Editorial Neurosurgery for Psychiatric Disorders

Home , Gottlieb Burckhardt, Neurosurgery, Psychosurgery

Journal of Neurology, Neurosurgery, and Psychiatry 1997;63:701–705 701 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.701 on 1 December 1997. Downloaded from

Editorial

Neurosurgery for psychiatric disorders

Daring must be an inborn trait. Egas Moniz, the neurolo- urban violence of the 1960s in the United States.13 By the gist who extrapolated from the abolition of experimental 1970s, only a few hundred operations were being done neurosis in two chimpanzees to the invention of a annually, and in subsequent years the number declined procedure to ablate pathways of the frontal lobes in further.14 15 mentally ill human beings, had already developed angiog- Secondly, over time the patient group seen as appropri- raphy and spent time in jail for opposition to the Portugese ate for surgery became narrower. Even in their earliest monarchy1 . Such a man could write, in recording the work, Freeman and Watts, the American popularisers of results in the first 20 cases of frontal leucotomy, that the psychosurgery, recognised “a substratum, a common procedure was highly eVective and “always safe”.2 denominator of worry, apprehension, anxiety, insomnia But Moniz’s may have been daring whose time had and nervous tension” which marked the surgically treatable come. Burckhardt, a Swiss psychiatrist, had operated on patient.16 Indeed, retrospective analysis of Moniz’s data six patients some 40 years earlier.3 He had reasoned that shows that it was patients with depression who improved.4 destruction of the sites responsible for mental symptoms, Results of surgical intervention in the large group of copyright. such as the auditory centres in the case of hallucinations, chronically hospitalised patients with schizophrenia were or the tracts conducting their abnormal influences on disappointing in controlled studies, but controlled investi- other structures, would ameliorate mental disorder. A gations of eYcacy in anxiety disorders were more brief vogue of surgical intervention for general paresis of favourable.17–20 the insane had occurred at about the same time.4 But Studies done in the early era were limited by the meth- Moniz reported frontal leucotomy in 1936, a year before ods of the time, with idiosyncratic ratings of eYcacy and Klüver and Bucy5 described the emotional and behav- safety by unblinded examiners involved in the treatment ioural changes due to temporal lobectomy and Papez6 and lacking confirmation of the site of injury (which was published his “proposed mechanism of emotion”. Perhaps often not the intended site21). “The published literature in the time was ripe for a psychiatric treatment based on a the field of psychosurgery was judged to be quite low in theory of the cerebral mechanism of mental illness. scientific merit”, concluded the reviewer in the 1977 report http://jnnp.bmj.com/ Indeed, Moniz devoted the bulk of his 1936 essay to an of the American National Commission studying explication of his theory of cerebral function in mental psychosurgery.22 The decline of psychosurgery, however, disorders.7 He thought that “there are no cellular areas in can be attributed directly to the advent of psychopharma- the brain that are assigned specifically to a determined cological treatments for mental disorders, rather than to psychic manifestation”. Rather, mental functions, “even deficiencies in the evidence. Yet the number of patients the simplest ones, originate from the activity of celluloco- refractory to currently available treatments, although nnective groups of diVerent parts of the central nervous incompletely delineated, is substantial.23 Thus reconsidera- system”. In other words, a network model of higher tion of the evidence for the safety and eYcacy of ablative on September 28, 2021 by guest. Protected functions—more modern in conception than the neurosurgery for psychiatric disorders is due. This is espe- localisationist/associationist model of Burckhardt’s cially so in view of the third trend in psychosurgery— work—underlay Moniz’s surgical intervention. In normal namely, that the anatomical target of the procedure grew conditions, the networks were flexibly elaborated under smaller and was more precisely lesioned by improved