ELECTROCONVULSIVE THERAPY

From Big Medical Encyclopedia

ELECTROCONVULSIVE THERAPY (Greek therapeia treatment; synonym: an electroshock, electroconvulsive therapy, a seismotherapy, an elektropleksiya) — a method of treatment mentally sick, based on calling at them convulsive states by means of electrostimulation of a brain.

AA. t. it is offered in 1938 by the Italian psychiatrists Cherletti and Bini. The method was widely adopted thanks to relative technical simplicity and bystry achievement to lay down. effect; however the exaggeration of the related risk, need of more careful, than at other methods of treatment, training of patients, and also (see) led progress of psychopharmacology to the fact that in 50 — the 60th are 20 century use E. t., as well as to an insulin therapy (see Schizophrenia), became limited. In a crust. time interest to E. t. again increased owing to growth long, resistant to psychopharmacological means (see) mental disorders, and also because numerous modifications of a method (carrying out E. t. against the background of muscle relaxants, in the conditions of a short-term anesthesia, monolateral E. t. — imposing of both electrodes in one temporal area; considerably reduced danger of complications and allowed to exclude many, earlier being considered as serious contraindications and complications).

Indications to E. t. long depressions at various mental diseases are, in structure to-rykh there are permanent depersonalizatsionny, crazy, struporous, senestopathetic, hypochiondrial and obsessivny frustration, persistent suicide tendencies, agitation. AA. t. it is most effective at a febrile catatonia (see Schizophrenia). At the maniacal, chronic hallucinatory paranoid conditions, the phenomena of mental automatism (see Kandinsky — Klerambo a syndrome) observed at schizophrenia after the long and not giving effect psychopharmacotherapy many researchers consider E. t. as method of the choice.

Absolute contraindications to E. t. — organic lesions of c. N of page with signs of increase in intracranial pressure, a tumor of a brain, vascular aneurism, coronary insufficiency, persistent arrhythmia, disturbance of the carrying-out system of heart, the dekompensirovanny heart diseases, a hypertension of the III stage, active forms of pulmonary tuberculosis which are followed by allocation of mycobacteria, exudative pleurisy, chronic pneumonia. Relative contraindications are the compensated heart diseases, a hypertension of the I—II stage, moderately expressed atherosclerotic disturbances postponed in the past of an injury of a skull with a long loss of consciousness, pulmonary diseases without respiratory insufficiency and danger of bleedings, a peptic ulcer, endocrinopathies. AA. t. do not carry out to the period of pregnancy.

At E. t. impact on a brain includes the electrostimulating, convulsive and anamnestic components. The mechanism of therapeutic action is found insufficiently out. Nek-ry researchers connect antidepressive effect E. t. with stimulation of a row of brain systems of biogenic amines. In particular, under the influence of electrostimulation emission of noradrenaline, dopamine and a 5-gidroksitriptamin accrues, and also sensitivity of noradrenalinovy, dopamine and 5-gidroksitriptaminovy receptors in hypothalamic structures of a brain increases that promotes recovery of normal functioning of those neurobiochemical systems, suppression to-rykh in many respects responsibly for development of affective frustration of a depressive range.

Depending on selection of such characteristics of electric current as its force (in amperes), tension and time of passing (ekpozition), can be caused in the person various on a razvernutost a wedge. pictures convulsive paroxysms: big convulsive attacks with a loss of consciousness, not developed (abortal) attacks, and also absentias epileptica — short-term switching off of consciousness (see Epilepsy). The antidepressive effect considerably is defined by the size of convulsive activity: the above the last, the bigger therapeutic effect can be expected. This circumstance should be considered also at purpose of the accompanying treatment. E.g., some tranquilizers of a benzodiazepine row (chlordiazepoxide, nitrazepams) possessing the expressed anticonvulsive action extend a latent phase of an attack, oppress him a convulsive component and in general reduce to lay down. effect E. t., therefore it is necessary to abstain from their appointment as the means stopping alarm and fear of the patient of the procedure E. t.

Anamnestic disturbances at E. t. are characterized by various expressiveness, are noted at most of patients after 4 — 5 sessions and in several days after end of a course of treatment pass, without demanding special intervention. Deep and long anamnestic disturbances can sometimes be observed owing to the overestimated dosage of electric current and unfairly long series of sessions. Use monolateral E. t., offered by Lancaster, Steynert and Frost (N. P. Lancaster, R. R. Steinert, I. Frost) in 1957, the risk of emergence of anamnestic disturbances allows to lower, especially at prolonged treatment.

