401
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Resnick AS, Foote KD, Rodriguez RL, Malaty IA, Moll JL, Carden DL, Krock NE, Medley MM, Burdick A, Haq IU, Okun MS. The number and nature of emergency department encounters in patients with deep brain stimulators. J Neurol 2009; 257:122-31. [DOI: 10.1007/s00415-009-5343-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Revised: 09/04/2009] [Accepted: 09/22/2009] [Indexed: 11/24/2022]
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402
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Andrade P, Fernández-Guasti A, Carrillo-Ruiz JD, Ulloa RE, Ramírez Y, Reyes R, Jiménez F. Effects of bilateral lesions in thalamic reticular nucleus and orbitofrontal cortex in a T-maze perseverative model produced by 8-OH-DPAT in rats. Behav Brain Res 2009; 203:108-12. [DOI: 10.1016/j.bbr.2009.04.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 04/10/2009] [Accepted: 04/20/2009] [Indexed: 11/26/2022]
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403
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Aouizerate B, Cuny E, Bardinet E, Yelnik J, Martin-Guehl C, Rotge JY, Rougier A, Bioulac B, Tignol J, Mallet L, Burbaud P, Guehl D. Distinct striatal targets in treating obsessive-compulsive disorder and major depression. J Neurosurg 2009; 111:775-9. [DOI: 10.3171/2009.2.jns0881] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The ventral striatum, including the head of the caudate nucleus and the nucleus accumbens, is a putative target for deep brain stimulation (DBS) in the treatment of obsessive-compulsive disorder (OCD) and major depression (MD). However, the respective roles of these structures in the pathophysiology of OCD and MD remain to be clarified. To address this issue, DBS of the ventral striatum was tested in 2 patients with severely distressing and intractable forms of OCD and MD. Comparisons of clinical outcomes and anatomical data on electrode positioning showed that caudate nucleus stimulation preferentially alleviated OCD manifestations, whereas nucleus accumbens stimulation improved depressive symptoms. These findings suggest that the caudate nucleus and nucleus accumbens participate differently in the pathogenesis of both of these psychiatric conditions.
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Affiliation(s)
- Bruno Aouizerate
- 1Service de Psychiatrie, Université Victor Segalen Bordeaux 2, Centre Hospitalier Charles Perrens, Centre Carreire
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
| | - Emmanuel Cuny
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
- 3Service de Neurochirurgie
| | - Eric Bardinet
- 4Centre National de la Recherche Scientifique, Unité Propre de Recherche 640, Hôpital Pitié-Salpêtrière
| | - Jerome Yelnik
- 5Laboratoire Neurologie et Thérapeutique Expérimentale, Institut National de la Santé et de la Recherche Médicale Unité 679, Hôpital Pitié-Salpêtrière
| | - Corinne Martin-Guehl
- 1Service de Psychiatrie, Université Victor Segalen Bordeaux 2, Centre Hospitalier Charles Perrens, Centre Carreire
| | - Jean-Yves Rotge
- 1Service de Psychiatrie, Université Victor Segalen Bordeaux 2, Centre Hospitalier Charles Perrens, Centre Carreire
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
| | - Alain Rougier
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
- 3Service de Neurochirurgie
| | - Bernard Bioulac
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
- 6Service de Neurophysiologie Clinique, Université Victor Segalen Bordeaux 2, Centre Hospitalier Universitaire de Bordeaux
| | - Jean Tignol
- 1Service de Psychiatrie, Université Victor Segalen Bordeaux 2, Centre Hospitalier Charles Perrens, Centre Carreire
| | - Luc Mallet
- 7Groupe Avenir Institut National de la Santé et de la Recherche Médicale, «Comportement, Emotion, et Ganglion de la Base», Institut Fédératif de Recherche 70; and
- 8Centre d'Investigation Clinique, Hôpital Pitié-Salpêtrière, Paris Cedex 13, France
| | - Pierre Burbaud
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
- 6Service de Neurophysiologie Clinique, Université Victor Segalen Bordeaux 2, Centre Hospitalier Universitaire de Bordeaux
| | - Dominique Guehl
- 2Laboratoire Mouvement Adaptation Cognition, Centre National de la Recherche Scientifique, Unité Mixte de Recherche 5227
- 6Service de Neurophysiologie Clinique, Université Victor Segalen Bordeaux 2, Centre Hospitalier Universitaire de Bordeaux
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404
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Rabins P, Appleby BS, Brandt J, DeLong MR, Dunn LB, Gabriëls L, Greenberg BD, Haber SN, Holtzheimer PE, Mari Z, Mayberg HS, McCann E, Mink SP, Rasmussen S, Schlaepfer TE, Vawter DE, Vitek JL, Walkup J, Mathews DJH. Scientific and ethical issues related to deep brain stimulation for disorders of mood, behavior, and thought. ACTA ACUST UNITED AC 2009; 66:931-7. [PMID: 19736349 DOI: 10.1001/archgenpsychiatry.2009.113] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT A 2-day consensus conference was held to examine scientific and ethical issues in the application of deep brain stimulation for treating mood and behavioral disorders, such as major depression, obsessive-compulsive disorder, and Tourette syndrome. OBJECTIVES The primary objectives of the conference were to (1) establish consensus among participants about the design of future clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and (2) develop standards for the protection of human subjects participating in such studies. RESULTS Conference participants identified 16 key points for guiding research in this growing field. CONCLUSIONS The adoption of the described guidelines would help to protect the safety and rights of research subjects who participate in clinical trials of deep brain stimulation for disorders of mood, behavior, and thought and have further potential to benefit other stakeholders in the research process, including clinical researchers and device manufactures. That said, the adoption of the guidelines will require broad and substantial commitment from many of these same stakeholders.
