Psychosurgery

According to archaeological evidence, approximately in the eighth millennium BC a craniotomy was performed in many cultures of the world; According to these data, after surgery, some patients survived. However, since there is no evidence that these operations were performed for the treatment of mental disorders, there is no firm reason to refer them to psychosurgery ^[2] .

In 1891, Gottlieb Burckhard reported on six "violent and aggressive" patients who underwent bilateral resection of the cerebral cortex . Two of these patients developed epilepsy (one of them died), and one developed muscle weakness ^[2] .

In 1908, Robert Henry Clark and Victor Horsley described the principles of stereotactic operations to study the functioning of the cerebellum in monkeys, and in 1935 Jacobsen and Fulton showed that in chimpanzees, resection of the prefrontal cortex leads to the disappearance of the “ frustration ” reaction to the failure to provide the expected reward ^[2] .

In 1936, Portuguese neuropathologist Egash Moniz and neurosurgeon Almeida Lima operated on 20 patients who suffered severe anxiety disorders , obsessive actions, and irrational fears . At the same time, the fibers connecting the subcortical regions and the frontal lobes were dissected; operation received the name "prefrontal leukotomy" (prefrontal lobotomy). In one third of operated patients, the condition improved, in one third it worsened, and in one third of patients the condition did not change ^[2] . Although the quality of research was criticized in a scientific audience, E. Monisch wrote hundreds of articles and books on lobotomy ^[3] .

In the same year in the United States, neuropathologist Walter Freeman and neurosurgeon James Watts began treating patients with depression using bilateral frontal leukotomy (the so-called “Freeman-Watts lobotomy”) ^[2] .

In 1940, Payton developed a method of “frontal lobotomy,” which was a massive destruction of tissues. This type of operation led to numerous cases of postoperative epilepsy ^[2] .

The method of transorbital leukotomy developed by Walter Freeman (“lobotomy with an ice pick”) developed in 1945 was widespread. It involved the introduction of a surgical instrument under the eyelids through the orbit- frontal cortex; at the same time, bark tissues and the corresponding frontal-talamic pathways were cut by a wide sweeping motion. This operation was performed most often in non-sterile conditions, it could be performed with minimal anesthesia (two sessions of electroconvulsive therapy were often used for pain relief) ^[2] .

Despite the severe side effects of lobotomy ^{[4] [5] [6]} and the insufficiently proven effectiveness of this method ^{[4] [7]} (recovery occurred or not, the issue was often decided on the basis of such a pragmatic criterion as improving patient manageability) ^[7] Lobotomy has become very common in the United States. In many respects, this was dictated by economic considerations: the cheap method allowed massively discharging Americans from closed psychiatric institutions and thereby reducing their maintenance costs ^[3] .

Between 1936 and the end of the 1950s, 40,000–50,000 Americans underwent a lobotomy ^[8] . Lobotomy was widely used not only in the United States, but also in a number of other countries of the world, including the United Kingdom , Finland , Norway , Sweden , Denmark , Japan , and the USSR ^[9] .

In 1947, the first stereotactic neurosurgical surgery was performed on a patient with a mental disorder in the USA. In the same year, the US Columbia – Greystone research project did not provide evidence of the usefulness of a lobotomy. Nevertheless, after Egash Moniz won the Nobel Prize in Physiology and Medicine for the development of a lobotomy in 1949, the frequency of its occurrence increases ^[2] .

The decline of lobotomy began in the 1950s after the serious neurological complications of this operation became apparent. Further, lobotomy was prohibited by law in many countries ^[3] .

After the decline of lobotomy, the development of psychosurgery has not stopped, other surgical interventions have evolved, associated with fewer side effects and lower mortality. In the end, psychosurgical intervention began to be admitted as possible in a small proportion of patients with resistant mental disorders , most often affective or anxious ^[3] .

In 1948, the method of “orbital notches” was developed, which involved dissecting the medial fibers connecting the frontal lobes with the thalamus; in 1962, the open anterior anterior cingulumotomy was first performed; in 1964, the subcaudial tractomy was developed — extensive destruction of the orbitofrontal cortex and frontal with the help of directional radioactive radiation ^[2] .

