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09/08/2013 09:33:03

ECT machines in Egypt

Figure A - Solus

On visiting the Behman Hospital Museum, I found a few machines, that could almost tell the history of ECT. The first one is big - a bit less than a metre in height measuring about (51 cm length * 51 cm width * 95 cm height). It is a Solus ECT machine (No.140), made in England shows an A.C. current, milliampere/second monitor (0-100, 0-500), with duration 1-5 seconds, has measurement-shock converter. I learned later from Dr Loza that this was the first ECT machine in Egypt and that the Solus device was available as early as 1939 (a photo of an identical machine was available in a journal) and is considered as modification to the original Bini's machine (Shepley and McGregor, 1939).

Spencer Paterson

The second ECT machine I saw was a smaller, beige machine in a brown covered  wood measuring about (42*24*11 cm) and it had the title of Elettroshock and it has a dial for resistance. One of the ECT electrodes is a classical scissors (forceps) electrodes, where the voltage can be adjusted. The forceps electrodes were considered more practical than rubber bands in treatment of uncooperative patients (Kalinowsky, 1949).

Spencer Paterson ECT Machine is a painted wood machine measuring about (31*24*10.5 cm) and, like the previous ones it is voltage-based (70-150 V) with a variable current and Ohms are determined manually - hence the current is variable according to Ohm's Law V=I*R. The voltage upper range is much lower than current ECT machines that can deliver up to 400 volts, which has variable voltage but fixed current. Spencer Paterson is an ECT machine, that is rectangular in shape. it has a rotary dial to adjust the duration, that has close resemblance to traditional phones. The duration on the dial ranges from (0.1-1.0) second.

MacPhail-Strauss Plexacon, is another machine measuring (37.5*28*13 cm), with an analogue rotating pointer. It uses the term 'electroplexy' instead of electroshock or ECT. The term seems to avoid the notion of shock or convulsions which seemed horrific at a point in time.(Spencer, 1982). Several other names were proposed in Egypt as Brain Synchronisation Therapy, Brain Stimulation Therapy, Rhythm Restoration Therapy (Okasha, 2007), in addition to other names that were proposed in other places as cerebroversion (Shorter and Healy, 2007), or Centred Stimulation with Patterned Response.  This machine shows energy-based titration (in joules), as opposed to the traditional voltage-based electric dose.

Eclonus MK4
There are about five Ectron machines including Ectonus (17.5*16*10*6) and Ectonustim (22.5*21.5*10*5).  Relatively smaller in size, they are made of metal (grey and blue coloured), with the dial surface slightly tilted like the Solus machine. The Ectonus MK4 is in wooden box. The MK4 electrodes have a fixed width from each other. They have the option of delivering unidirectional or bidirectional electric wave, There is diagrammatic representation of the wave shape on this machine.

There is current interest in pulse shape (Peterchev et al, 2010). El-Islam, stated that there was a special technique used, by dialling to the end and waiting for the tonic phase to end, and slowly returning the dial during the clonic phase. He also stated that he used to give unilateral sine wave ECT, via Lancaster electrode placement during a study, and during his practice (El-Islam et al, 1970) patients could drive their cars back home on the same day, with no reported incidents of accidents or feeling lost. 

The finding was not systematically observed, thus it was not reported in the article. Some of the senior clinicians regret the loss of some ECT techniques which required their observation, and the real time adjustment of the electric dose and duration, rather than a preset computerised software. A senior consultant informed me about the Ectonus method for administration of the session (Rao, 1958). Also, some regretted the loss of the simplicity of the procedure, as careful measures were taken in outpatient ECT.  Ectonustim, has the option of delivering sub-convulsive electric charge for cerebral stimulation (Talbot, 1984) (Not in use in contemporary practice).

In the largest mental hospital in Egypt, 'Abbasseya Mental Hospital', there is a museum that displays two ECT machines; a smaller Solus ECT machine, and another, named 'Minicoma', that has a label saying 'when no light, no shock'. They lie under an old blue street label that says 'CHAREH ESBETALIET EL MAGAZIB' which may mean 'Insane Hospital Street'. In Al-Wafd newspaper there was a report on an ECT machine named 'Beta 444'. It seems that it was an attempt for local manufacture of the device. However, it did not meet the basic requirements for a contemporary device, the electrodes' width was too small, the machine was devised to administer sine wave (8.3 ms), in an era where ultra brief pulse width (<0.5 ms) is being researched (Weiner et al, 2001). Following reports from Dr Al-Ajhuri and others, the Egyptian Ministry of Health banned the device. There was media coverage on the event, defining the problem of the machine and comparing it to standard ones. In contrast to the media coverage of ECT which is in general, negative, this one seemed quite balanced. The Egyptian media, at least three movies and two TV series depicted unmodified ECT as a punitive measure. Some websites seemed to attempt to counteract the stigma, explaining the treatment in detail.. However, in at least two websites attributed to physicians the electric dose mentioned was 9-12 V. which is less than the original voltage given by Cerletti, and certainly less than voltage given by currently available machines.

