NEUROPSYCHIATRIC

PRACTICE

Psychosurgery

AND

aged tively

Revisited

a recourse quick and

personality readily lump

Paul

Bridges,

It seems

M.D.,

likely

majority

that

the

of doctors

surrounded

Ph.D., topic

and

almost

F.R.C.Psych. of psychosurgery,

for

many

impenetrably

psychiatrists,

or less

than

neurosurgery

psychiatric

ifinesses.

impression

that

involved. idea that

used the

From there, psychosurgery,

for political

it is only quite

The

than

illness in general is more situation was not helped

gives

a view

psychosurgery atric illnesses; amygdalotomy, Kleinig2

to influencing

the is

common

among

by a World

Health

is a philosopher

behaviour.”

who

ethical issues in psychosurgery. psychosurgery procedures were were reserved for patients chronic...personality

disorders

wrote

selec-

a book

lumped

on

the

together

23, 1990; accepted June 21, 1990. From the Unit for Affective Disorders, Brook General Hospital, reprint requests to Dr. Bridges, the Geoffrey Knight April

Affective

Disorders,

don

4LW,

SEI8 Copyright

Brook

General

Hospital,

Shooters

as

Hill

Geoffrey

London. Unit for

Road,

England. © 1990

American

Psychiatric

Press,

Inc.

slum

to this

housing

the nation’s of these

dysfunction

and

Second seems

philosopher.

and

urban

riots

causes

may

in the rioters

physical

assault..

tragedies.” for political unacceptable,

who

to

In addi-

inadequate

is well

education

known,

have

but

blinded

engaged

the goal

to pinpoint, diagnose violence thresholds

and before

the

us to the

in arson,

of such

studies

sniping

would

treat those people they contribute

be

with low to further

Appallingly, the use of psychiatric treatments ends clearly is implied. It is equally totally to psychiatrists at least, to use open

cingulotomies communication).

for

HISTORICAL

BACKGROUND

cocaine

addiction

Contemporary Neurological

psychosurgery Congress held

John

the

Lon-

Fulton,

ported on behavioral two chimpanzees frontal association produced eratively

(T. Llosa,

personal

there

neurophysiologist,

changes which following bilateral areas. It was apparent

were

no

disturbed

of psychosurgery and

have

somewhat.

development

psychiatrists would had “experimental means normal tions.

of surgery.

almost

neurosurgeons, referring role.

the

animals

responses to frustrating Hence it could be said

JOURNAL

seemed

excluThis

with may

For example,

not consider that the neuroses,” which were The

after neurologist lobe removal

of what was called “experiit should be possible to by neurosurgical means.

sively involved neurologists psychiatrists only in a peripheral

retarded

that pre-opin the ani-

responses

a result, Moniz, a Portuguese suggested that if frontal

development

re-

were observed in ablation of their that the lesions

blunting. In situations fear, anxiety, and anger

prevented the development mental neurosis” in animals, relieve anxiety states in man early

began at the International in London in 1935 when

distinguished

emotional produced

operation. As in the audience,

The The Neuropsychiatric Practice and Opinion section is a forwn wherein experts from around the world are invited to answer clinically related questions or to explore and review cont roversial issues in the field of neuropsychiatry. Our readers are encou raged to write to me with clinical questions or issues that they wish to have addressed in this section. Fred Ovsiew, M.D. Neuropsychiatric Practice and Opinion Editor

326

unique

the

more subtle role of other possible factors,including brain

mals, Knight Address

entirely

after of resources

path-

schizophrenia). ...Hospital overcrowding and other pressures on resources after the Second World War encourReceived

convenient

of a shortage

The

He stated that “When first introduced, they with certain severe,

(often

idea

was

because

obviousness

aim of is to treat severe and intractable psychiit is intended only rarely, as in the case of to primarily influence behavior.

ways...with

War

underly

neurosurgery

Organization’ definition of psychosurgery as “the tive surgical removal or destruction...of nerve

psychosurgery

do not The idea

unemployment,

step to the bizarre neurosurgery, is

a short unlike

personality disorders to become schizophrenia.

