Нейрохирургическое лечение психических расстройств

Neurosurgical treatment of mental disorders

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Psychosurgery, also called neurosurgery for mental disorder (NMD), is the neurosurgical treatment of mental disorder. Psychosurgery has always been a controversial medical field. The first significant foray into psychosurgery in the 20th century was conducted by the Portuguese neurologist Egas Moniz who during the mid 1930s developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the neuropsychiatrist Walter Freeman and the neurosurgeon James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy, although the operation was called leucotomy in the United Kingdom. In spite of the award of the Nobel prize to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with depression or obsessive compulsive disorder (OCD). In some countries it is also used in the treatment of schizophrenia and other disorders. Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anaesthetic and using stereotactic methods, a small piece of brain is destroyed or removed. The most common types of psychosurgery in current or recent use are anterior capsulotomy, cingulotomy, subcaudate tractotomy and limbic leucotomy. Lesions are made by radiation, thermo coagulation, freezing or cutting.

All the forms of psychosurgery in use today (or used in recent years) target the limbic system, which involves structures such as the amygdala, hippocampus, certain thalamic and hypothalamic nuclei, prefrontal and orbitofrontal cortex, and cingulate gyrus—all connected by fibre pathways and thought to play a part in the regulation of emotion. There is no international consensus on the best target site. Subcaudate tractotomy was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra orbital part of the frontal lobe. Amygdalotomy, which targets the amygdala, was developed as a treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the Medical College of Georgia. There is debate about whether deep brain stimulation (DBS) should be classed as a form of psychosurgery.

Success rates for anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy in treating depression and OCD have been reported as between 25 and 70 percent. Modern techniques have greatly reduced the risks of psychosurgery, although risks of adverse effects still remain. Whilst the risk of death or vascular injury has become extremely small, there remains a risk of seizures, fatigue, and personality changes following operation. Psychosurgery is also used in the treatment of schizophrenia, depression, and other mental disorders. Cingulotomy and capsulotomy for depression and OCD continue to be used, for example at the BSES MG Hospital in Mumbai.

In Japan the first lobotomy was performed in 1939 and the operation was used extensively in mental hospitals. However, psychosurgery fell into disrepute in the 1970s, partly due to its use on children with behavioural problems.

In the 1980s there were 10–20 operations a year in Australia and New Zealand.

In the 20 year period 1971–1991 the Committee on Psychosurgery in the Netherlands and Belgium oversaw 79 operations. In 2005 the Health Authority recommended the use of ablative psychosurgery and DBS for OCD. In the early 2000s in Spain about 24 psychosurgical operations (capsulotomy, cingulotomy, subcaudate tractotomy, and hypothalamotomy) a year were being performed. OCD was the most common diagnosis, but psychosurgery was also being used in the treatment of anxiety and schizophrenia, and other disorders. In 2010, Frenchay Hospital in Bristol performed an anterior cingulotomy on a woman who had previously undergone DBS. In Russia in 1998 the Institute of the Human Brain (Russian Academy of Sciences) started a programme of stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on annually. In the Soviet Union, leucotomies were used for the treatment of schizophrenia in the 1940s, but the practice was prohibited by the Ministry of Health in 1950.

In the United States, the Massachusetts General Hospital has a psychosurgery program. Operations are also performed at a few other centres. In Mexico, psychosurgery is used in the treatment of anorexia and aggression. In Canada, anterior capsulotomies are used in the treatment of depression and OCD.

Venezuela has three centres performing psychosurgery. Capsulotomies, cingulotomies and amygdalotomies are used to treat OCD and aggression.

Evidence of trepanning (or trephining)—the practice of drilling holes in the skull—has been found in a skull from a Neolithic burial site in France, dated to about 5100 BC although it was also used to treat brain cranial trauma. There have also been archaeological finds in South America, while in Europe trepanation was carried out in classical and medieval times. The first systematic attempt at psychosurgery is commonly attributed to the Swiss psychiatrist Gottlieb Burckhardt. In December 1888 Burckhardt operated on the brains of six patients (one of whom died a few days after the operation) at the Préfargier Asylum, cutting out a piece of cerebral cortex. He presented the results at the Berlin Medical Congress and published a report, but the response was hostile and he did no further operations. Early in the 20th century, Russian neurologist Vladimir Bekhterev and Estonian neurosurgeon Ludvig Puusepp operated on three patients with mental illness, with discouraging results. In November 1935, under Moniz's direction, surgeon Pedro Almeida Lima drilled a series of holes on either side of a woman's skull and injected ethanol to destroy small areas of subcortical white matter in the frontal lobes. After a few operations using ethanol, Moniz and Almeida Lima changed their technique and cut out small cores of brain tissue. They designed an instrument which they called a leucotome and called the operation a leucotomy (cutting of the white matter). They started a psychosurgery program at George Washington University in 1936, first using Moniz's method but then devised a method of their own in which the connections between the prefrontal lobes and deeper structures in the brain were severed by making a sweeping cut through a burr hole on either side of the skull. Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in psychiatric hospitals. Freeman's patients included 19 children, one of whom was 4 years old. The 1940s saw a rapid expansion of psychosurgery, in spite of the fact that it involved a significant risk of death and severe personality changes. By the end of the decade, up to 5000 psychosurgical operations were being carried out annually in the US. Since then, a few facilities in some countries, such as the US, have continued to use psychosurgery on small numbers of patients. In the US and other Western countries, the number of operations has further declined over the past 30 years, a period during which there had been no major advances in ablative psychosurgery.

Lena Zavaroni (1963–1999), Scottish child star and singer who had suffered from anorexia and depression for many years, underwent a stereotactic anterior capsulotomy at the University of Wales Hospital in Cardiff in 1999. She died of pneumonia three weeks later. Josef Hassid: Polish violin prodigy who died at 26 following psychosurgery. Rosemary Kennedy: Walter Freeman's most famous patient and sister of President John F. Kennedy. She was left with permanent mental incapacity as a result of the procedure, unable to speak or walk. Rose Williams: Sister of Tennessee Williams. Howard Dully: One of Walter Freeman's youngest patients, author of My Lobotomy (2007).