Neuromodulation in Psychiatry

Clement Hamani, Paul Holtzheimer, Andres M. Lozano, Helen Mayberg

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118801062
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Neuromodulation in Psychiatry

Neuromodulation in Psychiatry

This is the first comprehensive and detailed reference work that focuses on neuromodulation strategies in psychiatry. Neuromodulation strategies are no longer confined to tertiary hospitals but are used in community practices and even by individual psychiatrists. Surgery for psychiatric disorders is one of the main advances in the field of functional neurosurgery.

Neuromodulation in psychiatry includes chapters on the history of this controversial field and the ethics of modern usage of such techniques. Specific chapters are devoted to neuromodulation and surgical strategies used in psychiatry including transcranial magnetic stimulation, transcranial direct current stimulation, vagus nerve stimulation, direct cortical stimulation and deep brain stimulation. A chapter describes the basic principles of each techniques, using figures and schematics to illustrate details for people who do not have personal experience of using these techniques. Another chapter then focuses on the results of clinical research, trials and applications for that strategy.

Written by an expert multidisciplinary editorial team across the fields of neurosurgery, psychiatry and neurology, this title:

• Encompasses basic principles, technical aspects and clinical applications including ethical considerations
• Clearly explains each technique with implications for clinical practice
• Presents evidence in a comprehensive summary suitable for all levels
• Allows psychiatrists to evaluate results obtained using such strategies and to make decisions regarding the best course of treatment for their patients

An essential reference guide for psychiatrists, psychologists neurosurgeons, neurologists and respective trainees.

The book is the first comprehensive reference work to cover all neuromodulation strategies now used or with potential use in psychiatry. It allows psychiatrists to evaluate results obtained using such strategies and to make decision regarding the best course of treatment for their patients.

CHAPTER 1
History of invasive brain stimulation in psychiatry: Lessons for the current practice of neuromodulation

Marwan Hariz

UCL Institute of Neurology, London, UK

Umeå University, Umeå, Sweden

The basic problem of psychosurgery is psychiatric. Therefore, the initiative in considering surgical treatment must be taken by the psychiatrist. As soon as he is sure that conservative treatment by every available method cannot cure the patient, he should consult the neurosurgeon. Psychosurgery will remain experimental for years. Therefore, its use should be concentrated and restricted to psychosurgical research units having strong and intimate affiliation with scientists from many disciplines.

Lauri V. Laitinen, ‘Ethical Aspects of Psychiatric Surgery’, 1977 [1]

The International Neuromodulation Society defines neuromodulation as the alteration of nerve activity through the delivery of electrical or electromagnetic stimulation, chemical agents or light (optogenetics) to targeted sites of the central or peripheral nervous system. The aim of neuromodulation is to modulate (aka normalize) pathological nerve function. Some examples of various means to provide ‘neuromodulation’ to treat various illnesses and symptoms are functional electrical stimulation, spinal cord stimulation, peripheral nerve stimulation, intrathecal drug delivery systems, occipital nerve stimulation, motor cortex stimulation, repetitive transcranial magnetic stimulation, sacral nerve stimulation, transcranial direct current stimulation, vagus nerve stimulation and deep brain stimulation (DBS).

Thus, it appears that electricity has been and still is the main agent used to provide ‘neuromodulation’, starting in antiquity with the electrical fish and gaining a momentum with the so-called ‘electrotherapy’ in the 18th and 19th centuries when electrotherapy was used for the ‘treatment’ of a variety of illnesses, including epilepsy, paralysis, chorea, deafness, blindness, rheumatism, glandular enlargement and also for artificial respiration and resuscitation [2].

According to the web site of the International Neuromodulation Society (http://www.neuromodulation.com/brief-history-of-neuromodulation consulted on 14 January 2014), ‘The modern era of neuromodulation began in the early 1960s, first with deep brain stimulation which was soon followed (in 1967) by spinal cord stimulation, both for otherwise intractable pain’. In the opinion of this author, this is a rather selective way of writing history! In fact, the modern era of neuromodulation began at least a decade before ‘the early 1960s’ and it was not ‘for otherwise intractable pain’. It is true that the main application of deep brain stimulation in the late 1960s and 1970s was for the treatment of chronic pain, and it is true that Medtronic trademarked the term ‘DBS’ with respect to chronic subcortical stimulation for pain in the mid-1970s [3]. However, scholar sources show that the history of deep brain stimulation before it was called ‘DBS’, that is, the history of electrical stimulation of subcortical structures delivered through chronically implanted electrodes, started in the early 1950s soon after the introduction of the method of human stereotactic surgery. It is also evident that subcortical brain stimulation was not initially intended to treat pain but rather was applied in psychiatry and to modify behaviour. In order to be able to fully grasp the ‘lessons learned for current practice’, as is suggested by the title of this chapter, one has to understand how DBS unfolded historically and why do we today need, in the first place, to ‘learn lessons’ from the ‘history of neuromodulation in psychiatry’.