even

is nothing to treat certain

name

disorders; together

that were relais of no value to

tion, a few neurosurgeons have not encouraged rational debate. As Mark et al.3 stated, the fact that “poverty,

social control, and for more women than men (although it is well known that

these operations

psychiatric women).

other

is

to treatment techniques easy.” Psychosurgery

and upon

ends involving of women, since

subjugation

have

now

be an

extent,

performed

The use of a special

something

for the

by controversy largely depends

dissent. In fact, the controversy lack of up-to-date knowledge and, to some on misinformation. Of course, psychosurgery more

that World

OPINION

chimpanzees “treated”

to show

and frightening that this was not

by

perfectly situaa “treat-

OF NEUROPSYCHIATRY

NEUROPSYCHIATRIC

ment”; voking

it involved situations.

league

Lima,

decided ing.

blunting Moniz, operated

to await

Moniz

surgical

on

the

shared

emotional with his about

long-term

the

responses neurosurgical 100

cases

outcome

Nobel

prize

to procoland

before

for being

then

continuthe

However, of psychosurgery their

the

of which

first

lobotomy

was

is certain

that

Britain

in

was

carried

out

was

to treat

the

frequently

ried

in the

times United

for schizophrenia.

States.

It

been

suggested were

it has

number

the

prefrontal

operated

on

occurred

in that car-

of operations This

despite

it difficult

to understand

unacceptable

complications,

tients. The answer that time an illness

why

this

was

used

total

is simply that often associated

behavior, which could continue it remitted; by then, the patient institutionalized. Thus, going schizophrenia tive treatments,

that

in those days, was associated

the patient

he or she

would

might

live

It has been shown 20% of schizophrenic frontal pital. time,

lobotomy

with

so

many

there were a definite

with

leave,

despite

and

Newton5

patients

who

had

sufficiently

that

nearly

a standard to leave

been an extremely clinical problem

over

the

be used

From with

the beginning

As the

severe

phrenia

VOLUME

depression after

2

‘

did

time,

not

undercut

unlike

the

“veg-

it was results.

psychosurgery,

NUMBER

3

than and

#{149} SUMMER

as

1990

clear

that patients

those

with

many

as

50%

of

of the

been

shown that However,

it had

stereotactic

frontal

was

refined,

the cingulum in the neurothe by,

variously for examO’Calused to

the bimedial operation of orbital undercut of Sco-

Neurosurgeon

With

having

developed

the ef-

by Knight.’4

his

an operation

accuracy

neurosurgery,

be-

of the

psyorbital

out on over

300 patients,’4

produced remained

good clinical unacceptable,

severe than those of the There was a very high and the death rate was the technique and in the that

was

of location and

Regional

Knight treating

modification

carried

this technique the side effects

the

at the London,

neurosurgeons

even though they were less original prefrontal lobotomy. chance of one or more seizures, .5%.’ Knight therefore revised

the

lesion

comparatively

provided was

by

produced

in a controlled way. The result was stereotactic subcaudate

way, many

schizo-

the

in southeast

active

disorders.

simple;

the

Valenstein,’#{176} and operations which

include

Consultant

process

and that of side

PSYCHOSURGERY

most

tractotomy)6”7

BRITISH

Psychosurgery

had been better

widely

by

the prefron-

of

and the results from have been discussed

Centre

the

that

increasingly

Bartlett,7

having

produced

quadrants

and Solomon,’2 its modification

Senior

chiatric

LOBOTOMY it always

quite

after

changes

subsequently becoming areas. Developments

and

Creenblatt yule,’3 and

THE PREFRONTAL

Bridges

time

some

be discontinued

laghan and Carroll.” Modified

He

lesion

lobotomy

to conclude

ventro-medial

technique operations

pre-

“vegeunsevere

him

should

the main sites the baso-frontal

hos-

good result at the was to balance the

died

as the mental

Thereafter, psychosurgery with and

came

etable” state. However, prefrontal lobotomy simply became obsolete with the discovery of chlorpromazine in the early 1950s. This antipsychotic drug produces better results than did psychosurgery, and with more tolerable side effects. Prefrontal lobotomy has not been indicated since the 1950s. It served its purpose at the time, and it now can be forgotten.

