Cingulotomy for intractable obsessive-compulsive disorder. Prospective long-term follow-up of 18 patients.

BACKGROUND: The purpose of this study was to assess prospectively long-term change in obsessive-compulsive disorder (OCD) symptoms in patients with an OCD diagnosis that was confirmed by structured interview and with documented unsuccessful trials of multiple medications and attempts at behavior therapy. METHODS: We conducted an unblinded preoperative and follow-up assessment of comorbid diagnosis; OCD, depressive, and anxiety symptoms; and functional status in 18 patients who underwent cingulotomy. RESULTS: At a mean follow-up of 26.8 months, five patients (28%) met conservative criteria for treatment responders, and three others (17%) were partial responders. The group improved significantly in mean functional status, and few serious adverse events were found. Improvement in OCD symptoms was strongly correlated with improvement in depressive and anxiety symptoms. CONCLUSIONS: The rate of clinical improvement was consistent with a previous retrospective study in the same setting, indicating that 25% to 30% of the patients who previously were unresponsive to medication and behavioral treatments are significantly improved after cingulotomy. Cingulotomy remains a last resort treatment for severely incapacitated patients who have not responded to all other state-of-the-art pharmacological and behavioral treatments for OCD and is not to be taken lightly.

Cerebral metabolic correlates as potential predictors of response to anterior cingulotomy for obsessive compulsive disorder.

BACKGROUND: As interventions for severe, treatment-refractory obsessive compulsive disorder (OCD), neurosurgical procedures are associated with only modest efficacy. The purpose of this study was to identify cerebral metabolic correlates as potential predictors of treatment response to anterior cingulotomy for OCD. METHODS: Clinical data were analyzed in the context of a retrospective design. Subjects were 11 patients who underwent stereotactic anterior cingulotomy for OCD. Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) before and at approximately 6 months postoperative. Preoperative F-18-fluorodeoxyglucose-positron emission tomography (FDG-PET) data were available. Statistical parametric mapping methods were used to identify loci of significant correlation between preoperative regional cerebral metabolism and postoperative reduction in Y-BOCS scores. RESULTS: One locus within right posterior cingulate cortex was identified, where preoperative metabolism was significantly correlated with improvement in OCD symptom severity following cingulotomy. Specifically, higher preoperative rates of metabolism at that locus were associated with better postoperative outcome. CONCLUSIONS: A possible predictor of treatment response was identified for patients with OCD undergoing anterior cingulotomy. Further research, utilizing a prospective design, is indicated to determine the validity and reliability of this finding. If confirmed, an index for noninvasively predicting response to cingulotomy for OCD would be of great value.

Deficits in visual cognition and attention following bilateral anterior cingulotomy.

A series of eight tests of visual cognitive abilities was used to examine pre- to post-operative performance changes in a patient receiving bilateral anterior cingulotomy. Compared with a set of eight matched control participants, post-operatively, the patient exhibited deficits in (a) the ability to sequence novel cognitive operations required to generate multipart images or rotate perceptual stimuli; (b) the ability to search for, select, and compare images of objects when the instructions did not specify precisely which objects should be visualized; and, (c) the ability to select a controlled and unpracticed response over an automatic one. Other imagery and cognitive tasks were not affected. Results are consistent with the hypothesis that anterior cingulate cortex is a component of an executive control system. One of the anterior cingulate's roles may be to monitor on-line processing and signal the motivational significance of current actions or cognitions.

Psychological, behavioral and biochemical risk factors for coronary artery disease among American and Italian male corporate managers.

Differences in psychological, behavioral and biochemical risk factors for coronary artery disease (CAD) among male corporate managers of 2 countries (United States and Italy), with very different age-specific rates of mortality for CAD were evaluated. In all, 129 American (mean age 43 +/- 7 years) and 80 Italian (mean age 45 +/- 7 years) managers volunteered to participate in this study. Each subject was administered several questionnaires assessing various psychological and behavioral risk factors for CAD, and all 129 Americans and 55 of 80 Italians had their blood drawn between 8:00 and 9:30 AM after overnight fasting for the measurement of plasma levels of dehydroepiandrosterone-sulfate (DHEA-S), total cholesterol, triglycerides, and apolipoproteins A-I and B. Italian managers reported significantly more cynicism and hostility, and less enjoyment in leisure activities than did American ones. Furthermore, 40 Italian (51%) and only 18 American (14%) managers were smokers (this difference being statistically significant). Although no significant differences were found in factors positively related with CAD (cholesterol, triglycerides and apolipoprotein B), there were clear differences in parameters inversely correlated with the incidence of CAD. Italian managers had significantly lower levels of plasma DHEA-S and apolipoprotein A-I than did American ones. In conclusion, this study found that Italian managers had a significantly more unhealthy psychological and behavioral profile than did American ones, and had lower levels of those biochemical parameters (apolipoprotein A-I and DHEA-S) thought to have a protective role against development of CAD.

Improvement in severe self-mutilation following limbic leucotomy: a series of 5 consecutive cases.

