Address for Dr. Rauch:
Department of Psychiatry
Massachusetts General Hospital
Building 149-13th Street-Floor 9
Charlestown , Massachusetts
(617) 726-6766

INTRODUCTION

Since its introduction as a treatment for severe mental illness in 1936, psychosurgery has at varied times been enthusiastically embraced and flatly rejected by both the medical profession and society at large. Currently, the accepted therapeutic approach to most psychiatric disease involves a combination of well-supervised psychotherapy, pharmacotherapy and, in some instances, electroconvulsive therapy. However, despite these modern treatment methods, many patients fail to respond adequately and remain severely disabled. In these patients, surgical intervention might be considered appropriate if the therapeutic result and overall level of functioning could be improved.

In this chapter, we will explore the historical background of psychosurgery and discuss the anatomic and physiologic basis for such procedures. Guidelines for the appropriate selection of surgical candidates will be presented and the four most common psychosurgical procedures practiced today will be described. Finally, the overall experience including indications, results and complications for each procedure will be reviewed and compared.

HISTORICAL PERSPECTIVE

Although trephination performed by ancient civilizations may represent the earliest form of surgical intervention for psychiatric disease, psychosurgery's first use in modern times was reported by Burkhardt in 1891. He described bilateral cortical excision in the treatment of six demented and aggressive patients with mixed results. Following this report, several other neurosurgical procedures were attempted for the treatment of the mentally ill.(Puusepp, Hollander) In 1935, Fulton and Jacobson presented their early experience with primate behavior following ablation of the frontal cortices. They observed that the lobectomized animals demonstrated less "experimental neurosis" to task failures, although they were also less able to complete the tasks successfully. These observations prompted Egas Moniz, the inventor of cerebral angiography, to perform prefrontal leucotomies by injection of absolute alcohol with the help of his neurosurgical colleague, Almeida Lima. Moniz reported that 14 of 20 severely ill, institutionalized patients showed "worthwhile" improvement after operation and coined the phrase ' psychosurgery ' to describe his interventions. ( Moniz, 1937)At that time, few satisfactory treatment options existed and the asylums for the insane were overflowing with the chronic mentally ill. Therefore, despite the lack of objective data and long term follow-up, an enthusiastic response was obtained from the medical community. This response resulted in Moniz receiving the 1949 Nobel Prize in Medicine and Physiology.

One of the most enthusiastic proponents of the procedure was Walter Freeman, a neuropsychiatrist, and within a few months of Moniz's publication, Freeman performed the first prefrontal lobotomy in the United States with the neurosurgical help of James Watts. The Freeman-Watts prefrontal lobotomy was performed through bilateral burr holes placed in the inferior frontal region at the level of the coronal suture. This disconnection procedure was carried out with a specially designed calibrated leucotome that was inserted blindly to the midline and swept back and forth to surgically interrupt the white matter tracts in the frontal lobes. In reporting their results on the first 200 patients in 1942, Freeman and Watts were favorably impressed although they did admit to a significant complication rate including frontal lobe syndrome, seizures, apathy, decreased attention and inappropriate behavior. Despite these side effects, prefrontal lobotomy became widely performed throughout the United States largely because of the lack of satisfactory therapeutic alternatives and the promotional zeal of Freeman himself.

Tooth and Newton reviewed 10,365 standard prefrontal lobotomy operations performed between 1943 and 1954 and confirmed that the rate of " improvement " was about 70% but also reported a 6% mortality, 1% epilepsy rate and 1.5% marked disinhibition. These complications prompted Fulton and others to call for a less radical and more specific approach to the surgery.(Fulton 1951) By the late 1940's more precise open surgical procedures were described including bilateral inferior leucotomy, bimedial leucotomy and orbital gyrus undercutting. Cerebral topectomies and anterior cingulectomies were also proposed and carried out during the same period. At the same time, Freeman described a new technique of "transorbital leucotomy" which involved inserting a small right angled instrument under the eyelids and pushing it through the bony orbit into the frontal orbital cortex with a sweeping motion to sever the thalamo-frontal radiations. This so called " ice pick procedure " could be performed quickly and with minimal anesthesia which led to its ready acceptance and widespread use. The broad and somewhat indiscriminate application of this particular technique contributed to the subsequent decline of pyschosurgery.

