Psychosomatics 48:290-293, August 2007
doi: 10.1176/appi.psy.48.4.290
© 2007 Academy of Psychosomatic Medicine
Complaints of Loss of Personal Memories After Electroconvulsive Therapy: Evidence of a Somatoform Disorder?
Max Fink, M.D.
Received December 16, 2006; accepted February 9, 2007. From the Depts. of Psychiatry and Neurology, Stony Brook University, Long Island, NY. Send correspondence and reprint requests to Max Fink, M.D., P.O. Box 457, St. James, NY 11780-0457. e-mail: mafink{at}attglobal.net
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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This selective review considers the rare complaints of the loss of personal memories after successful courses of electroconvulsive therapy (ECT), which are best characterized as somatoform disorders, rather than as evidence of brain damage, thus warranting psychological treatment for such disorders.
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INTRODUCTION
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The principal reason for reluctance to use electroconvulsive therapy (ECT) is neither a lack of efficacy nor a finding of untoward risks, but the anticipation that patients may suffer profound and prolonged loss of personal memories. Critics picture ECT as "erasing the memory slate," much as a cloth wipes away the scribbles on a chalkboard. Although an acute confusional syndrome commonly accompanies the anesthetic and the seizure, the memories of life events, the skills needed for work, and the learning of new material are as efficient as those experienced by older patients’ siblings, spouses, and relatives of similar age, who are likely to suffer age-impaired memory.1–4
The opinion that "for rare patients, the retrograde amnesia due to ECT can be profound, with the memory loss extending back years prior to the receipt of the treatment" is an example of the view of the treatment risks.5 The evidence comes mainly from personal reports and surveys of patient recollections of their experience with the treatment.5,6 Such reports are rare, even in the surveys, but the poignancy of the complaints and the devastating details of the losses are frightening to readers.7,8 Two voices, of Marilyn Rice,9 and Ann Donahue,10,11 both of whom were successfully treated with ECT for severe depressive illnesses, express these complaints eloquently.
A Disabled Economist
In 1974, the experience of Marilyn Rice, a federal economist, was described in The New Yorker under the title "All about Eve," as part of a series of medical stories.9 After persistent complaints of dental pain not relieved by extraction of all her teeth and replacement by dentures, Ms. Rice "fell into a deep depression," lost her appetite, and experienced a 20% loss in weight. She ruminated about her mouth and gums and believed that she had become ugly. A 9-week stay in a psychiatric hospital left her no better: "I am [now] on a rest cure with do-it-yourself treatment."
When her therapist despaired of success with psychotherapy, she was hospitalized for a course of ECT, after which she wrote: "I felt just fine, perfectly relaxed and comfortable, and also very hungry, as if I were making up for lost time. She also believed that her memory was altered: "I was puzzled—but only vaguely. I really felt too vague to care. Nothing really bothered me ... I felt physically very well ... and calm. I did not have enough memory to think, or even worry ... Work was just something that drifted across my mind from time to time. It did not interest me. I was too comfortable doing nothing."
After 1 month at home, she returned to her office. Although her associates appeared familiar, and she remembered their names, she found the work unfamiliar. "I was terrified. I’ve never been a crying person, but all my beloved knowledge, everything I had learned in my field during 20 years or more, were gone. I’d lost the body of knowledge that constituted my professional skill. I’d lost everything that professionals take for granted."
Dental pain and feelings of ugliness were now gone, replaced by the preoccupation with memory. She retired on medical disability. "I mean, I mustn’t give the impression that my experience with electroshock was a total disaster. There have been some beneficial results. For one thing, my physical health has improved. I am beginning to eat again; my digestion is much improved; and I have no trouble with sleep. I also feel emotionally relaxed. And I’ve lost a lot of bothersome inhibitions."
