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PubMed2001

SPECT-based tailoring of psychosurgical procedures: is it possible?

In contrast to the other areas of functional neurosurgery, psychosurgery has remained basically empiric and unchanged since the seventies, except for the recent suggestion to use chronic stimulation instead of ablative surgery. In this study, the authors investigated the value of SPECT abnormalities to guide psychosurgery and correlated the surgical results with the postoperative SPECT. This new approach, SPECT-based tailored psychosurgery, was applied in 4 of 11 patients referred for surgery, who fulfilled the inclusion criteria adopted. Excellent results were obtained in all of them after a follow-up of 30-52 months. Postoperative SPECT normalized in every case. We conclude, based on this small series, that it is possible to individualize and lateralize (tailor) psychosurgical procedures for every patient and that, to achieve this goal, SPECT is a rather impressive means and that postoperative SPECT closely correlated with the surgical results.

Adolescent↗
PubMed1991

Functional neurosurgery for psychiatric disorders: a historical perspective.

Functional neurosurgery for psychiatric disorders ('psychosurgery') has a colorful, and sometimes dubious, history. From the time of the first operations in 1935 to today, its usefulness has been overshadowed by doubts and ethical questions. Psychosurgery became popular in the 1940s and early 1950s, especially in the United States. Its main indications were for intractable mental illness, in particular, depression, anxiety, and obsessive-compulsive disorders. However, its side effects, especially the 'frontal lobe syndrome', led to the need for more refined surgical approaches; the most important of these was the use of stereotaxis. Cingulotomy, subcaudate tractotomy, limbic leucotomy, and anterior capsulotomy are generally the stereotactic treatments of choice today. Indications and postoperative sequelae vary slightly across treatments. The indications remain as affective, anxiety, and obsessive-compulsive disorders. Despite approval by the United States Department of Health, Education, and Welfare in 1978, psychosurgery is still not a common treatment. This low acceptance is perhaps due to continued concern over ethical problems and inadequate reporting of outcomes.

History, 19th Century↗
PubMed2004

Neuropsychological processing associated with recovery from depression after stereotactic subcaudate tractotomy.

OBJECTIVE: The authors compared patients who underwent stereotactic subcaudate tractotomy for depression, who were still depressed or recovered from depression, to identify therapeutic mechanisms. METHOD: Ten depressed and eight recovered psychosurgery patients, along with nine never-depressed subjects and nine who had recovered from depression with medication, completed the Iowa Gambling Task, a measure of decision making in the face of feedback. Psychosurgery patients also completed general neuropsychological testing. RESULTS: Recovered psychosurgery patients exhibited insensitivity to negative feedback on the Iowa Gambling Task compared to the other three groups. This difference between the groups remained when general neuropsychological performance was covaried out. CONCLUSIONS: These findings suggest acquired relative insensitivity to negative information as a specific mechanism mediating the antidepressant effect of stereotactic subcaudate tractotomy. Such insensitivity is not secondary to deficits in general neuropsychological functioning and is not a function of recovery from depression per se.

Adult↗
PubMed1982

Treatment of chronic obsessive compulsive states with stereotactic anterior capsulotomy or cingulotomy.

A neuropsychological model on how to evaluate patients subjected to stereotactic psychosurgery is presented. Four patients with chronic obsessive compulsive neurosis were randomly assigned to either stereotactic anterior capsulotomy or cingulotomy, and assessed pre-, peri-, and postoperatively according to this model. The best immediate and long-term follow-up results in reducing obsessional symptoms were obtained in the two capsulotomized patients. Psychosurgery should only be performed by a multidisciplinary team of specialists, with objective evaluation, adequate information on patients, and reliable test instruments.

Adult↗
PubMed2006

Frameless stereotactic subcaudate tractotomy for intractable obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a chronic, disabling disorder. Psychosurgery may be indicated for a subset of patients for whom no conventional treatment is satisfactory. This paper focuses on the stereotactic subcaudate tractotomy (SST). Thus far, these procedures have been carried out using frame-based stereotactic techniques. However, modern - highly accurate - frameless stereotactic procedures have successfully been introduced in neurosurgical practice. We developed a novel frameless stereotactic subcaudate tractotomy procedure with promising initial results in a patient suffering from intractable OCD. This is the first report on frameless SST. Future studies should examine whether other ablative stereotactic psychosurgery procedures can be done using frameless stereotactic methods.

Afferent Pathways↗
PubMed2003

Psychiatric neurosurgery: a historical perspective.

Psychosurgery. Psychiatric neurosurgery. Neurosurgery for psychiatric disorders. Whatever the name, each of these refers to the surgical treatment of mental disease. Indeed, as many have pointed out, the most common term, "psychosurgery," is itself a misnomer, because the target of these procedures is not the "mind" or "psyche" but the neural substrates of higher cognitive function.

Brain↗
PubMed1986

Electroconvulsive therapy and brain damage: the Ontario Supreme Court hearing of the evidence.