The next major advance in the neurosurgical treatment of psychiatric illness occurred with the introduction of stereotactic techniques to create well localized and discrete lesions in specific target sites. Stereotactic anterior cingulotomy was first reported by Foltz and White in 1962 and subcaudate tractotomy carried out in England by Knight in 1964. Lars Leksell described his experience with anterior capsulotomy in 1972 and Kelley reported limbic leucotomy (subcaudate tractotomy and cingulotomy combined) in 1973. Isolated reports of hypothalamotomy, bilateral amygdalotomy and thalamotomy can also be found in the literature during this same time period.

With the introduction of chlorpromazine in 1954, satisfactory medical management of psychiatric illness became possible. The availability of effective drug therapy in combination with the side effects of surgical intervention and its excessive use in the preceeding decades led to the sudden and almost complete disappearance of pyschosurgery for mental illness. Despite newer and even more specific psychotrophic medications, there remains a small percentage of patients with treatment refractory psychiatric disease that might be considered for surgical treatment. However, because of the ethical, legal and social implications of psychosurgery, only a limited number of surgical procedures are carried out at a handful of medical centers in the world today.

ANATOMIC AND PHYSIOLOGIC RATIONALE FOR PSYCHOSURGERY

In 1937, a year after Moniz reported his initial experience with prefrontal lobotomy, Papez published his paper entitled "A Proposed Mechanism of Emotion" in which he postulated that a reverberating circuit in the brain might be responsible for emotion, anxiety and memory. The components of this circuit consisted of the hypothalamus, septal area, hippocampus, mamillary bodies, anterior thalamic nuclei, cingulate gyri and their interconnections. These structures comprise the rudimentary limbic system of the human brain which was subsequently expanded by McLean in 1952 to incorporate the orbital frontal, insular and anterior temporal cortices, the amygdala and dorso-medial thalamic nuclei. As illustrated in the previous section, neurosurgical interventions for psychiatric disorders have all been directed at various targets within this system and therefore some have proposed the term ' limbic system surgery ' as an alternative to psychosurgery.

Although the neuroanatomical and neurochemical basis of emotion in health and disease remains undefined, there is evidence that this system and its interconnections with the cortico-striato-thalamic circuits play a central role in the pathophysiology of major affective illness, obsessive-compulsive disorder and other anxiety disorders. [Nauta]. Electrical stimulation of specific areas within the limbic system i.e. the anterior cingulum, has been shown in humans to alter both autonomic responses and anxiety levels [Kelly and Laitinen]. Stimulation of the hypothalamus in animals produces autonomic, endocrine and complex motor effects which suggest that the hyptohalamus integrates and coordinates the behavioural expression of emotional states. (Ranson and Hess) The Papez circuit represents the direct conduit to the hypothalamus. Paralimbic structures which include anterior temporal, insular, and parahippocampal cortex as well as anterior cingulate and medial orbito-frontal cortex form the link between heteromodal cortex and the limbic system proper. (mesalum) Thus, the limbic system appears strategically located to mediate and interconnect somatic and visceral stimuli with higher cortical functions and in this way may "add emotional coloring to the psychic process". Therefore, it is intuitively appealling, to believe that psychiatric disorders that are characterized by affective and cognitive manifestations (eg. depression, OCD, and other anxiety disorders) might reflect a final common pathway of limbic dysregulation. Contemporary neurobiological models of anxiety and affective disorders also emphasize the fundamental role of the limbic system and its related structures. (Gorman et al,Charney etal, Modell etal)Nauta, Gray, Warburton, Pitman, Reiman and Moddell].

Data from neuropyschological, neurosurgical, physiological and neuroimaging studies have also converged to implicate a circuit composed of orbitofrontal cortex, striatum, thalamus and anterior cingulate cortex in the pathophysiology of OCD( Modell, Baxter 1990, Baxter et al 1992, Insel etal, Rauch and Jenike, Rauch et al 1994) This frontal-striatal-pallido-thalamic-frontal loop which has been so well characterized for its control of motor function may well explain some features of OCD as many similarities exist between OCD and the pathology seen in Sydenhams chorea, Von Economos disease, focal striatal abnormalities and Tourettes syndrome. Anatomic imaging with MRI has suggested focal abnormalities in these striatal areas[Weilberg, 1989] and smaller caudate nuclei in patients with OCD.(LUxinber1988) Functional neuroimaging research has also suggested that abnormal activity in the lateral frontal cortex is a correlate of the depressive state (Baxter et al 1989), in concert with the presumed role of the limbic system.

