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Electroconvulsive Therapy (ECT)


Von Meduna in 1934, used 25% camphor in oil intramuscularly to produce convulsions for the first time for therapeutic purposes.
A much safer form of convulsive therapy was used by Cerletti and Bini in 1938. They called it EST or electroshock therapy. Later, this method of treatment came to be known as ECT or electroconvulsive therapy.
The indications for electroconvulsive therapy are: 

  1. Major severe depression
    1. With suicidal risk (This is the first and most important indication for ECT)
    2. With stupor
    3. With poor intake of food and fluids
  2. Severe catatonia (non-organic)
    1. With stupor
    2. With poor intake of food and fluids
  3. Severe psychoses (schizophrenia or mania)
    1. With risk of suicide, homicide or danger of physical assault
    2. With unsatisfactory response to drug therapy
    3. Severe Aggression not responding to drugs
The use of ECT in mania and schizophrenia is not a treatment of first choice and is
Employed only in the above-mentioned conditions.
Contraindications Absolute : none at present.
  1. Presence of Raised Intracranial Tension
  2. Recent Myocardial infarction (MI)
  3. Severe hypertension
  4. Cerebrovascular Accident (CVA)
  5. Severe pulmonary disease
  6. Retinal detachment, and
  7. Pheochromocytoma.
The techniques used for ECT administration are of two types:
  1. Direct ECT is administered in the absence of muscular relaxation and general anaesthesia.
  2. Modified ECT is modified by drug-induced muscular relaxation and general anaesthesia administered by an anaesthetist
ECT is of two types:
  1. Bilateral ECT: This is the standard form of ECT used most commonly. Each electrode is placed 2.5 to 4 cm above the midpoint, on a line joining the tragus of the ear and the lateral can thus of the eye.
  2. Unilateral ECT: In this type, electrodes are placed only on one side of head, usually the non-dominant side The unilateral ECT is safer, with much fewer side effects, particularly those of memory impairment.
The therapeutic adequacy of the treatment is usually gauzed by the occurrence of a generalized tonic-clonic seizure lasting for not less than 25-30 seconds.
Duration of Therapy
The total duration and number of treatments given depends on the diagnosis, presence of side effects, and the response to treatment. Usually 6-10 treatments are sufficient, although up to 15 treatments can be given if needed.
Mechanism of Action
Although the exact mechanism is unclear, one hypothesis states that ECT possibly affects the catecholamine pathways between diencephalon (from where seizure generalization occurs) and limbic system (which may be responsible for mood disorders), also involving hypothalamus.
Side Effects
  1. Side effects associated with general anaesthesia: Deaths during ECT are usually due to the general anaesthesia,
  2. Memory disturbances (both anterograde and retro-grade) are very common. These are usually mild and recovery occurs within 1 -6 months after treatment.
  3. Confusion may occur in the postictal period.
  4. Other side effects include headache, prolonged apnoea, prolonged seizure, cardiovascular dysfunction, emergent mania, muscle aches and apprehension.
ECT does not cause any brain damage.
Transcranial Magnetic Stimulation (TMS)
  1. It is a noninvasive method to cause depolarization in the neurons of the brain.
  2. TMS uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field; this can cause activity in specific or general parts of the brain with minimal discomfort, allowing the functioning and interconnections of the brain to be studied.
  3. A variant of TMS, repetitive transcranial magnetic stimulation (rTMS), has been tested as a treatment tool for various neurological and psychiatric disorders including migraines, strokes, Parkinson’s disease, dystonia, tinnitus, depression and auditory hallucinations.
Light Therapy
  1. The production of the hormone melatonin, a sleep regulator, is inhibited by light and permitted by darkness as registered by photosensitive ganglion cells in the retina.
  2. To some degree, the reverse is true for serotonin, which has been linked to mood disorders.
  3. Hence, for the purpose of manipulating melatonin levels or timing, light boxes providing very specific types of artificial illumination to the retina of the eye are effective Light therapy either uses a light box which emits up to 10,000 lux of light, much brighter than a customary incandescent lamp, or a lower intensity of specific wavelengths of light from the blue (470 nm) to the green (525 nm) areas of the visible spectrum.
Vagus nerve stimulation
  1. Vagus nerve stimulation (VNS) uses a programmable electrical stimulator to provide intermittent stimulation to a patient’s left vagus nerve.
  2. VNS was originally PDA-approved for treatment-resistant epilepsy and was recently approved for the adjunctive treatment of a major depressive episode that has not responded to at least four antidepressant medication trials.
  3. The potential mechanism(s) of action of VNS are not fully understood. The central projections of the vagus nerve via the nucleus tract us solitarius innervate multi­ple brain areas implicated in mood regulation, and func­tional brain imaging studies have confirmed that VNS alters activity of many of these cortical and subcortical regions.
  4. VNS may affect function of GABA. DA, and NE, though conflicting data have been reported.
  5. These neurotransmitter system effects have not been consistently associated with therapeutic response.
Deep brain stimulation
  1. Deep brain stimulation (DBS) involves a small electrical stimulator implanted into a defined brain location which typically provides chronic stimulation.
  2. Bilateral DBS of the subthalamus or globus pallidus is an accepted treat­ment for refractory Parkinson’s disease, and can be associated with significant mood changes in patients with Parkinson’s disease.
  3. If DBS is confirmed to be an effective treatment for some patients with depression, further improve of its mechanisms of action may greatly improve our understanding of the neurobiology of normal and abnormal mood regulation.
Biological therapy   -       Used in