sur- the control of internal and external necessities; in mental gical techniques. illness, they were fixed and required to be interrupted to At present most investigators use one of four neurosur- relieve the patient of the fixed ideas that constituted men- gical procedures to treat psychiatric disorders, with reports tal disorder. of other lesions occasionally appearing.24–28 Each technique Several trends characterised the ensuing four decades of grew up in a centre which remained comfortable with it for psychosurgery.8–12 Firstly, the population of patients oper- historical reasons; few head to head comparisons of ated on grew explosively, then collapsed. Only rough esti- techniques are available, and diVering methods of selecting mates are possible, but by 1954 more than 10 000 patients patients and of gathering and presenting data make had undergone lobotomy in England and Wales and comparison of published reports diYcult. All procedures several times that number in the United States.11 The employ bilateral lesions. claim that violence might be due to surgically treatable Cingulotomy entails MRI guided stereotactic thermoco- brain disease led to fears that psychosurgery would be agulation of the anterior cingulate gyrus and the cingulate misused to address complex social problems, such as the bundle 20–25 mm posterior to the anterior tip of the lateral 702 Ovsiew, Frim J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.701 on 1 December 1997. Downloaded from copyright. http://jnnp.bmj.com/ on September 28, 2021 by guest. Protected

Figure 1 (A) Coronal MRI of acute and (B) sagittal MRI of chronic cingulotomy lesions. ventricles and 7 mm from the midline.29 The lesion extends about 2 cm dorsally from the corpus callosum and is 8–10 mm in lateral diameter (ﬁg 1). Anterior capsulotomy is a lesion in the anterior one third of the internal capsule, 5 mm behind the tip of the frontal horns and 20 mm lateral to the midline, placed either by MRI guided stereotactic thermocoagulation or by radiosurgery (ﬁg 2).30 Stereotactic subcaudate tractotomy involves a lesion placed in the subcaudate white matter 5 mm anterior to the sella, Figure 2 (A) Axial MRI of acute and (B) axial CT of chronic anterior 15 mm from the midline, and 10–11 mm above the planum capsulotomy lesions. Neurosurgery for psychiatric disorders 703 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.701 on 1 December 1997. Downloaded from

movement disorders,33–35 and the possibilities of physiologi- cal measurement and reversibility after intraoperative or postoperative assessment of benefit make this a worthwhile option to explore for psychiatric indications. Studies reporting recent experience with surgery for psychiatric disorders do not completely correct the deficiencies of previous data.23 In the most recent reports on cingulotomy from the Massachusetts General Hospital, about a third of patients, mostly with obsessive-compulsive disorder, often with concurrent major depression, were considered improved and another quarter possibly improved.29 36 Fourteen of 31 consecutive patients had undergone a second procedure after the late failure of a first. Similarly, about a third of patients with depression or anxiety disorders, including obsessive-compulsive disorder, were found to benefit from subcaudate tractotomy.37 Anterior capsulotomy may show a somewhat higher success rate for anxiety disorders, including obsessive- compulsive disorder.30 38 None of the studies cited were controlled, nor were the evaluations blinded. Some investigators have argued that ethical problems preclude controlled trials of psychosurgery.31 However, the same argument could be made about any major surgical treatment,39 and especially in view of the unhappy history and controversial nature of surgical intervention for psychiatric illness, further controlled trials are urgently needed—as Birley suggested more than three decades ago.40 Mindus et al pointed out that the advent of radiosurgery allows sham procedures, which the necessity of placing burr holes precluded.41 Safety has been even more controversial than eYcacy. The perioperative morbidity of patients with stereotactic brain lesions is agreed to be minimal.24 Even the early, free- copyright. hand, extensive operations were remarkably free