BACKGROUND: The efficacy of neurosurgical intervention for self-mutilation behavior associated with severe, intractable psychiatric disorders remains undetermined. We report the effects of limbic leucotomy in 5 consecutive patients with severe self-mutilation behaviors. METHOD: After unsolicited referrals from their psychiatrists and careful consideration by the Massachusetts General Hospital Cingulotomy Assessment Committee (MGH-CAC), 5 patients were treated with limbic leucotomy. Their primary DSM-IV psychiatric diagnoses were either obsessive-compulsive disorder or schizoaffective disorder. Comorbid severe, treatment-refractory self-mutilation was an additional target symptom. Outcome was measured by an independent observer using the Clinical Global Improvement. Current Global Psychiatric-Social Status Rating, and DSM-IV Global Assessment of Functioning scales in addition to telephone interviews with patients, families, their psychiatrists, and treatment teams. The mean postoperative follow-up period was 31.5 months. RESULTS: All measures indicated sustained improvement in 4 of 5 patients. In particular, there was a substantial decrease in self-mutilation behaviors. Postoperative complications were transient in nature. and postoperative compared with preoperative neuropsychological assessments revealed no clinically significant deficits. CONCLUSION: In carefully selected patients as described in this report, limbic leucotomy may be an appropriate therapeutic consideration for self-mutilation associated with severe, intractable psychiatric disorders.

Depression and anxiety secondary to medical illness.

Mind and body remain stubbornly one. The distinction between primary and secondary disorders respects this unity. The distinction between "reactive" and "induced" carry causal implications and suggest the former is psychogenic and the latter organic--both of which are probably premature conclusions. The diagnostician, free of the demands on the pathologist, can pursue the correct nosology committed to demonstrating, not the pathophysiology, but the presence of adequate diagnostic criteria. Whenever a secondary disorder meets full criteria it may warrant the same treatment accorded to the primary disorder. Whether the disease is major or minor may also be of clinical significance. Only further application of psychiatric nosology to medically ill patients can resolve these issues. Karajgi et al recently found that the lifetime prevalence of panic disorder in a sample of patients with chronic obstructive pulmonary disease was 8%. The only respectable offspring of neurotic depression in DSM-III-R is dysthymia. As with neurotic depression, dysthymia is not a condition thought appropriate for or responsive to antidepressant drugs. Clinicians dealing with depression in the medically ill think of depression itself as "serious," that is, major.

Magnetic resonance image-guided stereotactic cingulotomy for intractable psychiatric disease.

We describe the modern operative technique of magnetic resonance (MR) image-guided stereotactic cingulotomy and discuss the indications, results, and complications of this procedure. A retrospective analysis of psychiatric outcome was performed for 34 patients with intractable major affective disorder and/or obsessive-compulsive disorder who underwent MR image-guided stereotactic cingulotomy since 1991. Fourteen patients underwent multiple cingulotomies (50 total procedures). Overall, 38% of the patients were classified as responders, 23% as possible responders, and 38% as nonresponders. Of the patients who did not respond to initial cingulotomies and who underwent multiple cingulotomies, 36% became responders, 36% possible responders, and 28% nonresponders. There were no deaths or long-term side effects related to the procedure. The therapeutic results of MR image-guided stereotactic cingulotomy are similar to the results of earlier methods of cingulotomy, and the use of MR imaging offers substantial technical advantages. This procedure also compares favorably with other neurosurgical procedures performed for intractable psychiatric disease with a low rate of undesired side effects. Cingulotomy is safe and well tolerated, with over one-third of the patients demonstrating significant improvement; however, prospective long-term follow-up studies are needed to further define the role of surgery in treating intractable psychiatric disease.

Volume reduction in the caudate nucleus following stereotactic placement of lesions in the anterior cingulate cortex in humans: a morphometric magnetic resonance imaging study.

OBJECT: The goal of this study was to test hypotheses regarding changes in volume in subcortical structures following anterior cingulotomy. METHODS: Morphometric magnetic resonance (MR) imaging methods were used to assess volume reductions in subcortical regions following anterior cingulate lesioning in nine patients. Magnetic resonance imaging data obtained before and 9 +/- 6 months following anterior cingulotomy were subjected to segmentation and subcortical parcellation. Significant volume reductions were predicted and found bilaterally within the caudate nucleus, but not in the amygdala, thalamus, lenticular nuclei, or hippocampus. Subcortical parcellation revealed that the volume reduction in the caudate nucleus was principally referrable to the body, rather than the head. Furthermore, the magnitude of volume reduction in the caudate body was significantly correlated with total lesion volume. CONCLUSIONS: Taken together, these findings implicate significant connectivity between a region of anterior cingulate cortex (ACC) lesioned during cingulotomy and the caudate body. This unique data set complements published findings in nonhuman primates, and advances our knowledge regarding patterns of cortical-subcortical connectivity involving the ACC in humans. Moreover, these findings indicate changes distant from the site of anterior cingulotomy lesions that may play a role in the clinical response to this neurosurgical procedure.

