30 Anterior Capsulotomy for Treatment of Refractory Schizophrenia
Abstract
Schizophrenia is a psychiatric disorder that may be associated with functional and structural impairments in the cortico-striato-thalamic circuitry. 1 It is a debilitating, disabling, and heterogeneous disorder that affects 1% of the population and is characterized by three symptomatic domains: There are positive symptoms such as hallucinations and delusions; negative symptoms include depression and apathy, and there are cognitive deficits. Conventional approaches to treatment have not yet been fully successful because of its symptom diversity and unclear etiology. First and second generation antipsychotics have been helpful for mild to moderate schizophrenia, but drug resistance, extrapyramidal side effects, and tardive dystonia complicate their use. Twenty to thirty percent of patients suffer a relapse during maintenance treatment. 2 , 3 Electroconvulsive therapy is the most rapidly effective treatment of refractory schizophrenia, but the cognitive deficits and memory impairments from it are still a major concern. 4 Repetitive transcranial magnetic stimulation is a promising therapy for the negative symptoms of schizophrenia and for auditory hallucinations. 5 It has not solved the issue of the heterogeneity of schizophrenic symptoms, and controlled trials will be required to validate its safety and effectiveness. Cognitive behavior therapy has moderate benefit, but it is time consuming. 6 , 7 Given the absence of an obvious answer for patients who are refractory to known treatment options, stereotactic surgery could be considered as an alternative treatment.
30.1 Patient Selection
An Ethics Committee should oversee all candidates for surgery. Informed consent must be obtained. In our practice immediate relatives can give consent for patients incapable of doing so.
This is an obvious ethically sensitive field. All candidates for neurosurgical treatment of schizophrenia must meet strict, accepted clinical criteria for severity, chronicity, disability, and treatment refractoriness. The risk of suicide should be considered when evaluating all of these individuals. 8
30.2 Inclusion Criteria
Candidates must be 18–60 years old, examined by two separate psychiatrists, and diagnosed as schizophrenic according to the DSM-IV. 9
Their Brief Psychiatric Rating Scale (BPRS) score must be ≥ 35 and the Clinical Global Impression (CGI) score must be > 4. 9 As such, their condition must impact their quality of life and prevent participation in normal activities, as clarified by a score of less than 60 on the Social and Occupational Functioning Scale.
Candidates must have failed at least two adequate treatment trials with different antipsychotic drugs. 10 Each drug must be tried for at least six weeks, and the dosage must have been equivalent to 600 mg or more of chlorpromazine daily.
Finally, patients must be intolerant to further nonsurgical approaches, and patients or their representatives must have the ability and willingness to give informed consent.
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