Neurochemical models suggest that the affective and anxiety disorders may be mediated via monoaminergic systems. In particular, the serotonergic system has received emphasis with respect to OCD. Because of the diffuse nature of the monoaminergic projections and their role as neuromodulators, however, these models are not particularly instructive in terms of the functional neuroanatomy relevant to different neurosurgical treatments as they are currently employed. Although the exact neuroanatomical and neurochemical mechanisms underlying depression, OCD and other anxiety states remain unclear, it is believed that the basal ganglia, limbic system and frontal cortex play a principal role in the pathophysiology of these diseases.

SELECTION OF PATIENTS

Only patients with severe, chronic, disabling and treatment refractory psychiatric illness should be considered for surgical intervention. Chronicity in this context refers to the enduring nature of the illness without extended periods of symptomatic relief. Moreover, the severity of the patient's illness must be manifest both in terms of subjective distress and a decrement in psycho-social functioning. In many cases, the chronicity of the illness may be less important than the severity of the illness. The illness must prove to be refractory to systematic trials of pharmacologic, psychologic and when appropriate, electroconvulsive therapy prior to considering neurosurgical intervention. As in all medical decisions, the potential benefit from such an intervention must be balanced against the risks imposed by surgery.

The major psychiatric diagnostic groups as defined by the DSM-III-R that might benefit from surgical intervention include 1.) obsessive compulsive disorder and 2.) major affective disorder (ie. major depression or bipolar disorder). In many instances patients present with mixed disorders combining symptoms of anxiety, depression and OCD and these patients remain candidates for surgery. Schizophrenia is not currently considered an indication for surgery. A history of personality disorder, substance abuse or other Axis II symptomatology is often a relative contraindication to surgery. In rare instances only, patients with severe violent outbursts and the potential for serious injury or self mutilation, might be considered for bilateral amygdalotomy, thalamotomy or hypothalamotomy.

Thoughtful assessment of psychosurgical candidacy requires that criteria for severity, chronicity, disability and treatment refractoriness be operationalized to form guidelines. In this regard, chronicity would require at least one year of enduring symptoms without significant remission although practically speaking confirmation of treatment refractoriness usually requires over five years of illness prior to surgery. Severity is usually measured using validated clinical research instruments corresponding to specific indicators such as a Yale-Brown Obsessive Compulsive Scale (YBOCS) score of >20 for OCD or a Beck Depression Inventory (BDI) score > 30. Disability may be reflected, for instance, by a Global Assessment of Function (GAF) score of <50.

In order to determine that their psychiatric illness is refractory to treatment despite appropriate care, all patients must be referred for surgical intervention by their treating psychiatrist. The referring psychiatrist must demonstrate an ongoing commitment to the patient and the evaluation process and must also agree to be responsible for post-operative management. Detailed questionnaires that document the extent and severity of the illness as well as a thorough account of the diagnostic and therapeutic history must be provided by the psychiatrist. The specifics of pharmacologic trials should include the agents used, dose, duration, response and the reason for discontinuation for any suboptimal trial. Adequate trials of electroconvulsive therapy or behavioral therapy when clinically appropriate must also be demonstrated.

The patient and their family must also agree to participate completely in the evaluation process as well as the post-operative psychiatric treatment program. In general, only adult patients [greater than 18 years] who are able to render informed consent and who express a genuine desire and commitment to proceed with surgery are accepted. Obviously, the surgery should only be performed to help a sick patient and never for social or political reasons.

