[Current state of psychosurgery. I. Indications for psychosurgery].
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Frontal Lobe↗
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[Current state of psychosurgery. IV. Selective frontal psychosurgery].
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Follow-Up Studies↗
Contemporary psychosurgery.
Psychosurgery is a safe and relatively effective treatment which should be offered to patients with intractable obsessive compulsive disorder (OCD), major affective disorders, and chronic anxiety states after a minimal period of 2 to 5 years and after all other reasonable treatments have been tried. A greater understanding of the biological basis of psychosurgery is developing from advances in functional brain imaging. The optimal site and size of the lesions remains to be established. The standard technique uses stereotactic radiofrequency thermolesions but stereotactic radiosurgery is an alternative. A good outcome following psychosurgery can be expected in 50-60% of cases, and some of the failures may respond to reoperation. This leaves about 40% who have not benefited or in a few cases may be worse. Unfortunately, there are as yet no reliable clinical or investigational predictive indicators for the good outcome group. Restricted accurate lesion placement minimizes personality change, epilepsy and cognitive decline. Careful safeguards, including approval by an independent multidisciplinary legally constituted review board are mandatory in selecting and following the patients, but unfortunately, there are individuals who are never referred or reside in a society which proscribes the operation, whose lives could be made more tolerable. Psychosurgery is probably underutilized due to negative perceptions based on historical factors, and strict regulations and legislation limiting its application. It is possible that with advances in psychiatric pharmacotherapy, the psychosurgery procedures will be made redundant, but we believe that until this eventuates there is still a small place for these operations. Psychosurgery should only be carried out in a national centre by a multidisciplinary team with experience in these disorders, and an intensive ongoing postoperative rehabilitation program is essential to achieve the best results. Copyright 1999 Harcourt Publishers Ltd.
Journal Article↗
Neuropsychological outcome from psychosurgery for obsessive-compulsive disorder.
Seventeen obsessive-compulsive disorder patients treated with psychosurgery were administered a comprehensive neuropsychological test battery. Their performance on neuropsychological testing was compared with that of an age and severity matched sample of 17 OCD sufferers who had not received psychosurgery. The psychosurgery and control groups did not differ in intellectual or memory functioning, consistent with earlier findings that psychosurgery does not reduce global ability estimates. The psychosurgery group performed more poorly than the control group on an adaptation of the Wisconsin Card Sorting Test, demonstrating the possible impact of frontal lobe lesions on the abilities underpinning the formation and shifting of response sets.
Adult↗
Psychosurgery in Britain now.
Between 1979 and 1986 the number of psychosurgical operations carried out in Britain fell from 70 to 15 procedures annually. There are a number of possible reasons for this change of which increased experience with new regimes of psychotropic medication is perhaps the most important. The new Mental Health Act (1983) which brought psychosurgery under the direct jurisdiction of the law was followed by a sudden reduction in the number of patients treated but referals are now increasing. In current psychiatric practice, classification relies largely on description of syndromes, each characterised by a set of core symptoms. Schizophrenia and affective psychoses (endogenous depression, mania and obsessional illness of late onset) are characterised by disturbances of mood, thinking and perception often so profound as to impair the patient's contact with reality. In contrast, neuroses produce symptoms which are quantitatively, rather than qualitatively different from normal experience and psychosurgery has no place in their treatment. Following the introduction of phenothiazines in the early 1950's schizophrenia ceased to be an indication for psychosurgery. For a small group of severely disabled and distressed people suffering from endogenous depressive and obsessional illnesses, when other treatments have failed or ceased to be effective, psychosurgery remains an appropriate treatment. Just over half the patients treated at the Geoffrey Knight Unit are relieved to the extent that they are either free of symptoms or such symptoms that remain do not significantly impair social function. Following operation recovery is slow and progressive and a programme of rehabilitation is usually necessary. Personality which is often severely damaged by the effects of long illness returns towards normal. Neuropsychiatric evaluation has consistently failed to demonstrate adverse cognitive effects. Evaluation and selection of patients for operation should be done by a psychiatrist and neurosurgeon working in partnership. Stereotactic techniques have made it possible to produce precisely located lesions of consistent size, virtually eliminating side effects and reducing the epileptic risk to between two and three percent. The Mental Health Act, contrary to early expectations, has allowed that psychosurgery retains a place in the treatment of a small highly selected group of patients.
Humans↗
Egas Moniz and the origins of psychosurgery: a review commemorating the 50th anniversary of Moniz's Nobel Prize.