of coarse neurological complications. Sensorimotor neurological signs did not appear, and language was undamaged.42–45 Motor control deficits could not be found; indeed, surgically treated schizophrenic patients may perform bet- ter than their unoperated counterparts.46 47 Even neuropsychological changes were subtle, variable, or absent.48 These findings must be interpreted in the context of the severe abnormalities seen in unoperated chronic schizophrenic patients. As Freeman and Watts commented, “A deterio- rated schizophrenic looks and acts about the same with or without his frontal lobes”.49 http://jnnp.bmj.com/ Nonetheless, in their earliest papers, Freeman and Watts—by contrast with Moniz—acknowledged an adverse eVect of surgery: “Every patient probably loses something by this operation, some spontaneity, some sparkle, some flavor of the personality”.16 Early investigators lacked the neuropsychological tools to measure the consequences of frontal injury, and even today “sparkle” is hard to quantify. Further, the neurobehavioural sequelae of severe illness on September 28, 2021 by guest. Protected Figure 3 (A) Sagittal and (B) low axial MRI of acute limbic leucotomy and extensive previous treatment make it hard to factor out lesions. The ventral lesions are similarly placed to those of subcaudate an eVect of surgery without careful attention to experimen- tractotomy. tal design. In recent studies of cingulotomy, neuropsychological sphenoidale. The British group at the Brook General data are not reported, so the investigators’ judgment that it Hospital has made this lesion by implanting two rows of is associated with “relatively mild, transient side eVects and five radioactive yttrium rods,31 but thermocoagulation is seems to be a safe procedure”29 must be considered some- employed elsewhere.28 what impressionistic, although in accord with earlier, Limbic leucotomy amounts to a combination of cin- detailed studies of the procedure.50 The impression is sup- gulotomy and a ventral lesion similar to that of subcaudate ported by a single case study using sensitive attentional tractotomy (fig 3). measures; this showed impairments in the immediate post- Newer techniques oVer promise. The use of focused operative period which had resolved by eight month follow necrosing doses of ã-irradiation, termed radiosurgery, up.51 However, alterations in appreciation of pain and dis- removes all perioperative risk, but the radiobiology of ruption of habituation of the orienting response have been capsulotomy is incompletely understood and clinical recorded using measures outside the usual clinical experience is limited.30 32 Brain stimulation using battery.52 53 Presumably these changes do not represent implanted electrodes is undergoing expanded use for clinically significant deficits. Vilkki used a projective test, 704 Ovsiew, Frim J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.701 on 1 December 1997. Downloaded from the Holtzman inkblot technique, and disclosed reduction standards, as all the major groups working in the field have in “imagination” after both cingulotomy and anterior cap- emphasised and as a Scottish Working Group has recently sulotomy; after capsulotomy perseveration increased.54 elucidated.70 Patients must be thoroughly evaluated Cumming et al found frontal deficits in a group of patients psychiatrically by clinicians not part of the surgical team; most of whom had undergone limbic leucotomy,55 and all indicated non-surgical treatments must have been tried Nyman and Mindus found that half of a group of 10 over an extended period. Patients must be able to give patients who underwent anterior capsulotomy showed informed consent for the procedure and must do so with- increased perseverative responding postoperatively.56 A out coercion, and appropriate psychiatric care subsequent careful, prospective neuropsychological study of subcau- to surgery must be assured. A capable surgical team must date tractotomy showed no adverse eVects on cognition at proceed only after neurodiagnostic as well as psychiatric six month follow up, although the finding that improve- assessment. ment of depression was correlated with reduced perform- Psychosis should not be considered responsive to ance on some neuropsychological tests raises concern.57 