Saturday, July 10, 2021

Devils and monsters 

Psychotic depression and electric shock treatment


'Is there any other treatment you can give my mother to make her better? Surely there must be something you haven't yet tried, Doctor.  I can't believe she is going to be like this for the rest of her life. She talks of nothing else but monsters, devils, hell, punishment and the earthquakes she's caused.  I can't bear watching her in this torment!' Ian made a desperate plea when he came to discuss Maria’s future in a ward-round. I looked at the faces of my team. Somewhat surprisingly, Loraine, the ward sister, looked composed and hopeful. 'Should I be hopeful too?' I thought to myself in a flash.
   'Perhaps… there is.' I continued aloud. 'ECT. You may have heard of the so-called "electric shocks"? The proper name is Electro-Convulsive Therapy. I have considered it, but rejected it because I thought your mother might have small strokes in her brain and her mental illness might be, at least partly, related to that. It's known as multi-infarct dementia. We might need a special brain scan to confirm this.
Ian looked distraught.
   'But, look, before all this she was absolutely normal. Six months ago she was normal! Like you or me. I can't understand this’ – he exclaimed.
I found it difficult to be re-assuring.
   'Your mother is now 82 years of age, had never previously suffered from depression or any other mental problems.  Initially, I assumed this was depression and we have treated her quite vigorously with medication that normally works, all of no avail. Therefore, I started to doubt a diagnosis of depression in her case. If she does have early dementia, she could be worse after ECT. Not so much because of the 'electric shocks' themselves, but because of the general anesthesia she will have to have’, I deliberated.
   'What exactly happens during these shocks?' - he asked.    
  'Under general anesthesia a patient receives a very small dose of electric current, applied by special electrodes to her head. They look a bit like earphones. In response to that a patient has a mini epileptic fit, like her toe will twitch. These mini fits seem to alter the chemistry in the brain. In severe depressive illness there is a diminution of certain substances in the brain and ECT probably restores them to a normal level. To be honest, we don't know exactly how it works, but it does' — I tried to explain the most controversial of treatments.

 'How long does it all last? Will she remember the shocks? —Ian looked somewhat apprehensive.
  'The single treatment lasts about ten minutes, not counting a full recovery from anesthesia. She would remember nothing',   I said.
 'If my mother had a severe depression, that's the treatment I would like her to have!' - interjected Loraine.
Ian became pensive for a while and then said
    'Look, if there is any hope at all that she can be better with this treatment you must give it too her. I can't imagine she can be any worse! What can be worse?'
    'Her memory, for instance. If this is primarily dementia she can be more confused'.  
I weighted the cons. But Ian was relentless -
    'It's probably better to have no memory, than to live in hell as she does.' And after a pose, he asked:
    'Will she have to agree to it?'
    'Yes, she must consent. But as she is not in a position to arrive at a balanced judgement, even if she signs the form, it would be invalid. We shall have to make this decision on her behalf. It means she will have to be treated under the law of the Mental Health Act. Another doctor and a specially trained Social Worker would have to sign a document.  In addition, an independent psychiatrist would have to examine her and agree to the treatment plan. It's a safeguard for your mother, as well as us.'
Ian said he would confer with his sister and let us know. After he left, Loraine said to me quietly:    
'You will find that the nursing staff will be very relieved at your decision'.

So, she and her team of nurses must have sensed all along that this was the right treatment for Maria, yet tactfully they have waited for me to arrive at this decision myself.  I had not been working in this hospital and this area for very long. In my previous experience the medication (namely Lithium Carbonate) would have been sufficient to bring about a recovery from depression even as severe as Maria's.  But patients here seem different, their illness more profound and they need different treatment. This case would turn out to be an important learning curve for me, and it would certainly increase my trust in the nursing staff of this acute admission ward.

It was almost difficult to believe that Maria had been quite well and active until about six months ago.  A widow for at least twenty years she managed well on her own. In her younger days, she worked in the library, always fond of books and of people who were fond of books. There was a small circle of friends with whom she would go for walks, or just meet for coffee and a chat. She was particularly friendly with Maggie, quite a few years her junior, an amateur painter and knowledgeable about arts. They would sometimes go for a week, or two, to Italy — Maggie to paint, Maria to get herself immersed in the art of Tuscan galleries. Sienna was their favourite spot. But Maggie developed a breast cancer and died, suddenly and unexpectedly. Maria took over the care of her cat, that from then on became her closest companion. When the cat died too, she felt she had nobody. Ian, wanting to take better care of his mother, arranged for her to come and live with his family. Initially Maria appeared to brighten up, but in the next three months she was sinking deeper and deeper into depression. Until one day in March she detached from reality completely…