In the contemporary discourse about the history of DBS, there is a commonly held belief that DBS was initiated for surgical treatment of movement disorders in 1987 [4], and entered the realm of psychiatry first in 1999 [5, 6]. Indeed, it was the paper by Veerle Vandewalle et al. on DBS for Tourette syndrome published in The Lancet in February 1999 [5], and the publication of Nuttin et al. on DBS for obsessive–compulsive disorder (OCD), also in The Lancet in October 1999 [6], that heralded the most recent era of DBS in psychiatry. As the field of psychiatric neuromodulation has literally exploded in the last decade, at least judging by the number of publications in the field, with new psychiatric applications of DBS on an ever-increasing number of brain targets [7], perhaps a sober look at past experience in this field may provide some clues about what is to be expected and what can go wrong in this specific area of psychiatric neuromodulation, aka psychiatric surgery.

The main aim of this chapter is thus to review the historical applications and trials of DBS in the realm of psychiatry and behaviour, and to summarize what lessons, if any, can be learned from these previous practices.

The birth, rise and fall of the 20th-century psychiatric DBS

Human stereotactic neurosurgery was initially and purposely devised with the intent to avoid the devastating side effects of the crude frontal lobotomy by allowing to perform anatomically focused tiny lesions in psychiatric patients. Thus, in the same way, as human stereotactic ablative surgery was applied at its inception in 1947 in the psychiatric domain [8], human subcortical brain stimulation was also first proposed in the realm of psychiatry: in 1952, neurophysiologist and neurobehaviourist José Delgado and his colleagues [9] described a technique of electrode implantation for chronic recording and stimulation to evaluate ‘its possible therapeutic value in psychotic patients’. The following year, the Mayo Clinic organized a symposium on ‘intracerebral electrography’. The proceedings of that meeting were published and included a paper on ‘Neurosurgical and neurologic applications of depth electrography’, where one could read: ‘An observation that may have some practical significance was that several of our psychotic patients seem to improve and become more accessible in the course of stimulation studies lasting several days’ [10]. The authors thought that a likely explanation for this effect ‘was that the local stimulation was having a therapeutic effect comparable to that of electroshock’ and concluded that ‘… this aspect of localized stimulation studies requires further investigation since it may lead to a most specific, less damaging, and more therapeutically effective electrostimulation technic than can be achieved by the relatively crude extracranial stimulation methods in use at present’ [10]. One of the authors in this paper was Carl Wilhelm Sem-Jacobsen, a Norwegian neurophysiologist and neuropsychiatrist who was a fellow at the Mayo Clinic and who continued to work with chronic subcortical stimulation for psychiatric illness when he returned to Norway (see further next).

Also in the early 1950s, a team at Tulane University in New Orleans, led by psychiatrist Robert Heath, had started chronic depth electrode stimulation, including stimulation of the ‘septal area’ in schizophrenic and other psychotic patients [11].

Furthermore, already in 1961, Daniel Sheer, Professor of psychology at the University of Houston, edited a book entitled Electrical Stimulation of the Brain – An Interdisciplinary Survey of Neurobehavioral Integrative Systems [12]. As the title indicates the main focus of electrical stimulation was on neurobehaviour and the authors of the chapters of that book discussed the use of subcortical recording and stimulation in epilepsy, obesity, aggressive behaviour and other neurological and behavioural conditions. Hence, from its very beginning, the technique of chronic stimulation of deep brain structures was intended and applied for behavioural and psychiatric studies and occasionally in the treatment of mental disorders.

What went wrong?

Studying the literature on old psychiatric DBS from the mid-1950s to the 1970s, it appears that DBS was used more for exploration and modification of behaviour, and less for the treatment of true psychiatric illness: those scarce publications detailing the few attempts to treat psychiatric illnesses with DBS were authored mainly by neurosurgeons, whereas the non-neurosurgeons were more prolific publishers on DBS mainly as a means to study and alter personality. To give few examples: in 1972, Mexican neurosurgeon Escobedo et al. [13] implanted quadripolar electrodes bilaterally in the head of the caudate nucleus in two patients with epilepsy, mental retardation and destructive aggressive behaviour, and described vegetative, motor and behavioural responses to stimulation. In 1979, West-German neurosurgeon Gert Dieckmann [14] performed unilateral stimulation of the non-dominant thalamus using a quadripolar Medtronic ‘deep brain stimulation electrode’ to treat a woman with phobia. The electrode contacts extended over 12 mm and were aimed at the parafascicular and rostral intralaminar areas. Stimulation was delivered intermittently at a low frequency (5 Hz) and resulted in disappearance of the phobias, while attempts at stimulation with 50 Hz ‘was experienced as being very disagreeable’. A possible reason for the scarcity of neurosurgical papers on psychiatric DBS as a treatment of psychiatric illness during the 1960s and 1970s was that during that period, which saw the demise of the previously popular lobotomy, focused stereotactic ablative procedures (anterior capsulotomy and cingulotomy) were gaining momentum and were the preferred surgical method to treat psychiatric illness, since the DBS hardware and technology of that period were quite cumbersome and not user-friendly.