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Affiliation(s)
- Peter Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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405
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Gubellini P, Salin P, Kerkerian-Le Goff L, Baunez C. Deep brain stimulation in neurological diseases and experimental models: From molecule to complex behavior. Prog Neurobiol 2009; 89:79-123. [DOI: 10.1016/j.pneurobio.2009.06.003] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 04/28/2009] [Accepted: 06/18/2009] [Indexed: 11/30/2022]
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406
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Long-term outcome following Intensive Residential Treatment of Obsessive-Compulsive Disorder. J Psychiatr Res 2009; 43:1118-23. [PMID: 19419736 DOI: 10.1016/j.jpsychires.2009.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Revised: 03/19/2009] [Accepted: 03/27/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND IRT has been demonstrated as an effective treatment for severe, refractory OCD. METHODS Consecutive IRT subjects were ascertained over a 12 month period (female N=26, male N=35). Psychometric measures were completed at admission and discharge from the McLean/MGH OCD Institute IRT, including the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) and the Work and Social Adjustment Scale (WSA)(N=61). These measures were repeated at one (N=57), three (N=42) and six months (N=36) following discharge. This study was IRB approved. RESULTS OCD mean severity did not significantly worsen from discharge to the one (17.4, SD 6.5), three (16.5, SD 7.4) or six month (16.2, SD 7.3) follow-up (p>0.25). Furthermore, the significant improvement from admission was maintained at each of the one (17.4, SD 6.5), three (16.5, SD 7.4) and six month (16.2, SD SD 7.3) follow-up time points (p<0.001). Relapsers were significantly more likely to be living alone following discharge (p=0.01), and were less likely to have comorbid illnesses (p=0.02). There were no significant differences found between study dropouts and completers with regards to YBOCS scores (P>0.47). CONCLUSION In the first OCD IRT long-term follow-up study to date, findings have indicated that mean treatment gains were maintained at one, three, and six months post-discharge. This finding is important as it suggests that improvements of OCD severity were subsequently retained in home and work environments. Improvement of depression severity from admission was also maintained.
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407
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Andrade P, Carrillo-Ruiz JD, Ramírez Y, Jiménez F. Effects of Thalamic Reticular Nucleus Electrical Stimulation in Rats in a T-maze Perseverative Behavior Model Induced by 8-OH-DPAT. Neuromodulation 2009; 13:2-9. [DOI: 10.1111/j.1525-1403.2009.00242.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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408
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A high resolution and high contrast MRI for differentiation of subcortical structures for DBS targeting: The Fast Gray Matter Acquisition T1 Inversion Recovery (FGATIR). Neuroimage 2009; 47 Suppl 2:T44-52. [DOI: 10.1016/j.neuroimage.2009.04.018] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 03/03/2009] [Accepted: 04/04/2009] [Indexed: 11/20/2022] Open
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409
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Abstract
Deep brain stimulation (DBS) has been used to treat various neurological and psychiatric disorders. Over the years, the most suitable surgical candidates and targets for some of these conditions have been characterized and the benefits of DBS well demonstrated in double-blinded randomized trials. This review will discuss some of the areas of current investigation and potential new applications of DBS.
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Affiliation(s)
- Nasir Raza Awan
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Canada
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410
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A Bayesian statistical analysis of behavioral facilitation associated with deep brain stimulation. J Neurosci Methods 2009; 183:267-76. [PMID: 19576932 DOI: 10.1016/j.jneumeth.2009.06.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Revised: 06/22/2009] [Accepted: 06/23/2009] [Indexed: 11/23/2022]
Abstract
Deep brain stimulation (DBS) is an established therapy for Parkinson's Disease and is being investigated as a treatment for chronic depression, obsessive compulsive disorder and for facilitating functional recovery of patients in minimally conscious states following brain injury. For all of these applications, quantitative assessments of the behavioral effects of DBS are crucial to determine whether the therapy is effective and, if so, how stimulation parameters can be optimized. Behavioral analyses for DBS are challenging because subject performance is typically assessed from only a small set of discrete measurements made on a discrete rating scale, the time course of DBS effects is unknown, and between-subject differences are often large. We demonstrate how Bayesian state-space methods can be used to characterize the relationship between DBS and behavior comparing our approach with logistic regression in two experiments: the effects of DBS on attention of a macaque monkey performing a reaction-time task, and the effects of DBS on motor behavior of a human patient in a minimally conscious state. The state-space analysis can assess the magnitude of DBS behavioral facilitation (positive or negative) at specific time points and has important implications for developing principled strategies to optimize DBS paradigms.
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411
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Mikell CB, McKhann GM, Segal S, McGovern RA, Wallenstein MB, Moore H. The hippocampus and nucleus accumbens as potential therapeutic targets for neurosurgical intervention in schizophrenia. Stereotact Funct Neurosurg 2009; 87:256-65. [PMID: 19556835 PMCID: PMC2836942 DOI: 10.1159/000225979] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Schizophrenia is a chronic and disabling psychiatric illness that is often refractory to treatment. Psychotic symptoms (e.g. hallucinations and delusions) in schizophrenia are reliably correlated with excess dopamine levels in the striatum, and have more recently been related to excess metabolic activity in the hippocampus. Multiple lines of evidence suggest that aberrantly high hippocampal activity may, via hippocampal connections with the limbic basal ganglia, drive excessive dopamine release into the striatum. In the present paper, we hypothesize that inhibition or stabilization of neural activity with high-frequency electrical stimulation of the hippocampus or nucleus accumbens, through different mechanisms, would treat the positive symptoms of schizophrenia. Thus, we suggest a direction for further experimentation aimed at developing neurosurgical therapeutic approaches for this devastating disease.
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Affiliation(s)
| | | | | | | | | | - Holly Moore
- Department of Neurological Surgery, Columbia University, New York, N.Y., USA
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412
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Lane RD, Wager TD. The new field of Brain-Body Medicine: what have we learned and where are we headed? Neuroimage 2009; 47:1135-40. [PMID: 19524045 DOI: 10.1016/j.neuroimage.2009.06.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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413
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Rakofsky JJ, Holtzheimer PE, Nemeroff CB. Emerging targets for antidepressant therapies. Curr Opin Chem Biol 2009; 13:291-302. [PMID: 19501541 DOI: 10.1016/j.cbpa.2009.04.617] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 04/17/2009] [Indexed: 01/11/2023]
Abstract
Despite adequate antidepressant monotherapy, the majority of depressed patients do not achieve remission. Even optimal and aggressive therapy leads to a substantial number of patients who show minimal and often only transient improvement. In order to address this substantial problem of treatment-resistant depression, a number of novel targets for antidepressant therapy have emerged as a consequence of major advances in the neurobiology of depression. Three major approaches to uncover novel therapeutic interventions are: first, optimizing the modulation of monoaminergic neurotransmission; second, developing medications that act upon neurotransmitter systems other than monoaminergic circuits; and third, using focal brain stimulation to directly modulate neuronal activity. We review the most recent data on novel therapeutic compounds and their antidepressant potential. These include triple monoamine reuptake inhibitors, atypical antipsychotic augmentation, and dopamine receptor agonists. Compounds affecting extra-monoamine neurotransmitter systems include CRF(1) receptor antagonists, glucocorticoid receptor antagonists, substance P receptor antagonists, NMDA receptor antagonists, nemifitide, omega-3 fatty acids, and melatonin receptor agonists. Focal brain stimulation therapies include vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), transcranial direct current stimulation (tDCS), and deep brain stimulation (DBS).
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Affiliation(s)
- Jeffrey J Rakofsky
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 2004 Ridgewood Dr, Suite 218, Atlanta, GA 30322, United States.
