SHOCK THERAPY (ELECTROSHOCK). - It is among the most important methods for the organic treatment of mental disorders; its various procedures developed not logically but empirically, a fact that is moreover understandable in a field in which the various etiopathogeneses are almost unknown. The beginning of s. can be traced back to the independent and almost simultaneous discovery of the curative action of hypoglycemic coma (that is, linked to a strong decrease in the glucose content of the blood) and of convulsant pharmacological therapy.
Introduced into psychiatry by Steck, insulin was at first administered with the double purpose of increasing the patient's weight and of influencing states of excitation, especially in morphine addicts. The decisive step in the passage from a purely symptomatic medication to a curative treatment was taken by Sackel, of the Vienna clinic, in 1933, when he made the important observation that the deep hypoglycemic states, which involuntarily arose during the symptomatic treatment of psychotics with insulin injections, had an evident beneficial effect on the psychosis itself: the hypoglycemic coma, which Sackel's predecessors sought to avoid by moderating the quantity of the medication introduced, became the focus of the new treatment of schizophrenia (v.), a treatment that is today universally widespread and adopted in the form of insulin shock therapy (IST). A few years earlier, in 1928, von Meduna had reported on his attempts to treat schizophrenia with epileptic convulsions artificially induced with cardiazol. He had been moved by two observations (subsequently shown to be only relatively correct): that epilepsy and schizophrenia are antagonistic to each other; that schizophrenic symptoms can disappear, at least temporarily, after spontaneous convulsions. The same observation had previously led Nyiro to attempt, without any success, the treatment of schizophrenics with blood transfusions from epileptics (von Meduna had been preceded in the distant year 1785 by Oliver, who in the London medical journal had reported a case of "mania" successfully cured by convulsions induced by camphor).
The great diffusion and importance of convulsant treatments in psychiatric therapy was demonstrated at the First International Congress for the Modern Treatment of Schizophrenia, held at Münsingen (Switzerland) in 1937; it was here that Cerletti and Bini mentioned for the first time the possibility of using electric current as a convulsant stimulus in the treatment of schizophrenia. After a long period of experiments on animals, the two Roman scholars provoked convulsions by means of electricity in mentally ill patients and published their first works in '38: this was the birth of electroshock therapy (EST), which from Rome spread rapidly throughout the world.
The electric discharge provoking the shock, delivered by special apparatuses at a voltage of 100-120 volts, is applied to the temporal regions for about 2-4 tenths of a second (for the details of method, technique and physiopathology see the volume by Cerletti and Bini on ES).
It is not yet well established whether the attack should be considered a phenomenon of release or a positive phenomenon of excitation. It has been much discussed whether convulsive electric therapy (ES) can produce irreversible alterations in the nerve cells. Bini and Cerletti, after examining the brains of a large number of dogs subjected for a long time to ES, affirmed that lesions of this kind never occur, whereas they have instead been demonstrated in animals subjected to insulin or cardiazol shock. Even the most recent authors agree on this important affirmation: after an average of 10 ES the electroencephalographic alterations resemble those observed in cerebral concussion, but the tracing returns to normal after about a month of rest.
The indications of IST are represented almost exclusively by schizophrenic syndromes; given its complexity and delicacy, this treatment must be practiced under rigorous health supervision, by specialized medical personnel, in a suitable hospital.
The indications of EST are the following: 1) the affective psychoses (v.), which indeed constitute the group of illnesses in which the most brilliant results are obtained, especially in the depressive forms: there is prompt recovery (with 3-10 ES) of the episode in progress; the efficacy is notable also in "involutional melancholias," in which however a greater number of applications is necessary. 2) The schizophrenic syndromes, when IST is not feasible for particular reasons; in this vast group of patients the results are undoubtedly better with IST. The two s. can be combined, carrying out the mixed treatment, when there is an intense affective involvement or a marked psychomotor agitation, and in cases that have previously responded poorly to IST alone; the ES can be practiced during the first phase of the insulin coma, or in alternation with the comas themselves. In catatonic states a few applications of ES are often able to unblock the patients. 3) In the psychoneuroses EST is justified only in very severe cases resistant to psychotherapy, and in those obsessive forms that are accompanied by a strong anxious charge: indeed in such cases Bini and Bazzi propose "annihilation," that is, closely spaced applications of ES, even twice a day, until a complete or almost complete amnestic syndrome is induced in the patient: the anxiety generally disappears, while the anancastic and phobic mechanisms remain unaltered, though they fade in their affective resonance, that is, they lose their obsessive character.
In conversion neuroses and in psychopathic personalities (v.) the results are not at all brilliant, and likewise in psychopathic developments.
The main contraindications are given by cardiovascular diseases, infections, febrile states of any nature, active tuberculosis, chronic affections of the lungs, severe thyrotoxicoses, organic diseases of the central nervous system, marked hypertensions. By rigorously observing these limitations, the dangers become quite scarce, reducing themselves practically to fractures alone, slightly more frequent in EST and in melancholias than in IST and in schizophrenias.
In general the s. do not contraindicate psychological treatments, which indeed at times can be facilitated by the psychic modifications induced by such organic methods; finally it must be noted that the practical and economic value of ES is notable: many thousands of distinctive subjects (manic-depressives) can be spared the declaration of mental alienation, since they are, if necessary, kept in good mental condition by means of some shock practiced occasionally; moreover, long hospitalization is avoided, that is, one avoids feeding and supervising innumerable apparently demented subjects, who in other times required a continuous assistance service.
Bibliography13 works
Bruno Callieri