Psychiatric Neurosurgery: A Survey on the Perceptions of Psychiatrists and Residents.

OBJECTIVES: To evaluate the attitudes and perceptions of psychiatrists and psychiatry residents regarding neurosurgical procedures for treating psychiatric disorders and to identify potential barriers to patient referral. METHODS: A survey consisting of 25 questions was created using SurveyMonkey and was distributed to psychiatrists and psychiatry residents in Quebec. The study was approved by the McGill University Health Center's Research Ethics Board. Descriptive statistics and Friedman's test were performed using SPSS software. RESULTS: A total of 99 participants, including 64 residents and 35 psychiatrists, completed more than 75% of the survey and were included in data analysis. Overall, participants were significantly (p < 0.0005) more comfortable in referring patients suffering from treatment-resistant obsessive-compulsive disorder than from treatment-resistant major depressive disorder and preferred to refer patients for deep brain stimulation (DBS) rather than for anterior cingulotomy/capsulotomy (AC). Only 11.43% of psychiatrists had ever referred a patient for AC or DBS, and 34.69% of respondents felt that these procedures were dangerous. Lack of knowledge (82.83%) was viewed as the principal limiting factor, and 57.58% of respondents identified ≥6 different barriers to patient referral. The majority of participants (69.39%) were interested in improving their knowledge on psychiatric neurosurgery, and 82.65% felt that this subject should be included in the psychiatry residency curriculum. CONCLUSION: Overall, participants acknowledged having many limitations to referring patients for neurosurgical interventions. While informative conferences discussing neuromodulation/neuroablation could easily address many barriers, further studies are required to assess how these could change attitudes and patterns of referral.

Reader comments to media reports on psychiatric neurosurgery: past history casts shadows on the future.

BACKGROUND: Comments made by readers in response to news articles about current events can provide profound insights into public understanding of and perspectives on those events. Here, in follow up to a paper published last year in this journal, we examined reader comments to articles in newspapers and magazines about neurosurgical interventions for treating psychiatric illness. METHOD: We conducted a thematic analysis of these comments (N = 662 coded units of data) posted in response to 115 newspaper and magazine articles from four countries (Canada, USA, Germany, and Spain) between 2006 and 2017. The comments were coded using an iteratively refined coding scheme that was structured around four a priori categories based on results from the parent study and two new categories that emerged. RESULTS: We found many references to historical psychosurgery and mostly negative and pessimistic comments about ablative neurosurgical interventions. Comments to deep brain stimulation were more positive, and comments to optogenetics most controversial. We also found many expressions of distrust of medical professionals in the context of interventions on the brain and concerns about social and individual control. CONCLUSIONS: Overall, results suggest there is still much work to be done to raise public awareness about re-emerging and new neurosurgical interventions. Balanced discussion is needed if these approaches are to find a place in health care for psychiatric disorders.

The contemporary practice of psychiatric surgery: results from a global survey of functional neurosurgeons.

BACKGROUND: Interest in neurosurgery for psychiatric diseases (NPD) has grown globally. We previously reported the results of a survey of North American functional neurosurgeons that evaluated general attitudes towards NPD and the future directions of the field. OBJECTIVES: The purpose of this study was to expand on our previous work and obtain a snapshot in time of global attitudes towards NPD among practicing functional neurosurgeons. We measure general and regional trends in functional neurosurgery and focus specifically on surgery for mind and mood, while exploring the future prospects of the field. METHODS: We designed an online survey and distributed it electronically to 881 members of the following international organizations: World Society for Stereotactic and Functional Neurosurgery, European Society for Stereotactic and Functional Neurosurgery, Asian-Australasian Society for Stereotactic Functional Neurosurgery and the South and Latin American Society for Stereotactic and Functional Neurosurgery. Subsequent statistical and thematic analysis was performed on the data obtained. RESULTS: Of 881 surveys distributed, 106 were returned (12.8%). Eighty-two percent of functional neurosurgeon respondents were fellowship trained, with movement disorders and pain making up the majority of their practice. Psychiatric indications are the most frequently treated conditions for 34% of survey respondents, and over half of participants (51%) perform epilepsy surgery. Of the psychiatric conditions, obsessive-compulsive disorder and depression are the most common disorders treated. The majority of respondents (90%) felt optimistic about the future of NPD. Two thirds cited the reluctance of psychiatrists to refer patients as the greatest obstacle facing the field, and a majority reported that a cultural stigma surrounding psychiatric diseases exists in their community. In response to hypothetical situations involving cognitive and personality enhancement, opinions varied, but the majority opposed enhancement interventions. Regional variations were examined as well and uncovered distinct attitudinal differences depending on geographic location. CONCLUSIONS: Surgery for psychiatric conditions is an expanding field within functional neurosurgery. The opinions of international functional neurosurgeons were largely in line with those of their North American colleagues. Optimism regarding the future of NPD predominates, and future editions of this survey can be used to track the evolution of neurosurgeons' attitudes towards NPD and neuroenhancement.