The equipment for E. t. it is based on use of an alternating harmonic current with a frequency of 50 Hz with a voltage from 60 to 110 in or the one-half-period straightened current of the same frequency by voltage of 220 V; current is varied from 0 to 250 ma, and its exposure — from 0,1 to 1 sec. At a usual method electrodes impose bilateralno on temporal areas of the head of border of growth of hair, at monolateral E. t. them have on the party of not dominating hemisphere, i.e. on the right side of the head of right-handed persons and on left at lefthanders: one on the line which is conditionally connecting outside acoustical pass to a lateral corner of an eye, and another — is several centimeters higher than the first.

The minimum electric characteristics (current, tension and exposure) necessary to cause a convulsive attack, are especially individual, select them empirically. Begin usually with 80 in and exposures 0,5 sec. In case of absence of an attack approximately in a minute the procedure is repeated, having increased tension on 10 — 15 in or exposure by 0,1 sec. If the attack did not come again, the procedure is carried out once again at the same increase in tension or time of passing of current (at the same time it is not recommended to increase both) and so continued before achievement of the developed convulsive attack. It is necessary to cause an attack, otherwise at the patient at superficial devocalization there will not come retrograde amnesia and extremely burdensome memories of the procedure and respectively the negative relation to this method of treatment will remain. At the subsequent sessions usually leave the picked-up dosage of current. If convulsive activity becomes more powerful and long, tension of current is reduced further, and at increase of a convulsive threshold it is increased (on 10 — 15 in).

The USSR applies electroconvulsive therapy only in the conditions of a psychiatric hospital, the doctor by means of an average and junior medical staff carries out it surely; abroad the method widely practices and is out-patient.

AA. t. carry out, as a rule, in the morning, after bladder emptying and intestines, it is obligatory on an empty stomach for prevention of possible vomiting and aspiration of emetic masses (with the same purpose delete removable dentures). The patient lays down on a couch, under a back enclose it the small roller (the curtailed sheet, a small rigid pillow) for prevention of retraction of language and disturbances of breath after the termination of an attack, and also for reduction of mechanical load of a backbone at sharp muscular contractions during spasms. Electrodes densely fix on the head a rubber tape. To prevent tongue biting and cheeks, between molars of the patient insert a wadded and gauze tampon in the form of the roller; the tampon is deleted as soon as reduction of masseters after the termination of an attack stops.

The developed attack without premedication has spastic, latent, tonic, clonic and coma phases. Inclusion of current instantly causes spastic reduction of face muscles, a neck and partially a trunk and upper extremities, the proceeding entire period of exposure of current (several tenth fractions of a second). In that case when tension of current is insufficient, at the termination of passing of current muscles of the patient immediately relax, eyes open, at the same time consciousness, despite devocalization, completely is not lost, i.e. not developed attack is observed. If tension is enough, there comes dead faint, the muscular spasm generalizutsya and there is an opisthotonos (see). After the termination of passing of current the opisthotonos weakens a little, the patient falls a back on a couch and remains without movements to 20 — 30 sec.; at the same time breath is absent, the cordial rhythm is speeded sharply up. The latent phase of an attack is replaced by a phase of tonic spasms, edges begins sometimes with the short squeezed shout. In this phase it is necessary to hold a mandible of the patient from below what it would not push out a tampon from a mouth or there was no her dislocation. Tonic spasms proceed to 10 — 15 sec. and are replaced clonic, to-rye, gradually generalizuyas, cover muscles of extremities and a trunk and proceed to 40 — 60 sec. By the end of a phase of clonic spasms intensity of muscular contractions gradually weakens, then spasms stop, and there comes the coma phase. At the beginning of a phase tachycardia is noted, pulse is intense, is raised the ABP, the apnoea, the taking place in a convulsive phase of an attack can keep. Breath is recovered in 10 — 20 sec., and most often right after the termination of spasms, cordial activity is normalized, and the coma phase can imperceptibly pass into the dream proceeding of several minutes before half an hour. Sometimes the coma phase passes into a dream, passing more or less short period of twilight disorders of consciousness with chaotic motive initiation, confusion, a disorientation and disturbance of judgment surrounding. If after a spastic phase of an attack at dead faint the convulsive phase does not develop (absentia epileptica), during the holding the subsequent sessions it is necessary to increase tension of current. Attacks at E. t., as well as at epilepsy, are followed by their full amnesia.

For prevention of traumatic damages (fractures and dislocations) of the patient it is not necessary to fix rigidly, it is enough to limit amplitude of movements of extremities only. To avoid compression spinal fractures or a separation of acanthas because of sharp muscular contractions, it is necessary to support the patient under a back and a waist and not to allow a sharp deflection of a back during spasms.

The course of treatment consists of several sessions: from 3 — 4 to 15 — 20 and more. It is possible to judge therapeutic effect after 3 — 4 sessions; if it is tended to improvement of a mental state, for achievement of good result there are enough 2 — 3 more sessions; if after the first sessions the state does not change, then to carry out E. t. it is inexpedient. However with reliability it is possible to judge results of treatment in several days after its end. The most optimum is the course E. t., consisting of 4 — 6 sessions held every other day. In some cases, napr, at heavy depressions with intensive agitation and persistent suicide tendencies, daily holding sessions is shown.

