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WNG*TERM EFFECTh OF' ELECTROCONVULSIVE THERAPY UPQMEMORY AND PERCEPTUAL-MOTOR PERFORMANCE

Ut&URTLDMAN, YBANK tkIOSlSlt, AND DONALD I. rZMPL$a

VA Ho.püal, Jcffcs Barvotha, Mo,

PU0BLZM

This study investigated whether there are memory and perceptual-motordeficits in patients who have had in excess of Ml electroconvulsive treatmentsECT. A number of investigators have explored the effects of ECT upon psychological tests sensitive to organicity. These researchers usually found decreasedperformance during and shortly after a course of ECT' *. S. 7, 5, iS, ii, II Thereappear to be only two investigations that determined the cognitive effects of ECTafter a number of months" S. However, in both of these studies neither controlpatients nor an adequate number of ECT patients were employed. In the reportof Pascal and Zeaman U, a patient's Wechsler-Bellevue and Rorsohach soot'sbefore 10 ECT and 7 months afterward were comparable. Stone°' reported that &patient's Henmon-Nelson Test of Mental Ability score 60 days after the last q4 ECT was comparable to her score of 7 years earlier.

An appropriate generalization is that the evidence as to whether ECT causespermanent cognitive impairment is inconclusive. The studies reported in theliterature have not been controlled adequately for the assessment of such impairment. Furthermore, the number of ECT have been far fewer than Lu the preseii$research.

Mwrnon

Ba were 40 male chronic schizophrenic patients in Jefferson Barracks VeteransAdministration Hospital. Twenty patients with a history of 50 or more ECT wereassigned to the ECT group1 and 20 patients with no record of ECT were matchedwith individual ECT Ba for age within 5 years, race, and level of educationwithin 2 years, and were assigned to the control group. Four Ss were eliminatedfrom the ECT group two refused to participate and two produced no scorabletest responses, and their controls also were dropped. The Bender-Gestalt and theBenton Visual Retention Teat Form C, Administration A were administeredsatisfactorily to 16 ECT and 16 control Ba. Table 1 indicates the extent of thebetween-groups matching. The ECT Ba had received from 50 to 219 ECT with a

p

median of 89.5, and there was a range of 10 to 15 years since the last course of ECT

T4a1a I. EXTENT CV &TWKKN-GMOUP MATCHING AND MKSN BENDKR-GEMTAIJI'ap &srosScons sos EC'I' AND C0NT5DL Osow'

-.-:--- - .-- -

S .

I ECT.Oroup Conuul Grjp

. Man 81 Mean 81

Age 45.8 4.2 43.6 4.9

Ywsol.Educai.iun 10.9 2.3 10.8 2.4

YarselHuspitaliaiioa 19.8 3.8 17.3 2.6

JknderError8cors $9 31.6 35.9 16.9

itmError8core 19.2 8.1 14.3 6.9

P*kaNo.Corr.ct 2.6 1.8 3.8

-

2.4-

LO

The Beàder

tests that refieci

systems. The Pa

Gestalt designs'

1 the number o

scores" that cons

card"'. The ii

p < .005 for i

error scores, and

As indicated

for the ECT grou

Benton error soo:

I - 1.90, ,ECT group and 3

For the ECT

and Bender-Gesti

* Benton error scan

correct score - .4

The groupsinvestigators maiiimportant in this

years of hospitali:

were .28 for Ben'

Benton number c

jere .04, .27, and

The signifieaiBender-Gestalt atcourse of treatmes

more, it seems pia

damaging effect of

between number oECT-produced strobservation of prktaWd".

Nevertheless,

permanent brain j;

to receive ECT ar

it has been reportorders tend to dolutely positive th

ECT psychopatol

1. BLNWN, A. Lions. New York; 5

2. Eawiw, E. F.trntmen Pr-i.'

3. KLNDAU, Bua effect 00

4. !*5 Pacsi,La. paca,o.a.SIMIvWpSIl

1HA

1N131

NATC.

it r1

LOMOSTUM SIflCTS OP SLWF&000WVULSIVS TUW.PT 33

I UPON The Bender-Gestalt and Benton were selected because they are well establishedteats that reflect brain pathology and because they have quantitative scoringsystems. The Pascal and Suttell'° method of scoring for deviations on the BenderGestalt designs was employed. Two scoring systems were used for the Beaten:1 the number of correct reproductions or "number correct scores", and 2 "errorscores" that consisted of a detailed analysis of specific errors in each figure of eachcard. The interecorer reliability coefficients between two scorers were .90

p < .005 for the Bender-Gestalt error scores, .97 p < .005 for the ,otoa

rceptuai-motor error acorns, and .W p <.005 for the Benton number correct acorns.

in treatments*

CT upon pay- RaSULTS .