Assessing evidence quality in research reporting neurocognitive outcomes following paediatric temporal lobe surgery for epilepsy.

PURPOSE: RCTs are the gold standard in determining intervention efficacy with journal impact factor assumed to index research quality. Flint et al's (2017) systematic review examined neurocognitive outcomes following paediatric temporal lobe epilepsy surgery. Retrieved evidence was restricted to non-RCTs, which pose greater risk of bias and thus diminish research quality. The current study evaluated risk of bias in sources retrieved by Flint et al. and explored whether impact factor related to research quality within this selected field. METHODS: Methodological and reporting bias was evaluated using categories of bias specified by Cochrane. The relationship between the identified number of biases and journal impact factors of retrieved sources was examined. RESULTS: All studies carried substantial risk for bias. Methodology bias included low sample size (76.71%; 56/73), risk of confounding cognitive outcomes due to failure to report pre-surgery neurocognitive data (21.92%; 16/73) and to determine whether patients were prescribed antiepileptic drugs at follow-up (53.42%; 39/73). Reporting bias included overstating claims based on findings (53.42%; 39/73), failure to report individual patient characteristics (66%; 33/50) and omitting the nature of surgical interventions (15.07%; 11/73). The number of sources of common bias within studies was not associated significantly with journal impact factor (p = .878). CONCLUSION: This evaluation highlights risk of bias when sources are predominantly uncontrolled non-RCTs and provides evidence that journal impact factor is not a reliable indicator of quality within this field. Authors should limit bias in their methods and reporting of results, to ensure the highest quality evidence possible is used to inform treatment decisions and prognosis.

A prospective study of anxiety with respect to seizure outcome after epilepsy surgery.

PURPOSE: To evaluate if degree of anxiety proneness is affected by seizure outcome after epilepsy surgery. METHODS: Five scales related to anxiety, which are part of the Karolinska Scales of Personality (KSP), were administered pre-operatively and 2-8 years post-operatively to 31 female and 26 male patients. High scores indicate a high degree of anxiety. Seizure outcome was either Engel I or Engel II-IV. RESULTS: Mean age of the patients was 39 years (S.D. 10). Forty-seven patients had temporal surgery and 10 patients had extra-temporal surgery. The outcome in 34 patients was classified as Engel I and in 23 patients as Engel II-IV. There were statistically significant decreases (paired t test) in t scores for the Somatic Anxiety scale (expected mean 50, from 55.4 to 50.2, P = 0.001) and the Psychic Anxiety scale (expected mean 50, from 56.2 to 51.6, P = 0.006) in patients in Engel I. No other significant differences were observed. After taking baseline imbalances into account (ANCOVA), there were no statistically significant differences in the change in degree of anxiety proneness between patients in the two outcome groups. CONCLUSION: Patients undergoing successful epilepsy surgery experienced small decreases in somatic anxiety and psychic anxiety. Since there were important pre-operative imbalances between the two outcome groups, these differences could not be attributed to the effect of seizure freedom after epilepsy surgery.

Evita's lobotomy.

For 60 years, the details about Eva Perón's illness and lobotomy at the end of her life have been obscured from the public. Here, we examine the sociopolitical factors that may have contributed to this secrecy. The first involves Eva Perón's political status and the personality cult surrounding her image, including partisan efforts to present her as a patron saint of Peronism. The second involves the social perceptions, which are often stigmatizing, regarding disease in political or public figures. Notably, neuropsychiatric illness and associated indications for treatment were viewed as oligarchic by the Perón regime, and admission to a lobotomy may have been perceived as anti-Peronist. A third factor involves the growing ignominy of prefrontal lobotomy as a surgical modality, which may have precluded operative exposés. A final factor may be that Eva Perón's lobotomy was in fact performed for behavior and personality modification, and not just for pain control. A brief history of lobotomy is presented, highlighting its adoption as a procedural panacea for psychiatric illnesses, relief of intractable pain from cancer, and management of belligerent behavior, and its subsequent fall from clinical favor. Although a shroud of secrecy still surrounds Eva Perón's prefrontal lobotomy, these factors provide a potential rationale for the circumstances, as well as foster a discussion of cultural elements that may still play a role in the public perception of psychosurgery today.