If the patient meets the above criteria, at our institution they would undergo a more detailed presurgical screening evaluation by an experienced, multidisciplinary group of psychiatrists, neurosurgeons and neurologists (Cingulotomy Assessnment Committee). Thorough review of the medical record is carried out to insure that the illness is indeed refractory to an exhaustive array of conventional therapies. The MGH evaluation also includes an electroencephalogram (EEG), brain MRI, neuropsychological testing and independently conducted clinical examinations by a psychiatrist, neurologist and neurosurgeon in the outpatient setting. Electrocardiogram and appropriate blood tests are obtained to assess medical risks and to exclude organic etiologies for mental status abnormalities. Validated clinical research instruments are employed to quantify psychiatric symptom severity. There must be unanimous agreement that the patient satisfies selection criteria, that the surgery is indicated and that the requirements for informed consent are fulfilled. A family member or close relative must also understand the evaluation process, the indications for, risks of and alternatives to surgery and agree to be available to provide emotional support for the patient during the hospitalization.

SURGICAL APPROACHES

While many methods have been utilized in the neurosurgical treatment of psychiatric disease, four procedures have evolved as the safest and most effective. These are all performed bilaterally and under stereotactic conditions to allow for precise lesioning of target structures. They include: 1.) Anterior cingulotomy. 2.) Subcaudate tractotomy. 3.) Limbic leucotomy. 4.) Anterior capsulotomy. Each procedure has different indications, techniques, results and complications which will be discussed in the following sections.

Subcaudate tractotomy

Subcaudate tractotomy was introduced by Knight in Great Britain in 1964 as one of the first attempts to restrict the size of the surgical lesion and therefore minimize the side effects seen with standard prefrontal lobotomy. The aim was to interrupt white matter tracts between orbital cortex and subcortical structures by placing a lesion in the region of the substantia innominata just below the head of the caudate nucleus. Surgical indications included major depressive illness, obsessive compulsive disorder and anxiety states as well as a variety of other psychiatric diagnoses.

The surgical procedure was performed using stereotactic technique using boney landmarks and ventricular outline. Target coordinates were calculated as 15 mm from the midline and approximately 10 - 11 mm above the planum sphenoidale at the most anterior part of the sella turcica. Lesions were created using radioactive implantableYttrium 90 seeds. Lesional volumes were estimated at approximately 2000 mm2.

In patients with depression and OCD, total improvement or improvement with minimal symptoms was clinically observed in two thirds of the patients. The best review of the surgical results for subcaudate tractotomy was presented by Goktepe in 1975. Using a five point global scale and rating scales for depression and anxiety they reviewed 208 patients with a mean follow up of 2.5 years. Of the 134 patients available for structured interview, good results were seen in 68% of patients suffering from depression, 62.5% of patents with anxiety states and 50% of patients with obsessive neurosis. Patients with schizophrenia, personality disorder, drug abuse or alcohol abuse did poorly. Some patients who had only temporary benefit from the initial lesion had second lesions created lateral to the first with good results seen in about half.

The incidence of complications was small but included post-operative seizures in 2.2 % and undesirable personality traits in 6.7 %. Transient disinhibition was common. Of the 25 patients that had died at the time of review, 3 patients had committed suicide. One patient died from inadvertent destruction of the hypothalamus when an yttrium seed migrated off target.

Anterior Cingulotomy

Fulton was the first to suggest that the anterior cingulum would be an appropriate target for psychosurgical intervention and cingulotomy was initially carried out as an open procedure. Foltz and White reported their experience with stereotactic cingulotomy for intractable pain and noted the best results were in those patients with concurrent anxiety-depressive states. Ballantine subsequently demonstrated the safety and effectiveness of cingulotomy in a large number of patients and it has been the surgical procedure of choice in North America over the last 30 years. Currently, the surgical indications are treatment refractory major affective disorder, chronic anxiety states or OCD. The procedure is still performed on occasion for some patients with severe chronic pain.

Initially these procedures were carried out with ventriculography but over the past several years this has been replaced by MRI guided stereotactic techniques. Target coordinates are calculated for a point in the cingulum 7 mm from the midline and 20 - 25 mm posterior to the tip of the frontal horns. Lesions are created by thermocoagulation, the technical details of which have been well described previously. Intraoperative stimulation is not performed routinely but neurological testing is carried out during lesioning to insure that no impairment of motor or sensory function especially in the lower extremities is incurred. On the day after surgery, a post-operative MRI scan is obtained to document the placement and extent of the lesions [Figure 1].

