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Functional Neurosurgery for Intractable Mental Health Disorder

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Functional Neurosurgery for Intractable Mental Health Disorder i Functional neurosurgery for intractable mental disorder: long term effects on mental health, neuropsychological performance, social function, and quality of life By David M. B. Christmas Thesis submitted for the degree of Doctor of Medicine University of Dundee December 2006 ii © Copyright 2006 by David M. B. Christmas All Rights Reserved iii TABLE OF CONTENTS TABLE OF CONTENTS ................................................................................................. iii LIST OF TABLES ........................................................................................................... vii LIST OF FIGURES ........................................................................................................ xiv ACKNOWLEDGMENTS .............................................................................................. xvi Signed Declaration......................................................................................................... xvii Abstract ......................................................................................................................... xviii 1. Foreword ...................................................................................................................... 1 1.1 Overview ............................................................................................................ 1 1.2 Assessment tools used ........................................................................................ 2 1.3 Omissions ........................................................................................................... 3 2. Background .................................................................................................................. 5 2.1 Major depressive disorder (MDD) ..................................................................... 5 2.2 Obsessive-compulsive disorder (OCD) ........................................................... 17 2.3 Neurosurgery for Mental Disorder in Dundee ................................................. 18 3. A History of Neurosurgery of Mental Disorder ........................................................ 20 3.1 Preface .............................................................................................................. 20 3.2 A Prehistory of NMD ....................................................................................... 21 3.3 The Story of Phineas Gage ............................................................................... 22 3.4 The Nineteenth Century: Gottleib Burckhardt ................................................. 24 3.5 The 20th Century .............................................................................................. 25 3.6 Psychosurgery in Europe ................................................................................. 37 3.7 The decline of lobotomy .................................................................................. 44 3.8 A renaissance (of sorts) .................................................................................... 50 3.9 Definitions of Neurosurgery for Mental Disorder ........................................... 51 3.10 Psychosurgery under the spotlight ................................................................... 53 3.11 Conclusions ...................................................................................................... 54 4. From Psychosurgery to Neurosurgery for Mental Disorder: A Review of Neurosurgical Procedures .......................................................................................... 56 iv 4.1 Development of lesion technique and location ................................................ 56 4.2 Modern Stereotactic Techniques ...................................................................... 57 5. The Neuroanatomical Basis of Neurosurgery for Mental Disorder ........................... 77 5.1 Towards an understanding of the cerebral cortex ............................................ 77 5.2 Imaging the brain ............................................................................................. 80 5.3 Key Brain Areas ............................................................................................... 86 5.4 Putative pathways involved in NMD ............................................................. 104 6. The Assessment of Outcomes following Neurosurgery for Mental Disorder ......... 111 6.1 A review of attempts to assess outcomes following neurosurgical interventions for mental disorder ................................................................... 111 6.2 A literature review of the quality of published research on NMD ................. 134 6.3 Recommendations for reporting of outcomes following NMD ..................... 140 7. Methods ................................................................................................................... 143 7.1 Aims and Objectives ...................................................................................... 143 7.2 Study Design .................................................................................................. 143 8. Statistical Methods................................................................................................... 150 8.1 Statistical Approach ....................................................................................... 150 8.2 Quality of the data .......................................................................................... 155 9. Participants .............................................................................................................. 161 9.1 Follow-up of participants ............................................................................... 161 9.2 Procedures ...................................................................................................... 163 9.3 Demographics ................................................................................................ 166 9.4 Socioeconomic status ..................................................................................... 173 9.5 Diagnosis ........................................................................................................ 179 9.6 Illness History ................................................................................................ 183 9.7 Assessing the adequacy of previous treatments ............................................. 186 10. Clinical Outcomes for Affective Disorders ............................................................. 198 10.1 Outcomes for patients not seen at long-term follow-up ................................. 198 10.2 Categorical Outcomes for mood disorders: Response and Remission .......... 199 10.3 Changes in Global Rating Scales following NMD for mood disorders ......... 209 v 10.4 Changes in Depressive Symptom Rating Scales for Mood Disorder ............ 219 10.5 Assessing Clinically Significant Change after NMD for mood disorders ..... 229 10.6 Changes in anxiety symptoms after NMD for mood disorders ..................... 234 10.7 Assessments of general symptom burden in mood disorders ........................ 238 10.8 Quality of Life after NMD for mood disorders .............................................. 243 11. Outcomes for Obsessive-Compulsive Disorder (OCD) .......................................... 249 11.1 Introduction .................................................................................................... 249 11.2 Categorical Outcomes for Obsessive-Compulsive Disorder ......................... 249 11.3 Response and remission rates for NMD for OCD ......................................... 251 11.4 Changes in OCD symptom rating scales after NMD ..................................... 252 11.5 Outcomes for OCD: conclusions ................................................................... 254 12. Outcomes from second procedures .......................................................................... 256 12.1 Description of subjects ................................................................................... 256 12.2 Response and remission rates after neurosurgery .......................................... 258 12.3 Changes in Rating scale scores after a second procedure .............................. 258 12.4 Further analysis .............................................................................................. 262 13. Neuropsychological Assessment ............................................................................. 263 13.1 Introduction: The reported effects of anterior capsulotomy and anterior cingulotomy on neuropsychological function ................................................ 263 13.2 Cambridge Neuropsychological Test Automated Battery (CANTAB) ......... 271 13.3 Clinical Neuropsychological Test Battery ..................................................... 283 13.4 Development of „grouped‟ indicators of Neuropsychological Function ....... 286 13.5 Exploratory data analysis ............................................................................... 290 13.6 General characteristics of participants ........................................................... 295 13.7 Statistical Considerations ............................................................................... 295 13.8 Results 1: General Neuropsychological functioning ..................................... 297 13.9 Results 2: Memory ......................................................................................... 305 13.10 Results 3: Executive Function .......................................................................
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