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414
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Tye SJ, Frye MA, Lee KH. Disrupting disordered neurocircuitry: treating refractory psychiatric illness with neuromodulation. Mayo Clin Proc 2009; 84:522-32. [PMID: 19483169 PMCID: PMC2688626 DOI: 10.4065/84.6.522] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Despite the premature and somewhat infamous rise and fall of psychosurgery in the mid-20th century, the current era of functional neuromodulation proffers immense opportunity for surgical intervention in treatment-resistant psychiatric disorders. On the basis of recent successes with novel, focused, less invasive, and reversible treatment strategies for movement disorders, several therapeutic trials have been conducted to investigate the effectiveness of deep brain stimulation (DBS) in treatment-resistant depression, obsessive-compulsive disorder (OCD), and Tourette syndrome. The many anatomic targets for these psychiatric disorders are indicative of both the system-wide effects of DBS and the network-level dysfunction mediating the emotional and cognitive disturbances. To gain insight into the application of neuromodulation therapies and their further advancement, we must elucidate neuroanatomic networks involved in refractory psychiatric illness, the neurophysiological anomalies that contribute to disordered information processing therein, and the local and system-wide modulatory effects of DBS. This review discusses the history of psychosurgical procedures, recent DBS clinical data, current anatomic models of psychopathology, and possible therapeutic mechanisms of action of DBS neuromodulation. Our search criteria for PubMed included combinations of the following terms: neuromodulation, DBS, depression, OCD, Tourette syndrome, mechanism of action, and history. Dates were not restricted. As clinical and basic scientific investigations probe the neuromodulatory effects of DBS in the treatment of refractory neuropsychiatric illness, our knowledge of these disorders and our potential to treat them are rapidly expanding. Indeed, this modern era of neuromodulation may provide the key that unlocks many of the mysteries pertaining to the biological basis of disordered emotional neurocircuitry.
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Affiliation(s)
- Susannah J Tye
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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415
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Tye SJ, Frye MA, Lee KH. Disrupting disordered neurocircuitry: treating refractory psychiatric illness with neuromodulation. Mayo Clin Proc 2009; 84:522-32. [PMID: 19483169 PMCID: PMC2688626 DOI: 10.1016/s0025-6196(11)60584-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Despite the premature and somewhat infamous rise and fall of psychosurgery in the mid-20th century, the current era of functional neuromodulation proffers immense opportunity for surgical intervention in treatment-resistant psychiatric disorders. On the basis of recent successes with novel, focused, less invasive, and reversible treatment strategies for movement disorders, several therapeutic trials have been conducted to investigate the effectiveness of deep brain stimulation (DBS) in treatment-resistant depression, obsessive-compulsive disorder (OCD), and Tourette syndrome. The many anatomic targets for these psychiatric disorders are indicative of both the system-wide effects of DBS and the network-level dysfunction mediating the emotional and cognitive disturbances. To gain insight into the application of neuromodulation therapies and their further advancement, we must elucidate neuroanatomic networks involved in refractory psychiatric illness, the neurophysiological anomalies that contribute to disordered information processing therein, and the local and system-wide modulatory effects of DBS. This review discusses the history of psychosurgical procedures, recent DBS clinical data, current anatomic models of psychopathology, and possible therapeutic mechanisms of action of DBS neuromodulation. Our search criteria for PubMed included combinations of the following terms: neuromodulation, DBS, depression, OCD, Tourette syndrome, mechanism of action, and history. Dates were not restricted. As clinical and basic scientific investigations probe the neuromodulatory effects of DBS in the treatment of refractory neuropsychiatric illness, our knowledge of these disorders and our potential to treat them are rapidly expanding. Indeed, this modern era of neuromodulation may provide the key that unlocks many of the mysteries pertaining to the biological basis of disordered emotional neurocircuitry.
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Affiliation(s)
| | | | - Kendall H. Lee
- Individual reprints of this article are not available. Address correspondence to Kendall H. Lee, MD, PhD, Department of Neurologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ().
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416
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Mundt A, Klein J, Joel D, Heinz A, Djodari-Irani A, Harnack D, Kupsch A, Orawa H, Juckel G, Morgenstern R, Winter C. High-frequency stimulation of the nucleus accumbens core and shell reduces quinpirole-induced compulsive checking in rats. Eur J Neurosci 2009; 29:2401-12. [PMID: 19490027 DOI: 10.1111/j.1460-9568.2009.06777.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Electrical deep brain stimulation (DBS) is currently studied in the treatment of therapy-refractory obsessive compulsive disorders (OCDs). The variety of targeted brain areas and the inconsistency in demonstrating anti-compulsive effects, however, highlight the need for better mapping of brain regions in which stimulation may produce beneficial effects in OCD. Such a goal may be advanced by the assessment of DBS in appropriate animal models of OCD. Currently available data on DBS of the nucleus accumbens (NAc) on OCD-like behavior in rat models of OCD are contradictory and partly in contrast to clinical data and theoretical hypotheses about how the NAc might be pathophysiologically involved in the manifestation of OCD. Consequently, the present study investigates the effects of DBS of the NAc core and shell in a quinpirole rat model of OCD. The study demonstrates that electrical modulation of NAc core and shell activity via DBS reduces quinpirole-induced compulsive checking behavior in rats. We therefore conclude that both, the NAc core and shell constitute potential target structures in the treatment of OCD.
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Affiliation(s)
- Adrian Mundt
- Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité University Medicine, Berlin, Germany
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417
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["Psychosurgery" and deep brain stimulation with psychiatric indication. Current and historical aspects]. DER NERVENARZT 2009; 80:781-8. [PMID: 19455295 DOI: 10.1007/s00115-009-2726-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Deep brain stimulation is a novel and reversible surgical intervention in the treatment of psychiatric disorders. Recent studies in small samples of patients with depression and obsessive-compulsive disorder have come up with promising results. Neurosurgical interventions in psychiatric patients raise ethical questions in the context of historical experiences with traditional and irreversible psychosurgical procedures that need to be discussed.