The most frequent complications E. t., especially if to carry out it without use of muscle relaxants, injuries of a musculoskeletal system are: dislocations of a mandible, a shoulder are also much more rare compression fractures of bodies of chest and lumbar vertebrae, and also fractures of a hip at the level of his neck. Are necessary for prevention of injuries premedication muscle relaxants and the correct nosotrophy in time a priladka. The second place on frequency is taken by complications from cardiovascular system (from lungs — tranzitorny arrhythmias p kollaptoidny attacks to very terrible, though extremely rare, such as cordial blockade or fibrillation of auricles). As a preventive measure introduction, especially sick with signs of vegetative stigmatization, for half an hour prior to a session of 0,5 ml of 0,1% of solution of Atropini sulfas is shown that prevents also undesirable aspiration of saliva at hypersalivation in a coma phase. For fight against disturbance of cordial activity enter Cordiaminum, caffeine, adrenaline is more rare, apply inhalations of oxygen. Complications from respiratory system are possible. It should be noted that short-term breath holdings directly after the termination of spasms are among components of the attack and a complication are not. If the apnoea proceeds longer 10 — 20 sec., stimulation of breath is necessary: that there was no retraction of language, the head of the patient is turned on one side and carry out massage of a thorax by rhythmical pressing by palms at the level of costal arches. It is possible to apply as well other methods of stimulation of breath (see. Artificial respiration). Usually several rhythmical pressing are enough for «start» of breath, but at its more long frustration are necessary introduction of stimulators of a respiratory center (lobeline, etc.) and transition to the managed breath. Are described a case of development of pneumonia and abscesses of the lungs caused by aspiration of saliva in coma and an aggravation of tubercular process. From complications disorders of consciousness with an oglushennost and confusion out of attacks are noted; they are very rare and demand the termination E. t. Spontaneous epileptiform spasms out of attacks during the carrying out E. t. speak about existence of organic pathology of c. N of page, in this case it is necessary to refuse continuation E. t. After several sessions E. t. maniacal states can develop that testifies to the bipolar course of psychosis (alternation of depressive and maniacal phases). Such maniacal flashes are successfully stopped by 2 — 3 additional sessions of electroconvulsive therapy.

After end of a course E. t. at many patients within several days the torpidnost (rigidity) of thinking, slackness, bystry fatigue is noted, eventually they pass independently.

The risk of traumatic complications is practically excluded during the use of muscle relaxants a chicken-repodobnogo of action (see Kurarepodobny substances), to-rye, causing short-term paralysis of skeletal muscles, eliminate a possibility of dislocations, fractures of bones or ruptures of sheaves during an attack. Widely apply Dithylinum (see) and other muscle relaxants. The effect occurs in the first 30 sec. and lasts sometimes up to 2 — 3 min. At emergence of signs of muscular relaxation (in 25 — 30 sec. after administration of drug) cause an attack.

AA. t. in the conditions of a short-term anesthesia carry out for the purpose of mitigation of fear of the patient of this procedure. For an anesthesia use most often barbiturates (see), for example 2 — 2,5% solution of hexenal or 2,5% solution of Thiopentalum-natrium, to-rye prepare just before the use. Sometimes the anesthesia is combined using muscle relaxants, at the same time permanent disturbances of breath, and also a condition of heavy psychomotor excitement after the termination of an attack develop. Therefore use of an anesthesia and muscle relaxants demands existence of the equipment for the managed breath. In this case E. t. the doctor and paramedical staff owning methods of resuscitation will see off.

Bibliography: Avrutsky G. Ya. and Neduva A. A. Treatment of mental patients. M, 1981; Depressions, Questions of clinic, psychopathology, therapy, under the editorship of E. Ya. Shternberg and A. B. Smulevich, page 7, M. — Basel, 1970; The Guide to psychiatry, under the editorship of A. V. Snezhnevsky, t. 1, page 258, M., 1983; Cerletti and. Bini L. Un nuovo metodo di shockterapia: «L'elettroshock», Boll. Accad. med. Roma. v. 64, p. 136, 1938; Ey H., Berhard P. et Brieset Ch. Manual de psychiatrie, P., 1974; Grahame Smith D. G., Green A. R. and. Costain D. W. Mechanism of antidepressare action of electroconvulsive therapy, v. 1, p. 254, 1978; Hamilton X Le pronostic dans les depressions, Rev Med. (Paris), t. 21, p. 139, 1980; Ottosson J. Lake of La sismotherapie uni-et bilaterale: mecanisme d’action, Encephale, t. 5. p. 617, 1979; Petit M. Indication actuelles de l'electrochoc, Rev. Med. (Paris), t. 21, p. 205, 1980.

B. B. Teal.

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