sad aecre*aed Js indicated in Table 1, the mean error score on tho Bender-Gestalt was 69.9.1. There for the ECT group and 35.9 for the control group S - 3.84, p <.001. The meaneS of ECT Benton error score was 19.2 for the ECT group and 14.3 for the control groupjeither control 1 - 1.90, p < .06, and the mean Benton number correct score was 24 for theUs the nport LOT group and 3.8 for the control group I - 1.62, p <.10.schach scores For the ECT group, the product moment correlation between number of ECTsported that a and Bender-Gestalt error score was .32 p <.15, between number of LOT andicc the Mat of Beaten error score .62 p <.005, and between number of LOT and Benton number

correct score -.43 p < .05.LOT auses The groups were not matched on length of hospitalization, a variable that some

in the investigators maintain affects test performance. However, this apparently was notIII1PIIir- important in this study, since the correlation coefficients between test score and

Jp the present years of hospitalization were not significant. For the ECT group, the coefficientswere .28 for Bender-Gestalt error score, .05 for Benton error score, and .05 forBeaten number correct sqore. For the control group, the rnsjsctive cop$ioas

Veterans,,aa4 .

pre LOT were CoNcLuazowsiere matched The significantly greater error scores obtained by the LOT Ss on both theTOE education Bender-Gestalt and the Benton after a relatively long time period Since the last

ShlilteCI course of treatment suggest that LOT causes irreversible brain damage. Further-no scorable more, it seems plausible that the cognitive impairment results from the cumulative

talt and the . damaging effect of each treatment, particularly in view of the significant correlationsshninistered between number of LOT and both Benton number correct and error scores. Suchixtent of the ECT-produced structural changes would be consistent with the common clinicalECT with a observation of progressive mental deterioration of epileptia, especially if u*

taated".

r Nevertheless, it cannot be inferred with complete certainty that LOT causes

____________________

qpermanent brain pathology. It is possible that schizophrenic patients more likelyto receive ECT are those whose psychotic symptoinatology is more severe. And,it has been reported that patients with the so-called functional psychiatric dii..

orders tend to do poorly on tests of organicity". Thereforq, one cannot be abeo

______

lutely positive that the LOT a$ control groups were equatS for deg of preLCD sychopathology.

4.9RSVZELNCM

2.41. Bzirniu, A. L. The Raised Dental Visual RetesAia Test: Clisiad md £zpeüsaSS Applies..

2.4 Semis. New York: PIychological Corporation, 1903.I Euwas, E. F. and Hsjsu E. Ass'earment of psraptual-motor rJicnp following ctruaboi*treatment. Perccpl. met. Skills, 1960, U 1970

IjI *9 3. Kareusu., B. S., Mews, W. B. and ¶I4aaix,t Comparison of two msthods of .hØboek iathsir effect on cognitive functions. J. cmiauIt. PsyrAol 1966 *1, 423-429.

4 Nisisos, .1. M. A Teithookef Clinical Neurology. }4ew turk: Paul B. Hoeber, 1961.

________

5. Psacu., 0. ft. and Su'rrna, k .J. The Bendsr.GssWAS Test. New York: Grune & Stratton, 1951.

4. Psica, 0. ft. and ZuMss, .J. B. Msasurecnaiit of some gsct, of v9coaYuMw!jrQY 09 .`

IhsIAdividU*Ipsta .1. as.a PqcML, 1961, a, 104-115.

a,

HSP$RRT GOLDMAN, hANk S. GOMS1I, AND DONALD I. TZMPLSM

7. &wn, C. P. Characteristic Ices and gains on the Wecbaür Memory Scale a sippliad artPSYcIWUO utnla belors during, and altar a eerie ci e&eolrocoavulsiy. shocks. Ass. Pap

B.thOAt 1C I'.'isL and gaMe on Ut. Mpha group rivamination as Sated to sMctrooouvuhiy.shocks. .1. oswp. phyalol. PsychoS., 1947 40, 183-180.

I 9* &TONK, C. P. Pie-Wa tel records compared with p.dormanoe durmg sad alter ele$roconvulsive shocks. J. abs. soc. PsychoS., 1950, 45, 154-159.

to. Suuaiu.., J., 8aua, W. and MEAuS, 0. W. An evaluation of post el.ctriahock ooohsoswith the Baiter apparatus. Astir. J. PsychioJ., 1952, UX, 836-838.

11. Wostoui, P. and NAscao, 3. C. Electroshock convulsions and memory: The interval beiwsenlearning and shock. J. abs. sac. PsychoL, 1950, 45, 85-98.

