Stereotactic lesions for the treatment of psychiatric disorders

Abstract

Object. The use of deep brain stimulation (DBS) has recently been expanded to the investigational treatment of specific psychiatric disorders. Much like movement disorders, the targets selected for DBS are based on past experience with stereotactic lesions. A literature review of past studies incorporating stereotactic lesions for psychiatric disorders was performed to provide historical context and possible guidance for current and future attempts at treating psychiatric disorders with DBS.Methods. Original copies of the proceedings of the second, third, fourth, and fifth World Congresses of Psychiatric Surgery meetings were reviewed, and a Medline search was conducted for studies with the word "psychosurgery" and each of 14 highly prevalent psychiatric conditions identified by the National Institute of Mental Health. Postoperative results for 1145 patients with stereotactic brain lesions targeting various anatomical foci were standardized using a 5-point scale (3 [free of symptoms] to −1 [worse]). Each patient was entered into a database as a unique data point and used for this literature review.Results. General anxiety disorder and obsessive-compulsive disorder had the greatest reported improvements from anterior capsulotomy, and bipolar disorder, depression, and schizoaffective disorder had the greatest reported improvements from anterior cingulotomy, supporting these areas for DBS investigation. Addiction and schizophrenia showed the least improvement from surgery. Therefore, pursuing the treatment of these disorders with DBS using the targets in these studies may be ineffective.Conclusions. This study provides retrospective data that suggest which anatomical focus may be effective to lesion or stimulate for the treatment of each of several psychiatric disorders.

Ethical Focal Points in the International Practice of Deep Brain Stimulation

“…More than three thirds believe that they are a valid alternative to DBS for some patients, but also almost half of the experts expect that soon there won't be experts who master lesion procedures. Also in the literature there is support to keep lesion procedures as an important alternative for appropriately selected patients both for movement disorders (e.g., Parkinson's disease; Bronstein et al 2011) and psychiatric disorders (Leiphart and Valone 2010) like OCD or anorexia nervosa (Barbier et al 2011;D'Astous et al 2013;Greenberg et al 2010;Kondziolka et al 2011). In particular, an international expert panel has recently stated in a consensus paper that "until scientifically proven otherwise, DBS is not superior to ablative surgery for psychiatric disorders" (Nuttin et al 2014).…”

Deep Brain Stimulation in Schizophrenia

“…A recent meta-analysis demonstrated that more than 170 individuals have been treated with ablative procedures (mainly cingulotomy and callosotomy, respectively). The clinical benefit in schizophrenia however lagged markedly behind the success achieved by DBS in other psychiatric disorders (Leiphart & Valone, 2010). Thus, no valid expertise regarding putative anatomical targets in schizophrenia can be drawn from previous neurosurgical approaches.…”

Augmentation strategies in obsessive–compulsive disorder

“…Review of the uncontrolled studies suggests that at least 50-60% of the patients show a response to surgery [112]. A recent review [113] suggests that capsulotomy may be a more effective procedure for OCD. There may be some rare serious adverse effects including intracerebral hemorrhage, infection, postoperative convulsions and so on which are more commonly seen with open surgeries.…”