioner's approximately 25 years of career doing ECT for a fairly large number of court-ordered patients, this group does not seem to represent a high risk for future bitter ECT complaining. As Abrams1 pointed out, a public forum held at the National Institute of Mental Health some decades ago revealed that the 2 sources of anti-ECT hostility involved patients given it involuntarily (and without court approval) and those not told in advance of possible memory problems. However, even accounting for these 2 elements of modern ECT practice, there are still patients who end up bitterly complaining. One strategy might be to use milder forms of ECT, such as right unilateral ultrabrief pulse technique, but it is not clear that that would prevent ECT hostility, and using such a technique on every patient just to avoid the rare, one-in-hundreds future complainer seems overly defensive. Of course, if during the pre-ECT evaluation process a clinician suspects that the patient may react highly negatively to ECT, then simply not doing the treatment must be considered unless it is emergently needed. From the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. Received for publication June 24, 2014; accepted July 15, 2014. Reprints: Keith G. Rasmussen, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 (e‐mail: [email protected]). The author has no conflict of interest or financial disclosures to report. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000171
Journal of ECT • Volume 31, Number 1, March 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.ectjournal.com
1
Journal of ECT • Volume 31, Number 1, March 2015
Editorial
The third issue regards lessons on human psychology to be learned by studying emotional reactions to ECT. For example, it is possible that transference-related reactions imbued by the symbolic nature of submitting oneself to “electrical stimulation” may, in susceptible individuals, lead to feelings of being victimized. Another profitable line of investigation would be to examine how an initial cognitive response to ECT, in the form of anterograde and retrograde amnesia, may set off a series of cognitive distortions that are self-fulfilling over time, leading to long-standing beliefs about one's own cognition that may be incorrect.
2
www.ectjournal.com
My general point here is that the ECT field would benefit from the study of emotional reactions to the ECT experience as a separate domain because there probably is more to this issue than mere objectively measured memory performance or subjectively assessed memory capability. REFERENCE 1. Abrams R. Electroconvulsive Therapy. 4th ed. New York, NY: Oxford University Press; 2002.
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