Although the patient may experience an immediate reduction in anxiety, there is generally a delay to the onset of beneficial effect on depression and obsessive compulsive disorder. This latency may be as long as six to twelve weeks and must be clearly explained to the patient and referring psychiatrist. If there has been no response to the initial cingulotomy after three to six months, then reoperation and enlargement of the cingulotomy lesion is considered.

The results of bilateral cingulotomy in 198 patients suffering from a variety of psychiatric disorders were reported retrospectively by Ballantine et al in 1987. With a mean follow-up of 8.6 years, 62% of patients with severe affective disorder were found to have had worthwhile improvement. Similarly, in patients with obsessive compulsive disorder approximately 56% were found to have undergone worthwhile improvement. In 14 patients suffering from nonobsessive anxiety disorders 50% were found to be functionally well and 29% were found to have shown marked improvement. A recent retrospective study evaluating cingulotomy in 33 patients with refractory obsessive compulsive disorder demonstrated that using very strict criteria for successful outcome, at least 25 to 30% of patients benefited substantially from the procedure. [Jenike and Baer, 1991]. In a prospective long term follow-up study of 18 patients who underwent cingulotomy for intractable OCD, five patients met very conservative criteria as treatment responders and two others were considered possible responders. [Baer and Rauch, submitted] Overall, the entire group improved significantly in terms of functional status and no serious adverse effects were found This is the first study to demonstrate in a prospective way that cingulotomy is effective in OCD as measured by standard psychiatric rating scales and independant observers.

In over 800 cingulotomies performed at the MGH since 1962, there have been no deaths and no infections. Two acute subdural hematomas occurred early on in the series secondary to laceration of a cortical artery at the time of introduction of ventricular needles but only one patient suffered permanent neurologic impairment. An independent analysis of 34 patients who underwent cingulotomy demonstrated no significant behavioral or intellectual deficits as a result of the cingulate lesions themselves. [Teuber and Corkin] They subsequently evaluated 57 patients before and after cingulotomy and found no evidence of lasting neurological or behavioral deficits after surgery. A comparison of preoperative and post-operative Weschler IQ scores demonstrated significant gains postoperatively. This improvement was greatest in patients with chronic pain and depression but negligible in those with the diagnosis of schizophrenia.

Limbic leucotomy

Limbic leucotomy was introduced by Kelly in 1973 and combines subcaudate tractotomy with anterior cingulotomy. This procedure was designed to disconnect orbital-frontal-thalamic pathways with the former lesion and interrupt an important portion of Papez's circuit with the latter. Kelly et al reasoned that these two lesions might lead to a better result for the symptoms of OCD than either lesion alone. Indications for surgical intervention included obsessional neurosis, anxiety states, depression and a variety of other psychiatric diagnoses.

This procedure was carried out stereotactically and three small (6mm diameter) lesion were placed in the lower medial quadrant of each frontal lobe and two lesions in each cingulate gyrus. Lesions were created using a either cryoprobe or thermocoagulation. Intraoperative stimulation was carried out and if pronounced autonomic responses were observed, this was felt to provide physiologic proof of correct location.

Using the same five point scale described in the study of Gotekpe, 66 patients were assessed pre- and postoperatively (mean 16 mos). In patients with obsessional neurosis, 89 % were clinically improved; in chronic anxiety, 66% were improved; in depression, 78% were improved and in a small number of schizophrenics, over 80% were improved. Kelly later reported in 49 patients with OCD, that 84% were improved 20 months after surgery. They too noted that post-operative symptom improvement was not immediate with a fluctuating but progressive reduction of symptoms over the first postoperative year.

Although many patients complain of lethargy, confusion and lack of sphincter control in the early postoperative period, persistent complications are rare. No patients developed seizures postoperatively, one patient suffered severe memory loss due to improper lesion placement and 12% of patients complained of persistent lethargy. Measurements of IQ showed slight improvement postoperatively.

Anterior capsulotomy

Although Talairach was the first to describe anterior capsulotomy, Leksell popularized the procedure for patients with a variety of psychiatric disorders. The aim was to interrupt presumed fronto-thalamic connections in the anterior limb of the internal capsule where they pass between the head of the caudate nucleus and the putamen. Clinical indications for capsulotomy initially included schizophrenia, depression, chronic anxiety states and obsessional neurosis.