AFTER

the

Neurosurgical

by Tooth

deterioration

that

age.

chance of discharge against the possibility of the table” personality, or of death. Of course, untreated, controlled schizophrenia itself produces personality

was

an important

site,with the least chance

STEREOTACTIC

no effecchance

the fact

lesion

fects, lobes.6

made

of the prefrontal

caused

appropriate

ple,

at

This

tal lobotomy

its

was disturbed

OPINION

of psychosurgery.

who

as well

most

surgical modified

pa-

sites

in patients

lesion.

in

for 10 years or more until had become irreversibly into the hospital with

to a good

recovered

This must have and the difficult

on

schizophrenia with very

when

never

operation,

mortem

each

Although

were

post

instigator, development

the precise

the operation,

lobotomy,

neurosis,

cases

and

that

his They

personality destruction (the “vegetable” personality) 3% of patients and a 4% death rate. Clinicians nowadays find

unintentional to the

studied

and D.C.

in 1936.

used

10,000

1940s,5

five

Freeman prefrontal

of Moniz over

development

in Washington,

of standard

most

perhaps out

Watts

operation

idea

in the early

the neurologist

colleague

devised original

force

was

neurosurgical

the

contribution

the driving

AND

those with depression were able to leave hospital. Thus, the way to move forward was, first, to refine the operations and, second, to target them to the relief of depressive and similar illnesses. Remarkably enough, John Fulton,

psycho-

pioneer.

PRACTICE

which parts

EXPERIENCE has

developed

perhaps has of the world.

in Britain

in a particular

made it more acceptable This may have depended

free National Health Service. have to pay for the consultants

Because treating

than in on the

patients do not them, it has been

327

NEUROPSYCHIATRIC

PRACTICE

possible for two units geon and a psychiatrist very close association. value

in regard

treatment

to the

and

Active

for

psychiatric

ation

with

in London involved This has

the

AND

of cases

deciding

on

treatment

being

and

mis-sited

to have both a neurosurwith psychosurgery proved to be of particular

assessment

surgery

OPINION

the

both

relevant

the

research

pairs

genic

of lesions

technique.

that

The

selection

of

stimulation, monitoring. al.,’8

are lesions

the

Mitchell-Heggs

site

during have

et al.,’9

with

obsessional

and

do

patients a death

with poorly rate by suicide

epileptic

seizures

20 months distorted

at least, by advice

six months Knight

set

surgical

apparently

after

shaved; taking this each

Hospital

very

yttrium 7 mm

up

has

to

does

be for

well.

The

psycho-

London.

is the carried

the

lesion

head

of this time stereotactic suits

the

small

purposes

of

been discussed tractotomy,

in any

personality in 11 clinical experience,

function.

In particular,

manage

a more the

perhaps

describe

apparent

and

more

Knight’s

operation

and

1,200

328

have

Carlisle,25 Goktepe Knight’s operation cases,

there

has

this

psychosurgical

operation

one

of

published

et al.,26 and has proved been

often

find

it difficult

to

years.

Hence, with

the

more

relatives

talkativeness

is an extremely

important

at least partly, found among The postoperative

for the high the patients incidence

It remains

to mention

that

but

there

the

precise

are

Since duced, When

obviously

ethical

indications the British psychosurgery

a patient

chosurgical of compulsory

the

operation

of amygdalo-

aggression occasionally value in a limited number uncertainties.

never Mental has

accepts

have

Moreover,

been

Health come

clarified.

Act (1983) was introunder legal control.

an operation

teams, the admission,

is carried of cases,

offered

patient, although nonetheless

by the

not the is required

to have an interview with three commissioners, whom

is a doctor.