In 1968, a gamma scalpel was created - a stereotactic method of tissue destruction using directional radiation, which did not require the creation of holes in the skull, in 1972 a method of thermal anterior capsulotomy was developed , and in 1973 the first limbic leukotomy operation was performed ^[2] .

All forms of psychosurgery used today (or used in the recent past) are carried out on the limbic system, including structures such as the amygdala , hippocampus , some thalamic and hypothalamic nuclei, the prefrontal and orbitofrontal cortex, and the cingulate gyrus — all of them pathways of nerve fibers and are thought to play a role in the regulation of emotions. ^[10] So far there is no international consensus on the most effective structure. ^[ten]

Anterior cinglotomy was first performed by Hugh Cairns in the UK and developed in the USA by H.T. Ballantyne Jr. In recent decades, it has been the most common psycho-surgical procedure in the United States. ^{[10] The} operation is performed on the anterior cingulate cortex, breaks the connection between the thalamic and posterior frontal regions, and also destroys the anterior cingulate region. ^[ten]

Anterior capsulotomy was developed in Sweden , where it became the most frequent procedure. It is also used in Scotland . The purpose of the operation is to separate the orbitofrontal cortex and the thalamic nuclei. ^[ten]

Subcaudial tractotomy was the most common form of psychosurgery in the UK from the 1960s to the 1990s. It is aimed at the lower medial quadrant of the frontal lobe, breaking the connection between the limbic system and the supraorbital part of the frontal lobe. ^[ten]

Limbic leukotomy is a combination of subcaudal tractotomy and anterior cingulotomy. It was used in the 1990s at Atkinson Morley Hospital in London ^[10] as well as at Massachusetts General Hospital. ^[eleven]

Amygdalotomy , the purpose of which is the amygdala, was developed to treat the aggressiveness of Hideki Narabayashi in 1961 and is used today from time to time, for example, at Georgia Medical College. ^[12]

There are discussions about whether deep brain stimulation (DBS) is a form of psychosurgery. ^[13]

Endoscopic sympathetic blockade (a form of endoscopic thoracic sympathectomy ) in patients with anxiety disorder is sometimes considered psycho-surgical treatment, although it does not apply to brain surgery. There is also a resurgence of interest in its use in the treatment of schizophrenia . ^{[14] The} ESB disrupts the brain regulation of many organs, usually suffering from emotions, such as the heart and blood vessels. Many studies show a significant decrease in anxiety and fear in patients with social phobias , as well as an improvement in their quality of life. ^[15]

Asia

In China, psychosurgery destroying the nucleus accumbens is used to treat drug and alcohol addiction. ^{[16] [17]} They are also used to treat schizophrenia, depression, and other mental disorders. Psychosurgery is not regulated in any way in China, for which its use there has been criticized by Western countries.

India used psychosurgery extensively until the 1980s to treat addiction and aggressive behavior in adults and children, as well as depression and obsessive-compulsive disorder . ^[18] Sculotomy and capsulotomy for depression and OCD continue to be used, for example, in the Mumbai hospital. ^[nineteen]

In Japan, the first lobotomy was carried out in 1939, and the operation was widely used in psychiatric hospitals ^[20] , but psychosurgery gained notoriety in the 1970s, in part because of its use in children with behavioral problems. ^[21]

Australia and New Zealand

In the 1980s, 10–20 operations per year were conducted in Australia and New Zealand. In the 1990s, their number dropped to one or two per year. In one report, not a single operation has been performed since 2000, despite the fact that the Supervisory Board of Victoria for Psychosurgery was considering 3 applications between 2006 and 2008. ^[22]

Europe

During the twenty-year period of 1971–1991, 79 operations were carried out under the direction of the Committee on Psychosurgery in the Netherlands and Belgium . Since 2000, only one center in Belgium has performed them, usually 8 or 9 operations per year (mainly capsulotomy and deep brain stimulation) and, as a rule, for the treatment of OCD.