surgery. Anxiety disorders, notably obsessive-compulsive Cognitive deficits may, however, be diYcult to detect disorder, and depression constitute appropriate indica- even when orbitofrontal brain injury has caused drastic tions. Self mutilative behaviour in the context of Tourette’s alterations in personality.58 The contemporary procedures syndrome may respond to surgery,71 although surgical certainly cause less adverse eVect on personality than the approaches to Tourette’s syndrome itself have been older, larger, freehand lesions; yet even with the former disappointing.72 Ablative neurosurgery for violence is reduction in initiative and energy may be seen.59 On the described at present only rarely28; whether it is in broader other hand, favourable changes in personality may occur.60 use than is published is hard to know. Especially rigorous Significant schizoid, antisocial, or histrionic personality ethical and legal safeguards must attend the use of surgery disorders or traits are considered contraindications to sur- for this indication. gery at some centres.28 61 Any time for daring in psychosurgery has passed. Scien- Impairments, even if subtle, occasion no surprise after tific rigor and clinical prudence may transmute the brain surgery; but how could surgical destruction of brain excesses of an earlier day into a rarely used but tissue produce an improvement in mental function? The irreplaceable procedure to relieve distress and save lives. renewed interest in the benefits of surgery for movement disorders lends plausibility to the idea that a malfunction- We are grateful to Dr G Rees Cosgrove, who provided the illustrations. ing network of inhibitory and facilitatory neurons can be F OVSIEW rebalanced to improve brain functioning.62–64a Findings Clinical Neuropsychiatry Service, after epilepsy surgery led Penfield to the concept of Department of Psychiatry, “nociferous cortex”.12 Hermann and Seidenberg indeed University of Chicago, Chicago, USA recently showed that the improvement of executive cogni- DMFRIM copyright. tive functioning after temporal lobectomy confirms that Section of Neurosurgery, adverse distant eVects of hippocampal epilepsy are Department of Surgery, relieved by surgery.65 In the case of epilepsy the tissue University of Chicago, Chicago, USA removed is presumably abnormal, and the objections Correspondence to: Dr Fred Ovsiew, Department of Psychiatry MC3077, often raised to ablative neurosurgery for psychiatric disor- University of Chicago Hospitals, 5841 S Maryland, Chicago, IL 60637, USA. Telephone 001 773 702 3770; fax 001 773 702 6454; email ders relate to surgical intervention in an anatomically nor- [email protected] mal brain. However, in the study just cited improvement in executive cognitive function was unrelated to the pres- 1 Damásio AR. Egas Moniz, pioneer of angiography and leucotomy. Mt Sinai ence or absence of hippocampal pathology in the removed JMed1975;42:502–13. 2 Moniz E. Prefrontal leukotomy in the treatment of mental disorders. Am J temporal lobe. An assertion that the brain of the patient Psychiatry 1994[1937];151(suppl):237–9. with a severe treatment refractory mood or anxiety disor- 3 Joanette Y, Stemmer B, Assal G, et al. From theory to practice: the uncon-

ventional contribution of Gottlieb Burckhardt to psychosurgery. Brain http://jnnp.bmj.com/ der is more normal than the histologically negative Lang 1993;45:572–87. hippocampus of an epileptic patient is questionable at the 4 Berrios GE. The origins of psychosurgery: Shaw, Burckhardt, and Moniz. History of Psychiatry 1997;8:61–81. least. 5 Klüver H, Bucy PC. Psychic blindness and other symptoms following bilat- In fact, the cerebral substrate of the disorders under eral temporal lobectomy in rhesus monkeys. Am J Physiol 1937;119:352–3. 6 Papez JW.A proposed mechanism of emotion. Archives of Neurology and Psy- consideration is poorly understood. For obsessive- chiatry 1937;38:725–44. compulsive disorder, attention has focused on a loop 7 Moniz E. Attempt at surgical treatment of certain psychoses. J Neurosurg 1964[1936];21:1110–4. involving the orbitofrontal cortex, limbic portions of the 8 Kucharski A. History of frontal lobotomy in the United States, 1935–55. basal ganglia, and thalamic nuclei, which is proposed to be Neurosurgery 1984;14:765–72.

