Psychosurgery: past, present, and future

NeuroDots: From Single-Target to Brain-Network Modulation: Why and What Is Needed?

OBJECTIVES

Current techniques in brain stimulation are still largely based on a phrenologic approach that a single brain target can treat a brain disorder. Nevertheless, meta-analyses of brain implants indicate an overall success rate of 50% improvement in 50% of patients, irrespective of the brain-related disorder. Thus, there is still a large margin for improvement. The goal of this manuscript is to 1) develop a general theoretical framework of brain functioning that is amenable to surgical neuromodulation, and 2) describe the engineering requirements of the next generation of implantable brain stimulators that follow from this theoretic model.

MATERIALS AND METHODS

A neuroscience and engineering literature review was performed to develop a universal theoretical model of brain functioning and dysfunctioning amenable to surgical neuromodulation.

RESULTS

Even though a single target can modulate an entire network, research in network science reveals that many brain disorders are the consequence of maladaptive interactions among multiple networks rather than a single network. Consequently, targeting the main connector hubs of those multiple interacting networks involved in a brain disorder is theoretically more beneficial. We, thus, envision next-generation network implants that will rely on distributed, multisite neuromodulation targeting correlated and anticorrelated interacting brain networks, juxtaposing alternative implant configurations, and finally providing solid recommendations for the realization of such implants. In doing so, this study pinpoints the potential shortcomings of other similar efforts in the field, which somehow fall short of the requirements.

CONCLUSION

The concept of network stimulation holds great promise as a universal approach for treating neurologic and psychiatric disorders.

Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases

BACKGROUND

Ablative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC.

METHOD

Presurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3).

FINDINGS

Both patients were responders with neither experiencing significant side effects including compromised executive functions.

LIMITATIONS

The generalizability of our findings is limited because the outcome is based on two subjects.

CONCLUSION

This work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC's use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.

Stereotactic neurosurgery as a symptomatic treatment for autism spectrum disorders: A systematic review

Stereotactic neurosurgery has been employed in autism spectrum disorders (ASD). However, its safety and effectiveness remain unclear owing to limited sample size and other methodological limitations. We aimed to systematically investigate the safety and efficacy of stereotactic neurosurgery for ASD. Eleven studies with 36 patients were included. Stereotactic neurosurgery alleviated the obsessive-compulsive disorder and aggressive behavior symptoms in ASD, with a mean improvement of 42.74% and 59.59% in the Yale-Brown Obsessive Compulsive Scale and Overt Aggression Scale scores, respectively. Systematic studies are necessary to explore the role of deep brain stimulation for social and communication difficulties in ASD.

[Contemporary methods of non-drug therapy for depression]

The review presents information on the most effective current non-drug methods of treatment of depression used in practice. A review of publications in PubMed and PsycINFO and Cochrane Library over the past 10 years was conducted. Non-drug biological therapies demonstrate high efficacy in the reduction of depressive symptoms in patients with recurrent depressive disorder. The use of non-drug therapy does not preclude the continuation of pharmacological therapy. In order to choose an optimal method of treatment, the psychophysical state of a patient, severity of depressive symptoms, response to drug therapy, and possibility of prescribing pharmacological therapy should be taken into account, and the principles of evidence-based medicine should be taken into consideration when making a decision.

Regional Difference in Myelination in Monocarboxylate Transporter 8 Deficiency: Case Reports and Literature Review of Cases in Japan

Background: Monocarboxylate transporter 8 (MCT8) is a thyroid hormone transmembrane transporter protein. MCT8 deficiency induces severe X-linked psychomotor retardation. Previous reports have documented delayed myelination in the central white matter (WM) in these patients; however, the regional pattern of myelination has not been fully elucidated. Here, we describe the regional evaluation of myelination in four patients with MCT8 deficiency. We also reviewed the myelination status of previously reported Japanese patients with MCT8 deficiency based on magnetic resonance imaging (MRI).

Case Reports: Four patients were genetically diagnosed with MCT8 deficiency at the age of 4–9 months. In infancy, MRI signal of myelination was observed mainly in the cerebellar WM, posterior limb of internal capsule, and the optic radiation. There was progression of myelination with increase in age.

Discussion: We identified 36 patients with MCT8 deficiency from 25 families reported from Japan. The available MRI images were obtained at the age of <2 years in 13 patients, between 2 and 4 years in six patients, between 4 and 6 years in three patients, and at ≥6 years in eight patients. Cerebellar WM, posterior limb of internal capsule, and optic radiation showed MRI signal of myelination by the age of 2 years, followed by centrum semiovale and corpus callosum by the age of 4 years. Most regions except for deep anterior WM showed MRI signal of myelination at the age of 6 years.