I shall never forget Maria's thin silhouette hovering in the ward corridor, looking more like a ghost than a human being. She often stood motionless for long periods, vacantly staring into space. Her large blue eyes were full of terror, filled with dread that only she could see. The corners of her mouths were rigidly fixed in a kind of downward bow, rather like a Greek mask of tragedy. Her thin, mostly grey hairs were sticking out of her head as if petrified in terror. With one hand she was continuously folding and unfolding a rim of her skirt, in a gesture that had neither purpose nor meaning. Sometimes she followed nurses around as if seeking their reassuring presence, or she would position herself in front of the nurses’ station, motionless, as if seized by an invisible fright. Occasionally, she muttered to herself incomprehensible phrases - 'I am wicked and I deserve it all. The monsters keep hovering around my bed at night. Devils in disguise. I think I am a monster too. They’ve come to get me…'
At night she often wandered aimlessly along the corridor, sometimes stopping in mid-movement with a fixed expression on her face, sometimes talking to "the monsters". In my mind's eye, I could almost see a cloud of owls and bats hovering over her head, rather like in the famous Goya’s etching ‘The sleep of reason produces monster'. Goya must have known what psychotic depression was like! From time to time, she would approach a nurse as if wanting to talk and then would stop mid-sentence, suspended in terror. Whatever nurses or I said to her, trying to assuage her suffering, made not the slightest difference. Her depression has reached a state of autonomy, has acquired an existence of its own, out of control, out of tune with the out-side world, out of reach, beyond hope.
'Why was she so preoccupied with hell?' I sometimes pondered. I knew still rather little about Maria’s early life, and this is where the seeds of psychosis are often sewn. She was not in a state of mind to tell me, and her family didn't seem to know an awful lot. I may have to wait for the answer, if it comes at all.  Meanwhile we had to concentrate on the immediate situation, as with Maria's fluid intake rapidly diminishing, there was no time to waste.

Ian telephoned me to say that his sister and him were in favour of ECT and would like us to go ahead. The legal papers, including the second opinion, were completed within a few days and soon afterwards we started the course of treatment.  After only two sessions, Maria started to smile, if faintly. More importantly her sleep was improving, almost night by night, and she was taking an adequate amount of fluid. Strokes or no strokes, I felt we took the right decision. Sometimes it is almost better not to know too much, otherwise one can end up in a sort of therapeutic nihilism. The trouble with science (as opposed to clinical experience) is the more one knows the less certain one becomes!

With a pace of two treatments per week, a month later Maria was beyond recognition. She was helpful on the ward, started to read again and was talking of going home. And this she did without further delay. She declined any practical help, or attendance at a day hospital, on account that she neither needed, nor had time for it.  

For well over a year, I was seeing Maria at regular intervals at the out-patient clinic. Whenever I looked at this handsome elegant and articulate old lady, I could hardly believe how ill she once was. She was taking Lithium, the best preventive medication against severe depression, and for this she required regular checks.  Even though she had only a faint recollection of her nightmarish illness, she did not want to risk having it again. And her memory… well, I thought it was better than mine. We also had a chance to build a trust and intimacy that could have not been established when Maria was in a grip of psychosis. We were now recovering the 'time lost'. She talked to me of her distant childhood, and this threw some light onto the content of her delusions.

Maria's family lived at the outskirts of a small town in Ireland, end the memories of Maria's early childhood were happy, almost idyllic. Her mother was a beautiful and affectionate woman and her father, a man of no mean intelligence, was employed as a top engineer by a railway company. Maria was the eldest of three children which meant that she had privileges, as well as responsibilities. Sundays were very special. The whole family would go for a mass to a Catholic church, even though it involved a long walk to the other side of the town. The ambience of the church itself, the sounds of beautiful music, the smell of incense and the 'mystery of transfiguration' made an indelible impression on Maria's young soul. Nobody was prepared for the tragedy that struck like a thunder-bolt. The mother was suddenly taken ill and for several weeks seemed to fluctuate between reality and the nightmare. Maria would never forget that shrill she heard, coming from her parents' bedroom. Was it her mother's or was it Satan himself?  This was far too difficult a problem for Maria's young mind. At the age of six one does not know, with certainty, what is real and what is not. Particularly when the parents, who normally should guide and re-assure, are themselves crushed by events.  The mother died in spring, just as nature was awakening to life.

But life in that family was never to be the same again.  Soon after the mother's funeral a distant aunt from a distant corner of Ireland arrived to take over the responsibilities. This she did all right. The children were clad and fed but the laughter had gone out of the house forever. The family resumed their visits to the church, but instead of benevolent angels, all Maria could think of were devils lurking from behind the sermon-giving priest. One day a thought struck her: could it be that it was her, Maria, who made her mother ill?  After all she had been naughty once or twice, maybe more… Many a night she cried herself to sleep, but was too proud to tell anyone how she felt. Besides, her father had more than enough to cope with, and the aunt…well, she would not understand, anyway. Also, there was a younger sister and a brother to care about. School turned out to be a kind of salvation at the time. Maria was a bright and disciplined child, often praised by the teachers for her qualities. She left school with good marks and went to work as a telephonist.  Not long before the outbreak of war she met her future husband, a handsome Englishman. They got married against the odds and moved to England. Although life was neither easy, nor particularly comfortable for much of the time, their marriage was a rock. Only important things mattered, and love was one of them. I could see it for myself years later when her two children, and particularly her son Ian, were not only able to meaningfully contribute to their mother's treatment, but impressed us all with their courage and trust.  With their rational, and yet risk accepting attitude, they have virtually saved Maria's life.
Back to the out-patient. Maria was now well for a long time and I thought she no longer needed me. She agreed that her GP, who knew her well, could take over. The last time I saw her was in the presence of her son who promised to get in touch with me immediately should Maria, God forbid, relapse. Several months passed and I heard nothing, until one day I received a card from Tuscany.  It was from Maria who wanted me to know that she was well end enjoying her trip to Italy, a surprise present from her son on her eighty fourth birthday.

This is a modified chapter from my book, All Trees Die Standing.