A malpractice action against the psychiatrist who administered ECT was not successful. Neuropsychological tests were unable to document decrements in memory or recall functions. She sought help in hypnosis and psychotherapy, and successfully organized an anti-ECT advocacy group: the "Committee for Truth in Psychiatry." She attended meetings of psychiatrists and complained that ECT had been administered without the prior explanation that the price would have been a severe loss of her memory. She read and critiqued the ECT literature. At a meeting dedicated to reports on progress in ECT research in 1982, Ms. Rice debated the literature with ECT experts, citing articles correctly.7 Her malpractice suit against the psychiatric hospital was also not successful. Before ECT, she had been hospitalized for multiple suicide attempts, threats that did not recur in her subsequent history.
An Enabled Lawyer
Ann Donahue, a lawyer and Vermont state legislator, described her experience with her depressive illness and her treatment.10 Episodes of depression responded to medication in 1987 and 1989, but a relapse in 1993 did not remit. After 2 years of trials with medication and psychotherapy, she received an extended course of ECT and recovered from her depressive illness. She described her experience: "Occasionally, I feel bitter. More often, it is a sadness, a sense of deep loss that may not even have had to happen. It is a grief that keeps deepening over time, because there is hardly a week that goes by that I do not discover yet another part of my life that is lost somewhere in my memory cells."
She continues: "Despite that, I remain unflagging in my belief that the ECT I received ... may have saved not just my mental health, but my life. If I had the same decision to make over again, I would choose ECT over a life condemned to psychic agony and possible suicide."
She describes the effects on memory: "My long-term memory deficits far exceed anything my doctors anticipated, I was advised about, or that are validated by research." About her recovery, she writes: "As the 6-month marker came and went with only partial recovery of my recollections for past events, my focus began to change. I was again not doing as well emotionally, which affected my positive attitude." She undertook a detailed research of the literature on cognition and ECT: "I was completely stunned by the discrepancies I found. While multiple studies found any long-term amnesia to be extremely rare ... informal accounts, advocacy-group information, and newspaper exposés described extensive and broad-based risks ... "
Despite her complaints, she has taken an active interest in community affairs and has appeared on radio interviews.11 In 2002, she was elected to the Vermont House of Representatives. She brought a malpractice lawsuit for improperly performed ECT against the Vermont hospital. In a settlement, the hospital formally adopted Vermont’s informed-consent guidelines and agreed to make a new informed-consent video available to all prospective ECT patients.12
The Camelford Incident
It is widely assumed that these complaints are consequences of the treatment. Can another process, not rooted in the biology of ECT, be a model for the association? The British Camelford incident and its social consequences offer a model.13,14
In 1988, an inadvertent deposition of 20 tons of aluminum sulfate in a reservoir distal to a water purification plant gave the villagers in a small town in southeastern England discolored, acid-tasting drinking water for 3 days. Nausea, vomiting, skin rashes, and mouth ulcers were immediately reported. Hair, skin, and fingernails were stained brown. Local and national TV and radio reports were soon filled with rumors of shoals of dead fish in local rivers, widespread sickness in farm animals, and disruptive behavior in schoolchildren. The water company was criticized as slow to act, and, when they did, the company was accused of giving false reassurances. After the clean-up, official reports found the risks of aluminum in the water to be aesthetic, but not toxic, because aluminum is not absorbed, and aluminum poisoning is rare. Rather than assuaging anxiety, the reports exacerbated people’s fears. Newspapers misquoted the official report as claiming the residents’ complaints were due to hysteria, thus adding insult to injury. Although the water standards were now excellent, litigation was underway as potential claimants formed a pressure group.
Academic reports that aluminum in drinking water is a risk factor for Alzheimer’s disease (AD) increased the indignation. Could the hazard of exposure lead to AD several years later? The idea was congruent with the reports that "mad-cow disease" caused a delayed onset of dementia. Soon, complaints of memory loss, poor concentration, and mental and physical fatigue dominated the Camelford community clinical picture. The April 2006 issue of the British Medical Journal offers the news that researchers have linked the death of a woman with a rare form of AD to the poisoning of the drinking water.15
Another commission assessed the evidence of long-term effects, and, despite the best evidence that there were none, the complaints persisted. Complainants were finally assuaged, in part, by out-of-court settlements. For the next decade, claimants related poor work performance, decline in memory, and symptoms of anxiety and depression to their Camelford exposure.
