Psychosurgery Part 4: Vagus Nerve Stimulation

For Treatment Resistant Depression

In 1997, the FDA approved vagus nerve stimulation for epilepsy, and in 2005, it was approved for treatment resistant depression. Vagus nerve stimulation is a procedure that stimulates the vagus nerve1 with electrical impulses. (noticing a trend in electrical impulses and psychosurgery?) It is being worked on to treat Alzheimers, MS and migraines. There is one vagus nerve on each side of the body, running from your brainstem to your chest and abdomen2.

With vagus nerve stimulation, a device is surgically placed under the skin of your chest (similar to deep brain stimulation) and a wire connects to the left vagus nerve. After it’s activated, signals are sent to the vagus nerve and in turn, sent to various areas of the brain. Vagus nerve stimulation is used when epilepsy medications no longer work, or if depression is treatment resistant and everything else has been tried. (There is a link between epilepsy and mood disorders, I’ll get into that at a later date)

Since vagus nerve stimulation (VNS) has been FDA approved and is out of the clinical trial stage, the FDA has set rules for who may undergo the procedure. Here are the following criteria:

  • Age 12 and older (epilepsy)
  • Have partial epilepsy
  • Seizures that aren’t controlled by medications
  • Have treatment resistant (hard to control) depression
  • Haven’t improved after trying 4+ medications / ECT.
  • Continue standard depression treatments after the VNS procedure.3

This is a relatively safe procedure, but all procedures have risks. Some include: pain from the incision, infection, scarring, difficulty swallowing, vocal cord paralysis (sometimes permanent).

After the surgery, when the VNS is turned on and working, other side effects include: voice changes, hoarseness, throat pain, cough, headache, chest pain, breathing problems (especially while exercising), difficulty swallowing, abdominal pain or nausea, tingling or prickling of the skin, and I’ve heard rumours that it can cause spontaneous orgasms! (I can’t cite the source at the moment, or I would)

If the side effects don’t go away, the device can be turned off. You can change the amount of stimulation to help control side effects.

This actually isn’t brain surgery. One incision is made in the chest, for the pacemaker like tool, and another incision is done in the neck. This mayor may not be done under general anesthesia, it depends on the doctor and your own preferences. It takes one to two hours to perform the operation and it is done on an outpatient basis.

You are given a hand held magnetic device to turn the device on and off, and adjust the amount of stimulation running through the vagus nerve. You can turn it on and off at will, if you feel you need it. MRI’s are now out of the picture, except for the head in carefully monitored conditions.

This isn’t a cure, but there can be improvement of 30-50% in seizures and depression. Some treatments and medications may have to be used after the procedure.

We evaluated the efficacy and safety of vagus nerve stimulation therapyinthe treatment of 11 patients with chronic treatment-resistant depression. Mood was evaluated at frequent intervals over the year following implantation. All measures of depression, including the Hamilton Rating Scale for Depression reduced significantly. The response and remission rates were 55% and 27% respectively at 1 year. Side-effects were common, and some were severe

This study suggests that vagus nerve stimulation may be an effective treatment for some individuals suffering from chronic treatment-resistant depression. The response rates for the acute phase of the study were disappointing, in that only one patient responded after 3 months. By 1 year, 55% of the sample had responded to treatment, suggesting that long-term follow-up is required to realise the therapeutic potential of vagus nerve stimulation treatment. The placebo response in these patients was typically poor and so probably does not account for the response rate 4.”

Compared to the other psychosurgeries, this one seems to have quite a few serious side effects, but they should go away. It is reversible, which is a bonus, because once you’ve burned away cells in the brain, they don’t come back. If I really needed it, I would have his procedure done. It seems much safer, as they aren’t actually doing brain surgery. The time spent in the operating room and hospital is less and it is FDA approved for epilepsy and depression, where some other psychosurgeries are still going through clinical trials with no long term reports.

 

  1. The vagus nerve is responsible for speech, swallowing, breathing, monitoring the digestive process, acting as an anti-inflammatory, mood and some parts of body weight.
    http://www.naturalnews.com/038473_Vagus_nerve_weight_loss_moods.html
  2. http://www.mayoclinic.com/health/vagus-nerve-stimulation/MY00183
  3. http://www.mayoclinic.com/health/vagus-nerve-stimulation/MY00183/DSECTION=why-its-done
  4. http://bjp.rcpsych.org/content/189/3/282.full

     

 

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Psychosurgery Part 3: Deep Brain Stimulation

Highly Experimental Surgery for Chronic Depression

Deep brain stimulation is a highly experimental neurosurgical treatment for chronic depression is stimulated with electrical impulses.

Although it’s been approved for several other conditions, deep brain stimulation hasn’t been approved by the Food and Drug Administration (FDA) for depression treatment and is in the early stages of research.

Requiring brain surgery, deep brain stimulation is the most invasive form of brain stimulation treatment for depression. Deep brain stimulation works much like a pacemaker for your brain.1

Deep brain stimulation is some serious shit we’re talking about. It is also used for Parkinson’s disease and has many side effects, some of them potentially fatal or life altering. We’ll start with the surgical aspect of it. It is similar to a pacemaker, but for your brain, which has a lot of risks on its own. To top it all off, the long term effects aren’t even known yet, it’s still in the experimental phases2.

