الفهرس 
Historical DevelopmentOnly 14 pages are availabe for public view
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Abstract
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SUMMARY
This work was carried out in search for a clear understanding
of the current views about electrooonvulsive
therapy. ECT. The starting point was the study of the
development of ECT. This shows that electricity as a
healing procedure is not new but was known to Hippocrate.
Long before electroshock was first used, methods for inducing
epileptic fits in schizoprenics were employed in
the hope of a therapeuticalJ..yuseful reaction. This was
based on the observation, which proved to be false, that
epilepsy and schizophrenia could not coexist in the same
body, and that schizophrenic symptoms may disappear, at
least temporerly, after medically induced therapeutic
convulsions.
Dr. Oliver (1958) gave camphor by mouth to induce
convulsion in melanocholic patients. Manfred Satle (1933)
gave insulin to induce deep hypoglycamic states for treatment
of schizophrenics. Nyiro (1937) attempts treatment
with transfusion of blood from epileptics.
Meduna (1938) used cardiazol for inducation of the
convulsion. Cerletti then used electricity to induce
convulsion instead of chemical induction and his colleague
Bini devised the first electroshock box and they induce
the first electro convulsion in man in 1938.
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In 1958 Esquibil, et al., used indoklon for convulsive
therapy, but it has not replaced ECT due to its
being more expensive, no longer obtainable, cause more
memory disturbance to the patient, and less convinent
than ECT.
Attention was paid to what constituted the optimal
strength and type of current, preparation and premedications
of the patient to lessen side effects and complications,
the most suitable part of the head to which
to apply the electrodes, and the psychiatric conditions
for which it seemed more appropriate. So many modifications
of the treatment were reconmended.
The preparation of the patient for ECT should include
careful medical and neurological preparation by complete
physical examination and doing the investigations needed.
To safe guard the patient before the treatment advise him
to take aothing by mouth after the preceding midnight and
also advise him of taking certain drugs. Prepare the
treatment area by equipment needed (as CO2 in oxYgen,
air way, resuscitator, tracheostomy tray, i.v. fluids,
mouth gag and head piece) then apply the procedure.
Premedicate the patient by giving atropine, general
anaesthesia and muscle relaxant. This premedication make
ECT more acceptable and take much of the unpleasantness
out of the treatment, as well as giving the patient maximal
protection. There are cogent medical reasons as well
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as overriding legal ones for never giving ECT without
anaesthetic and muscle relaxant except in special circumstances.
However unmodified ECT is still given in
some countries which cannot afford the expense, response,
and lacks manpower which an anaesthetic requires.
As regards electrode placement ECT was given bilaterally
either anterior to the pinna or to both temples.
Lancaster and others (1958) used unilateral ECT using
the non dominant hemisphere. Many varieties of electrode
placement has been used by different workers. The temporo-
parietal position is probably the most widely used.
The mastoid-frontal position and anterior bifrontal positions
are also used.
The efficacy of U/ECT is as good by the end of treatment
as BjECT, but B/ECT oftrn gives a quicker result.
Memory disturbance, disoriantation, post-ictal confusion
and other side effects are significantly less when U/ECT
is given.
Most psychiatricts have no information in either the
quantity of elect.ricity or the wavefo:rtn,so the electrical
aspect of the stimulus have been cleared up. Many other
factors also influence the production of convulsion include
quantity of electricity, current intensity, waveform
pulse rate and skull bone resistance.
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Later on brief stimulus ”pulse” and unidirectional
waveform have been used to reduce the amount of electrical
energy and side effects.
The number of ECT needed to relieve symptoms varies
from patient to another, from one disease to another, and
also from one technique to another. The frequency usually
varies between 2-) times a week, with an interval of not
less than 48 hours between successive treatments.
How ECT actually works remains unclear and there is
no convincing answer at present time. Hypotheses are
begining to explore that,the principal theories are:
Psychological theory and amnesia theory, but they
proved to be uncorrect.
Neurophysiological theory and biochemical theory,
but the facts are not well established.
A computer analogy theory suggesting that ECT works
by rectifying abnormal neuronal circuits.