Conclusion: The sequential pattern of myelination in patients with MCT8 deficiency was largely similar to that in normal children; however, delayed myelination of the deep anterior WM was a remarkable finding. Further studies are required to characterize the imaging features of patients with MCT8 deficiency.

Magnetic Resonance-Guided Focused Ultrasound Surgery for Obsessive-Compulsive Disorders: Potential for use as a Novel Ablative Surgical Technique

Surgical treatment for psychiatric disorders, such as obsessive-compulsive disorder (OCD) and depression, using ablative techniques, such as cingulotomy and capsulotomy, have historically been controversial for a number of scientific, social, and ethical reasons. Recently, with the elucidation of anatomical and neurochemical substrates of brain function in healthy controls and patients with such disorders using various functional neuroimaging techniques, these criticisms are becoming less valid. Furthermore, by using new techniques, such as deep brain stimulation (DBS), and identifying more precise targets, beneficial effects and the lack of serious complications have been demonstrated in patients with psychiatric disorders. However, DBS also has many disadvantages. Currently, magnetic resonance-guided focused ultrasound surgery (MRgFUS) is used as a minimal-invasive surgical method for generating precisely placed focal thermal lesions in the brain. Here, we review surgical techniques and their potential complications, along with anterior limb of the internal capsule (ALIC) capsulotomy by radiofrequency lesioning and gamma knife radiosurgery, for the treatment of OCD and depression. We also discuss the limitations and technical issues related to ALIC capsulotomy with MRgFUS for medically refractory OCD and depression. Through this review we hope MRgFUS could be considered as a new treatment choice for refractory OCD.

Dissociable Frontostriatal Connectivity: Mechanism and Predictor of the Clinical Efficacy of Capsulotomy in Obsessive-Compulsive Disorder

BACKGROUND

Little is known about the neural mechanism and response variability underlying neurosurgical interventions for intractable obsessive-compulsive disorder (OCD).

METHODS

Of 81 OCD patients screened for capsulotomy identified in our institutional database, 36 patients with clinical assessment before and after capsulotomy and imaging data (9 of 36 patients without postoperative imaging data used as an independent test group), and 29 healthy control subjects were retrospectively recruited. Twenty of 36 patients (56%) responded to the lesion procedure (determined as a ≥35% reduction in Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score). Seed-based (i.e., ventral and dorsal caudate, medial dorsal thalamus, and ventral and dorsal putamen) resting-state functional connectivity was used to examine alterations in frontostriatal circuitry after capsulotomy.

RESULTS

The Y-BOCS score significantly decreased (p < .001) after capsulotomy in OCD patients. Functional connectivity between the ventral striatum/nucleus accumbens and the dorsal anterior cingulate cortex was reduced (p < .05, corrected) after the surgical procedure. Moreover, change in connectivity significantly correlated with alteration in Y-BOCS score (r = .41, p = .033). In addition, preoperative connectivity between the dorsal caudate and the dorsal anterior cingulate cortex could differentiate nonresponders from responders and predict changes in Y-BOCS score (R² = .23, F_1,25 = 7.56, p = .011), which was generalized in an independent test group.

CONCLUSIONS

We demonstrated that restoration of ventral frontostriatal connectivity was associated with clinical improvement in refractory OCD, suggesting a therapeutic mechanism of capsulotomy. Moreover, preoperative variations in dorsal frontostriatal connectivity predicted clinical response, which may offer a predictor of treatment outcome.

Should DBS for Psychiatric Disorders be Considered a Form of Psychosurgery? Ethical and Legal Considerations

Deep brain stimulation (DBS), a surgical procedure involving the implantation of electrodes in the brain, has rekindled the medical community's interest in psychosurgery. Whereas many researchers argue DBS is substantially different from psychosurgery, we argue psychiatric DBS-though a much more precise and refined treatment than its predecessors-is nevertheless a form of psychosurgery, which raises both old and new ethical and legal concerns that have not been given proper attention. Learning from the ethical and regulatory failures of older forms of psychosurgery can help shed light on how to address the regulatory gaps that exist currently in DBS research. To show why it is important to address the current regulatory gaps within psychiatric DBS, we draw on the motivations underlying the regulation of earlier forms of psychosurgery in the US. We begin by providing a brief history of psychosurgery and electrical brain stimulation in the US. Against this backdrop, we introduce psychiatric DBS, exploring current research and ongoing clinical trials. We then draw out the ethical and regulatory similarities between earlier forms of psychosurgery and psychiatric DBS. As we will show, the factors that motivated strict regulation of earlier psychosurgical procedures mirror concerns with psychiatric DBS today. We offer three recommendations for psychiatric DBS regulation, which echo earlier motivations for regulating psychosurgery, along with new considerations that reflect the novel technologies used in DBS.