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418
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De novo and rescue DBS leads for refractory Tourette syndrome patients with severe comorbid OCD: a multiple case report. J Neurol 2009; 256:1533-9. [PMID: 19437063 DOI: 10.1007/s00415-009-5159-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 04/22/2009] [Accepted: 04/22/2009] [Indexed: 10/20/2022]
Abstract
Invasive treatment for Gilles de la Tourette syndrome has shown interesting results in a number of published reports; it seems to be evolving into a promising therapeutic procedure for those patients demonstrating disabling clinical pictures who are refractory to conservative treatments. There are important issues concerning the stimulated brain target, with different nuclei currently under investigation. Our group asked in this pilot study whether Tourette syndrome could be treated by tailoring specific brain targets for specific symptoms. Deep brain stimulation for Tourette syndrome may thus in the future be tailored and patient specific, utilizing specific target regions for individual clinical manifestations. In our early experience we did not adequately address non-motor clinical symptoms as we only used a thalamic target. More recently in an obsessive compulsive disease cohort we have had success in using the anterior limb of the internal capsule and nucleus accumbens region as targets for stimulation. We therefore explored the option of a "rescue" procedure for our Tourette patients with persistent obsessive-compulsive disorder following ventralis oralis/centromedianus-parafascicularis (Vo/CM-Pf) deep brain stimulation. Following two cases where rescue anterior limb of internal capsule/nucleus accumbens leads were employed, we performed two additional procedures (anterior limb of the internal capsule plus ventralis oralis/centromedianus-parafascicularis and anterior limb of the internal capsule alone) with some mild improvement of comorbid obsessive-compulsive disorder, although the number of observations in this case series was low. Overall, the effects observed with using the anterior limb of the internal capsule either alone or as a rescue were less than expected. In this report we detail our experience with this approach.
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419
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Giacobbe P, Mayberg HS, Lozano AM. Treatment resistant depression as a failure of brain homeostatic mechanisms: implications for deep brain stimulation. Exp Neurol 2009; 219:44-52. [PMID: 19426730 DOI: 10.1016/j.expneurol.2009.04.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 04/27/2009] [Accepted: 04/28/2009] [Indexed: 10/20/2022]
Abstract
Given the profound negative public health effects of major depressive disorder (MDD), and data suggesting only modest effectiveness of existing psychological and pharmacological treatments for this condition, there has been increasing interest in exploring the antidepressant potential of non-pharmacological, brain-based interventions, such as deep brain stimulation (DBS). The use of the DBS for psychiatric indications follows a decade of data suggesting that DBS is an effective, evidence-based strategy for the treatment of movement disorders such as Parkinson's disease. At the present time there is open-label case series data to suggest that DBS in the subgenual cingulate gyrus, ventral caudate/ventral striatum, and the nucleus accumbens, is associated with antidepressant effects in individuals who fail to respond to conventional treatments for MDD. However a number of unresolved issues about the optimal use of DBS for MDD remain, such as the optimal anatomical placement of the electrodes and the mechanisms of its antidepressant effects. This review summarizes the clinical experience of DBS for treatment resistant depression (TRD). The rationale for the use of DBS for TRD is reviewed in the context of the growing neuroimaging literatures exploring the biomarkers of antidepressant response, and the neural substrates of emotional regulation in both normal and pathological states.
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Affiliation(s)
- Peter Giacobbe
- Department of Psychiatry, University Health Network, University of Toronto, Canada
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420
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Lee KH, Blaha CD, Garris PA, Mohseni P, Horne AE, Bennet KE, Agnesi F, Bledsoe JM, Lester DB, Kimble C, Min HK, Kim YB, Cho ZH. Evolution of Deep Brain Stimulation: Human Electrometer and Smart Devices Supporting the Next Generation of Therapy. Neuromodulation 2009; 12:85-103. [PMID: 20657744 DOI: 10.1111/j.1525-1403.2009.00199.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Deep Brain Stimulation (DBS) provides therapeutic benefit for several neuropathologies including Parkinson's disease (PD), epilepsy, chronic pain, and depression. Despite well established clinical efficacy, the mechanism(s) of DBS remains poorly understood. In this review we begin by summarizing the current understanding of the DBS mechanism. Using this knowledge as a framework, we then explore a specific hypothesis regarding DBS of the subthalamic nucleus (STN) for the treatment of PD. This hypothesis states that therapeutic benefit is provided, at least in part, by activation of surviving nigrostriatal dopaminergic neurons, subsequent striatal dopamine release, and resumption of striatal target cell control by dopamine. While highly controversial, we present preliminary data that are consistent with specific predications testing this hypothesis. We additionally propose that developing new technologies, e.g., human electrometer and closed-loop smart devices, for monitoring dopaminergic neurotransmission during STN DBS will further advance this treatment approach.
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Affiliation(s)
- Kendall H Lee
- Department of Neurosurgery and Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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421
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Clark CR, Galletly CA, Ash DJ, Moores KA, Penrose RA, McFarlane AC. Evidence-based medicine evaluation of electrophysiological studies of the anxiety disorders. Clin EEG Neurosci 2009; 40:84-112. [PMID: 19534302 DOI: 10.1177/155005940904000208] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We provide a systematic, evidence-based medicine (EBM) review of the field of electrophysiology in the anxiety disorders. Presently, electrophysiological studies of anxiety focus primarily on etiological aspects of brain dysfunction. The review highlights many functional similarities across studies, but also identifies patterns that clearly differentiate disorder classifications. Such measures offer clinical utility as reliable and objective indicators of brain dysfunction in individuals and indicate potential as biomarkers for the improvement of diagnostic specificity and for informing treatment decisions and prognostic assessments. Common to most of the anxiety disorders is basal instability in cortical arousal, as reflected in measures of quantitative electroencephalography (qEEG). Resting electroencephalographic (EEG) measures tend to correlate with symptom sub-patterns and be exacerbated by condition-specific stimulation. Also common to most of the anxiety disorders are condition-specific difficulties with sensory gating and the allocation and deployment of attention. These are clearly evident from evoked potential (EP) and event-related potential (ERP) electrical measures of information processing in obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD) and the phobias. Other'ERP measures clearly differentiate the disorders. However, there is considerable variation across studies, with inclusion and exclusion criteria, medication status and control group selection not standardized within condition or across studies. Study numbers generally preclude analysis for confound removal or for the derivation of diagnostic biomarker patterns at this time. The current trend towards development of databases of brain and cognitive function is likely to obviate these difficulties. In particular, electrophysiological measures of function are likely to play a significant role in the development and subsequent adaptations of DSM-V and assist critically in securing improvements in nosological and treatment specificity.
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Affiliation(s)
- C Richard Clark
- Cognitive Neuroscience Laboratory, School of Psychology, Flinders University , Adelaide, Australia, Adelaide, Australia.