Brain synchronizing theory, that suggests that brain
organisation and function cculd be approached as
partly analogous to the physicelly pulsating heart
where a pace-maker is the leading level of organisation
at a given moment. There is not known single
dominant level but alternate interchanging levels
of dominance. ECT removes all waves leading to the
return of some waves while others do not. ECT also
strengthens the strongest wave and weakens the weakest.
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from the last hypothesis ECT may prove to be misnomer,
it is better to consider human as a growing organism
with periodical crises of rebirth sllowing healthy
or pathological unfolding, and it is likely to consider
ECT as a therapeutic microgeny repeating the ontogenetic
phases of development. This rebirth building up organisation
may not last more than a fraction of a second up
to few seconds. The response to ECT is related to many
factors rather than the simple application of the shock,
e.g. the milieu where it is given, the therapist giving
it, the immediate management, and the internal dicision
of the patient before he is submitted to it.
A variety of psychiatric symptoms have been raported
to respond to ECT. Specific indications for its use
include severe affective disorders and catatonic schizophrenic
states. There are some depressive symptoms that
predict a good responce to ECT. Endogenous depression or
that with more endogenous symptoms respond more than neurotic
ones. Involutional melanocholia react best to ECT.
Post partum depression, reactive depression and depression
associated with some forms of organic brain disease
may also get benifit from ECT.
For manic state ECT is useful for controlling hyperexcited
and agitated behaviour. For schizophrenia ECT is
more controversial than its use in affective illness. The
different types of schizophrenia respond with a different
varieties. ECT may be also helpful in neurosis,
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depersonalisation, hypochondriasis, certain organic psychoses
particularly loaded with affective component. Howeyer,
certain authors claim that some neurological disease as
parkinson’s disease, epilepsy and pseudodementia may get
some benifit. Lastly the favourable response to EeT may
reinforce the diagnosis of endogenous depression if not
settled before the treatment. As such it could be considered
as a diagnostic tool.
In comparison of ECT with antidepressant drugs in
depression, it was proved thst ECT had a significantly
greater percentage of marked improvement or complete
response. Delutional depressed patients respond much
more frequently to ECT. Suicide attempts in depressed
patients is less frequent in the ECT treated patients
than in the antidepressant treated patient.
ECT has side effects as any serious physical treatment
in medicine. Side effects and complications may
be immediate or delayed, immediate side effects include
frectures, fatalities, r~pture spleen, headach, agitation,
nausea, vertigo, (lJmage of teeth for tongue, or
confusion.
Delayed side effects may be psycnological, neurological
or physical changes. Psychological as memory disturbance,
transformation of depression into mania or hypomania,
transformation of schizo-affective disorders or
catatonic stupor into mania or hypomania. Neurological
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side effects include EEG ohanges, epilepsy, pathologioal
brain damage, development of tardive dyskinesia, development
of post ECT astrixis, temporary breakdown of B.B.B.
and muscle stiffness.
Physical changes include neurological, neuropathol~
ogioal, cardiovascular, respiratory, endocrine, blood,
autonomic nervous system and sleep changes.
ECT is contraindicated in some cases. Absolute
contraindication include brain tumours, any space ooouping
lesion or pre-existing inorease I.C.P. Relative oontraindioation
include psychiotrio and medioal conditions.
Psychiatric oontraindioation inoludes depressive hysterics,
oboessive oompulsive sy~ptoms, hysterical symptoms, anxiety
reaotion, border line personality disorders, organio brain
disease and sexual deviation.
Medioal oonditions inolude any medioal illness that
inoreases the risk of anaes.thetic prooedure, disease
likely to be made worse by the changes in blood pressure
and oardiac rhythm, a history of post oerebrovasoular aooident,
severe hypertension, bone disease, poorly controlled
diabetio patients.
ECT oan be used in special oases but with Bome oautious,
as patients with oardiao paoemaker, patients reoeiving
B-adrenergio blook:ade, hypertensive patients, epileptio
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patients, high risk pregnanoy and in depressed patient
after oraniotomy.
Finally medioologal aspeot must be taken in oonsideration
before giving ECT. Cooperation among psychiatrists,
lawyers and civil libertarians can help to establish
a better set of ethical guidelines for the treatment as
well as protection of both the patients’ health and civil
r.ights.