Treatment of psychiatric illness by stereotactic cingulotomy.

The treatment of 198 psychiatrically disabled patients with stereotactic cingulotomy was evaluated prospectively for a mean follow-up of 8.6 years. Patients with major affective disorders and anxiety disorders fared the best, with a return to normal functioning in the majority. Patients with obsessive-compulsive disorders, schizophrenia, and personality disorders improved less predictably, with an uneven improvement in functioning that required active ongoing psychiatric treatment. Low mortality and morbidity, a reduction of violent behavior, a possible reduction of suicidal risk, and a lessening of the intractable suffering of chronic psychiatric illness all indicate that cingulotomy can be an effective, safe treatment for patients with affective disorders that are unresponsive to all other forms of therapy.

Arterial hypertension and multiple cerebral aneurysms in a patient treated with electroconvulsive therapy.

The authors successfully instituted two courses of ECT at a 1-year interval for drug-resistant major depression in a patient with arterial hypertension and intracranial aneurysms. Both ECT courses required arterial and central venous cannulas, but the first course was complicated by an unusual and excessive degree of hypertension, which was not appropriately responsive to high doses of sodium nitroprusside (9 micrograms/kg/minute). Appropriate responsiveness to nitroprusside was established after therapy with timolol. The combination of sodium nitroprusside and timolol proved effective throughout the second course of ECT.

Diagnostic decision making.

Diagnostic or screening tests are used to help determine whether or not a patient has a certain condition or disease. The ability of a diagnostic test to correctly classify subjects is expressed by the four test characteristics-sensitivity, specificity, predictive value positive, and predictive value negative. This paper describes these characteristics and discusses methods for choosing optimal tests or cutoff points to maximize expected value considering the consequences of incorrect diagnoses. Data drawn from ongoing studies of facial pain are used to illustrate some of these concepts.

Monoamines in the brain cerebrospinal fluid of facial pain patients.

The purpose of the study was to assay monoamines in cerebrospinal fluid (CSF) obtained from the trigeminal cistern of 64 patients with intractable facial pain. The CSF was analyzed for homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG), end-product markers of activity for the dopamine, serotonin, and norepinephrine systems, respectively. HVA averaged 121 ng/mL in these facial pain patients, compared to 150 to 550 ng/mL in 10 studies of ventricular brain CSF in assorted psychiatric and pain patients. 5-HIAA averaged 29 to ng/mL in our facial pain patients compared to 60 to 120 ng/mL in nine studies of ventricular brain CSF in assorted psychiatric and neurological patients. Trigeminal cistern CSF MHPG averaged 9 ng/mL, similar to the range of 13 studies of lumbar CSF of assorted psychiatric and pain diagnoses. These results indicate that (1) the electrochemical detection method provides a unique way of accurately measuring nanogram concentrations of multiple monoamines in a little as 0.25 mL of CSF; (2) trigeminal cistern and posterior fossa brain CSF monoamine metabolites reflect a different profile of dopaminergic and serotonergic functioning in these facial pain patients from that previously reported with lumbar CSF measurements of other patients; and (3) trigeminal sensory ganglion or brain dopamine and serotonin systems may be concomitantly dysfunctional in intractable facial pain.

Ethics of psychosurgery.

The ethics of psychosurgery involve questions of moral philosophy and pragmatism in alleviating human suffering. The weighing of scientific data along with philosophical oughts and shoulds is required. The medical literature indicates definite efficacy for some kinds of limbic surgery, mainly cingulotomy and capsulotomy, in some kinds of conditions, namely major depression, pain and anxiety. The relative utility of these procedures given the severity of the illnesses and the safety of the procedures described is significant. Ethical and moral conflicts over altruism, autonomy and suffering require recognition before their due considerations (Kleinig 1985). The following recommendations emerge from these considerations: 1. No consideration of ethics in psychosurgery is complete without consideration of both the scientific data and moral conflicts. 2. The considerable efficacy and safety of cingulotomy and capsulotomy must be acknowledged. 3. Indications and contraindications do exist for selecting patients. Major psychiatric Axis I diagnoses of depression and anxiety are the indications. Personality disorders are not indications. 4. Peer review, unfettered consent and knowledge of the psychodynamics of severe illness are three ingredients necessary for wise decisions about performing limbic surgery. 5. The liberal advocation of autonomy without responsibility is an amoral, not liberating, point of view. 6. Politics should be denounced as the most serious ethical problem in medical decision making. Political intrusion into the scientific matters and the doctor-patient relationship has created ethical problems with psychosurgery and continues to do so today.

Pharmacologic treatment for chronic facial pain.

Chronic orofacial pain often requires pharmacologic treatment in conjunction with surgical, physical, and psychologic treatments. Myofascial pain, neuralgias, vascular pain, and limbic system dysfunction are the elements of orofacial pain that may respond to treatment with nonsteroidal anti-inflammatory drugs, anticonvulsants, membrane-stabilizing and monoaminergic medicines, respectively.

Trigeminal facial pain: a model of peptides and monoamines in intracerebral cerebrospinal fluid.

A biochemical model of chronic trigeminal facial pain with elevated substance P (SP) and co-dysfunctional dopamine (DA), norepinephrine (NE) and purinergic systems is proposed. The serotonergic system is hypoactive as judged by low 5 hydroxyindoleacetic acid (5HIM). In distinction, intracerebral opioids may not be dysfunctional in facial pain as measured by normal levels of beta endorphin (BE). The neuropeptides somatostatin (SOM), cholecystokinin (CCK), met and leu-enkephalin (MENK, LENK) have very small picogram concentrations in these pain patients, but no definite conclusion can be reached on their role in trigeminal pain, alone or with monoamines, because of the small numbers, both sample size and concentrations. Interpretive obstacles to such human neurochemical studies suggest that future work might move to human clinical trials comodulating SP down, inhibitory peptides (SOM, CCK) up, and enhancing monoamine systems.

Methohexital Dosage in Electroconvulsive Therapy.

A comparison of methohexital at 0.5 mg/kg versus 1 mg/kg iv as anesthesia for unilateral brief pulse electroconvulsive therapy showed no difference in systolic or diastolic blood pressure before, immediately after, or 5 or 10 min after the seizure. Mean seizure duration was not significantly shorter using the higher methohexital dosage. These results show that methohexital can be safely used in a broad dosage range without undue effects on blood pressure or seizure duration.

A prospective multicenter study of competency evaluations by psychiatric consultation services.

Psychiatric consultation for assessment of competency is common but infrequently studied. Past studies have used chart reviews. The authors prospectively studied 88 consecutive psychiatric consultations at 3 centers. Competency evaluation was performed to determine whether the patient could 1) sign out of the hospital against medical advice (AMA) (N = 16); 2) give informed consent (N = 16); 3) take care of him-/herself (N = 33); 4) refuse medical care (N = 24); or 5) deal with other matters (N = 12). Patients with a favorable risk-benefit ratio were more likely to be seen in consultation compared with those with an unfavorable ratio. Patients in whom there was concordance in the assessment of the psychiatric consultant and the referring physician (N = 61) were more likely to be male, single, to have psychotropics recommended, to sign out AMA, and to be discharged from the hospital. Patients in whom there was disagreement between the consultee and the consultant merits further study.