Leucotomized and nonleucotomized schizophrenics: comparison on tests of attention.

Deficits in attention have been strongly linked with both schizophrenia and pathology in the prefrontal cortex. This observation was tested by administering a battery of commonly used tests of attention, sustained mental activity, and tracking to 16 patients who had undergone prefrontal leucotomy approximately 25 years earlier. Presurgical diagnosis in each patient was schizophrenia. The 16 were divided into three groups based on their recovery after surgery. A control group of nonleucotomized schizophrenics was established to control for psychiatric symptomatology. A second control group consisted of subjects without history of psychiatric or CNS disorder. In general, there was no statistically significant impairment of performance in attention tests between the patients with prefrontal psychosurgery and the normal control subjects. The nonoperated schizophrenic control group performed most poorly. Lesion chronicity, interaction of leucotomy and presurgical psychiatric state, and conditions of test administration are suggested as possible explanations for the unexpected results.

Do I know you? Face perception and memory in patients with selective amygdalo-hippocampectomy.

In 1968, Milner (Neuropsychologia 6 (1968) 191) demonstrated a face-memory impairment in patients with right, but not left, temporal-lobe excisions. Because all the removals included lateral and inferior temporal neocortex together with amygdala, parahippocampal gyrus and varying amounts of hippocampus, a combined-lesion effect could not be ruled out. We therefore examined the contribution of right temporal structures to recognition of previously unfamiliar faces by repeating Milner's original study, testing patients who had undergone selective amygdalo-hippocampectomy (AH), in addition to those with anterior temporal-lobectomy (TL). The paradigm involved selecting 12 previously studied faces from an array of 25 photographs. The Mooney Closure Faces Test was also administered. Subjects included 29 AH patients (14 left (LAH) and 15 right (RAH)) and 59 TL patients (30 L and 29 R) who were categorized further based on extensive (18 LTH and 21 RTH) or minimal (12 LTh and 8 RTh) hippocampal encroachment. Twenty age- and education-matched normal control subjects (NC) were also tested. For the face-memory task, one-way ANOVA revealed a strong group effect (P<0.001), and post-hoc tests confirmed that both the RTH and RAH groups recognized fewer faces than the NC and LAH groups; the RAH group also differed from the LTh, LTH and RTh groups. No group differences were found for the closure test. Our findings suggest that right medial temporal-lobe structures are critically involved in the retention, but probably not in the perception, of new faces.

Redundancy gains for visual search after complete commissurotomy.

Redundant-targets effects (RTE) for visual search were investigated in 2 commissurotomy patients (L.B., N.G.). L.B., who showed no evidence of visual interhemispheric transfer, exhibited a paradoxical enhancement of the redundancy gain in the bilateral compared with the within-hemifield redundant-targets conditions, whereas N.G., who showed evidence of interhemispheric transfer of visual information, exhibited no enhancement of the bilateral redundancy gain. When only uncrossed responses were considered, both bilateral and within-field RTE were evident only when attentional demands were high. Bilateral redundant targets led to stronger gains, some indicative of coactivation, in the slower response hand. The authors suggest that the enhancement of the bilateral RTE comes about by neural coactivation, which is especially pronounced when the slower hemisphere elicits the response.

Epilepsy neurosurgery: a patient's perspective.

Contemplation of epilepsy neurosurgery for a patient with lifetime epilepsy poses difficult decisions and can be quite fearful. As epileptologists, we often do not appreciate the degree of patients' concerns, especially whether quality of life could be worsened by surgical complications. In this poem, a patient lyrically describes this dilemma.

Epilepsy brain surgery: a Pittsburgh perspective.

The views of the authors are presented about the past history and recent situation of epilepsy brain surgery in the United States. Issues of efficacy and quality of life are reviewed, and little empirical evidence is found supporting epilepsy brain surgery as a cost-effective treatment modality. Prospective randomized clinical trials have not been run to address these issues and various problems with patient recruitment and funding seem destined to preclude them.

Practical problems of epilepsy management in children.

The problems associated with the investigation, diagnosis and treatment of epilepsy in children are considered in this paper, together with aspects of intellectual development. In addition, the difficulties encountered in family and school environments are reviewed. The problems which arise when medication is discontinued, and the possible importance of the loss, as well as the acquisition, of a condition, are also discussed.

Psychosocial function following temporal lobectomy: influence of seizure control and learned helplessness.

