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PubMed1980

Social implications of deinstitutionalization.

Attacks on custodialism offered the hope of more humane treatment approaches. Mental health planners thought that the costs of state hospital care could be reduced by discharging patients into the community. For state governments, this involved a shift of costs and responsibility to the federal government. This shift was accompanied by an increase in cost-effective planning at both state and federal levels. Cost-effective planning uses corporate-style standardization techniques to provide precise, measured types of treatment to certain categories of patients. Such planning is primarily oriented to balanced ledgers of the government budget, rather than meeting specific human needs. The shift in costs also increases profits in the private sector. This is most noticeable in the nursing and boarding home industry where entrepreneurs derive large returns from a newly custodialism mainly funded by government reimbursements. The institutional overuse of psychiatric drugs is continued in community programs. Cost-effective approaches also involve firing mental health staff and increasing the workload of those remaining. Community mental health centers and state hospital deinstitutionalization programs have largely failed to meet most of their promises such as noninstitutional treatment, more humane care, prevention, and rehabilitation. These failures have produced the beginning of a delegitimation of the new mental health approaches. This delegitimation is also used as part of more general attacks on social services so prevalent in this period of economic crisis. This reinforces the reliance on cost-effective plans which do not benefit clients. It also poses the danger of increasing the number of persons classified as psychological misfit among the marginal underclass. Even though this is an unintended effect, it can then be used to deflect onto these victims popular resentment against big business and the government. Further, the growth of such a misfit group, along with other types of social decay, may prompt an increase in the already growing forms of social control psychotechnology such as psychosurgery.

Community Mental Health Services↗

PubMed1993

Technical possibilities and limitations of stereotaxy.

The availability of CT-Scanners and MRI coupled to stereotactic systems has made a stereotactic neurosurgical intervention an everyday tool. The indications, contra-indications and complications concerning intracranial tumours, the hypophysis, combined open stereotactic procedures, third ventriculostomy, diseases of the extrapyramidal motor system, pain, epilepsy, psychosurgery and the transplantation of embryonal cells are discussed.

Biopsy↗

PubMed1979

A CNV rebound effect.

Fifty normal volunteers were tested in two conditions: (1) a constant-foreperiod reaction time situation consisting of a flash-tone-key press sequence (control trials); (2) a '50%-letters' condition, in which two types of trials occurred randomly--no letters trials, which were identical to control trials, and letters trials, which were similar to control trials but also involved the presentation of four auditory letters within the flash-tone interval as part of a short-term memory task. Compared to control trials, CNV amplitude showed a pattern of reduction in letters trials accompanied by slower reaction times to tone (CNV distraction effect). Compared to control trials, CNV amplitude showed an unexpected supranormal increase in no-letters trials. The CNV rebound effect observed in no-letters trials was interpreted as reflecting a switching of attention from the divided attention set intrinsic to letters trials (listening for letters and preparing for response to tone) to an undivided attention set in no-letters trials (simply preparing for response to tone). The CNV rebound effect, which is diminished in aging individuals and absent in psychosurgery patients, appears to represent a non-invasive technique of possible value in assessing pathophysiology of human brain functioning.

Adult↗

PubMed1981

Bilateral infarction of the anterior cingulate gyri and of the fornices. Report of a case.

A 70-year-old woman had complex behavioural changes of sudden onset. The symptoms consisted of indifference, docility and inappropriate urination, but predominantly in a lack of attention. She was unable to maintain the attention necessary to perform a goal-directed activity and she was distracted by any stimulus, such as a sound, an object, or a word, which might induce behaviour irrelevant to the preconceived activity. She also exhibited confabulatory-amnestic syndrome. Neuropathological examination of the brain revealed infarcts in th territories of both anterior cerebral arteries. The rostral part of the anterior cingulate gyrus (Acg), small areas of the adjacent medial prefrontal cortex, and the underlying white matter were destroyed bilaterally. Infarction involved the deep territory of the left anterior cerebral artery, with a bilateral lesion of the fornices. This cingulate damage was more restricted than the Acg lesions reported in some cases of akinetic-mutism, which extended more caudally, but was presumably larger than the lesions created in psychosurgery. The impairment of attention was analyzed according to the possible roles of the cingulate and of the fornix lesions as causing a dysfunction between the frontal lobes and the hippocampal formations.

Aged↗

PubMed1994

The role of law in the patient-physician relationship.