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422
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What functional neurosurgery can offer to psychiatric patients: a neuropsychiatric perspective. SURGICAL NEUROLOGY 2009; 71:337-42, discussion 343. [PMID: 19249581 DOI: 10.1016/j.surneu.2008.08.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Accepted: 08/25/2008] [Indexed: 11/23/2022]
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423
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Gutman DA, Holtzheimer PE, Behrens TEJ, Johansen-Berg H, Mayberg HS. A tractography analysis of two deep brain stimulation white matter targets for depression. Biol Psychiatry 2009; 65:276-82. [PMID: 19013554 PMCID: PMC4423548 DOI: 10.1016/j.biopsych.2008.09.021] [Citation(s) in RCA: 167] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 09/16/2008] [Accepted: 09/19/2008] [Indexed: 01/11/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subcallosal cingulate white matter (SCCwm) or anterior limb of the internal capsule (ALIC) may be effective in treating depression. Connectivity patterns of these regions may inform on mechanisms of action for DBS of these targets. METHODS Diffusion tensor imaging (DTI) and probabilistic tractography were performed in 13 nondepressed subjects to determine connectivity patterns of SCCwm and ALIC. Tract maps were generated for each target in each subject, and tract voxels were coded as being unique to either target or shared. Group level tract maps were generated by including only those voxels common to at least 10 of 13 (>75%) subjects. RESULTS The two targets have distinct patterns of connectivity with regions of overlap. The SCCwm showed consistent ipsilateral connections to the medial frontal cortex, the full extent of the anterior and posterior cingulate, medial temporal lobe, dorsal medial thalamus, hypothalamus, nucleus accumbens, and the dorsal brainstem. The ALIC seed, in contrast, demonstrated widespread projections to frontal pole, medial temporal lobe, cerebellum, nucleus accumbens, thalamus, hypothalamus, and brainstem. Common to both targets, albeit through distinct white matter bundles, were connections to frontal pole, medial temporal lobe, nucleus accumbens, dorsal thalamus, and hypothalamus. CONCLUSIONS Connectivity patterns of these two DBS white matter targets suggest distinct neural networks with areas of overlap in regions implicated in depression and antidepressant response.
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Affiliation(s)
- David A Gutman
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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424
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Malone DA, Dougherty DD, Rezai AR, Carpenter LL, Friehs GM, Eskandar EN, Rauch SL, Rasmussen SA, Machado AG, Kubu CS, Tyrka AR, Price LH, Stypulkowski PH, Giftakis JE, Rise MT, Malloy PF, Salloway SP, Greenberg BD. Deep brain stimulation of the ventral capsule/ventral striatum for treatment-resistant depression. Biol Psychiatry 2009; 65:267-75. [PMID: 18842257 PMCID: PMC3486635 DOI: 10.1016/j.biopsych.2008.08.029] [Citation(s) in RCA: 579] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 08/06/2008] [Accepted: 08/15/2008] [Indexed: 12/28/2022]
Abstract
BACKGROUND We investigated the use of deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) for treatment refractory depression. METHODS Fifteen patients with chronic, severe, highly refractory depression received open-label DBS at three collaborating clinical sites. Electrodes were implanted bilaterally in the VC/VS region. Stimulation was titrated to therapeutic benefit and the absence of adverse effects. All patients received continuous stimulation and were followed for a minimum of 6 months to longer than 4 years. Outcome measures included the Hamilton Depression Rating Scale-24 item (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Global Assessment of Function Scale (GAF). RESULTS Significant improvements in depressive symptoms were observed during DBS treatment. Mean HDRS scores declined from 33.1 at baseline to 17.5 at 6 months and 14.3 at last follow-up. Similar improvements were seen with the MADRS (34.8, 17.9, and 15.7, respectively) and the GAF (43.4, 55.5, and 61.8, respectively). Responder rates with the HDRS were 40% at 6 months and 53.3% at last follow-up (MADRS: 46.7% and 53.3%, respectively). Remission rates were 20% at 6 months and 40% at last follow-up with the HDRS (MADRS: 26.6% and 33.3%, respectively). The DBS was well-tolerated in this group. CONCLUSIONS Deep brain stimulation of the VC/VS offers promise for the treatment of refractory major depression.
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425
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The rebirth of neuroscience in psychosomatic medicine, Part II: clinical applications and implications for research. Psychosom Med 2009; 71:135-51. [PMID: 19196806 DOI: 10.1097/psy.0b013e318198a11f] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
During the second half of the last century, biopsychosocial research in psychosomatic medicine largely ignored the brain. Neuroscience has started to make a comeback in psychosomatic medicine research and promises to advance the field in important ways. In this paper we briefly review select brain imaging research findings in psychosomatic medicine in four key areas: cardiovascular regulation, visceral pain in the context of functional gastrointestinal disorders, acute and chronic somatic pain and placebo. In each area, there is a growing literature that is beginning to define a network of brain areas that participate in the functions in question. Evidence to date suggests that cortical and subcortical areas that are involved in emotion and emotion regulation play an important role in each domain. Neuroscientific research is therefore validating findings from previous psychosomatic research and has the potential to extend knowledge by delineating the biological mechanisms that link mind and body more completely and with greater specificity. We conclude with a discussion of the implications of this work for how research in psychosomatic medicine is conducted, the ways in which neuroscientific advances can lead to new clinical applications in psychosomatic contexts, the implications of this work for the field of medicine more generally, and the priorities for research in the next 5 to 10 years.
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426
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Bandelow B, Zohar J, Hollander E, Kasper S, Möller HJ, Zohar J, Hollander E, Kasper S, Möller HJ, Bandelow B, Allgulander C, Ayuso-Gutierrez J, Baldwin DS, Buenvicius R, Cassano G, Fineberg N, Gabriels L, Hindmarch I, Kaiya H, Klein DF, Lader M, Lecrubier Y, Lépine JP, Liebowitz MR, Lopez-Ibor JJ, Marazziti D, Miguel EC, Oh KS, Preter M, Rupprecht R, Sato M, Starcevic V, Stein DJ, van Ameringen M, Vega J. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision. World J Biol Psychiatry 2009; 9:248-312. [PMID: 18949648 DOI: 10.1080/15622970802465807] [Citation(s) in RCA: 428] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In this report, which is an update of a guideline published in 2002 (Bandelow et al. 2002, World J Biol Psychiatry 3:171), recommendations for the pharmacological treatment of anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are presented. Since the publication of the first version of this guideline, a substantial number of new randomized controlled studies of anxiolytics have been published. In particular, more relapse prevention studies are now available that show sustained efficacy of anxiolytic drugs. The recommendations, developed by the World Federation of Societies of Biological Psychiatry (WFSBP) Task Force for the Pharmacological Treatment of Anxiety, Obsessive-Compulsive and Post-traumatic Stress Disorders, a consensus panel of 30 international experts, are now based on 510 published randomized, placebo- or comparator-controlled clinical studies (RCTs) and 130 open studies and case reports. First-line treatments for these disorders are selective serotonin reuptake inhibitors (SSRIs), serotonin-noradrenaline reuptake inhibitors (SNRIs) and the calcium channel modulator pregabalin. Tricyclic antidepressants (TCAs) are equally effective for some disorders, but many are less well tolerated than the SSRIs/SNRIs. In treatment-resistant cases, benzodiazepines may be used when the patient does not have a history of substance abuse disorders. Potential treatment options for patients unresponsive to standard treatments are described in this overview. Although these guidelines focus on medications, non-pharmacological were also considered. Cognitive behavioural therapy (CBT) and other variants of behaviour therapy have been sufficiently investigated in controlled studies in patients with anxiety disorders, OCD, and PTSD to support them being recommended either alone or in combination with the above medicines.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Gottingen, Gottingen, Germany.