Learned helplessness is the perception that one's behaviour cannot produce a desired outcome. Individuals with intractable epilepsy who have learned that the occurrence of a seizure is beyond their control can develop such a helpless attitude with cognitive, affective and behavioral components which may generalize to many aspects of life. Post-operative testing was done on 42 patients, aged 17-60 years with I.Q. > 80 who had temporal lobectomies (25 R, 17 L) with follow-up 1-14 years (mean 5 years). In addition to seizure outcome, psychosocial adjustment was measured using the Washington Psychosocial Inventory (WPSI) and a structured interview. Three variables of learned helplessness were also assessed: internal or external locus of control, resourcefulness, and depression. Seizure outcome was: completely seizure free, 36%; > 90% improvement, 38% < 90% improvement, 26%. Overall post-operative psychosocial adjustment was good, marked improvement in lifestyle was noted by 85%, personality change for the better by 65% and improved mood by 47%. A transient mood disorder was noted by 38% in the first six months following surgery. Psychosocial adjustment was better in patients who were seizure free or had > 90% reduction in seizures compared to those with < 90% improvement. Two measures of learned helplessness, depression and lack of resourcefulness correlated with poor postoperative psychosocial adjustment. Other variables beside seizure control must be considered in determining the ultimate outcome of epilepsy surgery.

The new Maudsley series of temporal lobectomy. I: Short-term cognitive effects.

Cognitive effects of temporal lobectomy for the relief of focal seizures were examined in 59 adult cases (29 left and 30 right). Verbal and non-verbal intelligence and memory were tested pre-operatively and four weeks post-operatively. Slight, non-significant differences between left and right cases pre-operatively were added to by slight, non-significant differences in change across the operation, to produce some significant post-operative differences--right cases being significantly higher on verbal IQ and lower on non-verbal IQ, for example. Variation in cognitive outcome was related to certain subject variables. Those who showed no deterioration or more improvement across the operation tended to be younger, less intellectually able pre-operatively, had an earlier first seizure and an earlier onset of regular seizures. The implications of these results for a model of the effects of temporal lobectomy are discussed.

Felonious sex crime: the possibility of unilateral cerebral irradiation for the offenders.

Some felonious sex crimes might result from compulsions that the perpetrator finds impossible to control. Under judicial systems derived from British law, the court should be extraordinarily careful in mandating any medical procedure. However, if a rapist or child molester voluntarily asks a physician for help, then medical ethics might allow destruction of part of the patient's brain for the purpose of controlling compulsive behaviour. The part of the human brain primarily associated with volition might be near the anterior cingulate sulcus. Could unilateral irradiation of an area near the anterior cingulate sulcus partially destroy the patient's volition? By leaving intact the patient's will based on language and by partially destroying the patient's will based on intuition, could the physician diminish the patient's will to commit felonious sex crimes? Would some patients reject chemical castration but accept unilateral irradiation of an area near the anterior cingulate sulcus?

Using a multidisciplinary follow-up program to assist patient adjustment following temporal lobectomy.

A follow-up program for patients following temporal lobectomy for seizure control was established in 1983 at the UCLA Neuropsychiatric Hospital in response to patients' requests for information and assistance. The purpose of this program was to identify changes requiring adaptation and to offer assistance. Forty patients were contacted monthly by telephone for one year after surgery. They were interviewed by either a nurse or occupational therapist about medical and psychosocial issues. The information, support or referral needed were provided by the nurse, occupational therapist or social worker in consultation with appropriate member(s) of the multidisciplinary team. Problems encountered when beginning a less disabled lifestyle might not have been detected or resolved without active intervention through a multidisciplinary follow-up program.

Quality of life of people with epilepsy following temporal lobectomy: a preliminary report.

This is a preliminary report of the quality of life of 9 people, 5 men and 4 women, in Hong Kong who underwent temporal lobectomy for seizure control. The Chinese version of World Health Organization Quality of Life Measure Abbreviated Version, validated in Hong Kong, was used as the outcome measure. Analysis suggested that the quality of life of these participants after successful temporal lobectomy was poorer than that of 157 healthy controls in the physical and psychological domains as measured. This suggests that other factors in addition to achieving complete seizure control play significant roles in promoting the quality of life of such patients.

[Dynamic syndrome formation in patients with schizophrenia in the late period after a prefrontal leucotomy]. / Dinamika sindromoobrazovaniia u bol'nykh shizofreniei v otdalennom periode posle provedeniia prefrontal'noi leikotomii.

The authors analyze the course of the underlying process after prefrontal leucotomy in 15 patients with schizophrenia. Types of syndrome transformation are analyzed on the basis of a long-term follow-up (30 years). Three variants of the course of the underlying disease and the initial status of patients are described. Destructive postoperative morphological changes in the brain are examined by unidimensional echoencephalography. The relationship between classical leucotomy and modern methods of psychosurgery is considered.