So, how does it work? There are electrodes placed deep in various areas of the brain that create pulses to override pre-existing ones causing disorders like depression, OCD and bipolar disorder. It is also said that the probes can effect certain cells and chemicals in the brain2. The amount of stimulation to the brain is controlled by a pacemaker like device implanted in the chest, with a wire (under the skin) connecting it to your brain. That sounds a little too much like Frankenstein to me!

Most people undergoing deep brain stimulation are in clinical trials. It has found to be generally safe, with normal surgery risks, but does have some permanent side effects that are irreversible. Generally, it is used in people who have tried everything. Currently it is used for Parkinson’s and other movement disorders, such as Tourette’s, but it is being tested in epilepsy, depression and more.

The surgery involves drilling small holes into the skull to implant the electrodes and surgery on the chest to install the pacemaker. There are complications to these surgeries such as: bleeding in the brain, stroke, infection, breathing problems, nausea, heart problems and scarring. It’s not a one time thing, either, those batteries aren’t changing themselves. There can also be malfunctions in the system, but the positive is that it would generally be where the pacemaker is, or where the wires run, so you don’t have to go through more brain surgery2.

Side effects after the surgery include: seizure, infection, headache, insomnia, memory problems and temporary swelling. The device is turned on after a couple of weeks which has a bundle of side effects, itself. These include: Numbness/tingling sensations, muscle tightness in the face or arm, speech problems, balance problems, lightheadedness and unwanted mood changes.

I thought it was supposed to help your mood?!

And the entire procedure is done while you’re awake, with a local anesthetic.

From the famous Mayo Clinic in the USA:

“Deep brain stimulation won’t cure your disease, but it may help lessen your symptoms. If deep brain stimulation works, your symptoms will improve significantly, but they usually don’t go away completely. In some cases, medications may still be needed for certain conditions. Deep brain stimulation isn’t successful for everyone. ”

To me, this surgery sounds scary and I don’t think it will be used frequently in mental illness due to the “unwanted mood changes” side effect. It’s serious surgery and needs constant upkeep (the battery in the pacemaker) plus you might still have to take daily meds. It would be a worst-case last-resort scenario, but you could be permanently brain damaged (well, any surgery can permanently damage you) and the success rate isn’t guaranteed.

  1. http://www.winmentalhealth.com/psychosurgery_lobotomy_cingulotomy.php

  2. http://www.mayoclinic.com/health/deep-brain-stimulation/MY00184

Psychosurgery Part 2 – Capsulotomy and Anterior Capsulotomy

*Note: This surgery is also used for cataracts and laser eye surgey, except in the eye, not the skull.

This involves drilling holes in the skull. That sounds pretty scary, but it’s actually pretty safe! This surgery was originally performed in Sweden. Small holes are drilled into the skull and electrodes are inserted into the brain, then heated up and small areas of tissue are destroyed. If there is no response, a second surgery is performed. 20% of the surgeries done are being performed again.

Since this surgery was introduced, some neurosurgeons use gamma knives to avoid drilling into the skull.

In the first 116 patients operated on by Leksell, 50% of patients with obsessional neurosis and 48% of depressed patients had a “satisfactory” response. Only 20% of patients with anxietyneurosis and 14% of patients with schizophrenia showed any improvement. In this classification system, only patients who were free of symptoms or markedly improved were judged as having a satisfactory response.

Of the patients who were rated as worse after capsulotomy, nine were schizohphrenic, four were depressives and three obsessives.

Percentages of Success and Failure with Capsulotomy Psychosurgery

Satisfactory Response to Capsultomy

  • Obsessional Neurosis – 48%

  • Anxiety Neurosis – 20%

  • Schizophrenia – 14%

Rated Worse After Capsultomy Psychosurgery – 14%”1

Side effects from this surgery include: emotional blunting, indifference, low initiative, fatigue and urinary incontinence. Studies2 have shown that the procedure is relatively safe.

However, at the 1-year follow-up, 7 patients reported fatigue, 4 reported poor memory, 2 felt more talkative, and 2 reported carelessness. In a recent study 13 of 15 patients had a permanent behavior disorder after postoperative brain edema, but the other 14 did not have any permanent adverse effects, and the study therefore indicates that the procedure is relatively safe.“2

Safety:

Brain surgery sounds dangerous, and it can be! There are risks to any surgery, though, especially when a general anesthetic is used. A case study2 shows that 9 patients attempted suicide before undergoing the procedure and one committed suicide after the surgery. One of the 9 patients developed radiation necrosis (infection), apathy, memory problems and executive dysfunction. This can be caused by using too strong a gamma ray.

It appears to be weight neutral, but can effect libido, a side effect of many medications.

I found an interesting case study on a woman killing herself through anorexia with obsessive-compulsive disorder, here it is:

Successful anterior capsulotomy in comorbid anorexia nervosa and obsessive-compulsive disorder: case report.

