Lesioning and Stimulation as Surgical Treatments for Psychiatric Disorders

Abstract

This review outlines and compares current attempts at the treatment of psychiatric disorders through neurosurgical techniques. In particular, we have undertaken to compare the results of lesioning techniques with those of stimulation of the brain. The original lesioning techniques, and in particular the use of frontal lobotomy as used and developed at the end of the 19th century and early 20th century represent an interesting period of strong interplay between the neurosurgery and psychiatry and are described in the first section. With the advent of modern stereotaxy, more selective procedures were developed that were also guided by concurrent advances in the neurosciences and the early interpretations of the limbic circuitry. These selective procedures included the anterior cingulotomy, the anterior capsulotomy, the subcaudate tractotomy, and the general limbic leucotomy. A discussion of implementation of these procedures and their neurobiologic justification has also been included in the second section. Besides being the targets of procedures, which cause gross mechanical disruption, several of these brain regions have been used as radiosurgical targets, and are also being considered for electrical stimulation as a treatment modality. The next 3 sections of the review focus on the newer uses of deep brain stimulation for treating specifically major depressive disorder, obsessive-compulsive disorder, and Tourette syndrome. Several choices of targets are described for these diseases along with their proposed physiologic rationale. The sixth section subsequently compares the lesioning and stimulation techniques with a particular focus on their relative merits and complications.