'A matter for conjecture': leucotomy in Western Australia, 1947-70

Very little has been published on the rise and fall of psychosurgery in Australia. In the mid-twentieth century, Western Australia was the largest but most sparsely-populated of the six Australian States, and its local psychiatry practice was, as one commentator put it, 'backward'. Nonetheless, electroconvulsive therapy was introduced in 1945, and leucotomy in 1947. This paper will explore the introduction of leucotomy to Western Australia in the context of wider national and international trends in psychiatry, and posit some reasons for its decline and abandonment in the 1970s. It will present a narrative reconstruction of the local introduction and practice of leucotomy, using retrieved, reconstructed and previously unpublished data.

Controversial treatments in psychiatry

Psychiatry uses some of the most controversial treatments in medicine. This may be partly because several are administered under coercion and opposed to the patient's expressed will, under the protection of the relevant mental health legislation. Electroconvulsive therapy (ECT) is perhaps the archetypal controversial treatment; although it is considered to be effective, the research supporting it is much less impressive than one would expect. The prescription of stimulant drugs for childhood attention-deficit hyperactivity disorder (ADHD) and substitution therapy (such as methadone maintenance) in addictions treatment remain topical and appear to be subject to political interference. ‘Treatment’ for homosexuality and psychosurgery were common in the past but are now rare. These issues are discussed to give insight into how once common controversial treatments can decline and become obsolete. However, seclusion and covert medication remain in practice and are highly scrutinised.

Learning Objectives

• Recognise that many controversial treatments, such as psychosurgery, have been superseded by psychotropic drugs used since the 1950s

• Be aware of the limitations of evidence supporting controversial treatments, such as stimulants for childhood ADHD and ECT for depression in adults

• Be aware that controversial treatments are highly emotive and may be viewed negatively by the public or politicians, despite evidence for their safety and effectiveness

Topectomy versus leukotomy: J. Lawrence Pool's contribution to psychosurgery

Surgery of the mind has a rather checkered past. Though its history begins with the prehistoric trephination of skulls to allow "evil spirits" to escape, the early- to mid-20th century saw a surge in the popularity of psychosurgery. The 2 prevailing operations were topectomy and leukotomy for the treatment of certain mental illnesses. Although they were modified and refined by several of their main practitioners, the effectiveness of and the ethics involved with these operations remained controversial. In 1947, Dr. J. Lawrence Pool and the Columbia-Greystone Associates sought to rigorously investigate the outcomes of specific psychosurgical procedures. Pool along with R. G. Heath and John Weber believed that nonexcessive bifrontal cortical ablation could successfully treat certain mental illnesses without the undesired consequences of irreversible personality changes. They conducted this investigation at the psychiatric hospital at Greystone Park near Morristown, New Jersey. Despite several encouraging findings of the Columbia-Greystone project, psychosurgery practices began to decline significantly in the 1950s. The uncertainty of results and ethical debates related to side effects made these procedures unpopular. Further, groups such as the National Association for the Advancement of Colored People and the American Civil Liberties Union condemned the use of psychosurgery, believing it to be an inhumane form of treatment. Today, there are strict guidelines that must be adhered to when evaluating a patient for psychosurgery procedures. It is imperative for the neurosurgery community to remember the history of psychosurgery to provide the best possible current treatment and to search for better future treatments for a particularly vulnerable patient population.

Hippocampal - diencephalic - cingulate networks for memory and emotion: An anatomical guide

This review brings together current knowledge from tract tracing studies to update and reconsider those limbic connections initially highlighted by Papez (1937) for their presumed role in emotion. These connections link hippocampal and parahippocampal regions with the mammillary bodies, the anterior thalamic nuclei, and the cingulate gyrus, all structures now strongly implicated in memory functions. An additional goal of this review is to describe the routes taken by the various connections within this network. The original descriptions of these limbic connections saw their interconnecting pathways forming a serial circuit that began and finished in the hippocampal formation. It is now clear that, with the exception of the mammillary bodies, these various sites are multiply interconnected with each other, including many reciprocal connections. In addition, these same connections are topographically organised, creating further subsystems. This complex pattern of connectivity helps to explain the difficulty of interpreting the functional outcome of damage to any individual site within the network. For these same reasons, Papez' initial concept of a loop beginning and ending in the hippocampal formation needs to be seen as a much more complex system of hippocampal-diencephalic-cingulate connections. The functions of these multiple interactions might be better viewed as principally providing efferent information from the posterior medial temporal lobe. Both a subcortical diencephalic route (via the fornix) and a cortical cingulate route (via retrosplenial cortex) can be distinguished. These routes provide indirect pathways for hippocampal interactions with prefrontal cortex, with the preponderance of both sets of connections arising from the more posterior hippocampal regions. These multi-stage connections complement the direct hippocampal projections to prefrontal cortex, which principally arise from the anterior hippocampus, thereby creating longitudinal functional differences along the anterior-posterior plane of the hippocampus.