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427
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Deep Brain Stimulation. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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428
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H. Lee K, D. Blaha C, Bledsoe JM. Mechanisms of Action of Deep Brain Stimulation. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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430
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Neurosurgical treatment of mood disorders: traditional psychosurgery and the advent of deep brain stimulation. Curr Opin Psychiatry 2009; 22:25-31. [PMID: 19122531 DOI: 10.1097/yco.0b013e32831c8475] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW From its peak in the 1940s and 1950s, psychosurgery (or, neurosurgery for psychiatric disorders) has had a gradual decline, with only a few centers around the world continuing with the procedure into the 1980s and 1990s. With recent developments in brain stimulation techniques, the continuing relevance of psychosurgery in the treatment of psychiatric disorders is worthy of examination. RECENT FINDINGS A review of databases (PubMed, Medline, Current Contents and Embase) suggests that psychosurgery in the form of stereotactic focal ablation is still practiced in a few centers, although the number has decreased further from the 1990s. Procedures have not changed substantively, although modern imaging and stereotaxy have made them more precise. No good predictors of treatment response have been identified. There is a major shift in interest to deep brain stimulation (DBS) instead of ablative surgery. Studies of DBS in resistant depression and obsessive-compulsive disorder have been few and have involved small numbers, but this field is growing rapidly. SUMMARY Although ablative psychosurgery using stereotactic procedures continues to be used to a small extent, psychiatrists remain ambivalent about this procedure. The baton of psychosurgery, however, appears to have been passed on to DBS, but more data are needed on technical details and outcomes before the possible therapeutic role of DBS can be established.
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431
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Denys D, Mantione M. Deep brain stimulation in obsessive-compulsive disorder. PROGRESS IN BRAIN RESEARCH 2009; 175:419-27. [PMID: 19660670 DOI: 10.1016/s0079-6123(09)17527-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The use of deep brain stimulation in psychiatric disorders has received great interest owing to the small risk of the operation, the reversible nature of the technique, and the possibility of optimizing treatment postoperatively. Currently, deep brain stimulation in psychiatry is investigated for obsessive-compulsive disorder, Gilles de la Tourette's syndrome, and major depression. This chapter reviews the application of deep brain stimulation in obsessive-compulsive disorder. Preliminary results suggest that deep brain stimulation in obsessive-compulsive disorder can effectuate a decrease of 40-60% in at least half of the patients. Although various side effects occur, most of these are transitory and linked to specific stimulation parameters which can be changed. Because only a few studies have been performed with a limited number of patients in accordance with varying research protocols, appliance of deep brain stimulation to obsessive-compulsive disorder is still at an experimental stage. The speed of the effect of deep brain stimulation causes fundamental assumptions on the pathophysiology of obsessive-compulsive disorder.
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Affiliation(s)
- Damiaan Denys
- Department of Psychiatry, AMC, Netherlands Institute for Neuroscience, Amsterdam, The Netherlands.
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432
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Schläpfer TE, Bewernick BH. Deep brain stimulation for psychiatric disorders--state of the art. Adv Tech Stand Neurosurg 2009; 34:37-57. [PMID: 19368080 DOI: 10.1007/978-3-211-78741-0_2] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
A substantial number of patients suffering from severe neuropsychiatric disorders do not respond to conventional therapeutic approaches. Results from functional neuroimaging research and the development of neuromodulatory treatments lead to novel putative strategies. Recently, one of those methods, deep brain stimulation (DBS) has been applied in selected patient with major depression and obsessive-compulsive disorder (OCD) and major depression. We summarize in this review, the state of art of knowledge about the neurobiology of depression and OCD and historical treatment methods. Principles of DBS and reasons for the use of DBS in neuropsychiatry are discussed. Different targets have been chosen in a hypothesis-guided way and first results have demonstrated that DBS might be able to modulate dysfunctional neural networks in both major depression and OCD. Although DBS is a unique and promising method for otherwise treatment resistant psychiatric patients, mandatory treatment standards have to be applied for patient and target selection. Therefore, a distinct focus of this review lies on ethical aspects for DBS in neuropsychiatric disorders.
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Affiliation(s)
- T E Schläpfer
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Germany
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433
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Mathew S, Charney D. Anxiety and depression: leading edge of therapy. ACTA ACUST UNITED AC 2008; 75:171-3. [PMID: 18704975 DOI: 10.1002/msj.20049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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434
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Dumitriu D, Collins K, Alterman R, Mathew SJ. Neurostimulatory therapeutics in management of treatment-resistant depression with focus on deep brain stimulation. ACTA ACUST UNITED AC 2008; 75:263-75. [PMID: 18704979 DOI: 10.1002/msj.20044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Treatment-resistant depression continues to pose a major medical challenge, as up to one-third of patients with major depressive disorder fail to have an adequate response to standard pharmacotherapies. An improved understanding of the complex circuitry underlying depressive disorders has fostered an explosion in the development of new, nonpharmacological approaches. Each of these treatments seeks to restore normal brain activity via electrical or magnetic stimulation. In this article, the authors discuss the ongoing evolution of neurostimulatory treatments for treatment-resistant depression, reviewing the methods, efficacy, and current research on electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, focal electrically administered stimulated seizure therapy, transcranial direct current stimulation, chronic epidural cortical stimulation, and vagus nerve stimulation. Special attention is given to deep brain stimulation, the most focally targeted approach. The history, purported mechanisms of action, and current research are outlined in detail. Although deep brain stimulation is the most invasive of the neurostimulatory treatments developed to date, it may hold significant promise in alleviating symptoms and improving the quality of life for patients with the most severe and disabling mood disorders.
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Affiliation(s)
- Dani Dumitriu
- Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, USA.
