Deep Brain ... Foreword Deep brain stimulation (DBS) makes it possible for psychosurgery to get a...
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Deep Brain Stimulation
Damiaan Denys • Matthijs Feenstra Rick Schuurman Editors
Deep Brain Stimulation
A New Frontier in Psychiatry
Editors Damiaan Denys Department of Psychiatry Academic Medical Center, University of Amsterdam Amsterdam The Netherlands
Neuromodulation and Behaviour Netherlands Institute for Neuroscience Amsterdam The Netherlands
Matthijs Feenstra Neuromodulation and Behaviour Netherlands Institute for Neuroscience Amsterdam The Netherlands
Rick Schuurman Department of Neurosurgery Academic Medical Center, University of Amsterdam Amsterdam The Netherlands
ISBN 978-3-642-30990-8 ISBN 978-3-642-30991-5 (eBook) DOI 10.1007/978-3-642-30991-5 Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2012946624
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Deep brain stimulation (DBS) makes it possible for psychosurgery to get a second chance. In particular, it does those proud who initiated the method and developed it for new indications. It permitted the rebirth of psychosurgery. But, on the other hand and at the same time, the reappearance of psychosurgery because of the merits of DBS, also has threatening aspects since one should not forget the dark ages of malpractice and overuse of psychosurgery, that led the discipline into dismay and even into oblivion. The advent of psychosurgery was a huge wave of hope. One could get rid of the plague of mental disorders, affecting hundreds of thousands of people who, because of lack of treatment as well as understanding, were confined by society to prisons or, camps, or later to more humane places such as asylums and psychiatric hospitals. Unfortunately, because of the haste of application, the lack of wisdom, the desire to exploit this new medical opportunity, and also the distorted manner in which it was applied to modify the brain and the mind of patients, and even of healthy persons, psychosurgery was finally banned for the treatment of mental disorders.
For a long period, it was almost obscene to mention terms such as lobectomy, psychosurgery, and even electroconvulsive therapy. The new era, which is announced by the current book, was possible only because surgeons and psychi- atrists in the USA and Europe kept pursuing the hard work to heal their patients in the most cautious and meritorious way. The breakthrough came from neurosci- entists using the newly developed functional imaging methods to build up a new model to understand the anatomical structures involved in consciousness, the mind, and behavior. Presenting a new scheme of the organization of the basal ganglia to understand mood and anxiety disorders, is in my view of paramount importance, similar to the work that has been done for movement disorders. It will be a milestone on the future road for the treatment of mental disorders.
DBS was an appropriate tool to translate the newly formed anatomofunctional concepts into therapy-oriented surgical strategies. The experience acquired in a large range of indications demonstrates the validity of the functional inhibition concept. The long-term follow-up of cohorts of patients will establish the merits of DBS: precision and adaptability, leading to low morbidity and minimal mortality.
Above all, the reversibility of the effects of DBS is important since it minimizes the risk of irreversible changes of behavior, mood, and personality, which haunted the outcome of early lesioning surgery. We now have the right tool, an adequate scalpel, to perform surgery for the treatment of mental disorders again. We must take advantage of the unique opportunity to precisely locate the right targets, and doing so to, increase our knowledge of the physiology of the mind and its dis- turbances. We have to do this only for the patients’ benefit. We have to resist the temptation of achieving spectacular changes or to be driven by technology. We have to be extremely cautious in selecting patients, in analyzing indications, and in evaluating the results, and we have to report them carefully to the medical com- munity. We have to be aware of our huge societal responsibility, and being proud of this privilege, not to miss the second chance that DBS offers to treat, and who knows, to cure, mental illnesses.
Clinatec Institute, CEA, Grenoble, France Alim Louis Benabid
Deep brain stimulation (DBS) was introduced in the 1980s for the treatment of therapy-resistant neurological disorders, and has been applied since 2000 on an experimental basis for the treatment of therapy-resistant psychiatric disorders. Since its introduction, DBS has evolved into a well-accepted therapy to treat patients with movement disorders, but the use of electrical stimulation to inten- tionally alter emotion, motivation, and cognition of psychiatric patients often causes amazement and even disbelief. Neurosurgery for the treatment of psychi- atric disorders has always been and still is surrounded by controversy.
The relation between DBS and psychiatry is fascinating because it is both appealing and threatening. First, DBS for the treatment of psychiatric disorders is attractive because it offers an ultimate treatment option for a group of seriously ill, untreatable psychiatric patients. Second, the risk of the operation is relatively small and the technique renders the possibility of continual adjustment, which is an important issue for psychiatric patients. Finally, DBS has the potential to increase our understanding of the brain pathophysiology of psychiatric disorders; it offers a view into the pathological brain. DBS is also threatening because psychiatric disorders are less discrete and objectifiable conditions than movement disorders. Second, psychiatric symptoms are more intimately connected with a person’s identity and integrity than motor symptoms, therefore raising more challenging ethical issues. Finally, the boundary between treatment and enhancement in psy- chiatry is vague. Altering cognition, emotion, and motivation is an intended goal in psychiatry and not a side effect, and may result in changes beyond the natural self.
In the past decade, DBS has been applied in obsessive–compulsive disorder, major depressive disorder, Tourette syndrome, and addiction. The results have consistently shown a promising success rate. However, the number of patients treated world-wide is still only limited and most reports deal with small-scale studies or case reports. Moreover, little is still known about how DBS acts in psychiatry, emphasizing the need for translational animal studies.
The purpose of this book is to conduct the first comprehensive overview of DBS in psychiatric disorders, with a particular emphasis on the relation between pre- clinical animal studies and clinical patient studies. The book starts with the basic
principles of stimulation (Chap. 1), neuroanatomical circuits (Chap. 2), and hypotheses of the mechanism of action (Chap. 3). Separate chapters subsequently review DBS in different psychiatric disorders and animal models: obsessive– compulsive disorder (Chaps. 4–7), major depressive disorder (Chaps. 8–11), Tourette syndrome (Chap. 12), addiction (Chaps. 13, 14), and psychiatric symp- toms in Parkinson’s disease (Chaps. 15, 16). We have also included a discussion on the role of intracranial recordings (Chap. 17), neurotransmitter changes (Chaps. 18), glial cells (Chap. 19), the significance of animal studies (Chap. 20), neuroimaging (Chap. 21), and optogenetics (Chap. 22). The future of next-gen- eration electrodes (Chap. 23) and nanotechniques (Chap. 24) is reviewed, and we end with a discussion of ethical issues of DBS in psychiatric disorders (Chap. 25) and a critical review of the history of DBS (Chap. 26).
We thank the authors, all experts in th