Against Strong Ethical Parity: Situated Cognition Theses and Transcranial Brain Stimulation

According to a prominent suggestion in the ethics of transcranial neurostimulation the effects of such devices can be treated as ethically on par with established, pre-neurotechnological alterations of the mind. This parity allegedly is supported by situated cognition theories showing how external devices can be part of a cognitive system. This article will evaluate this suggestion. It will reject the claim, that situated cognition theories support ethical parity. It will however point out another reason, why external carriers or modifications of the mental might come to be considered ethically on par with internal carriers. Section “Why Could There Be Ethical Parity between Neural Tissue and External Tools?” presents the ethical parity theses between external and internal carriers of the mind as well as neurotechnological alterations and established alterations. Section “Extended, Embodied, Embedded: Situated Cognition as a Relational Thesis” will elaborate the different situated cognition approaches and their relevance for ethics. It will evaluate, whether transcranial stimulation technologies are plausible candidates for situated cognition theses. Section “On the Ethical Relevance of Situated Cognition Theses” will discuss criteria for evaluating whether a cognitive tool is deeply embedded with a cognitive system and apply these criteria to transcranial brain stimulation technologies. Finally it will discuss the role diverse versions of situated cognition theory can play in the ethics of altering mental states, especially the ethics of transcranial brain stimulation technologies.

Ethics, Science and Mind Control: J. M. Rodríguez-Delgado’s Legacy

This work analyses the evolution of the scientific visibility of the neurophysiologist José Manuel Rodríguez Delgado. It examines the longitudinal evolution from 1955 to 2013 of an article (Delgado, Roberts, & Miller, 1954) studying the neurological basis of learning and motivation and compares it with a coetaneous article (Olds & Milner, 1954) with a similar subject and methodology. Both studies have been essential in Psychology. This work analyses the number of times each article has been cited between 1955–1984 and 1985–2013. The results show that the visibility of James Olds and Peter Milner’s article (expressed in number of citations between 1955–1984 and 1985–2013) has longitudinally increased (p < .001), whereas the number of citations received by José Manuel Rodríguez Delgado et al.’s article has significantly reduced (p < .001). The results are discussed and the low visibility of Delgado’s article is explained through historical and social factors, including the growing concern about compliance with bioethical and research guidelines and the controversial media projection of the Spanish scientist, not by the intrinsic value or the scientific repercussion of the compared articles.

Multi-tensor investigation of orbitofrontal cortex tracts affected in subcaudate tractotomy

Subcaudate tractotomy (SCT) is a neurosurgical lesioning procedure that can reduce symptoms in medically intractable obsessive compulsive disorder (OCD). Due to the putative importance of the orbitofrontal cortex (OFC) in symptomatology, fibers that connect the OFC, SCT lesion, and either the thalamus or brainstem were investigated with two-tensor tractography using an unscented Kalman filter approach. From this dataset, fibers were warped to Montreal Neurological Institute space, and probability maps with center-of-mass analysis were subsequently generated. In comparing fibers from the same OFC region, including medial OFC (mOFC), central OFC (cOFC), and lateral OFC (lOFC), the area of divergence for fibers connected with the thalamus versus the brainstem is posterior to the anterior commissure. At the anterior commissure, fibers connected with the thalamus run dorsal to those connected with the brainstem. As OFC fibers travel through the ventral aspect of the internal capsule, lOFC fibers are dorsal to cOFC and mOFC fibers. Using neuroanatomical comparison, tracts coursing between the OFC and thalamus are likely part of the anterior thalamic radiations, while those between the OFC and brainstem likely belong to the medial forebrain bundle. These data support the involvement of the OFC in OCD and may be relevant to creating differential lesional procedures of specific tracts or to developing deep brain stimulation programming paradigms.

Dorsal anterior cingulotomy and anterior capsulotomy for severe, refractory obsessive-compulsive disorder: a systematic review of observational studies

OBJECT

The object of this study was to perform a systematic review, according to Preferred Reporting Items of Systematic reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality (AHRQ) guidelines, of the clinical efficacy and adverse effect profile of dorsal anterior cingulotomy compared with anterior capsulotomy for the treatment of severe, refractory obsessive-compulsive disorder (OCD).