It is required

consent, that

operation,

that

the

patient

he or she understand that the operation

and

This compulsion who are entirely

psy-

subject by law

one of give

free,

the nature be indicated

seems rather unsatisfactory free agents.3#{176}

by Bartlett et al.23 In the the main indication is that

Reports been

more of the

personality changes when of normal personality

This

tomy for pathological out in Britain.29 It has

has

In general,

schizophrenia.

many

aggressiveness.

likely

helped.

of intel-

patient postoperatively, in a state of depressive with-

factor and well may account, incidence of failed marriages referred for this operation.28

THE AMERICAN

for

at

of cases. With much feel that relatives

7%26

now

disinhibition

depressive disease, now usually described as affective disorders, either unipolar or bipolar.24 In addition, obsessional illnesses and cases of intractable tension and anxiety (chronic, phobic, and panic attacks) are also to be

controlled

deterioration

relatives

for

was

changes. This observation with reported effects on the

extroverted has been

patient

drawal,

correctly. for patients

of manic

propriate

measurable

and we

%25

this

with no subsequent probthis stereotactic operation

patients tend to report adverse they are describing a resumption

of the

rods,

long

techniques have case of stereotactic

result

informed

by radio-

ceramic

and 1 mm in diameter. Indications for these two stereotactic

to be

used for means,

is produced as

His

only operation out in the past

require

that

(#{176}y)introduced

for

in southeast

not

frame

beds

and

miscalcuhemorrhage.

of one or more epileptic seizures is 1.5%. It has been shown in several studies with preand postoperative testing that, with the modern operations, there is no impairment of intelligence.’9

to about

tends phenytoin

Neurosurgical

tractotomy have been

McCaul

operation

occur

Regional

about 1.5 hours, most to site the lesion by

a simple

active

not

of eight

the

operation

it lasts x-rays

using

unit

within

subcaudate nearly 1,200 This

Kelly22

major depression 1 5%.’ Postoperative

did

a unique

Centre at the Brook

25 years.

et that

operation.

operations

stereotactic used, and

best.

not

when

electrical

physiological by Kelly

although this finding to the patients to take

the

up

by

patients; at 20 months, But it is well recognized

controlled of about

so far,

ligence or adverse personality has to be taken into account

by Kelly.2#{176}It seems

illnesses

occurred

a second, emergency operation lems. We are confident that does

been

of a stereotactic

of a postoperative

has

it is suggested

continuous been reported

reported on the results for 148 eight (5.4%) had died by suicide. that have

and

has

a result

in associ-

by a cryo-

is aided

one

rod, is a risk

also

originally

are small,

precise

carried out The results

patients

produced,

There

out

facilitated. Hence, in Britain the referral is not from a psychiatrist to a neurosurgeon, but from a psychiatrist to a neuropsychiatric team, which includes a neurosurgeon and a psychiatrist, both of whom have special experience. The team at Atkinson Morley’s Hospital in south London uses what is called a stereotactic limbic leukotomy. Two

yttrium

lation. Only

for

diagnoses.

carried

wider

in

is not the

results

apof

by Strom-Olsen

Poynton et al.27 very safe. Out of all

death.

This

was

due

to a

The psychosurgical intense in the United sive mon

observed therapy], origin

interventions ping, tubs.”

that

EXPERIENCE controversy States. On

has been much more the one hand, Breggin3’

“Psychosurgery,

ECT

[electroconvul-

and the major tranquilizers share a comwith the vast majority of other psychiatric over

the years-from

to arsenic-poisoning On the other hand,

castration

and forced the excessive

JOURNAL

and

submersion enthusiasm

OF NEUROPSYCHIATRY

whipin bath of M.

NEUROPSYCHIATRIC

Hunter type

Brown,32 a neurosurgeon,

of treatment.

for some

He strongly

prisoners

and

a schizophrenic,

carried

out

as “a bilateral (p. 544).

by psychiatrists,

using

as part

Psychiatric sent

six-target We also

two

task to

force

1,450

operations; 162 operations and psychiatric disorders.

volved reviewed reported mean

carried these

were In

must

out

In the case

for these

of Canada,

stitutes

annual States

the highest

who

years.

The

in-

recently

of stereotactic cingulotomy. evaluated prospectively,

of 8.6

considerable

He with

a

majority

23% continued to need medication functioning normally, that 51% had

of psychiatric

disability,

or to a neurosurgical

1%

had

complication.

consent.