Back to the Behman Museum, there is a relatively newer machine named ElCoT MF-500 (47*45*17.5) that resembles modern ECT machines  Its titration is apparently charge-based, it has the option of delivering sine wave, and brief pulse (1.0-2.0ms).  Frequency, duration, and current can also be adjusted. It is also supplied with electrodes for EEG and ECG.

ElCoT MF-500

I also found a table that describes the parameters for titration of the electric charge. I learned from one of the consultants about the impact of the studies that illustrated the importance of electric dosages above the seizure threshold, and how this impacted the ECT practice (Sackeim et al, 2000).

During a chat with a senior nurses (retired for over than 10 years), who attended ECT for over 50 years, he said 'In the past ECT was simple and safe, but now, patients have wires on the head, chest, hand, and foot. Doctors are busy with tables, charts, wires and graphs in addition to monitoring the fit. Back in the good old days, we practiced both Insulin coma therapy and ECT, sometimes on the same day. The strength of the seizure and its duration seemed to be what mattered after the safety of the patient'. He pointed at a greyscale photo in the museum, saying 'did it not look a bit simpler?'

During a chat with a senior nurses (retired for over than 10 years), who attended ECT for over 50 years, he said 'In the past ECT was simple and safe, but now, patients have wires on the head, chest, hand, and foot. Doctors are busy with tables, charts, wires and graphs in addition to monitoring the fit. Back in the good old days, we practiced both Insulin Coma therapy and ECT, sometimes on the same day.

ECT in Egypt

The strength of the seizure and its duration seemed to be what mattered after the safety of the patient'. He pointed at a greyscale photo in the museum, saying 'did it not look a bit simpler?

The museums, media and talks reflect on the history of the development of ECT machines, with electric dosing that changed from voltage-based, to joule-based, to charge-based titration and electric wave that changed from sine wave to brief pulse.

The nomenclature is also showing changes; 'elettroshock', 'minioma', 'electroplexy' and ECT. 

The machine morphology seems to reflect on technological advances from the rotary dial to the current touch screen machines.

Bibliography

  1. Edward Shorter and David Healy, Shock Therapy, Rutgers University Press, 2007
  2. Kalinowsky, L., Present status of electric shock therapy, Bulletin of the New York Academy of Medicine, 1949, Vol. 25(9), pp. 541-553
  3. M. Fakhr El-Islam et al, The Effect of Unilateral E.C.T. on Schizophrenic Delusions and Hallucinations, British Journal of Psychiatry, 1970, Vol. 117, pp. 447-448
  4. Okasha, T., Electro-Convulsive Therapy (ECT): An Egyptian perspective, South African Psychiatry Review, 2007, Vol. 10, pp. 22-14
  5. Peterchev, et al, ECT Stimulus Parameters: Rethinking Dosage, Journal of ECT, 2010, Vol. 26, pp. 159-174
  6. Rao, M., The Ectonus Method of E.C.T., Indian Journal of Psychiatry, 1958, Vol. 1, pp. 13-15
  7. Sackeim et al, A Prospective, Randomized, Double-blind Comparison of Bilateral and Right Unilateral Electroconvulsive Therapy at Different Stimulus Intensities, Archives of General Psychiatry, 2000, Vol. 57, pp. 425-434
  8. Shepley, W. McGregor, J., Electrically induced convulsions in treatment of mental disorders, British Medical Journal, 1939, Vol. 2:4121, pp. 1269-1271
  9. Spencer, D., ECT wall chart, Psychiatric Bulletin, 1982, Vol. 6, pp. 143
  10. Talbot, J., ECT instructions concerning cerebral stimulation, Psychiatric Bulletin, 1984, Vol. 8, pp. 76
  11. Weiner, R. et al, The Practice of Electroconvulsive Therapy, American Psychiatric Association, 2002
18/06/2013 15:52:47

Questions about demonic possession

Clinical experience in answering questions about demonic possession

In daily practice in psychiatry in Egypt, various forms of mental illness are commonly attributed to magic spells or demonic possession. These illnesses are usually manifested by overt motor behavioural disturbances. Top of the list of these disorders are epilepsy and schizophrenia. Unusual ideas and actions found mythical explanations in witchcraft and demonic aetiology by patients and relatives in this traditional community. Symptoms that are typical of obsessions are intrusive, unacceptable thoughts which many patients attribute to a demonic agent known as the devil. It's not uncommon for patients and carers to enquire whether this is due to demons or supernatural agents known as jinn. The psychiatrist tries to find culturally acceptable answers to patients' questions about demonic and jinn possession. The basic essence in answering this questions can be summarised as doctors can adopt an empathic subjective (emic) approach to understand supernatural beliefs and attitudes within this culturally shared context (1).