On the other hand, there is a wealth of publications on DBS from the 1950s through the 1970s, authored by very few psychiatrists and neurophysiologists, in which DBS was not mainly a tool to treat psychiatric disease, but rather to study the brain and to alter human behaviour, as stated earlier. The scholar literature reveals three main workers, a neurophysiologist, a psychiatrist and a neurophysiologist-psychiatrist, who, independently of each other, devoted much of their career to study the effect of DBS in humans and sometimes to promote its use for aims beyond psychiatric disease.

José Delgado, a Spanish neurophysiologist and neurobehaviourist who moved from Spain to Yale University in 1950 and worked there with Fulton, is probably best known for a motion picture showing a bull whose charge in the arena could be stopped through remote brain stimulation. Delgado worked extensively with chronic subcortical stimulation in rats, goats and monkeys and then in humans. In a lecture delivered in 1965 titled Evolution of Physical Control of the Brain, he reported: ‘Monkeys may learn to press a lever in order to stimulate by radio the brain of another aggressive animal and in this way to avoid his attack’. Heterostimulation in monkey colonies demonstrates the possibility of ‘instrumental control of social behaviour’ [15]. He concluded, ‘Autonomic and somatic functions, individual and social behaviour, emotional and mental reactions may be evoked, maintained, modified, or inhibited, both in animals and in man, by electrical stimulation of specific cerebral structures. Physical control of many brain functions is a demonstrated fact…’ [15]. Delgado’s enthusiasm for this new technology and its possible effects on behaviour led him to publish in 1969 a book titled Physical Control of the Mind: Towards a Psychocivilized Society [16]. This book’s title provoked a storm of critic and Delgado was compelled to negate the impression that mind control could be achieved by electrodes wired into people’s brain. He emphasized that the technique of ‘Electrical Stimulation of the Brain (ESB)’, as he called it, was meant as a research tool to study and understand the human mind. Delgado then developed a technique of subcortical stimulation using chronically implanted electrodes connected to a subcutaneous receiver implanted in the scalp that he labelled ‘Stimoceiver’, which could be remotely controlled by radio waves. This technique of ‘radio communication with the brain’ was developed by Delgado explicitly for use in psychiatric patients [16–18], although there are no testimonies in the scholar literature to its results in ‘real’ patients. Anecdotically, Harvard physician turned writer Michael Crichton described in his semi-fictive and famous book The Terminal Man first published in 1972 [19] a patient whose personality and behaviour were changed by stimulation through several electrodes implanted in various parts of his brain initially for control of epilepsy, but who also suffered from psychosis. Some of the stimulation effects experienced by the hero of this novel bear strange resemblance to the DBS experiments conducted on real people by another psychiatrist, Robert Heath, at Tulane University in New Orleans.

Robert Heath was a psychiatrist at Tulane University, New Orleans. He implanted a multitude of electrodes in several subcortic...

Table of contents

• Cover
• Title Page
• Table of Contents
• Contributors
• CHAPTER 1: History of invasive brain stimulation in psychiatry: Lessons for the current practice of neuromodulation
• CHAPTER 2: Ethics of neuromodulation in psychiatry
• CHAPTER 3: Neurocircuits commonly involved in psychiatric disorders and their stimulation and lesion therapies
• CHAPTER 4: Magnetic resonance imaging in neuromodulation
• CHAPTER 5: Nuclear medicine in neuromodulation
• CHAPTER 6: Basic principles of deep brain and cortical stimulation
• CHAPTER 7: Electrophysiology in neuromodulation: Current concepts of the mechanisms of action of electrical and magnetic cortical stimulation
• CHAPTER 8: Transcranial magnetic stimulation: Introduction and technical aspects
• CHAPTER 9: Magnetic stimulation for depression: Subconvulsive and convulsive approaches
• CHAPTER 10: Repetitive transcranial magnetic stimulation for psychiatric disorders other than depression
• CHAPTER 11: Direct current stimulation: Introduction and technical aspects
• CHAPTER 12: Transcranial direct current stimulation
• CHAPTER 13: Deep brain stimulation: Introduction and technical aspects
• CHAPTER 14: Deep brain stimulation: Clinical results in treatment-resistant depression
• CHAPTER 15: Deep brain stimulation for the treatment of obsessive–compulsive disorder
• CHAPTER 16: Deep brain stimulation: Emerging indications
• CHAPTER 17: Vagus nerve stimulation: Introduction and technical aspects
• CHAPTER 18: Vagus nerve stimulation for treatment-refractory depression
• CHAPTER 19: Gamma Knife radiosurgery: Introduction and technical aspects
• CHAPTER 20: Gamma knife surgery: Clinical results
• CHAPTER 21: Radiofrequency lesions: Introduction and technical aspects
• CHAPTER 22: Ablative procedures in psychiatric neurosurgery
• CHAPTER 23: Electroconvulsive therapy: Introduction and technical aspects
• CHAPTER 24: Electroconvulsive therapy: Clinical results
• CHAPTER 25: Neuromodulation in psychiatry: Conclusions
• Index
• End User License Agreement