The issue of whether electroconvulsive therapy (ECT) causes brain damage was examined by the Supreme Court of Ontario when an involuntarily hospitalized patient attempted to overturn a treatment order for ECT made by a review board. The Ontario Mental Health Act (MHA) specifically prohibits the authorization of psychosurgery by a review board. In this case, the patient argued that the board had exceeded its jurisdiction in authorizing ECT because ECT fell within the definition of psychosurgery in the Ontario MHA. This paper reviews the legal issues involved and summarizes the most substantive evidence presented for and against any causal association between ECT and demonstrable brain damage. The judicial decision upholding the treatment order is discussed.

Brain Damage, Chronic↗
PubMed2002

[Egas Moniz and the leukotomy debate with special reference to Portuguese literature].

Although the practice of psychosurgery had already been introduced in 1888 by the Swiss psychiatrist Gottlieb Burckhardt, the most widely practiced form of psychiatric surgery--the so-called, lobotomy'--was first performed in 1935 by the Portuguese neurologist Egas Moniz (1874-1955). Although the reaction to his intervention was mixed, Moniz was awarded the Nobel Price for his work in 1949. The present article concentrates on both the Portuguese and the international perception of Moniz' lobotomy and its apparent ethical implications. One particularly important question that Moniz's work brings to the fore concerns the role of psychosurgery in contemporary psychiatry and--consequently--the role of the spirit of the age in judging psychosurgical interventions. Therefore the early reactions to lobotomy are opposed to recent and actual statements in and outside Iberia.

History, 19th Century↗
PubMed1992

An integrated approach to treatment of obsessive compulsive disorder.

Except for rarely performed psychosurgery, obsessive compulsive disorder seldom improved with reversible treatments before 1966. In that year, Victor Meyer reported successful treatment of OCD with behavior therapy, and clomipramine was first released. For the past 25 years, controlled research has demonstrated specific efficacy of exposure for obsessional anxiety and ritual or response prevention for reducing ritual time, interference, and associated distress. Over the same time span, clomipramine has been conclusively shown to be an effective treatment for obsessive compulsive disorder in double-blind controlled trials against placebo and other nonpotent serotonin uptake inhibitor antidepressants. Fluvoxamine, fluoxetine, and sertraline, all potent serotonin uptake inhibitors, have also demonstrated efficacy in obsessive compulsive disorder; fluvoxamine is the best studied of these three compounds. The combination of behavior therapy and a potent serotonin uptake inhibitor is currently the best treatment for most patients. Psychosurgery still has a part to play in the treatment of a small proportion of severely disabled and distressed obsessive compulsive patients unresponsive to other effective treatments.

Behavior Therapy↗
PubMedDate not supplied

[The case of a patient with treatment-refractory obsessive-compulsive disorder operated by stereotactic bilateral cingulotomy].

This case report presents the first patient in Poland with treatment-refractory obsessive-compulsive disorder, operated by stereotactic bilateral cingulotomy. The patient, aged 38 years, with 20-year duration of illness, despite intensive pharmacological and psychotherapeutic treatment was totally unable to function due to obsessive-compulsive symptoms of extreme intensity. The paper presents the neuroimaging documentation of psychosurgery performed on 3rd December 2002. On the basis of nearly two-year follow-up of the patient, the result of the psychosurgery can be assessed as moderately favorable. The patient's subjective mood and social functioning have improved, as well as his cognitive functions measured by means of neuropsychological tests. In patients with severe, chronic and treatment-refractory obsessive-compulsive disorder psychosurgical treatment may be a therapeutic option.

Adult↗
PubMed1983

[Late EEG sequelae following psychosurgical interventions].

The tardive EEG-features resulting from psychosurgery are more prominent than commonly admitted. The different types of surgical interventions, the localized scar-formation and the secondary degenerative lesions at a distance, mainly in the thalamic nuclei, resulting from disruption of corticothalamic connections following decortication, may lead to variable EEG-patterns. The pathology underlying the tardive EEG-features may be complex and progressive for many years. In the author's experience the most prominent EEG-features consist in localized beta-waves, sleep-spindles-asymmetry with spindles-activation at the undercut cortical regions and the development of a slow-wave focus in synchronized sleep-stages. The pathophysiology of these EEG-characteristics is discussed in accordance with the clinical and experimental data available. The value of activation procedures, with special reference to sleep, and the importance of psychotropic drugs for the development and interpretation of EEG-features following psychosurgery is particularly stressed.

Adult↗
PubMed1999

[Sex differences relating to psychiatric treatment].

