Psychiatry Section, Department of Clinical Neuroscience, Karolinska Institutet, Karolinska Hospital, SE-171 76 Stockholm, Sweden
Matthews & Eljamel (2003) gave an excellent overview of the controversial field of neurosurgery for mental disorders (NMD). I agree with them that the accumulated literature on neurosurgery for mental disorder remains highly unsatisfactory but would like to point to some recent evidence.
Matthews & Eljamel state that there is surprisingly little evidence to support the occurrence of adverse personality change. In my opinion, some of the literature suggests otherwise. Herner (1961) noted that in a group of 116 capsulotomy cases, frontal lobe deficit syndrome was obvious at follow-up in 30%. In the anxiety group, 40% and 13%, respectively, had adverse events of mild and of modest severity. In another study (Kullberg, 1977), capsulotomy caused some personality changes in the majority of the patients. Adverse events in those studies included fatigue, emotional blunting, emotional incontinence, indifference, low initiative, disinhibition and impaired sense of judgement.
In a very recent study (Rück et al, 2003), 26 anxiety patients who had undergone bilateral thermocapsulotomy were followed up after a mean of 13 years. Psychiatric methods included symptom rating scales and neuropsychological testing. To avoid bias, ratings were done by psychiatrists not involved in patient selection and postoperative treatment. Seventeen of 23 patients alive at long-term follow-up were seen in person and relatives were interviewed. The reduction in anxiety ratings was significant both as 1-year and long-term follow-up. Seven patients were, however, rated as experiencing significant adverse events, the most prominent symptoms being apathy and dysexecutive behaviour; also neuropsychological performance was significantly worse in these patients. I therefore agree with Matthews & Eljamel that we must continue to evaluate the efficacy and safety of NMD.
C.R. has participated in numerous educational events sponsored by pharmaceutical companies and has been a consultant for Pfizer.
REFERENCES
Herner, T. (1961) Treatment of mental disorders with frontal stereotaxic thermo-lesions: a follow-up study of 116 cases. Acta Psychiatrica Scandinavica Supplementum, 37, 45 60.
Kullberg, G. (1977) Differences in effect of capsulotomy and cingulotomy. In Neurosurgical Treatment in Psychiatry, Pain, and Epilepsy (eds W. H. Sweet, S. Obrador & J. Martín-Rodríguez), pp. 301 308. Baltimore, MD: University Park Press.
Matthews, K. & Eljamel M. S. (2003) Status
of neurosurgery for mental disorder in Scotland. Selective literature review
and overview of current clinical activity. British Journal of
Psychiatry, 182, 404
411.
Rück, C., Andréewitch, S., Flyckt, K., et
al (2003) Capsulotomy for refractory anxiety disorders:
long-term follow-up of 26 patients. American Journal of
Psychiatry, 160, 513
521.
Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
K.M. has received payment for lectures on the management of depression from various pharmaceutical companies.
Rück makes reference to a series of studies reporting personality change following anterior capsulotomy, including his recent review of 26 patients undergoing thermal capsulotomy for anxiety (Rück et al, 2003). He raises interesting questions about the prevalence of personality change following certain (if not all) neurosurgical procedures for mental disorder, and such questions remain, we believe, essentially unaddressed by previous research. Rücks rate of apparent personality change following anterior capsulotomy is comparatively high at approximately 30% of patients. This rate is higher than those rates reported in earlier literature, which suggest rates of up to 10% for stereotactic subcaudate tractotomy (Ström-Olsen & Carlisle, 1971; Goktepe et al, 1975) and 2% for stereotactic cingulotomy (Dougherty et al, 2002). However, 24% of patients undergoing limbic leucotomy had transient apathy which resolved fully (Montoya et al, 2002).
In addition to the lack of uniformity of measurement across studies, another key difference may lie in the fact that many of the larger studies included patients with a variety of diagnoses, including depressive disorder, obsessivecompulsive disorder (OCD) and anxiety disorder. In fact, non-OCD anxiety disorders made up a small percentage of most of the studies cited above, whereas Rücks study sample comprised entirely patients diagnosed with non-OCD anxiety disorder.
The lesions of anterior capsulotomy disrupt the continuity of the frontostriatalpallidalthalamic circuits which are believed to be dysfunctional in OCD (Modell et al, 1989). Important connections between the orbitofrontal cortex, anterior cingulate regions and the thalamus also lie in the anterior part of the internal capsule and are thought to play an important role in the pathogenesis of major depressive disorder (Tekin & Cummings, 2002).
Most psychiatrists, neurologists and neurosurgeons would probably predict high rates of serious psychopathology including personality changes if such lesions were made within healthy brains. If the existing literature can be considered reliable, including the report of Rück and colleagues, it is quite remarkable that the reported rates of significant frontal psychopathology are so infrequent. Hence, three possibilities (at least) must be considered:
In reality, the true picture may represent a combination of influences from these three factors. What is clear is that all NMD must be accompanied by detailed prospective audit with comprehensive evaluation of frontal neuropsychology and personality functioning.
REFERENCES
Dougherty, D. D., Baer, L., Cosgrove, G. R., et al
(2002) Prospective long-term follow-up of 44 patients who
received cingulotomy for treatment-refractory obsessivecompulsive
disorder. American Journal of Psychiatry,
159, 269
275.
Goktepe, E. O., Young, L. B. & Bridges, P. K. (1975) A further review of the results of stereotactic subcaudate tractotomy. British Journal of Psychiatry, 126, 270 280.[Medline]
Kolb, B. & Gibb, R. (1993) Possible anatomical basis of recovery of function after neonatal frontal lesions in rats. Behavioural Neuroscience, 107, 799 811.[CrossRef][Medline]
Modell, J. G., Mountz, J. M., Curtis, G. C., et al (1989) Neurophysiologic dysfunction in basal ganglia/limbic striatal and thalamocortical circuits as a pathogenetic mechanism of obsessivecompulsive disorder. Journal of Neuropsychiatry and Clinical Neuroscience, 1, 27 36.[Abstract]
Montoya, A., Weiss, A. P., Price, B. H., et al (2002) Magnetic resonance imaging-guided stereotactic limbic leukotomy for treatment of intractable psychiatric disease. Neurosurgery, 50, 1043 1049.[Medline]
Rück, C., Andréewitch, S., Flyckt, K., et
al (2003) Capsulotomy for refractory anxiety disorders:
long-term follow-up of 26 patients. American Journal of
Psychiatry, 160, 513
521.
Ström-Olsen, R. & Carlisle, S. (1971) Bi-frontal stereotactic tractotomy. A follow-up study of its effects on 210 patients. British Journal of Psychiatry, 118, 141 154.[Medline]
Tekin, S. & Cummings, J. L. (2002) Frontalsubcortical neuronal circuits and clinical neuropsychiatry: an update. Journal of Psychosomatic Research, 53, 647 654.[CrossRef][Medline]
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