Neuromodulation and Treatment for Autism Spectrum Disorder: IIA Electroshock Therapies: The Good, the Bad and the Ugly

Modern medicine is an atavism. Our way of thinking hasn’t changed much since the ancient Greeks, only the ways of implementing cures have made any progress.  Several centuries before Christ a corpus of work spanning several volumes recorded what was known about medicine. Although many authors are thought to have contributed, history has given preference to one: Hippocrates. In terms of medical concepts these volumes espoused the idea that disease was caused by an imbalance of 1 of the 4 bodily humors. Medicine was supposed to cure disease by overcoming this imbalance. As an example, ancient Greeks used leeches to purge the body of excess blood (see Hirudotherapy for more information). Leeches are still used in modern times during the reattachment of amputated limbs. Surgeons can anastomose major vessels but not microscopic ones The end result of limb reattachment is swelling caused by the accumulation of fluids that can’t flow through the small vessels. Leeches take away the engorging fluid in a painless manner as the bite of the animal may arguably be accompanied by an anesthetic agent.

leeches

Hydrotherapy (water therapy) according to Hippocrates was a way to allay lassitude, meaning, physical or mental weakness. The goal of hydrotherapy was to improve both circulation and the “quality” of the blood. This type of therapy was taken to extremes when, according to an apocryphal account, a psychotic patient fell from a bridge into an icy river and upon being rescued was found to have been “cured’ of his psychosis. From there onwards this therapy was taken to the extremes. Doctors installed trap doors in their offices in order to plunge unsuspecting patients into deep ice water tanks. After some minutes, almost as patients drowned, they were rescued by several assistants. A similar attempt at a cure was the so-called “boat therapy”. In this misguided therapeutic attempt psychotic patients were invited to a boat cruise. Sometime during the cruise, by surprise, they were pushed overboard into the icy waters. After struggling to survive the patients were rescued. I am sure that patients so the humor in this therapeutic attempt.

For those who are older they may remember a medical procedure where air was injected into their ventricles. The procedure was called a pneumoencephalogram and was carried out in a revolving chair that could rotate so as to put a patient’s head pointing to the floor. The chair’s popular name was the vomit chair. As a job, medical students in training who were rotating through the radiology service had to clean up after every patient. A similar implementation of a gyrating chair was invented in Germany and introduced into the United States by Benjamin Rush (1746-1813), the father of American Psychiatry. Dr. Rush thought that the gyrating chair would increase blood supply to the brain.  Rush’s tactic was to bring patients who were hearing voices or exhibited unruly behaviors into the gyrating chair. They would then be gyrated until they begged for the gyrations to stop. In some cases, patients vomited, urinated and/or defected upon themselves. If the voices disappeared or if they promised to stop their maladaptive behaviors, they were allowed to rest in bed. If the voices or behaviors resumed so did the gyrating chair therapy. As in many unchallenged publications, the medical therapy using gyration met with a great deal of “success”- something that today would be called evidence-based therapy.

gyrating-chair

The history of electrical stimulation has a similar ancient origin. I believe that man has a long standing preoccupation with passing electricity through his body and getting electrocuted. Lost in antiquity a man found that the electric catfish had the capacity to produce electric shock (note: the electric catfish have an electric organ capable of producing a discharge up to 350 volts).  Must have been soon after this discovery that the ancient Egyptians started using the electric catfish out of the Nile River to treat various nervous disorders. In Roman times the physician Scribonius Largus treated a patient with gout by using a live torpedo fish. He wrote that headaches and other pains could be cured by standing in shallow water near these electric fish. Similarly, Ibn Sidah, a Muslim doctor of the eleventh century, believed that a live electric catfish had beneficial effects when placed on the brow of a person suffering an epileptic seizure. Back then epileptics were supposed to be possessed by an evil spirit and seizures were its manifestation. In order to prevent the spirit jumping from the possessed individual to those witnessing the convulsion it was customary to spit on the unconscious individual. You have to imagine the surprise of somebody waking up from a convulsion quite dazed only to find himself/herself covered with spit and having a fish stuck to his/her brow. The famous phrase, “What the heck?” came after one such seizure.