OBJECTIVE: This paper reviews the literature discussing the influence of gender factors on the efficacy of the most frequently used psychiatric treatments. It recommends taking into account patient gender in order to optimize the treatment efficacy and tolerance. METHOD: Pharmaceutical and psychotherapeutic treatments as well as other types of therapy (psychosurgery, electroconvulsive therapy [ECT]) are discussed in the overview. Each section draws intermediate conclusions. RESULTS: Literature on the subject is scarce and uneven. From a pharmaceutical perspective, gender differences are marked; they affect substance absorption, distribution, metabolism, and elimination. As a result, differences in bioavailability affect efficacy and side effects of antidepressants, neuroleptics, and lithium as well as of hypnotics, sedatives, and anxiolytics. The menstrual cycle and birth-control pills also produce significant interactions. Few studies have discussed the influence of the gender-specific effect on the outcome of psychotherapy. However, some differences might exist, and serious further research is required before repeatable conclusions can be reached. Patient gender does not seem to affect certain physical kinds of treatment such as psychosurgery or ETC as much. CONCLUSIONS: Patient gender has a definite influence on the efficacy of the treatment administered. This influence, however, is often limited and should be considered for the optimization of treatment response and tolerance. Research in this field of psychiatry should be encouraged.

Female↗
PubMed1995

Microelectrode monitoring of cortical and subcortical structures during stereotactic surgery.

We describe microelectrode recording and stimulation techniques to delineate the cellular boundaries and neural projections of stereotactic brain targets. These techniques have applications in the surgery for pain, movement disorders and in psychosurgery. Neuronal records from stereotactic operations including thalamotomy, pallidotomy, cingulotomy and anterior capsulotomy are discussed. These tools are used to distinguish gray matter from white matter, to obtain direct measures of cellular activity in the target, to identify the physiological properties and receptive fields of the subpopulation of neurons at the electrode tip and to avoid lesion making induced injury to adjacent structures. Microelectrode recording and stimulation techniques improve physiological localization and decrease the possibility of unwanted neurological complications with functional stereotactic procedures.

Brain↗
PubMed1991

A prospective study of tardive dyskinesia in Japan.

A large-scale, prospective study of tardive dyskinesia (TD) was performed in 11 psychiatric facilities in Japan. A total of 1595 psychiatric patients were enrolled in this study in 1987. The progress of these patients, with the exception of 490 dropouts, has now been followed up to 1988. The prevalence of TD at study entry was 7.6%, the annual incidence rate was 3.7% and the annual remission rate was 28.7%. Newly developed TD patients tended to be older, to have undergone more psychosurgery, and to have had lower neuroleptic doses than the patients who had not developed TD, whereas no specific variable could be detected as a factor associated with remission of TD. The results suggest that the incidence of TD is lower in Japan than that in Europe and North America.

Antipsychotic Agents↗
PubMed1983

The involvement of orbitofrontal cerebrum in cognitive tasks.

Although the frontal lobes are frequently associated with high-level cognitive functions, patients with significant frontal damage often maintain normal "intelligence". While recent research has clarified some aspects of this enigma, specific questions remain concerning the nature of the deficit in these patients and its relation to lesion localization within the frontal lobes. A group of psychiatric patients who had undergone prefrontal leucotomy 25 years earlier and whose frontal lesions were bilateral and maximal orbitofrontally were evaluated. Sixteen leucotomized schizophrenics, divided into three groups based upon recovery after psychosurgery, were compared to two control groups: (1) non-leucotomized chronic schizophrenics; (2) normal subjects. Four tests were administered: Wechsler Adult Intelligence Scale, Wisconsin Card Sorting test, Visual Metaphor test, and the Visual Verbal test of abstraction. The results suggest that orbitofrontal pathology does cause impaired performance on certain cognitive tests, which appeared independent of IQ measures.

Cognition↗
PubMed2003

Biography: history of developments in imaging techniques: Egas Moniz and angiography.

Angiography, the primary imaging technique used for visualizing the brain's blood vessels and any accompanying abnormalities, also is used for imaging aneurysms and other lesions having an infectious cause. A Nobel laureate who later was recognized for his radical treatment for mental illness, Antonio Caetano de Abreu Freire Egas Moniz, has been credited with discovering angiography. However, despite the tremendous impact it has had on the field of medicine, angiography did not receive the recognition that the researcher's later work in psychosurgery did. For many years, the reason for this seeming oversight remained a mystery, especially considering that leucotomy subsequently was superseded by psychopharmaceutical drugs and other management modalities, whereas angiography continues to play a vital role in medicine. This article looks at the various achievements of Egas Moniz, who excelled in many disciplines, as well as at the circumstances surrounding his being denied the Nobel Prize for the discovery of angiography.

Angiography↗
PubMed2000

Depression: a role for neurosurgery?

After providing an overview of depression this article briefly reviews the development of psychosurgery and outlines the current procedures in use world wide. Stereotactic subcaudate tractotomy (SST) is described in particular detail, and the rationale for its use in the treatment of resistant depression is then discussed by considering the findings of neuropsychological, neurophysiological and neuroimaging studies. The emerging evidence suggests that the prefrontal cortex subserves an essential function in emotion and that disruption of its connections modifies mood.

Depressive Disorder↗