The

membership

of

verge on established

doctors, there a sociologist, two

the

incredible. such a board

conreview

In 1972, and, in

was a political scientist, a a research biochemist, and

from the patients,

local community.37 both of whom a condition disorder.

They suffered

that

17%

were

As many Mitchell-I-Ieggs

OF LAST

does

not

RESORT

justification

for psychosurgery.

these

circumstances,

abolish

psychosurgery

therapy,

especially

so effective It is no

only

as 9% et

disorder for many

and years.

that

when

that

that

he

this

used

in the

1970s.

side efof 696 while

other

tried,

3

have legal

“well

controlled

by

been made on the British which is quite recent, and procedures adopted in the

#{149} SUMMER

1990

of ECT

to be

and

try

what

of drugs. for an-

it was

at some admitted

a

he had tried it was not to

the figure is 3%. Concerning reported that in a series there were two cases of hemiplegia,

course

be-

referred

persuaded

necessary for lithium to be used But, in the I 980s, this unit has

illness. It was

psychiatrist

unduly

other

can last to define

to be generally

of psychosurgery, he felt were appropriate; be

any

psychiatric unit

are

depression

than

that the depression It used to be difficult

colleagues

should

available

severe

distress

a consultant

patient for consideration all the treatments that felt

say and

uncertainty,

of referring

lieved

surgery

alternative

now

by a treatment-resistant

of the

tolerant

to pain

finds

choice. But it is restrict or to

or combinations a recommendation

seizures

It must

suggesting

the operations

mental

is meant

patient

the patient’s to excessively

without since

and so safe. exaggeration

more

Because

the

is entirely to plan

might be more potent doses Sometimes there would be

#{149} NUMBER

that

what

died by stereo-

postoperative

2

in Oregon.

it determines

that 5% of their patients In the case of Knight’s

phenytoin.” Observations already regulation of psychosurgery, which obviously follows

VOLUME

that

In comparison,

al.’9 and Kelly20 reported suicide postoperatively. tactic tractotomy, fects, Ballantine cingulotomies,

nine

the information

that a patient referred for consideration of should have had all other reasonable without a significant response. The clinical

psychiatric relentlessly

that 6% were unchanged, and that 6% to the progression of the psychiatric

suicide.

and

and

unacceptable, that quite unreasonable

what

by

statutes:

to a patient,

is the unique

despite

but vary-

died

prescribes

student,

be established psychosurgery treatments

recovered, that were otherwise

later

in Britain

informed

This

causes

illness

members

addition to two

disorwere fully

degrees

such

situation is then quite simple. If an operation is not carried out, then the patient will continue in an extreme degree of suffering, which is untreatable. Of course, if,

particu-

regularly

is Ballantine,35

his operation on 198 patients

is not comAfter all, major psywhy so two

neurosurgeon

psychosurgery

slightly improved, deteriorated due

be given

have

OPINION

California (established is by a review board.

legislation

boards sometimes can the Boston City Hospital

of his patients were described as having affective ders; unipolar, bipolar, and schizoaffective illnesses treated. It was reported that 13% of the patients

ing

three

states

and the regulation

case

THE TREATMENT

for both Britain,

same three years, the operations in the United

was 27. last American

follow-up

has

California

two

AND

replied. He reports, for the years for intractable pain and 1,039

300 annually.

with

In each

least

from temporal lobe epilepsy, necessarily involve a psychiatric

He Canadian

neurosurgical treatment for intractable pain mon and never is considered psychosurgical. intractable pain is not associated often with chiatric illnesses. So it is difficult to understand

over

At

two representatives initially reviewed

reviewed

and

pain

annual number Perhaps the

as

on psychosurgery.

American

psychosurgical intractable

was

The

was

and 78% operations

were

This

by an American

476

operations

for

prison

treatments

in America

Association

lar problems. During number of psychosurgical

(established in 1973)

medical

neurosurgeons, 1971-1973,

many

States.

Oregon in 1977).