Relevance to Memory Complaints in ECT?
In discussing these events, British neuropsychiatrists David and Wessely did not find evidence of a biological (toxic) consequence.13 Instead, they saw various complaints resulting from public concerns about physical effects of environmental events after this well-publicized incident. Physical symptoms are commonplace in any population. Professional, "authoritative" statements about unusual exposure to potentially toxic agents alter individual perceptions of their symptoms. Difficulties in recollection of names, dates, and events occur frequently in everyday life. When they surface after clinical recovery with ECT, particularly when patients return to work, it is easy to ascribe the difficulties to a trauma widely envisioned as inherent in the ECT process.
In ECT, the public believes that patients thrash about helplessly, often being treated without their consent. The images in the films "One Flew Over the Cuckoo’s Nest," "Titicut Follies," and "A Beautiful Mind" are forcefully horrific.7,16,17 Widespread fears of epilepsy and fears of electricity enhance the traumatic images. Overall, the shadow of compensation and relief from work sustain the complaint.
The association of the treatment with memory loss is self-evident. With each seizure, the patient awakens with a headache and muscle aches; he or she is confused and poorly able to recall what has just happened, the names of those in the treatment room, or family members.1–4
The psychiatric profession confirms the effects.1–4 Before consenting to treatment, the patient is asked to sign a detailed consent form that states: "Patients often become confused and may not know where they are when they awaken.... Memory for recent events, mainly for the period of illness and the treatment may be disturbed. Dates, names of friends, public events, telephone numbers, and addresses may be difficult to recall. In most patients, the memory difficulty is gone within 4 weeks after the last treatment, but, rarely, the problems remain for months or even years."1
Anxiety is exacerbated by well-meaning therapists who encourage patients to review family scrapbooks and photo albums before treatment in the hopes that at least some fragment of one’s sentimental past will remain.17
Supporting Factors
The complaints have a superficial validity, and are readily ascribable to ECT. Surprisingly, the prolonged effects on personal memory were not noted in the literature for the first four decades, at the time when ECT was deemed an effective treatment and was applied worldwide.7,8 The immediate memory effects were considered a small price to pay for the relief of a severe illness. In reviewing ECT during recent decades, the possibility of prolonged memory effects has been widely accepted. The complaints have been promulgated by the Church of Scientology and by the psychiatrists and psychologists who vehemently insist that brain damage is a consequence of electrically-induced seizures.7,8
The impact of societal expectation on the perception of ECT as a source of persistent memory loss is demonstrated in the experiences of Kitty Dukakis, the wife of a three-time Governor of Massachusetts and 1988 U.S. Presidential candidate, in her newly published book Shock: The Healing Power of Electroconvulsive Therapy.17 She describes her recovery from a lifelong depressive illness and polysubstance abuse with ECT; the benefits are being sustained by continuation ECT. Despite her recovery and acknowledgment that illness no longer limits her activity, her book is filled with complaints of memory loss that have been the focus of press interviews.18–20
Somatoform Disorder
Michael Trimble, the British neuropsychiatrist at London’s Institute of Neurology, offers a detailed history of somatoform disorders.14 Unexplained symptoms, inconsistent with known anatomy, physiology, or biology, have been a focus of medical practice for millennia. The "faints" and "convulsions" of the Victorian era highlighted by the dramatic presentations by Charcot are passé today, replaced by complex behaviors described as "somatoform," "somatization," and "posttraumatic."21,22 The syndromes offer minimal evidence of physiologic or anatomic abnormalities, yet are treated as systemic disorders by the patients, their families, and their clinicians. The rare complaints of persistent loss of personal memories as a consequence of ECT are well within the family of these syndromes.
