Saturday, December 10, 2022
This blog post discusses an inside look into working with a patient who experienced Catatonia and their journey recovering with Electro-convulsive therapy (ECT). My hope is that this post will provide education and de-stigmitazation on catatonia, ECTs, and In-patient Psychiatric hospital wards.
***This individual has read through my writing post-discharge, and has given me verbal permission to share both their and my experience, including the things they told me throughout their journey. They know that the story is published on this website. I have made sure to protect their identity ***
Stepping into my Medical School's In-Patient Psychiatric ward for the first time during my Psychiatric Clerkship had me initially stop in my tracks. It was clean, quiet, and had beautiful paintings and photographs lining the cream colored walls. As I walked through the halls I began to see patients dressed in scrubs and sweat pants just hanging out. Some were lounging while watching tv, others were drawing with huge Crayola markers, and others were having a debate about their favorite singers.
During this clerkship, I had the amazing opportunity to speak with an individual who had just been through multiple sessions of ECT and had finally “awoken” after a month stent of being in a catatonic state.
I want to pause for a moment and talk about Catatonia. Normally individuals think of catatonia as people who are frozen in space and time, as if they are a clay statue. One can move their arm into the air and it will stay in that position until you move it into another position. This is actually one type of four catatonic states and is classified as "waxy stiff catatonia.The consequences of being in a catatonic state include being at an increased risk of choking and aspirating on their food or drinks since they are not fully mentally present.
See the table below from "Prototypes of Catatonia: Diagnostic and Therapeutic Challenges in the General Hospital"
Azzam PN, Gopalan P. Prototypes of catatonia: diagnostic and therapeutic challenges in the general hospital. Psychosomatics. 2013 Jan-Feb;54(1):88-93. doi: 10.1016/j.psym.2012.06.008. Epub 2012 Dec 4. PMID: 23218059.
Upon learning that this patient had recently "awoken" from a Catatonic state, my breath was taken away, and I desperately wanted to talk to her. I wanted to hear her story, her experience of being in that catatonic state, and what the ECT treatments had felt like.
My heart ached for them as thier voice quivered stated they didn’t "remember anything" from the past couple weeks. They just couldn’t believe that they had lost so much time.
How could they not remember? I had assumed that people in a catatonic state could hear what is going around them but just couldn't communicate.
They shocked me once again by saying that they had some vague memories of looking at their body being surrounded by medical staff taking care of them. This is an example of a “dissociative” state, which is also a common trauma coping response.
They then remembered that most of the time they had felt like they were in a dream, particularly on a “large boat with tons of cabin rooms, and was on some sort of mission.” She reflected upon little pockets of time where she saw her mother and sometimes her partner visiting her, but she wasn’t sure if she was imagining it or not.
When I asked her if she remembered having the ECT treatments she stated that she remembered having a mask being put on her face and the doctor telling her to count back from ten and then immediately falling asleep once again. During this initial discussion, she was interested in what the treatment procedure was. I told her I did not know much myself since it was just my second day on my psychiatric clinical rotation, but would be back once I learned more. I told her that the little I understood was that the doctor shocks her brain, like they shock a heart during CPR, to help her wake up from her catatonic state.
Later that night I wondered what previous bias’ she had on ECT procedure. Had she also seen the depictions I had seen in movies and on tv? She didn’t seem fearful, but instead very intrigued. I would have been terrified to wake up and then be told that my brain had been shocked multiple times.
Her story led me to dive into my studies on ECT to see what it truly was, how it has helped other individuals, and what community bias’ were prevalent regarding this taboo procedure.
My bias, similar to the majority of individuals, toward Electro-convulsive therapy (ECT) was based on movies (One Flew over the Cukoo’s nest, Silence of the Lambs) and TV shows (American Horror Story, Ratched). Frequently the scene would depict a disheveled psychiatric ward where patients were treated as inmates, screams and manic laughter echoing off the ominous walls. The compounding image would be a “psychotic patient” fully strapped down to a steel “bed” as they begged for mercy. Without anesthetic (an old technique) a doctor would grab a device and shock the patient until their screams became whimpers or silence.**
My arms would be covered in goosebumps and my heart would race as I watched on the screen as this poor individual would be electrocuted over and over, leading to their body to shake uncontrollably in response. Some media would even depict their patients being shocked almost to death.
The storyline would portray ECT as not just a “therapeutic tool” but also as a form of punishment to silence them and leave them in a dazed mute or frozen state. The media portrayed ECTs as not just a “therapeutic tool” but a form of punishment and/or to remove a character flaw.