Transcranial Magnetic Stimulation  - Resistant major depression (baseline hypofrontality can be reversed)
                                                  - Obsessive compulsive disorder (OCD)
                                                  - Post traumatic stress disorder (PTSD)
                                                  - Map the motor cortex, help determine hemispheric dominance & short term memory
                                                  - To improve some symptoms of Parkinson’s disease like
                                                    diminished reaction time.
Phototherapy                         - Seasonal depression (seasonal affective disorder)
                                               - Sleep disorders
                                               - Decreased irritability and diminished functioning associated with work
                                              - Jet lag
Vagal stimulation                  - Chronic, recurrent major depression
Sleep deprivation                  - Depression
Psycho therapy
Psychotherapy is defined as, the treatment by psychological means of problems of an emotional nature, in which a trained person (therapist) deliberately establishers professional relationship with the patient to,
  1. Remove, modify or retard existing symptoms,
  2. Mediate disturbed patterns of behavior, and /or
  3. Promote positive personality growth and development
Psychotherapy can be done by verbal or non-verbal means.
Psychodynamic Approach
  1. This is one of the most popular approaches to personality. It focuses on change, development and conflicts in people lives, this view owes largely of the contributions of Sigmund Freud.
  2. Freud was a physician and he developed the theory in the course of his clinical practice.
  3. The theory visualizes human mind in terms of different levels of consciousness.
  4. Thus, we are aware of the current thoughts, which are in the consciousness. Beyond the conscious is the preconscious, which is immediately not accessible but can be accessed.
  5. Beyond the preconscious lies the unconscious, of which we are not aware. It contains the repressed desires and impulses.
Levels of consciousness
  1. Conscious – this is conceptualized as awareness
  2. Preconscious – as thought & feeling that are easily available to consciousness
  3. Unconscious – Thoughts & feelings that cannot be made conscious with out overcoming strong resistance. The unconscious contain non verbal forms of thought function and gives rise to dreams, Para praxes (slip of tongue) and psychological symptoms.
  4. Goal – the chief requirement is the gradual integration of the previously repressed maternal into the total structure of personality
Process involves
  1. Free association – in which patients say whatever comes into their minds – allows repressed memories to be recovered and thereby contributes to cure. In the “interpretation of dreams.
  2. Transference – it concerns the patient’s feelings and behaviors towards the Therapist that are based on infantile wishes the patient has towards parents of parental figures.
  3. Counter transference – the emotion of Therapist for the client.
Arises From Couch wherein patient used to lie on couch while speaking. It is not psychotherapy.
  • Unconscious has Primary process thinking : Seen in
  1. Young children            
  2. Severe psychosis            
  3. Dreams & MR
Important points
  1. Freud believed that the unconscious was a reservoir of instinctive drives.
  2. Also, it stores all the ideas and wished that are concealed form conscious awareness, perhaps, because they cause psychological conflict.
  3. We are constantly engaged in the struggle to either find some socially acceptable way to express unconscious impulses or in effort keep those impulses from being expressed.
  4. The goal of psychoanalytic therapy is to bring repressed unconscious material to consciousness and to thereby aid us in living our lives in a more self aware and integrated manner.
Personality Structure:
  1. The personality consists of three structures i.e. Id, Ego, and superego.
  2. They however, should not be treated like three distinct entities.
  3. They are used as strong psychological forces and not physical locations in the brain.
  4. Freud was able to infer these forces from the way people behave. Let us understand these terms in some detail.
Id : Desires :
  1. It is that part of personality conscious drive that deals with immediate gratification of primitive needs, sexual desires, and aggressive impulses.
  2. It is totally unconscious.
  3. It follows principle.
  4. Thus, the Id seeks one thing only and that is the discharge of tension arising out of biological drives.
  5. Need gratification in any manner is its main concern.
  6. Reflexes and primary processes are its mechanisms of functioning.