BACKGROUND AND IMPORTANCE:

State-of-the-art treatment of anorexia nervosa (AN) and obsessive-compulsive disorder (OCD) often proves ineffective. Both disorders have common features, and anterior capsulotomy is a last-resort treatment for OCD. We document the effect of bilateral anterior capsulotomy in a patient with comorbid AN and OCD.

CLINICAL PRESENTATION:

A 38-year-old woman with life-threatening, chronic, treatment-refractory AN and OCD underwent anterior capsulotomy. Psychiatric and neuropsychological evaluations at baseline and at follow-up document the severity and progress of the case. Bilateral anterior capsulotomy resulted in normalization of eating pattern and weight and a significant decrease of food-related and overall obsessive-compulsive symptoms. Psychiatric evaluations and exposure to food cues confirmed the clinical improvement that was evident immediately after surgery and sustained at 3-month follow-up.

CONCLUSION:

This case report suggests that bilateral anterior capsulotomy can be a therapeutic option for patients with comorbid AN and OCD. However, a well-controlled study is warranted.3”

 

Controversy

A 58 year old woman underwent the surgery and became mute and robotic (sort of like catatonic) Due to the location of the surgery the frontal lobes can get damaged badly, there can be damage to high mental functions, judging, insight, future planning, social awareness and creativity. It really is a modern day lobotomy, with a different name.

This is something I would never try, the fail rates are too high and the benefit outweighs the risk.

  1. http://www.winmentalhealth.com/psychosurgery_lobotomy_cingulotomy.php

  2. http://archpsyc.jamanetwork.com/article.aspx?articleid=210096

  3. http://www.ncbi.nlm.nih.gov/pubmed/21471837

  4. http://breggin.com/index.php?option=com_content&task=view&id=148

Modern Psychosurgery Part 1: Cingulotomy

That one word scares the shit out of us. Short for “psychiatric neurosurgery”. What do we think of? The icepick lobotomy, Dr. Walter Freeman, “One Flew Over the Cuckoo’s Nest”. But surgeries like this are still being performed, safely and humanely. They are generally last-last resort treatments (with ECT, electroconvulsive therapy, being a last resort treatment quite often) and aren’t offered now as much as they were in the past. It’s not easy to get a lobotomy anymore,they aren’t even called that. Between 1932 and 1954 (when the drug Thorazine became available), there were around 50,000 psychosurgeries performed. Now, there are 200-300 recorded a year1 in the USA (mostly, some are done abroad).

cin·gu·lot·o·my

Electrolytic destruction of the cortex and white matter of the cingulate2

Image

Howard Dully, author of “My Lobotomy”

“Only patients with severe, chronic, disabling and treatment refractory psychiatric illness should be considered for surgical intervention.”3

A cingulotomy is like a modern day, less destructive, version of the frontal lobotomy we’ve heard so much about. Basically, rather than severing or poking the frontal lobes themselves, a bundle of nerves connecting them are “interrupted4”. It is used now to treat obsessive compulsive disorder, some anxiety disorders and mood disorders, and rarely, psychosis4.

The patient, as for all psychosurgeries, must have tried all other therapies (medication, CBT, DBT, maybe ECT or TMS, regular talk therapy and so on and such forth) before being considered for a psychosurgery.

The frontal lobes control reason, impulse control and judgement. This is targeted, along with the “cingulate gyrus”, a small part of the limbic system involved with many emotions6. The functions of the cingulate gyrus are coordinating sensory input with emotions, emotional response to pain and regulating aggressive behaviour.

An electrode or gamma (laser; radiation) knife is used to perform the operation and a small lesion (about half an inch) is created. Patients notice immediate affect on anxiety, but it may take time (6 to 12 weeks) for depression or obsessive-compulsive disorder to lessen. It is still being investigated in the treatment of bipolar disorder.

If there is no response to the surgery, it may be repeated 6 months later. There is a 62% improvement rate. There are con’s, though, to this operation. Short term can be nausea, vomiting and headache. Reaction to anesthesia. The patient is generally functioning well after four days and kept in the hospital for 48 hours. However, there can be permanent unwanted side effects. Those with a history of seizures can risk having more seizures, and those who haven’t had a seizure before risk having one, in the first two months. Memory loss can also occur. It is the decision of the doctor and patient to decide if the benefits outweigh the risks.

Though this surgery isn’t specified for bipolar disorder, it is interesting that the modern day lobotomy is for obsessive-compulsive disorder, rather than what it was previously used for (any mental illness, from depression to schizophrenia, even homosexuality, which was removed from the DSM after III) It has far less risks and is a less invasive procedure, but I don’t think I’d want to go through brain surgery on a 62% improvement rate.

  1. http://www.psychologytoday.com/articles/199203/psychosurgery

  2. http://medical-dictionary.thefreedictionary.com/cingulotomy

  3. Neurosurgical department of Massachusetts General Hospital/Harvard Medical School

  4. http://neurosurgery.mgh.harvard.edu/Functional/cingulot.htm

  5. http://bipolar.about.com/od/treatment/a/bilcingulotomy.htm