Watts dissolved leukotomy to be ECT

United

with what cingulo-inneed to re-

in

of an investigation

a questionnaire

to this involving

did well

of Freeman and a transorbital

an anesthetic!33 The state of psychosurgery by Donnelly

history man

apparently

the team advocated

service psychosurgery

a case

retarded

who

nomino-amygdalotomy”

no

advocated

described

mentally

attempted murder, the author described member that when Freeman

did

PRACTICE

certainly

stage. some

patients

who were referred for psychosurgery so that further attempts with medication could be tried. This proved very

successful.

usually commonly

In our

opinion,

treatment-resistant there

is progressive

at

these their failure

illnesses onset.

are

not

Much

more

to respond

over

329

NEUROPSYCHIATRIC

PRACTICE

AND

some years. Thus, a relapsing illness sponded at first to a low dose of a tricyclic Subsequent episodes required a higher perhaps helped.

tricyclic Later,

result, lithium Resistance

medication ECT lost its

was begun. to treatment

unipolar

gesting when

the need to assess for 1) at least one, and preferably

have

been

sponded increasing dosage

and

to a tricyclic, to about

with 300-400

cannot

be

reached

illnesses

and

treatment-resistant given for perhaps times

an

the

doses mg

illness of the daily.

because

unipolar

drug,

occurs of ECT not

tricyclic If this

re-

slowly level of

effects,

then

be given for at least lithium is added?8

mania

when lithium two months, are

augmenting

sug-

has

of side

should then

re-

ECT as a

depression,

psychosurgery, two, courses

2)

another tricyclic is tried. This six weeks. If it is not successful Bipolar

might have antidepressant. dose. Thereafter,

was not successful but effectiveness; perhaps

with

ineffective,

OPINION

are

regarded

as

and carbamazepine, not successful. Some-

given

in addition,

increases

the effectiveness of these two compounds. Augmenters would include triiodothyronine, thyroxine, clonazepam, and sodium valproate. In the last 10 years the annual referrals to this national unit

have

remained

operations

at

carried

about

out

about 50 to 20. We due to the effectiveness

70,

annually

while

has

the

number

been

consider that this is almost of this more determined

from

entirely prescrib-

ing. Strictly speaking, psychosurgery is not the treatment of last resort. Clinical experience shows that medication and ECT, which were ineffective before surgery, become more effective afterwards. A woman admitted to the unit had

responded

wards,

poorly

she

was

medication,

as described

fect. But she did with psychosurgery, ECT, it is suspected The indications operations treatments, Moreover, tively

to psychosurgery.

readmitted.

safe,

and

to

and

controversies

above,

was

respond

to a course plus high-dose that her recovery for psychosurgery

are carried pursued now that

ject

High-dose

year

and

combined

used

with

afterlittle

of ECT x 20. medication is not stable. are now clearer,

efEven and and

out only when all other reasonable with determination, have failed. the operations are refined and rela-

particularly

medical-legal

One

now

that

supervision, virtually

our

surgery

ethical

have

is sub-

uncertainties

disappeared.

References 1. World

Organization:

Health

Aspects

Unwin,

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1954. Reports on Public Health and Medical Subjects, London, Ministry of Health, 1961 6. Fulton IF: Frontal Lobotomy and Affective Behaviour: physiological Analysis. New York, WW Norton, 1951 7. Bridges PK, Bartlett JR: Psychosurgery: yesterday and Psychiatry 1977; 131:249-260

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JOURNAL

OF NEUROPSYCHIATRY

NEUROPSYCHIATRIC

p421-438 37. Annas

GJ, Glantz

imentation:

LH,

The

Katz

BF: Informed

Subject’s

Consent

Dilemma.

to Human

Cambridge,

MA,

ExperBallinger,

bundle

has

been

sponses

and

patterns

Thus,

1977, pp 232-233 38. Hale AS, Procter A, lithium in combination

BrJ Psychiatry

Bridges PK: for resistant

Clomipramine, depression:

tryptophan seven case

and studies.