The exact target coordinates as described by Leksell are in the anterior one third of the anterior limb of the internal capsule 5 mm behind the tip of the frontal horns, 20 mm lateral to the midline at the level of the intercommisural plane. Intraoperative electrical stimulation has not been helpful in terms of determining optimal placement of lesions within the capsule. Lesions were created by thermocoagulation using a bipolar electrode system. Several cases were also performed using the Gamma knife.

In the first 116 patients operated on by Leksell, 50% of patients with obsessional neurosis and 48% of depressed patients had a satisfactory response. Only 20% of patients with anxiety neurosis and 14% of patients with schizophrenia were improved. In this classification system, only patients who were free of symptoms or markedly improved were judged as having a satisfactory response. Of the patients who were rated as worse after capsulotomy, 9 were schizophrenics, 4 depressives and 3 obsessives. In another series of 35 patients with OCD who underwent capsulotomy and were followed prospectively by independent psychiatrists, 16 were rated as free of symptoms and 9 were much improved for an overall satisfactory result of 70%. In a review of all cases of capsulotomy previously reported in the literature, Mindus found sufficient data to categorize outcome in 213 of 362 patients. Of these 137 [64%] were deemed to have a satisfactory result.

More recently Mindus has followed 24 patients prospectively with standardized rating scales. Complications of the surgery included transient episodes of confusion during the first week in 19 of 22 patients available for followup with occasional nocturnal incontinence. One patient was noted to have an intracranial hemorrhage without neurological sequelae and one patient suffered seizures. One patient committed suicide in the postoperative phase and 8 patients suffered from depression requiring treatment. Excessive fatigue was a complaint in 7 patients, 4 had poor memory. Two patients showed slovenliness. Weight gain is common after capsulotomy with an overall mean weight gain of about 10% in all patients. No evidence of cognitive dysfunction has been reported in 200 capsulotomy patients studied using a variety of psychometric tests. [Mindus et al] Reoperation was required in 2 patients who did not achieve a satisfactory result with only one improving after the second operation. Burzaco subjected 17 of his 85 patients to a second procedure at which time the lesions were enlarged and half of these reoperations yielded satisfactory results.

Much of the controversy surrounding the use of psychosurgery may be attributed to its rather indiscriminate application and the high incidence of side effects seen with the early procedures. Stereotactic techniques have certainly minimized the side effects of surgery but the issue of case selection remains a major consideration. Although initially any patient with a severe psychiatric illness was once considered a candidate for surgical intervention, it is now clear that the indications for psychosurgery are more restrictive. There is general agreement among centers that patients with major affective disorder, chronic anxiety states and obsessive compulsive disorder are the best candidates for surgery. It can be safely concluded that schizophrenia is not an indication for psychosurgery although patients with concommitant psychotic disorders and depression might still be helped with surgery and should not be excluded. Personality disorders or psychoactive substance use disorder are significant relative contraindications to surgery. Appropriate selection of patients for surgery remains a major issue and the responsibility of the psychiatrist, guided by the informed and expert opinions of the other members of the psychosurgical team.

With currently available data, it is impossible to determine whether there is one optimal surgical technique or strategy. All procedures seem to be well tolerated with minimal side effects or complications when applied with the modern stereotactic techniques. No matter which structure in the limbic system is chosen for ablation, the clinical outcome appears similar.

There are many obstacles that prevent a direct comparison of results across centers. These include diagnostic inaccuracies, nonstandardized presurgical evaluation tools, center bias and varied outcome assessment scales. However, in virtually all published reports, some modification of the Pippard Postoperative Rating Scale or equivalent has been used to determine clinical outcome. The Pippard Scale rates outcome in five categories:


A. symptom free
B. much improved, some symptoms remaining but no additional treatment necessary
C. slightly improved
D. unchanged
E. worse

Although comparisons are imperfect, these scales do appear to have some clinical validity.(Mindus 1991, Waziri, 1990) If category A and B are considered satisfactory outcome, then in patients with OCD, subcaudate tractotomy in 50%, cingulotomy was effective in 56%, limbic leucotomy in 61% and capsulotomy in 67%. In patients with major affective disorder, subcaudate tractotomy in 50%, cingulotomy was effective in 56%, limbic leucotomy in 61% and capsulotomy in 67%.