A magnetic resonance imaging study of regional cortical volumes following stereotactic anterior cingulotomy.

The purpose of this study was to test the hypothesis that orbitofrontal cortical volume would be reduced following anterior cingulotomy for obsessive-compulsive disorder (OCD). Whole brain cortical parcellation was performed on magnetic resonance imaging (MRI) data from nine patients, before and 9 (+/-6) months following anterior cingulotomy. No significant volumetric reductions were found in the orbitofrontal cortex. Exploratory findings of reduced volume in ventral temporo-fusiform and posterior cingulate regions were consistent with chance differences, in the face of multiple comparisons. Therefore, though the circumscribed lesions of anterior cingulotomy have recently been associated with corresponding volumetric reductions in the caudate nucleus, no comparable volumetric reductions are evident in cortical territories. Taken together, these results are most consistent with a model of cingulo-striatal perturbation as a putative mechanism for the efficacy of this procedure. While limitations in sensitivity may have also contributed to these negative findings, the methods employed have previously proven sufficient to detect cortical volumetric abnormalities in OCD. The current results may reflect a relatively diffuse pattern of cortico-cortical connections involving the neurons at the site of cingulotomy lesions. Future functional neuroimaging studies are warranted to assess possible cortical or subcortical metabolic changes associated with anterior cingulotomy, as well as predictors of treatment response.

Psychiatric complications in the critically ill cardiac patient.

Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. A description of delirium associated with the use of the intraaortic balloon pump and its treatment with high doses of intravenous haloperidol is also included. After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion.

Depressive disorders in the medically ill. An overview.

Depressive disorders are far more serious than most people realize, and depressive disorders are disabling affected persons progressively earlier in life. Heavy utilization of medical services, extensive disability and morbidity, and high suicide risk exact a staggering economic toll in the United States annually. Depressive illness is, like pneumonia and septic shock, a dread complication of major medical illness, and depressive illness appears more frequently as the medical illness worsens; diseases affecting the brain may have the highest rates of depressive symptoms. Correctly diagnosing a depressive disorder in a medically ill patient is a clinical challenge that requires systematic, persistent clinical scrutiny. Compassion demands that depressive disorders, when diagnosed, be treated aggressively.

Pediatric intensive care training: confronting the dark side.

PURPOSE: To describe the dark side of pediatric intensive care fellowship training and offer educational approaches for understanding feelings of fallibility, anger, frustration, and loss. DATA SOURCES: Listening and observing fellows in the courses of their pediatric intensive care training and later careers. STUDY SELECTION: Studies that discussed pediatric residency and fellowship training, especially in the context of intensive care. DATA EXTRACTION: From group meetings, unit conferences, rounds, individual discussions, and child psychiatric consultations. RESULTS OF DATA SYNTHESIS: Pediatric intensive care unit (ICU) fellows gain a sense of mastery from the nature of their work: complex, technological, and frequently lifesaving. They face the usual personal stresses of extended training, including long work hours, limited financial resources, and relative isolation from family and friends. Pediatric ICU fellows confront deeper, "dark" feelings regarding their own high expectations, fallibility, anger, sense of loss, frustration, limited control, and the need to work closely with tense, grieving families. If the dark side is not acknowledged, fellows, team members, and faculty are likely to experience anger, detachment, and depression that may extend beyond work into their personal lives. CONCLUSIONS: Since the dark side is expected, normal, and inevitable, fellowship training programs should help fellows cope with and understand these feelings. Such understanding requires a sense of trust among intensive care staff and can be gained through group discussions, mentorship, specific team conferences, and child psychiatric consultation.

Objective estimates of the probability of death from burn injuries.

BACKGROUND: Over the past 20 years, there has been remarkable improvement in the chances of survival of patients treated in burn centers. A simple, accurate system for objectively estimating the probability of death would be useful in counseling patients and making medical decisions. METHODS: We conducted a retrospective review of all 1665 patients with acute burn injuries admitted from 1990 to 1994 to Massachusetts General Hospital and the Shriners Burns Institute in Boston. Using logistic-regression analysis, we developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. The resulting mortality formula was used to determine whether changes in mortality have occurred since 1984, and it was tested prospectively on all 530 patients with acute burn injuries admitted in 1995 or 1996. RESULTS: Of the 1665 patients (mean [+/-SD] age, 21+/-20 years; mean burn size, 14+/-20 percent of body-surface area), 1598 (96 percent) lived to discharge. The mean length of stay was 21+/-29 days. Three risk factors for death were identified: age greater than 60 years, more than 40 percent of body-surface area burned, and inhalation injury. The mortality formula we developed predicts 0.3 percent, 3 percent, 33 percent, or approximately 90 percent mortality, depending on whether zero, one, two, or three risk factors are present. The results of the prospective test of the formula were similar. A large increase in the proportion of patients who chose not to be resuscitated complicated comparisons of mortality over time. CONCLUSIONS: The probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.

The physician's responsibility toward hopelessly ill patients. A second look.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physician's response to the dying patient who is rational and desires suicide or euthanasia.