66 9 Valenstein ES. Great and Desperate Cures: the rise and decline of psychosurgery on September 28, 2021 by guest. Protected dysregulated in a reverberating fashion. This hypothesis and other radical treatments for mental illness. New York: Basic Books, 1986: calls to mind Moniz’s early allusion to “fixed” networks 338. 10 Pressman JD. InsuYcient promise: John F Fulton and the origins of psycho- and ideas. Recent evidence regarding depression has surgery. Bull Hist Med 1988;62:1–22. pointed to the cingulate gyrus and adjacent and related 11 Swayze VW. Frontal leukotomy and related psychosurgical procedures in 67–69 the era before antipsychotics (1935–54): a historical overview. Am J prefrontal areas. Data emerging from detailed neu- Psychiatry 1995;152:505–15. ropsychiatric studies of treatment-refractory patients being 12 Jasper HH. A historical perspective: the rise and fall of prefrontal lobotomy. In: Jasper HH, Riggio S, Goldman-Rakic PS, eds. Epilepsy and the functional considered for surgery, or possibly electrophysiological anatomy of the frontal lobe. New York: Raven Press, 1995:97–114. . studies undertaken during surgery, may lead to increased 13 Mark VH. Psychosurgery versus anti-psychiatry. In: Boston University Law Review and Center for Law and Health Sciences, Boston University School understanding of these disorders. of Law, eds. Psychosurgery: a multidisciplinary symposium. Lexington, Certainly nothing in the available data justifies compla- Massachusetts: Lexington Books, 1974:1–14. 14 Donnelly J. The incidence of psychosurgery in the United States, 1971–3. cency about what must still be considered a “desperate Am J Psychiatry 1978;135:1476–80. cure”.9 Yet the patients are desperately ill and their lives 15 Hay PJ, Sachdev PS. The present status of psychosurgery in Australia and New Zealand. Med J Aust 1992;157:17–9. severely impaired. Possibly even an intervention that risks 16 Freeman W, Watts JW. Prefrontal lobotomy in the treatment of mental dis- subtle neuropsychological impairment or mild adverse orders. South Med J 1937;30:23–31. 17 McKenzie KG, Kaczanowski G. Prefrontal leukotomy: a five-year controlled personality change could be judged acceptable under such study. Can Med Assoc J 1964;91:1193–6. circumstances. But the ethical undertaking of neurosurgi- 18 Marks IM, Birley JLT, Gelder MG. Modified leucotomy in severe agoraphobia: a controlled serial inquiry. Br J Psychiatry 1966;112:757–69. cal intervention for psychiatric indications requires rigor- 19 Robin AA. A controlled study of the eVects of leucotomy. J Neurol Neurosurg ous attention to psychiatric, surgical, and ethical and legal Psychiatry 1958;21:262–9. Neurosurgery for psychiatric disorders 705 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.701 on 1 December 1997. Downloaded from

20 Tan E, Marks IM, Marset P. Bimedial leucotomy in obsessive-compulsive 47 Carnahan H, Elliott D, Velamoor VR. Inﬂuence of object size on prehension neurosis: a controlled serial enquiry. Br J Psychiatry 1971;118:155–64. in leukotomized and unleukotomized individuals with schizophrenia. J Clin 21 Evans P. Failed leucotomy with misplaced cuts: a clinico-anatomical study Exp Neuropsychol 1996;18:136–47. of two cases. Br J Psychiatry 1971;118:165–70. 48 Joschko M. Clinical and neuropsychological outcome following psychosur- 22 Valenstein ES. The practice of psychosurgery: a survey of the literature gery. In: Grant I, Adams KM, eds. Neuropsychological assessment of neuropsy- (1971–6). In: National Commission for the Protection of Human Subjects chiatric disorders. New York: Oxford University Press, 1986:300–20. of Biomedical and Behavioral Research, ed. Psychosurgery. Washington, 49 Freeman W, Watts JW. Psychosurgery: an evaluation of two hundred cases DC: Government Printing OYce, 1977:I-1–I-183. over seven years. JMentSci1944;90:532–7. 23 Ovsiew F, Bird J. The past and future of psychosurgery. Current Opinion in 50 Teuber H-L, Corkin S, Twitchell TE. A study of cingulotomy in man. In: Psychiatry 1997;10:45–8. National Commission for the Protection of Human Subjects of Biomedical 24 Cosgrove GR, Rauch SL. Psychosurgery. Neurosurg Clin North Am 1995;6: and Behavioral Research, ed. Psychosurgery. Washington, DC: Government 167–76. Printing OYce, 1977:III-I–III-115. 