Kullberg attempted to compare cingulotomy and capsulotomy in the treatment of 26 patients in a randomized fashion. Six of 13 capsulotomy patients and 3 of 13 cingulotomy patients were better but transient deterioration in mental status was much more marked after capsulotomy than after cingulotomy. Recently two prospective studies were concluded that attempted to evaluate the efficacy of cingulotomy and capsulotomy in OCD. Using the best available research methodologies and well accepted rating scales of disease and outcome, exhaustive pre and post operative evaluations were carried out. Of the capsulotomy patients, 45% had clear cut improvement and in cingulotomy patients 39% were improved.

Based upon these methods of comparison, the clinical superiority of any one procedure is not convincing. While many centers claim advantages for their specific surgical intervention, at this point we are unable to determine whether one of the four major psychosurgical procedures is superior to the others. Cingulotomy is the treatment of choice in this country whereas in Europe, capsulotomy and limbic leucotomy are more prevalent. They all appear roughly equivalent therapeuticly but in terms of unwanted side effects, cingulotomy appears to be the safest of all procedures currently performed. Regardless of the choice of procedure, surgical failures should be investigated and if the lesion size or location is suboptimal than consideration should be given to a repeat procedure. In 5 of the 24 patients in Mindus series, a significant correlation was found between neuroradiologic ranking of a target site and the psychiatric outcome suggesting that the site and extent of lesion may be important factors influencing outcome. At least 45% of patients undergoing cingulotomy require repeat operation with good results being salvaged in half. Repeat surgery in capsulotomy patients has been reported as 20%. The exact size or volume of tissue required for an effective outcome at each of the target sites has yet to be determined.

The method used for creating the lesion itself does not appear to influence results or complication rates. There is some interest in the potential use of external radiosurgical techniques for psychosurgery but this remains controversial. Although radiosurgery does not require introduction of a subcortical electrode, it remains a surgical procedure with a small but significant complication rate. Little is known about the exact dosimetry required for satisfactory lesions and the latency to onset of beneficial effect as radionecrosis develops may not be reasonable for patients who are in grave psychiatric condition. In view of the proliferation of radiosurgical centers and the inexperience of these same groups with psychosurgery, the potential for misapplication of this technique is great.

While controversy exists regarding the exact choice of surgical procedure to be employed, there is unanimous agreement that the presurgical evaluation be performed by committed multi-disciplinary teams with expertise and experience in the surgical treatment of psychiatric illness. Diagnosis based upon the DSM classification scheme is encouraged and although it is impossible to mandate uniformly across all centers , prospective trials employing standardized clinical instruments with long term follow-up are needed. Comparisons of preoperative and postoperative functional status remain an important parameter in addition to target psychiatric symptoms, in characterizing outcome. All centers with experience emphasize the importance of rehabilitation postoperatively and the need for ongoing psychiatric follow-up. The operation is not a panacea and should be considered as only one aspect in the overall management of these patients. Despite the advent of new and effective psychopharmacologic agents it is generally felt by centers employing this form of psychosurgery, that the procedure is underutilized. Caution must be urged however regarding the surgical treatment of psychiatric disease to ensure that the indiscriminate application of this form of therapy never recurs.

CONCLUSIONS

The surgical treatment of psychiatric disease can be helpful in certain patients with severe, disabling and treatment refractory major affective disorders, obsessive compulsive disorder and chronic anxiety states. Psychosurgical treatment should only be carried out by an expert multidisciplinary team with experience in these disorders. Surgery should be considered as one part of an entire treatment plan and must be followed by an appropriate psychiatric rehabilitation program. Many patients are greatly improved after surgery and the complications or side effects are few. Surgical intervention remains an important therapeutic option for disabling psychiatric disease and is probably underutilized.

Acknowledgements:

We are indebted to H. Thomas Ballantine Jr MD, Ned Cassem MD and Ida Giriunas RN for their insight, experience and guidance and to Rosemary Dolan for her expert secretarial assistance.

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