Modern psychosurgery began in 1936 with the work of the Portuguese neurologist, Egas Moniz, who attempted to treat the symptoms of mental illness by severing neural tracts in the frontal lobes. This procedure eventually became widespread and applied to thousands of institutionalized, psychotic patients in the United States and other countries. Despite serious side effects associated with psychosurgery, the apparent importance and validity of the treatment was recognized in 1949 when Moniz received the Nobel Prize for his innovation. Psychosurgery was largely replaced by anti-psychotic drugs in the mid-1950s, and the procedure and its practitioners rapidly fell into disrepute. This article reviews Moniz's career, the factors that led up to his first clinical trials of frontal lobe surgery, and the circumstances that allowed psychosurgery to flourish in the 1940s, eventually leading to Moniz's Nobel Prize.
Animals↗
Psychosurgery: a historical overview.
Neurosurgical treatment for psychiatric disorders has a long and controversial history. From the Stone Age use of trephining to release the demons of the spirit to the millimeter accuracy of stereotactic instruments currently used in the operating room, psychosurgery has enjoyed enthusiastic support as well as experiencing scorn. Today, psychosurgery is a minimally invasive and highly selective treatment that is performed for only a few patients with severe, treatment-refractory, affective, anxiety, or obsessive-compulsive disorders. Recent advances in technology and functional neuroanatomic techniques, as well as economic pressures to decrease the costs of caring for chronically ill patients, may provide an opportunity for psychosurgery to become a more attractive option for the treatment of psychiatric diseases. In this historical overview, the rise and fall of psychosurgery are described. A better understanding of the colorful history of this interesting topic should enable modern neurosurgeons and other health care professionals to meet the social, ethical, and technical challenges that are sure to lie ahead.
History, 17th Century↗
Psychosurgery and the abuse of psychiatric authority in Ontario.
Over the past two decades political and legal decisions have sharply curtailed psychiatric authority. One area in which psychiatric authority has been most limited is psychosurgery. This paper uses archival evidence from Ontario to show how psychiatrists ordered and administered psychosurgery for a wide variety of reasons. In some cases psychosurgery was administered to ease staffing problems, for experimental purposes, or simply out of sheer curiosity. Often the consent of patients or relatives was not obtained. This egregious abuse of psychiatric authority contributed to the critical movement against psychiatry and to strict laws limiting and sometimes banning resort to psychosurgery.
Behavior Control↗
Review of long-term results of stereotactic psychosurgery.
Stereotactic psychosurgery is an effective method for treating some medically intractable psychiatric illnesses. However, it is unfamiliar and the long-term clinical results have not been reported in Asia. The long-term results of psychosurgery are evaluated and the neuroanatomical basis is discussed. Twenty-one patients underwent stereotactic psychosurgery for medically intractable psychiatric illnesses since 1993. All were referred from psychiatrists for these disorders. Two patients showed aggressive behavior, 12 had obsessive-compulsive disorder (OCD), and seven had depression with anxiety disorders. Bilateral amygdalotomy and subcaudate tractotomy were performed for aggressive behavior, limbic leucotomy was performed for OCD, and subcaudate tractotomy with or without cingulotomy was performed for depression with anxiety. OCD was evaluated with the Yale-Brown Obsessive Compulsive Scale (YBOCS), the visual analogue scale, the Clinical Global Impression Scale, and the Overt Aggression Scale (OAS). The Mini-Mental State Examination and the Wechsler Adult Intelligence Scale-Revised were used for the evaluation of aggressive behavior. The 17-item Hamilton Depression Rating Scale (HAMD) was used for evaluation of depression. Ventriculography was used in the first seven patients and magnetic resonance imaging-guided stereotaxy was used in the recent 14 cases for localization of the target. The lesions were made with a radiofrequency lesion generator. OAS scores in the two patients with aggressive behavior during follow up declined from 8 to 2 with clinical improvement. All 12 patients with OCD returned to their previous life and showed the mean YBOCS scores decreased from 34 to 3. Ten patients with OCD could be followed up (mean 45 months). All patients returned to their previous social life. In seven patients with depression with anxiety, HAMD scores declined from 28.5 to 16.5. There was no operative mortality and no significant morbidity except for one case of mild transient urinary incontinence. These long-term results indicate that stereotactic psychosurgery is a safe and effective method of treating some medically intractable psychiatric illnesses.
Brain↗
Contemporary psychosurgery and a look to the future.