METHODS

The authors included studies comparing objective clinical measures before and after cingulotomy or capsulotomy (surgical and radiosurgical) in patients with OCD. Only papers reporting the most current follow-up data for each group of investigators were included. Studies reporting results on patients undergoing one or more procedures other than cingulotomy or capsulotomy were excluded. Case reports and studies with a mean follow-up shorter than 12 months were excluded. Clinical response was defined in terms of a change in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. The authors searched MEDLINE, PubMed, PsycINFO, Scopus, and Web of Knowledge through October 2013. English and non-English articles and abstracts were reviewed.

RESULTS

Ten studies involving 193 participants evaluated the length of follow-up, change in the Y-BOCS score, and postoperative adverse events (AEs) after cingulotomy (n = 2 studies, n = 81 participants) or capsulotomy (n = 8 studies, n = 112 participants). The average time to the last follow-up was 47 months for cingulotomy and 60 months for capsulotomy. The mean reduction in the Y-BOCS score at 12 months’ follow-up was 37% for cingulotomy and 55% for capsulotomy. At the last follow-up, the mean reduction in Y-BOCS score was 37% for cingulotomy and 57% for capsulotomy. The average full response rate to cingulotomy at the last follow-up was 41% (range 38%–47%, n = 2 studies, n = 51 participants), and to capsulotomy was 54% (range 37%–80%, n = 5 studies, n = 50 participants). The rate of transient AEs was 14.3% across cingulotomy studies (n = 116 procedures) and 56.2% across capsulotomy studies (n = 112 procedures). The rate of serious or permanent AEs was 5.2% across cingulotomy studies and 21.4% across capsulotomy studies.

CONCLUSIONS

This systematic review of the literature supports the efficacy of both dorsal anterior cingulotomy and anterior capsulotomy in this highly treatment-refractory population. The observational nature of available data limits the ability to directly compare these procedures. Controlled or head-to-head studies are necessary to identify differences in efficacy or AEs and may lead to the individualization of treatment recommendations.

Ablative Limbic System Surgery: Review and Future Directions

The limbic system is a network of interconnected brain regions regulating emotion, memory, and behavior. Pathology of the limbic system can manifest as psychiatric disease, including obsessive-compulsive disorder and major depressive disorder. For patients with these disorders who have not responded to standard pharmacological and cognitive behavioral therapy, ablative surgery is a neurosurgical treatment option. The major ablative limbic system procedures currently used are anterior capsulotomy, dorsal anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy. In this review, we include a brief history of ablative limbic system surgery leading up to its current form. Mechanistic justification for these procedures is considered in a discussion of the pathophysiology of psychiatric disease. We then discuss therapeutic efficacy as demonstrated by recent trials. Finally, we consider future directions, including the search for predictors of treatment response, the development of more precise targeting methods, and the use of advances in neuroimaging to track treatment response.

Deep brain stimulation for psychiatric disorders: where we are now

Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned.

Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry.

This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.

Deep brain stimulation for the treatment of severe, medically refractory obsessive-compulsive disorder

Deep brain stimulation is a rapidly expanding therapy initially designed for the treatment of movement disorders and pain syndromes. The therapy includes implantation of electrodes in specific targets of the brain, delivering programmable small and safe electric impulses, like a pacemaker, that modulates both local and broad neurologic networks. The effects are thought to primarily involve a focus in the brain, probably inhibitory, which then restores a network of neural circuitry. Psychiatric diseases can be refractory and severe, leading to high medical costs, significant morbidity, and even death. Whereas surgery for psychiatric disease used to include destructive procedures, deep brain stimulation allows safe, reversible, and adjustable treatment that can be tailored for each patient. Deep brain stimulation offers new hope for these unfortunate patients, and the preliminary results are promising.

Lesion analysis for cingulotomy and limbic leucotomy: comparison and correlation with clinical outcomes

OBJECT

Cingulotomy and limbic leucotomy are lesioning surgeries with demonstrated benefit for medically intractable psychiatric illnesses. They represent significant refinements of the prefrontal lobotomy used from the 1930s through the 1950s. However, the associations between anatomical characterization of these lesions and outcome data are not well understood. To elucidate these procedures and associations, the authors sought to define and compare the neuroanatomy of cingulotomy and limbic leucotomy and to test a method that uses neuroanatomical data and voxel-based lesion-symptom mapping (VLSM) to reveal potential refinements to modern psychiatric neurosurgical procedures.