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435
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Synofzik M, Schlaepfer TE. Stimulating personality: Ethical criteria for deep brain stimulation in psychiatric patients and for enhancement purposes. Biotechnol J 2008; 3:1511-20. [DOI: 10.1002/biot.200800187] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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436
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Sustained improvement of obsessive-compulsive disorder by deep brain stimulation in a woman with residual schizophrenia. Int J Neuropsychopharmacol 2008; 11:1181-3. [PMID: 18700054 DOI: 10.1017/s1461145708009188] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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437
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Abstract
Most depressed patients fail to achieve remission despite adequate antidepressant monotherapy, and a substantial minority show minimal improvement despite optimal and aggressive therapy. However, major advances have taken place in elucidating the neurobiology of depression, and several novel targets for antidepressant therapy have emerged. Three primary approaches are currently being taken: 1) optimizing the pharmacologic modulation of monoaminergic neurotransmission, 2) developing medications that target neurotransmitter systems other than the monoamines, and 3) directly modulating neuronal activity via focal brain stimulation. We review novel therapeutic targets for developing improved antidepressant therapies, including triple monoamine reuptake inhibitors, atypical antipsychotic augmentation, dopamine receptor agonists, corticotropin-releasing factor-1 receptor antagonists, glucocorticoid receptor antagonists, substance P receptor antagonists, N-methyl-D-aspartate receptor antagonists, nemifitide, omega-3 fatty acids, and melatonin receptor agonists. Developments in therapeutic focal brain stimulation include vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, transcranial direct current stimulation, and deep brain stimulation.
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Affiliation(s)
- Paul E Holtzheimer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 101 Woodruff Circle Northeast, Suite 4000, Atlanta, GA 30322, USA.
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438
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Mallet L, Polosan M, Jaafari N, Baup N, Welter ML, Fontaine D, du Montcel ST, Yelnik J, Chéreau I, Arbus C, Raoul S, Aouizerate B, Damier P, Chabardès S, Czernecki V, Ardouin C, Krebs MO, Bardinet E, Chaynes P, Burbaud P, Cornu P, Derost P, Bougerol T, Bataille B, Mattei V, Dormont D, Devaux B, Vérin M, Houeto JL, Pollak P, Benabid AL, Agid Y, Krack P, Millet B, Pelissolo A. Subthalamic nucleus stimulation in severe obsessive-compulsive disorder. N Engl J Med 2008; 359:2121-34. [PMID: 19005196 DOI: 10.1056/nejmoa0708514] [Citation(s) in RCA: 606] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Severe, refractory obsessive-compulsive disorder (OCD) is a disabling condition. Stimulation of the subthalamic nucleus, a procedure that is already validated for the treatment of movement disorders, has been proposed as a therapeutic option. METHODS In this 10-month, crossover, double-blind, multicenter study assessing the efficacy and safety of stimulation of the subthalamic nucleus, we randomly assigned eight patients with highly refractory OCD to undergo active stimulation of the subthalamic nucleus followed by sham stimulation and eight to undergo sham stimulation followed by active stimulation. The primary outcome measure was the severity of OCD, as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), at the end of two 3-month periods. General psychopathologic findings, functioning, and tolerance were assessed with the use of standardized psychiatric scales, the Global Assessment of Functioning (GAF) scale, and neuropsychological tests. RESULTS After active stimulation of the subthalamic nucleus, the Y-BOCS score (on a scale from 0 to 40, with lower scores indicating less severe symptoms) was significantly lower than the score after sham stimulation (mean [+/-SD], 19+/-8 vs. 28+/-7; P=0.01), and the GAF score (on a scale from 1 to 90, with higher scores indicating higher levels of functioning) was significantly higher (56+/-14 vs. 43+/-8, P=0.005). The ratings of neuropsychological measures, depression, and anxiety were not modified by stimulation. There were 15 serious adverse events overall, including 1 intracerebral hemorrhage and 2 infections; there were also 23 nonserious adverse events. CONCLUSIONS These preliminary findings suggest that stimulation of the subthalamic nucleus may reduce the symptoms of severe forms of OCD but is associated with a substantial risk of serious adverse events. (ClinicalTrials.gov number, NCT00169377.)
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Affiliation(s)
- Luc Mallet
- The authors' affiliations are listed in the Appendix
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439
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A case-based review of troubleshooting deep brain stimulator issues in movement and neuropsychiatric disorders. Parkinsonism Relat Disord 2008; 14:532-8. [DOI: 10.1016/j.parkreldis.2008.01.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 12/28/2007] [Accepted: 01/06/2008] [Indexed: 11/20/2022]
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440
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Klavir O, Flash S, Winter C, Joel D. High frequency stimulation and pharmacological inactivation of the subthalamic nucleus reduces 'compulsive' lever-pressing in rats. Exp Neurol 2008; 215:101-9. [PMID: 18951894 DOI: 10.1016/j.expneurol.2008.09.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 09/15/2008] [Accepted: 09/17/2008] [Indexed: 01/02/2023]
Abstract
In recent years there have been several attempts to establish high frequency stimulation (HFS) as an additional treatment strategy for obsessive-compulsive disorder (OCD). Two studies reported that bilateral HFS of the subthalamic nucleus (STN) dramatically alleviated compulsions and improved obsessions in three patients with co-morbid Parkinson's disease and OCD. A recent study reported that HFS as well as pharmacological inactivation of the STN alleviate compulsive checking in the quinpirole rat model of OCD. As the quinpirole model is based on a dopaminergic manipulation, the aim of the present study was to test whether HFS and pharmacological inactivation of the STN exert an anti-compulsive effect also in the drug-naive brain, using the signal attenuation rat model of OCD. The main finding of the present study is that both HFS and pharmacological inactivation of the STN exerted an anti-compulsive effect, although the two manipulations differed in their effects on other behavioral measures. These findings support the possibility that HFS of the STN may provide an additional therapeutic strategy for OCD.
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Affiliation(s)
- Oded Klavir
- Department of Psychology, Tel Aviv University, Ramat-Aviv, Tel Aviv 69978, Israel
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441
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Rezai AR, Machado AG, Deogaonkar M, Azmi H, Kubu C, Boulis NM. Surgery for movement disorders. Neurosurgery 2008; 62 Suppl 2:809-38; discussion 838-9. [PMID: 18596424 DOI: 10.1227/01.neu.0000316285.52865.53] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Movement disorders, such as Parkinson's disease, tremor, and dystonia, are among the most common neurological conditions and affect millions of patients. Although medications are the mainstay of therapy for movement disorders, neurosurgery has played an important role in their management for the past 50 years. Surgery is now a viable and safe option for patients with medically intractable Parkinson's disease, essential tremor, and dystonia. In this article, we provide a review of the history, neurocircuitry, indication, technical aspects, outcomes, complications, and emerging neurosurgical approaches for the treatment of movement disorders.
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Affiliation(s)
- Ali R Rezai
- Center for Neurological Restoration, and Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio 44122, USA.