In American Horror Study-Asylum, Sister Jude, who despised the patient, stated the patient's “memories are [their] worst enemy.” Therefore, the Psychiatrist responded, “so you would like to help erase some of them, bring our own peace of mind.”
After the ECT the patient would no longer be actively “psychotic,” a burden, or at risk of causing harm to them-selves or others.
However, was ECT really “treatment” for the patient or for the staff of the Psychiatric ward? This question remained and was never addressed in the tv show. The response to the ECT in the tv show focused on the staff no longer being burdened with the patient, so could just move on to the next “problem patient.”
There is a significant history, studied technique, and consistent scientific evidence of the successful use of ECT treatment on patients with refractory catatonia and schizophrenia who are not responding to pharmacological medications.
Here are two major articles that talk about ECTs:
1. Electroconvulsive Therapy Part I: A Perspective on the Evolution and Current Practice of ECT
Payne NA, Prudic J. Electroconvulsive therapy: Part I. A perspective on the evolution and current practice of ECT. J Psychiatr Pract. 2009 Sep;15(5):346-68. doi: 10.1097/01.pra.0000361277.65468.ef. PMID: 19820553; PMCID: PMC3042260.
2. Electroconvulsive Therapy Part II: A Biopsychosocial Perspective
The following night I returned, and I was devastated to see that she had quickly regressed to her previous silent, and distant state of mind. She barely answered my questions and responded with with one or two words. When I asked her how she was feeling, her eyes furrowed as I could tell that her mind was having difficulty connecting the emotions to the part of her brain where she could then speak the words out loud (possibly Broca’s area). I pulled out my phone to show her my emotions wheel and said, “I sometimes also have difficulty expressing what I am feeling, and I like to use this.” I zoomed into the middle and started with the 6 major emotions: sad, afraid, disgusted, angry, proud, joyful, intrigued, trusting, loving, peaceful, ashamed. She continued to stare at it intensely, but I also wasn’t sure if she was here with me any more. In her hands she spun a little ball over and over.
I tried a new strategy: "I heard earlier you felt sad, do you feel sad?" Again silence. I waited, as I have been trained a good psychiatrist does.
The brain processes things at different speeds and in different ways which scientists and doctors have just stepped our toe into the mystery of how it works.
I tried a couple different techniques like asking what she is thinking about or bringing up topics we talked about the day before. To my surprise she remembered the college I went to because she had visited the town before. She would also follow commands like looking at me in the eyes when I asked her to. She was there, but something was preventing her full self from coming out.
After sharing with her a couple memories and hobbies she had shared with me the day before, I knew it was best to let her rest. I stood up from my crouch and I said “it was good to see you,” and she responded “it was good to see you too.”
The next night she was a bit more awake after undergoing another ECT procedure. We chatted a bit more and she told me that she sort of remembered talking about being on the boat. However, this time she mentioned that she had been experiencing more “paranoia” and about people trying to take over her life as she stayed in the hospital. It was fascinating because she would recognize that the delusions were false, but that they had come back to haunt her as she began to return to a catatonic state. She asked me if I would return the next night, and I promised her I would.
Between these talks she had multiple ECT treatments, which have been shown to be more effective than just a couple for such severe cases as hers, where she would decompensated (become catatonic) so quickly. The plan for cases catatonia would be to do anywhere from 12-16 total treatments.
After more treatments, I visited her and she was the most conscious, vocal, and animated person I had yet to see from her. She stated that today she truly had “woken up,” and felt that she finally could think clearly. She did not remember talking to me earlier about the boat or when she had first met me but her fragmented memory became more put together as she explained to me more about the internal stress that had caused her to stay in that shocked and mute state.
People react to stress and trauma in various ways but her’s could be described as a “dear in the headlights” where she froze in complete panic over a month ago and could not jump out of that perpetual loop on panic that her life was essentially over and that all her dreams would be coming to an end after working so hard towards one of her life goals.
I related to her so much as I explained to her I had a similar stress reaction when I was faced with the possibility that I might have to give up medical school after failing my Step1 exam twice and was sent to the board of the school to decide my fate. We both reflected and like old friends recounted the horrors that her mind had gone through as she sat in the hospital bed without realizing how much time had passed between first being picked up by an ambulance over a month ago.