The demographic features of the complainants are interesting. In the published reports and malpractice actions, the plaintiffs are well-educated women, often nurses, with histories of prolonged depressive illness marked by somatic features and suicidal episodes. ECT was the last resort, reluctantly advised and administered, that resulted in relief of depression, physical complaints, and suicide risk. The loss of personal memories is a new focus of illness that is described in painful terms, making a return to work impossible. Remarkably, however, the plaintiffs function extremely well in new roles as critics of psychiatry.
Instead of endorsing these reports as the direct consequence of ECT, especially in patients who have recovered from their depressive illness, lost their suicidal drive, and have improved social functioning, is it not more useful to accept the complaint as a somatoform disorder, explore the basis in the individual’s history and experience, and offer appropriate supportive treatment?
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ACKNOWLEDGMENTS
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Dr. Fink acknowledges Richard Abrams, David Healy, Jan-Otto Ottosson, Edward Shorter, and Simon Wessely for their helpful critiques. The conclusions are solely those of the author.
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REFERENCES
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- Fink M: Convulsive Therapy: Theory and Practice. New York, Raven, 1979
- American Psychiatric Association: The Practice of Electroconvulsive Therapy. Washington, DC, American Psychiatric Association, 2001
- Scott AIF (ed): The ECT Handbook. London, UK, Royal College of Psychiatrists, 2005
- Abrams R: Electroconvulsive Therapy. New York, Oxford University Press, 2002
- Freeman CP, Kendell RE: Patients’ experiences of and attitudes toward electroconvulsive therapy. Ann N Y Acad Sci 1986; 462:341–352[Medline]
- Rose D, Wykes T, Leese M, et al: Patients’ perspectives on electroconvulsive therapy: systematic review. BMJ 2003; 326:1363–1367[Abstract/Free Full Text]
- Ottosson J-O, Fink M: Ethics in Electroconvulsive Therapy. New York, Brunner-Routledge, 2004
- Shorter E, Healy D: Shock Therapy: The History of Electroconvulsive Treatment in Mental Illness. New Brunswick, NJ, Rutgers University Press (in press)
- Roueché B: Annals of Medicine: as empty as Eve. New Yorker Sept. 9, 1974, pp 84-100
- Donahue AB: Electroconvulsive therapy and memory loss: a personal journey. J ECT 2000; 16:133–143[Medline]
- Donahue AB: www.lilly.com/about/awards/wba/2003_donahuer_lifetime.pdf
- Dartmouth-Hitchcock Medical Center, Dept. of Psychiatry: Electroconvulsive Therapy. Tulatin, OR, MECTA Corporation, 2003
- David AS, Wessely SC: The legend of Camelford: medical consequences of a water pollution accident. J Psychosom Res 1995; 39:1–9[CrossRef][Medline]
- Trimble M: Somatoform Disorders: A Medicolegal Guide. Cambridge, UK, Cambridge University Press, 2004
- McIntosh K: "Screen Camelford residents," researchers say, after woman’s death linked to poisoned water supply. BMJ 2006; 332:992[Free Full Text]
- Gabbard K, Gabbard GO: Psychiatry and the Cinema. Chicago, IL, University of Chicago Press, 1987
- Dukakis K, Tye L: Shock: The Healing Power of Electroconvulsive Therapy. New York, Penguin Group, 2006
- Boston Globe Magazine: The First Lady’s Shocking Story. Sept 17, 2006, pp 39-41
- Brody JE: Shock therapy loses some of its shock value. New York Times, Sept 19, 2006
- Newsweek: I Feel Good; I Feel Alive. Sept. 18, 2006; pp 62-63
- Shorter E: From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era. New York, Free Press, 1992
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
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ABSTRACT
INTRODUCTION