Free or bound decision, individual responsibility or professional ethical control, conduct according to conscience or to legal directives: these buzzword dyads indicate just a few of the issues with which a physician sees himself confronted in his decision-making. And indeed not only in cases of extraordinary procedures, such as reanimation and transplantation, sterilization and fertilization, abortion and perinatology, psychosurgery and sex-change operations, experiments on human subjects and gene manipulation; but also in the day-to-day routine of patient referral or non-referral, or of continuation or termination of treatment, a physician faces the dilemma of whether or not he may take advantage of opportunities that present themselves. These problems could be summed up under the rubric of the justifications and limits of 'medical discretion'. This, however, is certainly wide open to misunderstandings because, in this way, the doctor appears to usurp an exemption for himself which ethicists and legal experts do not believe they can grant him unconditionally. In order to elucidate this problem, two issues are subject to closer analysis. First, the widespread prejudice that medical conduct is determined largely by impartial medical facts for which the establishment of norms is fundamentally elusive: this issue will be disputed on the basis of problems determining the concept and criteria of death and the appropriate termination of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Death↗

PubMed2006

Deep brain stimulation for neurologic and neuropsychiatric disorders.

In the 1960s, ablative stereotactic surgery was employed for a variety of movement disorders and psychiatric conditions. Although largely abandoned in the 1970s because of highly effective drugs, such as levodopa for Parkinson's disease (PD), and a reaction against psychosurgery, the field has undergone a virtual renaissance, guided by a better understanding of brain circuitry and the circuit abnormalities underlying movement disorders such as PD and neuropsychiatric conditions, such as obsessive compulsive disorder. High-frequency electrical deep brain stimulation (DBS) of specific targets, introduced in the early 1990s for tremor, has gained widespread acceptance because of its less invasive, reversible, and adjustable features and is now utilized for an increasing number of brain disorders. This review summarizes the rationale behind DBS and the use of this technique for a variety of movement disorders and neuropsychiatric diseases.

Animals↗

PubMedDate not supplied

Chaos theories and therapeutic commonalities among depression, Parkinson's disease, and cardiac arrhythmias.

This report reviews and compares all therapies that have shown efficacy in depression and Parkinson's disease, although some are not in current use and others are at the experimental stage. They include pharmacological modification of neurotransmitter pathways, electroconvulsive therapy (ECT), sleep deprivation, psychosurgery, electrical stimulation through cerebral electrodes, and transcranial magnetic stimulation. Stemming from a pathophysiological model that stresses the brain as an open, complex, and nonlinear system, all therapies have been attributed a common mechanism of action. This report suggests that the therapeutic isomorphism is related to their ability to help the CNS deactivate cortical-subcortical circuits that are dysfunctionally coupled. These circuits are self-organized among neurons of their informational subsystem (rapid conduction) and modulating subsystem (slow conduction). Finally, this report extends the analysis and comparison of these therapies to some cardiac arrhythmias.

Arrhythmias, Cardiac↗

PubMed1996

The legal framework for mental health nursing.

This article sets out basic legal principles underlying the care and treatment of mentally ill clients. Legal considerations are important for nurses, because it is now felt that the care of the mentally ill is as much a legal matter as a medical one. The frequent ordering of compulsory care, detention and administration of medication takes place in a climate of ever-increasing emphasis on autonomy, and has resulted in the need for nurses to ensure that they do not violate clients' human and legal rights. Legislation is concerned not primarily with the finer points of what mental illness is--that is left to the medical profession--but with criteria which warrant the detention and treatment of a person against their will. The article points to international documents which set out principles for the care of the mentally ill, as well as both Commonwealth, state and territory legislation. It summarises the main provisions of these in relation to involuntary detention and treatment, as well as electroconvulsive therapy and psychosurgery. Nurses who care for mentally ill clients need, therefore, to understand in some detail the legislation that applies to them in their professional capacity, as well as the human rights it seeks to protect.

Australia↗

PubMed2004

A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation.

This article provides an overview of the etiology, epidemiology, and first-line treatment options for obsessive-compulsive disorder (OCD). The subject of treatment-resistant and treatment-refractory OCD is then discussed, including a definition of these often-debated terms, and the latest treatment options delineated. This includes a review of the latest research concerning the pharmacological agents that have been studied as monotherapy or augmenting agents for the treatment of OCD, the use of experimental medications and procedures, treatment with reversible, minimally invasive procedures, such as vagal nerve stimulation and transcranial magnetic stimulation, invasive but the potentially reversible deep brain stimulation, and irreversible lesioning with ablative psychosurgery. A discussion of the role of psychotherapy in the treatment of OCD is also included.

Antipsychotic Agents↗

PubMed2005

[Intervening between brain and mind: an ethical analysis of the new possibilities of the neurosciences].

