Effects of Electroconvulsive Therapy

Jean asks:

I have a question related to cerebral hypoxia as a complication of old-style electro-convulsive therapy.

I’m plotting out a story that takes place in a psychiatric hospital. My protagonist is a patient at the hospital who was sane and healthy when he was forcibly admitted. He was formerly a thief, and escaped prison by being diagnosed with kleptomania, as a form of monomania. During the year he is incarcerated at the asylum and as a result of the treatments he undergoes, he gradually loses his sanity and his memory.

One of the anachronisms I have in the setting is the existence of electroconvulsive therapy, or ECT, which will be done using the early, more damaging methods. As such there will be no anesthetic, muscle relaxants, bilateral electrode placement or oxygen administered during the procedure. Other than the existence of ECT, the medical knowledge of the doctors at the hospital largely reflects the state of medical knowledge from about 1850 or thereabouts.

I’ve learned that one of the complications of ECT is the possibility of triggering a prolonged seizure or series of seizures that can last for many minutes during which the patient might be unable to breathe. Currently, doctors can prevent this by administering oxygen and using anticonvulsants to arrest a seizure that continues for too long. Neither of these options is available in a Victorian-based setting in which there were no effective treatments for seizures or coma.

In the plot, the ECT triggers a prolonged seizure and the protagonist is unable to breathe for several minutes. The resulting hypoxia puts him into a shallow coma for a short period of time. After he wakes again, the complications from the hypoxia produce symptoms in him that mimic the psychiatric symptoms that the doctors were expecting to see as a result of his “insanity”, such as memory loss, confusion, hallucinations, etc.

The research I’ve been able to do suggests to me that this is a plausible scenario, but I have no medical training and would greatly appreciate a more experienced opinion. Can hypoxia from a prolonged seizure triggered by old-style ECT send a patient into a coma if given no treatment? How long might be a realistic length of time for the coma to last? How severe could the resulting symptoms be?

Jordyn Says:
Thanks so much for sending me this question Jean and it is an interesting question!
I ran this by a physician friend of mine (thanks Liz!) and here are her thoughts and then I’ll add some of mine.

Liz Says:

I am sure with ECT “anything could be possible” but nowadays it is total disinhibition. These patients become very “frontal”—driven by the frontal lobe and lose their filter, become hypersexual, will say and do anything.

Some can become psychotic which can be accompanied by hallucinations. I don’t know if they could have hallucinations WITHOUT psychosis. But I don’t think anyone would argue the point since strange things happen in the brain with electricity especially in the setting as the early years of ECT. I’m sure hallucinations could also happen after the hypoxia and coma.

Jordyn Says:

The brain is one organ that we still know very little about. In the presence of hypoxia (or lack of oxygen) the length of coma and the severity of symptoms is largely up to the writer. There is a lot of leeway here. I’ve seen patients wake up from a coma that I would never thought should have survived and I’ve seen patients with more what seemed to be treatable head injuries progress to death.

Hope this helps and best of luck with your book! 

Author Question: Cerebral Hemorrhage

Carol Asks:

I know that cerebral hemorrhages usually don’t show symptoms, but for my plot, I want this young character to die quickly and not of an accident. I want foreshadowing of the event. I’ve given him headaches and tests will show he’s got the bulging artery–they’re going to fix it because it had leaked (thus the headaches.) He dies before that.

Is that plausible?
Jordyn Says:
Yes, this is plausible though I don’t know if I would say cerebral hemorrhages usually don’t show symptoms. This IS bleeding on the brain. Blood, where it shouldn’t be, tends to be very irritating and will show up in symptoms (things that only the patient can tell us) and signs (things that we can measure.)

I did a post on the difference between signs and symptoms that you can find here

That being said, it also depends on the size of the bleed and the location of the bleed. With a very tiny bleed– the patient may not experience any symptoms. I would say on the continuum that this would be more rare. If this aneurysm has started leaking already they may not want to postpone surgery. So, I think finding the bulging aneurysm is sufficient enough.

Other signs and symptoms of cerebral hemorrhage are:

  • Seizures
  • Weakness and/or numbness in an extremity
  • Nausea
  • Vomiting
  • Changes in vision
  • Hard to speak/Understand speech
  • Balance Issues

Don’t forget the FAST acronym for stroke:

  • Face: Is their smile equal? If they stick out their tongue– does is stray to one side and not stay in the middle?
  • Arms: Have the person lift both arms and hold them out with their palms up. If one hand turns inward or a whole arm drifts down this is called pronator drift and signals a neurosurgical emergency.
  • Speech: Have the person repeat a simple phrase. Is it clear or slurred and strange?
  • Time: If any of these are present call 911. 