Ego : Reason :

  1. It develops out of Id. It works on reality principle. It tries to maximize pleasure and minimize the pain.
  2. It follows the secondary processes.

Super Ego :

  1. Conscience: It deals with the ideals.
  2. It represents the societal demands and ideas.
  3. It also creates the feelings of guilt and punishes the person if he or she falls short of the societal norms and ideals.

The term psychoanalysis denote a psychological theory of mind and personality development based on the concept of intrapsychic conflict.

Freud’s Psychosexual Stages

Source of pleasure
Psychiatric disorders resulting
from fixation & regression
to this phase
1. ORAL (0-1 ½ years)
2. ANAL ( 1 ½ -3 years)
3. PHALLIC (3-5 yrs)
4. LATENCY PHASE (5-12 yrs)
5. GENITAL ( >12 yrs)
Oral gratification
Anal gratification( excretion)
Males:          castration anxiety
Oedipus complex      
Females: Penis envy, Electra complex
quiescent sexual activity
Superego develops   
adult sexuality
Schizophrenia, Addiction
Sexual dysfunctions
Neurotic disorders
Neurotic disorders

Defense Mechanism: these are the unconscious psychological processes defending the ego.
Types of Defense Mechanism :

  1. Primary
  2. Narcissistic       
  3. Neurotic-Immature
  4. Mature


  1. Primary                             
    An idea or feeling is withheld from consciousness ; unconscious forgetting. it is mother of all defense mechanism ( most important defense) eg “ sexual abuse in childhood”. it is mother of all defenses.
  2. Narcissistic                       
    Attributing your own wishes, thoughts, or feeling onto someone else.
    eg “I do not like him because he does not like me”
    Avoiding the awareness of some painful aspect of reality
    eg “ I know I do not have cancer”
  3. Neurotic-Immature
    External objects are divided into all good or all bad without considering the whole range of qualities  eg “seeing all people without mustache as feminine”.
    Return to an earlier stage of development. eg “ dependence on others”
    Psychic derivatives are converted into bodily symptoms
    eg “ just thinking of the exam, I get butterflies in my stomach”
    Features of the external world are taken and made part of self
    eg “ the resident physician dresses like the attending”
    An emotion of drive is shifted to another that resembles the original in some aspect.
    eg “I had to get rid of the dog since my husband kicked it every time we had an argument”.
    Excessive use of intellectual processes(ie logic) to avoid affective expression(emotion).
    eg “It is interesting to note the specific skin lesions which seem to arise as a consequence of my end   stage disease”
    Separation of an idea from the affect that accompanies it
    eg “ability to discuss traumatic event without the associated disturbing emotion, with passage of  time”.
    Rational explanations are used to justify unacceptable attitudes, beliefs or behaviors.
    eg “ I did not pass the test because it was very difficult”
    Unconscious adaptation of behavior opposite to behavior that would reflect true feelings & intentions. eg “ Listen to him tell his family he was not afraid, when I saw him crying”
    Acting out the reverse of an unacceptable behavior.
    eg “ I need to wash my hands whenever I have these thoughts” 
  4. Mature defense mechanism
    1. Altruism
    2. Anticipation
    3. Ascetism
    4. Humour : Permits the expression of feelings and thoughts without personal discomfort.
    5. Sublimation: Achieving impulse gratification but altering a socially objectionable aim to a socially acceptable one.
      It is the most mature defense Mechanism.
      eg “channelizing sexual or aggressive impulses into creative activities (painting etc)”.
    6. Suppression: Conscious suppression of pleasure of pleasurable impulses for the benefit of future .
      it is also called as Pseudodefect or False defense mechanism.
      As it is a Conscious and rest all are Unconscious
      eg “ I would rather forget that my dog was run over by a car”.

Defense mechanism in OCD

  1. Isolation
  2. Undoing
  3. Reaction formation.

Defense mechanism in Psychosis

  1. Projection
  2. Denial

Psycho dynamic Psychotherapy is a shorter version of psycho analysis

  1. The traditional psychoanalytic approach is criticized on many grounds.
  2. It is said that its concepts are vaguely defined; logical distinctions are not made, the case studies are biased, the theory is not testable, the techniques have low reliability and validity, and the efficacy of psychoanalytic therapy is questionable.
Dream :
  1. Dreams are considered as the royal road to unconscious.
  2. They have manifest content the dream that we remember - and latent content – the hidden meaning that can be deciphered from the manifest content.
  3. Dreams serve three purposes.
  4. They work as wish fulfillment device, release of unconscious tension, and work as guardians of sleep.
  5. According to Friend symbols in dreams represent different things, wishes, desires, etc. For instance viewing a house has reference to one’s body, clothe means nakedness, bath means birth, and beginning a journey means death.

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