It is recommended to ask explicitly in the drug and treatment history about non-medical interventions such as therapy offered by a traditional/religious healer, as some patients or relatives may not volunteer this information on their own. One cannot tell for sure why, but some relatives expressed their embarrassment from the experience, especially that some rituals may include physical harm, animal sacrifice, or an emotionally charged ceremony known as 'Zaar'. Others assume the doctor may be critical of such notions. Some think it is not relevant to the psychiatrist. Conversely, some patients are referred from traditional healers who confirm that what they suffer is mental illness.
 
When the patient or the carers ask about whether their illness is caused by demonic or jinn possession, some doctors may answer that the clinical picture presented is a usual or typical presentation of mental illness, implicitly ruling out the supernatural explanation, and explicitly stating the role of biopsychosocial treatments in managing the condition. Restating the symptoms as psychiatric syndromes offers the medical point of view. Avoiding plain Yes or No answers may be a culturally sensitive choice to avoid implicit notions that the doctor claims knowledge about the supernatural which is beyond the scope of medical practice. Some doctors may explicitly express the medical limits of their role. Aal-e Yassin,1995 (2) found that patients who adhered to their religious code seemed to benefit more from religious therapy (e.g. obsessional disorder). He further stated that patients may seem to possess 'religious receptors' which accept religious advice by others. Some psychiatrists would state that illnesses have precipitating factors that could be either as natural as bereavement or divorce, or supernatural as demons or jinn.

Fig 1

El-Islam offered the following framework to answer these questions (Figure 1). Some people believe that supernatural precipitating factors could evoke the biochemical mechanisms involved in symptoms formation e.g. neurotransmitter and transporter mechanisms. It is through these mechanisms that biomedical treatments act irrespective of the nature of the precipitating factors. The effect is the stirring up of the chemical imbalance that may have caused the mental health problem. Many relatives of patients who have psychiatric treatment would like to negotiate the option of traditional healing in order to deal with their demono-dynamics. Approval of involving a traditional healer may be sought from the clinician. El-Islam (3), proposed that three conditions should be fulfilled explicitly by the patient in order to have traditional healing.

  1. The patient may not seek the traditional healing, if he/she does not wish to do so on relatives' advice.
  2. The patient should not discontinue the biopsychological treatment, even if instructed by the traditional healer to do so.
  3. The patient should not let anybody harm him/her physically or by use of herbs. Some herbs are poisonous, or may not work well with medication.

Alternatively, recitation of religious verses can be done by the patient for himself/herself as 'autoreligious therapy' i.e. self-help. Occasionally, a direct question to the doctor tries to find out whether the treating doctor shared their belief in demonic or jinn possession. It may be helpful to say 'I've never encountered something like that'. A direct answer about personal privacy of the clinician may be perceived as 'offensive' by the patient. Equally, collusion with the patient and relatives' cultural explanation may trigger role confusion. Some patients who attribute their illness to supernatural forces expressed their scepticism that natural elements as medication can offer a cure, however, they expressed that it helped them to become calmer.

Despite the diversity of the explanatory models to mental health problems, phenomenological description, empathic reflection, respect of cultural beliefs and genuine attitude of care from the clinician's side seem to help bridging or even aborting an anticipated clash of explanatory paradigms.

When I started practising psychiatry these questions seemed quite awkward to answer especially, I could not find ready made answers about this in handbooks of psychiatry and textbooks seemed to provide a comprehensive overview about culture-bound syndromes, that I could not directly translate to daily clinical work. I tried asking senior doctors and I found an array of different answers. I tried to present the answers that seemed more comprehensive. During this journey of understanding, I learned that the role of the doctor is basically to help people get better with their illness.  Maintaining the focus may be hard as there is the temptation to wonder about cultural beliefs and even a frank invitation to offer answers. I learned that it is best to resist the temptation to advocate a certain explanatory model of mental illness, collude or collide with cultural beliefs.

References

  1. El-Islam, Some cultural aspects of the Arab patient-doctor relationship, International Psychiatry, 2005
  2. Incawar et al, Psychiatrists and traditional healers unwitting partners in global mental health, WPA Transcultural Psychiatry, Wiley-Blackwell 2009
  3. Personal communication with Dr El-Islam, 2013
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        About this blog


Dr Emad Sidhom

 

Dr Emad Sidhom, is a psychiatrist working in an old age psychiatry department in a private hospital in Cairo, Egypt. He is board certified by the Arab Board of Psychiatry.