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442
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Halpern CH, Wolf JA, Bale TL, Stunkard AJ, Danish SF, Grossman M, Jaggi JL, Grady MS, Baltuch GH. Deep brain stimulation in the treatment of obesity. J Neurosurg 2008; 109:625-34. [DOI: 10.3171/jns/2008/109/10/0625] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Obesity is a growing global health problem frequently intractable to current treatment options. Recent evidence suggests that deep brain stimulation (DBS) may be effective and safe in the management of various, refractory neuropsychiatric disorders, including obesity. The authors review the literature implicating various neural regions in the pathophysiology of obesity, as well as the evidence supporting these regions as targets for DBS, in order to explore the therapeutic promise of DBS in obesity.
The lateral hypothalamus and ventromedial hypothalamus are the appetite and satiety centers in the brain, respectively. Substantial data support targeting these regions with DBS for the purpose of appetite suppression and weight loss. However, reward sensation associated with highly caloric food has been implicated in overconsumption as well as obesity, and may in part explain the failure rates of conservative management and bariatric surgery. Thus, regions of the brain's reward circuitry, such as the nucleus accumbens, are promising alternatives for DBS in obesity control.
The authors conclude that deep brain stimulation should be strongly considered as a promising therapeutic option for patients suffering from refractory obesity.
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Affiliation(s)
| | | | | | - Albert J. Stunkard
- 3Psychiatry, and
- 5Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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443
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High-frequency stimulation of the anterior subthalamic nucleus reduces stereotyped behaviors in primates. J Neurosci 2008; 28:8785-8. [PMID: 18753380 DOI: 10.1523/jneurosci.2384-08.2008] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Growing evidence shows that dysfunction of the limbic basal ganglia (BG) network is implicated in repetitive behaviors, such as obsessive compulsive disorder (OCD) and Tourette's syndrome (TS), in humans. Because deep brain stimulation (DBS) of the posterior subthalamic nucleus (STN), which modulates the sensorimotor BG network, is beneficial in movement disorders, stimulation of the anterior, limbic STN might improve intractable behavioral disorders. We therefore evaluated the effect of anterior STN stimulation on the repetitive behaviors induced in two monkeys after bicuculline-induced dysfunction of the limbic external globus pallidus. DBS in the anterior STN dramatically reduced the stereotypies, but had no effect on the performance of a simple food retrieval task. Stimulations outside the STN were less effective in reducing the stereotypies. Electrode trajectories, reconstructed postmortem, confirmed that the effective contacts were in the anterior STN. DBS in the limbic STN might therefore provide relief from the severe stereotyped behaviors observed in OCD and TS.
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Abstract
An estimated 20% of patients with major depression are refractory to existing therapies. The purpose of this review is to provide a theoretical and neuroscientific framework in which to interpret new work in the field of surgical treatment for depression. This review focuses on existing clinical and imaging data, current disease models, and results of recent case reports and patient series that together may inform the construction of appropriate clinical trials for the surgical treatment of refractory depression.
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Affiliation(s)
- Aviva Abosch
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
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445
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Elias WJ, Ray DK, Jane JA. Lennart Heimer: concepts of the ventral striatum and extended amygdala. Neurosurg Focus 2008; 25:E8. [DOI: 10.3171/foc/2008/25/7/e8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dr. Lennart Heimer, the famous neuroanatomist of Swedish descent, died last year but left a legacy that will impact the neurosciences and potentially psychosurgery for years to come. He developed an anatomical technique for demonstrating the terminal boutons that helped to delineate basal forebrain anatomy. During these studies, he realized the relationship of basal forebrain structures to the limbic system, thus initiating the concept of the ventral striatum and parallel basal ganglia circuitry.
Heimer excelled as a teacher as well and honed his brain dissection technique to one of the most effective tools for understanding neuroanatomy. His legendary sessions with neurosurgical residents resulted in his recognition as one of the world’s leading fiber tract dissectors. His gentle, engaging manner has been documented in several media formats.
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446
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Wind JJ, Anderson DE. From prefrontal leukotomy to deep brain stimulation: the historical transformation of psychosurgery and the emergence of neuroethics. Neurosurg Focus 2008; 25:E10. [DOI: 10.3171/foc/2008/25/7/e10] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The history of psychosurgery is described and analyzed. This historical perspective largely begins with analysis of the work of Egas Moniz in the development of the leukotomy, and follows the rise and fall of its popularity in the 1900s. The reemergence of psychosurgical procedures and the development of new therapeutic technologies such as vagus nerve stimulation and deep brain stimulation are discussed. In addition, an introduction to the field of neuroethics is provided, given its importance in any discussion about surgical therapy for psychiatric patients.
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Affiliation(s)
| | - Douglas E. Anderson
- 1Department of Neurosurgery, The George Washington University School of Medicine, Washington, DC and
- 2Department of Neurosurgery, Loyola University Medical Center, Maywood, Illinois
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447
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Stelten BML, Noblesse LHM, Ackermans L, Temel Y, Visser-Vandewalle V. The neurosurgical treatment of addiction. Neurosurg Focus 2008; 25:E5. [DOI: 10.3171/foc/2008/25/7/e5] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Addiction or substance dependence is a psychiatric disorder that affects many individuals in the general population. Different theories concerning the neurobiological aspects of addiction have been proposed. Special attention has been paid to models concerning dysregulation of the reward circuit and the inhibitory control system within the cortico-basal ganglia-thalamocortical pathways. In the past, attempts have been made to treat patients suffering from addiction by performing psychosurgery. Lesions were created in specific brain regions that were believed to be dysfunctional in addiction. Procedures such as cingulotomy, hypothalamotomy, and resection of the substantia innominata and the nucleus accumbens have been described as a treatment for severe addictive disorders. Deep brain stimulation, a neurosurgical treatment that has been proven to be a safe alternative for lesions in the treatment of movement disorders, has more recently been proposed as treatments for severe psychiatric conditions such as treatment-refractory obsessive-compulsive disorder and depression. With the expanding knowledge of the neurobiology of addiction, deep brain stimulation could be a future option in the treatment arsenal of addiction.
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Affiliation(s)
| | | | | | - Yasin Temel
- 1Maastricht Institute for Neuromodulative Development and
| | - Veerle Visser-Vandewalle
- 1Maastricht Institute for Neuromodulative Development and
- 2School for Mental Health and Neuroscience, Maastricht University and Medical Centre, Maastricht, The Netherlands
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448
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Elder JB, Hoh DJ, Oh BC, Heller AC, Liu CY, Apuzzo ML. THE FUTURE OF CEREBRAL SURGERY. Neurosurgery 2008; 62:1555-79; discussion 1579-82. [DOI: 10.1227/01.neu.0000333820.33143.0d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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449
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450
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Berlin HA, Hamilton H, Hollander E. Experimental therapeutics for refractory obsessive-compulsive disorder: translational approaches and new somatic developments. ACTA ACUST UNITED AC 2008; 75:174-203. [DOI: 10.1002/msj.20045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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