OBJECT: Despite a long and controversial history, psychosurgery has persisted as a modern treatment option for some severe, medically intractable psychiatric disorders. The goal of this study was to review the current state of psychosurgery. METHODS: In this review, the definition of psychosurgery, patient selection criteria, and anatomical and physiological rationales for cingulotomy, subcaudate tractotomy, anterior capsulotomy, and limbic leukotomy are discussed. The historical developments, modern procedures, and results of these four contemporary psychosurgical procedures are also reviewed. Examples of recent advances in neuroscience indicating a future role for neurosurgical intervention for psychiatric disease are also mentioned. CONCLUSIONS: A thorough understanding of contemporary psychosurgery will help neurosurgeons and other physicians face the ethical, social, and technical challenges that are sure to lie ahead as modern science continues to unlock the secrets of the mind and brain.
Humans↗
Psychosurgery; present indications and future prospects.
Although the advent and widespread use of ataractic drugs has more or less eclipsed lobotomy as a method of dealing with severe psychotic states, variations and adaptations of the operation still can be used with benefit in certain pretty well defined circumstances."Chemical lobotomy" and regressive electroshock bring about alterations in behavior superficially resembling those of lobotomy, but without the changes in personality that are the object of lobotomy. These desirable changes consist in increased extraversion, decreased preoccupation with self and decreased sensitivity to the opinions of others. With restricted operations, undesirable changes-the "frontal lobe syndrome"-do not occur. OPERATIVE FAILURES ARE DUE TO THREE MAIN CAUSES: (a) Preoperative emotional deterioration; (b) progress of the underlying disease; (c) relapse, possibly due to inadequate operation. Lobotomy is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait. The future of psychosurgery lies in prompt application, in favorable patients, of selective operations that will reverse the trend of illness. There is particular need for further exploration of the temporal lobes in the hope of finding some procedure that will suppress hallucinations. Some 90 per cent of patients remaining in hospitals after psychosurgery are experiencing hallucinations. If these phenomena can be eliminated without producing serious personality defects, another large field for the application of psychosurgery will be opened.
Hallucinations↗
Psychosurgery and personality disorders.
Defining personality and its pathological variants is a hazardous enterprise. The personality concept refers to the global coherence of functioning of a person as a whole and can be divided into two components, temperament and character. Personality disorders will be discussed according to the DSM III-R (1987) (The Diagnostic and Statistical Manual of Mental Disorders) the most recent psychiatric taxonomy of the American Psychiatric Association. The interaction between psychosurgery and personality is multiple. It will be stated that the mere presence of a personality disorder in a patient should never be an indication for psychosurgery. It may sometimes even act as a contraindication. Psychosurgery can produce changes in some basic psychic dysfunctions and although there is no universally accepted understanding of how it works, some hypothetical neurobiological foundations will be discussed.
Humans↗
Treatment of obsessive-compulsive disorder by psychosurgery.
We report a longitudinal study of 26 patients with medically intractable obsessive-compulsive disorder (OCD) who were treated with psychosurgery and had a comprehensive follow-up for a mean 10 years. Seventeen patients had combined orbitomedial and cingulate lesions, 6 cingulate lesions only and 3 orbitomedial lesions only. Eighteen patients were interviewed personally and lesions verified on magnetic resonance imaging scans in fourteen. On a 6-point global rating scale, 10 (38%) patients had obvious improvement, another 6 (23%) showed mild improvement of doubtful clinical value, and the remaining 10 showed either no change (n = 6; 23%) or were judged to be worse (n = 4; 15%). Both obsessive and compulsive symptoms improved, and this change was independent of the changes in anxiety and depression scores. No significant predictors of improvement were identified. Patients with cingulate lesions only fared worse. Eight patients who had a second operation did not show much improvement. A comparison of a subgroup of patients with 10 matched nonsurgical OCD controls supported the contention that the improvement in OCD was attributable to the psychosurgery. Important adverse effects in the stereotactic surgery group (n = 20) were epilepsy (1 patient) and personality change (2 patients). The psychosurgery group performed relatively poorly on the Wisconsin Card Sort Test but did not show any deterioration in Wechsler Intelligence and Memory scores.
Adult↗
The origins of psychosurgery: Shaw, Burckhardt and Moniz.
The concepts and techniques involved in the origins of psychosurgery during the late nineteenth century are analyzed, particularly in the work of Claye Shaw and Gottlieb Burckhardt. It is shown that their views and therapeutic behaviour were guided by scientific, ethical and social warrants not dissimilar from those of today. The debate that followed their work can thus be considered as a trial run to that elicited by the work of Moniz. This paper focuses on the work of Shaw, Cripps, Tuke and Duncan for, until now, it has not featured in any history of psychosurgery. From the point of view of the history of science, their work is important, for it relates to the debate on brain localization, neuronal circuits and the neurobiological representation of mental illness that took place at the dawn of the twentieth century. Nothing is said on the history of psychosurgery subsequent to the work of Moniz.