In the hospital setting, I use this exact tool as a quick screening method for stroke (which can be either caused by bleeding or a clot.) A negative test doesn’t mean something didn’t happen– it just means something isn’t happening at that moment.

A friend of mine was recently on the phone with her father (who lives in another state) when he confessed to her that one of his arms had gone completely numb. She instructed him to call 911– which he did and his symptoms completely resolved by the time he got to the ED. However, he did have a transient ischemic attack (or TIA) or mini-stroke which increases his risk of a bigger event happening in the future.

For more information about cerebral hemorrhage (or stroke) you can check out this link.  

Also, these You Tube videos have a very nice, simple explanation of the genesis of stroke.


Give Carol McClain a challenge, she’s happy. Her interests vary from climbing high ropes to playing the bassoon to Habitat for Humanity and to stained glass creation. If it’s quirky or it helps others, she loves it. Significant Living, Vista, and Evangel have published her non-fiction articles. In her spare time, she coordinates the courses for ACFW, is team leader for The Christian Pulse, and has written four novels. She lives in upstate New York with her husband, a retired pastor, and their overactive Springer spaniel. You can read her work at http://carol-mclain.blogspot.com.

Author Question: Speech Therapy after Traumatic Brain Injury

Karen Asks:

I’m writing a story about a man who is shot in the head in a way that impacts his ability to speak.  Long months of rehab restore his speech but leave him with a stutter.  Is this feasible?  Which part of the head would he need to be shot in?  What else could be impacted by such a wound?  Can you recommend any websites or resources about gunshot wounds or speech therapy?

Jordyn Says:

Karen– thanks so much for sending me your question.

Generally, the left side of the head is considered to contain the speech centers of the brain–in most cases. It might depend on whether or not your character is right or left handed.

97% of right handed people have their speech centers on the left hemisphere.

19% of left handed people have their speech centers on the right hemisphere– which may be where the phrase “left-handed people are the only ones in their right mind” come from. I LOVE this phrase speaking as a left-handed person.

68% of people have language abilities in BOTH hemisphere.

To read more on these areas– check out this link: http://webspace.ship.edu/cgboer/speechbrain.html
A good case to look into would be former Arizona Congresswoman Gabrielle Gifford’s. She received a serious gunshot wound to the head and had extensive rehab– over many many months. It might give you an idea of how long the road to recover is for some of these victims. It can be years.




I think you have a lot of leeway as an author to decide what you want to do after brain injury because we don’t understand as much about the brain as we do other organs. It might be hard to pinpoint sources of “speech therapy after gunshot wound to the head” (which is how I first started to Google your inquiry) but a gunshot wound would be considered a traumatic brain injury so I started to Google that and came up with several other resources as well. Here’s a great You Tube Video that demonstrated a speech therapy session that could be great for a fiction novel.

What else could be impacted? Anything really. Again– you have a lot of leeway here. There could be motor issues as well. Difficulty walking. Difficulty with fine motor skills. To the other extreme which would be coma.


After creating Christian education curriculum for 25 years and writing over 250 published articles, Karen Wingate has turned her attention toward historical and contemporary fiction.  She lives with her husband and Welsh Corgi in Western Illinois.

Strangulation: What Really Kills the Victim 1/3

I got a message from a new blog reader with this comment:

Finding this blog is so timely for me, as my protagonist witnesses a strangulation in the first scene of my WIP, and I haven’t been able to find out the precise observable symptoms.  I wanted to ask if you’d done a posting on strangulation.  I’ve looked back a bit in the blog archives, but haven’t seen that topic yet.

Well, let’s just fix that for Colleen.

I’m sure many of you, particularly if you’re an avid crime show TV watcher, have seen the scene with the medical examiner and the victim splayed open on the table talking about damage to the “hyoid” bone. Though this is true, damage to this bone or the trachea itself is not what ultimately kills a victim who is strangled to death, though it can complicate their care if they live.

For instance, there have been instances of individuals with tracheotomies hanging themselves and the ligatures were above the level of the trach– which means the person would still be able to breathe.