The fast progress in neuroscience opens up unprecedented opportunities of research and intervention. Due to their far-reaching medical, social and anthropological implications they raise new ethical issues regarding their goals and legitimacy. The "neuroethical evaluative matrix", which is presented in this article, provides an ethical orientation in neuroscientific research and clinical interventions. Its practicability is demonstrated for the following central neuroethical fields: neuroscientific research, neural grafting, psychopharmacology, neuroimaging, neuro- and psychosurgery, and allocation in neuroscience. It will turn out that the neuroethical matrix provides a systematic and practical possibility to obtain a normative reference frame in neuroscience and neurology.

Brain↗

PubMed1991

[Psychobiology of compulsive disease].

The predominant psychobiological hypotheses regarding the pathophysiology of obsessive-compulsive disorder (OCD) are that a selective basal ganglia dysfunction and a dysregulation of one or several central serotonin (5-HT) subsystem are related to at least some aspects of the syndrome. Recent neuroanatomical, -pharmacological, and -ethological studies indicate a complex perceptual and cognitive role for the basal ganglia, particularly the striatum and the pallidum, in addition to the well-established motor functions. Obsessive-compulsive symptoms in syndromes with extrapyramidal-motor dysfunction, such as Gilles de la Tourette syndrome or Chorea minor (Sydenham), response to specific pharmacotherapy, behavioural therapy, and psychosurgery, as well as findings derived from brain imaging studies including positron emission tomography (PET) support the view of a frontal cortex/basal ganglia dysfunction in OCD. In addition, growing evidence suggests that potent inhibitors of 5-HT reuptake and other 5-HT subsystem-selective agents, such as the azapirones with partial agonist properties at the 5-HT1A receptor, are effective in OCD not only has improved the therapeutic perspective but may also reveal clues to the aetiopathogenesis of OCD. Much of this evidence has resulted from the discovery of multiple receptors and signal transduction pathways for 5-HT and from experiments relating the action of 5-HT receptor-selective agents to discrete effects in different subsystems. Among these 5-HT subsystems the 5-HT1D and 5-HT1A receptor-effector system complex appears to play a central role in the pathophysiology of OCD symptoms and the mechanism of action of antiobsessional drugs. Recent psychoneurobiological findings are reviewed briefly and evaluated in the context of the 5-HT and basal ganglia hypothesis of OCD.

Basal Ganglia↗

PubMed1994

Buspirone in obsessional compulsive disorder. A prospective case study.

A longitudinal case study of a man who is suffering from obsessional compulsive disorder, who failed to respond to all possible treatments, including psychosurgery. We present his good response to the recommended dose of the anxiolytic Buspirone and its effect on the severity of his obsessive compulsive symptoms.

Adult↗

PubMed1977

Four taboos that may limit the success of psychotherapy.

Painful though it may be, it must be accepted as fact that psychotherapy has a lower success rate than it should. Whatever questions we therapists raise about the validity of research in psychotherapy, whatever the problems in defining success, whatever the arguments about therapeutic outcome studies, we are stuck with a great deal of evidence which indicates that between one-third and two-thirds of patients do not benefit from treatment (Bergin, 1971; Eysenck, 1952, 1966; Garfield et al., 1971). In contrast, behavior modifiers and those using physical treatments such as psychosurgery claim rates of improvement and success which sometimes exceed 90 percent (Baily et al., 1973; Hunter-Brown, 1972; Paul, 1965; Rachman, 1971). This paper examines four current practices which may contribute to our failure. These practices are linked to taboos and examined with a view toward understanding both the functions they serve and the limits they impose on therapeutic effectiveness.

Emotions↗

PubMed1976

Somatic therapies in older depressed patients.

While psychotherapy is the treatment of choice in neurotic situational depressions of older patients, it is not effective enough in endogenous bipolar or monopolar depression of elderly. These respond better to somatic therapy, mainly pharmacotherapy, or, if necessary, ECT. Experience shows the aged endogenous depressions respond favorably to tricyclic antidepressants as well as to mono-amino oxidase inhibitors, although the dosage may have to be kept lower than with younger patients. ECT, if necessary, is well tolerated and effective in aged patients. However, proper precautions have to be taken before this treatment is commenced. Patients with a history or signs of recent coronary thrombosis or decompensated heart failure should be excluded. Also, the number of treatments should be kept at a minimum. The individual treatments should be spaced farther apart and so-called "intensive treatment" avoided. If an endogenous depression lasts for more than 2 years and does not respond to any other kind of treatment, psychosurgery may have to be considered. Experience has shown that long-lasting, deep depressions of the aged can be helped by this method without any important personality change.

Age Factors↗

PubMed1992

Treatment of the neuroleptic-nonresponsive schizophrenic patient.