My own experience assisting with an ECT:
On one of the mornings of my Psychiatry rotation, I had the opportunity to dress up in surgical scrubs and assist in an ECT procedure on two patients. We met the anesthesiology team in the "post-op" room and waited for the patient and psychiatrist attending physician to arrive. We rolled out the ECT machine from the corner of the closet and started setting up. There wasn't much to get ready besides getting out gloves, a mouth block, and some lubricant like jelly.
Our first patient arrived and jumped up on the hospital bed. As someone started an IV we chatted that he gets these once a month so he can maintain his job at a law firm. With a push of ketamine, a sedative which also causes dissociative amnesia, he fell calmly fell into a sleep-like state. I helped put two straps on him to keep him from falling off the bed, one on his chest and another on across his legs. The psychiatrist adjusted the settings to the proper voltage that had previously worked for this patient. He then used two black paddles to gently place them on the patient's temples. In less than a minute it was over.
I rubbed my eyes with the back of my gloved hand, he hadn't even moved?! Did we really just shock his brain? Where was the huge seizure from the electrical stimulation? Apparently we had also given him Succinylcholine a depolarizing neuromuscular blocker, also called a muscle relaxant, which decreases the movement of the patient during the procedure.
We then rolled the machine to the bed next to him where an older women was quietly waiting. She told me she had been receiving ECTs from this same Psychiatrist for longer than I had been alive! This time I knew the drill and helped place the jell on her temples. The Psychiatrist then handed me a paddle! I was about to do my very own ECT! With one hand on my paddle pressing on her temple and the other hand on the button we shocked her. This time I think I saw a finger twitch....maybe. That was it! We wheeled the machine back into the closet as the nurses attended to the sleeping patients who would awake within the hour. They would have forgotten the past couple hours of their life, a small side effect of the ECT procedures and the sedatives.
The final day of my patient's psychiatric in-patient stay I went back and visited her to discuss her experience. At that point she had been through over 10 ECT's in-patient and was going to continue ECTs out-patient on a weekly basis.
When questioned, she said she would recommend ECTs to others because it helped her “feel more like me.”
My goal in writing this blog post is to acknowledge that mental health treatment is scary, especially when it involves having to stay in a psychiatric in-patient hospital. We will all deal with mental health challenges at some point in our lives in one way or another. In turn, it is OK to ask for help, especially from the medical system.
Even though it is scary at first to be placed on a Hospital floor with locked doors for a set period of time, everyone just wants you to feel better and get you back to living your life. The purpose of the in-patient wards is to protect and care for individuals who do not have the momentary ability to meet their basic biological needs. This could be because they want to harm their bodies, commit suicide, or are in a catatonic state which prevents them from feeding themselves.
It is ok to take time away from work/academics/life in order to return to a state where you are more in control of your life and emotions.
If you take the time to heal, you will come back mentally stronger and better able to handle challenges that arise in your life. From my own experience as a medical student and as a patient who took a year off from medical school it is worth it. Even though it was physically, emotionally, and financially devastating to take time off to focus on my health, I wouldn’t be at the place I am today without it. I am mentally stronger, more in control of my pain, and able to be more present when academic and life challenges arise.
More Data on ECTs: American Psychiatric Association www.psych.org National Alliance for Mental Illness and its local chapters www.nami.org www.medhelp.org/lib/ect.htm National Mental Health Association www.nmha.org Personal account by patient www.electroboy.com/electroshocktherapy.htm
*Kerr RA, McGrath JJ, O'Kearney RT, et al. ECT: Misconceptions and attitudes. Aust N Z J Psychiatry 1982;16:43–9. PubMed: 6956328
**Fink, PJ.; Tasman, A. The stigma of electroconvulsive therapy: A workshop. In: Fink, PJ.; Tasman, A., editors. Stigma and mental illness. Washington, DC: American Psychiatric Press; 1992. p.189-201.
Reasoner J, Rondeau B. Anesthetic Considerations In Electroconvulsive Therapy. [Updated 2022 May 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK576431/
Lally J, Tully J, Robertson D, Stubbs B, Gaughran F, MacCabe JH. Augmentation of clozapine with electroconvulsive therapy in treatment resistant schizophrenia: A systematic review and meta-analysis. Schizophr Res. 2016 Mar;171(1-3):215-24. doi: 10.1016/j.schres.2016.01.024. Epub 2016 Jan 27. PMID: 26827129.
***This Blog Post is for educational purposes only and is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. This does not imply a doctor-patient relationship. All opinions are the opinions of the writer and not reflective of any institution or employer. Please follow up with your health provider and therapist for any additional questions or support.***
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