So the following theories are proposed as explanations for the cause of death related to strangling.

Venous obstruction, leading to cerebral stagnation, hypoxia, and unconsciousness, which, in turn, produces loss of muscle tone and final arterial and airway obstruction.

Arterial spasm due to carotid pressure, leading to low cerebral blood flow and collapse.

Vagal collapse, caused by pressure to the carotid sinuses and increased parasympathetic tone.

Which is a lot of scientific language to say “death ultimately occurs from cerebral hypoxia and ischemic neuronal death“.

Which means– when a person is strangled, they die because their brain is no longer getting blood flow from the carotid arteries, which leads to brain cells dying from lack of oxygen.
As you can see from this photo, the major blood vessels that drain blood from the brain but also, more importantly, feed it with oxygen– are in very close proximety to the trachea or windpipe.

It is the vital oxygen these vessels carry to the brain that upon slowing or stopping– is the biggest problem for the victim.

Next post we’ll discuss some strangulation facts. Third part of this series will include treatment of the strangulation victim.

Source:  http://emedicine.medscape.com/article/826704-overview

Other Resources:

Wisconsin Medical Journal: Strangulation Injuries http://www.wisconsinmedicalsociety.org/_WMS/publications/wmj/pdf/102/3/41.pdf

Emergency Medicine Reports: Strangulation Injuries. http://www.ahcmedia.com/public/samples/emr.pdf:

How to Improve Your Investigation and Prosecution of Strangulation Cases. http://www.ncdsv.org/images/strangulation_article.pdf:

Dissociative Fugue: Tanya Goodwin

I’m so pleased to have Dr. Goodwin back. She is a lot like me in that the rare and unusual fascinate her. I thoroughly enjoyed this post and I think it makes for a good character disease/developemnt.

Welcome back, Tanya!

In case you missed my last month’s guest post on necrotizing fasciitis, rare or unusual medical conditions fascinate me. Today’s weird condition is dissociative fugue, the basis of my debut novel, If Memory Serves, in which my protagonist, Dr. Tara Ross experiences this disorder.

The Merck Manual defines dissociative fugue as one or more episodes of amnesia resulting in the inability to recall one’s past and the loss of one’s identity accompanied by the formation of a new identity with sudden and unexpected travel from home; a traumatic nature that isn’t explained by normal forgetfulness.

The DSM IV (a diagnostic manual of psychiatric disorders) characterizes dissociative fugue by 1) sudden and unplanned travel from home 2) inability to recall past events or important information from the person’s life 3) confusion or loss of memory 4) significant distress or impairment.

Fugue is temporary and there isn’t a physical or organic cause (ie brain injury or stroke). Although it’s rare (2% of population), it can happen to those that are chronically stressed, often with a major inciting event noxious enough to catapult them into a fugue state. It’s the brain’s defense mechanism, and eventually resolves within days, weeks, or months, leaving them unaware of occurrences during their amnesic state. They are fully functional but may not recall their identity or parts of their identity. They are often called travelers since they wander or travel away from home. Their nomadic adventure generally occurs after a stressful event.

Physiologically, the hippocampus of the brain is bathed in cortisol, the stress hormone secreted by the adrenal glands, those glands that sit on top of the kidneys. Normally cortisol is ushered away from the brain by calming hormones that bind or pick up cortisol and send it to the kidneys for excretion. The chronic wearing of the nervous system leads to the decrease of important neuropeptides and neurotransmitters necessary for memory creation, processing, and storage. The brain is like a computer and if pressed with too many requests in too short of time freezes from the overload.

So what’s the treatment? Dissociative fugue is temporary and will eventually resolve, but psychotherapy and cognitive therapy can be very helpful. If the person is very anxious or clinically depressed, pharmacologic remedies are considered. And of course, other organic sources of memory loss should be ruled out by blood work and radiologic tests such as CAT scans.

Because the disorder is self-limiting, the prognosis is good. Attention to the underlying emotional issues decreases the likelihood that dissociative fugue may reoccur.

So how did I get interested in dissociative fugue? When I was an OB/GYN resident (doctor in training) I often left the hospital exhausted and stressed. One day, I couldn’t remember how I had made it home, waking up in my bed completely disorganized. It was a frightening experience, at least for a minute or two. That prompted me to think of dissociative fugue and what it must feel like to be totally lost.
Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com