The treatment and management of neuroleptic-resistant schizophrenic patients, who comprise 5 to 25 percent of all patients with that diagnosis, are major problems for psychiatry. In addition, another large group of schizophrenic patients, perhaps 5 to 20 percent, are intolerant of therapeutic dosages of neuroleptic drugs because of extrapyramidal symptoms, including akathisia, parkinsonism, and tardive dyskinesia. Because about 60 percent of neuroleptic-resistant schizophrenic patients respond to clozapine and a large percentage of neuroleptic-intolerant patients are able to tolerate clozapine, it should be considered the treatment of choice for such patients until other therapies are proven to be superior. A trial of clozapine alone should usually be continued for up to 6 months before it is terminated or supplemental agents are tried. Plasma levels of clozapine may be useful to guide dosage. The major side effects of clozapine are granulocytopenia or agranulocytosis (1%-2%) and a dose-related increase in the incidence of generalized seizures. Psychosocial treatments such as education of the patient and the family about the nature of the illness, rehabilitation programs, social skills training, and assistance in housing are generally needed to obtain optimal benefit from clozapine, as with other somatic therapies. If clozapine is unavailable, unacceptable, or not tolerated, a variety of approaches may be employed to supplement typical antipsychotic drugs for patients who do not respond adequately to these agents alone. These include lithium; electroconvulsive therapy; carbamazepine or valproic acid; benzodiazepines; antidepressant drugs; reserpine; L-dopa and amphetamine; opioid drugs; calcium channel blockers; and miscellaneous other pharmacologic approaches. The evidence for the efficacy of these ancillary somatic therapies in treatment-resistant patients is relatively weak. Polypharmacy should be tried only for discrete periods and with clear goals. If these are not achieved, supplemental medications should be discontinued. Psychosurgery is not a recommended alternative at this time.

Antipsychotic Agents↗

PubMed1994

Definition and differential diagnosis of treatment-resistant depression.

There are no agreed criteria for treatment-resistant depression, but the failure to respond adequately to two successive courses of monotherapy with pharmacologically different antidepressants, given in an adequate dose for sufficient time is one pragmatic definition. Inherent within this definition are notions of what constitutes an adequate dose of drug, the length of treatment and pharmacological specificity of treatments. When these factors are accounted for, treatment resistance may be encountered in 15-20% of patients. In attempting to treat such patients a number of pharmacological strategies have been adopted and some are briefly reviewed. Psychosurgery may have a role to play in cases of absolute treatment resistance.

Antidepressive Agents↗

PubMed1996

Introduction of the human Horsley-Clarke stereotactic frame.

It is well known that the Horsley-Clarke frame was developed and first used by Robert Henry Clarke and the pioneer neurosurgeon Victor Horsley in 1906 for making lesions in the central nervous system of animals. The Horsley-Clarke frame was extensively used throughout the next 4 decades for excitation and lesion production in animals. Aubrey Mussen, a student of Clarke, designed a stereotactic apparatus for use in humans, but no procedures were actually performed with the instrument. It is less appreciated that a Horsley-Clarke frame was also constructed for human use and first applied for depth electroencephalography by Robert Hayne and Frederic Gibbs in 1947. The assumed relationship between external landmarks and intracranial structures provided initial target localization, and pneumoencephalography confirmed depth electrode position. In many ways, the work of Hayne and Gibbs paralleled the simultaneous efforts of Ernest A. Spiegel and Henry T. Wycis. Events leading to the development of stereotactic frames and their subsequent use in humans for the treatment of epilepsy, movement disorders, and psychosurgery are reviewed.

Animals↗

PubMed2006

Ethical issues in neuroscience.

PURPOSE OF REVIEW: The study gives an overview of ethical questions raised by the progress of neuroscience in identifying and intervening in neural correlates of the mind. RECENT FINDINGS: Ethical problems resulting from brain research have induced the emergence of a new discipline termed neuroethics. Critical questions concern issues, such as prediction of disease, psychopharmacological enhancement of attention, memory or mood, and technologies such as psychosurgery, deep-brain stimulation or brain implants. Such techniques are capable of affecting the individual's sense of privacy, autonomy and identity. Moreover, reductionist interpretations of neuroscientific results challenge notions of free will, responsibility, personhood and the self which are essential for western culture and society. They may also gradually change psychiatric concepts of mental health and illness. These tendencies call for thorough, philosophically informed analyses of research findings and critical evaluation of their underlying conceptions of humans. SUMMARY: Advances in neuroscience raise ethical, social and legal issues in relation to the human person and the brain. Potential benefits of applying neuroimaging, psychopharmacology and neurotechnology to mentally ill and healthy persons have to be carefully weighed against their potential harm. Questions concerning underlying concepts of humans should be actively dealt with by interdisciplinary and public debate.

Brain↗