12. YansA. J. The validity of sara psychokigical tale of brain damage. PsychoS. BulL, 19M,

13. Zauoaa,E. N. and KazIauMo, ft. Memory and electro-convulsive therapy. Assm.J. Py4S,J$, AU, 4466*0.

Malvaria is a psychiatric disease proposed by Hoffer and smond7, thecriterion for which is simply a mauve chromatograph stain extracted frou the urine.Mauve producers were either schizophrenic or displayed features of this diagnosis.Other studies" were less conclusive, but found these patients to be nwre disturbed,particularly in their thinking. A considerable relationship has been found betweenthe mauve and ingestion of certain tranquillizers, but another investigator` it-

ported that kryptopyrro1roduced the mauve. This substance is unlikely to resultfrom tranquillizers. The HofferOsmonda Diagnostic test HOD, a self-rating setof true-false statements, differentiated between mauve and noninauve producingpatients in tle same way that it differentiated between schizophrenia and ui

If malvaria is truly a valid classification or a consequence of medication..reliably and validly given for specific psychiatric disorders, then mauve-producingpatients should differ from non-mauve producers in terms of objective ratinp of

qwtoms HOD

From the psychiatric ward of a teaching general hospital, 82 patients wereobtaided, all of whom were examined 4uring the first few days after admission. Only14 were on any tranquilliser, age ranged from 18 to 55, none was an alcoholic, drugaddict, psycbojath, brain damaged as far as was known, or below dull-normalintelligence. Their symptoms were rated on the Wittenborn Psychiatric RatingScales", and their ward behavior rated on the Nursing Observation of Behavior'Scales"1. These measures were filed for scoring at a later date. The mauve andHOD data were excluded from clinical use, and the results were not even known to

this investigator until long after the project was completed. Thus, all sets of datewere separated to prevent experimental bias as the project proceeded.

`The data were gathered ruin the psychiatric wards of the University Hospital baskatoon,with sufrom Canadian Mautal health Grants. Analysis wa assietal by the ksdioal Ba

*

4.

p..

4;

MaLvARL&, Rot

The numb

as follows: par;psychotic depn

14 2 mauve, athe mauve is n

the psychoneutwould differentinvalid becaustThe schusophreactivity, and p..

p <.01. TheIn a coup

the HOD againborn scal.cs, ma

in the NOlISs

chance. The re

between the tOne perha

from those witi

patients were 1,;

pearcd in 8 of

scales different;

and belligerenc

five scores wert

HOD depressi

.91, and so all.

for delusional t

From the

and if it is a ri

We bad no con

hospital, so thclaimed power

groups of hunt

between small;differentiate an

have been imp'

1. Cssiu,W.J.1968, *4, 321-3

2. Casio, W. 3se, 91-91.

3. Etaan, 0.Psychiat, 1968

4. hvtN% U.

human unns an5. Kuia, hi. `1

a 6. Horns, A.

7. iloni.a, A. i

39, 33546.8. O'htLILLT P1966, it,, hi

4rI. Jk1B `

,i/3N4

NAIl

Y

1$'e MALVABJA, ThE HOFFERQSMOND DiAGNOSTIC TEST, AND TU

BEJIAtIOR OF PATLENTh'

w. J4A1G

Qss'e Uaflei4 ad &iapelon Onlaria Psychiatric iloepüol

PaosI.SM

Mnuon

`up

T2 IU,

tvt>$ 6

q - L L

SUPPLEMENTUM 77

"C1JRR. LIST MED. LIT."

CEREBRAL CHANGES FOLLOWING

ELECTRICALLY INDUCED

CONVULSIONS

An Experimental Study on Cats

BY

EJNAR MUNKSGAARD

r,`; I w -

ip

.11:.

ACTA PSYCHIATRICA ET t4EuRoLoolçA SCANDINAVICA

C,

5 DEC. 1992

COPENHAGEN 1952

I `

considerably greater Possibilities of' noting changes iii the nerve cells than oF

discerning a more or less diffuse elective dropping out of' cells. The period

dci ring which such positive findings may he ant id pa ted a ppea FS 10 be ft irly

liiiiited t he survial times fixed in the present investigation i.e., 24, 48 and

96 hours and 8 clays theref'ore appear to he suitable. They were actually

chosen on the basis oF the aforegoing considerations.

lii earlier stu lies on ECT in an i inals, the cli a Ti ges we re also in I Ti ii in tli ose

cases in which t hey could he observed to be distributed th roughoTit t lie brain

b ii t to be soniewlia t more marked I Ti the Iru ut al pa rts oF the curt cx.

A gai Tlst the back grou iid of 1 lie a loregni Ti g con side ratio us, my sea rcli for

irreversible nerve cell changes was ficLlsed OTI two phenomena, i.e., shadow

cells and neuronophagia, aTid the study was coTlhned to the frontal parts oF

the brain.

A two-grade scale was used to evaluate the shadow cells. The first grade

slight denotes that the cell damage was possibly irreversible; the second

grade more severe denotes that the damage was probably irreversible.