METHODS

T1-weighted MR images of patients who had undergone cingulotomy and limbic leucotomy were segmented and registered onto the Montreal Neurological Institute T1-weighted template brain MNI152. Using an atlas-based approach, the authors calculated, by case, the percentage of each anatomical structure affected by the lesion. Because of the infrequency of modern lesion procedures and the requirement for higher-resolution clinical imaging, the sample size was small. The pilot study correlated cingulotomy and limbic leucotomy lesion characteristics with clinical outcomes for patients with obsessive-compulsive disorder. For this study, preoperative and postoperative Yale-Brown Obsessive Compulsive Scale scores for 11 cingulotomy patients and 8 limbic leucotomy patients were obtained, and lesion masks were defined and compared anatomically by using an atlas-based method. Statistically significant voxels were additionally calculated by using VLSM techniques that correlated lesion characteristics with postoperative scores.

RESULTS

Mean lesion volumes were 13.3 ml for cingulotomy and 11.8 ml for limbic leucotomy. As expected, cingulotomy was isolated to the anterior cingulum. The subcaudate tractotomy portion of limbic leucotomy additionally affected Brodmann area 25, the medial orbitofrontal cortex, and the nucleus accumbens. Initial results indicated that the dorsolateral regions of the cingulotomy lesion and the posteroventral regions of the subcaudate tractotomy lesion were associated with improved postoperative Yale-Brown Obsessive Compulsive Scale scores.

CONCLUSIONS

Cingulotomy and limbic leucotomy are lesioning surgeries that target pathological circuits implicated in psychiatric disease. Lesion analysis and VLSM contextualize outcome data and have the potential to be useful for improving lesioning neurosurgical procedures.

Neuromodulation for obsessive-compulsive disorder

This article describes the basis for neuromodulation procedures for obsessive-compulsive disorder (OCD) and summarizes the literature on the efficacy of these interventions. Discussion includes neural circuitry underlying OCD pathology, the history and types of ablative procedures, the targets and modalities used for neuromodulation, and future therapeutic directions.

A history of deep brain stimulation: Technological innovation and the role of clinical assessment tools

Deep brain stimulation involves using a pacemaker-like device to deliver constant electrical stimulation to problematic areas within the brain. It has been used to treat over 40,000 people with Parkinson’s disease and essential tremor worldwide and is currently undergoing clinical trials as a treatment for depression and obsessive–compulsive disorder. This article will provide an historical account of deep brain stimulation in order to illustrate the plurality of interests involved in the development and stabilization of deep brain stimulation technology. Using Latour’s notion of immutable mobiles, this article will illustrate the importance of clinical assessment tools in shaping technological development in the era of medical device regulation. Given that such tools can serve commercial and professional interests, this article suggests that it is necessary to scrutinise their application in research contexts to ensure that they capture clinical changes that are meaningful for patients and their families. This is particularly important in relation to potentially ethically problematic therapies such as deep brain stimulation for psychiatric disorders.

An evaluation of irreversible psychosurgical treatment of patients with obsessive-compulsive disorder in the Netherlands, 2001-2008

Admissions for irreversible psychosurgical treatment of obsessive-compulsive disorder (OCD) by the Working Group for Indication Psychosurgery in the Netherlands were analyzed, and the postsurgical effects on symptom severity and quality of life were evaluated. The data were extracted from patient records in the period 2001-2008, and there was a postoperative assessment with a semistructured interview. Fourteen patients applied, having severe OCD with mostly one or more comorbid disorders. The mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 32 points. Four of seven patients in whom psychosurgery was deemed useful were operated on. The decrease of the Y-BOCS score from registration to after surgery was 9 points (range, 3-17 points). An improvement in social function was present in three of four patients. In conclusion, psychosurgery can be a valuable treatment option for patients with severe OCD in whom other treatments fail.

Brain structures associated with executive functions during everyday events in a non-clinical sample

Executive functions involve control processes such as goal-oriented planning, flexible strategy generation, sustaining set maintenance, self-monitoring, and inhibition. Executive functions during everyday events (EFEEs) are distinct from those measured under laboratory settings; the former can be severely impaired while the latter remain intact. Non-routine everyday problems due to executive dysfunctions affect individual functioning in everyday life and are of great clinical interest. Despite the importance of anatomical bases underlying better EFEEs, such bases have never been investigated among non-clinical samples. Using voxel-based morphometry to measure regional gray matter volume (rGMV) and regional white matter volume (rWMV) and diffusion tensor imaging to determine fractional anisotropy values, we identified the anatomical correlates of better EFEEs using the Dysexecutive Questionnaire in 303 normal young subjects (168 men and 135 women). Better EFEEs were associated with a smaller rGMV in the orbitofrontal cortex (OFC) spread across Brodmann areas (BA) 25, 11, and 12 and larger rWMV in the WM area of OFC adjacent to BA 11. Furthermore, individual EFEEs were positively associated with rWMV in the temporal areas, primarily the inferior longitudinal fasciculus and inferior fronto-occipital fasciculus, the latter of which connects OFC and posterior regions. Thus, our findings suggest that brain structures involving OFC, together with other regions, contribute to the maintenance of effective EFEEs among non-clinical subjects.