History, 19th Century↗
Psychiatrists' attitudes to psychosurgery. Proposals for the organization of a psychosurgical service in Yorkshire.
A survey of attitudes to psychosurgery among consultant psychiatrists in two regions of Britain was undertaken by a postal questionnaire. Most psychiatrists considered that there is still a role for psychosurgery in psychiatric practice and over 75 per cent of psychiatrists working in general adult psychiatry requested facilities for the referral of patients; the majority of those requesting preferred local facilities and thought that the psychosurgical team should carry out both the assessment and postoperative rehabilitation. Respondents to the questionnaire were conservative in their indications for considering psychosurgery. The effect that the revision of the Mental Health Act might have on psychosurgical practice was then considered and finally the organization of the authors' own practice is described.
Attitude of Health Personnel↗
Sixty years of psychosurgery: its present status and its future.
After its introduction 60 years ago, psychosurgery witnessed a remarkable rise followed by a decline. In the 1990s, it is a marginal treatment practised by a few psychiatrists in some specialised centres around the world. The psychiatric profession, however, continues to support it, and there is some evidence for a recent renewal of interest in the procedure. In this paper, the reasons for this reluctant acceptance of psychosurgery are examined, and the factors that are likely to determine its future are identified. The profession is urged to keep the interest in psychosurgery alive until further theoretical and empirical developments can either announce its death or lead to a resurgence of psychiatric neurosurgery in its present or modified form.
Attitude of Health Personnel↗
[Contribution of Gottlieb Burckhardt (1836-1907) to psychosurgery from the medical history and ethical viewpoint].
Psychosurgery is defined as the practice of destroying or removing healthy brain tissue in order to change behaviour. Although the neurologist Egas Moniz (1874-1955) is occasionally said to be the founder of psychosurgery, the first psychosurgical operations were performed by Gottlieb Burckhardt, a Swiss psychiatrist who practised in the late 19th century. In 1891 he reported the results of topectomies on six patients suffering from different psychiatric diseases. The aim of the present article is to illuminate the life of Burckhardt as well as his contribution to psychosurgery. Special attention is paid to the ethical aspects of his operative interventions. First of all, we have to make allowance for the fact that the therapeutic chances in 19th-century psychiatry were quite poor. Therefore, Burckhardts topectomies might have been seen as a new and hopeful way of therapy. But by analysing Burckhardt's case reports, it becomes clear that he did not intend to cure his patients but only to ameliorate their disturbing behaviour and their non-compliance. Burckhardt himself tried to justify the immense risk of his operations by referring to the necessity of progress in medicine. Although Burckhardt spoke of promising improvements, his positive appraisal can hardly be maintained. For this and other reasons, his contemporary colleagues mainly declined his methods and reports.
Ethics, Medical↗
[Psychosurgery and the neurosurgical treatment of pain: a systematic review of the experience gained in these kinds of treatment].
INTRODUCTION: Psychosurgery and the neurochemical treatment of pain (NTP) are therapeutic options restricted to patients who show resistance to medical treatments. Surgical techniques have been perfected over the last few decades. AIMS: Our aim was to conduct a systematic review of the studies dealing with psychosurgery and NTP reported in the literature, based on the standards of quality used in evidence-based medicine. DEVELOPMENT: Following screening and selection, nine of the 178 papers found (MEDLINE, 1990-2002) were selected for the study: three referring to the treatment of neuropathic pain and six about the treatment of obsessive-compulsive disorder (OCD). The objectives were the therapeutic results in all cases, the study of the anatomical-functional bases in three of them and the description of side effects in five. After adapting the standards of quality used in evidence-based medicine (there are no standards for papers about surgery), one was classified in group B, six in group C and two as C-D. The three papers about the treatment of pain reported a significant improvement in the pain scales in 40-77% of patients. As regards the treatment of OCD, results showed an overall improvement of the scales in 20.4-70% of the patients with an improvement above 50%. The side effects are also described. CONCLUSIONS: Data published support the indication of psychosurgery and NTP for selected patients with neuropathic pain and OCD. The methodological limitations of the papers prevent us from drawing conclusions about the other diseases for which these techniques have been indicated.
Diagnosis, Differential↗