The following schema shows how seldom such elm nges were l'ouTid at the

ti Ti biased exam inn t ion of' speci TiiTi5 fro TB t lie gy ru s signi nide uS a iii erio r, gy rtT 5

si gmoideus posterior a iid gyrus ha tera Ii s i.i `., fro in t he f'ron Ia 1 parts.

No. oF shadow cells: No. of shadow cells:;rtiip possibly irreversible probably irreversible

clii ma ge d a uiage

5

A 6

13 7 3

F t he extremely Ia rge number of ITCfl e cells exa miTled several liii Tid red i

each spcci uiei is ta ken iTito account, t he very snia 11 tigiT res are rem ark able.

TruTe TiC Li OTi opha gin seeTned to he still TU ore rare. It wa ii ot observed iii

any of' the control animals and eotTld oTily be suspected OTi seven occasioTis iTi

the animals subjected to ECT. This phenomenon should Tiot he con I'used with

so-called satellitosis. Refereice is also made to the photomicrographs.

A TitTmber of earlier workers have reported disappearance of' cells anti

acelliTlar areas in the cerebral cortex of' t lie experiTiieTita I a iii mais. I was there-

lore part icula rlv interested 1 Ti ascc rt ai Ti i Ti g whet lie r 5 LTcli phe ii ome ii a were

present. I hliund that the cytoarchitect iTre coTisisten t ly exhibited sonic irregular

ity. rIme nerve cells were assembled in groups, these groups appearing to have

reIn t ioTi5fl i p to the vascular architect nrc. l'his irregularity seemed to he greater

in the deeper layers of the cortex. It is therefore, iTi all probability, likely to be

ext reniely di Ilicult to deterni I ne t lie puss i hlc 0cc LI rrence of small acel In Ia r areas

or ol' an elective droppiTig out of cells. This has also tieeii pointed wit 1i

Schohz , among others.

&w-eti DC4.7c 1/.-/°` vr, i

At the uTibiased examination, I was unable to find any large Tiecrotic area

Single, small arbis with .cuspeeu'd dropping out of cells were observed sporad

cally in animalssubjected to larger seriesll - I 6[CT's aTid with a long'

survival time goup 13. In only one specimen could this finding he considert

as definite. ITi slveral cases, however, the suspicion could not lie regarded

altogether uTifo4nded. Finally, the Following facts may be mentioned. It

a question of a few cells iTi 7 specimens out of the total 2X2 exaiiiiTled; th

phenomenon was not found in any ol' the coTitrol aTiimals. It was seen especial

iTi group B.

The qiestion of whether or not irreversible damjtgp,,jo the nerve cells ni- `

________________

ocetli in association with ECT IiiLTst therefore lie aTiswered in the aflirmati'

This is the first eonelusioTi tobërawn trofl Tieo& rvations reported. 1

it ii ges ouTi wero , iowever,tensive t hey aI, oply in- `U .-

ot the nerve cells and occurred principally in those animals given the larg

series of ECT's. On the other liaTidl, only a very small proportion' oF the ccclTrerehra1

cortex were exami Tied in the i ndi' idual aTlimal. ITi absoli

figures, the number of damaged nerve cells iTi the whole cortex shiotTId

considerably greater. There is, however, TiO reason to aTiticipate a liu

proportioTi IF clii Tiiaged cells iii ot her seci ions oh' t lic cortex, n t lie conf ra

it is posihle that they would he less t ha Ti in the trilTital pa rts.

With regard to the animals given less inteTisi e treatTilerit Lu., 4 EU

only it may he coTicluded that it was not possible to demonstrate any ii

versible nerve cell damage of aTly consequence.

The following statement niay also he riiade. It appears almost impossil

Ti the ease of aniTimals surviving for a longer period al'ter a series of E' I

to recogniie a dropping out oF cells of this type arid on the aforementioi

scale. 1 Ti my opinioTi, such cell chin nges can only lie rccoeiiized if the nut.

scopical e xa Til i Tia t ion is nu ade in t lie cci u rse iF t tie pat Ii ological process,

clii ri rig t lie ci a ys liii mccli a tely l'o Il owi rig t lie E'l'. Eli is eTuiphiasi ics 1 lie iicce

oF choosing a suitable survival time for the aTuiTmials in such ileuropatholot!

ex per i in en t 5.

ciiAi'ruTt ii

`on.chk'ration.c on 11w I'aIIlog'n `si.v vi' tin'

C'crehrai Iiange.v

In the present experiments, the most easily discernible changes in the hi

of die animals subjected to FC'E' were found in t lie ascuIar systeni. In e

ease the blood vessels were dilated aiicl tilled w itlu blood. Since this also a

to the control animals, this phieiuonuenon was Tiut considered to he corrcl