In France in the early 1980s, about five people a year underwent psychosurgery. ^[23] In 2005, health authorities recommended the use of ablative psychosurgery and DBS to treat OCD. ^[24]

In the early 2000s, about 24 psychosurgery operations (capsulotomy, cingulotomy, subcaudal tractotomy and hypothalamotomy) were performed in Spain annually. OCD was the most common diagnosis, but psycho-surgery was also used to treat anxiety, schizophrenia, and other disorders. ^[25]

In the UK , between the end of the 1990s and 2010, there were only two centers performing psychosurgery: several stereotactic anterior capsulotomies are held every year at the University Hospital of Wales, Cardiff; stereotactic anterior cingulotomy performed at Royal Dundee Hospital in collaboration with the psychiatric ward of Ninewells Hospital in Dundee, Scotland. Patients are diagnosed with depression, OCD, and anxiety. Ablative psychosurgery was not used in England between the late 1990s and 2010, although some hospitals experimented with DBS. ^[26] In 2010, Frenchay, Bristol, performed anterior cingulotomy on a woman who had previously undergone DBS. ^[27]

In Russia, leukotomy was used to treat schizophrenia in the 1940s, but this practice was banned by the Ministry of Health in the 1950s. ^[28] In 1998, the Institute of Human Brain (Russian Academy of Sciences) began a program on stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on a year. ^[29]

North America

In the US, Massachusetts General Hospital has a psycho-surgical program. ^[30] Operations are also conducted at several other centers. In Mexico, psychosurgery is used to treat anorexia. ^[31]

South America

Venezuela has three centers engaged in psychosurgery. Capsulotomy, cingulotomy and amygdalotomy are used to treat OCD and aggression. ^[32]

It is believed that modern neurosurgery can be used to treat three large categories of mental disorders: obsessive-compulsive disorder , anxiety disorders and depressive disorders, and only therapeutically resistant patients suffering from a disease with a clearly long-term course can be recommended for such treatment ^[2] . In particular, with therapeutically resistant depression, psychosurgery can be applied only when all other treatment methods (pharmacological and non-pharmacological), including non-destructive surgical methods (including stimulation of the vagus nerve ), have already been used to no avail and doctors can refer to this final step as to despair therapy. This is exactly what happens in Western countries, but in Russia psychosurgery is sometimes used at earlier stages of treatment of therapeutically resistant depression due to the lack or low availability of modern non-drug methods in Russia ^[33] .

In the 1960s and 1970s, operations such as bilateral amygdalotomy, talamotomy and hypothalamotomy were performed to treat aggressive and hypersexual behavior, but now these conditions are no longer attributed to indications for neurosurgical interventions ^[2] .

The main contraindication for neurosurgical measures is the inability of the patient to give informed consent . In any case, such intervention can be carried out only after a thorough and detailed assessment of the possible risk and benefits for the patient in each particular case ^[2] .

Neurosurgical measures should not be applied if affective or obsessive symptoms are caused by a recurring organic or degenerative brain disease or the presence of a pervasive developmental disorder is suspected ^[2] .

There is no evidence that neurosurgical intervention is effective in personality disorders , anorexia nervosa or schizophrenia, so patients with these disorders should not use such treatment measures if they are not aimed at comorbid chronic therapeutically affective or obsessive symptoms ^[2] .

Neurosurgical interventions for mental disorders are contraindicated if the patient cannot be operated on because of low blood clotting , the presence of infections, or a high risk associated with anesthesia ^[2] .

According to research, the positive results of modern neurosurgical interventions are very modest. So, Montoya et al. (2002) showed that out of six patients with severe depressive disorders who underwent limbic leukotomy, the condition of two people met the improvement criteria, defined as a 50% reduction in the Beck Depression Scale .

Poynton et al. (1988) reported improvement in nine patients with bipolar affective disorder after stereotactic subcaudal tractotomy , but in three (33%) patients a "slight or moderate decrease in cognitive functions " was observed.

According to Dougherty et al. (2002), out of 44 patients suffering from obsessive compulsive disorder and undergoing stereotactic cingulotomy, 19 (44%) showed improvement or partial improvement. A decrease by an average of 28.7% on the Scale of Obsessive-Compulsive Symptoms (Yale – Brown Obsessive Compulsive Scale –Y – BOCS) was observed. Согласно данным Montoya и др. (2002), из 15 пациентов, которым проводилась лимбическая лейкотомия, у шести (42%) отмечалось улучшение по показателям Шкалы общего клинического впечатления, а у пяти пациентов (33%) — снижение на 35% показателей по Шкале Y–BOCS.