[Egas Moniz: a genius, unlucky looser or a Nobel committee error?]

Portuguese neurologist António Egas Moniz is one of the most intriguing figures in the history of medicine. While an invention of angiography in 1927 is his acknowledged merit, lobotomy, invented in 1935 became a black legend of psychiatry, although sporadically it is performed also today. There are even postulates to withdraw the Nobel Prize, which Moniz received in 1949 for inventing the lobotomy. Moniz in fact re-invented lobotomy, primarily introduced in 1888 by a Swiss psychiatrist Gottlieb Burckhardt and later forgotten. Its popularisation, including its abuses was chiefly done by American neurologists Walter Freeman and James Watts. Aside the science, Moniz was an exceptionally colourful person, a merited politician, Portuguese minister of foreign affairs, the head of its delegation at Versailles in 1918, in 1951 he was even proposed a position of a President of Portugal. He was a versatile humanist and a writer, even a gambling expert. His person is hard for black and white evaluation, definitely deserving a re-evaluation from today's historical perspective.

The promises and perils of non-invasive brain stimulation

Non-invasive brain stimulation promises innovative experimental possibilities for psychology and neuroscience as well as new therapeutic and palliative measures in medicine. Because of its good risk-benefit ratio, non-invasiveness and reversibility as well as its low effort and cost it has good chances of becoming a widespread tool in science, medicine and even in lay use. While most issues in medical and research ethics such as informed consent, safety, and potential for misuse can be handled with manageable effort, the real promise of brain stimulation does raise one prominent moral worry: it may lay the foundation of reliable, precise and stable manipulations of the mind. This article addresses this worry and concludes that it is not the possibility of manipulation, but the shift in our understanding of our mind which stands in need of careful consideration.

Identification of neural targets for the treatment of psychiatric disorders: the role of functional neuroimaging

Neurosurgical treatment of psychiatric disorders has been influenced by evolving neurobiological models of symptom generation. The advent of functional neuroimaging and advances in the neurosciences have revolutionized understanding of the functional neuroanatomy of psychiatric disorders. This article reviews neuroimaging studies of depression from the last 3 decades and describes an emerging neurocircuitry model of mood disorders, focusing on critical circuits of cognition and emotion, particularly those networks involved in the regulation of evaluative, expressive and experiential aspects of emotion. The relevance of this model for neurotherapeutics is discussed, as well as the role of functional neuroimaging of psychiatric disorders.

Deep brain stimulation in the media: over-optimistic portrayals call for a new strategy involving journalists and scientists in ethical debates

Deep brain stimulation (DBS) is optimistically portrayed in contemporary media. This already happened with psychosurgery during the first half of the twentieth century. The tendency of popular media to hype the benefits of DBS therapies, without equally highlighting risks, fosters public expectations also due to the lack of ethical analysis in the scientific literature. Media are not expected (and often not prepared) to raise the ethical issues which remain unaddressed by the scientific community. To obtain a more objective portrayal of DBS in the media, a deeper collaboration between the science community and journalists, and particularly specialized ones, must be promoted. Access to databases and articles, directly or through science media centers, has also been proven effective in increasing the quality of reporting. This article has three main objectives. Firstly, to explore the past media coverage of leukotomy, and to examine its widespread acceptance and the neglect of ethical issues in its depiction. Secondly, to describe how current enthusiastic coverage of DBS causes excessive optimism and neglect of ethical issues in patients. Thirdly, to discuss communication models and strategies to enhance media and science responsibility.

"This is Why you've Been Suffering": Reflections of Providers on Neuroimaging in Mental Health Care

Mental health care providers increasingly confront challenges posed by the introduction of new neurotechnology into the clinic, but little is known about the impact of such capabilities on practice patterns and relationships with patients. To address this important gap, we sought providers' perspectives on the potential clinical translation of functional neuroimaging for prediction and diagnosis of mental illness. We conducted 32 semi-structured telephone interviews with mental health care providers representing psychiatry, psychology, family medicine, and allied mental health. Our results suggest that mental health providers have begun to re-conceptualize mental illness with a neuroscience gaze. They report an epistemic commitment to the value of a brain scan to provide a meaningful explanation of mental illness for their clients. If functional neuroimaging continues along its projected trajectory to translation, providers will ultimately have to negotiate its role in mental health. Their perspectives, therefore, enrich bioethical discourse surrounding neurotechnology and inform the translational pathway.