The story of electroconvulsive therapy (ECT) began in 1938 when Italian psychiatrist Ugo Carletti visited slaughterhouse in Rome. According to Carletti, “As soon as the hogs were clamped by the [electric] tongs they fell unconscious, stiffened, then after a few seconds they were shaken by convulsions…During this period of unconsciousness [epileptic coma], the butcher stabbed and bled the animals without difficulties… At this point I felt we could venture to experiment on man, and I instructed my assistants to be on the alert for the selection of a suitable subject.” Carletti’s first victim was provided by the local police; a diagnosed schizophrenic with delusions, hallucinations and confusion. After surviving the first blast without losing consciousness, the victim overheard Carletti discussing a second application with a higher voltage. He begged Carletti, ”Non una Seconda! Mortifiere!” (Not a second time, I will die). Ignoring the objections of the assistants, Carletti increased both voltage and duration and fired again. With the successful induction of a convulsion, Ugo Carletti brought about the application of slaughtering skills to humans.  For his efforts Carletti received an honorary degree from the Sorbonne and a long list of awards.

Multiple modifications have made ECT a fairly safe technique There are no absolute contraindications to ECT. It has been proven safe in elderly, children, or pregnant women.  It is now used schizophrenic patients with catatonia and depressive individuals at risk for suicide.  Most individuals that respond do so within 3 to 4 treatments. Usually treatments are extended for 10-12 sessions given during a period of 2-3 weeks (2-3 times per week at about $250 per session).

There are anecdotal accounts within the internet of ECT used in autism, primarily for maladaptive behaviors (http://slate.me/1secj9T). According to a very flawed argument, “Autism is increasingly diagnosed, but therapeutic options are limited in many children. ECT is considered as a safe, effective, and life-saving treatment in people of all ages who suffer from affective disorders, acute psychosis, and, in particular, catatonia [i.e., a state of apparent unresponsiveness to external stimuli in an awake individual]. There are recent speculations that certain types of autism may be the earliest expression of catatonia and that both disorders have identical risk factors. Therefore, ECT may improve autism and, if started early enough, may prevent further development of autistic symptoms in some children” (Dhossche and Stanfill, 2004).

A few case reports support the use of ECT in ASD individuals suffering from maladaptive behaviors associated with catatonic symptoms especially those that are agitated or excited (Sajith et al., 2016). For some children with self-injurious behaviors ECT has proven to be an effective treatment, one apparently approved by the EASI Foundation in Philadelphia (Ending Agression and Self-Injury in the Developmentally Disabled) (Dhorter, 2013).

ECT has been readily entertained to be of use in autism with little conceptual backing. Anecdotal reports seemingly support its effectiveness in individual cases. No large clinical trials have been undertaken. Some mental health professionals dispute the claims in popular media: “Dr. Gregory Fritz, President-Elect of the American Academy of Child and Adolescent Psychiatry, said there’s virtually no reliable data this type of aversive shock therapy is effective in bringing about a change in behavior, over the short or long term, once the shock is withdrawn…In government documents, it’s noted a majority of the FDA advisory panel that evaluated banning shock devices [in some of these reported cases] felt there’s inadequate evidence it works. A majority also felt using the electrical stimulus presented a “substantial and unreasonable risk” of illness or injury” (Burkholder, 2014).

References

Burkholder A. Controversy over shocking people with autism, behavioral disorders. CBS News, 2014 (http://www.cbsnews.com/news/controversy-over-shocking-people-with-autism-behavioral-disorders/

Dhossche DM, Stanfill S. Could ECT be effective in autism? Med Hypothesis 63(3):371-6, 2004.

Sajith SG, Liew SF, Tor PC. Response to electroconvulsive therapy in patients with autism spectrum disorder and challenging behaviors associated with symptoms of catatonia. J ECT Jul 2016 (Epub ahead of print).

Shorter E. A double whammy to autism. Psychology Today, 2013 (https://www.psychologytoday.com/blog/how-everyone-became-depressed/201310/double-whammy-autism)

5 responses to “Neuromodulation and Treatment for Autism Spectrum Disorder: IIA Electroshock Therapies: The Good, the Bad and the Ugly

    • I would use ECT only under special circumstances. In autism, rTMS has shown more promising results. I am biased about rTMS as most clinical trials stem from my laboratory. Otherwise I think the future will bring better techniques that are not so “perturbing” to the brain. There are many studies beginning to show the benefit of entrainment of brain waves. I would like to apply this technique to autism.

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    • rTMS remains an experimental technique in regards to ASD. I would say that centers that offer the same at great expense without any published results should be frowned upon. Otherwise there are a few centers that offer the same but only under an experimental trial. Unfortunately they may have as exclusionary criteria admitting people from outside their catchment area- if only to prevent a large drop out rate. I would say that Cincinatti (Dr. Pedapati), Brown (Oberman), Toronto (Dr. Ameis), and Australia (Enticott) are the ones that I trust.

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