1987; 151:213-217

this

it has area

shown

been

may

PRACTICE

postulated

patient with OCD. Positron emission

Obsessive

resonance

Thermal

their

for

role

Disorder Robert

frontal

L. Martuza,

E. Antonio Chiocca, Michael A. Jenike, Ida E. Giriunas, R.N. H. Thomas Ballantine, Conventional pulsive tion and However,

Ph.D.

behavioral as many

refractory to conventional main severely disabled.

of

for surgery. selection, our

dure,

technique

the

surgical

and benefits with studies peared

can be OCD

treatment.2 It is this group

that is considered method of patient

itself,

Herein choice and

very successful.’ patients may

be

Some of these reof OCD patients we discuss our of surgical procethe complications

that we have observed. These of this and other procedures

in the

are compared that have ap-

literature.

STUDIES

OF

OCD

LOCI

obsessive mic loci some distinct

symptoms

compulsive for these two

should

evidence from

suggests each

tion are thought within the Papez

that

they

other.

Symptoms

to be circuit,

mediated consisting

2 #{149} NUMBER

3

#{149} SUMMER

of a of OCD

changes

the orbitofrontal

in the

the possinuclei and

areas

may

play

a

of OCD. a model of dysfunction a fronto-striatal-pallido-thalamicexists

in the

in OCD.7

brain.

This

loop

interconneurotransmitter

a fronto-orbital-striatal-thalamic

that

intersuch They

anxiety component and 2) an obsessive through approaches

the

manner. as attempts

may

be, at least of anxiety

in part, and

emo-

by brain structures of the hippocampus,

1990

OCD

mediated compulsive

However,

of activities

the neuroanatonot well defined,

tract, associated

this

context,

through the component

while

within

thain

not

continue

Received

May

to learn

obtained by the this benefit.

11, 1990; accepted

June

circuit mediated

that

any

are so accumeasurable in a rigorously

view with

biologic basis of OCD so that more medical treatments can be developed. judge our current surgical therapy basis of the benefit the risk in obtaining

consider

circuits

Rather, we should to help the patient we

to the 1) an

Papez

procedures as to modulate

these

of

et al. Several surgical to alter these functional

we should

used surgical or so precise

it

area,

or of the midline with improvement

FSPTF loop of Modell have been developed

defined dures

While are

In

of the orbitofrontal

obsessive compulsive symptomatology?’#{176} Thus, there may be two important components neuroanatomy of obsessive compulsive disorder:

levels

are anxiety and

ablation

the orbito-fronto-thalamic lamic nuclei has been

AS

the septal area, the mamillary bodies, the anterior thalamic nuclei, the cingulum bundle, and their interconnections. Electrical stimulation of the anterior cingulum

VOLUME

detected

interconnection.

be noted

FOR

of OCD

behavior. symptoms

scanning

a fronto-orbital-thalamic by the excitatory

orbital-thalamic

tory

The two prominent

have

FSPTFL)

and

relationships.

GUIDES TO POSSIBLE SURGERY

(PET)

within

of anxiety

mediated by various neurotransmitters, dopamine, GABA, and serotonin.

of the currently rately designed BIOLOGIC

lesions

level

suggest that in OCD, abnormalities occur in either the modulatory activity of the fronto-caudate-pallido-thalamic connection or in the primary activity of the fronto-

M.D.

therapy as 20%

(the

acid

connection as glutamate,

therapy of the patient with obsessive com(OCD) with both psychotropic medica-

disorder

with

components: mediated

glutamic

M.D. M.D., M.D.

studies

pathogenesis

loop

has two nection

the

re-

in humans.3

abnormalities of glucose metabonuclei and in the orbitofrontal rex-ray tomography and magnetic

Modell et al. proposed They postulated that

Compulsive

autonomic

emotion

surgical

alter

OPINION

striatum of OCD patients.56 Thus, be considered that the caudate

connections in the

both

and

tomography

imaging

caudate and bility should

alter that

beneficially

patients has revealed lism in the caudate gions.4 Computerized

Stereotactic Radiofrequency Cingulotomy

to

of anxiety

AND

current severe more

procerefrac-

about

the

refined surgical or Thus, we must empirically, on the patient

as opposed

21, 1990. From

to

the Departments

of Surgery and Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston. Address reprint requests to Dr. Martuza, ACC 312, Massachusetts General Hospital, Boston, MA 02114 Copyright

© 1990

American

Psychiatric

Press,

Inc.

331