ELECTROSHOCK THERAPY (SHOCK THERAPY).— 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 understandable in a field where the various etiopathogeneses are almost unknown. The beginning of shock therapy can be traced to the discovery, independent and almost simultaneous, of the curative action of hypoglycemic coma (i.e., linked to a strong reduction in blood glucose content) and convulsive pharmacological therapy.
Introduced into psychiatry by Steck, insulin was initially administered with the dual purpose of increasing the patient's weight and influencing states of eczematism, especially in morphinomaniacs. The decisive step in moving from a purely symptomatic medication to a curative treatment was taken by Sakel of the Vienna clinic in 1933, when he made the important observation that deep hypoglycemic states, which involuntarily arose during the symptomatic treatment of psychotics with insulin injections, had a clear beneficial effect on the psychosis itself: the hypoglycemic coma, which Sakel's predecessors sought to avoid by moderating the amount of medication administered, became the cornerstone of the new treatment for schizophrenia (v.), a treatment now 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 artificially induced epileptic convulsions using cardiazol. He had been motivated by two observations (later shown to be only relatively correct): that epilepsy and schizophrenia are antagonistic to each other; and that schizophrenic symptoms can disappear, at least temporarily, after spontaneous convulsions. The same observation had previously led Nyirő to attempt, without success, the treatment of schizophrenics with blood transfusions from epileptics (von Meduna had been preceded as early as 1785 by Oliver, who in the *London Medical Journal* had reported a case of mania cured by convulsions induced by camphor).
The great spread and importance of convulsive treatments in psychiatric therapy was demonstrated at the International Congress for the Modern Treatment of Schizophrenia, held in Münsingen (Switzerland) in 1937; it was here that Cerletti and Bini first mentioned the possibility of using electric current as a convulsive stimulus in the treatment of schizophrenia. After a long period of experiments on animals, the two Roman scholars induced convulsions in mental patients by means of electricity and published their first works in 1938: this was the birth of electroshock therapy (EST), which spread rapidly from Rome throughout the world.
The electric discharge provoking the shock, delivered by special apparatus at a voltage of 100–120 volts, is applied to the temporal regions for about 0.2–0.4 seconds (for details on method, technique, and physiopathology, see the volume by Cerletti and Bini on ES). It has not yet been definitively established whether the seizure should be considered a phenomenon of release or a positive phenomenon of excitation. Much has been discussed about whether electric convulsive therapy (ES) can produce irreversible alterations in nerve cells. Bini and Cerletti, after examining the brains of a large number of dogs subjected for a long time to ES, asserted that such lesions never occur, whereas they were demonstrated in animals subjected to insulin or cardiac shock. Even the most recent authors agree on this important finding: after an average of 10 ES sessions, electroencephalographic alterations resemble those observed in cerebral concussion, but the tracing returns to normal after about a month of rest.
The indications for IST are almost exclusively represented by schizophrenic syndromes; given its complexity and delicacy, this treatment must be administered under strict medical supervision by specialized personnel in a suitable hospital setting.
The indications for EST are as follows: 1) affective psychoses (v.), which in fact constitute the group of diseases in which the most brilliant results are obtained, especially in depressive forms: rapid recovery (with 3–10 ES sessions) of the current episode is achieved; the efficacy is also notable in involutional melancholia, though a greater number of applications is required. 2) Schizophrenic syndromes, when IST cannot be implemented for particular reasons; in this broad group of diseases, the results are undoubtedly better with IST. The two therapies can be combined, implementing mixed therapy, when there is intense affective participation or marked psychomotor agitation, and in cases that have previously responded poorly to IST alone; ES can be administered during the first phase of insulin coma or alternately with the comas themselves. In catatonic states, often only a few ES applications succeed in unlocking patients. 3) In psychoneuroses, EST is justified only in very severe cases resistant to psychotherapy, and in obsessive forms accompanied by strong anxiety: indeed, in such cases Bini and Bazzi propose "annihilation," i.e., closely spaced ES applications, even twice daily, until a complete or near-complete amnestic syndrome is induced in the patient: anxiety generally disappears, although the ananastic and phobic mechanisms remain unchanged, albeit diminished in their affective resonance, i.e., losing their obsessive character.
In conversion neuroses and psychopathic personalities (v.), the results are not at all brilliant, nor are they in psychopathic developments.
The main contraindications are cardiovascular diseases, infections, febrile states of any nature, active tuberculosis, chronic lung conditions, severe thyrotoxicosis, organic diseases of the central nervous system, and marked hypertension. By strictly observing these limitations, the dangers become very minimal, practically reducing to only fractures, which are slightly more frequent in EST and in melancholia than in IST and schizophrenia.
In general, shock therapies do not contraindicate psychological treatments, which can sometimes even be facilitated by the psychic modifications induced by these organic methods; it should finally be noted that the practical and economic value of ES is considerable: many thousands of individuals (manic-depressive) can be spared the declaration of mental alienation, since they can, if necessary, be kept in good mental condition through occasional shocks; moreover, long-term hospitalization is avoided, i.e., the need to feed and monitor countless apparently demented individuals who, in other times, would have required continuous care.