25 Zamboni R, Larach V, Poblete M, et al. Dorsomedial thalamotomy as a 51 Janer KW, Pardo JV. Deﬁcits in selective attention following bilateral treatment for terminal anorexia: a report of two cases. Acta Neurochir 1993; anterior cingulotomy. Journal of Cognitive Neuroscience 1991; :231–41. (suppl 58):34–5. 3 26 Ramamurthi B. Stereotactic operation in behaviour disorders. Amy- 52 Davis KD, Hutchison WD, Lozano AM, et al. Altered pain and temperature gdalotomy and hypothalamotomy. Acta Neurochir 1988;(suppl 44):152–7. perception following cingulotomy and capsulotomy in a patient with 27 Jeanmonod D, Magnin M, Morel A. Low-threshold calcium spike bursts in schizoaVective disorder. Pain 1994;59:189–99. the human thalamus: common pathophysiology for sensory, motor and 53 Cohen RA, Kaplan RF, Meadows M-E, et al. Habituation and sensitization limbic positive symptoms. Brain 1996;119:363–75. of the orienting response following bilateral anterior cingulotomy. 28 Gybels JM, Cosyns PR. Cerebral lesions for psychiatric disorders and pain. Neuropsychologia 1994;32:609–17. In: Schmidek HH, Sweet WH, eds. Operative neurosurgical techniques: 54 Vilkki J. Changes in complex perception and memory after three diVerent indications, methods, and results. Philadelphia: WB Saunders, 1995:1413–21. psychosurgical operations. Neuropsychologia 1981;19:553–63. 29 Spangler WJ, Cosgrove GR, Ballantine HT, et al. Magnetic resonance 55 Cumming S, Hay P, Lee T, et al. Neuropsychological outcome from psycho- image-guided stereotactic cingulotomy for intractable psychiatric disease. surgery for obsessive-compulsive disorder. Aust N Z J Psychiatry Neurosurgery 1996;38:1071–8. 1995;29:293–8. 30 Mindus P, Meyerson BA. Anterior capsulotomy for intractable anxiety dis- 56 Nyman H, Mindus P. Neuropsychological correlates of intractable anxiety orders. In: Schmidek HH, Sweet WH, eds. Operative neurosurgical disorder before and after capsulotomy. Acta Psychiatr Scand 1995;91:23– techniques: indications, methods, and results. Philadelphia: WB Saunders, 31. 1995:1443–55. 57 Poynton AM, Kartsounis LD, Bridges PK. A prospective clinical study of 31 Bridges PK, Bartlett JR, Hale AS, et al. Psychosurgery: stereotactic subcau- stereotactic subcaudate tractotomy. Psychol Med 1995;25:763–70. date tractotomy: an indispensable treatment. Br J Psychiatry 1994;165:599– 58 Eslinger PJ, Damasio AR. Severe disturbance of higher cognition after bilat- 611. eral frontal lobe ablation: patient EVR. Neurology 1985;35:1731–41. 32 Kihlström L, Guo W-L, Lindquist C, et al. Radiobiology of radiosurgery for 59 Sachdev P, Hay P. Does neurosurgery for obsessive-compulsive disorder refractory anxiety disorders. Neurosurgery 1995;36:294–302. produce personality change? JNervMentDis1995;183:408–13. 33 Caparros-Lefebvre D, Blond S, Pécheux N, et al. Évaluation neuropsy- 60 Mindus P, Nyman H. Normalization of personality characteristics in chologique avant et après stimulation thalamique chez 9 parkinsoniens. Rev patients with incapacitating anxiety disorders after capsulotomy. Acta Psy- Neurol (Paris) 1992;148:117–22. chiatr Scand 1991;83:283–91. 34 Iacono RP, Lonser RR, Mandybur G, et al. Stimulation of the globus 61 Mindus P. Present-day indications for capsulotomy. Acta Neurochir pallidus in Parkinson’s disease. Br J Neurosurg 1995;9:505–10. 1993;58(suppl):29–33. 35 Benabid AL, Pollak P, Gao D, et al. Chronic electrical stimulation of the 62 Kapur N. Paradoxical functional facilitation in brain-behaviour research: a ventralis intermedius nucleus of the thalamus as a treatment of movement critical review. Brain 1996;119:1775–90. disorders. J Neurosurg 1996;84:203–14. 63 Obeso JA, Guridi J, DeLong M. Surgery for Parkinson’s disease [editorial]. 36 Baer L, Rauch SL, Ballantine HT, et al. Cingulotomy for intractable J Neurol Neurosurg Psychiatry 1997;62:2–8. obsessive-compulsive disorder: prospective long-term follow-up of 18 64 Ovsiew F. Paradoxical functional facilitation in brain-behaviour research: a patients. Arch Gen Psychiatry 1995;52:384–92. critical review [letter]. Brain 1997;120:1261-3. 37 Hodgkiss AD, Malizia AL, Bartlett JR, et al. Outcome after the psychosurgi- 64a Vilensky JA, Gilman S. Positive and negative factors in movement control: cal operation of stereotactic subcaudate tractotomy, 1979–91. J Neuropsy- a current review of Denny-Brown’s hypothesis. J Neurol Sci 1997;151:149– chiatry Clin Neurosci 1995;7:230–4.