Neurosurgical treatment of bipolar depression: defining treatment resistance and identifying surgical targets

OBJECTIVES

Bipolar disorder (BD) is a complex psychiatric disorder that is often underrecognized, misdiagnosed, and challenging to detect. During the past decade, substantial progress has been made in the development of pharmacotherapeutic and psychosocial interventions for various phases of BD. Notwithstanding these developments, the majority of BD individuals, and particularly patients with bipolar depression, receiving guideline concordant care do not experience syndromal or functional recovery, underscoring the need for novel treatments. Early success with deep brain stimulation (DBS) in the treatment of major depressive episodes as part of major depressive disorder (MDD) has provided the impetus to explore its application in other treatment-resistant psychiatric disorders, notably BD. Herein, we provide the rationale for employing DBS as an alternative treatment avenue in individuals with bipolar depression.

METHODS

We conducted a PubMed literature search, focusing on English language articles beginning in 1950 to the present day, and employed the following search terms: bipolar disorder, neurosurgery, deep brain stimulation, neuroimaging, and circuitry. Search results were then manually reviewed and relevant articles selected for analysis. Relevance was determined by author consensus and overall manuscript quality. We also reviewed articles on currently available treatment options for BD in order to develop a coherent and practical definition of treatment resistance with a focus on surgical intervention.

RESULTS

Several lines of evidence indicate that although mania is the defining feature of bipolar I disorder, depressive symptoms and episodes dominate the longitudinal course, account for most of the illness burden including premature mortality, and are least responsive to contemporary treatments. Disease models in bipolar depression implicate abnormalities in the structure and function of discrete neural circuits that subserve affective processing and cognitive function with the subgenual cingulate cortex occupying a central role. Modulation of the cingulate cortex with DBS in treatment-resistant MDD populations has proven to offer acute and sustained antidepressant effects, suggesting possible benefits for other mood disorder populations.

CONCLUSIONS

A surgical intervention for bipolar depression would not only be a proof of concept regarding disease modeling but also an important and novel treatment avenue for individuals affected by bipolar depression.

Self-rated versus family-rated personality in patients undergoing capsulotomy for obsessive-compulsive disorder

BACKGROUND

The Karolinska Scales of Personality (KSP) is a self-rated personality inventory. The validity of an observer-rated version of the KSP in unknown.

AIMS

The aim of the study was to investigate how self-rated and observer-rated KSP scores related in a sample of severe obsessive-compulsive disorder (OCD) patients who had undergone neurosurgical treatment.

METHODS

The KSP was adapted for relatives by revising each item content where "I" was replaced by "NN", where "NN" was representing the relative's name. Eighteen patients and relatives completed the different versions of the KSP at a long-term visit following capsulotomy for OCD. Correlations and congruence between ratings and between KSP scores and symptom and adverse effect-ratings were calculated.

RESULTS

There was no significant difference between the patient's own ratings and those of their relative's in 13 of the 15 KSP scales. The correlations ranged from 0.14 to 0.86 and were significant in 11 scales.

CONCLUSIONS

The self-rated KSP can be used in an observer-rated version and is a relatively reliable instrument when compared with the self-rated version even in a sample of severely ill patients.

Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research

This article is based on a consensus conference, which took place in Certosa di Pontignano, Siena (Italy) on March 7-9, 2008, intended to update the previous safety guidelines for the application of transcranial magnetic stimulation (TMS) in research and clinical settings. Over the past decade the scientific and medical community has had the opportunity to evaluate the safety record of research studies and clinical applications of TMS and repetitive TMS (rTMS). In these years the number of applications of conventional TMS has grown impressively, new paradigms of stimulation have been developed (e.g., patterned repetitive TMS) and technical advances have led to new device designs and to the real-time integration of TMS with electroencephalography (EEG), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI). Thousands of healthy subjects and patients with various neurological and psychiatric diseases have undergone TMS allowing a better assessment of relative risks. The occurrence of seizures (i.e., the most serious TMS-related acute adverse effect) has been extremely rare, with most of the few new cases receiving rTMS exceeding previous guidelines, often in patients under treatment with drugs which potentially lower the seizure threshold. The present updated guidelines review issues of risk and safety of conventional TMS protocols, address the undesired effects and risks of emerging TMS interventions, the applications of TMS in patients with implanted electrodes in the central nervous system, and safety aspects of TMS in neuroimaging environments. We cover recommended limits of stimulation parameters and other important precautions, monitoring of subjects, expertise of the rTMS team, and ethical issues. While all the recommendations here are expert based, they utilize published data to the extent possible.