week 3.2

ELECTROCONVULSIVE THERAPY (ECT)

  • Definition: Electroconvulsive therapy (ECT) is the induction of a grand mal (generalized) seizure through the application of electrical current with electrodes bilaterally or unilaterally applied to the brain.

    • The electrical current dose is carefully controlled by the ECT machine.

    • The amount of current differs for each patient due to the need to reach the seizure threshold.

  • Types of ECT:

    • Right unilateral ECT is associated with fewer cognitive side effects.

    • Its efficacy can be ensured with adequate dosing strategies.

    • While unilateral treatments were traditionally conducted on the hemisphere of the nondominant hand, research by Sadock and associates (2015) indicates that the right hemisphere plays a significant role in sustaining depressed mood, regardless of handedness.

  • Reputation:

    • Historically, ECT has maintained a negative reputation and is considered one of the most controversial treatments for psychological disorders.

    • Despite its controversial image, ECT has been in use for more than 50 years.

PHYSIOLOGICAL EFFECTS OF ECT

  • Seizure Threshold:

    • A patient’s seizure threshold may increase by 25 to 200 percent during the course of ECT treatments.

    • ECT acts as an anticonvulsant, as the seizure threshold rises with ongoing treatment.

    • Due to the administration of a muscle relaxant before treatment, movements during the seizure are minimal.

  • Phases of Seizure:

    • Tonic Phase: Lasts about 10-15 seconds characterized by rigid plantar extension of feet.

    • Clonic Phase: Involves rhythmic muscle movements that gradually decrease in frequency and eventually disappear.

MECHANISM OF ACTION OF ECT

  • Unknown Mechanism:

    • The exact mechanism by which ECT produces therapeutic responses remains unknown.

    • Multiple parts of the central nervous system (CNS) are affected by ECT.

  • Affected Components:

    • Hormones

    • Neuropeptides

    • Neurotrophic factors

    • Nearly every neurotransmitter including:

    • Serotonin

    • Norepinephrine

    • Dopamine

  • Note: These are the same biogenic amines that antidepressant drugs also affect.

CLINICAL USES OF ECT

  • Severe Depression:

    • Can be considered the treatment of choice when a rapid response is necessary.

    • Particularly pertinent for patients who are extremely suicidal or refusing food, leading to nutritional compromise.

  • Bipolar Disorder:

    • ECT can be as effective as lithium in treating this condition.

  • Acute Schizophrenia:

    • Especially effective in cases of catatonia, which involves abnormal movements, behaviors, and communication.

  • Other Conditions:

    • Episodic psychosis

    • Obsessive-compulsive disorder

    • Delirium

    • Neuroleptic malignant syndrome

    • Seizure disorders

    • Parkinson’s disease

    • ECT may be safer than medications for elderly patients or pregnant women.

ASSESSMENT PRIOR TO ECT

  • Indications:

    • Less invasive treatments should be attempted first and proven unsuccessful.

  • Pre-existing Conditions:

    • Heart Conditions:

    • Recent heart attack (within 3-6 months)

    • Severe hypertension

    • Heart failure

    • Other Conditions:

    • Stroke (within 3-6 months)

    • Aortic or cerebral aneurysms

    • Increased intracranial pressure

    • Pulmonary conditions

    • Severe osteoporosis

  • Preparation:

    • Patients must be NPO (nothing by mouth) for 6-8 hours prior to minimize aspiration risk.

    • ECT should not be used when the patient is on lithium, as it lowers the seizure threshold and can result in prolonged seizures.

  • Required Labs:

    • Urine studies

    • Skeletal history and X-rays

    • Informed consent

    • Assessment of suicidal ideation, anxiety, memory baseline, medications, allergies, vital signs, mood, and activities of daily living (ADLs).

RISKS AND SIDE EFFECTS OF ECT

  • Common Side Effects:

    • Temporary memory loss and confusion, which are mostly reversible but can occasionally lead to permanent memory loss.

    • Other side effects may include difficulties in:

    • Processing speed

    • Attention

    • Problem-solving capabilities.

  • Mortality Rate:

    • The mortality rate associated with ECT is less than that of childbirth, quantified at approximately 0.002 percent per treatment and about 0.01 percent for each patient.

    • Although death is rare, it is primarily related to cardiovascular complications.

    • No evidence has been found suggesting brain damage resulting from ECT.

SOMATIC SYMPTOM AND DISSOCIATIVE DISORDERS

  • Somatic Symptom Disorders: Characterized by physical symptoms suggesting a medical disease without demonstrable organic pathology.

  • Dissociative Disorders: Defined by a disruption in the usually integrated functions of consciousness, memory, and identity.

    • Dissociative responses occur when anxiety overwhelms the individual, leading to a disorganized personality.

  • Types of Somatic Disorders:

    • Illness Anxiety Disorder: Previously termed hypochondria, involves fear of illness.

    • Conversion Disorder: Involves motor or sensory symptoms without physical injury or illness.

    • Factitious Disorder (Munchausen): Involves fabricating or inducing illness.

  • Types of Dissociative Disorders:

    • Depersonalization-Derealization Disorder: A temporary alteration in self-awareness or perception of the environment.

    • Dissociative Amnesia: Can be localized, selective, or generalized.

    • Dissociative Fugue

    • Dissociative Identity Disorder: Previously known as multiple personality disorder.

FACTORS CONTRIBUTING TO SOMATIC DISORDERS

  • Genetic Factors:

    • Hereditary factors may be associated with somatic symptom disorders, conversion disorder, and illness anxiety disorder.

  • Biochemical Factors:

    • Decreased levels of serotonin and endorphins may be involved in the etiology, especially in somatic symptom disorders featuring pain.

  • Family Dynamics:

    • A family focus on illness rather than conflict may contribute.

  • Learned Behaviour:

    • Children may learn to exhibit somatic symptoms to avoid school or to attract attention.

  • Neuroanatomical Factors: Brain dysfunction (impaired information processing) has been implicated in factitious disorder.

    • Brain imaging studies reveal hypometabolism in the dominant hemisphere and hypermetabolism in the nondominant with reduced volume and connectivity of the amygdala.

  • Psychodynamic Factors:

    • Ego defense mechanisms are believed to play a role.

FACTORS CONTRIBUTING TO DISSOCIATIVE DISORDERS

  • Lack of Genetic Evidence: No substantial evidence indicates genetic factors as influential in dissociative disorders.

  • Psychological Trauma: Traumatic experiences are critical factors in the development of these disorders.

  • Psychodynamic Factors: They may serve as defense mechanisms against unresolved, painful issues.

  • Neurobiological Factors: Electroencephalogram (EEG) abnormalities have been observed in patients with Dissociative Identity Disorder (DID).

NURSING CARE FOR SOMATIC AND DISSOCIATIVE DISORDERS

  • Goals:

    • Relieve physical symptoms

    • Implement strategies for coping with stress

    • Restore normal thought processes

    • Conduct reassessments and evaluations periodically.

MEDICAL CARE

  • Psychotherapy Options:

    • Individual psychotherapy

    • Group psychotherapy

  • Therapies:

    • Cognitive Behavioral Therapy (CBT) and psychoeducation

    • Psychopharmacology, including:

    • Antidepressants

    • Antianxiety medications

    • Mood stabilizers

    • Antipsychotics

  • Additional Techniques:

    • Persuasion and hypnosis can assist patients in recovering memories.