58. copyright. 38 Waziri R. Psychosurgery for anxiety and obsessive-compulsive disorders. In: 65 Hermann B, Seidenberg M. Executive system dysfunction in temporal lobe Noyes R, Roth M, Burrows GD, eds. Handbook of anxiety. Vol 4. The treatment of anxiety. Amsterdam: Elsevier, 1990:519–35. epilepsy: eVects of nociferous cortex versus hippocampal pathology. J Clin 39 Price JS. A paradox of psychosurgical evaluation. In: Ballantine HT, Meyer- Exp Neuropsychol 1995;17:809–19. son BA, eds. Modern concepts in psychiatric surgery. Amsterdam: Elsevier, 66 Modell JG, Mountz JM, Curtis GC, et al. Neurophysiological dysfunction in 1979:337–48. basal ganglia/limb striatal and thalamocortical circuits as a pathogenetic 40 Birley JLT. Modified frontal leucotomy: a review of 106 cases. Br J Psychia- mechanism of obsessive-compulsive disorder. J Neuropsychiatry Clin Neuro- try 1964;110:211–21. sci 1989;1:27–36. 41 Mindus P, Rasmussen SA, Lindquist C. Neurosurgical treatment for refrac- 67 Bench CJ, Friston KJ, Brown RG, et al. The anatomy of melancholia—focal tory obsessive-compulsive disorder: implications for understanding frontal abnormalities of cerebral blood flow in major depression. Psychol Med lobe function. J Neuropsychiatry Clin Neurosci 1994;6:467–77. 1992;22:607–15. 42 Benson DF, Stuss DT, Naeser MA, et al. The long-term eVects of prefrontal 68 Dolan RJ, Bench CJ, Brown RG, et al. Neuropsychological dysfunction in leukotomy. Arch Neurol 1981;38:165–9. depression: the relationship to regional cerebral blood flow. Psychol Med 43 Benson DF, Stuss DT. Motor abilities after frontal leukotomy. Neurology 1994;24:849–57. 1982;32:1353–7. 69 Drevets WC, Price JL, Simpson JR, et al. Subgenual prefrontal cortex 44 Stuss DT, Benson DF, Clermont R, et al. Language functioning after bilat- abnormalities in mood disorders. Stroke 1997;386:824–7. eral prefrontal leukotomy. Brain Lang 1986;28:66–70. 70 CRAG Working Group on Mental Illness. Neurosurgery for mental disorder. 45 Illowsky Karp BP, Juliano DM, Berman KF, et al. Neurologic outcome of HMSO Scotland, 1996. http://jnnp.bmj.com/ patients with dorsolateral prefrontal leukotomy. J Neuropsychiatry Clin 71 Robertson M, Doran M, Trimble M, et al. The treatment of Gilles de la Neurosci 1992;4:415–21. Tourette syndrome by limbic leucotomy. J Neurol Neurosurg Psychiatry 46 Carnahan H, Chua R, Elliott D, et al.EVects of schizophrenia and prefron- 1990;53:691–4. tal leukotomy on movement preparation and generation. J Clin Exp 72 Rauch SL, Baer L, Cosgrove GR, et al. Neurosurgical treatment of Neuropsychol 1994;16:253–60. Tourette’s syndrome: a critical review. Compr Psychiatry 1995;36:141–56. on September 28, 2021 by guest. Protected