По результатам исследования, осуществлённого в 2003 году, у 23 из 26 пациентов, страдавших генерализованным тревожным расстройством , социальной фобией или паническим расстройством , через год после операции наблюдалось улучшение, а у 12 из 18 пациентов (67%) было отмечено улучшение по результатам долговременного (в среднем 13 лет) катамнестического обследования. Однако при этом у пяти пациентов (28%) отмечались проявления дисфункции лобных долей, что может быть следствием как операции, так и самого психического расстройства.

Уже критики Эгаша Мониша отмечали, что проводимая им операция могла приводить к тяжёлым поражениям головного мозга и таким осложнениям, как менингит , эпилепсия , мозговые абсцессы ^[34] . Проводившиеся Уолтером Фрименом и его последователями операции были не менее опасными. Так, в 1950-е годы исследования выявили, что, кроме летального исхода , который наблюдался у 1,5—6 % оперируемых, лоботомия вызывает такие плачевные последствия, как припадки, большое прибавление в весе, потерю моторной координации , частичный паралич и др. ^[4] Она приводила также к значительным нарушениям интеллекта у пациентов ^{[5] [6] [35]} , ослаблению контроля за собственным поведением, апатии ^{[5] [6]} , эмоциональной неустойчивости ^[6] , аффективному уплощению ^[36] , безынициативности и неспособности осуществлять целенаправленную деятельность ^[7] .

Более современные формы психохирургии являются гораздо более щадящими ^[3] . Они тоже не лишены побочных эффектов, однако не приводят к настолько тяжёлому когнитивному снижению , как метод лоботомии.

In studies of psycho-surgical operations conducted from 1971 to 2003 ^[2] , there were such negative effects as mental confusion (in 10% of patients who underwent surgery), seizures (up to 6%), personality changes (clear data absent) ^{[2] [33]} , apathy and asthenia (up to 24% of cases), insomnia, transient drowsiness, headache and nausea. Incontinence of urine and feces (almost in 30% of patients after bilateral medial leukotomy, with a lower frequency after limbic leukotomy and anterior capsulotomy), weight gain (from 5.6% to 21% of cases, depending on the type of surgery). In many cases, body weight after 3 months returned to previous indicators, however, an increase in body weight could reach 10-15 kg and persist for a long time ^[2] .

Attention and memory impairments were more often observed in older studies, when operations such as prefrontal leukotomy were used. In more recent studies (2002 publication), memory loss was found in 5% of patients; this side effect disappeared in 6-12 months. In a study of cognitive function in 23 patients who underwent subcaudal tractotomy, significant cognitive impairment was noted within two weeks after surgery (1991 publication); these phenomena were generally reduced after 6 months. In a study of 66 patients who underwent limbic leukotomy (1976 publication), it was found that the Wechsler test scores increased within six weeks after surgery ^[2] .

It is believed that surgical intervention is indicated primarily for symptomatic epilepsy caused by local disorders, such as a tumor.

Surgical treatment of the so-called temporal epilepsy is currently used quite widely, especially when drug therapy is ineffective. In some cases, surgery not only eliminates seizures, but also normalizes the general condition of patients.

In epilepsy, anterior lobectomy is performed, transventricular amygdala-hippocampectomy. V. M. Ugryumov proposed a modification of the latter method: a sparing, phased subpial resection of the temporal lobe under the control of an electrocorticogram (ECOG). He also developed a stereotactic method that allows widespread intervention in deep structures and is shown in the so-called single-focal and multi-focal epilepsy. ^[37]

• Lobotomy
• Neurosurgery

• Dobrokhotova T.A. What is the place of psychosurgery in modern medicine? // Independent Psychiatric Journal. - 1995. - № 4. - p. 18-22.
• Christmas D, Morrison C, Eljamel MS, Matthews K. Neurosurgical Interventions for Mental Disorders
• Canadian Psychiatric Association Psychosurgery